Columbia SSnitJem'tp College of ^ijpjsicians; anb ^urgeong ^D ■VXi^ Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/clinicalhistoryoOObarn A CLINICAL HISTORY MEDICAL AND SURGICAL DISEASES WOMEN. BY ROBERT BARNES, M. D., Lond., FELLOW AND LUMLEIAN LECTURER (1873) ROYAL COLLEGE OF PHYSICIANS ; EXAMINER IN OBSTETRICS AND THE DISEASES OF WOMEN AT THE UNIVERSITY OF LONDQN AND THE ROYAL COLLEGE OP SURGEONS; OBSTETRIC PHYSICIAN AND LECTURER ON OBSTETRICS AND THE DISEASES OF WOMEN TO ST. THOMAS'S HOSPITAL. WITH ONE HUNDRED AND SIXTY-NINE ILLUSTRATIONS. PHILADELPHIA: H E N K Y C. LEA. 1874. SHERMAN & CO., PRINTERS, PHILADELPHIA. 1;^ io( CD to CO Dear McClintock: i beg of you to accept the dedication of this book, i offer it in geateful acknowledgment of the services rendered to the department op medicine of -which it treats by the dublin school, whose spirit op clinical observation and faithfulness in record you so eminently represent, op the honor conferred upon me by the Dublin Obstetrical Society by electing me an Honorary Member, and in testimony of a friendship begun in Paris IN our student-days. Believe me yours ever, EGBERT BARNES. To Alfred H. McClintock, M.D., Honorary President of the Dublin Obstetrical Society, &c. PREFACE. The design of this work is to give such a description of the medi- cal and surgical diseases of women as will assist the medical practitioner in their diagnosis and treatment. In our systematic treatises on medi- cine and surgery, and even in those on obstetrics proper, these diseases are for the greatest part either ignored, or imperfectly appreciated and described. Hence, in all countries, the want of works devoted to this branch of the healing art has been felt. To a great extent this want has been successfully met by authors of the highest reputation, in France, Germany, America, and Great Britain. The subject is wide and important, not only in its direct application to the relief of the special diseases it embraces, but also in its endless and interesting rela- tions to the physiological and pathological history of women. In the woman the reproductive organs exert a vastly greater influence than they do in the man. The reactions in health and disease between these organs and the rest of the economy are multiform and incessant. The physician who neglects the study of the pelvic diseases in women is constantly in danger of overlooking the efficient cause, or a serious complication, of the more obvious disorder which he undertakes to treat. He cannot possibly understand many of the disorders of the organs of assimilation, of respiration, of circulation, and especially of the nervous system, without a careful investigation of the condition of the reproductive organs. It is here that lies concealed the missing link in his chain of reasoning, the want of which will frequently vitiate all his deductions, and thwart all his efforts in treatment. To some physicians of the class referred to, the bulk of this volume may seem excessive. I would suggest the reflection that this apparent VI PREFACE. excess may represent the extent of their neglect. My own fear, which I have no doubt -will be shared by those most competent to judge, is that many things of importance are inadequately discussed. In a sub- ject of comparatively recent inquiry, necessarily, to some extent, un- settled and open to controversy, a fuller statement of fundamental facts, and more argumentative discussion are called for, than are necessary in the exposition of the more generally cultivated depart- ments of medicine. In the preparation of this work, although not, I trust, unmindful of the published works of others, I have drawn greatly from my own ex- perience. I have endeavored to bring into the circle of gynaecological literature new illustrations. With this view I have explored the rich mines of pathological material in the museums of the College of Sur- geons and of the London hospitals. I am anxious to take this oppor- tunity of acknowledging the courteous, even warm assistance, given to my artists and to myself by the curators and other officials of these museums. To my friend Dr. McClintock T am indebted for permis- sion to use two illustrations from his admirable clinical work on the "Diseases of Women." I have also to express my thanks to Messrs. William Garton, formerly Resident Accoucheur, A. S. L. JSTewington, Ernest Carr Jackson, and Fancourt Barnes, lately my clinical clerks at St. Thomas's, for valuable assistance in the labor of compiling the indexes. Robert Barnes. 31 Grosvenor Street, London, November, 1873. CONTENTS. Introductory, PAGE . 17 CHAPTEK I. THE GENITAL OKGANS. Ovaries; Corpus Luteum, CHAPTER II. The Fallopian Tubes, . . . , • CHAPTER HI. The Shape of the Cavities of the Uterus, . CHAPTER IV. 19 29 . 45 Structure of the Uterus, CHAPTER V. The Vagina, CHAPTER VI. CHAPTER VII. The Significance of Leucorrhcea, 48 56 Conditions Indicating Necessity for Examination ; Disorder of Function ; Dis- tant and Constitutional Reactions ; the Subjective Signs of Local Disease Indicate Appeal to Objective Signs; Comparison of Study of Disease of Pelvic Organs to that of Skin and Eye ; Disturbance of Functions of Ovaries, Uterus, and Vagina; Amenorrhoea, Real and Occult; Menor- rhagia ; DysmenorrhcBa ; Dyspareunia ; Retention of Urine ; Sterility ; Abortion; Discharges, Sanguineous, Mucous, Purulent, Albuminous, Watery, Fleshy, Membranous ; Pain, Lumbo-Dorsal, Inguinal, Pelvic, . 65 73 Vlll CONTENTS. CHAPTEK VIII. / PAGE Discharges of Air, ............ 82 CHAPTER IX. The Watery Discharges, ........... 83 CHAPTER X. The Purulent Discharges, ........... 87 CHAPTER XL The Significance of Hemorrhagic Discharges, 88 CHAPTER XII. The Significance of Pain, 98 CHAPTER XIII. The Significance of " Dyspareunia," including "Vaginismus," . . . 102 CHAPTER XIV. The Significance of Sterility, 107 CHAPTER XV. The Instruments Serving for Diagnosis and Treatment, 115 CHAPTER XVI. The Diagnosis of Diseases of the Pelvic Organs ; the Touch ; the Sound ; the Speculum, ............. 132 CHAPTER XVII. THE PATHOLOGY OF THE OVARIES. The History of Menstruation and its Disorders, 146 CHAPTER XVIII. Disordered Menstruation (Paramenia, W. Parr) ; Amenorrhcea, . . . 163 CHAPTER XIX. Amenorrhoea from Retention ; Retained Menses from Occlusion or Atresia of the Uterus, Vagina, or Vulva, or from Imperforate Hymen; Occult Men- struation ; Hajmatomelra, .......... 175 CONTENTS. IX ^ CHAPTER XX. PAGE Dysmenorrhoea ; Neuralgic; Congestive; from Obstructed Excretion; In- flammatory, ............ 192 CHAPTER XXI. Ovarian Dysmenorrhoea ; Dysootocia ; Oophoria (Hysteria) ; Tubal Dysmen- orrhoea, 217 CHAPTER XXII. Inflammatory Dysmenorrhoea ; Dysmenorrhoea Membranacea, . . . 225 CHAPTER XXIII. The Menstrual Irregularities of the Climacteric Epoch, 234 CHAPTER XXIV. The Eelations of Menstruation to various Diseases; the Influences of Ovula- tion and Menstruation in Evoking Morbid Influences, .... 242 CHAPTER XXV. The Disorders of Senility or Decrepitude, . . . . . . . 249 f CHAPTER XXVI. Ovary: Absence of Abnormal Conditions of ; Displacement; Hernia, . . 252 CHAPTER XXVII. Ovary: Hyperemia, Hemorrhage, and Anomalies of the Corpus Luteum, . 255 CHAPTER XXVIII. Ovary : Tubercle ; Cancer ; Solid Tumors, 268 CHAPTER XXIX. Ovarian Cystic Tumors : their Nature — Simple; Multiple; Proliferous; Cysto- Sarcomatous ; Tubo-Ovarian — Contents of Ovarian Cysts : Dermoid Cj'sts, 277 CHAPTER XXX. Cutaneous Proliferous Cysts ; or. Dermoid Cysts of the Ovary, . . . 290 CHAPTER XXXI. Natural Course and Terminations of Ovarian Tumors, ..... 294 X CONTENTS. CHAPTER XXXII. PAGE Diagnosis of Ovarian TumorS; 305 CHAPTER XXXIII. Treatment of Ovarian Cystic Disease ; Medicinal ; Tapping by Vagina, and by Abdomen, 325 CHAPTER XXXIV. The Fallopian Tubes; Absence of ; Separation ; Cysts; Carcinoma; Tubercle; ; Fibroid Tumors; Hypertrophy; Elongation; Dilatation; Inflammation (Salpingitis); Catarrh; Haematoma; Occlusion; Cystic Enlargements; Dropsy, 350 CHAPTER XXXV. The Broad Ligaments; Dropsy; Inflammation; Phlegmasia Dolens; Phle- bolithes ; Fibroid Tumors, 360 CHAPTER XXXVI. Extra-uterine Gestation ; Tubal ; Ovarian ; Tubo-Ovarian ; Abdominal ; In- terstitial ; One-Horned Uterine Gestation, 362 CHAPTER XXXVII. Special Pathology of the Uterus ; Abnormal Conditions ; Developmental Faults, 395 CHAPTER XXXVIII. General Observations on Uterine Pathology ; Eftects of Labor and Lactation ; Involution in Defect and Excess, 405 CHAPTER XXXIX. Conditions marked by Altered Vascularity or Blood-Supply; Fluxion; Hyper- temia; Congestion; Inflammation, ........ 423 CHAPTER XL. Metritis ; Endometritis ; Follicular Excoriations ; Aphthous Eruptions ; Vari- cose Ulcer, 433 CHAPTER XLI. Pelvic Cellulitis (Parametritis) ; Pelvic Peritonitis (Perimetritis) ; Perimetric Inflammation (Peri-Uterine Inflammation) ; Metro-Peritonitis, . . 479 CHAPTER XLII. Perimetric Hasmatocele ; Retro-Uterine Htematocele ; Pelvic Hsematocele ; Blood-Effusions in the Neighborhood of the Uterus, .... 603 CONTENTS. XI CHAPTER XLIII. PAGE Displacements of the Uterus; Definhion ; Varieties of: Prolapsus Described; Hypertrophy of the Vaginal-Portion, 533 CHAPTER XLIV. DISPLACEMENTS OF THE UTEEUS {continued): Oblique or Lateral Inclinations ; Elevation ; Depression ; Elongation by Stretching and Pressure ; Dislocations of Uterus by External Pressure ; Versions and Flexions ; Anteversion ; Anteflexion, ..... 577 CHAPTER XLV. Ketroversion ; Ketroflexion, .......... 595 CHAPTER XLVI. Inversion of the Uterus ; Definition ; Acute and Chronic ; Causes, in the Parturient and Non-Pregnant Uterus; Symptoms, Course, and Termina- tions ; Prognosis; Diagnosis; Treatment, . . . . . .615 CHAPTER XLVII. Tumors of the Uterus ; Malignant and Non-Malignant ; Fibroid or Myoma ; Description of Fibroids, their Natural History, Rise, Progress, and Ter- minations ; Varieties of Fibroid Tumors ; the Difi^use Tumor ; the Fibro- Cj'stic ; the Recurrent Fibroid ; the Erectile Tumor of Carswell ; the De- velopment and Decay of Fibroids ; Effects of Fibroids upon the Uterus and Surrounding Organs and System Generally ; the Symptoms and Diagnosis ; the Treatment, ......... 639 CHAPTER XLVIII. POLYPUS UTERI. Definition; Forms of; Fibroid or Myoma; Glandular or Mucous; Hyper- trophic ; Vascular ; Placental ; Fibrinous ; History of Fibroid ; Fibror Cystic Variety ; Synxptoms ; Terminations ; Intra-Uterine and Extra- Uterine Polypi ; Diagnosis ; Treatment ; Slow Strangulation, Dangers of; Torsion, Crushing, and Excision by Scissors; Removal by Polyp- tome, Eeraseur, Galvanic Wire-Cautery, 676 CHAPTER XLIX. Tubercle of the Uterus, 695 CHAPTER L. Cancer ; Definition ; Degrees of Malignancy ; its Local Origin ; Hereditary Transmission ; its Frequency ; Causes ; Forms of : Medullary ; Epitheli- oma ; Sarcoma ; Scirrhous ; Myxoma. Cancer and Pregnancy. The Course and Terminations of Cancer ; Diagnosis ; Prognosis. Treatment : XU CONTENTS. PAGE Question of Curability ; Total Extirpation of Uterus ; Amputation of Yaginal-Portion, Selection of Cases for ; the Operation ; Cautery, Actual and Potential. Treatment of Cancer of Body of the Uterus. Palliative Treatment ; Local and Constitutional, . . . . . . . 701 CHAPTER LI. THE DISEASES OE THE VAGINA. Colpitis ; Simple, Infectious, Acute, Chronic ; Displacements ; Wounds ; Di- latation ; Atrophy ; Sloughing ; Cicatrices ; Vesico-Vaginal and Hecto- Vaginal Eistulse ; Euptured Perineum ; New Eormations ; Fibrous Tu- mors ; Sarcomata ; Cystic Tumors ; Hsematoma ; Calculi ; Cancer, . 739 CHAPTER LII. THE DISEASES OF THE VULVA. Inflammation : General or Partial ; of the Vulvo-Vaginal Glands; Abscesses ; Ulcerations ; Sloughs ; Hsematoma ; Varicosity ; Pruritus ; Hypertrophy of Labia and Clitoris; " Endermoptosis ;" Neuromata; Cysts; Syphil- itic Warty Excrescences; Lupus; Cancer; Melanosis; Vascular Ex- crescence of the^ Meatus Urinarius ; Fissure of the Vulva. Coccygo- dynia, 754 INDEX, 769 LIST OF WOOD ENGRAVINGS. PIG. 1. 2. 3. 4. 5. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 80. 31. 32. 33. 34. 35. 36. 37. 38, Tubes (A. Fan- Genital Organs, in situ (Savage), .... Adult Paroi^arium, Ovary, and Fallopian Tube (Kobelt), Eight Fallopian Tube laid open (Richard), Ovary enlarged under Menstrual Nisus (Eaciborski), Menstrual Corpus Luteum and Ovary (Eaciborski), . Bulb of Ovary (Savage), Ovary in old age, .... Longitudinal Section of Pelvis (Breisky) Uterus and Appendages of an Infant (A. Farre Eegional Divisions of the Uterus (A. Farre), Vertical Section of the Uterus (A. Farre), Virgin Os Uteri and Vaginal-Portion (A. Farre), Os Uteri in old age, ..... The Uterus in old age (A. Farre), Thinning of the Walls in old age (A. Farre), Cervix laid open (Hassall and Tyler Smith), Section of Uterus, above entrance of Fallopian Section through centre of cavity of Uterus, Section through centre of Cervical Canal Uterus of Virgin, set. 17, . Multiparous Uterus, set. 25-30, . Multiparous Uterus, set. 42, Multiparous Uterus, set. 35, Villi of Os Uteri, Epithelium removed (Tyler S Extremities of Villi of Os Uteri (Tyler Smith Villi of Os Uteri, covered with looped Bloodvessels (Tyler Hassall), Mucous Discharge from healthy Cervix Uteri (Tyler Smith and Has Cervical Leucorrhoea (Tyler Smith and Hassall) Epithelium from Vaginal Leucorrhoea (Tyler Smith and Hassall) Fergusson's Speculum, ..... Henry Bennet's Speculum modified (Barnes), . Cusco's Speculum, ...... Sinis's Speculum, ...... Barnes's Modification of JSfeugebauer's Speculum Simpson's Uterine Sound, ... . . . Barnes's Whalebone Sound, .... Kiichenmeister's Metrotome Scissors, . Simpson's Metrotome, ..... mith and Hass and Hassall), mith ;all), PAGE 19 21 21 23 24 26 28 33 39 40 40 42 42 42 43 43 45 46 46 46 46 47 47 52 52 53 71 71 72 119 119 120 120 121 124 124 124 126 XIV LIST OF WOOD ENGRAVINGS. MG. PAGE 89. Sims's Tenaculum Hook, , . " 126 40. Improved Wire Ecraseur, . . . . . . . . . . 127 41. Barnes's Instrument for introducing Laminaria or Sponge-Tents into Uterus, . 127 42. Barnes's Nitrate of Silver Cautery, ........ 129 43. Barnes's Tube for depositing Sticks of Sulphate of Zinc in Uterus, . . 129 44. Barnes's Uterine Ointment Positor, . . . . . . . .129 45. Higginson's Vaginal Syringe, ......... 131 46. Barnes's Speculum for application of Medicated Cotton-Wool in Vagina, 131 47. 48. Skeleton Diagrams for recording Alterations of Size, Position, and Eelations of Pelvic and Abdominal Organs, 133, 134 49. Diagnosis of early Pregnancy, ......... 139 50. Showing Pteversal of Sound in Vtero, 141 51. Dilated Utei-us and Vagina (St. George's Museum), 179 52. Complete Occlusion of Vulva (Kadcliffe Museum), ..... 180 53. Atresia of Vagina, 187 54. Conical Vaginal-Portion, . 202 55. Conical Vaginal-Portion, 202 56. Conical Vaginal-Portion, .......... 202 57. Common form of narrow Os Uteri in Dysmenorrhoea and Sterility, . . 202 58. Section of Conical Cervix with small Os Externum, 203 59. 60. Sections of Uterus made at Os Internum, 207 61. Eepresenting the Action of two-bladed Metrotomes, 210 62. Action of Kiichenmeister's Scissors, 216 63. Exfoliated Mucous Membrane of Vagina, . 231 64. Uterine Mucous Membrane shed entire, ....... 231 65. Blood Coagulum in a Cyst of Ovai-y, ........ 256 66. Fibrous Tumor of Ovary, 257 67. Early Stage of Cystic Disease, 278 68. Surface of Ovary, Prominences of Dilated Graafian Follicles, . . . 278 69. Incipient Cystic Enlargement of Graafian Follicles, 279 70. Fibrous Stroma of Compound Cystic Tumor of Ovary (H. Arnott), . 282 71. Epithelial Lining of a Compound Ovarian Cyst (H. Arnott), . . .283 72. Section of Ovarian Tumor showing Alveolar Structure, .... 284 73. Ovaries aifected with Proliferating Malignant Disease, .... 285 74. Tubo-Ovarian Cyst (Carswell), " . 286 75. Dermoid Cyst of Ovary, 291 76. Ovarian Tumor and Pregnane}', . . . . . . . .311 77. 78, 79. Diagrams: Diagnosis of Ascites and Ovarian Dropsy, . . 317, 318 80. Inflammation of Fallopian Tubes, 354 81. Dropsy of Fallopian Tube, 358 82. Gestation in Fallopian Tube, 366 83. Gestation in Eudimentary Horn of Uterus, 368 , 84. Tubo-Uterine Gestation, 389 85. Uterus strongly developed to right, 396 86. Double or Bicornute Uterus, 397 87. Bicornute Uterus, 398 88. Bicornute Uterus, Septum dividing Cavity, 399 89. Double Uterus and Vagina, 400 90. Transverse Section of Vagina of preceding Figure, 401 91. Atrophy of the Uterus and Ovaries, 403 LIST OF WOOD ENGRAVINGS. XV FIG. PAGE 92. Stenosis ; Atresia ; Dilatation of Uterus, .. . . . . . . 404 93. Kepresenting Bulk of Uterus arrested in its Involution after Pregnancy, and also the Bulk it ought to attain (Simpson), ..... 409 94. Congestion of Vaginal-Portion of Cervix after Labor, .... 419 95. Showing Loss of Epithelium, leaving Villi of Os Uteri bare (Hassall), . 420 96. Epithelial Abrasion after Labor, 422 97. Marion Sims's Curette, 476 98. Eecamier's Curette, 476 99. Collar of Hard Inflammatory Effusion encircling Cervix Uteri, . . 498 100. Remains of a Eetro-Uterine Hfematocele (Guy's), ..... 510 101. Eetro-Uterine Haematocele from Diseased Ovary, . . . . .515 102. Eetro-Uterine Hsematoeele, ......•-. 517 103. Sectional View of the Parts, 518 104. Illustrating Stages of Prolapse of Uterus, ...... 535 105. Complete Procidentia Uteri, ......... 536 106. Prolapsus Uteri, 587 107. One form of Hypertrophy of Vaginal-Portion of Cervix Uteri, . . 540 108. Appearance of same after Complete Cicatrization from Amputation by the Galvanic Cautery, . . . . . . . . . . 541 109. Eversion of Mucous Membrane of Cervix Uteri, 542 110. Prolapse of Uterus, with Hypertrophic Elongation and Complete Ever- sion of Vagina, . . ' . . . . . . . . . 543 111. Hypertrophy with Procidentia of Vaginal-Portion of Cervix Uteri, . 544 112. Early Stage of Hypertrophic Elongation of Cervix Uteri, . . . 545 113. Advanced Hypertrophic Elongation of Cervix Uteri, .... 546 114. Hypertrophic Elongation of both Supra and Infra Vaginal-Portions of Cervix Uteri (King's College), ........ 547 115. Great Hypertrophic Elongation of Supra Vaginal-Portion of Cervix Uteri (Bartholomew's), 549 116. Hypertrophic Elongation of Uterus (St. Thomas's), .... 550 • 117. The Galvanic Pessary, 564 118 The Cup-and-Stem Pessary, 569 119. Diagram illustrating Versions and Flexions of Uterus, .... 581 120. Thomas's Anteversion Pessary, ........ 587 121. Ditto when in Use, 587 122. Thomas's Anteversion Pessary in Action, . . . . . ' . 588 123. Extreme Anteflexion of Uterus, ........ 590 124. Anteflexion of Uterus, 591 125. Diagnosis of Anteflexion of Uterus, ........ 592 126. Mode of applying Hodge or Lever Pessary for Eetroflexion, . . . 598 127. Second Stage in Application of the Hodge, 599 128. Third and Final Stage, 600 129. Extreme Eetroflexion of Uterus, ........ 603 130. Diagnosis of Eetroflexion by Vaginal Touch, ...... 607 131. Diagnosis and Eeposition of Eetroflected Uterus by the Sound, . . 609 132. Occasional Vicious Action of the Hodge in Extreme Eetroflexion of Uterus, . 613 133. Combination of Intra-Uterine Pessary and the Hodge, .... 614 134. Illustrating Three Degrees of Inversion of Uterus (Crosse), . . . 616 135. Extreme Inversion in Section (Crosse), ....... 617 136. Specimen of Inverted Uterus (Crosse), 617 XVI LIST OF WOOD ENGRAVINGS. B'lG- PAGE 137. Barnes's Operation for Inversion of Uterus, ...... 636 138. Barnes's Elastic Pessary for Eeduction of Chronic Inversion of Uterus, 638 139. Structure of Fibroid of Uterus (Arnott), 642 140. Conglomerate of Fibroid Tumors of Uterus (St. Thomas's), . . . 644 141. Subperitoneal Fibroid Tumor of Uterus (London Hospital), . . . 645 142. Fibroid Tumor of Uterus (St. Thomas's), 646 143. Uterus with two large Fibroid Tumors (St. George's), .... 647 144. Fibrous Tumors of Uterus (St. George's), 649 14-5. Fibroid or Muscular Tumor of Uterus (St. Thomas's), .... 650 146. Erectile Tumor of Uterus (Carswell), 6-52 147. Ossified Fibroid Tumor of Uterus (St. Thomas's), 655 148. Fibroid Polypus filling Cavity of Uterus (College of Surgeons), . . 678 149. Fibroid Polypus extruded from Cavity of Uterus (College of Surgeons), 678 150. Fibroid Polypus moulded to shape of Uterine Cavity (College of Sur- geons), 679 151. Mucous or Glandular Cervical Polypus, ....... 683 1-52. Section of " Channelled " Glandular Polypus (Arnott), .... 684 153. Uterus with Fibrous Polypus attached to Upper "Wall and ligatured (Bartholomew's), 691 154. Aveling's Polyptrite, 692 155. Operation for removing Polypus by Wire Ecraseur, .... 693 156. Tubercular Disease of Uterus (Guy's), .' 698 157. Phthisis Uteri (Carswell), 699 158. Cancer of Uterus (Bartholomew's), ........ 707 159. Uterus enlarged from Infiltration with Encephaloid Matter (St. Thomas's), 708 160. Uterus lower two-thirds Destroyed by Ulceration (Bartholomew's), . 709 161. Cancer eating away lower half of Uterus (St. Thomas's), . . . 709 162. Pavement Epithelioma of Uterus (Lancereaux), 711 163. Malignant Disease of Uterus (St. George's), ...... 712 164. Cauliflower Growth of Cervix Uteri (Arnott), 713 165. Spindle-cell Sarcoma (Arnott), 714 166. Intra-Uterine Speculum, .......... 737 167. Cicatricial Band Binding Os Uteri to Koof of Vagina, .... 746 168. Syphilitic Hypertrophy of Nympha, 763 169. Hypertrophic Lupus of Vulva, 764 TEEATISE DISEASES OF WOMEN. INTRODUCTORY. It may seem superfluous to state that a clear knowledge of anatomy is the antecedent condition of a correct understanding of disease, diag- nosis, and treatment. All sound medicine is based upon this proposi- tion. But it is more strictly true of the diseases of women than it is of disease in general. For example, it is quite possible to imagine a satis- factory diagnosis to be made of a fever and to treat it successfully, without any precise knowledge of anatomy ; but in the diagnosis and treatment of morbid conditions of the female pelvic organs it is hardly possible to move a step without precise knowledge of their anatomy and physiology ; that is, without imminent risk of falling into error in practice. It therefore becomes especially desirable to introduce the study of the medical and surgical diseases of women by an adequate description of the organs specially concerned. It might be thought to be suffi- cient to refer the reader for this to any one of the many admirable works on anatomy which Ave now possess ; but this, it would quickly be found would very imperfectly answer the purpose. Anatomical text-books teach j)iure anatomy only, certainly as far as the diseases of women are concerned. What we want is the applied anatomy of the sexual system. Almost every physiological or pathological condition of the pelvic organs is attended by variations more or less marked either in their tissues, in their shape, size, or in their relative positions, and often in all. Hence the necessity of keeping constantly before us the normal standard by which we may estimate the abnormal deviations and un- derstand how these are to be corrected. The principal organs we are concerned with are all contained loithin the true pelvis. They are further inclosed or packed between the peri- toneum above and the perineum below. 2 18 IISTTEODUCTOR Y. These organs are, the uterus, the Fallopiau tubes, the ovaries, the vagina, and vulva. The rectum and bladder, also contained within the same region, are indirectly important, in consequence of their phys- iological and pathological relations to the genital organs. The pelvic organs are all related to each other by position or by con- necting tissues. The connective tissue being distributed everywhere at the points of union of the organs, carries the bloodvessels, nerves, and lymphatics to the organs. In certain parts this connective tissue is limited by fasciae. In addition to these organs, we have to remember that the pelvis is traversed by bloodvessels and nerves, which are not strictly related to the genital organs, but which are liable to be implicated in various ways, as by pressure, during gestation and labor, by tumors, or dis- placement of the ovaries or uterus. These vessels and nerves lie in close contact with the walls of the pelvis, and have their exit at the sacro-sciatic notches, at the brim under Poupart's ligament, and the obturator foramina. Then there are muscles, all cushioned by fat and cellular tissue. CHAPTEK I. THE GENITAL ORGANS. OVARIES — CORPUS LUTEUM. The genital organs consist of, 1st, two glands, the ovaries, in which the ova are formed ; 2d, the tderine tubes, called Fallopian, which are true excretory ducts to the ovaries ; 3d, the uterus, a muscular organ in which the fecundated ovum is received and is developed, and which is the principal agent in the expulsioij of the foetus ; 4th, the vagina, a canal which connects the uterine cavity with the exterior, and serves in copulation ; 5th, the vulva, an assemblage of organs placed around the entrance of the genital organs. Associated with the genital organs are the breasts, whose function it is to secrete the milk, the first nourish- ment of the infant. Transverse section just above pelvic rim, showing the relative position of the organs as seen from above — (after Savage), m, pubes ; a, a, (in front) remains of hypogastric arteries; a, a, (behind) spermatic vessels and nerves ; b, bladder ; l, l, round ligaments ; u, uterus seen by its fundus ; t, i, Fallopian tubes ; o, o, ovaries ; r, rectum ; g, right ureter resting on the psoas muscle ; c, utero-sacral ligaments forming the lateral borders of Douglas's pouch ; v, last lumbar vertebra. 1. The ovaries are so called from their containing small vesicles or ova. They are two ; they are placed in front of the rectum, from which they 20 ANATOMY. are often separated by convolutions of the small intestine, on either side of the uterus, behind the Fallopian tubes, and in that portion of the broad ligaments Avhich is called the posterior wing or fold. They are maintained in position by the broad ligaments, which make for them a kind of mesentery, and by a special ligament, the ligament of the ovary. The situation, however, varies according to the age and the condition of the uterus. In the fcetus, they are placed in the lumbar region, like the fundus of the uterus. During pregnancy they rise in the abdomen with the body of the uterus, to the sides of which they are applied. Immediately after delivery, they occupy the internal iliac foss£e, where they sometimes remain throughout life, fixed by accidental adhesions. Frequently they are found turned backwards and adhering to the pos- terior surface of the uterus. Sometimes an ovary is found in the sac of an inguinal, a femoral, or even of an umbilical hernia. Cases have been met with in which no ovaries were found. It must be very rare that organs so essential are absolutely wanting ah initio. There is a preparation in University College Museum from a girl, aged 20, who had never menstruated. The uterus presents the features characteristic of early childhood, and no ovaries are manifest. "When not discovered, the ovaries may have disappeared by atrophy, the result of some morbid process. The size of the ovary varies according to age, the condition of the uterus, and health or disease. In the adult it measures an inch to two inches in length, an inch in breadth, and half an inch in thickness. The average weight is 87 grains. It is proportionally larger in the foetus; it diminishes after birth, it enlarges considerably, becoming softer and more vascular at the epoch of puberty, and becomes atro- phied and hard in old age. Towards the end of pregnancy it acquires double or treble the size of the ordinary state. The shape is that of an ovoid a little flattened from before backwards ; the outer extremity, that looking towards the fimbriated end of the Fallopian tube, is rounder and thicker than the inner extremity, which looks towards the uterus. The anterior surface, like that of the uterus, is flatter than the posterior, which is gibbous. The upper border is convex ; the lower one is straight or concave. The color is whitish. The surface is smooth during childhood (as seen in Fig. 2) ; after pu- berty it becomes rough, scarred by repair of the rents made in the tissues to afibrd escape to the ova at the menstrual periods (as seen in Fig. 3). The ovary is free in front, above, and behind ; it floats in the pelvic cavity, fastened, 1st, by its lower border to the broad ligament wliich is furnished with a peritoneal investment, and represents the hilum of the gland. Along this border bloodvessels penetrate and emerge ; 2d, it is fastened by its outer extremity to the pavilion of the Fallopian tube (see Fig. 3); and 3d, by its inner extremity to the corresjionding side of the uterus, a little below the superior angle of this organ, by a cord named the ligament of the ovary (see h, Fig. 3). This cord is fibrous and muscular, and is simply a prolongation of the proper tissue of the uterus. The structure of the ovary is composed of an investment and paren- chyma. The investing structure consists of the peritoneal or serous coat, THE OVARIES. 21 and of an inner fibrous coat, called also the tunica albuginea ; but the two are so intimately blended that it is impossible to separate them ; nor is it easier to separate the fibrous coat from the parenchyma. The Fifi. 2. ^E Adult parovarium, ovary, and Fallopian tube — (after Kobelt). a, a, tubules of the original Wolffian body or parovarium ; 6, remains of the upper set which occa- sionally become distended by collections of fluid, and constitute one form of dropsy of the broad liga- ment ; c, middle set of tubules ; d, lower set atrophied ; e, atrophied remains of the excretory duct of the WoMan body ; /, terminal bulb of the same, converted here into the hydatid often seen attached to the broad ligament ; h, the former duct of Miller, now the Fallopian tube, with its infundibulum, from which hangs i, the terminal bulb, now converted into a pedunculated hydatid ; I, generative gland, now the ovary. bundles of connective tissue composing this coat are arranged in seve- ral layers, circular or longitudinal. Within this is a layer of connec- tive tissue, the bundles of which are crossed in every direction : this Eight Fallopian tube laid open. Prom an adult who had not borne children — (after Eichard). a, funnel-shaped canal, leading from the uterus to 6, uterine portion of the tube ; c, point at which the large plicte commence ; d, infundibulum covered by plicce, continuous with those lining the canal ; e, tubo-ovarian ligament and fringes ; /, ovary ; g, round ligament ; h, ligament of the ovary. belongs to the parenchyma, although the naked eye fails to distin- guish the boundary that divides it from the fibrous coat. On making an antero-posterior section of the ovary, the parenchyma is seen to be 22 A N A T O M Y. formed of two distinct parts : the one central or medullary, the other peripheral or cortical. The medullary substance looks spongy and red, owing to the vessels of the hilum which ramify in its interior. The color gradually fades into a grayish- white, and as the cortical substance is approached, it becomes quite white. The medullary substance is formed of connective tissue ; the large bundles of the connective fibres are arranged in a parallel direction to the vessels, and from these bun- dles spring nets of more delicate fibres which fill up the interspaces. Around the first are often twined nets of very fine elastic fibres ; and in the neighborhood of the larger arteries these elastic fibres are often mixed with parallel bundles of smooth muscular fibres prolonged from those which compose the ligament of the ovary. M. Rouget' says these muscular fibres constitute, the vessels excepted, the principal mass of the medullary substance ; that the greater number proceed from the posterior surface of the uterus, and that they reach the ovary either by the round ligament or by the broad ligament, whilst others spring from the fascia propria of the lumbar region, accompanying the spermatic vessels which they surround. M. His^ is even of opinion that the entire interstitial tissue of the ovaries is nothing but a peculiarly modified and confused mass of mus- cular tissue, and he proposes for it the name " fusiform mass." Rouget regards the arrangement by which these muscular fasciculi accompany the vessels in the form of sheaths, as analogous to that which obtains in erectile tissues. Waldeyer, however, says^ that at present we cannot be said to possess any direct observations on the erection of the ovaries. The peripheral or cortical portion constitutes the essential part of the ovary, that in which the ovule is formed. In it are distinguished : 1. The ovisacs or Gh^aafian vesicles, destined to secrete and expel the ovum ; 2. An intermediate structure in which vesicles are scattered. This is called the stroma. Immediately beneath the tunica albuginea the stroma is composed of bundles of connective tissue variously crossed ; near the medullary substance it presents the irradiations of the connective fibres of this part. What distinguishes the connective tissue is the enormous quantity of interstitial nuclei revealed by acetic acid. Between these two layers of connective tissue is a layer, the variable thickness of which mainly determines the differences in size which the ovary presents. It consists essentially of fusiform nucleated cells, strongly compressed against each other, and sometimes furnished with filiform prolongations, very short and penetrating into the interstices of the adjoining cells. The Graafian vesicles or follicles are scattered in the stroma of the cortical substance, chiefly in the most superficial layer. The limitation of the ovules to the peripheral portion is most marked in infancy. After puberty they are apt to invade the medullary portion. Towards puberty the folli- cles are found close together. Their number is very great. To give an approximate idea, Henle makes the following calculation : In the ' "Journal de la Physiologie," i, p. 737. 2 " Beobachtungen iiber den Bau des Saiigethiereierstocks." Max Schultze's Archiv f. mikrosp. Anat., 1865. 3 Strieker's " Manual of Histology," N. Sydenham Soc.,1872. ' THE OVARIES. 23 ovary of a person eighteen years old an antero-posterior section, form- ing about a sixth of the periphery of the organ, showed 20 follicles ; in the entire section there would be 120 follicles; and as it would be possible to divide the ovary into 300 sections, it follows that each ovary contained 300 times 120, or 36,000 follicles, or 72,000 for each woman. The follicles, at first microscopic, rapidly grow after puberty when they are destined to mature. They invade the medullaiy substance, and form a hemispherical bulging on the surface of the ovary. This ripening appears to take place rapidly, since only a small number of follicles is usually made out by the naked eye ; that is, in process of development ; yet it is certain that every month one follicle, at least, arrives at complete maturation. When ripe, the follicle consists of an investing membrane and contents. 1. The investing membrane presents an outer or fibrous tunic, a middle or proper tunic, and an inner or epithelial or granular layer. The first is thick, very vascular, and very retractile ; it is united to the stroma by a loose cellular tissue : hence it is easily isolated. It is formed of compact bundles of connective tissue arranged in concentric layers. The tunica propria is also composed of connective tissue ; but this is in a more embryonic state, and contains a multitude of nuclei and fusiform cells. This tunic is also much less retractile than the fibrous tunic. The epithelium which lines the membrane of the follicle inside is composed of one or more layers of polygonal cells, inclosing a large nucleus and some fatty granules. The epithelium is much thicker at the part which surrounds the ovum. At the level of this part the ac- — A A, A, ovary enlarged under menstrual nisus ; b, ripe follicle projecting on surface; a, a, a, traces of previously burst follicles — (after Raciborski). cumulated cells form a warty swelling, which bulges into the cavity of the follicle. This swelling is the cumulus or discus proligerus. The ovum is situated in the middle of the cells of the proligerous disk, part of which it carries along with it, when, after the dehiscence of the fol- licle, it leaves the ovary to enter the oviduct. The ovum is a spherical 24 ANATOMY. vesicle ; it may be represented as a simple cell. The membrane of the cell is called the vitelline membrane ; it is very thick, perfectly hyaline and transparent, resisting and very elastic. The contained matter is called the vitellus; this is a viscous liquid, of yellowish color, in which are seen a multitude of granulations. A large vesicular nucleus, called the germinal vesicles, is situated excentrically in the vitellus, and itself contains a small nucleolus, the germinal spot. It is rare to find two ova in the same follicle. The follicle contains a transparent, yellowish fluid, resembling serum ; at first this is very small in quantity, but increases gradually as the follicle approaches maturation, until the tunics, swollen and thinned by this accumulation of liquid, burst at the culminating point, and dis- charge their contents. Corpoixi lutea. — When the follicles have burst, and the ovum has escaped, a process takes place which results in the formation of the so- called yellow bodies. On the bursting of the follicle, its membranes collapse. The retraction is due entirely to the fibrous membrane ; the internal membrane and the granular layer having no elasticity simply follow the movements of the fibrous tunic, and form folds, just as the mucous membrane of the stomach does under the influence of the con- traction of the muscular coat. The cavity of the follicle is thus greatly contracted ; a small quantity of blood, escaped from some ruptured vessel, is retained, but only as an exception, according to Coste, in the cavity, which is early invaded by a plastic and gelatinous secretion furnished by the inflamed part. Soon the cellular and granular layer, Fig. 5. Showing menstrual corp. lut. and ovary — (after Eaciborski). B, cavity of Graafian sac from which ovum has escaped ; 6, clot of blood in sac. a part of which has been expelled with the ovum, undergoes a kind of hypertrophy, which gives it an enormous size. Every cell becomes about six times as large as before ; this growth is especially due to the accumulation, in the inside of the cells, of a multitude of yellow granules of albuminous nature, giving to the whole follicle the color THE OVARIES. 25 which suggested the name of yellow body. Owing to this hypertrophy and to the folding of the inner membrane, the cavity of the follicle is at last completely closed. The circumvolutions of the inner membrane coming into contact grow together ; and even after having obliterated the cavity they continue to grow, and thus, not finding room in the retracted external tunic, they often project as a hernia through the rent of the follicle, and are seen outside resembling luxuriant fleshy granu- lations. At this stage the burst follicle is a rounded tumor, bulging on the surface of the ovary, in size sometimes equal to or exceeding that of the rest of the organ. The process which gives rise to the corpus luteum begins soon after the escape of the ovule, and increases in activity up to the thirtieth or fortieth day of pregnancy. The yellow bodies then remain stationary until near the end of the third month, and from that date they begin to decline ; the convolutions, united together by adhesions more or less intimate, atrophy and leave true fibrous bands ; at the same time the yellow granulations are absorbed, the cells disap- pear, whilst the vessels retract and are atrophied. At the moment of labor the corpora lutea are still large, but the process of absorption goes on after delivery, and ends by bringing about their complete dis- appearance. Then there remains on the surface of the ovary nothing but an irregular scar to mark the place of the rupture. There are considerable differences in the evolution of the corpora lutea. The most remarkable is that which depends upon whether the discharge of the ovum has been followed by pregnancy or not. In the latter case the yellow bodies run through all their stages rapidly, and never reach a great development ; these have been called false cotyora lutea. They wither early ; and, at the end of one or two months, only traces of them are found on the surface of the ovary. The Vessels of the Ovary. — The ovary is extremely vascular; its arteries spring from a trunk common to the ovary and the uterus — the utero-ovarian artery. Having reached the inferior border of the ovary, this artery, which springs from the aorta on the level of the renal artery, and which is remarkable for its flexuous course, suddenly gives off ten or twelve branches. These ascend in a parallel direction, describing numerous flexuosities, divide, intertwine, and penetrate the ovary at its lower margin or hilum. In the thickness of the medullary sub- stance the arterial ramifications subdivide and anastomose, always pre- serving their spiral disposition. From the medullary substance the arteries spread into the stroma of the cortical substance, and on the walls of the Graafian follicles. The veins of the ovary, voluminous and plexiform, arise from the capillary networks which surround the Graafian follicles. Their radi- cles unite into small trunks twisted spirally, and run to the hilum coursing between the arteries, where they form a kind of vascular bulb, the ovarian bulb of Rouget. Directly below the ovary these veins form a rete mirabile, the vessels of which are distant 0.04 inch to 0.12 inch from each other, a true corpus spongiosum described by M. Jarja- vay in 1852.^ ^ "Anatomie Chirurgicale," vol. i, p. 288. 26 ANATOMY. According to M. Rouget^ this is traversed in all directions by mus- cular fibres, constituting an erectile organ comparable to the bulb of the vestibule. From the outer part of this bulb proceed two veins, which run to empty themselves directly into the vena cava on the right side, and into the renal vein on the left. The ovarian veins receive almost immediately after leaving the ovary, the veins issuing from the body of the uterus, and now earn the name of utero-ovarian veins. They, like the arteries, are of enormous size at the end of gestation, and immediately after delivery. Fig. 6. Bulb of ovary — (after Savage;. The venous erectile system of the ovary, the anterior layer of the tubo-ovarian mesentery dissected off. u, uterus ; o, ovary and utero-ovarian ligament ; t, Fallopian tube. 1. Utero-ovarian vein ; 2. Pampiniform venous plexus ; 3. Commencement of spermatic vein. The lymphatiG vessels follow the course of the ovarian arteries and veins. Their radicles, still little known, unite into small trunks, which issue from the ovary at the hilum, and run to the lumbar ganglions. According to His, lymphatics are found in the hilum; moreover, he says, wide sac-like lymphatics are here found, which invest the follicle and yellow body like a shell, and are the cause of the easy isolability of these structures. They are often found filled with pus, the conse- quence of puerperal peritonitis, which is often complicated with ovaritis and inflammation of the lymphatic vessels. The nerves of the ovary proceed from the ovarian plexus, which comes from the renal plexus. Development. — The ovaries, like the testicles, are developed at the expense of a secondary blastema, which forms upon the inner edge of the Wolffian body. They are relatively larger in the foetus than in the adult. This great proportional development is especially observed in the length ; for, instead of being ovoid, they are thin and flattened. The surface is perfectly smooth and polished. Placed outside the cavity of the pelvis, in the lumbar region, it seems analogous in this respect to the testicle. But this appears to be due simply to the want of development of the pelvis, the bladder and uterus being also as yet seated in the abdomen. At this period the ligament of the ovary is so little developed that the inner extremity of the ovary touches the cor- responding border of the uterus. The ovarian follicles exist already • Anatomie Pathologique," 17* livraison. THE OVARIES. 27 in the foetus ; and, at the moment of birth, they are seen in very com- pressed layers throughout the whole cortical substance of the ovary. They are composed of a small rounded mass of granular substance, sur- rounded by a simple layer of cells. The stroma divides them into groups, separated from each other by bundles of connective tissue, which send finer prolongations betsveen the follicles of each group. An extremely fine membrane bounds the follicles externally. On the inner surface is a layer of epithelial cells, each of which contains an elongated nucleus. The contents of the follicles consist of a finely granular substance, in which is distinguished a spherical transparent vesicle. The ovaries are extremely small after birth, and undergo no change until the epoch of puberty. This epoch is more precocious for the ovaries than for the other genital organs. In girls of thirteen and fourteen years old, whose internal genital organs, and the uterus itself, still showed all the characters of the foetal state, the ovaries had already acquired their full development : they were ovoid, soft, spongy, and full of blood. At the epoch of puberty very important changes take place in the ovary, the merit of pointing out which is due to Negrier,' Gendrin,^ Gird wood, Pouchet, Letheby,^ Bischoff,* and Raciboi'ski. From the facts brought to light by these observers it results : 1st. That every menstrual period is accompanied in the ovary by a particular process, which appears to be limited to one Graafian follicle, which increases remarkably in size, raises and thins the fibrous investment of the ovary, and finally ruptures it. 2d. That this rupture of the Graafian follicle has for its object to permit the passage of the ovule of Baer into the Fallopian tube. 3d. That hence there takes place in woman, at every menstrual period, independently of any special cause, something analo- gous to the spontaneous oviposition of the Ovipara. 4th. That the same phenomenon is effected in the females of the Mammalia at the time of heat. 5th. That the follicle of Graaf, immediately after its bursting, becomes the seat of a special pi:ocess, which gives rise to the corpus luteum. 6th. That in consequence of the work of resorption in the corpus luteum, the follicle will be replaced by a slate-colored cica- trix, which penetrates more or less deeply into the substance of the ovary. 7th. Lastly, that the cicatrices or scars on the surface of the ovaries and the corpora lutea, are not the result of follicles torn by the act of fecundation or of any erotic excitation, as Haller believed. The ovaries maintain, throughout the » period of menstrual life, the development acquired at the epoch of puberty. Throughout this period, also, we meet with Graafian follicles in progress to maturation, so that the question arises : Do the vesicles, formed in such multitude in the foetus, continue without change until the time when they are roused to complete development, that is, from the age of fifteen to fifty ? or are these first vesicles destroyed at the end of a certain time, to be replaced 1 " Recherches anatomiques et physiologiques sur les ovaires de I'espece humaine," &c. Paris, 1840. - " Traite philosophiques de Medecine pratique." Paris, 1839. 3 Philosophical Transactions, 1852. * " Zeitschrift fiir rationelle Medicin," 1853. 28 ANATOMY. by others of more recent formation ? Another question, not less inter- esting, is whether a single vesicle arrives at maturity at each menstrual period, or whether several accomplish their full development at the same time ? These questions are not yet clearly solved. Sometimes several corpora lutea are found in the same ovary. If only a single vesicle were spent at each menstruation, it would take about 300 vesicles for the same number of menstruations, which, excluding the suspensions during pregnancy and suckling, take place during the reproductive period of life. Setting aside, therefore, the possibility of the new formation of vesicles, there exist in the ovary of the fcetus infinitely more vesicles than are wanted for all the purposes of reproduction. After the critical epoch the ovary is deprived of follicles. It shrinks, shrivels, and in old age loses its ovoid form, becomes flattened, atroj)hied, rough, knot- ted, and seems reduced to its shell. Fig. 7. Showing ovary in old age — (ad nat.). Bischoff says that in every instance the full consequences of menstru- ation are not necessarily carried out, but that a follicle may swell and the ovum ripen without the bursting of the follicle or the escape of the ovum. Such a condition will cause sterility notwithstanding menstru- ation. The ovaries, then, are the essential organs of generation. The de- struction of one ovary by disease, or its loss by extirpation, does not entail sterility ; but the destruction or loss of both condemns the woman to absolute sterility. In connection wdth the history of the ovary, it is convenient to de- scribe an organ immediately contiguous — the organ or body of Rosen- rniUler. This body is placed in the thickness of the broad ligament, between the outer extremity of the ovary and the last convolution of the Fallopian tube. (See Fig. 2, p. 21.) It is a small tubular organ to which Kobelt^ gave the name of parovarium. It has been described with great care by M. Follin.^ It is seen M^hen the broad ligament is put on the stretch and held up to the light ; but is made out more clearly by removing the thin peritoneal lamina which covers it. It is situated in front of the ovarian vessels ; it is of triangular shape, the summit directed towards the ovary. It is generally composed of fifteen to twenty small tubes, slightly flexuous, of unequal length, from 0.12 in. to 0.20 in. in diameter, and separated fi-om each other by a variable ' " Der Nebenstock des Weibes." Heidelberg. 1847. 2 " Eecherches sur les Corps de Wolff." These inaug. Paris, 1850. FALLOPIAN TUBES. 29 space. In the adult woman this collection of tubes is attached to the outer half of the ovary ; in the foetus at term, it corresponds to the upper border of this gland. One tube, that which occupies the upper border of the body of Rosenmiiller, is distinguished from the rest as performing the part of a common excretory duct. In its middle it lies transversely ; its two ends bend downwards at right angles, and are directed towards the upper border of the ovary. The other tubes spring perpendicularly from the transverse portion of the marginal tube, and converge slightly towards the ovary. In this course they are flexuous, of unequal calibre, and sometimes the seat of cystic or hydatidiform enlargements. Their ovarian extremity ends in a cul-de-sac. The wall of these tubes is composed of an outer investment formed of an- nular fibres ; and of an inner tunic, having longitudinal fibres, and lined in its interior with a layer of vibratile epithelium. As an ap- pendage to the organ of "Rosenmiiller, we must mention a vesicle more or less pedunculated, situated at the outer extremity of the broad liga- ment, and often adhering to one of the fringes of the pavilion of the Fallopian tube. This is the analogue of the vesicle of Morgagni in man. M. Follin has searched the broad ligament in order to find something analogous to the duct of Gaertner which is seen in some animals ; but, like De Blainville, he has seen nothing resembling that which has been described by A. C. Baudelocque, Gardien, and others. It appears to be established that the organ of Rosenmiiller is the remains of the Wolffian body, a transitory organ which very prob- ably fulfils the functions of the kidney before the development of this gland. CHAPTER II. THE FALLOPIAN TUBES. The Fallopian or uterine tubes are truly oviducts. They are, in fact, the excretory ducts of the ovaries, differing, however, from all other excretory ducts in being entirely detached from their proper glands. They are situated in the thickness of the broad ligaments, and extend from the superior angles of the uterus to the sides of the cavity of the pelvis. Floating in the pelvis between the ovaries which are behind, and the round ligaments which are in front, the tubes occupy the middle wing of the broad ligaments, of which they form the upper border ; they run at first transversely outwards, and, just before termi- 30 ANATOMY. nating, bend downwards, backwards and inwards, to approach the outer end of the ovary, to which they are connected by a remarkable prolongation, (See Fig. 3, p. 21.) For the inner half of their course they are nearly straight, but usually describe in the rest of their length great flexuosities resembling the sinuous disposition of that part of the vas deferens which is nearest the epididymis. The broad ligament serves as a long mesentery to the oviduct, allowing it to perform very extensive movements. It is not rare to find the tube doubled up, either before or behind, and bound down by pathological adhesions. These accidental adhesions give to the pavilion of the tube a direction alto- gether different from the normal one. The tubes may be dragged into a hernia with the ovaries. And the uterus cannot change its position without drawing at least the inner end of the tube along with it. From its form the tube was likened by Fallopius to a trumpet ; it begins from the uterus as a canal of extremely fine bore (see Fig. 3, p. 21), gradually enlarges, and ends by an extremity opening out like a funnel, named the pavilion of the trumpet. The internal orifice, very narrow, leads into the uterine cavity ; the outer orifice opens into the peritoneal cavity, and here presents the solitary example in the human organism of a direct communication between a mucous and a serous cavity. Around this free orifice, which is a little more contracted than the portion of tube immediately behind it, the pavilion is developed. This is a membranous prolongation surrounding the orifice as the corolla of a flower surrounds the stamens and pistils ; it is cut or divided into fringes or irregular and folded festoons, whence the name oi fimbriated extremity, or the quaint metaphorical designation of morsus diaboli. The largest of the fimbriae are themselves subdivided or notched into smaller fimbrise. To see this disposition well the tube must be plunged into water. The inner surface of the fimbriae pre- sents longitudinal or oblique folds, very prominent, and which are pro- longed into the interior of the oviduct. The number and dimensions of the fimbriae are very variable ; sometimes they scarcely exist : then the edge of the pavilion looks simply festooned ; sometimes they are very large, measuring as much as an inch in length, and are so numer- ous as to quite conceal the mouth of the oviduct. Often the base of the fimbriae is pierced with holes. One fimbria is especially re- markable by its size ; it constitutes the posterior part of the corolla, and numerous secondary fimbriae are developed on its borders. It is turned down from within outwards, and is supported by a small liga- ment — the tuho-ovarian ligament — which extends from the pavilion to the outer extremity of the ovary, fixing the one to the other. A curious arrangement, described by Deville, is that this long and broad fringe is doubled up to form a channel open below and behind. Ac- cording to Richard, the tubo-ovarian fringe is not constant. The ovi- duct may be divided into three portions : that which is contained within the uterine wall ; the free portion or body of the tube, and the pavilion. The intra-uterine portion is about 00.4 inch long; it is straight, or describes a slight curve with an inferior concavity. Its cavity is uni- form and very narrow; it prolongs outwardly the kind of horn or funnel, which tlie uterine cavity presents at its upper part, on either FALLOPIAN TUBES. 31 side. The orifice of communication between the uterus and the tube — ostium uterinum — is usually filled with thick mucus, which prevents liquid injected into the uterine cavity from passing into the cavity of the peritoneum. It forms a well-defined boundary between the uterine and the tubal mucous membrane. The first is smooth, polished, rosy, and pierced with numerous glandular openings; the second is pale, white, and folded in its longitudinal direction. The body of the oviduct springs from the summit of the superior angle of the uterus, and is immediately embraced in the middle wing of the broad ligament ; it is straight at its origin for about two inches ; it then forms curves variable in degree and number, generally the more marked in proportion to the youth of the subject. These con- volutions are independent of the peritoneal investment; they persist, even when the tube is inflated after being stripped. The inner or rec- tilineal portion of the tube is narrower than the outer or undulating portion. The first, sometimes called the isthmus, has a diameter of 0.8 in. to 0.12 in.; the second, which Henle calls the "ampoule," is slightly flattened from before backwards, and measures .25 in. to .30 in. in diameter or more. Often it narrows a little near its termination. The transition between the two portions is commonly very abrupt. The most external convolution of the tube presents a very constant arrangement; its convexity is directed upwards and outwards: in other words, the peripheral extremity of the oviduct is turned at first down- wards, then backwards, so that the abdominal orifice looks backwards and downwards. Whilst the inner portion of the tube is scarcely large enough to admit a hog's bristle, the outer portion receives easily the extremity of a moderately-sized sound. The walls of the oviduct are in contact, and the cavity, completely obliterated, presents on trans- verse section the figure of a star, the rays of which penetrate between the numerous longitudinal folds of the mucous membrane. In the uterine portion of the tube the bore is capillary, and it is only with great trouble that one succeeds in seeing the ostium uterinum with the naked eye. The tube expanding on the one side into the cavity of the uterus, and on the other into that of the peritoneum, it follows that the two cavities communicate, a disposition which has favored the develop- ment of peritonitis by permitting the passage of irritating matters from the uterus along the tubes into the peritoneal cavity. It is not rare to find the abdominal orifice obliterated. In such cases the tube is dilated in the form of a cone, with its base directed outwardly ; its inflexions then become very marked. The whole inner surface of the oviduct is of a pale pink color, and is marked by longitudinal folds of unequal sizes, which touch by their surfaces, converting the channel of the tube into a series of capillary tubes. These folds, always parallel to the axis of the tube, begin in the intra-uterine portion by two or three small ridges, and become more numerous and prominent at the inner portion of the body of the tube, and are developed to the greatest extent in the expanded portion of the canal. (See Fig. 3, p. 21.) They project in variable degree : some scarcely rise above the level of the mucous membrane; others are 0.9 in. in height. On transverse section they sometimes resemble csecal glands ; at others, arborescent villosities. In 32 ANATOMY, the latter case, the principal folds are provided on both surfaces with secondary folds, which themselves may be covered with tertiary folds. Often, also, the surface of the folds present linear reliefs, like project- ing ridges, united together, and inclosing irregular spaces or pits. 'No valves are met with either in the course or orifice of the oviduct. In its narrow portion the tube is firm to the touch, inextensible, and much resembles the vas deferens ; in its large portion it is collapsed upon itself, and its walls are thin and extensible. Richard has ob- served an interesting feature in the history of the oviducts. It is not very rare to meet on the surface one or two small supernumerary pavil- ions, formed like the terminal pavilion by the mucous membrane of the tube cut up into fringes, and pierced by a hole opening into the canal. The tube is composed of three coats : an external, or serous ; a middle, or muscular; and an inner or mucous coat. The peritoneum supplies the serous tunic, which adheres but loosely to the tube, and only sur- rounds three-quarters of its circumference. The adhesion becomes closer at the level of the pavilion, the peritoneum of which clothes the outer surface, and is continuous with the mucous membrane at the free edge of the fringes. In the very loose cellular tissue which unites the serous coat to the muscular coat, small longitudinal muscular bundles are sometimes met with. The muscular coat of the oviduct forms a white membrane of dense and close texture. Richard and Robin have doubted the muscular character of the middle coat. It is affirmed, however, by Kolliker. Dr. Arthur Farre has found well-marked, smooth, muscular fibres in the genera, Simia, Bos, Cervus, and in the pregnant dolphin, and also in the human female during middle life. It is composed chiefly of annular fibres : on its surface some bundles of longitudinal muscular fibres, which seem to proceed from the muscular fibres of the uterus, are attached. Where the tube traverses the uterine wall, the muscular coat of tlie oviduct preserves its own character quite distinct from that of the uterus. The mucous coat, which alone forms the numerous folds of the inner surface of the oviduct, presents o. funda- mental stratum formed by connective tissues and longitudinal muscular fibres, and by a vibratile or ciliated epithelmm. It contains neither glands nor villi. The cilia which cover the free surface of the cells execute movements the effect of which is to carry on liquids and the ovum to the uterine cavity. This is one function of the tube; the other is to receive and transmit towards the ovary the fecundating principle of the male. If the tubes are closed by ligature or by disease sterility is the consequence. The ovum may be fecundated and arrested in the tube, and be developed there, constituting tubal gestation. The pavilion of the tube is charged with the duty of embracing the ovary at the moment of dehiscence of the Graafian follicle, and of applying itself closely to the point whence the ovum detaches itself. Hence it follows that any adhesion of the ovary or of the tube which prevents this relation is a cause of sterility. The Fallopian tubes, like the uterus and vagina, result from the development of the canals of Miiller, which stretch over the surface of the Wolffian bodies, with which they have no connection, and terminate at the pedicle of the allantois, unit- THE UTERUS. 33 ing together in the median line. At first, the uterine tubes are rela- tively more developed than the body of the uterus ; so much so that they seem to be continuous one with the other at their uterine ends. They preserve this relative development until the epoch of puberty. The uterine tubes are much more flexuous during the last two months of intra-uterine life than at any later period. THE UTERUS. The Uterus {utriculus, a bag) is the organ of gestation and of partu- rition. It is a hollow organ possessing thick muscular walls, destined to receive the fecundated ovum, to supply to it the materials necessary for its development, and to expel it when mature. Fig 8 Longitudinal section of the pelvis — (after Breisky). The uterus is situated in the cavity of the pelvis, in the median line between the bladder and the rectum, beneath the mass of intestines, and above the vagina (see Fig. 8). It is held in its position slung or suspended by different folds of the peritoneum and by muscular bun- dles, principally situated in these folds. Closely connected also with the bladder, Fallopian tubes, rectum, and vagina, these structures all concur in maintaining the position of the uterus. The ligaments of the uterus are six in number, three on each side ; namely, the broad liga- ments, the round ligaments, and the utero-sacral ligaments (see Fig. 1, p. 19). The broad ligaments are two folds, formed by the peritoneum, 3 34 THE UTERUS. and stretched across the cavity of the pelvis, extending from the borders of the uterus to the sides of the pelvis, and thus, with the uterus sus- pended between them, forming a septum which divides the pelvis into two parts. The broad ligaments are of quadrangular form, their inner border is attached to the border of the uterus, or more correctly speak- ing, the two laminse which form them separate to receive the uterus in the space between them. It is to be remarked that the broad ligaments are attached on a level with the anterior aspect of the uterus, so that the Avhole thickness of the uterus lies behind the ligaments. Their external border is continuous with the peritoneum which lines the pelvic cavity. At the level of their inferior border the two laminae of the broad ligament separate to line the floor of the pelvis ; a loose cellular tissue, including very little fat, is interposed at this level between the laminae, and unites them to the superior pelvic fascia. This cellular tissue is directly continuous with that which is found on the sides of the vagina and rectum below, in the iliac fossa laterally, and around the bladder in front ; it also communicates through the sciatic notch with the deep cellular tissue of the nates. This disposition is of im- portance to bear in mind in the study of the collections of blood and pus which may form in this region. The upper border of the broad ligaments is divided on either side into three secondary folds, formed, the posterior one by the ovary and its ligament, the anterior one by the round ligament, and the third or middle one by the Fallopian tube. It is this arrangement which has caused the broad ligament to be likened to the wing of the bat {ala vespertilionis). (See Figs. 1 and 3.) The middle fold or winglet is the largest and the highest, and constitutes the true upper border of the broad ligaments. These ligaments are formed of two peritoneal laminae and by an intermediate layer of cel- lular tissue, in which run the numerous vessels and nerves belonging to the uterus and ovary, as well as a multitude of muscular fibres springing from the uterus. They also inclose the remains of the Wolffian body or organ of Rosenmiiller. The muscular fibres of the broad ligament, according to M. Rouget, all rise from the sides of the uterus, and are directed towards the wall of the pelvis. They do not form a continuous layer, but their bundles of various sizes form a kind of lace- work or open canvas, mixed' with the vascular and nervous net- works, the whole covered and masked by connective tissue. M. Rouget describes the uterus and its appendages as being inclosed in a broad muscular membrane, of which the peritoneal ligaments are a depend- ency. The broad ligaments do not prevent the uterus from inclining backwards or forwards. M. Richet says they oppose flexions of the body on the neck. Although never fully on the stretch, they resist lateral deviations of the uterus. They allow the uterus to be sensi- bly lowered without being dragged. The structure of the round ligament has been carefully examined by Mr. Rainey.^ He says it is a muscle rather than a ligament, and he has shown that it consists principally of striped or voluntary nniscle. It arises by three fasciculi of tendinous fibres ; the inner one from the ' Philosophical Transactions, 1850. THE ROUND LIGAMENTS. 35 tendon of the internal oblique and transversalis muscle near to the symphysis pubis, the middle one from the superior column of the ex- ternal abdominal ring, near to its upper part, and the external fasciculus from the inferior column of the ring just above Gimbernat's ligament. From these attachments the fibres pass backwards and outwards, soon becoming fleshy; they then unite into a rounded cord, which crosses in front of the epigastric artery and behind the lower border of the internal oblique and transversalis muscles ; it then gets between the layers of the peritoneum forming the broad ligament, along which it passes backwards, downwards, and inwards to the anterior and suJDe- rior part of the uterus, into which its fibres, spreading out a little, may be said to be inserted. The striated muscular fibres are not confined to the surface of the round ligament, but form almost the whole of its substance, and are more particularly distinct near to its centre; nor do they extend com- pletely to the uterus, but after passing between the layers of the broad ligament to about an inch or an inch and a half from its superior part, they gradually lose their striated character, and degenerate into fascic- uli of granular fibres mixed with long threads of fibro-cellular tissue. Mr. Rainey found a similar structure in the monkey, dog, sheep, and cow. The round ligaments contain also numerous vessels, also some nerves and absorbents. The arterial trunks are large, but the capillaries into which they ultimately divide have the same size and arrangement as those of ordinary muscle. The lymphatics are situated on the outer side of the ligament; their glands are sometimes of considerable length, and even pass through the external abdominal ring ; connecting all these parts together there is a considerable quan- tity of areolar tissue, especially where the striated muscular fibres are absent, or are about to terminate. Mr. Rainey, reasoning from the structure of the round ligaments, says the presence of voluntary muscular fibre proves that they are not fitted to serve as mechanical supports to the uterus ; but that their real use is in some way or other to act in copulation. Considering the position of their points of attachment and the direction of their fibres, it is evident that their combined action will bring the uterus nearer to the symphysis pubis, and thus tend to draw it somewhat from the vagina, in this way increasing the length of the latter. Now the only way in which it can be imagined that these changes assist in sexual intercourse, is by their causing the semen to be attracted into the upper part of the vagina and vicinity of the os uteri. This opinion, as to the use of the round ligaments, had been enunciated by Velpeau and Maygrier. The round ligament also contains a great number of vessels, espe- cially veins, which may become varicose, says Cruveilhier, particularly at the level of the external orifice of the inguinal canal, where they have sometimes simulated a hernia. In the foetus, and occasionally even after birth, the round ligaments are accompanied in the inguinal canal by a prolongation of the peritoneum, quite analogous to that which accompanies the spermatic cord. This diverticulum, known under the name of the canal of Nuck, sooner or later becomes obliter- 36 THE MOVEMENTS OF THE UTERUS. ated. But sometimes this obliteration does not take place, and this explains the frequency of inguinal hernia in women. The round liga- ments are never on the stretch, and cannot resist displacements of the uterus. The anterior or utero-vesical ligaments are two lateral folds of peri- toneum, containing bundles of fibrous tissue. They are found where the peritoneum is reflected forwards on to the bladder, opposite the point of junction of the body and neck of the uterus, and from the lateral boundaries of the utero-vesical peritoneal pouch. The posterioi' or utero-sacral ligaments extend from the lower part of the body of the uterus to the outer sides of the sacrum, enveloped by ■peritoneum ; they form two semilunar or falciform folds — the folds of Douglas ; their inner borders are concave and sharp, and pass on to the .sides of the rectum, forming an oval opening, which leads to a cavity formed by the recto-vaginal depression of the peritoneum. These ligaments, and the pouch between them (Douglas's sac), are well seen when the uterus is drawn forwards. The utero-sacral ligaments are composed of smooth, muscular fibres, which spring from the uterus, and of a peritoneal investment. The experiments of Malgaigne seem to demonstrate that these ligaments constitute the princif>al obstacle to the falling of the womb towards the vulva. When traction is made upon the cervix uteri, these ligaments are immediately seen to be tight- ened ; when divided, the uterus sensibly drops, but is soon arrested by the broad ligaments and the resistance of the floor of the pelvis, chiefly by the floor of the peritoneum, which is reflected from the walls of the pelvis over the bladder, uterus, and rectum. M. Richet believes that the utero-sacral ligaments further serve to prevent the uteras from being driven forwards upon the bladder, thus preserving this organ from the severe compression to which it would otherwise be subjected. The extent and directions of movement of which the uterus is capa- ble form an important subject of study. The first question to determine is, AYhat is the normal position of the uterus ? A line drawn from the upper margin of the symphysis pubis to the lumbo-sacral articulation will strike the upper margin of the fundus of the uterus. Another line drawn from the lower border of the symphysis pubis to the lower margin of the fourth sacral vertebra, will touch at its middle the point of the cervix (see Fig. 8). The movements of the uterus are limited by its connections, and are influenced by the changes of condition of the surrounding organs. The greatest amount of mobility is enjoyed by the fundus. The cervix, being bound to the bladder and vagina, enjoys a more limited amount of motion. The fundus may be thrown backwards or forwards, and thus acting as a lever it will throw the os in the opposite direction. The fundus does not move round the os exactly as upon a pivot, but the os is projected a little forwards or backwards whenever the fundus moves in the opposite direction. Distension of the bladder will throw the fundus backwards ; loading of the rectum will ])ress the fundus forwards and downwards. In retroversion of the fundus of the uterus, enlarged by gestation or other causes, the cervix may be driven so firmly against the symphysis pubis as to close the urethra ; and as the base of THE MOVEMENTS OF THE UTERUS. 37 the bladder to which the cervix uteri is attached has a certain amount of mobility, in anteversion of the body of the uterus, the cervix may be carried back close to the promontory of the sacrum, dragging the attached wall of the bladder with it. But the upward mobility of the part of the bladder to which the cervix is united is limited ; hence it happens that when the fundus is thrown backwards the cervix, held down in some degree by its vesical attachments, becomes bent, so that the OS looks downwards, instead of being projected forwards exactly in a line with the axis of the fundus. There is one condition in which the whole uterus is driven forwards closely behind the pubes. This is when a considerable accumulation of blood takes place in Douglas's pouch. In this case — retro-uterine hsematocele — the collected blood behind the uterus may be felt as a tumor projecting in the fundus of the vagina, and also by the rectum. In addition to the backward and forward or see-saw movement, the uterus may move to either side. Here again it is the fundus especially that is displaced. These lateral movements are restricted somewhat by the broad ligaments. It must, however, be remembered that there exists commonly a certain lateral obliquity. Tlie fundus is generally inclined a little to the leftside; and this left lateral obliquity is usually increased during pregnancy. It may be due to the situation of the rectum in the left side of the pelvis. Another movement is upwards or downwards. The pressure of the abdominal viscera may carry down the entire mass of the pelvic viscera towards the perineum, or the uterus may be elevated slightly by up- ward pressure on the cervix. Some amount of alternate elevation and depression of the uterus takes place normally, under the influence of respiration and of volun- tary muscular exertion. On inspiration, the entire mass of abdominal viscera is forced downwards, pressing the uterus before it. On expira- tion there is a general movement of collapse towards the centre of the body, under the influence of atmospheric pressure. This, of course, bears most directly upon the external soft parts. The perineum and vulva are pressed inwards, and the uterus rises towards the abdomen. Under the influence of defecation, again, or of any powerful muscular exertion in which the chest-walls are fixed, the uterus is driven down- wards ; sometimes, indeed, so violently that complete prolapsus has been thus induced. I have known complete prolapsus of the uterus occur in a virgin, under the violent efibrts of epileptic convulsions. The descent of the uterus, anterior wall of the vagina, and base of the bladder, is very obvious, if vomiting or coughing occur during an ex- amination by speculum. The instrument is easily driven out, as the OS uteri is often brought quite down to the vulva. This observation proves that the so-called ligaments of the uterus exert but a small in- fluence in preventing prolapsus. All these movements may be verified by manual examination. By placing the tip of a finger of one hand on the os uteri, as in examina- tion per vaginam, and applying pressure upon the fundus, by the other hand, through the abdominal wall above the pubes, the cervix may be 38 THE MOVEMENTS AND AXIS OF THE UTEEUS. felt to move about according to the direction of the pressure applied by either hand. The true Axis of Movement of the Uterus. — The centre around which the chief movements take place is, of course, its most fixed point. This is the anterior part of the supra-vaginal portion of the cervix, which is closely connected with the base of the bladder (see Fig. 8, Breisky's section, p. 33). At this part the uterus is held, whilst its two extremities, body and vaginal portion, are free. Hence the move- ments of which the uterus is capable are relative and general. The first order of movements are those in which the uterus inclines back- wards or forwards, or to either side. The second order, or those in which the uterus moves upwards and downwards, can only be accom- plished simultaneously with corresponding movements of the base of the bladder. The organs move en masse, preserving more or less com- pletely their relative positions, as when the rectum is distended by fecal accumulations, or, when empty, it retreats. The Direction of the Uterus. — The longitudinal axis is directed ob- liquely from above downwards, and from before backwards ; that is, it is nearly coincident with the axis of the brim of the pelvis, and forms with the axis of the vagina an obtuse angle. It follows that the fundus of the uterus looks upwards and forwards, its apex, or the os, back- wards and downwards (see Fig. 8). This, the normal direction, is, however, subject to variations, which cannot be always regarded as of pathological significance. As a general fact, it is to be observed that the connections of the uterus are loose and extensile, and permit the organ to float in the cavity of the pelvis, performing more or less extensive movements. The ease with which the uterus can be drawn down towards the vulva in certain surgical oj^erations, and the displacement which it undergoes during pregnancy, when it rises into the abdomen, are proofs of its great mobility. This property is turned to account to facilitate ex- ploration, and the detachment of the ovum in cases of hemorrhage in abortion. For these purposes strong pressure is made upon the fundus by the hand applied to the lower part of the abdomen. There is one deviation from the standard axis of the uterus which appears to be nearly constant : it is that in which it takes an oblique direction from right to left. It is thought to depend vipon the presence of the rectum on the left side of the pelvis. During pregnancy this inclination is much exaggerated ; it corresponds with the most usual position of the foetus, that in which the occiput is directed to the left cotyloid cavity of the mother. MM. Boulard, Verneuil, Follin, H. Bennet, Richet, Arar, and others, have made very jjrecise observations, which establish the fact that the uterine axis is not a straight but a curved line, that it is bent about the middle, presenting an anterior concavity. In introducing the uterine sound it is therefore proper to give a small curvature to the instrument, and to make the point de- scribe a gradual curve forwards after passing the os uteri externum. In the human subject the uterus is single ; in most animals it is double. The so-called double uteri observed in the human species are in reality only bifid or divided uteri, depending upon an arrest of THE SIZE AND WEIGHT OF THE UTERUS. 39 development. The bifid character may be limited to the body, or may extend to the cervix, and even to the vagina. The nterus may even be absent. In one case I failed, after the most minute exploration, to discover a trace of such an organ. But most commonly, where dissec- tion has been instituted, a rudimentary uterus has been discovered be- tween the rectum and the bladder. The abnormal forms of the uterus will be described with its patho- logical conditions. The size of the uterus varies according to the age and certain physio- logical conditions. It is very small before puberty, the neck predomi- nating over the body (see Fig. 9). When menstruation sets in it grows greatly, and it enlarges a little at every period, returning during the intervals to the ordinary size. Pregnancy exerts a more durable in- fluence ; after delivery the uterus commonly retains an increased bulk. In old age the uterus shrinks, so that it is sometimes reduced to the size presented in new-born children. uterus and appendages of an infant — (after A. Farre). a, cavity of body laid open; 6, cavity of cervix ; c, anterior lip of the cervix ; d, left ovary opened ; e, Fallopian tube ; /, right ovary ; ff, internal os uteri, marking the division between the body and cervix. The development of the uterus is sometimes imperfect. It may re- tain the dimensions and other characters of immaturity. This imper- fection may bear upon the body or upon the cervix. In the latter case, the part which projects into the vagina is often more conoid than natu- ral, and the os externum is a very small round opening which barely admits the uterine sound. In these cases there is also commonly pres- ent a greater curvature of the uterus, sometimes amounting to angula- tion at the union of the body and cervix. This condition is usually associated with sterility, dysmenorrhoea, or menorrhagia, sometimes amenorrhcea, and it may even lead to menorrhagic eiFusions into the peritoneum, by opposing the free natural exit of the menstrual fluid. The weight of the uterus in girls at the age of puberty is from 360 40 THE DIVISIONS OF THE UTERUS. to 1000 grains ; from 1200 to 1800 grains, in women who have borne children ; it may be reduced to 100 or 200 grains in old women. At the term of gestation it may weigh from 26 ounces to 52 ounces. The shape of the uterus is that of a pear, or rather of a cone flat- tened from before backwards ; it is divided into body and neck. A narrowing, or isthmus, marks the boundary between these two parts. This isthmus is very marked in infants ; it diminishes, sensibly at pu- berty, and is still more indistinct after several pregnancies. The vagina being inserted on to the neck of the uterus, divides it into a vaginal portion and a supra-vaginal portion (see Fig. 10). Fig. 10. Fig. 11. Showing the regional divisions of the uterus — (after A. Farre). A'ertical section of the uterus parallel with its lateral border — (after A. Farre). Fig. 10. — a, the fundus; a, a, b, b, mark the body of the uterus; b, b, c, c, mark the cervix ; 6, the OS uteri. Below c, c, which marks the reflection of the vagina, is the vaginal portion. Fig. 11. — a, anterior;^, posterior, lip of cervix ; i, internal os uteri- va, vagina;/, fornix, or posterior pouch of fundus of vagina; c, loose connective tissue immediately above the fornix ; r, point of pos- terior reflection of the peritoneum on to the rectum, forming the retro-uterine pouch or space of Douglas ; 6, 6, line of attachment of the cervix to the bladder. The peritoneum ceases at the upper h in front. To study the uterus thoroughly, it is necessary to describe two sur- faces, the anterior and the posterior; two lateral borders, an upper border ov fundus, and an inferior extremity, perforated, projecting into the vagina, called the vaginal portion of the neck, with the os tinea'. In its upper three-fourths the anterior surface is slightly convex, and smooth like all parts covered with peritoneum, and is in relation with the posterior surface of the bladder, from which it is often sepa- rated by coils of small intestine. When the bladder is full, the uterus is pushed away from the anterior abdominal wall ; hence the precept, THE RELATIONS OF THE UTERUS. 41 always to empty the bladder before exploring the uterus through the abdomen. In its lower fourth the anterior surface of the uterus is in direct relation with the base of the bladder, to which it is united by a loose cellular tissue. This relation explains the frequency with which cancerous affections of the uterus spread to the base of the bladder. This portion of the pelvic cellular tissue is also especially liable to be- come inflamed from injury received during labor and to be the seat of abscess (see Fig. 11, 6, b). The posterior surface of the uterus is covered by peritoneum through- out its whole extent. It is in mediate relation with the anterior sur- face of the rectum, from which it is said to be often separated by folds of small intestine. But Claudius of Marburg* says that in the living subject the uterine sound passed into the uterus may always be felt by the finger in the rectum, showing that Douglas's sac is not filled by intestine. In the dead subject frozen, the uterus with its broad liga- ments and ovaries is mostly found lying as close to the posterior wall of the pelvis as the lungs are to the ribs. The rectum passes close by the left border of the body of the uterus. Having examined sections of many frozen subjects, he concludes that there is always anteversion, anteflexion, or antefraction of the uterus when intestinal loops are pres- ent in Douglas's sac. My own observations confirm those of Claudius. The anterior and posterior walls of Douglas's sac are always in close apposition in the normal condition. The posterior surface is more convex than the anterior, and can be explored by the finger introduced into the rectum. The lateral margins of the uterus are slightly concave, thick, and situated between the two laminse of the broad ligaments. They are in relation with the trunks of the uterine arteries, the venous plexuses, the nerves, and the cellular tissue confined within the thickness of the broad ligaments. This cellular tissue is the frequent seat of inflamma- tion and abscess after labor. The upper border or fundus is convex, thick, rounded, and forms the base of the flattened cone which the uterus represents. Clothed with peritoneum and covered with the coils of the small intestine, the fundus of the empty uterus never rises to the level of the brim of the pelvis; it is therefore only in the diseased state or during pregnancy that it is possible to feel it by the fingers applied to the hypogastrium. In the imparous woman the upper border is nearly straight and on a level with the Fallopian tubes ; after one or more pregnancies, it always remains convex, being more raised in the middle than near the origin of the tubes. The inferior extremity of the uterus is the apex of the uterine cone. The OS tincce, or vaginal portion, has the form of a rounded cone. It usually projects 0.25 in. to 0.5 in., but in certain pathological states it may be lengthened so as to reach the vulva or even to protrude ex- ternally. Caseaux says the length of the vaginal portion diminishes in proportion to the number of pregnancies, and may even disappear altogether in women who have had many children. But this disap- 1 "Med. Times and Gazette," 1865. 42 THE CAVITIES OF THE UTERUS. pearance is commonly due to senile atrophy. The apex is pierced by an opening which leads to the cavity of the uterus. This opening, the OS externum or os tincce, looks a little backwards. In the virgin it is a transverse fissure, bordered by two lips, one anterior, the other pos- terior, both smooth, the anterior being thicker and more prominent than the posterior (see Fig. 12). To the touch, says Cruveilhier, the Fig. 12. Fm. 13. Virgin os uteri and vaginal portion of the cervix — (after A. Farre). The u^ uteii in old OS tincse gives the same sensation as the lobule of the nose. At the menstrual epoch the neck is a little gaping. In women who have had children the os externum uteri represents a larger fissure, often large enough to admit easily the end of the index finger ; the lips are thicker, uneven, and often present notches, the remains of the rents they have undergone during labor. One of these notches is almost always seen towards the left commissure, which is explained by the frequency of the left occipito-anterior position. Sometimes the portion of the uterus which projects into the vagina quite disappears. The vagina then terminates in a cul-de-sac, at the bottom of which is felt only a contraction separating the cavity of the Fig. 14. The uterus in old age, showing a return to the infantine proportions between the body and cervix (after A. Farre), half natural size ; o, o, the shrivelled ovaries. vagina from that of the uterus. This condition is most frequent in old age. The Cavity of the Uterus. — The uterus is hollowed by a cavity very small in proportion to the volume of the organ. Excepting during pregnancy, and certain morbid states, the walls of this cavity are always THE CAVITIES OF THE UTERUS. 43 ill contact. It represents an irregular canal, divided by a sort of hour- glass constriction in the middle into two parts : the one upper, flattened out transversely, is the cavity of the body of the uterus ; the other, in- ferior, fusiform, is the cavity of the neck of the uterus. The constricted part which separates the two cavities is the os uteri internum, or isthmus of the uterus (see Fig. 10). The cavity of the body is triangular, and has an orifice at each angle : one inferior, which communicates with the cavity of the cervix, and one at each upper angle, which lead to the Fallopian tubes. The uterine orifices of the tubes are situated at the bottom of the funnel- FiG. 16. Half natural size. Shining of the walls in old age, and return to the triangular form of the infantine and undeveloped uterus — (after A. Farre). Natural size of cervix laid open — (after Hassall and Tyler Smith). shaped cavities, which are vestiges of the jjrimitive division of the body of the uterus into two halves or horns. This bifidity, normal in the lower animals, is sometimes observed in the human species. The three borders of the uterine cavity are convex inwards. In the mul- tiparous uterus the cavity of the body is more developed, its borders are less convex or nearly straight, the upper angles are enlarged, and the cavity of the neck has lost in length. The cavity of the neck of the uterus is cylindroid ; flattened from before backwards, slightly enlarged at the middle, it presents on either wall rugee, or elevations, forming a tolerably regular series, known as the lyra or arbor vitce (see Fig. 16). On each of these walls is disting-uished a vertical column runnino; along; the entire length of the neck, swelling out above and continuous with the median column of the body of the uterus. The two columns of the neck do not descend quite so low as the os externum, but stop a little above the circle of the orifice, which is always smooth (see Fig. 16). M. Guyon has observed that these columns are never situated exactly on the median line; the anterior one is a little on the right, the pos- terior one a little on the left ; so there results a kind of dovetailing of the walls of the neck, especially marked at the upper part of the cavity. From the two borders of each column a certain number of smaller folds proceed, at more or less acute angles, and are directed upwards and outwards, resembling a fern leaf. These oblique folds have their free border directed downwards and inclose furrows or pits, in which are 44 DIMENSIONS OF THE UTERUS. seen the gaping orifices of the uterine glandules. Sometimes they bifurcate. The arbor vitse is commonly much smoothed down after the first labor. But this is not constant, since the arbor vitse is some- times found intact after several labors. The isthmus is generally 0.20 in. to 0.25 in. long; 0.16 in. across, and 0.12 in. from before backwards in imparous women. In multiparse the length of the isthmus, which is always included in the measurement of the body, is reduced to 0.16 in. and even less. A female catheter is commonly arrested by the constriction of the isthmus, and only pene- trates it under a certain pressure. After the cessation of menstruation the isthmus contracts considerably, and often is completely obliterated. The orifice of the os externum also I have frequently found obliterated in old women. M. Guy on says this obliteration always coincides with the obliteration of the isthmus. This, however, I have found to be far from constant. The inner surface of the body of the uterus is much more vascular than that of the neck. This diiference is especially marked in women who have died during menstruation. The lualls of the uterine cavity, apart from pregnancy, are 0.40 in. to 0.60 in. thick. The thickness is greater in women who have had children than in the virgin. The thinnest part corresponds with the insertion of the tubes. The walls of the neck are thinner than those of the body. The dimensions of the uterus have been determined by M. Richet in the following manner : The uterus remaining intact he first measured the cavity by the sound, then having removed the uterus from the pelvis, he split it from before backwards along the median line, and measured it again from the neck to the fundus of the uterine cavity first, and then from the neck to the upper border of the organ. He obtained the following dimensions : The vertical diameter of the uterus, . Vertical diameter of the cavity, Transverse diameter of the uterus, . Transverse diameter of the cavity, . M. Guyon,^ as well as Richet, has examined the uterus at the different physiological epochs, and both find that the uterus attains its maximum during the menstrual periods, and its minimum in the intervals. It is important in practice to bear in mind that during the five or six days which precede and follow the catamenia, the uterine diameters will generally exceed the means, whilst during the intermediate period they will fall a little below. The vertical diameter of the uterus is divided unequally between the body and the neck. In the virgin the longest portion belongs to the neck. In multiparous women, the two diameters are nearly equal, the difference, if any, inclining in favor of the body. In multiparse the body continues to grow, whilst the neck has undergone an absolute or comparative shortening, which reduces its vertical diameter in some cases below that of the body. 1 Etudes sur les cavites de 1 'uterus, thbses inaug., 1858. the virgin. In women. In mothers. 2 20 in. 2 52 in. 2.72 in. 1.80 in. 2.20 in. 2.44 in. 1.24 in. 1.80 in. 1.90 in. 0.60 in. 1 08 in. 1.24 in. THE CAVITIES OF THE UTERUS. 45 CHAPTER III. THE SHAPE OF THE CAVITIES OF THE UTERUS. The shape of the cavities of the body of the uterus and of its cervix, and the relations of their walls, are best demonstrated by longitudinal sections, and by transverse sections made at different points. If we first make a vertical section in the antero-posterior direction, as in Figs. 8, 11, we see that the walls of the body of the uterus lie in contact. The cavity is represented by a line running from the fundus to the cervix. This cavity is, under ordinary circumstances, potential rather than actual. But when fluids are retained, or a solid body is introduced into or grows in the space between the two walls, the cavity is capable of enlarging to an almost indefinite extent. This enlarge- ment of the cavity is always, at least when considerable, effected chiefly by gradual growth of the uterine walls. When the uterus is emptied this growth ceases, a process of absorption and involution takes place ; and generally the triangular form of the cavity is resumed, the anterior wall being again flattened upon the posterior. Where any distinct hollow remains, it may be assumed that there is more or less habitual retention of fluids, and that there is some pathological condition of the mucous membrane, or obstruction at a lower point of the canal. This contact of the walls of the body of the uterus, together with the mucous plug usually filling the cervix, and the closing of the vagina by approximation of its walls, prevent the intrusion of air into the cavity, and thus obviate the foulness that would otherwise result from decomposition of the secretions. The cervical cavity is fusiform in some cases, conical in others, ac- cording to the extent of the opening of the os externum. Although Fin. 17. Ad uat. — (after A. Farre.) Section made through cavity of the body of the uterus above the entrance of the Fallopian tubes. the columns of the arbor vitce are so adapted as to dovetail with each other, there is usually a distinct cervical cavity, the walls not being commonly in close apposition. If we next make a longitudinal section transversely, so as to separate 46 THE CAVITIES OF THE UTEHUS. along the entire length the anterior half of the uterus from the posterior, we see the triangular shape of the cavity of the body of the uterus, with its two superior angles drawn out funnel-wise, to be continuous with the Fallopian tubes, and its inferior angle contracting to be con- (After A. Farre.) Section through centre of cavity. Fig. 19. (After A. Farre.) Through centre of cervical canal. tinuous at the isthmus with the canal of the cervix. Below the isthmus is the cervical cavity, fusiform or conical. In multiparse, in whom the OS externum is a wide fissure, the conical form is more manifest in this section than in the antero-posterior section, from its giving the whole width of the os tincse : but even in these the base of the cone at the os tincse is commonly more contracted than the middle part of the canal. In nulliparse the os externum is still more contracted, so that the canal approaches the fusiform character. In many cases of sterility. CASTS OF CAVITIES OF UTERUS. (AFTER GUYON.) Fig. 20. Fig. 21. 1. Uterus of virgin, ret. 17. 2. Multiparous uterus, set. 25 — 30. a. Narrowing and lengthening of isthmus. 6. Dilatation of cavity of neck. c. Narrowing of os externum. the OS externum is a mere round hole no bigger than the os internum, and the central part of the canal is then generally more dilated than usual, so that it is completely fusiform. THE CAVITIES OF THE UTERUS. 47 A series of horizontal sections, made through the walls of the body, will exhibit a narrow line marking the contact of the anterior wall flattened upon the posterior ; made through the isthmus or os uteri internum, a round hole of about the calibre of a No. 8 or 9 catheter, the fibres of the wall disposed in a circular or sphincteric manner around it ; and at the margins, right and left, the gaping orifices of the vessels which enter the uterus in greatest size and number at this level; made lower down across the cervical canal, the cavity of this canal is seen somewhat flattened antero-posteriorly. (See Fig. 19.) CASTS OF CAVITIES OF UTERUS. (AFTER GUYON.) Fig. 22. Fig. 23. 3. Multiparous uterus, set. 42. a. Dilated isthmus. 6. Marked narrowing of os externum. 4. Multiparous uterus, set. 35. a. Dilatation of cavity of body. 6. Narrowing and torsion of isthmus. There is another way of representing the shape and size of the uter- ine cavities, namely, by taking casts or moulds with wax or plaster of Paris. The information thus acquired has a certain value, but it is apt to mislead. Liquid poured into the uterus distends the cavity, and when it has set we get a mould of a cavity such as does not normally exist. But in the case of morbidly dilated cavities, these casts give more accurate representations. 48 THE TISSUE OF THE UTERUS. CHAPTER IV. STEUCTUKE OF THE UTEEUS. The structure of the uterus must be examined under the opposite conditions of vacuity and of fulness. A serous investment pertaining to the peritoneum, a proper tissue of muscular nature, an internal or mucous membrane, vessels and nerves, are the constituent parts of the uterus. A. The External or Pe7'itoneal Memb^xine. — The peritoneum, which has invested the posterior face of the bladder, is reflected over the an- terior surface of the uterus, covering, however, the upper three-fourths only, the lower fourth being in immediate relation with the bladder. It passes over the fundus of the uterus, clothes the posterior surface throughout, and is prolonged for a short distance down the vagina, be- low the utero-sacral ligaments, and then is reflected upwards over the rectum. It is the transverse extension of the peritoneum which con- stitutes the hroacl ligament. In the space which separates the bladder from the uterus, this membrane forms two very small falciform folds, which bear the name of vesico-uterine ligaments. Two other folds, much larger, stretching from the posterior aspect of the neck of the uterus to the sides of the sacrum, constitute the utero-rectal, or utero- sacral ligaments. The adhesion of the peritoneum to the uterus, on a level with the neck and towards the borders, is very loose, but becomes closer the more we approach the median line. It is also more intimate on the posterior than on the anterior aspect. The looseness of the connection of the peritoneum at the level of the neck and borders of the uterus, explains the reason why the peritoneum so rarely shares in even considerable rents of the cervix uteri, and why the effusion of blood in such cases takes place between the tissue of the uterus and the peritoneum. It has been held that the uterus growing during pregnancy appropriates to itself the peritoneal folds of the broad ligaments, which open out to permit of the development of the organ. B. The Proper Tissue. — In the non-pregnant state, this tissue is gray- ish, very dense, very resisting, and creaks like fibrous tissue under the scalpel. If the consistency of the body of the uterus seems less than that of the neck, this is solely because the first is the more frequently the seat of sanguineous congestion. The proper tissue which consti- tutes the principal portion of the uterine wall is composed of fibres, that is, of parts disposed in a linear direction. These fibres belong to the muscular tissue of organic life. The contrary opinion was long held. But comparative anatomy, the microscope, examinations during gestation, and physiological observations, have dispelled all doubts upon this point. During pregnancy, and in consequence of the development THE MUSCULAR WALL OF THE UTERUS. 49 of tumors, or of an accumulation of liquid in the uterine cavity, the proper tissue assumes all the external characters and properties of mus- cular tissue, as it is seen in the instruments of organic life. The direction of the muscular fibres of the uterus has been the sub- ject of numerous researches. Malpighi and Monro thought there was nothing regular in the disposition of these fibres ; and in the empty state this appears to be the case. They are so interlaced and compressed, that it is in vain we seek to disentangle them. But during gestation, the muscular elements having undergone very considerable develop- ment, the mingling of the bundles becomes easier to follow. It may be admitted that the muscular wall of the uterus is formed of three layers or planes of bundles — an outer, a middle, and an inner. These three layers are not clearly defined, as is the case in the heart ; but they send communicating bundles to each other. The arrangement of these muscular bundles is by no means constant, but they, neverthe- less, always approach a determinate type. 1st. The external or superficial layer comprises a longitudinal bun- dle, or rather a broad median ribbon, and transverse fibres. The me- dian band, the looped band of M. Helie,* arises on the posterior aspect of the uterus, on a level with the union of the body with the neck, by fibres continuous with the transverse fibres. At its origin it is often overlaid by a thin stratum of these transverse fibres. Ascending over the posterior surface of the uterus, it is reinforced successively by simi- lar fibres, which are added to its bordere, and by new fibres which spring up in the openings of its primitive fibres. It then curves over the fun- dus uteri, where its fibres, hitherto parallel, proceed diverging, so that three portions may be distinguished — an inner, an external, and a mid- dle. The inner portion often crosses partially with that of the oppo- site side of the median line ; the external portion runs towards the an- gles of the uterus, and mixes with the transverse fibres. The fibres of the middle portion descend over the anterior aspect, then successively curve outwardly, to be continued with the fibres forming the round lig- aments. Sometimes the innermost fibres of this bundle reach the level of the isthmus of the uterus, and in their turn curve outwardly to min- gle with the transverse fibres. The transverse fibres form the principal mass of the external layer. On the lower half of the body they are directly transverse ; at a higher level they converge towards the angles of the uterus. Towards the median line, the most superficial fibres sometimes turn up so as to be- come longitudinal, and to be continuous with the looped bundle. The deeper fibres proceed directly from one side of the uterus to the other. Externally the superficial fibres are prolonged into the broad liga- ments, over the oviducts, and into the round and ovarian ligaments ; the deeper fibres curve round the borders of the uterus, passing from one aspect to the other. In this course they meet the arteries and veins, which they surround with contractile rings. At the same time ^ Kecherches sur la disposition des fibres musculaires de I'uterus developpe psir la grossesse. Paris, 1864. 4 50 THE MUCOUS MEMBEANE OF THE UTEEUP. the fibres pass from one plane to another, so that those which were at first superficial, become deeper as they get behind. The j^ire.s of the neck are generally transverse, but are a little oblique downwards and inwards, and often crossed on the median line. They send expansions outwardly into the broad ligament, backwards into the utero-sacral ligaments, and sometimes forwards into the utero-vesi- cal ligaments. 2d. The middle layer of the muscular fibres of the uterus forms about one-third of the uterine wall. When sections of this wall are made, it is distinguished by the great size of the vessels, principally veins, which traverse it. It is composed of muscular bundles, which cross each other in all directions, and send off frequent branches, which circumscribe more or less completely large holes or canals in which the bloodvessels are contained. This texture is the same throughout the whole body of the uterus, but is especially manifest in the region which corresponds to the insertion of the placenta. There is nothing like it in the neck. 3d. The internal layer is principally composed of annular fibres from the isthmus as far as the orifices of the Fallopian tubes. But these fibres are covered on each of the surfaces of the uterus by a broad and thick band of longitudinal fibres, forming a triangular bundle, whose base is superior, and stretches from one tubal orifice to the other; and whose apex, directed downwards, descends nearly to the OS internum uteri. It is formed of transverse fibres, which curve from below upwards, run for a certain distance in the longitudinal direction, and then again become transverse. An annular bundle, very power- ful, and always a little prominent, surrounds the os internum uteri, forming a true sphincter, which explains the habitual constriction of this orifice. Muscular rings, whose diameter goes on diminishing from within outwards, surround the infundibula of the uterine cavity. On the median line of the anterior wall, and on the median line of the posterior wall, the rings of the right and left sides meet, and even interlace. Their upper halves constitute antero-posterior arcs, which form the roof of the uterine cavity. By their inferior halves they begin the series of the transverse annular fibres. In the neck, on the middle of each wall, a branched muscular bundle gives rise to the projections of the arbor vitfe ; it rises from the middle of each wall, and forms arches right and left. Beneath this bundle, but rather deeply, the fibres are transverse or annular, and are con- founded Avith those of the external layer. C. The Internal or Mucous Membrane. — Some anatomists, and in par- ticular Morgagni and Chaussier, who observed the inner surface after delivery, have denied the existence of the uterine mucous membrane. But the microscope has set at rest all disputes upon this point. The mucous membrane, however, presents different characters in the cavity of the body and in that of the neck. 1. The mucous membrane in the body of the uterus is of a grayish or rosy white ; its surface is smooth and finely punctuated. Its thickness, in the intermenstrual period, in general does not exceed 0.04 in., and in certain points is only 0.02 in.; during the menstrual jJeriods it swells considerably, and may even exceed 0.12 in. THE MUCOUS MEMBRANE OP THE UTERUS. 51 Differing from what is usually seen in mucous membranes, the uter- ine membrane is not separated from the muscular tunic by a distinct layer of connective tissue allowing it to slide on this tunic, or at least marking the exact limits between the two tunics. These limits can, indeed, scarcely be properly distinguished by the microscope ; for a cer- tain number of muscular bundles are seen to penetrate into the thick- ness of the mucous membrane between the uterine glands. Two distinct layers compose the uterine mucous membrane ; an epi- thelial layer and a basement layer. The latter incloses in its substance glands, vessels, and nerves. The epithelium is composed of a simple layer of cylindrical cells, furnished on their free surface with extremely fine cilia, which sweep from without inwards. The vibratile epithelium is continued as far as the middle of the cervix ; below this, it is replaced by a pavement- epithelium . The basement layer is composed in the body of the uterus of an em- bryonic connective tissue, in which are seen closely packed nuclei and fibre-cells or flattened lamellse. The uterine glands are either simple or bifurcated utriculse, very analogous to the glands of Lieberkiihn of the intestines. Their length is determined by the thickness of the mucous membrane. Their width is from 0.02 in. to 0.03 in. Often the cul-de-sac, or blind extremity, is curved like a crook or twisted like a corkscrew. They open sepa- rately or in groups of two or three by an orifice 0.03 in. in diameter, at the bottom of little depressions observed on the surface of the mucous meiubrane. AVheu the membrane becomes hypertrophied under the influence of menstruation, the glandules assume a development even greater in proportion. They are formed of a very thin amorphous membrane, furnislied interiorly with a layer of cylindrical epithelium, which is only distinguished from that on the free surface of the mucous membrane by the absence of vibratile cilia. These glandules are ex- tremely numerous. Generally they are separated from each other by a distance of only 0.04 in. to 0.08 in. 2. Neck of the Uterus. — Here the mucous membrane is much thicker than in the body ; it is whiter, denser, and less friable. It is 0.04 in. thick ; but this thickness is much increased at the level of the folds of the anterior and posterior walls. The mucous membrane of the neck is furnished in its lower third or half with warty or fili- form papillae, 0.08 in. to 0.25 in. high, and which are very numerous on the external surface of the os tincse. Formed of an amorphous substance, including a multitude of nuclei, they make no projection on the surface of the epithelium. They are, however, well seen when the epithelium is removed by maceration, as in Fig. 24, a preparation made by Dr. Hassall. Between these folds are seen a multitude of round or oval orifices from 0.12 in. to 0.16 in. wide, arranged in linear series and leading to the irregular cavities lined with cylindrical epithelium. The diameter of these cavities, which occupy the whole thickness of the mucous membrane, is scarcely larger than that of their openings. They represent rudimentary follicles ; and secrete the trans- 52 THE MUCOUS MEMBRANE OF THE UTERUS. parent and viscous mucus which is usually found in the uterine neck. The mucous membrane of the neck is composed of a mucous chorion Fig. 24. (After Tyler Smith and Hassall.) Villi of the os uteri, from which the epithelium has been removed. formed almost exclusively of connective tissue, and of an epithelium formed of cylindrical cells in the upper two-thirds of the neck, and of pavement cells in the lower third. Fig. 25. (After Tyler Smith and Hassall.) Extremities of villi of os uteri, covered by squamous epithelium, showing their central deprossious VESSELS AND NERVES OF THE UTERUS. 53 We often meet, on the surface of the uterine mucous membrane, with spherical transparent vesicles called ovula Nabothi. These are simply muciparous follicles which are found in the cavity of the body as well as in that of the neck, but which especially abound in the (After Tyler Smith and Hassall.) Villi of OS uteri, covered by pavement-epithelium and containing looped bloodvessels. neighborhood of the os uteri. "When small they remain buried in the mucous membrane. They only become visible when the mucus ac- cumulates in their cavities through the obliteration of their orifices. When very largely developed they have given rise to the suspicion of serious disease. They are formed of an investing membrane of con- nective tissue, and of cylindrical epithelium ; and contain a transparent, vitreous, or colloid liquid. Vessels and Nerves : 1st. Arteries. — The arteries of the uterus spring from two sources: 1st. Some arise from the hypogastric, and take the name of uterine arteries. Placed at first on the sides of the vagina, they penetrate the broad ligaments in the neighborhood of the cervix uteri, ascend along the borders of the uterus, and anastomose with the utero-ovarian arteries. 2d. The others, not less considerable, spring from the ovarian arteries, called for this reason by Cruveilhier, utero- ovarian ; they reach the upper angles of the uterus, then descend along the borders of this organ, to anastomose with the uterine arteries. The branches furnished by the two arteries which, on either side, run along the border of the uterus, course at first under the peritoneum, surrounded by the muscular bundles Avhich proceed from the uterus ; then, after a certain course, they plunge into the substance of the muscular tissue, where they ramify and anastomose with each other, 54 VESSELS AXD NERVES OF THE UTERUS. and with the branches of the opposite side. All these branches, which are very numerous, are remarkable for tlieir corkscrew twistings. It was thought at one time that this helicine disposition was designed to favor the development of the pregnant uterus by uncurling, and be- coming straight as the uterus grew ; but, the fact is, that the arteries, eveu in advanced pregnancy, are as flexuous as in the non-pregnant state. These arteries are not distributed equally to all parts of the uterus ; the neck receives but a small number ; at the neighborhood of the upper angle of the uterus, on the other hand, the utero-ovarian artery supplies suddenly from twelve to eighteen tufts of arteries, spi- rally curled, which cover with their ramification the whole of this region. At the level of the furrow which separates the body from the neck, M. Huguier has described an arterial circle formed by the anastomoses of the arteries of the right side with those of the left. The ultimate ramifications of the arteries of the uterus are distributed in the mucous membranes. The ramuscules in this membrane are of importance as to size only in the deeper layers ; beneath the epithelium they form a capillary network, very fine and close, the interspaces of which receive the orifices of the glands. The coats of the arteries are, as Mr. Raiuey pointed out, very thick, and are apt, unless care be ob- served, to be mistaken for the proper fibre of the uterus. 2d. The veins of the uterus are remarkable for their enormous development ; they are large canals hollowed out of the thickness of the muscular substance, and frequently communicating with each other. They have been called the uterine sinuses, and INI. Rouget has de- scribed them under the name of the corpus spongiosum of the uterus. The uterine sinuses occupy all the body of the uterus, and cease abruptly at the level of the os uteri internum. The neck itself has a much less marked venous development. Between the uterine sinuses, we find in the wall of the uterus venous ducts twisted spirally, like the arteries, and which are analogous to the retce mirahiles of the gland and corpus spongiosum of the male urethra. On the lateral borders of the uterus these sinuses communicate with vast venous plexuses, situated in the thickness of the broad ligaments, and continuous below with the vaginal plexus, and above with the subovarian plexus. They have received the name of the jjamjnniform plexuses. From these plexuses proceed below, the pudic veins ; in the middle, the uterine veins ; above, the ovarian veins. These last pre- sent but very few valves, and assume full development only after puberty. 3d. The lymphatic vessels, during pregnancy and after delivery, are, like the veins, of considerable size. They form several planes in the thickness of the uterus ; the superficial are the largest. They are di- vided into two groups ; those of the neck, which run to the pelvic ganglia ; those of the body, which terminate in the lumbar ganglia. These last accompany the utero-ovarian veins. Dr. Lucas-Champon- niere^ describes a ganglion situated above the lateral vaginal cul-de-sac, 1 Lymphatiques uterins et lymphangite uterine. Bull, dc la Soc. Med. deshopi- taux de Paris. Vol. vii. THE NERVES OF THE UTERUS. 55 closely applied at the union of the body and neck. When missing, there are always networks of lymphatics closely packed. Gallard thinks this ganglion or network plays an important part in pathology, as the starting-point of puerperal and other affections. 4th. The nerves proceed, some from the renal plexuses and inferior mesenteric, to reach the uterus, being closely bound to the utero- ovarian arteries ; others, proceeding from the hypogastric plexus, are formed by some anterior branches of the sacral nerves, and by branches proceeding from the lumbar ganglia of the great sympathetic. These two plexuses anastomose in the thickness of the broad ligaments, and send oif filaments over the two surfaces of the uterus which penetrate into the substance of the organ, keeping in intimate contact with the arteries, or coursing in the spaces between the arteries. The filaments are found in greatest number at the union of the neck and body of the uterus. The existence of nerves in the uterine neck was denied by Jobert, but has been affirmed by Robert Lee, Lud. Hirschfeld, and Richet. This last anatomist says he has several times been able to trace nervous filaments as far as the middle of the neck, and everything points to the belief that the labia of the os tincse are not absolutely deprived of nerves, although it has not been possible to demonstrate them in this part. The question of the supply of nerves to the uterus has been the sub- ject of keen and protracted controversy ; and it is a source of satisfac- tion that numerous appeals to nature have been made by able anato- mists to determine the points at issue. I am not aware that any recent observer, possessing full means of investigation and bringing all the modern aids to minute dissection to the task, has confirmed the descrip- tions of Dr. Robert Lee. It would, therefore, only incumber a didactic work to reproduce the unsupported views of this autlior. The researches of Hirschfeld, Richet, Lobstein, and Boulard, conducted with unques- tionable skill and candor, all go to negative the conclusions of Dr. Lee, and to substantiate the accuracy of the descriptions of Dr. Snow Beck. The best and most impartial summary of this important matter, and which may be taken to be the latest and most authentic expression of anatomical science, is the following account by M. Boulard, adopted by Cruveilhier : 1. The nerves of the uterus are very few in number. 2. They do not increase in size during pregnancy. The principal differences, observed during pregnancy and in the non-pregnant state, bear more upon the state of the plexuses than on the volume of the nerves. 3. In the child, the elements of these plexuses, crowded together, seem to constitute a true nervous membrane ; from these there proceed very delicate nerves, which run to the uterus and broad ligaments to give off their filaments, which are entirely capillary. 4. In woman whose uterus is developed, the plexus, as Beck observed, is carried higher up ; its elements are separated, and form more or less considerable spaces ; and as to the nerves issuing from it, they only dif- fer in being longer, coinciding with greater tenuity if compared with those met with in the normal uterus of an adult woman. 56 THE VAGIXA. 5. These nerves issue from the hypogastric ganglion, as well as from the nervous ring or ganglion which surrounds the urethra at its entry into the bladder. They reach the sides of the uterus, and thence fol- low in part the distribution of the arteries. In every case they are con- stantly accompanied by a very fine arteriole. Some, very fine, reach the anterior and posterior surfaces, as well as the fundus of the uterus. 6. As to the neck, imitating the prudent reserve of Longet, Boulard does not absolutely decide the question, on account of the extreme dif- ficulty of the dissection. He, however, believes that the uterine neck, that is the vaginal portion, is not completely deprived of nerves. He thinks he has traced a nervous filament ramifying in the anterior lip of the OS tinc£8. 7. ]M. Boulard has never seen uterine plexuses or ganglia. It is enough, he says, to cast the eye upon the walls of a developed iiterus, after having removed the peritoneum, to recognize how easy it is to fall into error, and how easy to represent as nerves and ganglia, muscular fibres, venulse, lymphatic vessels, &c., especially after a prolonged submer- sion. On the other hand, Frank enhaiiser,^ whilst to a great extent coin- ciding with those who doubt the real nervous character of the structures described as such by Lee, says Snow Beck's plates and descriptions con- tain many errors. This he attributes to Beck's not having dissected the parts in situ, but removed from the body. He points out that in Beck's plates of the gravid uterus, the nervous filaments are remark- ably few and small, and suggests that the specimens must have been extraordinarily scantily supplied, or what is more likely, were cut away. Frankenhaiiser says the plates of Walter^ are the best yet pub- lished, being far more accurate than the oft-repeated ones of Tiedemann. Walter was the first to demonstrate a lateral ganglion on the uterine neck. CHAPTER V. THE VAGINA. The vagina is a membranous canal extending from the vulva to the uterus. It is at the same time the organ of cojnilation in women, and the canal serving for the passage of the menstrual blood on the one hand, and of the product of conception on the other. It is situated in the cavity of the pelvis, between the bladder and 1 Die Nerven der Gebiirmutter. Jena, 1867. 2 Tabulse nervorum thoracis et abdominis. Bcrolini, 1783. THE VAGINA. 57 the rectum. Maintained in its position by intimate adhesions with the surrounding parts, the vagina is still not so fixed but that it may un- dergo an inversion upon itself like the finger of a glove or an invagina- tion. This, in fact, is the true nature of most of the cases of so-called prolapsus with procidentia of the uterus. It is to be observed that the anterior wall of the vagina is shorter than the posterior wall ; the dif- ference being from 0.4 in. to 0.8 in. The vagina is not of equal width in all parts of its length. Its lower or vulvar orifice is the narrowest part : its upper extremity has much larger dimensions. In women who have had children, the fundus of the vagina forms a large bag, in which the speculum may be made to sweep freely, and in which also a large quantity of blood may accumulate in cases of uterine hemorrhage. Moreover, this canal is eminently dilatable, as is proved by parturition : it is at the same time elastic ; and after labor it returns nearly to its original dimensions. The part which is most dilatable and the least elastic is certainly the upper part, to which the name of vaginal bag might well be given, whilst the lower orifice might be called the vaginal strait. When not dilated by a foreign body, the walls of the vagina touch each other at every part, so that its cavity is completely closed. This may be clearly demonstrated by watching the behavior of the vagina during the withdrawal of the tubular or bivalve speculum. As the instrument retreats from the fundus, the walls of the vagina close up behind it, and even help to expel the speculum by its elasticity and contractile action. There are, however, cases in which the fundus of the vagina presents a true cavity, the walls not being in contact. This I have chiefly seen in women who were subject to prolapsus. If a horizontal section of the organ is made, it exhibits a transverse slit not always of exactly similar shape. Generally this slit is slightly curvi- linear, with anterior convexity, and each of the two extremities falls upon an antero-posterior slit, which gives to the whole the form of the letter H. This form is perfectly adapted to that of the neighboring parts; for the urethra is placed in the opening of the anterior bi'anches, and the rectum is received into the posterior space. The transverse branch is generally about 0.25 inch long in the adult. In the child it is shorter, and the section takes rather the shape of a star. Relations. — 1. The anterior aspect of the vagina, which presents a slight concavity in the transverse direction, answers above to the base of the bladder. To this oro;an the vagina is united bv a dense fila- mentous cellular tissue. Lower down the vagina is united to the urethra, and the relation is so intimate that the urethra seems to be hollowed out of the anterior wall of the vagina. The urethra may thus be felt like a prominent cord running along the median line. It thus forms an excellent guide to the situation of the meatus, serving as a direct clue in passing the catheter. This intimate adhesion of the vagina with the bladder and urethra explains why these latter organs are constantly dragged down in displacements of the uterus. 2. The idosterior aspect of the vagina answers to the rectum, through the peritoneum in its upper third quarter, and immediately in its two lower thirds or three quarters. Hence it is seen that when the pos- 58 THE VAGINA. terior wall of the vagina is torn in its upper third or fourth, the intes- tines may fall through the rent. The vagina adheres to the rectum by a cellular tissue much looser than that between the bladder and vagina, so that the rectum is not so liable to be dragged down in the displace- ment of the vagina. The recto-vaginal septum is the septum formed by the apposition of the posterior wall of the vagina and of the anterior wall of the rectum. Inferiorly the rectum detaching itself from the vagina, there is formed a triangular space, whose base is below, and whose antero-posterior diameter defines the thickness of the perineum. 3. The lateral borders of the vagina give attachment above to the broad ligaments; below to the pelvic aponeurosis. They are crossed by the levatores ani muscles, which, however, take no insertion here, and answer to the adipose tissue of the perineum and to the venous plexuses. The inner surface, or mucous membrane of the vagina is smooth in its upper portion, and presents on its two walls flattened rounded tubercles, measuring from 0.04 in. to 0.12 in. in diameter, and pressed against each other; or else there are crests or transverse imbricated prominences representing very nearly the irregular asperities of the roof of the palate. These different prominences all spring from a median crest, which stretches under the form of a raphe along the walls of the vagina. The two median raphes are called the columns of the vagina. They present wide dissimilarities in individuals in form and size, and appear to be a vestige of the vice of conformation which con- sists in a median vaginal septum — a vice which, although coinciding most frequently with bifidity of the uterus, may exist independently. The anterior column sometimes begins immediately behind the meatus urinarius, sometimes at a little distance from this orifice under the form of a large tubercle which serves as a guide in introducing the catheter. Greatly developed and very prominent at this point, it gradually diminishes, and is insensibly lost in the upper third of the vagina. The anterior column is often divided by a median groove, more or less deep, into two lateral portions. The posterior column is generally less prominent than the anterior. The columns of the vagina are formed of a kind of cavernous or spongy tissue. The venous plexuses situated around the vagina send numerous prolongations into the thickness of the muscular tunic, and even into the mucous tunic; around these the bundles of muscular fibres interlace in all directions, representing the trabeculse of erectile tissues. The rugse of the vagina, very numerous in the new-born child and in virgins, are partly obliterated after delivery in the upper part of the vagina; but they always persist in the lower part, and especially at the vulvar orifice and in front. These rugosities are not folds, and cannot serve in facilitating the distension of the vagina. The inferior or vulvar orifice presents in front an extremely rugous transverse prominence. This prominence, which is seen as soon as we separate the labia majora and minora, narrows, and even seems to close the entrance of the vagina. It belongs to the anterior column. STRUCTURE OF THE VAGINA. 59 The vulvar orifice is not situated in the centre of the inferior strait of the pelvis ; it approaches the pubic arch, and is separated from the coccyx by a much more considerable space. Even after labor, and throughout life, the vulvar orifice remains narrower than the rest of the vaginal canal. Hence, a well-designed speculum should pass the vulva easily, and admit of expanding at the fundus of the vagina. In virgins, the orifice is provided with a membrane, the existence of which is constant in the normal state, but whose form is subject to numerous variations. This is the hymen, from o/iijv, a pellicle ; it is a kind of diaphragm interposed between the internal genital parts on the one side, and the external parts and the orifice of the urethra on the other. This membrane is usually crescentic with the concavity anterior ; it occupies the posterior half of the circumference of the vulvar orifice, and its extremities come forward to lose themselves on the sides of the meatus urinarius. Sometimes it forms two-thirds of a circle, or even a complete circle, perforated near the anterior part of its circumference. The adherent border of the hymen is its thickest portion. Its free border is thin, concave, often irregular, notched in shreds or fringes, which lap over the meatus. Not seldom the hymen forms a membrane which completely closes the inferior orifice of the vagina, constituting the vice of conformation known as imperforate vagina. The hymen is usually thin and fragile, and is easily ruptured on the first sexual rela- tions. But it may be very resisting, fibrous, or even cartilaginous, and rendering copulation impossible. It has also happened that the hymen is very loose, or provided with a large opening ; has been simply pushed back by the penis without being torn, and has been preserved intact until the moment of labor. It has even been known to persist in prostitutes. When the hymen has been torn, the bleeding shreds are retracted and cicatrize; they shrink, and give rise to the tubercles called carimculce myrtiformce. The number, form, and situation of these carunculae vary extremely. Most frequently they are three, thick and fleshy, and occupy — one, the posterior part, the other two the sides of the entrance of the vagina. Sometimes, instead of tubercles, lengthened shreds are found, or slight eminences with hooked border, like a cock's- comb, or small pediculated polypi. The laceration of the hymen may be partial ; then it persists as a complete half-circle, narrow, with notched edges, or with fissures extending to the base. The hymen is constituted by a mucous fold, containing between its lamellae a layer of cellular tissue, inclosing numerous elastic fibres, and some muscular bundles of organic life. Some bloodvessels ramify in its thickness. Pavement-epithelium covers its two surfaces. Structure of the Vagina. — Thin above, the vagina thickens considera- bly at the level of the urethra, and terminates by a rugous, and very prominent enlargement, forming the protuberance at the entrance of the vagina, already described. The vagina invested behind, for a short space, by the peritoneum, has membranous walls not at all resembling those of the uterus. They are composed essentially of an internal or mucous coat, and of an external or muscular coat, which it is impossible to isolate by the scalpel, but which, on section, may be distinguished 60 THE BULB OF THE VAGINA. by their color. The first is white, the second reddish. Their thickness increases as we approach the vulvo-vagiual orifice. Around these two tunics is stretched a thin layer of cellulo-fibrous tissue, in which are found numerous elastic fibres. The muscular tunic of the vagina is composed of bundles anastomos- ing and crossing so as to form nets in the large openings filled up with connective tissue. Sometimes the connective tissue, sometimes the muscular predominates. The disposition of the muscular bundles presents nothing regular. The longitundinal and the circular fibres do not form distinct layers. The first, however, predominate near the mucous membrane, the latter near the external surface of the vagina. According to M. Rouget, the longitudinal or oblique fibres cross from side to side of the vagina; one part are continuous above with the external longitudinal fibres of the uterus; the other part, more numerous, run downwards and backwards on the sides of the rectum, and pass between the large vessels, united here into plexuses. The vaginal mucous membrane is formed of a very dense connective tissue, abounding in elastic fibres. This it ig which explains its great strength and the enormous distension it can undergo in the act of labor, without bursting. Numerous vascular papillae, conical or fili- form, cover the surface of the membrane ; but they are buried and hidden in the investing stratified pavement-epithelium. They are met with also in the interval of the prominences of the vaginal mu- cous membrane. They are absent only in the neighborhood of the uterine neck. There are no glandules in the vaginal mucous membrane. Accord- ing to Henle there are found exceptionally follicles analogous to the solitary follicles of the intestine, especially in the upper portion and on the uterine neck. The Bulb of the Vagina. — Besides the rugous tubercle found in front of the orifice of the vagina there exists around this orifice a swell- ing or large cavernous body, filling the space which separates the en- trance of the vagina from the roots of the clitoris. This is the bulb of the vagina. Not very thick in front where it is placed between the meatus urinarius and the clitoris, it swells progressively from this middle portion, and ends below on the sides of the vagina by a rounded extremity. The posterior part of the vaginal orifice only is deprived of bulb. It would be more exact, perhaps, to admit two bulbs, one on either side. These two bulbs have been compared by Kobelt to two gorged leeches. The dimensions of the injected bulb according to Kobelt are: length, 1.50 in.; width, 0.50 in. to 0.80 in.; thickness, 0.36 in. to 0.50 in. But these vary extremely according to age, fre- quency of sexual relations, of labors, and, lastly, to individual peculi- arities. The external surface of the bulb is convex, and covered by the constrictor muscle of the vagina ; it answers to the ischio-pubic ramus. Its internal surface is concave, and is applied around the vaginal orifice. The two halves of the bulb are united anteriorly, from which part issue numerous veins, establishing a communication between the bidb and the gland and corpora cavernosa of the clitoris. INDICATIONS FOR EXAMINATION. 65 CHAPTER VI. CONDITIONS INDICATING NECESSITY FOR EXAMINATION DISORDER OF FUNCTION DISTANT AND CONSTITUTIONAL REACTIONS — THE SUB- JECTIVE SIGNS OF LOCAL DISEASE INDICATE APPEAL TO OB- JECTIVE SIGNS — COMPARISON OF STUDY OF DISEASE OF PELVIC ORGANS TO THAT OF SKIN AND EYE DISTURBANCE OF FUNC- TIONS OF OVARIES, UTERUS, AND VAGINA AMENORRHGEA, REAL AND OCCULT; MENORRHAGIA; DYSMENORRHCEA DYSPAREUNIA RETENTION OF URINE STERILITY ABORTION DISCHARGES, SANGUINEOUS, MUCOUS, PURULENT, ALBUMINOUS, WATERY, FLESHY, MEMBRANOUS PAIN, LUMBO-DORSAL, INGUINAL, PELVIC, There is nothing special in the mode of studying the diseases of women. Just as the ophthahnic surgeon is led to examine the eye be- cause the patient complains of loss or disturbance of its function, or because he feels pain in it, or has some other subjective symptom re- ferred to that organ, so by disturbances of function or some other sub- jective sign are we led to the discovery of disease of the sexual organs. When the function of an organ is disturbed, the prima facie inference is that the organ itself which constitutes the mechanism by which that function is performed is out of gear. This is not indeed always abso- lutely true ; because an impaired state of the blood, or disordered in- nervation, or derangement of a different organ, may entail the func- tional disorder which arrests our attention. The genital organs are no exception to this proposition. The functions of the ovaries, uterus, or vagina may be seriously deranged by a state of anaemia or blood poi- soning, by disease of the nervous centres, by disease of the heart, lungs, or liver. These functions may be even more seriously affected by me- chanical pressure in contiguous parts. Still the fact remains that we can hardly appreciate rightly or successfully treat these primary or correlated diseases if we do not take into careful consideration the state of the genital organs themselves. The general or distant affections require to be investigated and treated ; but it is not sate to overlook the organs that may be secondarily involved. It is needless to say that every woman who is ill and seeks advice does not suffer from disorder of the sexual system. She may labor under various constitutional disorders, and under disorders of parts of the body quite independent of the sexual system. On the other hand, general or local disorders may in their course react upon, and induce disorder in, the sexual system. And there are disorders of this special system, commencing in it, aud in their turn reacting upon, and induc- ing disorder in, distant organs or in the general system. These inter-reactions are exceedingly frequent. Indeed, it may be 66 INDICATIOiSrS FOR EX A MIUT AT 10 N. affirmed that no severe constitutional disorder can long continue in a woman during the predominance of the ovarian function without en- tailing disturbance in this function. And the converse is also true, that disorder of the sexual organs cannot long continue without entail- ing constitutional disorder, or injuriously affecting the condition of other organs. These facts point to the necessity of guarding against the error of fixing our attention too specially uj)on one particular class of symp- toms or upon one organ. Whilst searching out the part which is more especially the seat of diseased action, we must be careful not to over- look possible disease elsewhere, and not to neglect to observe the mu- tual reactions. The clinical physician, although led by the intuition of experience to seize quickly upon the offending j)art^ will not omit to pass under review the state and working order of the other parts. In this manner most important complications are often brought most un- expectedly to light; and in every case some useful indication in treat- ment is discovered. The late Professor Chomel, a man of admirable skill, sagacity, and judgment, never failed, when a new case of disease came under his care, to interrogate successively every function. Thus, I have seen him in a case of pneumonia, the signs of which at once arrested attention, proceed nevertheless to explore the abdomen, the uterus, and the rectum. This may look like carrying out a principle to extremes. Yet who shall say that Chomel, as a clinical teacher or as a physician, was wrong ? It is not, indeed, necessary, in ordinary practice, to follow out in rigorous completeness the plan which to the clinical professor may seem desirable. It will therefore be usefal to ascertain lohat are the leading symptoms ivhioh, alone or grouped, indicate such disorder of the sexual organs as to call for direct exploration? This is the question we have set before us : When a woman presents herself, complaining of certain symptoms, chiefly subjective, some, or perhaps none, referred to the pelvis, how are we to act ? Will these subjective symptoms enable us to refer them to their cause, to establish a diagnosis, to give satisfactory indications for treatment ? Hardly. We must therefore call to our aid the objective signs ; we must weigh and determine the significance of these before we can arrive at a conclusion at all precise or trustworthy as to the underlying pathological condi- tion. The whole tendency of modern medicine is to subject every organ which manifests functional disorder to direct physical explora- tion, in order that it may solve the question presented obscurely by the subjective signs. The sound, the probe, the stethoscope, the laryngo- scope, the otoscope, the ophthalmoscope, the various forms of specu- lum, are only so many contrivances for enabling us to project or ex- tend the senses of touch, sight, and hearing into the internal struc- tures. In the case of the skin, all is at once exposed to direct observa- tion ; and, as Alibert remarked, we should be glad to have the same advantage in investigating and treating the diseases of the heart, lungs, liver, kidneys, and nervous centres. Why is it that the study of the pathology of the skin and of the eye is invested with such fascinating interest? Those who devote themselves with the greatest zeal and INDICATIONS FOE EXAMINATION. 67 success to this study affirm that it is because the skin and the eye re- veal their condition directly to the senses, and thus furnish not only positive objective signs which the patient can neither suppress nor mis- represent, but also because in this direct observation of the skin and eye they can read and follow, as on a map or on a telegraphic dial, the working of distant organs and of many affections of the general sys- tem. Here, then, we see how the reputed special practitioner, turning to account his special experience, often acquires an insight into general pathology denied to those who neglect the lessons they might read upon the visible organs. This advantage we possess to a great extent of perfection in the case of the pelvic organs. It is by the proper use of this advantage that so great a degree of precision in knowledge, and of success in treat- ment of diseases of women, has of late years been attained. And there is one property in a high degree characteristic of the instruments employed in the investigation of the diseases of women of such singular value that it ought to completely silence the objections at one time so passionately urged against them. It is this : the instru- ments have a therapeutical as well as a diagnostic application ; the speculum, for instance, revealing a lesion of the cervix uteri, enables the surgeon at once to apply his remedy. Thus treatment follows upon the track of diagnosis, one sitting and one operation serving for both. Here then, as in medicine generally, our first indication of the di- rection in which we have to look for the disease which causes the patient to complain, lies in the disturbance of function. We have then to consider what these functions are. The first in importance, because it is continued with occasional interruptions throughout the period of active sexual life, is menstruation. The other functions are incidental to married life only ; these are the relation to the other sex, pregnancy and lactation. Most of the diseases which attack the ovaries and uterus, whether j)rimary or secondary, entail some disturbance in the menstrual func- tion. The flow is diminished or in excess, or its periodicity is de- ranged. It is attended with pain in the pelvic organs and other nervous phenomena. We shall discuss the history of amenorrhoea, menorrhagia, and dys- menorrhoea hereafter. Our object now is simply to determine the con- ditions which suggest local examination. In the great majority of cases of amenorrhoea in single women, no local exploration is necessary ; but in some cases it becomes imperative : for examj^le, amenorrhoea is sometimes presumptive only — that is, the secretion takes place, but owing to some imperfection of structure it is retained in the cavity of the uterus or vagina. This may be called oceult menstruation. The suffering becomes urgent in the highest degree, and nothing short of an operation which shall liberate the retained secretion will save the patient. Some cases again of suppressed menstruation, leading to effusion of blood behind the uterus, setting up circumscribed perito- nitis, and displacing the uterus so as to press upon the bladder, may cause retention of urine. Here again local examination is imperative. This may be said of every case of retention of urine. In almost every 68 INDICATIONS FOR EXAMINATION. case of retention of urine in women the cause is external to the bladder, and in the great majority it is due to some disease or displacement of the uterus. Menorrhagia is a relative term; that is, some women lose much more than the average without suiFering in health ; but whenever the loss continues profuse, obviously entails anaemia and general debility, and persists in spite of internal remedies, local examination is clearly necessary. We shall often find a sufficient local cause in polypus, tumor, inflammation, congestion, hypertrophy, displacement, or malig- nant disease, all of which conditions require local treatment. When we come to study the history of dysmenorrhoea we shall find abundant proof of the almost constant association of this disorder with a mechanical condition of the uterus impeding the easy performance of the function. So long, however, as the distress does not clearly affect the general system, so long as it does not exceed endurable bounds, and if it appears to be moderated by general remedies, it is not neces- sary to examine ; but in the contrary event, examination should not be long postponed. To postpone examination is to postpone discovery of the cause and effective treatment. This is more especially impera- tive in the case of a married woman in whom dysmenorrhoea is com- plicated with " dyspareunia " and sterility. Abortion, if not primarily depending upon some local disease or displacement of the uterus, is so very likely to be followed by some such condition that an examination should be instituted. If a sanguineous discharge, even periodical, re- sembling -menstruation, goes on during lactation, especially if it be excessive in quantity, and attended by leucorrhoeal discharge, it may be almost confidently predicated that there exists some uterine disorder requiring local treatment. I have used a new word, " Dyspareunia." It is incumbent upon every one who coins a new word to explain its meaning and to justify the innovation. Just as the word " dysmenorrhoea " has been coined in order to express compendiously the condition of difficult or painful menstruation; just as "dyspepsia" is used to signify difficult or pain- ful digestion, — we want a word to express the condition of difficult or painful performance of the sexual function. Such a word would be convenient in many ways. It would enable us to avoid the longer and coarser forms in use, by substituting a single word at once euphonious, expressive, and in harmony with medical language. After consulting with my colleague, Dr. W. H. Stone, whose high classical attainments give authority to his advice, I have determined to adopt the word " dyspareunia." It is derived from durrr^dp^woc, a word used in this sense by Sophocles. However disagreeable the topic may be, it is im- possible to escape reference to a function so important. Dyspareunia in the female is, perhaps, the most absolute of all the indications of local malformation or disease. It calls the most imperatively for local examination as to its cause. In its milder forms it may make the sufferer's life a course of physical and mental wretchedness ; in its severe forms it virtually unsexes her ; and in any form it may lead to the most disastrous social calamities. Taking this condition, dyspareunia, as a symptom of disordered INDICATIONS FOE EXAMINATION. 69 function, we shall be astonished, when we proceed to direct examination of the organs concerned, at finding how many those causes may be, and what a wide field of pathological inquiry is associated with it. For example, there may be original defect or malformation ; there may be obstructing tumors or growths, inflammation, dislocation or altered form, disordered innervation. In short, almost every disease to which the sexual organs are liable may entail dyspareunia for one of its conse- quences ; and in not a few of these diseases disregard of this symptom may entail positive danger. The existence of certain discharges, such as blood, under conditions of quantity and times of occurrence which distinguish it from normal menstruation, mucous, purulent, albuminous, aqueous, fleshy, or mem- branous, if at all protracted, point clearly to some local disorder as their origin which requires direct exploration. Then there are some subjective signs, as 'pain, lumbo-dorsal, iliac, pelvic, or crural, and a sense of bearing down or pressure upon the rectum or bladder, entailing disorder in the function of these organs. These, especially if connected with abnormal discharges and other symptoms, call distinctly for local investigation. Then we must observe the constitutional or remote effects of the fore- going conditions. Disorder of the pelvic organs seldom goes on long without entailing anaemia, disordered digestion, hypersesthesia, neural- gia, or other manifestations of nervous derangement or prostration. When these conditions are observed in association with marked signs of derangement of function of the pelvic organs, the necessity for ex- ploring the physical state of these is as clear as is that of examining the state of the heart or lungs when these organs perform their function with distress, and the whole system suffers. Such, then, is a summary view of the conditions, chiefly subjective, which point out to us the desirableness of instituting direct observation of the pelvic organs. This direct observation commonly enables us to analyze the groups of subjective symptoms ; to determine the cause and significance of each, separately and collectively. It always brings to our assistance the discovery of other symptoms, entirely objective; and almost always puts it in our power to apply the proper treatment. The special study of the significance of the several symptoms of pelvic disease, subjective and objective, will be traced in subsequent chapters. We have ranked discharges amongst the most pressing indications for instituting local exploration. In health it may be said that, except- ing the monthly discharge of menstruation, there is no escape of fluid from the vagina. It is true that in some women leucorrhcea to a mod- erate extent precedes and follows the menstrual sanguineous flow ; it is also true that in some, leucorrhcea continues throughout the inter- menstrual period without in any obvious way entailing local or consti- tutional distress. Admitting this, the rational and safe rule in practice still is, to examine in all cases where a discharge at all copious escapes from the vagina attended by pain and signs of constitutional impair- ment. This may be stated as a general proposition without distinction as to the nature of the discharge. But we will now examine what the discharges are, and what is the special significance of each. And, in 70 INDICATIONS FOR EXAMINATION. limine, let us agree upon the meaning to attach to two words which we shall frequently have occasion to use, " Secretion " and " excretion " must be accurately applied. Following Continental custom, I shall use the word " secretion " to distinguish the act of separation of the discharge from the free surface of the organs; and the word "excre- tion " to distinguish the act of voiding from the body altogether. To take an example : the menstrual fluid may be poured out from the mucous surface of the Fallopian tubes and uterus — that is secretion. The escape of the fluid by the vulva is excretion. Excretion is the natural complement of secretion. But the process may stop short at secretion — that is, the secreted fluid may be retained. Thus, if there be occlusion of the genital canal at any point below the os uteri in- ternum, the secreted menstrual fluid will be shut up in the cavity of the uterus and in the Fallopian tubes. There is no excretion, and, therefore, apparently no discharge. Taking the discharges as they first come under the notice of the clinical observer, that is, after their excretion, they may be roughly classed under the following heads : 1. Sanguineous. 2. Mucous. 3. Purulent. 4. Watery. 5. Membranous. 6. Solid or fleshy. 7. In the case of fistulous opening into the bladder or rectum, urine or fseces may escape. 8. Then there are foreign matters, fluid or solid, which find their way into the uterus and vagina from without. Amongst these may be mentioned semen distinguished by spermatozoa. If we limited our inquiry to the examination of these discharges when excreted, we should hardly attain to any more precise knowledge than is expressed in the general terms by which we have designated them. We cannot arrive at a certain knowledge of their source, or form a trustworthy estimate of their pathological significance, unless we examine minutely the organs from which they are secreted. I may state another proposition : most of the diseases of the uterus and vagina are attended by discharges. But it must not be assumed that, when no discharge exists, or is noticed by the patient, there is no disease. Serious disease of the ovaries and uterus may exist for a long time without being attended with any discharge. And still more fre- quently discharges are overlooked by the patients, but become obvious enough on examination. Of all the discharges, the only one which can be called strictly nor- mal is blood ; and this is only normal within certain conditions of cir- cumstance, time, and quantity. Previous histological study will lend the most material aid to direct observation in determining the sources and significance of discharges. We may start from the proposition that, with one or two rare exceptions, all the discharges we have to deal with come from mucous membrane, or at least from organs nor- mally clothed by mucous membrane. The discharges will generally bring with them some of the distinctive elements of the part of the mucous tract from which they are secreted. Hence microscopical ex- amination of a discharge will almost always reveal epithelium cells which tell their own tale as to the region they come from. In this way we can distinguish uterine mucus from vaginal. The whole genital tract secretes mucus. It is only when excessive THE SECRETIONS OF THE UTERUS, ETC. 71 in quantity, or altered in quality, that the secretion of mucus acquires a pathological significance. The natural mucous secretions are : 1. A whitish mucus from the Fallopian tubes and cavity of the uterus proper. This probably comes principally from the uterine glands. It has an alkaline reaction. It is distinguished under the microscope by the presence in it of columnar ciliated epithelium cells. In health this secretion is moderate in quantity, and attracts no atten- FlG. 27. Fig. 27. — Mucous discliarge from the healthy cervix uteri, taken from the mucous cryiits. The mucous corpuscles are arranged in strings by the viscidity of the plasma in which they are en- tangled. (After Tyler Smith and Hassall.) Fig. 28. — Mucous corpuscles, epithelial particles, and oil-granules from cervical leucorrhoea. (After Tyler Smith and Hassall.) tion. But in the condition known as uterine catarrh it is very abun- dant, sometimes, especially in aged women, accumulating in the uterine cavity, and causing colic pains to expel it. The uterine mucous mem- brane may also be stimulated to excessive secretion by gonorrhoeal infection spreading from the vagina. 2. A transparent viscid mucus in the cervix uteri. This is also alka- line. It consists chiefly of mucous corpuscles, caudate corpuscles, minute oil-globules, and occasionally dentated epithelium, all entangled in a thick tenacious plasma (see Fig. 27). In health this secretion is rarely formed in such excess as to appear externally, but it is almost always found in the cervix filling up the canal. The mucous plug thus formed is washed away at each menstrual flow ; it exists gene- rally throughout pregnancy. Its uses are probably to shut off the ute- rine cavity, so as to protect it from external agencies, and to form a suitable medium for the passage of the spermatozoa. At the begin- ning of labor this secretion is formed in increased copiousness, and serves to lubricate the passages, and to facilitate their dilatation. In certain morbid conditions the cervical glandular structure also ac- 72 VAGINAL, DISCHARGES. quires extraordinary activity, and then the proper cervical mucus assumes the character of a discharge. It is poured in large quantity into the vagina, so freely, indeed, as to be a serious drain upon the sys- tem, and a source of weakness. It constitutes the most frequent form of so-called " whites " or leucorrhoea. If the speculum be used it may be seen issuing from the uterus as a glairy, albuminous fluid, re- sembling unboiled white of egg. This exaggerated secretion is almost always the consequence of inflammation, more or less acute, of the cervical canal, or of a condition analogous to catarrh of the bron- chial or intestinal mucous membrane. 3. A mucus consisting of plasma, not viscid, but containing multi- tudes of scaly epithelium cells. This comes mainly from the external surface of the cervix uteri, labia uteri, and the fundus of the vagina. It is of acid reaction. The proportion of epithelial cells to that of the fluid plasma varies considerably. In some cases the fluid part is so scanty that the secretion adheres to the mucous membrane, covering the OS uteri as with flakes, or a layer of opaque yellowish-white friable membranous-looking substance, simulating and suggesting diphtheria. It often adheres in the form of a thick layer upon india-rubber pessa- ries. Under the microscope this is found to consist almost entirely of scaly epithelium and oil-globules. In other cases, the plasma being a little more abundant, the secretion looks like cream or pus. But in these cases the microscope reveals the same constituents — namely, scales of epithelium. These forms of secretion depend upon chronic or sub- acute inflammation of the mucous membrane — vaginitis, not necessarily accompanied with abrasion or ulceration. The puriform mucus, more or less opaque and viscid, varying in tinge from creamy white to yellow- ish or light green, is often due to gonorrhoeal infection, or to suppura- tion from surfaces denuded of epithelium and granulating. When due to gonorrhoeal infection the mucous membrane from os uteri to vulva is swollen, angry red, and pain- ful, and the meatus urinarius ex- hibits the same characters. The creamy form of secretion is fre- quently found during pregnancy on the vaginal portion of the uterus. It is the result of the active throw- ing ofl" of squamous epithelium due to hypersemia. 4. The remaining or lower tract of the vagina secretes an acid mucus. Under morbid states this sometimes contains pus-globules, an infuso- rium, the Trichomonas vaginalis of Donne, and a fungus, the Lepto- thryx buccalis of Robin. But the parasites are really mainly due to neglect of cleanliness. Whitehead suggests that the use of the acid of the vaginal mucus is to prevent the Fig. 29. Epithelium from vaginal leucorrhoea— (after Tyler Smith and Hassall). LEUCOEEHCEA. 73 coagulation of the catamenial fluid in the vagina. It certainly seems to possess the property of coagulating the alkaline mucus coming from the cervix. I doubt the correctness of Whitehead's theory. It is im- portant that the blood should not coagulate in the uterus, because clots there cause severie pain and congestion, and are apt to keep up hemor- rhage ; but a clot in the vagina is of little consequence. Pus stops coagulation ; so does mucus, provided the proportion of blood is small. I believe it is the normal mucus which maintains fluidity. Whenever the proportion of blood is greatly in excess it is apt to coagulate. 5. There is a clear viscid secretion from Bartholini's glands, which is discharged in jets during copulation. It has been seen to escape on irritation, expelled by the action of the muscular fibres in the ducts. It is also poured out freely during labor, serving to lubricate the vulva. 6. The small sebaceous and mucous glands of the vulva and labia majora secrete an oily mucus, serving for lubrication. This is some- times increased in quantity, becoming puriform. We may here refer very briefly to one or two other points connected with mucous discharges. Donn6 says when the acidity of the vaginal mucus, or the alkalinity of the uterine secretion, is morbidly exagger- ated, the spermatozoa are killed. Hence one explanation of the fre- quency of sterility when there is inflammatory disease of these parts ; and of the recurrence of pregnancy when the disease which gives rise to the morbid secretions is cured. CHAPTER yil. THE SIGNIFICANCE OF LEUCOEKHCEA. The preceding summary of the various mucous discharges will en- able us to estimate more accurately the history of leucorrrhoea. Although leucorrhoea, or white discharge, is generally a symptom only, and not an essential morbid condition, it is necessary to study its history and significance separately from the morbid conditions which produce it. In a considerable number of cases leucorrhoea may be regarded as a catarrh of the uterine or vaginal mucous membrane analogous to catarrh in other mucous tracts. We accordingly see not infrequently that leucorrhoea is cured or cures itself without topical treat- 74 LEUCOEEHGEA. ment. Nearly twenty years ago I drew attention to the fact, that the uterine mucous membrane was subject, like other mucous membranes, to epidemic influence. For example, M^hilst in some this influence would affect the alimentary canal causing diarrhoea ; whilst in others, or at other seasons, it would cause bronchitis or pneumonia ; in some women it would give rise to uterine catarrh. This is explained in some cases by sudden changes of temperature, checking the secretions of the skin ; in other cases the direct exposure of the patulous vagina to draughts of cold air, as from using an open privy, has appeared to be the cause. Certainly, I have known this to bring on pelvic cellulitis and peritonitis in patients who were predisposed by recent delivery, or the recent performance of operations on the pelvic structures. In the article " Leucorrhoea" in the Dictionnaire des Sciences Medi- cales, facts illustrating the occasional epidemicity, are referred to on the authority of the physicians of Breslau, in 1702 ; of Morgagni in 1710; of Bassius in 1730; by Raulin, at Paris, in 1765 ; and by Leake, in England. Certain forms of leucorrhoea may be regarded as 'physiological. Amongst these may be classed that excessive secretion of mucus which often attends the hypersemia of pregnancy. This may not always be so profuse as to escape externally and attract the notice of the subject ; but it is rarely absent, and by the speculum it is seen as a white opaque secretion of creamy consistency, occupying the bag of the fundus and furrows of the vagina. This secretion also consists chiefly of epithe- lium scales. If the vaginal mucous membrane exhibit with this secre- tion a deep violet-red or purple color, and prominent rugse or brain- like corrugations, the presumption in favor of pregnancy is great. This form of leucorrhoea requires no treatment. Another form of leucorrhoea which may be called physiological, is that pale mucous discharge which precedes and follows, but chiefly follows, the proper menstrual flow. The first effect of the flux which takes place under the ovarian nisus, is to stimulate the glands of the uterus to increased activity. Hence the secretion of mucus in larger quantity, which sometimes appears externally before the proper men- strual blood exudes and mixes with it. This increased secretion of mucus goes on all through the stages of menstruation, and persists for a while after the exudation of blood has ceased. This post-men- strual leucorrhoea may be likened to the so-called " green-waters " of childbed. It flows from the uterine cavity, as does the proper men- strual discharge. An allied variety of this form of leucorrhoea is that which is often witnessed in girls who do not menstruate properly. In these cases, leucorrhoea is the substitute for the healthy menstrual sanguineous flow. It is evidently the result of an imperfect menstrual molimen. It is provoked by ovulation more or less perfect. It may, therefore, with strict justice be called " menstrual leucorrhoea." It is more es- pecially prevalent in chlorotic girls, and then may degenerate into a morbid flux. What has been said about physiological leucorrhoea sufficiently proves that inflammation is not a necessary factor. Indeed, inflam- LEUCOREHGEA. 75 mation may exist without leucorrhoea^ and leucorrhoea without inflam- mation. In the great majority of cases of leucorrhoea^ uterine, vaginal, or vulvar, there has been no history of inflammation. Those forms which are more directly traced to inflammatory conditions, as acute and chronic catarrhal metritis, will be more conveniently discussed when describing the pathology of the uterus. Leucorrhoea may be the expression of a constitutional diathesis. Thus the strumous diathesis is known to be commonly attended by a tumid development of the mucous membranes, and a disposition to glandular engorgements. Girls and women possessing this diathesis are frequently the subjects of leucorrhoea without showing any special alteration of the genital mucous membrane. But occasionally there is a distinct tuberculous condition of the mucous membrane. When this is the case, the attendant leucorrhoea is peculiarly intractable, even incurable. Leucorrhoea is not uncommon in women suffering from tubercular disease of the lungs. The syphilitic diathesis produces analogous effects ; and that not only when the diathesis has been acquired by primary infection, or throuo'h the o-estation of an infected ovum, but also when the diathesis has been transmitted hereditarily. The gouty and the rheumatismal diathesis are described by some writers as disposing to leucorrhoea, and that of a very obstinate form. In certain states of great debility, marked by anaemia and defective nutrition of the tissues, mucous fluxes are easily excited, and the geni- tal mucous tract is especially prone to be so affected. In such cases there need be no inflammation, no breach of surface, no abnormal growth. The coats of the vessels, the tissues of the mucous mem- brane, the muscular structure of the uterus are all so deficient in tone and contractility, and the blood is so wanting in plasticity, that an exudation of the watery element, mingled with mucous secretion, readily takes place. This state of anaemia may be induced by various causes, as acute or chronic disease, hemorrhages, or by oversuckling. It may also be induced by town-life and unhealthy occupations pur- sued in bad hygienic conditions. Accordingly, leucorrhoea is believed to be more frequent in towns than in the country, although the statis- tics cited to prove this position are by no means free from fallacy. The feeble, relaxed state of health induced in Europeans living in tropical climates, is certainly often attended by leucorrhoea ; and in this we see another example of the relationship between leucorrhoea and hemorrhage. Thus, I have known instances of women who always suffered from leucorrhoea whilst in India, remain free whilst staying in England. Diet has been supposed to have some influence in the production or promotion of leucorrhoea. No doubt a diet deficient in nutritive power may, by inducing general debility, favor the occurrence of leucorrhoea ; and it is equally certain that a good nutritive diet, by imparting tone and general health, will tend to prevent or cure leu- corrhoea ; but I am not aware of any jjrecise observations to prove 76 LEUCORRHGEA. that any particular articles of food have a distinct or specific action in promoting leucorrhoea. Leucorrhoea is common in association with disorder of the digestive organs. Dyspepsia, flatulence, distension of the stomach and abdomen, constipation or diarrhoea are frequently observed. To determine which was the antecedent disorder is not always easy ; but this much is cer- tain : almost all the dyspeptic women who have copious leucorrhoea, and in whom physicians are so ready to explain the leucorrhoea by the disorders of digestion, have uterine disease. Leucorrhoea rarely lasts any considerable time without entailing dyspepsia and mal-nutrition. Leucorrhoea, however, is frequent among women who follow seden- tary occupations, and in whom the bowels are habitually loaded. I have known women who were leading a fairly active life always sub- ject to leucorrhoea when their bowels were constipated. The same con- dition favors menorrhagia. But after making every allowance for the influence of disordered digestion, and of other distant or indirect factors in producing leucor- rhoea, the fact remains that in the great majority of instances, after childhood, lucorrhoea is dependent upon some uterine abnormality. I may repeat what I have already said that almost every morbid condi- tion of the uterus is liable to be attended by discharge. When there is acute or chronic endometritis, abrasion, tumor, polypus, or displace- ment, leucorrhoea is rarely absent. Hence the significance of leucor- rhoea as a symptom pointing to uterine disease. In women who are in any way constitutionally predisposed to leu- corrhoea slight causes will provoke it. Excessive exercise, as in walk- ing, excess in sexual indulgence, the wearing a pessary, in short, almost any local irritation is sufficient. "When there is no special predisposi- tion, the like causes long acting may provoke leucorrhoea. The pres- ence of a tumor in the wall of the uterus attracting an undue quantity of blood, the chafing of a polypus against the walls of the cervix or vagina, or even the presence of a hypertrophied vaginal portion will seldom fail to produce leucorrhoea. The division of leucorrhoea into uterine, vaginal, and vulvae-, as propounded by Donn6 and Tyler Smith, is based not less on clinical than on anatomical foundation. As we have seen, the microscopical and chemical analysis exhibit distinctive characters, and the pathological history too is often different. It may be stated as a general proposition, one admitting, indeed, of numerous exceptions, that vulvar leucorrhoea is more peculiar to childhood, vaginal to young women, and cervical and uterine to middle and advanced age. All the forms may coexist in the same patient, but in many one may exist alone. This is especially the case wuth the vulvar leucorrhoea of children. It is also often true of the vulvar leucorrhoea attending pruritus in aged women. The char- acters of the discharge in vulvar leucorrhoea are diflPerent at different ages. Thus in children in whom the sebaceous glands are not yet de- veloped the discharge is serous or sero-purulent, resembling that which results from eczema of the skin. At puberty, and during the child- bearing epoch, the same kind of sero-purulent secretion may exist, but it is commonly mingled with the proper secretions of the vulvo-vagi- L E U C O R R H ffi A. 77 nal glands and of the sebaceous glands which are at the acme of their development at this time. The secretion will be viscid, unctuous, giv- ing a characteristic cheesy or fishy odor. The vulvar leucorrhoea of advanced age reverts to the characters of infancy, the sebaceous folli- cles having in great measure disappeared from atrophy. Vaginal leucorrhoea at all ages consists essentially of an exaggerated formation and shedding of pavement-epithelium scales (see Fig. 28). In many instances a great part of the fluid element of the vaginal dis- charge arises from the cervical cavity. Cervical leucorrhcea is most frequent in the childbearing period. It is essentially mucous, and exhibits the characters seen in Figs. 27 and 28. TJtei'ine leucorrhoea or catarrh will vary in character according to age. During the childbearing epoch the uterine glands contribute a quantity of mucus to mix with the epithelial debris. At a later period the epithelial debris assume a creamy or milky consistence from fatty metamorphosis and the admixture with a serous exudation. In all the cases pus may be found if there is breach of surface, as from ul- ceration and granulation. Uterine and cervical leucorrhoea is a fre- quent attendant upon dysmenorrhoea, especially of that form which is characterized by partial retention. If there be atresia or narrowing at the OS externum, the congestion consequent on the futile attempts of the uterus to expel its contents excites to increased activity of the uter- ine and cervical glands. And the product of this increased activity finding in its turn difficult escape, tends to accumulate, and to dilate the cavities of the cervix and body of the uterus. Thus spasm or colic is exerted, and the mucous accumulation may be expelled en masse. It is in this way we account for the frequently intermittent character of leucorrhoeal discharges. If called upon to describe summarily the distinguishing characters of uterine, vaginal, and vulvar leucorrhoea, we might say that the first is mucous, the second epithelial, and the last sebaceous. The somewhat greasy character of vaginal leucorrhoea is mainly attributable to the fatty metamorphosis of the epithelial scales. The leucorrhoea of children deserves careful attention. The occur- rence of a discharge being often attended with local irritation, the child is likely to resort to friction or scratching for relief. The redness and tumefaction thus added to the discharge are very apt to excite suspi- cions of foul play, and thus to lead to false accusations. It is, there- fore, in the last degree important to bear in mind the conditions under which leucorrhoea in children may arise, lest we too hastily adopt the suspicions that may be suggested to us by others. Many years ago^ I made the observation that acute exanthemata, as small-pox and scarlatina, which we know affect the whole mucous tract, as well as the skin, occasionally left, as sequelae, vaginitis, and leucor- rhoea, even in children. Graves, Scanzoni, and others have confirmed this observation. Strumous children are especially subject to vaginal and vulvar leu- corrhoea. Irritation of the rectum as from ascarides, commonly pro- 1 Medical Gazett-e, 1850. 78 LEUCORRHCEA. duces it. In children of this taint it alternates with, or accompanies crusta lactea or impetigo, herpes, eczema. It is said to be due to the irritation of teething, but this I have not noticed, except in cases where a strumous diathesis offered a sufficient explanation. In many cases the vulvar leucorrhoea in children is kept up by neglect of cleanliness. The principal features which would favor the conclusion that leucor- rhoea observed in a child is due to a criminal attempt, are: marks of contusion, swelling, ecchymosis, turgescence of the vessels of the vulva and vagina ; extreme rapidity and intensity of the disease. If there was gonorrhoeal infection, then there will be a purulent discharge, greenish-yellow in color, copious enough to bathe the external parts and to stain the linen, thick enough when drying to glue together the lips of the vulva, and flowing equally from the vagina and urethra. This urethral complication is especially important, for according to Tardieu, violence done to the sexual organs of a child by a healthy man may produce an inflammation as acute, and a discharge as copious and thick, as that done by a man affected with gonorrhcea. It is obvious from the foregoing considerations that the greatest pos- sible circumspection is necessary before committing one's self to the expression of a positive opinion as to the origin of an apparently viru- lent discharge in a child. A question which has attracted some attention is this : Does the leucorrhceal discharge by contact with the mucous membrane, on whose surface it is retained or over which it flows, exert any irritating or injurious action? We frequently find associated with leucorrhoea patches of the surface of the vaginal portion denuded of epithelium, small ulcerations they may be called, a state of tumefaction, even red- ness. Are these caused by the leucorrhoea? In the majority of cases they assuredly are not. They mostly take their origin in those pro- cesses which produced the leucorrhoea as well. They are frequently the consequence of labor or abortion, during which processes the cervix uteri undergoes severe injury. It is conceivable, however, that long- continued maceration of a mucous membrane in leucorrhceal fluid may effect some alteration, as softening of its tissue, and this, leading to excessive exfoliation of its epithelial layer, may facilitate the denuda- tion of the basement layer. This would be especially likely to happen under the influence of any unusual accidental irritation, as excessive walking, or sexual indulgence. Dr. Tyler Smith, however, submitted that sometimes the discharge possessed decided acrid or irritating proper- ties, capable of directly inducing ulcerations, granulations, follicular cysts, and other disorders. That is, he looked upon leucorrhoea as a primary disease. This opinion appears to me to want confirmation. It is intelligible that the permanent increased turgidity of vessels, and the consequent altered condition of the tissues attending habitual leu- corrhoea, may in the end entail the alterations named ; but this is a dif- ferent thing from their direct production by the irritating property of the discharges. If fluid be retained inside the cavity of the uterus, then it will act mechanically according to hydrostatic laws. It then excites contractile LEUCOEEHCEA. 79 efforts of the uterus, and as the fluid does not escape, or only partially, the equal eccentric pressure of the fluid against the walls of the con- taining cavity leads to the dilatation of this cavity. Its retention on the surface of the mucous membrane would also interfere materially with the performance of some at least of the functions of this mem- brane, as for example, the healthy course of menstruation and the carrying of spermatozoa. There is, however, reason to believe that the sebaceous secretion of vulvar leucorrhoea, if retained, may become especially offensive and acrid, and keep up or produce an inflammatory state of the tissues bathed by it. Another question has been started : Can the secretions classed as leucorrhoea be absorbed, and give rise to constitutional tox- aemia? I content myself with citing the question. I know of no precise evidence to support an affirmative answer. There is, however, evidence to show that such poisons as lead, carbolic acid, chromic acid, used to vaginal surfaces bared of epithelium may be absorbed, and pro- duce their specific toxical effects on the system. It is also certain that foul secretions retained in utero may be taken up into the uterine veins and lymphatics, and give rise to inflammation of the broad ligaments, peritonitis, and general septicsemia. This is especially the case in the puerperal state after childbirth at term and after abortion, and also from cancerous ulceration. But these facts, although proving that the way is open to invasion, do not prove that the system is ever so invaded by the matter of ordinary leucorrhoea. The diagnosis of the kinds of leucorrhoea from each other is some- times presumptive, sometimes almost absolute. It is generally pre- sumptive in cases of constitutional disorder, as in strumous or chlorotic girls, in whom it may be reasonably inferred that there is no uterine lesion, and in whom physical exploration is not pursued. Diagnosis is still presumptive, even in married women who have had children, until local examination is made. The sources of the discharge may Jbe de- monstrated by the speculum. We may actually see the viscid albu- minous secretion coming out of the cervix. So again in the chronic uterine catarrh of old age, with narrowing of the os externum, and in that form which is associated with dysmenorrhoea from retention, we may by dilating the os uteri through the speculum give vent to the retained secretion. Not rarely, leucorrhoea exists to a very considerable degree, and yet escapes the observation or attention of the subject. Women not seldom, when questioned as to the existence of discharge, say they have none, whilst examination shows copious collection of mucous fluids in the vagina, and issuing from the cervix uteri. This arises from the patient either not being conscious of the escape of discharge, or being careless about it. Sometimes the uterine viscid secretion is expelled in a mass during defecation, and thus is not noticed. This unobserved leucorrhoea might be called " occult leucorrhoea." As a general rule, wherever leucorrhoea exists, other subjective symp- toms are present, and indicate the expediency of examination. Treatment. — The principle in therapeutics should be, first, to de- 80 LEUCOERHCEA. termine whether the leucorrhoea depend upon or be complicated with any constitutional diathesis or disorder. If this be determined in the affirmative, our treatment should first be directed to the correction of this complication. The treatment, even when the leucorrhoea depends upon a morbid diathesis, is general and local. We may, for example, accomplish a certain amount of good by internal remedies and hygienic means, in producing improved general nutrition, and thus in improving the condi- tion of the tissues, including the affected mucous membrane. And in some cases, perhaps in many, these general measures may be successful. This is especially true of the strumous and chlorotic cases. But in others, topical applications to bring about a healthier tone of the mu- cous membrane will be extremely useful, if not indisjjensable. We must not then too hastily assume that the treatment of strumous or of syphilitic leucorrhoea resolves itself into the constitutional treatment of the struma or the syphilis. When the conjunctiva is affected with catarrh or ofcher form of inflammation which takes its rise in, or some of its characters from a strumous or syphilitic taint, we find the most precious adjuvant in topical applications to the eye. So of the skin. No less so is this the case with uterine and vaginal leucorrhoea. It would unnecessarily incumber this work to enter with any degree of detail into the general treatment of scrofula or syphilis. If I pass this by, it is not because I in any way undervalue its importance. General treatment is indispensable. Before topical treatment is adopted, we ought to form a fairly pre- cise diagnosis as to the source of the leucorrhoea, that is, whether it be uterine, vaginal, or vulvar. It is for want of attention to this point that vaginal injections are found to be so often useless. Vaginal in- jections fail, because they do not touch the main seat of the disorder, which, in the majority of cases, is in the uterus itself. But although they fail to cure, they may be useful as far as they go. In constitutional leucorrhoea, the vaginal mucous membrane as well as the uterine is commonly involved ; and something is gained if we improve the con- dition of a part of the affected tract. There is therefore sufficient rea- son to prescribe them, and thus to enlist the patient in her own service. She may herself manage the vaginal injection. For the topical treat- ment of the uterine mucous membrane she must have recourse to her physician. The most useful and convenient topical applications in strumous and most other forms of leucorrhoea are astringent liquids. Amongst these, acetate of lead, sulphate of zinc, sulphate of alumina, decoction of oak-bark, solutions of tannin. The topical applications best suited for the interior of the uterus are sulphate of zinc, nitrate of silver, sulphate of alumina, iodine. The best mode of applying these will be described hereafter. (See Chapter XV.) In the case of syphilitic taint the same means are useful, but in ad- dition I commonly use the iodide of mercury ointment, introduced by means of the ointment-carrier I have contrived for the purpose. (See Chapter XV.) LEUCOERHCEA. 81 In the strumous leucorrhcea of childreu, cod-liver oil and iron are of signal service. The second indication is, if we discover any local disease, as a tumor, a polypus, displacement, abrasion, congestion, hypertrophy, to en- deavor to remove this cause or complication. The third indication is, in the event of our detecting no constitutional diathesis or local disease, to treat the leucorrhoea as an independent disease, if the discharge be excessive or entailing obvious local distress or general weakness. In this class of cases we should begin by correct- ing any disorder of the digestive organs. We should be especially careful to regulate the action of the bowels, to remove and to prevent the accumulation of faeces in the lower bowel. We should then en- deavor to restore the general tone and strength by good diet, tonics, and exercise. Amongst the remedies most useful are strychnine, iron, quinine, and arsenic. The last is often remarkably efficacious in leu- corrhoea depending upon debility. Local remedies, as alum or zinc injections, are often useful adjuncts; but in young women, in whom the presumption is against any morbid condition of the mucous mem- brane, they will be generally unnecessary, and for other reasons it is desirable to avoid them. Balsamic medicines, especially turpentine, are often very useful, and now that they can be given in capsules, or " pearls," the chief objection to their use is overcome. Courty speaks highly of the advantage to be derived from tar-water mixed with the wine drunk at meals. It is made palatable at first by mixing with seltzer-water. The same excel- lent author extols hydrotherapeutics. In the chronic forms of leucor- rhoea cold water in every form, as full baths or hip baths, produces the best results. It is at the same time the best revulsive and the best tonic. In this chapter I have attempted to give merely a general account of leucorrhoea, regarding it, as for practical purposes it often is regarded, as a distinct pathological condition. Leucorrhoea, as a symptom de- pendent upon morbid conditions of the uterus and vagina, will be in- cidentally described as a part of the history of these several morbid conditions. The watery and purulent discharges might not inaccurately be in- cluded under the common head of " Leucorrhoea." But I have thought it more useful to describe them in distinct chapters. 82 DISCHARGES OF AIR. CHAPTER VIII. DISCHAEGES OF AIR. Air may get into the vagina, if not into the uterus, in the non-preg- nant state. In the normal condition the walls of the vagina are main- tained in perfect contact, and no air, or probably very little, is admitted. But where the parts are greatly relaxed, the vulva open, as when the perineum is torn, the lower part of the vagina is no doubt exposed to the contact of air, but the very condition of patency prevents the re- tention of the air to such a degree as to lead to its escape in perceptible volume. Air also penetrates where too large a pessary is worn, which keeps the vaginal walls apart. But under peculiar circumstances air enters in large quantity, to be expelled with noise. Dr. George Harley details' a curious case, in which he carried out decisive experiments, to prove the correctness of the diagnosis, A pluripara frequently expelled air from the vagina with a loud noise. It was ascertained that no con- nection existed between the rectum and vagina. Dr. Harley took a full-sized male catheter, to which was attached a long india-rubber tube with a stopcock at the other end. The catheter was introduced into the uterus, the end of the tube wdth the stopcock being placed in a tumblerful of water. No air escaped when the instrument was in this position ; but, on placing the open end of the catheter in the vagina, an instantaneous discharge of gas took place. The water was found to be sucked up through the tube into the vagina. It was found that the vagina sucked in and expelled the air by spasmodic action. It was further observed that the abdominal muscles assisted in the suction pro- cess. The uterus was completely retroverted. This displacement being remedied, and the health improved by tonics, a cure ensued. Dr. McClintock says :^ " Two or three women who had prolapse of the w^omb have told me that soon after getting up in the morning they have been conscious of the escape of air from the vagina. The vagina was enlarged, the lower part of the uterus hypertrophied. There was no fistula ; the air came from without." If we observe the vagina when the duck-bill speculum is applied, the movements of rise and fall under the influence of the rise and fall of the diaphragm are seen. Dr. Adolph Rasch has investigated^ these phenomena with great care. He says, if a multipara, whose genitals are normal, be placed on her back, with the thighs flexed and abducted, and the vaginal orifice closed, movements caused by respiration are seen, but no air enters. In the lateral position the same thing is ob- served even if the vagina is lax, and even when the perineum is 1 "Obpletrical Transactions," 1863. 2 "Diseases of Women," p. 54. 2 " Obstetrical Transactions," 1870. WATERY DISCHARGES. 83 ruptured. When the patient is placed in the prone position, or on all-fours, if the vulva be open, air will enter, because the intestines falling downwards by gravity causes a vacuum. Under this condition violent exertion may expel air, giving rise to vaginal flatus. If the abdomen be supported by the hands or a bandage, no air enters. There are several interesting applications of this knowledge. It teaches that the best position after labor, if not during labor also, is the dorsal decubitus ; that the same position is also best in the case of pelvic abscess or hsematocele discharging into the vagina ; and that we must carefully consider this respiratory rise and fall of the vagina when selecting pessaries. It is by turning to account this action that we derive the greatest advantage from the spoon or Sims's speculum. The blade drawing the perineum well back, whilst the semi-prone position of the patient favors the falling forwards of the abdominal viscera, air fills the vagina, counteracts the effect of inspiration, and thus enables us to get a good view of the os uteri. The same position also greatly aids our efforts at reducing inversion of the uterus, and in replacing a prolapsed umbilical cord. On the other hand, in most operations upon the uterus and vagina, where it is of importance to bring the uterus as low doM^n near the vulva as possible, the dorsal position, by bringing the force of gravity to counteract the re- spiratory rise of the uterus, and which can further be greatly aided by direct pressure by an assistant's hand above the symphysis pubis j is the best. . CHAPTER IX. .^ THE WATEET DISCHAEGES. When these occur, we must first of all determine the presence or absence of pregnancy. It is no uncommon thing that discharges of water, more or less profuse, take place in pregnant women. This is the " hydrorrhoea gravidarum." Gushes of water, quite clear, may occur at almost any time during pregnancy ; but they are more fre- quent in the latter months, and especially in the last month. Happen- ing at this time, they are commonly taken as an indication of commencing labor, and many are the false alarms which patient and doctor have to suffer from this cause. " The waters have broke," says the nurse. You go, as in duty bound, and find probably the os uteri closed, nothing resembling active labor pains. What are you to do ? 84 WATERY DISCHAEGES. If you wait for labor, you may wait for a week, or two or three weeks. If, on examination, by ballottement, you find the child still floats in the uterus, the os uteri not open, and no active pains, you may go home and wait in peace for another summons. What is the source and nature of this hydrorrhoea gravidarum ? Several theories have been expounded. The character of the fluid differs in some respects from that of liquor amnii. It is odorless, and resembles blood-serum or the serous fluid effused in the peritoneal sac. Ruysch and Roederer thought it came from rupture of lymphatic vessels, or of hydatids of the uterus ; Bohmer thought it escaped from a second abortive ovum ; Delamotte and Cruveilhier that it came from a cyst near the ovum ; Deleurye, Puzos, ISTaegele, and Dubois, that it came from the inner surface of the uterus, being secreted externally to the ovum. Dubois says it is the result of loosening of the membranes from the uterus when the vessels pour out serum. Hegar says the source is the uterine glands of the decidua. Thus he describes^ the glands of the mucous membrane as being found in the decidua at the sixth month of gestation, and argues that their sudden disappearance in the subsequent months is improbable. In a case of hydrorrhtea he found in the decidua vera, at the beginning of the eighth month, an enormously developed glandular body. At the bottom of this morbid growth was a general hypertrophic condition of the decidua and its glands. These gave out the excessive secretions. In a case related by Dr. Graef,^ repeated discharges took place, and the foetus was ex- pelled at the end of six months. The membranes were very delicate, and openings were found in them. In this case, it is probable that the fluid was true liquor amnii. In another case the patient suffered, during the last three months, from repeated watery discharges ; the uterus rising and falling with the gathering and escape of the fluid. The membranes were found without rent. Graef regarded this as a case of catarrhal hydrorrhoea. I believe there are various sources. In some cases the fluid is liquor amnii. This may come either from rupture of the membranes ; from rapid transudation under pressure ; from rapid formation and accumu- lation of liquor amnii in the amnion ; or from the bursting of a cyst formed between the amnion and chorion, or between two layers of cho- rion, the proper amniotic sac remaining intact. In the majority of cases, however, the fluid is not amniotic. It is then, the result of a rapid secretion from the uterine glands or from the cervical cavity. In the early months, whilst there is still a free space between the decidua vera and the decida reflexa, there is a large area of developed glandu- lar surface. I have observed a puerperal form of hydrorrhoea. Thus watery dis- charges may continue for a month or longer beyond the proper lochial flow. Generally in these cases the water is dirty, discolored, occasion- ally stained with blood, and offensive. The most common cause I have found to be the retention of a portion of placenta or of clots in the ' "Monatsschrift fiir Geburtskunde," 1863. 2 " Jenaische Zeitschrift," 1865. WATERY DISCHARGES. 85 uterus; but a polypus may produce like results. The watery dis- charges alternate, but not always, with discharges of blood. The fluid may, under certain conditions, collect in considerable quantity in the uterus, so that the organ becomes greatly distended before the collec- tion is expelled in a gush. Sometimes watery fluid is mingled with air, constituting physo- hydrometra. This is also a puerperal or post-puerperal condition, and is commonly the result of retention of some portion of placenta or membranes, and the admission of air into the uterine cavity. If an examination is made when the uterus is relaxed after labor, especially if the hand be introduced into the uterus, the vaginal walls are sepa- rated from their usual contact, and a channel is formed along which air easily enters. Merely turning on the side, or a little more prone, will often, by favoring the fall of the uterus forwards, produce a vacuum into which air will rush. This is one reason amongst others why I am unable to approve of the abolition of the old-fashioned binder, which some people would condemn, for no better reason that I can see than because it is old-fashioned. After labor, especially in pluriparse, the abdominal walls are so relaxed that they can give no support to the uterus. The binder does temporary duty for the inert abdominal walls. The history of physo-hydrometra is, I believe, this : a portion of placenta, membranes, or clots, remains in the cavity of the uterus after labor ; some air gets in as I have described ; decompo- sition ensues, and the gases of putrefaction are added to the air from without, while the os uteri is occluded by the placental or blood-mass falling over it. When this occurs, there is invariably hectic or irrita- tive fever; peritonitis and septicaemia commonly attend ; great abdomi- nal pain. The enlarged, distended uterus can be mapped out rising as high as, or higher than the umbilicus ; and resonance is made out on percussion. One condition, the result of impregnation, often leads to copious and repeated discharges of watery fluid; the hydatidlform degeneration of the chorion. In this case the ordinary signs of pregnancy may not be present, and even the patient herself may not think she is pregnant. There is, however, always evidence of enlargement of the uterus, and generally great pelvic distress. The water escapes in gushes at uncer- tain times; it .is often tinged with blood, resembling red currant water; it has not the offensive odor belonging to the watery discharges of can- cer; sometimes, but not often until late in the progress of the case, cysts will be found swimming in the water; it is generally expelled with painful uterine contractions. In a case we recently had in St. Thomas's Hospital, the nature of the disease v/as not at first suspected. There was some abdominal enlargement, retention of urine requiring the catheter, and most distressing pelvic pain Avith irritative fever. The OS uteri was found high up above the symphysis pubis, whilst behind it the pelvic cavity was filled with a large, rounded, firm mass, taken to be either the retroverted gravid womb or a fibroid tumor. One day a large quantity of water, blood, and a mass of chorion-cysts were expelled. We had, in fact, the condition of retroverted gravid 86 WATERY DISCHARGES. womb complicated with liydatidiform or cystic degeneration of the chorion. Apart from pregnancy, watery discharges are often of grave signifi- cance. During and after the climacteric period, the most frequent cause is some form of malignant disease, especially the so-called cauli- flower excrescence of the uterus. In this case other symptoms will probably point to the seat and nature of the disease. The fluid dis- charge is seldom clear; it is generally turbid, dirty, often tinged with blood, resembling water in which flesh has macerated; it contains shreds or flocculi of solid matter, the proceeds of superficial erosion or necrosis of the surface of the diseased growth, and is almost always of a peculiar oifensive odor. It often alternates with hemorrhage. Local exploration will place the nature of the case beyond doubt. Another form of malignant disease giving rise to watery discharges is the "oozing excrescence of the labia." But we must remember that similar discharges may take place from polypus or inversion of the uterus. Hence we have another example of the wisdom of not pronouncing a diagnosis until we have made an internal examination. Water may escape in large quantity from the rupture or perforation of an ovarian cyst in the vagina. In such a case, the rapid concurrent diminution of the abdominal tumor will lead to the right conclusion. Watery discharge may be urine escaping from a vesico-vaginal fistula. The character of the fluid and other circumstances seldom fail to estab- lish the exact nature of the case. Under certain conditions of the mucous membrane of the uterus, more especially of the cervix, copious secretion of watery fluid may take place rapidly. I believe this chiefly occurs when the mucous membrane is hypertrophied. In this case the numerous glands are probably also hypertrophied, and acquire a greatly-increased activity. It will be remembered that all the mucous membranes at times dis- charge large quantities of watery fluid. Thus the mouth is the seat of ptyalism, the stomach of pyrosis, the intestinal canal of diarrhoea. It is rational to infer that causes analogous to those which induce watery secretion from the mucous membranes in these organs, may induce the like event in the mucous membrane of the genital tract. PURULENT DISCHAEGES. 87 CHAPTER X. THE PUEULENT DISCHARGES. Some purulent-looking discharges are in reality mucous, the appear- ance being due to epithelium-cells, not to pus-globules. When pus- globules in large proportion are found, they indicate generally a breach of continuity of the mucous surface — that is, a granulating or ulcerated surface. When pus escapes in quantities, suddenly at intervals, and sometimes by continuous draining, the source probably is an abscess whose seat is outside the uterus or vagina, as in what is called pelvic cellulitis, opening into the vagina. In such a case examination by touch internally, and externally in the iliac regions, will reveal the extra- uterine disease. The uterus will be felt set fast by surrounding firm plastic effusion. The os uteri will generally be found in the centre of the pelvis, low down, or inclined to one side, if the pelvic peritonitis is chiefly unilateral. This position of the os uteri distinguishes pelvic peritonitis from retro-uterine hsematocele, which pushes the os uteri forwards close behind, and sometimes above the symphysis pubis, and which may also be attended by suppuration. A suppurating ovarian cyst may contract adhesion with the roof of the vagina, and form a fistulous perforation through which pus may escape. I have now under my care a case in which pus is voided by the vagina, the origin of which is an abscess in the left hypochondriac region opening into the intestine, and which at a lower part has formed a fistulous communication with the vagina. We thus see how numerous and strange are the sources of pus in the vagina, and that a purulent discharge is no sure evidence of disease of the uterus or vagina. Ex- ploration must extend beyond these organs. Many discharges, which to the naked eye cannot be distinguished from pus, are really mucous. The microscope discriminates them easily. The distinction is important, because it is generally true that the un- broken mucous membrane of the genital tract does not yield pus. When true pus appears, it is, therefore, mostly an indication of erosion, ulcer- ation, or abscess. As Virchow has pointed out, all mucous membranes with cylinder-epithelium are little disposed to form pus. The matter which is produced is found, on accurate examination, to be only epi- thelium, though it may, to the naked eye, have a thoroughly purulent appearance. The intestinal mucous membrane rarely produces pus without ulceration. The mucous membrane of the uterine tubes, which is often covered with a thick mass of entirely puriform appearance, shows almost always only epithelial elements. On other mucous membranes — the urethra, for example — we observe copious discharges of pus without the least ulceration. 88 HEMORRHAGES. CHAPTER XI. THE SIGNIFICANCE OF HEMORRHAGIC DISCHARGES. Discharges of blood from mucous membranes are not necessarily significant of local disease. For example, epistaxis from the Schnei- derian membrane is not infrequent in childhood and old age, uncon- nected with organic disease anywhere. Although when it has once set in, the bleeding is apt to go on to an excessive, to an alarming, and sometimes even to a fatal extent ; it seems in the first instance to be determined, by an eifort of the vascular system, to unburden itself of a superfluous accumulation. It appears to be critical, and in many cases to be beneficial. During the period of sexual life the uterine mucous membrane is the outlet towards which any overflow is directed; during this period Schneiderian epistaxis or other forms of hemorrhage are rare ; the seat of election for critical and other hemorrhages is the uterus. And it is remarkable that, as a result probably of the dispo- sition which the uterus had acquired of acting as a periodical evacuant long after the cessation of menstruation proper, it still continues to be the safety-valve by which vascular repletion is relieved. The aptitude of the uterus to serve in this way is occasionally mani- fested also at an early age ; that is, just before or about the institution of the menstrual function. Young girls sometimes begin with a copious flooding, which does not appear to be distinctly determined by ovulation. In the cases referred to, hemorrhage even copious does not imply disease, at least not disease of the ovaries or uterus, any more than does bleeding from the nose imply disease of the Schneiderian membrane. It is an expression of constitutional or general vascular tension. Still hemorrhage from the uterus, especially if prolonged or repeated, is so commonly a consequence of disease of that organ, that it ought, as a general rule, to be taken as a warning to make local examination. This is the more imperative, because in many cases this examination leads at once to the detection of a cause which can be quickly removed ; and in almost all cases the surest way of stopping dangerous hemorrhage is by topical applications. This tendency of the vascular system to seek its outlet by the uterus is fortunate. If a vent were not found here, the risk of internal eifusions would be enormously increased. And not even excepting the Schneiderian membrane, the uterine mucous membrane is the most under control. Climacteric uterine hemorrhage may avert an attack of apoplexy. The outlet of blood from the uterus may avert effiision from the ovary or its plexuses into the peritoneum. In this way nature often proves herself a better physician than the modern practitioner who has aban- doned the use of the lancet. HEMORRHAGES. 89 It may be stated, as a general proposition, that whatever produces hypersemia predisposes to hemorrhage. Thus inflammation takes high rank as a cause of hemorrhage. Inflammation involves a vis a fronte, attracting blood to a part, and so filling the capillaries that they juay burst. As in other parts of the body, hemorrhage from the uterus may be active or 'passive. In active hemorrhage rupture of vessels arises from the attraction of an inordinate quantity of blood into them. In pas- sive hemorrhage the escape arises not simply from distension from excess of blood, but generally also from the depraved quality of the blood, from the ill-nourished, weakened condition of the coats of the vessels, and the impeded return of the venous blood. In a woman who had suffered much from metrorrhagia, the blood contained only 2 parts in 1000 of globules, 1.8 of fibrin, 61 of solid materials of serum, and 915 of water. Hemorrhage from the uterus is sometimes called menorrhagia, some- times metrorrhagia, sometimes flooding. The term menorrhagia implies an excessive flow of the menstrual discharge. Although in fact the menstrual nisus or ovulation exerts a powerful initiative and aggravating influence in the production of hemorrhage, yet there often exists in association with apparent menor- rhagia some local disease which is more strictly the cause. That is, without this local disease the ovarian stimulus would produce no more than the ordinary menstrual flow. But a mucous membrane once set bleeding easily goes on pouring off blood. It may be likened, and indeed often is so by patients, to the turning on of a tap. The vessels of the mucous membrane, whether they have burst or not, pour off blood with the greatest readiness ; and the stream being once directed to a given part which affords ready outlet, a derivative action towards this part is easily kept up. Metrorrhagia means very much the same thing as flooding. It is used to express a copious flow of blood not obviously associated with menstruation. Uterine hemorrhage is another synonym. As a gene- ral term it is free from the objection which applies to " menorrhagia,'' as it expresses simply a fact independently of all theory of causation. In almost every case of uterine disease leading to hemorrhage, peri- odicity more or less regular is observed. There are commonly intervals of remission or cessation. Women observe that their courses last for two or three weeks at a time, leaving only one or two weeks of freedom. This periodicity is often preserved long after the natural menopause, when any disease, as cancer or tumor, continues to be the cause of hemor- rhage. In the same way as patients of tuberculous diathesis are eager to persuade themselves that occasional haemoptysis is due to accidental insignificant causes, so women in whom losses of blood, more or less periodical, continue or recur long after the menopause, are ready to believe that these losses are natural or exaggerated menstrual discharges, and that they may be taken as evidence of protracted sexual life. To determine what losses must be ascribed to natural menstruation and what to pathological causes, we must seek to define the characters of natural menstruation. Any marked departure from these characters 90 HEMORRHAGES. inust then be made the subjects of closer investigation, in order to separate or analyze the often combined physiological and pathological factors. The history of menstruation will be studied more methodically hereafter. It will be enough to state the leading features of healthy uncomplicated menstruation. Fluid blood, somewhat glutinous, is discharged gradually, to the amount of two to four or six ounces, over a period of two, three, or four days, at regular intervals of twenty- eight days, or nearly so, beginning at the age of twelve, thirteen, or fourteen, and lasting until forty-five or forty-eight. There is a range of variation in all these characters, depending in some cases upon individual peculiarities. For this allowance must be made. But it is a safe and prudent clinical rule to suspect that any wide departure from these characters depends upon some pathological complication. Taking the characters of normal menstruation as our standard, we shall be justified in concluding that discharges of coagu- lated blood, discharges habitually exceeding four or six ounces, dis- charges continued for a week or more, leaving intervals of freedom shortened to three weeks or less, discharges occurring during the proper intervals between the periods, and discharges occurring long after the age of forty-five or forty-eight, especially if excessive or irregular as to periodicity, are of pathological significance. The same thing may be said of hemorrhagic discharges recurring in women after the menopause ; that is, after a complete cessation of the ordinary menstrual flow for a year or more. It may be assumed, as a physi- ological fact, that the function of ovulation is not resumed after having been suspended at its natural term. The ovary then has undergone a process of involution or atrophy which is incompatible with the de- velopment of ova. Discharges of blood, then, after the menopause depend upon other causes than normal ovarian stimulus. The circum- stances under which hemorrhage appears will occasionally declare its character. For example, hemorrhage may immediately follow some accident, as sudden exertion, or coitus. In addition to the general or average standard deduced from the study of the natural history of menstruation, Ave shall often draw the most trustworthy conclusions from the particular study of the individual pa- tient. She herself must often furnish her own standard of comparison. Any marked change from the habitual characters of the menstrual func- tion will point to the necessity of inquiring into the cause. All hemorrhages may be considered abnormal which are irregular in their appearance, or excessive in duration or quantity, or which ob- viously tell upon the system by inducing anaemia or debility. An- other test of abnormality will often be found in the association of other symptoms with the hemorrhage. Abnormal hemorrhage is not always marked by excessive quantity. Blood may appear in streaks or small quantities mixed with the mucus of leucorrhcea. This will often be connected with breach of surface of the mucous membrane, as abrasion or ulceration ; often, however, with simple congestion or inflammation. Apart from pregnancy, a copious flow of blood will generally depend upon some organic alteration in HEMORRHAGES. 91 the structure of the uterus, as hypertrophy of the body or cervix, the growth of tumors or polypi, or malignant disease. If copious hemorrhages occur in a woman past the childbearing age, the probability is great that the cause is malignant disease ; and this probal)ility rises if the cessation or diminution of the blood-flow is fol- lowed by a watery discharge stained with blood, offensive in odor, and showing debris of tissue in the form of shreds. It must be remembered, however, that the discharges attendant upon polypus and inversion of the uterus may present very similar characters. Many cases of poly- pus have been seen in which the history, subjective symptoms, and dis- charges so nearly resembled those of malignant disease that the prob- ability in favor of cancer seemed great until examination was made. Abortion or labor at term is not seldom followed by hemorrhages more or less continuous or intermittent for many weeks or even months ; so long, indeed, that their dependence upon the puerperal changes may be lost sight of. Uterine hemorrhages may be classified as follows : A. Hemorrhages escaping externally, without alteration of the struc- ture of the uterus, as — 1. From primordial disease of the heart, liver, or lungs. 2. Exaggerations of the menstrual function, as in plethoric girls at the onset of menstrual life, and in women at the menopause. 3. Throughout menstrual life, or beginning towards its close, from abdominal or hepatic congestion or obstruction. In some, hem- orrhagic menstruation seems hereditary. 4. From emotion or physical shock. 5. Complementary of hemorrhages suppressed elsewhere. 6. From sudden suppression of the action of the skin. 7. From ovarian or mammary excitation. Excess of coitus, espe- cially if at menstrual epoch. 8. The climacteric and senile hemorrhage. 9. From blood disease ; as variola, scarlatina, tyj)hoid, acute atrophy of the liver, leucocythemia, scurvy. In this class we see that the cause of hemorrhage may be distant from the uterus. Hypertrophy of the heart is a not uncommon cause of uterine hemorrhage, especially in pregnancy and childbed. The hypertrophy may be the result of antecedent disease, or of pregnancy. This is one cause why the risk of hemorrhage increases with the num- ber of pregnancies. There is an increasing difficulty in the process of involution of the heart, and an increasing disposition to fall into fatty degeneration. A feeble, fatty heart also, I have observed, disposes to uterine hemorrhage. Liver disease may act simply or as complicating heart disease. It acts especially in women past forty, during the climacteric, and in those who indulge in drink. Lung diseases, especially those marked by dyspnoea and hypersemia or oedema, dispose to uterine congestion and hemorrhage. Uterine hemorrhage is sometimes observed in phthisis, although more commonly this disease induces amenorrhoea. It is not always safe or judicious to stop hemorrhage depending upon 92 HEMORRHAGES. remote obstructions to the circulation hastily or completely. There can be no doubt that they act as useful evacuants and derivatives. Menorrhagia has occasionally proved fatal at the onset of the men- strual function in girls. The late Mr. Obr6 related the case of a vir- gin, aged fourteen years and three months, in whom the first menstru- ation set in violently, and could not be checked. Everything was found healthy, except the uterine mucous membrane, which was softened and ecchymosed, and in some places detached from the muscular coat. This alteration was probably nothing more than the menstrual decidua in- filtrated M'ith blood. B. The hemorrhages of pregnancy — 1. Abortion. 2. Detachment of placenta. 3. Extra-uterine gestation. 4. Retained placenta or clots, — placental or fibrinous polypus. 5. Hydatidiform placenta. 6. Varix of the vulva or vagina. It must be borne in mind that in many cases of hemorrhage in preg- nant women the blood does not come from the cavity of the uterus, but from the cervix uteri, which may be abraded and hypertrophied. The intense hypersemia of pregnancy easily issues in hemorrhage when the mucous surface is unsound. Many of the conditions, with or without alteration of structure, which occur in non-pregnant women, may occur also in the j)regnant; and pregnancy may even increase the disposition to hemorrhage. C. Hemorrhages with alteration of structure — 1. Metritis proper. 2. Inflammation of the cervix uteri. 3. Engorgement of the body and cervix induced by stenosis or displacement or distortion of the uterus or other causes. 4. Hypertrophy of the cervix or of the body of the uterus, espe- cially of the mucous membrane, as from syphilis. 5. Fungous granulations of the os, abrasions, ulcerations, especially if there is syphilitic complication. 6. Fibroid tumors. 7. Polypi of the uterine cavity, cervix, or os, or of the vagina. 8. Cancer or sarcoma in the non-ulcerated state, and in the ulcer- ated state. 9. Wounds of the uterus, vagina, or vulva from accident, opera- tions, leech-bites, abrasion or irritation, as from ill-selected pessaries. 10. Voiding the blood of thrombi or of retro-uterine hsematoceles. 11. Varicosity of the vessels of the labia, which may burst. 12. Imperfect involution of the uterus and obstruction of circulation kept up by impeded mobility from peri-uterine eflusions. 13. Hyjiersemia induced by the uterus being within the range of any abnormal vascular activity, as an extra-uterine gesta- tion cyst. Hematuria, or disease of the meatus urinarius, may possibly be mistaken for hemorrhage of uterine origin. HEMOREHAGES. 93 D. Hemorrhages poured out internally — 1. Retri-uterine hsematocele, from blood from ovary, ovarian plexuses, or Fallopian tubes, under menstrual nisus. 2. Peri-uterine lijematocele or thrombus, or effusion into the con- nections of the broad ligaments, or between the bladder and cervix uteri. Similar events may happen from abnormal ovarian congestions ; from rupture of ovarian tumors, or of vessels in their walls; from rupture of varices of the ovary or broad ligaments. Under ovarian menstrual stimulus blood may be poured out into the abdominal cavity because there is some obstruction in the course of the genital canal. 1. The Fallopian tubes may be occluded; there may be stenosis or atresia of the uterus, vagina, or vulva; there may be re- troflexion of the uterus. In these cases blood may accumulate above the seat of the ob- struction, and regurgitate into the abdomen. 2. There may also be retrograde hemorrhage from abortion. 3. Abdominal hemorrhage may arise from rupture of the sac of an extm-uterine gestation. External hemorrhage commonly precedes or attends the rupture and the internal effusion. 4. The gravid uterus may rupture, with or ^¥ithout violence, after the fourth month. This is more likely to happen when the gestation is mural, or in one horn of a two-horned uterus. In these cases there will probably be some external hemorrhage also. A methodical analysis of the various causes of uterine hemor- rhage for diagnostic purposes would carry us through almost the en- tire field of ovarian and uterine pathology. The morbid conditions which are attended by hemorrhage will be described in their proper places. We can only now enumerate the conditions, physiological or pathological, which are associated with hemorrhage; and seek to lay down compendious principles of diagnosis and treatment. In practice we are continually called upon to treat symptoms or consequences of disease. It is the merest folly, or affectation of science in many cases, to pretend to remove a disease by at once attacking the presumed cause. The folly is as great to postpone treatment until we have discovered the cause. In no case is this pretension more absurd or more dangerous than in that of hemorrhage from a mucous membrane. Whilst we are waiting to discover the cause, the patient may bleed to death. If we apply ourselves at once to stop the hemorrhage, we may save her. Treatment. — The first practical rule to observe when in presence of a profuse flooding is to take off" the pressure of gravitation, by placing the patient in a horizontal posture with the pelvis somewhat ele- vated; to remove all articles of dress which, by their pressure upon the chest or waist, impede the circulation ; to remove, as far as pos- sible, all sources of excitement or emotion ; above all, to obtain abso- lute rest. Wounds or injuries which would be of no consequence if the patient remained perfectly quiet and recumbent, may, so rich is the 94 HEMOREHAGES. vascularity and so free the intercommunication of the vessels of the pelvis, lead to fatal hemorrhage, if she assume the erect posture, or undertake any bodily exertion. The next practical rule is to endeavor to stop the bleeding as quickly as possible, without waiting to inquire into its cause. This can rarely be done effectually or certainly without the application of topical reme- dies. This necessarily implies a preliminary examination by the finger, hand, or speculum. We thus obtain incidentally useful, often adequate, diagnostic information. For example, we may find a polypoid tumor or a wound. The hemorrhage may then be stopped by removing the cause. We may find malignant disease ; and then all we can do is to stop the bleeding by the application of powerful astringents or cau- teries, as the perchloride of iron or chromic acid. We may find a fibroid of the uterus ; and the hemorrhage may be controlled by the same remedies, postponing treatment adapted to prevent the recurrence of bleeding to a more favorable opportunity. We may find an ovum presenting at the os uteri, or some other form of heuiorrhage connected with pregnancy. The treatment of these forms cannot be discussed in this work. I have described it carefully in my " Lectures on Obstetric Operations." Where we find no cause that admits of immediate removal, we may still arrest the hemorrhage. The method which is commonly the readi- est, because it requires no special appliances, is plugging the vagina. Whilst waiting for these special appliances, it may be desirable to plug. This is done by pushing pieces of lint, linen, sponge, or silk handker- chiefs into the vagina. First of all, it is desirable to remove clots by the hand, and to wash out the vagina with cold water. Then holding the labia apart with the expanded fingers of one hand, the plugging materials, lubricated in oil, or better, Avith oil containing an eighth or tenth part of carbolic acid, or lard, are pushed in gradually by the fin- gers of the other hand, or by aid of the uterine sound, the handle of a tooth-brush, or any other accessible instrument. The plugging must be firm, packing the vagina pretty tightly. It is, however, generally preferable to plug by the aid of a speculum. The pieces ai^e thus ac- curately packed, and the speculum is gradually withdrawn. In this way uterine and vaginal hemorrhage may frequently be checked for a while, and time be gained for choice of more scientific remedies. But plugging is not free from objections. In the first place, if the case be one of malignant disease, tight packing of the vagina is apt to break down the fragile malignant tissue, to increase the bleeding, and favor ulceration. In the next place, after a while the elastic and contractile vagina compresses the plug, saturated with blood, into a compact ball or cylinder, which no longer fits its calibre ; blood then easily flows past ; or being retained concealed, may give rise to a false security, and lead us to defer more effectual remedies. In the third place, plugs, by heating and distending the parts, are a source of irritation and distress; they often in this way seem even to keep up hemorrhage. In the fourth place, if retained a few hours, the plugs, or the retained blood, decom- pose and become exceedingly foul. Fifthly, the compression of the ure- thra, or the metastatic irritation, often causes retention of urine. And HEMORRHAGES. 95 even if the plug have arrested the hemorrhage, this often breaks out again when the phig is removed. In the majority of cases, therefore, it is wise to look upon plugging as a mere temporary expedient, to be adopted whilst preparing for more trustworthy means. I could give no rule of more general application or more valuable than this : In all cases of hemorrhage coming from the body of the uterus obtain and maintain free patency of the cervical canal. In cases of abortion, of the hemorrhages of gestation, of intra-uterine polypi, or fibroids, of hypertrophy of the mucous membrane, of malig- nant disease of the interior of the uterus, to obtain free external escape for the hemorrhage and free access to the source, in order to control the bleeding, is the first necessity. We might, it is true, in almost every case introduce a catheter or tube to carry a styptic injection into the uterus. But this proceeding, invaluable if properly carried out, may be useless or even dangerous if resorted to whilst the cervix uteri is contracted. Blood retained in the cavity of the uterus forms clots which, under the spasmodic contractions they excite, become compressed into firm masses of fibrin by the squeezing out of the serum. These coagula cannot make their way through the constricted cervical canal ; they may even become closely adherent to the walls of the uterus, form- ing the "fibrinous polypi." Their presence in any form is a source of irritation and suffering : by causing alternate contraction and dilatation of the uterus they keep uj) hemorrhage ; and occupying the uterus, in- jections thrown into the cavity are lost upon the clots instead of con- stringing the bleeding surface. Moreover, as I shall show hereafter, wherever there has long existed a narrowing of the cervical canal, there will be produced a dilatation of the genital tract above the stenosis. Hence, there will be serious danger of injected fluids being driven along the dilated Fallopian tubes into the abdominal cavity. As a conse- quence of the same condition, there is also serious danger of the blood which gathers in the uterine cavity and tubes being driven in a retro- grade course into the peritoneum. This is one way in which retro- uterine hematocele is produced. It is the way which may most suc- cessfully be guarded by securing a free outlet by the vagina. In the case of retained ova, membranes, or placenta, or clots, the first indication is usually to remove these. To do this it is often necessary to pass in one or two fingers to break them up and to bring them away. In the case of intra-uterine polypi, there must be room to introduce an instrument, as well as a guiding finger. In the case of an unhealthy condition of the uterine mucous membrane, free passage is Avanted for the application of haemostatics. These are, I believe, most useful if ap- plied in a tolerably concentrated form. To do this, it is preferable to introduce them soaked in swabs mounted on sticks or whalebone rods. If a swab cannot be introduced, and it is difficult to do it unless the cervix be very widely open, because the charged swab as it touches the cervix in its passage contracts the canal, it is then necessary to resort to injection, or the introduction of styptics in the solid form. If any further reason were wanted to recommend the preliminary dilatation of the cervix uteri, it would be this : It is in many cases 96 HEMOEEHAGES. enough to arrest the bleeding. And, if not of itself successful, it at any rate opens the road by which we can pursue a treatment that will succeed. What are the means of dilating the cervix f — These are various, and the choice will 'depend upon the nature of the case. If it be one of abortion, of intra-uterine polypus or tumor, or of morbid condition of the mucous membrane, it will generally be easy to place one or more laminaria-tents or sponge-tents, which in the course of a few hours will etFect the desired dilatation, and, Avhilst acting, will generally check the bleeding. If the case be metrorrhagia from fibroid tumor, or menstruation obstructed by stenosis of the os externum uteri, it may be necessary to dilate the part by incision. This operation wdll frequently not only prepare the way for relief from the immediate danger, but it is an essential condition of prevention in the future. When we have stopped or moderated the bleeding, our next inquiry will be, how we are to prevent its recurrence ? This will lead to the study of the causes, immediate and remote, of the hemorrhage, and of the means of alleviating or removing those causes. I cannot in this place further anticipate the history of the conditions associated w^ith hemorrhage. They will be systematically discussed under their ap- propriate heads. Active hemorrhage is characterized by symptoms of fluxion or rapid determination of blood to the pelvic organs, by heat, throbbing, per- haps pruritus, pain, sense of fulness at night, and bearing down of the uterus. If examination be made by touch the vagina is felt hot; per- haps the vaginal pulse is perceived ; there is increased softness of the vaginal portion ; and tenderness of the uterus, when pressure is made upon its walls through the vaginal roof. The general system evinces the perturbation caused by the local molimen. There is a state of febrility, of vertigo, of swimming of the eyes, the eyes are suffused, and nervous symptoms of an hysterical kind are frequent. Passive hemorrhage is not marked by the signs of fluxion or active determination. There is not the same local hypersemia as in the active form ; and it is not preceded by the same heat, vascular tension, or at- tended by the vaginal pulsation. Having once occurred, passive hemor- rhage tends to establish itself by degrading the quality of the blood, and by altering the tissues, impairing their tonicity, and rendering them more easily permeable. The blood discharged often becomes more serous in character. We may try to turn aside the fluxion from the uterus by the appli- cation of cold. This is best done by introducting ice into the vagina. It is usual to apply cold wet cloths to the vulva and abdomen. This may sometimes be serviceable, but it is often the reverse. The patient gets soaked in water ; and the resulting chill may favor the develop- ment of subsequent j^eritonitis or bronchitis. In the passive hemorrhages it is of great importance to secure free evacuation of the bowels. Passive hemorrhages are most frequent in women W'ho have reached or passed middle age. It is then that he- patic congestion and inaction of the intestines are most common. And any loading of the colon or rectum is always a serious aggrava- tion in cases of pelvic hypersemia. HEMORRHAGES. 97 Marked advantage is sometimes obtained from the use of remedies which promote contraction of the uterine muscular fibre ; or which in some other way possess haemostatic properties. Amongst these the most trustworthy are ergot of rye, digitalis, cinchona, turpentine, ipecac- uanha, acetate of lead, tannin, alum, dilute sulphuric acid. After-treatment. — Hemorrhage, especially the active form, is followed by a stage of reaction, of erethism, which has been, not inaptly, called hemorrhagic fever. The pulse is quickened, the skin is warm and dry, there is intense beating headache, restlessness, hyperesthesia manifested in general irritability, and morbid sensitiveness to light and sound. In this condition it is a serious clinical error to administer iron. It may be theoretically true that the vascular system wants iron ; but the effect of giving it is to add fuel to the fever and excitement, to parch the tongue and mucous membranes generally, to check secretion, to increase headache and restlessness, to disturb digestion and nutrition. The system may want iron, but it wants saline solutions more; and it wants these first. Saline solutions serve better than anything else to rejjienish the exhausted circulating fluid. The vessels seem to crave in the first instance for a sufficient volume of fluid as a necessary condition for the efficient dynamic action of the circulating apparatus. It is a fact deter- mined by the observations of Dr. Little and Mr. L. S. Little on cholera patients, that the injection of saline solutions of about the specific grav- ity of the blood will revive persons on the point of sinking. I can affirm, from large experience, that the exhibition of salines after hemor- rhages is followed by the best effects. They exert a marked influence in subduing vascular excitement ; they allay the fever, calm nervous irritability, improve the secretioVis, and prepare the way for iron and other tonics, which at a later stage find useful application. The best form of saline is the acetate of ammonia, freshly prepared. To this may usefully be added a sedative, as Battley's solution, and sometimes digitalis. At a later stage mineral acids and bark, in decoction, or the liquor cinchonse may be given ; and later still iron. The best chalyb- eate preparations are the citrate of iron, given in an effervescent form, or the acetate of iron. The doses at first should be small, so as to feel the way. Strict rest must be maintained, so as to economize to the utmost the feeble powers of the system ; to promote this, sedatives to procure sleep are often of signal service. If opium can be borne, as it often is, it may be given with the saline, or separately, in the solid form, as the compound opium pill, in 5-grain doses, or as Dover's powder, in 10-grain doses. If it is not borne, we have a precious resource in chloral, which may be given in scruple doses. Alcohol, in the form of wine or spirits, will, at times, act as an efficient sedative, as well as a stimulant. But stimulation, or " keeping the patient up," is often overdone. Stimulants must be given watchfully, and with discretion. Taken largely, they disturb the balance of the stomach, provoke vomiting, excite the circulation unduly, and may even maintain or cause a return of the hemorrhage. Light, easily assimilable nourishment should be given in small quantities, at short intervals. 98 PA IX. CHAPTER XII. THE SIGNIFICANCE OF PAIN. It may be stated, as a general law, that pain referred to a particular part or organ is presumptive evidence of disorder, structural or func- tional, of that part or organ. Of course, in some cases, the disorder is onlv secondary or consequential upon disorder in some other part. Thus, one form of headache is the consequence of disordered stomach, and is cured by correcting the condition of the digestive organs. Pain in one part may be the reflex response to distress in another part. Of this we see repeated examples in the history of ovarian and uterine disease. Pain in the dorsal, lumbar, and sacral parts of the spine is a frequent phenomenon in connection with uterine disease. It is often the predominant symptom. The spinal pain may be so severe and enduring that it attracts the chief attention ; and, unless the rule of interrogating all the functions be carefully followed, it is easy to fall into the snare of regarding the case as one of spinal irritation, vertebral disease, or simply hysteria. If this error be committed the patient will probably be doomed to a long course of mechanical or medicinal treatment, under which the general health may break down, the original disease pursuing its course all the while. Attempts well deserving consideration have been made by observing the seat of the pains complained of, and interpreting by the knowledge of the sources and distribution of the nerves supplying the pelvic organs, to diagnose, with something like precision, the nature and seat of the pelvic disease. There are certain facts which are so frequent in their recurrence and association as to lend weight to this method of analysis. But like all other methods of clinical research conducted upon one line, it is ex- ceedingly apt to lead astray. It is useful as a means, but not as the only means. We want help from every quarter. Pain, in association with ovarian and uterine disease, is referred, first, to the region of the ovary or uterus itself; secondly, chiefly to the sacral, or lumbar, or lumbo-sacral region ; thirdly, to the hips, thighs, and down the legs. In many cases pains may be said to radiate from the pelvis as a centre, in various directions, as to the back, abdomen, and thighs. Pain in an organ, arising during or aggravated by the performance of its functions, is especially presumptive evidence of structural disorder of that organ. This is true of pain during menstruation, and of pain in the performance of the sexual act. This part of the subject will be discussed more particularly under the heads " Dyspareunia " and " Dysmenorrhoea." Pain described as in one or other inguinal region or rather deeper, \s PAIN. 99 often referred to the ovary, and is taken as evidence of ovaritis, or of ovarian irritation. But in the great majority of instances this presumed ovarian pain is the signal of subacute or chronic inflammation of the neck of the uterus. This has been insisted upon by Dr. Henry Bennet. I find this pain so frequent in connection with, disease of the neck of the uterus, there being no perceptible concurrent disease of the ovary, that I hesitate in every case to regard it as due to ovarian disease until I have examined by touch the ovaries themselves, as well as the uterus. , If under touch we make out that the ovaries are swollen, and exhibit increased tenderness, we get the required confirmation as to the impli- cation of these organs. I have several times obtained experimental proof of pain in the ovary being due to uterine disease. Touching the OS uteri has caused pain referred to the region of the ovary. By those who do not examine at all, either uterus or vagina, except by external palpation, this ovarian pain is often called " ovarian irrita- tion," or " ovaritis ;" and leeches, blisters, or irritating ointments are resorted to to subdue it. This so-called " ovarian irritation," however, does not deserve to be ranked as a morbid entity demanding special treatment. There may, indeed, be irritation of the ovary ; but then there must be something to irritate it. It is this something we should search for. And this something, in the majority of cases, has its seat not in the ovary itself, but in the uterus. The pain is more frequent in the left ovary than in the right. Pain referred to the uterus itself, intensified under touch, is often attributed to " irritable uterus," and this vague expression is sometimes accepted as a satisfactory diagnosis. ISTow, as is the case of " ovarian irritation," logic and clinical observation compel to the conclusion that since the uterus shows signs of being irritated, there is an irritating cause, which it is our business to find out. Another expression which is often adopted as a conventional substi- tute for precise diagnosis is " neuralgia of the uterus," or "hysteralgia." These terms really mean nothing more than " pain in the uterus." To employ Greek comjsounds to express this idea seems superfluous, unless it be to lull the spirit of inquiry by fostering the false belief that these terms embody a pathological entity. It must not be forgotten that these terms, seemingly so definite, and yet so vague, took their rise at a period when the precise and minute methods of investigation at present in vogue were comparatively unknown. These imposing terms, there- fore, are the reflection of imperfect pathological knowledge. They no longer satisfy any but those who are satisfied with the imperfect patho- logical knowledge of the past. Advancing knowledge has gradually contracted the proportion of cases in which pain cannot be referred to its cause. And with this advance we are less under the necessity of treating pain as an essential disease ; we are more able to attack suc- cessfully the real disease of which the pain is a symptom. If then we consent to retain the terms " irritable uterus " and " hysteralgia," it must be because they have, by long prescription, es- tablished for themselves a kind of footing in nosology. jSI^euralgia of distant parts, as of the face or breast, is often, if not strictly symptomatic, certainly consequent upon uterine and ovarian 100 PAIN. disease. This dependence is often quite overlooked by physicians who devote special attention to neuropathy. Neuralgia, studied apart from its antecedents, is apt to assume much of the importance attached to an idiopathic or essential disease ; and being treated accordingly, it persists, rebellious against all the artillery of the Pharmacopoeia. The follow- ing is the chronological history of a large proportion of the cases of neu- ralo-ia in women. Uterine disease, attended by hemorrhagic and leucorrhoeal discharges, saps the general strength, degrades the quality of the blood ; then all the organs, especially those concerned in diges- tion and assimilation, being badly nourished, perform their functions imperfectly. Concurrently with this general impairment of nutrition, the nervous centres suffer ; these centres become extremely susceptible to the exhausting influence of pain — and pain is constantly proceeding from the uterine disease. Thus the tone of the nervous centres is con- stantly being worn down, and preparation is made for every kind of irregular or aberrant nervous action. The nerves of the face, breast, and limbs become keenly sensitive to external impressions of cold, and to what are called the sympathetic impressions brought from internal oro-ans. Neuralgia is the culmination of all this. To cure it we cannot depend upon quinine, morphia, actea, alteratives, the hot iron, or divi- sion of the nerve ; we must trace the disorder back to its source, and by curing the uterine disease, arrest the primary cause of the blood- degradation and nervous Avear and tear. This done, constitutional correctives and tonics will act beneficially, and we may reasonably ex- pect the neuralgia to disappear. The history of a vast number of cases of " hysteria " is exactly the same. In short, hysteria is commonly one phase of aberrant nervous action, the result of nervous exhaustion from disease and mal-nu- trition. Pains referred to the uterus, and described as " expulsive," " bear- ing down," likened to colic, generally indicate retention of fluid, or solid matter, in the uterine cavity. This explains the chief part of the pain of dysmenorrhoea, though, no doubt, the ovaries, by their direct participation in the trouble of menstruation, and by the reflected distress from the uterus, contribute to the suffering. Pain referred to the uterine region, causing the patient to bend the body forward, is often found in connection with subacute metritis and subinvolution of the uterus after labor. Pain in the lumbo-sacral region of a dull wearing character, attended with more or less impairment of the use of the legs, is frequently as- sociated with retroversion and retroflexion of the uterus. The pre- sumption that this displacement exists will be increased, if there is dyschezia and habitual constipation. The want is proba))ly not due so much to direct pressure of the body of the uterus, even when enlarged, upon the sacral nerves, as upon the indirect pressure occasioned by the accumulation of hardened fjeces in the rectum. Pain and irritability of the bladder frequently attend ante version of the uterus, or pressure from the uterus enlarged by fibroid, or the ad- vance of cancer. It may also, of course, be the consequence of dis- ease of the bladder or urethra. y PAIN. 101 Pains extending down the legs, especially if attended with sensation of numbness and a degree of motor paralysis, is presumptive evidence of pressure upon the sacral plexus and other nerves in the pelvis. This presumption acquires greater force if there be attendant oedema of the feet and legs, indicating pressure upon the pelvic and abdomi- nal veins. Pains in either side of the pelvis, described as of a dragging char- acter, and attended often with lumbo-sacral aching, is a frequent con- sequence of prolapsus. It is, in all probability, due to stretching of the uterine ligaments. A pain, described as "throbbing," and attended with a sense of ful- ness, often precedes the onset of the menstrual flow, especially in women who, from the presence of tumors or other disease in the uterus, are subject to metrorrhagia. A valuable presumptive test of the dependence of pain upon local diseases, especially inflammation or displacement, is the production or aggravation of it, after exertion and fatigue. In some cases pain is relieved by walking or by the erect posture, and is aggravated by the sitting or recumbent postures. Where there is uterine disease, attended by inflammatory action or enlargement, the pain is usually aggravated in a remarkable degree by the kneeling posture. Various reflex pains in distant parts are often associated with uterine and ovarian disease. The dorsal, lumbar, and sacral pains have been already referred to. Other instances are the occipital headache, the left hypochondriac stitch or pain, and pains in the breasts. Pain, described as "pricking," "stabbing," "shooting," usually persistent, is commonly considered to be pathognomonic of cancer. In the advanced stages of malignant disease pain of this kind is not unusual. But it is by no means constant. Its presence cannot be ac- cepted as proof of malignant disease, nor can its absence be accepted as proof of the absence of malignant disease. Physical examination alone can solve this question. Pain must be taken as an indication for this proceeding. Pains in one side of the body, attended with sensations of numb- ness and pricking, or tingling in the arm, and especially of the leg of the affected side, constituting what might be called pseudo-paralysis, are not uncommon at the climacteric age. They do not indicate ovarian or uterine disease, although the two conditions are frequently associated. 102 DYSPAREUNIA. CHAPTER XIII. THE SIGNIFICANCE OF " DYSPAREUNIA," INCLUDING "VAGINISMUS," I HAVE ventured to introduce the term " dyspareunia " as a conveni- ent and concise description of an affection which is often the immediate occasion of great physical and mental suffering, which is apt to entail the most serious disruptions of conjugal relations, and which is almost always a symptom of some morbid condition that admits of more or less successful treatment. There is no disturbance of function, no subjective symptom which more imperatively dictates resort to physical exploration than difficulty or pain in the performance of the sexual function. In the great ma- jority of cases dyspareunia depends upon some local imperfection or disease. In many instances it is not safe to neglect the warning which this symptom gives of something wrong ; in many this neglect con- demns the subject to the keenest agony — agony not the less hard to bear because affection or other motives too often induce her to conceal it. The causes of dyspareunia may be classed under the congenital and the acquired. Under congenital conditions are ranged absence or imperfection of the vagina or vulva ; a dense unyielding hymen ; too short a vagina, the uterus being set too low in the pelvis, so that the os uteri is within an inch or a little more of the vulva ; undue length of the vaginal- portion, or its projection as a conical mass into the vagina. I lately amputated, at St. Thomas's Hospital, by the galvano-caustic wire, a redundant vaginal-portion, the cause of intolerable dyspareunia, with complete relief. In the case of the uterus being set too low in the pelvis, the vagina being short and not easily distensible, dyspareunia results from the uterus not being able to rise or retreat under the im- pact of the male organ. Hence congestion and inflammation not uncommonly arise. In many cases a compensatory condition is estab- lished in time, by the gradual dilatation of the post-cervical vaginal roof. This is developed into a considerable pouch. Although the dyspareunia may gradually subside, these cases often remain sterile. I have met Math a form of dyspareunia which, in one case, gave rise to the question of seeking for a divorce. The pubic arch was unusually deep and continued so far back that tlie vulvar fissure was carried far behind the normal seat. In this case, as in many others where in- effectual or unsatisfactory attempts at intercourse have been continued for a long time, an extreme degree of mental irritability and local hypersesthesia had been induced. Acquired Causes of Dyspareunia. — Amongst these are found : con- traction or atresia of the vulva and vagina, the result of disease, DYSPAEEUNIA. 103 injury, or cicatricial processes. Cases belonging to this order will be discussed under "Atresia." * Almost all the inflammatory affections of the pelvic organs entail dyspareunia. Congestion and inflammation are commonly attended with increase of nervous irritability. Structures which in the ordinary state evince little sensibility become, when congested or inflamed, in- tensely painful. This is markedly the case with the vaginal-portion. Proof of this is obtained when the finger presses upon it; by the speculum when the. blades are being expanded, and the ends chafe against the inflamed vaginal-portion ; when in adapting a Hodge pes- sary the posterior limb is being pushed back across the os ; in some cases, when the patient is at stool the solid motion pressing upon the tender os. In all these cases pain is complained of; it is not sur- prising that coitus should also be painful. When the body of the uterus is enlarged from hypersemia or con- gestion, dyspareunia is an almost certain result. In this case on making an examination, touching the vaginal -portion may not evoke pain ; but pressure by the finger upon the body of the uterus, through the roof of the vagina or through the rectum, is almost sure to do it. Inflammation or congestion of one or other ovary is attended by the same result. A frequent cause of dyspareunia is colpitis or inflammation of the vagina, no matter to what the inflammation may be due. Thus in- flammation from blennorrhagia, or from injuries during labor, will frequently render sexual relations intolerable. When colpitis exists there is often entailed a spasmodic contraction of the vagina which greatly intensifies the suffering. This condition, for which Dr. Marion Sims proposed the name "Vaginismus," is exceedingly distressing. It may be likened to colitis or dysentery. The inflammation excites spasmodic contractions of the muscular coat, and especially of the vulvar sphincter. The friction of the inflamed mu- cous surfaces against each other under these morbid contractions is the immediate source of pain, and it increases the inflammation and spasm. The cure of dyspareunia here depends upon the cure of the colpitis. This is to be accomplished by " rest " in the most comprehensive sense of the word. It is mainly by its efficacy in securing rest from the spas- modic contractions of the muscular coat, that Dr. Marion Sims's and my instruments for keeping the walls of the vagina apart, act so bene- ficially. Two or three weeks' use of one of these instruments during the daytime, and lead lotions on removing it at night, will often effect a cure. Pelvic cellulitis and peritonitis, whether in the acute or chronic stage, almost constantly entail dyspareunia. This is due not only to the in- creased sensibility attendant upon inflammation, but also upon the loss of mobility of the uterus. Whenever the uterus is fixed at a definite low level in the pelvis, unable to retreat before the propulsion of the male organ, dyspareunia is an almost inevitable consequence. Hence this condition is frequently observed in cancer of the uterus, and in fibroid tumors affecting the lower segment. 104 DYSPAEEUNIA. Various conditions of the vulva are peculiarly apt to cause dyspar- eunia. This is not surprising M^hen it is remembered that the struc- tures of this part are richly supplied with sensitive nerves, and that they have to encounter the chief force and irritation. All the varieties of inflammation of this part necessarily expose the patient to this form of suffering. I have known it depend upon Avascular excrescence of the meatus urinarius, and upon fissure at the fourchette, and removed when these affections were cured. It attends pruritus and the follicular inflammation. But the most severe distress is often produced when the entire cir- cumference of the vulva is involved in a peculiar inflammatory process, which may in many cases be traced to violent or unskilful attempts at intercourse. In these cases there may be observed a dark red, angry-looking ring of inflammation around the orifice, sometimes even abrasions or slight fissures, which easily bleed on touch, and generally the carunculse myr- tiformes present the appearance of swollen inflamed excrescences. This local inflammation entails extreme sensitiveness or hypersesthesia ; the slightest touch is intolerable; the patient shrinks at the very thought of examination, and actual touch excites uncontrollable spasmodic con- striction of the part. This constitutes oneof the conditions which may be included under the general term " Vaginismus," although the vagina itself immediately beyond the vulva may be quite free from disease. In some cases of this kind it is almost certain that there has never been complete intercourse. Indeed, where this condition is developed at the outset of married life, the dyspareunia and spasmodic contraction are so acute that complete intercourse is all but impossible. The distress, so long as the patient continues exposed to attempts at intercourse, is gen- erally aggravated by time ; health breaks down under the nervous ex- haustion produced by repeated suffering, and what may be called the disappointment of Nature under an unfulfilled function. In some cases the irritability of the nervous centres becomes so great, the sensitive- ness of the peripheral nerves at the vulva so acute, and reflex action thereby so intensified, that the attempt at intercourse will induce con- vulsion, or be followed by syncope. Exaggerated emotions, the conflict between affection and the dread of pain, may induce similar results. Sometimes vaginismus is due to the presence of small fissures or sores on the edge of the perineum or vulva. These cases are analogous to those of spasmodic contraction of the anus from similar causes. Courty relates a case which he cured by forcible stretching by the fingers under chloroform. Vaginismus and dyspareunia may also be occasioned by disease of the rectum, as fistula, or fissure, or inflamed piles. Indeed, these reflected consequences are sometimes so much more extensive than is the direct distress at the seat of mischief, that the true origin of the pain is apt to be overlooked. It may arise from a vascular or irritable tubercle of the meatus uri- narius. In some cases no lesion of surface, no inflammation can be discovered ; and we are driven to the conclusion tluit the spasmodic irritability is due to hysteria, or simple hypersesthesia, or to emotional influences. DYSPAEEUNIA. 105 The cure of this painful affection obviously depends mainly upon a period of rest, that is, suspension of all attempts to renew sexual inter- course. The exhausted nervous system must have time and opportunity to recruit, the general health must be restored, and the local source of irri- tation must be relieved. To accomplish the last indication various measures are useful. In a first order of cases of minor severity, such as are not unfrequent during the first few days of married life, a few days' rest, fomentations with warm water, or tepid hip-baths, and the use of lotions or injections of subacetate of lead, may be sufficient. In a second order of cases of longer standing than the first, and including some cases where the difficulty has arisen after complete in- tercourse, and even after labor, the remedies mentioned may be most usefully supplemented by wearing for several hours during the day Dr. Marion Sims's dilator, or my " vaginal rest." The action of these con- trivances is to keep the irritable surfaces apart, and thus, by avoiding the irritation of friction, to allow the inflammation to subside. They also further act beneficially by distending the vulvar orifice, stretching the muscular sphincter, thus wearing out spasmodic contraction, and using the parts to bear the presence of a foreign body. Vaginal pes- saries, containing acetate of lead, belladonna, bismuth, borax, or zinc, and made up with glycerin, are useful adjuncts. In the third and more serious order of cases surgical intervention will commonly be required. After subduing the acute inflammation by rest, fomentations, and lead lotions, it may be necessary, if the ori- fice of the vulva is found unusually small, to enlarge it by making- two or three incisions through the skin on either side of the fourchette. The subcutaneous division of some of the fibres of the sphincter vaginse has been recommended. This, if adopted, could be done by passing a tenotomy knife under the mucous membrane, just where it merges into skin at the posterior edge of the vulva, near the perineum, and when the knife has penetrated flatwise about an inch by turning the edge on and cutting outwards towards, but not through, the skin. A period of rest should follow this operation. If there are remains of hymen, or carunculse myrtiformes, presenting an inflamed hypersensitive condition, there is no remedy so effectual as the removal of these parts by the scissors. The operation is performed by putting the patient under chloroform, placing her in the lithotomy position or in the semiprone position, with the nates hanging well over the edge of the bed or operating table. Assistants aid in holding apart the labia vulvae by fingers or retractors, whilst the operator, seizing a portion of the aifected structures with tenaculum forceps, snips them away all round, removing, if need be, a complete ring. The incision should not be deep, the aifected structure being generally quite super- ficial. Some bleeding usually attends. This may be controlled by ice and by pressure, or by Richardson's spray of ether or styptic colloid. Pressure should be applied by plugging the vagina with pledgets of lint soaked in carbolized oil. The plug may be removed and renewed next day. During the healing of the surface it is well to wear an elastic vaginal rest. At the end of three or four weeks a cure will generally be effected. 106 DYSPAEEUNIA. Disappointment is apt to follow this operation if the smallest caruncle or other aflPected portion be left. Almost as much irritation and suffer- ing may be maintained by the presence of a small remnant of diseased structure as if the whole were allowed to remain. Hence the expedi- ency of carefully removing the entire circle. In some cases where the hymen is very dense and the fourchette is thick and unyielding, so as to contract excessively the vulva, enlarge- ment of the opening by slight incisions is the least painful and the readiest proceeding. Scanzoni, summing up his own very considerable experience of cases of which vaginismus was the urgent symptom, opposes the use of the knife. He has always succeeded in bringing relief by first subduing all inflammatory complications, and next by effecting gradual dilata- tion by means of graduated glass specula worn for short intervals at a time. Dr. Tilt prefers the proceeding adopted in the case cited from Courty, namely, of forcible stretching. This is carried out, the pa- tient being in the state of ansesthesia, by introducing the two thumbs, back to back, and then forcibly distending the vulva for five or six minutes. I have cured many cases by methods similar to those used by Scan- zoni; but I have met with cases where the knife or scissors gave, in my opinion, not only the quickest and most efficient relief, but also at the least cost of pain and other distress. Certainly the judicious use of these instruments may be far less painful than forcible stretching. It is needless to observe that inflammation of Bartholini's glands is a cause of dyspareunia and vaginismus. The swelling attending this condition often nearly closes the vulva, and the pain is so exquisite that the slightest touch is intolerable. The painful excrescence of the meatus urinarius commonly entails dyspareunia. In this case the attendant dysuria will direct the physi- cian to the source of the evil. Dyspareunia may be the result of imperfect or disproportionate development. This is a form not unfrequently observed in girls who marry too young. It may also be experienced by women who marry late in life. After the climacteric, especially in women who have not been accustomed to sexual relations, the uterus, vagina, and vulva un- dergo a kind of atrophic involution, in the course of which the vagina and vulva lose much of their glandular structure, and the tissues lose elasticity and distensibility. Sexual relations under these circum- stances may be not only painful but even dangerous. There is a prep- aration in St. George's Museum of a vagina ruptured through the roof by the sexual act. The condition called coccygodynia by Sir J. Simpson may also be a cause of dyspareunia. It must be remembered that dyspareunia in women may in many cases be traced to the other sex. Imperfect, awkward intercourse in- duces a chronic, nervous irritability, which in turn renders approach intolerable. This is a not infrequent source of distress in couples ill- matched as to age and physical strength and disposition. I think it important to insist that Avhenever a discharge of blood STEEILITY. 107 follows sexual intercourse, whether it be accompanied by pain or not, a local examination should be instituted. Bleeding excited in this manner is often the first indication obtained of the existence of organic disease of the uterus and vagina ; and it is superfluous to say that the prospect of curing organic disease will, in many cases, depend greatly upon seizing the earliest indications. CHAPTER XIV. THE SIGNIFICANCE OF STERILITY. The discussion of the significance of sterility naturally follows upon that of the significance of dyspareunia. It may be stated as an obvious general proposition, that dyspareunia entails sterility. Of course there are many exceptions ; for although intercourse may be difficult and painful, still it may be accomplished, and numerous cases prove that complete intercourse is not necessary to impregnation. But these ex- ceptions do not invalidate the general law that dyspareunia is an obstacle to fertility. This is further proved by the frequent occurrence of preg- nancy when dyspareunia is cured. It is not simply because dyspareunia so frequently involves the suspension or incomplete performance of the sexual act that it entails sterility. Various conditions, as inflammation, displacement, which produce dyspareunia, are also often of themselves obstacles to impregnation. This is proved by the fact that in numerous instances these conditions entail sterility, although sterility is not com- plained of. It is no part of the object of an essentially clinical work to dwell upon the moral or social aspects of this question. But it is strictly within the scope of medical discussion to observe that sterility is not a ,purely negative evil, that is, the history of sterility is not summed up by saying that it is simply the negation of fertility. Complete sexual life in woman implies the due succession of the functions of ovulation, of gestation, and of lactation. The ovaries, the uterus, and the breasts ought, in the natural cycle or order to relieve each other. Where the ovaries alone act continuously under the excitation of married life, a sense of an unfulfilled function arises, which, in many organizations, is likely to induce physical as well as mental disturbance. The familiar saying that women in a certain condition of health would be well if 108 STERILITY. they could have children is a popular mode of expressing this physio- logical fact. Referring to the evils attending sterile marriage, Dr. AYest observes that chronic ovarian irritation and chronic congestion of the womb leading to hypertrophy and menorrhagia are apt to ensue. This is undoubtedly true ; but I may remark that these cases would be less frequent, if the necessity of dilating the narrow os externum uteri were more generally recognized. When this is done, even although preg- nancy do not follow, the injurious local aifections are much less liable to arise. The significance of sterility, from a medical point of view, then may be taken generally to be painful or imperfect sexual relations, some disease of the vulva, vagina, uterus, or ovaries, or disability on the part of the husband. Sterility is in itself a symptom or condition that may call for medical investigation and treatment, apart from the pain or other symptoms which take their rise in concomitant diseases. In discussing the subject it is necessary to bear in mind the distinc- tion between sterility in a woman from conditions inherent in herself, and sterility with potential fertility. It would be convenient if we could differentiate these cases by the appropriation to each of definite terms. Thus we might say a woman was "sterile" whose inherent conditions precluded her from conceiving, and we might say a woman was " barren " who was in every respect apt to conceive, but who re- mained childless, because, first, the fertilizing element was wanting ; or, secondly, because if she conceived, the ovum did not come to maturity. We should fall into grievous error, however, if we were to conclude that sterility always implied an abnormal condition of the sexual organs in either the man or the woman. jSTumerous instances prove that sterility may be relative only. Certain degrees of affinity seem to be unfavora- ble to fertility. Upon this subject Captain Galton has adduced many most interesting and valuable historical and statistical illustrations. Thus, he shows in his book on " Hereditary Genius " how evil is the influence of consanguineous marriages. The historv of the Ptolemies is especially striking. Alexander the Great had for half-brother Ptolemy I, king of Egypt. This king had twelve descendants, who became also kings of Egypt, and all were called Ptolemy. They were matched in and in like prize cattle, but these near marriages were unprolific. The inheritance mostly passed through other wives. Ptolem}^ II mar- ried his niece, and afterwards his sister; Ptolemy IV married his sister. Ptolemies VI and VII were brothers, and they both consecu- tively married the same sister ; Ptolemy VII also subsequently married his niece ; Ptolemy VIII married two of his own sisters consecutively. Ptolemy XII and XIII were brothers, and both consecutively married their sister — the famous Cleopatra. Captain Galton also shows the bad influence of marriage with " heiresses." Heiresses are presumptively single children, the feeble fruit of worn-out stock. Many peerages have become extinct through this. One-fifth of the heiresses have no male children at all, a full third have not more than one child, three-fifths have not more than two. It has been the salvation of many families that the husband outlived the heiress whom he first married, and was able to have issue by a second wife. " I look," says Galton, " upon the peerage as a STERILITY. 109 disastrous institution, owing to its destructive effects upon our valuable races." The researches of Captain Galton are confirmed by those of Sir J. Simpson on the fertility of the peerage. Thus Sir James found that out of 495 marriages in the British peerage 81 were without issue, giving 1 in 6.11 as the proportion of sterile marriages; whilst 675 marriages in the villages of Grangemouth and Bathgate, one being agricultural, the other seafaring, gave 65 sterile, or about 1 in 10. The available materials for estimating the proportion of sterile women are very scanty, so much so that no precise deductions can safely be drawn from them. Indeed, here, as in so many other cases where the phenomena of life are concerned, the complicating conditions, and therefore the sources of fallacy, are so numerous that it is almost im- possible to isolate the bare fact of sterility, the word being taken to imply incapacity, absolute or temporary, to bear children, in any con- siderable number of instances^ so as to make up a statistical column, all the constituent elements of which shall have equal significance. Under the usual statistical process there remains nothing but a caput mortuuin, from which all the facts, all the truth, have been sublimed away. As a matter of general political interest, however, it may be stated that Dr. Farr calculates the mean fruitfulness of marriages in England in ordinary periods to be in every 100 marriages 420 children, giving an average of 4^^^ children to every marriage. The subject is pursued in many of its bearings in Dr. Matthews Duncan's work on " Fecundity, Fertility, and Sterility." All speculations and calculations of this kind are obviously of little use in elucidating medical problems. The practical physician deals with the concrete, he has to study the individual case that comes before him, to search out the conditions associated with the particular disorder for which relief is sought, to endeavor to estimate the influence these conditions may exert upon the disorder, and by removing as far as he can all presumed interfering conditions, to enable nature to resume her course. Applying this, the clinical method, we find that sterility in woman may be either congenital or acquired; it may be absolute and incurable, or relative and temporary. The cases may be ranged under the follow- ing heads : 1. Those in which ovulation does not take place; or, if taking place, the escape of the ovule from the ovary is prevented. The ovary may be absent, in which case there will probably be absence or im- perfect development of the uterus also. The ovary may be diseased, so that the Graafian follicles, quoad their proper structure, may be destroyed. The ovaries may be covered with false membranes, form- ing an investment through which the ova cannot penetrate. There may be a general or local failure of nutrition arresting the maturation of ova. In such cases menstruation is generally absent. This con- dition may be temporary ; indeed, it is often cured by appropriate constitutional treatment. It is exceptional for women who do not menstruate to conceive. But Bischoff relates a case which appears to 110 STERILITY. show that an ovum may ripen; the menstrual flow occur, and sterility ensue, because the follicle does not burst. The ovum may decay in the Graafian sac. A not uncommon result of protracted difficulty of ovulation is gradual atrophy of the ovary, and hence entailed sterility. This fact is an illustration of the general law, that if an organ is long left idle it is apt to degenerate in structure, and to lose its functional capacity. Scanzoni further suggests that a diseased ovary may pro- duce diseased ova. 2. Those in which the ovum may mature and escape from the ovary, but in which its due progress along the Fallopian tube and into the uterus is prevented. This is the case when the Fallopian tubes are absent, twisted, or severed ; occluded by strictures, or false membranes ; ■where the fimbriae are absent (Baillie) ; where there is multiplication of the abdominal orifices, and pavilions (Richard) ; where the fimbriae are bound down to neighboring structures, so that they cannot be brought into apposition with the ovary. This was described by Ruysch. The uterus itself may be absent, or, as Courty calls to mind, may have no cavity. Fibrous tumors growing at the uterine orifices of the tubes, blocking them up, or in the walls of the uterus, especially of its lower segment and neck, by compressing and distorting the canal, may cause sterility. Indeed, when fibroid tumors exist, im- pregnation is comparatively rare. 3. Those in which obstruction is interposed to the meeting of the spermatozoa and ovum. This order necessarily includes the preceding cases ; for the obstruction which arrests the progress of the ovum will equally arrest that of the spermatozoa in the oj)posite direction. But to the causes which arrest the ovum must be added those which block out the spermatozoa, as atresia, congenital or cicatricial, of the os uteri, vagina, and vulva ; those which produce closure or deviation of the uterine canal, as excessive involution or atrophy, tumors, polypus, versions, flexions ; certain peculiar formations of the uterus, especially of its vaginal-portion, as a narrow os externum, excessive length ; excessive hypertrophic elongation of the vaginal-portion, whether original or acquired, offers a decided obstacle to impregnation. It is a not uncommon cause of dyspareunia. For this double reason I have amputated the part with success ; tolerance of the sexual function, im- pregnation, and natural labor ensuing. Dupuytreu, Huguier, and others have related cases in point, and Scanzoni relates one in which impregnation followed six weeks after amputation of the hypertrophied posterior lip. Excessive development of the labia vulvae may prove an obstacle to intercourse. In such a case resection is indicated, and may be safely performed. Some cases of double uterus and vagina, as the following : Dr. Laa- ser describes^ the case of a lady who had been married several years without pregnancy. On examination it was found that the finger entered easily into a capacious vagina of normal length, which ended above in a nearly blind sac. There was only a rudiment of a vaginal- 1 "Monatsschrift fiir Geburtskunde," 1864. STEEILITY. Ill portion without os uteri ; but there was a longitudinal septum forming a smaller vagina, which latter was surmounted by a portio-vaginalis and OS uteri. It was presumed that the uterus was also double. The sterility was accounted for by the blind vagina only being used, the vagina connected with the normal cervix being pushed aside. The septum Avas slit, so as to throw the two vaginae into one. Inflammatory diseases which induce hypertrophy, or other changes of structure or form, 4. Those in which there is some imperfection in the performance of the sexual act. If A-^elpeau and Rainey be right in their- view of the use of the round ligaments in drawing forward the fundus of the ute- rus, so as to throw back the os uteri into direct relation with the penis during ejaculation, and if this relation is as a rule necessary for im- pregnation, the reason why women who are the subjects of flexions, dis- placements, and disease of the uterus are so commonly sterile, is partly explained. This relation is absent in many cases where the vagina is unduly short, where the uterus seems set too low down in the pelvis, and where — under the effect of intercourse — the vagina is gradually lengthened by stretching into a pouch extending considerably above and beliind the os uteri. In many cases it is not simply the flexion which prevents impregnation by distorting the uterine canal and throwing the os uteri out of relation, but the secondary accidents, as inflammation or congestion, attended by unhealthy secretions, which act adversely. It is of course necessary that the seminal fluid should be retained. But there are cases, including many in which the vagina being too short, shallow, and irritable, it is forcibly expelled by spas- modic contraction. It has been said that spasmodic stricture of the OS internum may cause sterility ; but the reality of this condition is not easy to prove. I have also known many cases of extreme gaping of the vulva, from laceration of the perineum, in which impregnation did not take place until the normal condition was restored by operation. 5. Those in which unhealthy secretions are formed, unfitted for the maintenance of the vitality of the ovum and spermatozoa. Donn6 ob- served that some kinds of vaginal secretion instantly killed the sperma- tozoa. The qualities shown to be uncongenial are excessive alkalinity of the cervical mucus, excessive acidity of the vaginal mucus, the mu- cus of uterine catarrh, and other abnormal secretions ; indeed, any se- cretion excessive in quantity, amounting to leucorrhoea, is also likely to have an unfavorable effect. Menorrhagia is often attended by sterility. Sterility where a vesico-vaginal fistula exists is not, of course, a nec- essary result, but it is nevertheless frequent. Treatment. — Examining the foregoing summary of causes from a therapeutical or practical point of view, it will be seen that there is one order of cases in which the sterility is absolute from defect of structure or other conditions which cannot be removed, and which render im- pregnation impossible. The number of such cases is not great. We see another order of cases in which there exists some mechanical obstacle, congenital or acquired, which may be removed by surgical operation. The number of these cases met with in practice is consid- 112 STERILITY. erable. Fecundity in these exists potentially. It is only necessary to remove the obstructions. We see another order of cases in which actual proof of fecundity has been given by the birth of a child. With this one eifort the capacity seems to be exhausted, at least for a time. This is " acquired sterility." This condition is in some cases due to excessive involution of the ova- ries and uterus, which shrinking, appear to undergo premature senility. In other cases it is due to the flexions, hypertrophies, subacute inflam- mations attended by unhealthy secretions which sometimes follow labor. In these the sterility commonly ceases with the cure of the abnormal condition. In some, however, in which there has been pelvic periton- itis, the ovaries and tubes may have been involved in membranous ad- hesions which impede the escape of ova or their reception into the tubes. But it must not be supposed that pelvic peritonitis is at all a necessary cause of sterility. I have known many cases where there was no in- terruption to sulDsequent pregnancies. Peritonitis may cause temporary sterility by binding down the uterus in an unfavorable position, espe- cially in retroversion. This will often admit of cure by wearing a suita- ble lever-pessary, which, constantly tending to lift up the fundus, puts the adhesions on the stretch, and gradually causes their removal by ab- sorption. 6. Those cases in which the mucous membrane of the uterus is un- fitted to afford a nidus for the impregnated ovum. Thus there is a class of cases — and it is a large one — in which pregnancy fails, not because there is an obstacle to impregnation, but because the structures upon which the ovum should be grafted and supported are not in a condition to perform their part. In such an event the ovum, falling as it were upon bad soil, decays. The break-down occurs at variable periods. In many, probably, the ovum hardly gets any hold of the unhealthy mu- cous membrane or decidiia. In many others, the mucous membrane undergoes the proper development for a stage, then breaks down. In many cases also there is little doubt that the ovum itself, although im- pregnated and ingrafted on the decidua, perishes from inherent defect. We thus see how, by a large class of cases, sterility is brought into re- lation with abortion. It may seem paradoxical to say that many of the causes of sterility are also causes of abortion ; but the proposition is nevertheless true. Some of the conditions above described, such as a minute os uteri externum and flexions of the uterns, do not oppose ab- solute obstruction to impregnation. But when this occurs, especially in the case of retroflexion, abortion is very apt to ensue. The same is true of hypertrophy, engorgement, ulceration, attended or not with dis- placement. In these conditions impregnation is not very rare, but the unhealthy state of the organ will be apt to lead to abortion. There is a kind of hyperplasia of the mucous membrane, sometimes depending upon a strumous, sometimes upon a syphilitic diathesis, which is very unfavorable to the support of tlie impregnated ovum. It is liable to undergo fatty degeneration and to break down. Abortion is the result ; and when this happens, as it often does, repeatedly, other chronic changes, as hypertrophy, engorgement, are more and more likely to en- sue, and to add new obstacles to impregnation and gestation. STERILITY. 113 Ovarian irritation is also likely to cause sterility and early abortion, especially when it leads to menorrhagia. Excessive and prolonged flow will so alter the mucous membranes that it becomes unfitted to form healthy decidua. And if impregnation have occurred, the ensuing men- strual nisus, too powerful to be controlled by the pregnancy, may be attended by a profuse hemorrhage which brings about extravasation into the decidua, or such other disturbances in the uterus as are incom- patible with the maintenance of the ovum. In many cases of this class it is difficult or impossible to determine whether impregnation have taken place or not, that is, whether or not the case be one of early abor- tion. The practical result, however, is the same, and the indication for treatment is the same. Correct the unhealthy state of the uterine structures, allay the morbid irritability of the ovaries, and not only will impregnation be likely to occur, but the ovum may be supported and matured. By far the most common associated conditions with sterility, in my experience, are congenital narrowing of the os externum and retroflex- ion of the uterus. These conditions are frequently combined. They are commonly attended by dysmenorrhoea ; and dysmenorrhoea is often presumptive of sterility. The importance of this narrowing of the os externum uteri as an obstacle to impregnation is questioned by some physicians, and amongst others by Scanzoni. He urges that he has known impregnation take place where the os externum was no bigger than a millet-seed. Of this I too have seen examples, but I am satisfied from very extensive observation that these cases are quite exceptional. So preponderating is the association of a minute os externum and retro- flexion, separately or combined, that in any given case of a woman who remains sterile five years after marriage and suffers from dysmenor- rhoea, it may be predicated with almost certainty that one or other of these conditions exists. That these are efficient causes of sterility is further proved by the frequency with which pregnancy follows upon their removal. Of this I have seen many striking examples. Two sisters, both young, were referred to me by their brother, a former pupil. Both had always suffered from dysmenorrhoea, which had been increased by marriage, and both remained sterile after two to four . years. In both I found exactly the same congenital formation, namely, retroflexion of the uterus and a minute os externum. In both I divided the OS externum and corrected the retroflexion by the use of a Hodge pessary. Both were relieved of the dysmenorrhoea, became pregnant, and bore children. This subject will be further discussed under the head of "Dysmenorrhoea." The waters of Schwalbach and Kreuznach have acquired a certain reputation for the cure of sterility. It is true that a number of women have become pregnant after visiting these places; but I have good rea- son for saying that in some of them at least the happy result was not due to using the waters. Some had previously tried them in vain, and having subsequently been submitted to surgical treatment for the re- moval of physical impediment, had returned to ScliAvalbach or Kreuz- nach, and then conceived. In some cases, however, those for example which depend upon chronic engorgement or hypertrophy, with un- 114 STERILITY. healthy secretions, the influence of change of air, repose, and the use of saline chalybeate and iodized M^aters in curing these conditions is de- cided ; and these being cured, the attendant sterility will often disap- pear. With this qualification, I can speak well of Schwalbach, Kreuz- nach, and other places ; but they do not deserve the blind faith which many patients and some physicians award to them. The rational course is to remove all abnormal local conditions first, and then, but not till then, the patients may be sent to Schwalbach or other con- venient place for time to do the rest. The above-mentioned conditions account for a large proportion of the cases of sterility. All these conditions may, in the majority of in- stances, be remedied, and in all the prospect of impregnation is rea- sonable. That disappointment in this respect will occasionally follow, even when a detected associated morbid condition is removed, is no valid argument against treatment. It is sound practice to remove every abnormal condition we can. It is possible that any given abnor- mal condition which we discover, and which we know is in itself suffi- cient to entail a certain result, may be the only cause. It is of course possible that another cause lying beyond the first may coexist, and con- tinue after the first is removed; but there is no harm done in removing the first. On the contrary, the first detected condition is often the cause of other evils beside the particular one which it is our special ob- ject to cure ; and it not infrequently happens that the removal of one condition opens the way to the discovery and cure of other conditions. In short, the obvious principle of acting is to obtain as healthy a state as possible of the genital organs. The vulva, vagina, and uterus, and in some cases the Fallopian tubes, are within our range. When this portion has been brought into a satisfactory state, and when all morbid action of the ovaries has been subdued, we shall have overcome a very large proportion of the causes of sterility. The residuum wall comprise those cases of obstruction from adhesions of the tubes and ovaries, of ovarian disease or defective development, which are mostly beyond the reach of successful treatment. Sterility being, in so far as the fault lies in the woman, a consequence of some abnormal condition of the sexual organs, the treatment of it is involved in the treatment of these abnormal conditions. These cover a wide range of ovarian and uterine pathology, and form the subject- matter of this work. Sensual gratification is not necessary to conception ; neither does its absence preclude conception. The essential condition is that the fer- tilizing element should have ready entrance to the cervix uteri at the right time. Failure in this condition may result from a variety of causes in persons to whom no fault of structure in the ovaries or uterus can be found. Ovulation may be perfect, the Fallopian tubes and uterus may be healthy, the elements on both sides may be normal, and yet there may be persistent sterility. It is difficult to follow out this subject minutely. Some of the conditions referred to hardly fall within the scope of strictly medical discussion. It is not, however, out of place to remember that the cause of sterility may reside in the man. It is customary to say that sterility in man is ex- THE aYNJECOLOGIST's BAG. 115 tremely rare. I am inclined to think otherwise. It does not fall within the design of this work to investigate the causes of sterility in the male sex. But I may refer to a memoir by Mr. Curling^ for some interest- ing information on this subject. He confirms by precise observations the opinion expressed by John Hunter, " that when one or both testicles remain through life in the belly, they are exceedingly imperfect, and probably incapable of performing their natural functions." Thus, Mr, Curling shows that in cryptorchids the seminal fluid is commonly desti- tute of spermatozoa. In nine men this was ascertained to be the case, and their wives were barren. Several of these did not seem to be de- ficient in copulative power, and emissions occurred. When, therefore, we find no marked abnormity in the wife, we must consider the possibility of defect in the husband ; and it will be proper, before subjecting her to a distressing and perhaps painful course of treatment, to ascertain whether the fault is not on the other side. OHAPTER XV, THE INSTKUMENTS SERVING FOR DIAGNOSIS AND TREATMENT. Having taken a cursory survey of the principal symptoms, chiefly subjective, attending ovarian, uterine, and vaginal disease, the methods of investigation by which we bring out the objective signs and seek to establish a full diagnosis might now be described. But as the means to be employed in this investigation involve the use of instruments, I have thought this would be the most convenient place to introduce a description of the instruments employed and the mode of using them. Having become acquainted with our tools, and knowing what they can do, we shall then be in a better position to proceed to diagnostic analysis. The Gyncecologisfs Bag. . It will serve the purpose of order and conciseness if we gather into one view the chief instruments and materials employed in the diag- nosis and treatment of the diseases of women. This may be conveni- ently done by describing the contents of the gynaecologist's bag, which has been designed on the idea of the " obstetric bag " contrived by me some years ago. Independently of reasons of economy and method for collecting all these things into one compact portable case, stands ' Brit, .arad For. Med -Ohir. Review, 1«64. 116 THE gy:n^cologist's bag. the great practical fact that, when about to investigate a case of pre- sumed ovarian, uterine, or vaginal disease, we cannot tell what instru- ments we may want to carry out the indications in diagnosis and treat- ment which may present themselves. For example, all local examina- tion necessarily begins with the digital touch ; this may be sufficient, but often it gives information which is imperfect, and which requires to be followed out by the speculum or sound; and when we have got the full diagnostic knowledge which finger, speculum, and sound can give, it frequently happens that we are immediately in a position to apply an appropriate remedy. Thus diagnosis is made the true hand- maid of treatment. The patient is often spared the double distress of two separate examinations. It is in this quality that lies the highest recommendation of the diagnostic instruments we employ ; it is this quality which invests them with a practical superiority over most of the instruments employed in the investigation of diseases of other parts of the body. The stethoscope, for example, an instrument invalu- able, but not absolutely indispensable, for diagnosis, and thus helping to form a scheme of treatment, is of no use in carrying out the treat- ment. Like the sphygmograph or the thermometer, it is purely an instrument of observation. It would appear to be a natural classification of our appliances to divide them into diagnostic and therapeutical. Rigorous adherence to this is defeated by the double qiiality which some of the instruments possess. But still this division is rational and convenient. It is not, perhaps, superfluous to preface the enumeration and de- scription of instruments by recalling attention to the hand and eye of the physician. The eye, of course, is simply an instrument of observa- tion ; its application is often only possible when aided by other instru- ments, as for instance, the speculum ; and in a great many cases it is not wanted either for diagnosis or treatment. But the hand is pre- eminently the obstetric instrument; it possesses a wide diagnostic and therapeutical range of usefulness; it is not only in itself compe- tent to the detection of many morbid conditions, and to the treatment of some, but it is also an indispensable element in the use of other instruments. I have ventured to make these remarks about the hand because the use of the speculum and sound in diagnosis is so very great and strik- ing, that we are apt to attach to this more importance than is really due, and thence to underrate the value of the hand. The Diagnostic Instruments are : The speculum. The endoscope. The speculum-forceps. The uterine sound. A flexible whalebone sound. The sponge or laminaria-tent. The Therapeutical Instruments are : The uterine sound. The catheter. THE gynecologist's BAG. 117 The speculum-forceps, Simpson's metrotome-knife. Marion Sims's or Kiichenmeister's metrotome-scissors. Wright's intra-uterine expanding pessary, or other intra-uterine pessary. Sims's single tenaculum-hook to hold the vaginal portion. A wire ecraseur. The intra-uterine caustic-carrier. " " ointment-carrier. The tube for carrying sticks of sulphate of zinc, or other sub- stances, into the uterus. Barnes's laminaria-tent carrier. A scarificator. EiOuth's lancets. An intra-uterine injecting apparatus. A probang mounted with sponge. A glass rod and a glass brush to carry bromine or chromic acid. A syringe for washing out the vagina. The most useful Ilateria Medica are: Perchloride of iron (solid). Chloroform and inhaler (Skinner's is the most portable, and very efficient). Chromic acid, in crystals. Richardson's styptic colloid. Bromine of caustic power. Carbolic acid. Tincture of iodine. Acetic acid, concentrated. Nitrate of silver. Sticks of potassa cum calce. Sticks of sulphate of zinc. Iodide of mercury ointment. Medicinal pessaries : 1. Perchloride of iron pessaries. 2. Belladonna. 3. Morphia. 4. Gallic acid. The following articles should also be at hand in the bag : Cotton-wool, lint. String, silk. Needles, half-curved, carrying silver wire. Forceps for holding needles. A small collection of pessaries. (The most useful are three sizes of Hodge's lever-pessaries.) ■ One or two of Thomas's pessaries for anteversion. One or two of Simpson's intra-uterine galvanic pessaries. A stem-pessary. A vulcanite intra-uterine pessary. A Sims's or Barnes's vaginal rest. A Gariel's or other air pessary. 118 SPECULUM. The pessaries will be described in a succeeding chapter. The stethoscope and thermometer are, of course, the constant com- panions of every medical practitioner. Instruments for use hy Patients : Higginson's vaginal syringe. Barnes's speculum for self-application of vaginal pessaries, and wool carrying solutions of lead, bromine, &c. The special requirements of particular cases, or the views of the practitioner, will suggest further or different things to make up the equipment of the bag. My object is to enumerate those which are the most generally useful. Some of the articles require a more particular description. To take first the speculum. In private practice, the most generally useful spec- ulum is Fergusson's glass tubular instrument, silvered and coated with vulcanite (Fig. 30). The light this gives is superior to that which any other form of speculum can give; and this is an advantage of primary importance, for we cannot always in the houses of patients command a good direct horizontal light. Two sizes should be kept : one of compara- tively large size for women who have had children, and one of small calibre for others. Both should be six or seven inches long, otherwise the vagina may not be distended enough to bring the os uteri into view. The tubular speculum has the disadvantage that, when introduced its full length, it possesses no power of increasing the distension of the fundus of the vagina, so as to bring out the vaginal-portion from be- hind overlapping folds of a lax vagina ; therefore, unless an instrument of adequate size be used, it may fail to exhibit the os uteri. It is also liable to break if it falls upon the ground. Good valvular specula overcome this difficulty. Being introduced their full length in a closed state, the blades can be opened at their extreme points so as to stretch out the folds at the roof of the vagina, and thus bring the os uteri well into the field, without in any way increasing the distension at the vulva. One might devote a volume to the description of the multitude of instruments, each of which, in the estimation of its contriver, is the best. Some are designed to an- swer particular indications ; for example, to be self-retaining, to liber- ate the hands, and thus to facilitate the performance of operations. This is a good reason for introducing a new speculum. But many, it must be admitted, have no better raison d'etre than the gratification of a taste for novelty, the passion of mechanical invention, or the am- bition to associate something with one's name. After studying many, I am afraid to say most, of these contrivances, and submitting many to clinical proof, I think we may usefully retain the following : 1. The tubular glass speculum already described ; 2. The bivalve, known as Coxeter's, or Dr. Henry Bennet's (Fig. 31). This is an excellent instrument. If furnished Avith a plug, it is very easy of introduction, and the two expanding blades command good access to sight and sur- gical application. I have used it for many years, having made two slight modifications in it, which much facilitate its use. In its ordinary SPECULA. 119 form this speculum, when closed for introduction, is a cylinder, slightly conical, the two blades being of equal length. The practical defect of this is, that when the stem-plug is in situ, the projecting margin — Fig. 30. Fig. 31. Fergusson's Speculum. (Half natural size.) Dr. Henry Bennet's Speculum, as modified by Dr. Barnes. (Half size.) made to fit on the edge of the ends of the blades, so as to protect the vulva and vagina during introduction — is not easily released when it is wanted to withdraw it ; it hangs upon the end of one blade. This awkward defect is overcome by flattening the cylinder a little, so as to make the closed instrument slightly oval in section, and also by bevel- ling off the ends of the blades, leaving one slightly longer than the other. The effect of this double alteration is, that when the operator turns the plug on its axis, the projecting rim is immediately thrown off the end of the blades, and is generally thrown out by the contrac- tion of the vagina, or, at any rate, is easily withdrawn. The total length of this instrument should be 5J inches, exclusive of the plug; the circumference at the uterine extremity, 4 inches; at the handle extremity, 5 inches. The bivalve has another advantage over the simple tube. As the 120 SPECULUM. Fig. 32. uterine ends of the blades expand, it is not only more easy to bring the vaginal portion into the field, but by continuing the expansion, the roof of the vagina is put on the stretch, and thus pulls open the os uteri, exposing often a considerable part of the cavity of the cervix, and thereby much facilitating the direct application of remedies. 3. A very useful form of bivalve is that known as Cuseo's (Fig. 32). The blades are wide and nearly flat, so that, when brought together, they touch along the whole extent of their margins, and represent a wedge with smooth edges. This makes the plug superfluous. It is not, however, quite so easy to introduce; some care is requisite to keep off the rather narrow edge from the os pubis. When introduced, the screw at the handle expands the blades at the uterine end and distends the vaginal roof in a very effi- cient manner. This instrument is in many cases self-retaining. It is virtu- ally a double duck-bill speculum. I have found it useful to increase by an inch or more the part in which the screw This takes the hand clear of the range of vision, and the screw from entangling the pubic hair. 4. Marion Sims' s Single Duck-bill or Spoon Speculum (Fig. 33.) — This is a most serviceable instrument. It is almost indispensable in Cusco's Speculum. (Half size.) is worked at the handle. Fig. 33. Sims's Speculum. the performance of protracted operations, such as the closure of vaginal fistulse. It is not, however, so convenient for ordinary practice. In many cases an additional instrument to serve as a retractor to hold back the anterior vaginal wall is required ; and this makes an assistant necessary. SPECULUM. 121 5. If there is one speculum better than the rest for hospital practice, it is Neugebauer's. This consists of two distinct pieces. It is at once a bivalve and a double duck-bill. It is made in sets of six or more single blades, so graduated in size that No. 2 adjusted with No. 1 makes a complete speculum ; No. 3 with No. 2, and so on through the series. Nos. 1 and 2 form a speculum large enough for the most capacious vagina; whilst Nos. 5 and 6 can be introduced into the smallest. Unless the patient's nates can be brought to overhang the end of a table or bed, in lithotomy position, this instrument can only be used in the lateral or semi-prone position. It requires two hands, one to hold each blade, which is not inconvenient for mere diagnosis, but renders it necessary to have an assistant to hold one blade, if treatment is to be carried out. These conditions render Neugebauer's instrument generally unsuitable for private practice. Fig. 34. Barnes's Modification of Neugebauer's Speculum. (Half size.) Finding that, when dealing with stout patients, the handles of Neu- gebauer's instrument were too short to be easily commanded, I have made what I find in practice a very convenient modification. I have substituted for the handle another blade. Fig. 34 represents the form thus designed by me, and executed by Messrs. Weiss. Two pieces make a series — three different sizes of speculum. The gradation is effected by having Nos. 1 and 3 in one piece, and Nos. 2 and 4 in the other. By using No. 1 with No. 2, we get the largest size; by using No. 2 with No. 3, we get the next size ; by using No. 3 with No. 4, we get the smallest size. The ends outside the vagina form excellent handles. In many cases this instrument is sufficiently self-retaining to afford the manipulator the opportunity of applying remedies to, or even of 122 ENDOSCOPE UTERINE SOUND. performing operations upon, the cervix uteri without assistance. It gives freer space for operative manipulation than any other speculum. It brings the os uteri so near that it is commonly easy to reach it by the finger. The tubular and valvular specula afford a perfect inspection of the whole tract of the vagina and vulva. The time for making this in- spection is during the withdrawal of the instrument. As this is slowly done, the vaginal walls close in upon the retreating speculum, and come successively within its field. Except in very extreme cases of relaxa- tion, the contractility and resilience of the vagina are powerful enough to aid in expelling the sjDeculum. Weiss's Self-retaining Duck-bill Speculum. — This instrument is the adaptation of an ajDparatus for fixing a duck-bill or Sims's spoon-blade in the vagina, so as to dispense with the use of hands to hold it in situ. In this way many operations may be conveniently carried out without assistants. I have used it, and find that it answers its purpose. All the above-described specula, excepting Fergusson's^ should be plated with nickel. This gives a beautifully smooth surface, which resists the action of many of the corroding agents employed, and is easily kept bright. The Endoscope. — In connection with the speculum, it is proper to refer to the endoscope, which may be defined as a prolongation or ex- tension of the ordinary speculum. The design of the uterine endoscope is to enable the surgeon to see beyond the os uteri externum into the cavity of the cervix, and even into the cavity of the body of the uterus. Several ingenious instruments have been contrived for this purpose. One, that of Jobert, consists virtually of a small two-bladed speculum, capable of being introduced closed into the cervix uteri. The two blades being mounted on a long stem are, after introduction, made to diverge by working a screw in the handle. It resembles in principle and ac- tion Weiss's urethra dilator. Another contrivance that may be men- tioned is that of Tyler Smith.^ This instrument is applied through a modified Cusco's speculum. It consists of a mirror and a cylindrical tube both provided with long handles. By means of a screw the mir- ror can be inclined at any angle, so as to receive and transmit a ray of light through the tube which is passed into the uterine cavity. The Uterine Sound is an instrument designed on the principle of the sound made to explore the male bladder. It is a special form of the surgical probe. The probe, indeed, or some form of it, has long been used to facilitate the exploration of the uterus. Its application to the diagnosis of polypus from inversion of the uterus is described in the early editions of Samuel Cooper's "Surgical Dictionary." Huguier says the uterine sound was known to Hippocrates. Harvey relates a case in which he used an equivalent instrument for the express purpose of exploring the cavity of the uterus. But still the application of the sound to uterine examination, an application which would seem to flow so naturally from the familiar use of the instrument in investi- gating the condition of the bladder, remained in abeyance until it was 1 Obstetrical Society's Catalogue of Instruments, 1867. UTERINE SOUND. 123 revived by Lair, who described a uterine sound in 1828.^ The late Sir James Simpson, in 1843, made known his conclusions upon the mode of examining by help of a uterine sound or bougie, and de- scribed the form of instrument he recommended. His instrument is the one which I have selected for illustration in this work. It is the one which I most frequently employ. It is provided, like the common male sound, with a flat handle to facilitate manipulation, and termi- nates at its other extremity in a rounded knob or bulb, which enables it to ride more easily over the rugse of the cervical canal, and lessens the risk of injuring the uterus. The stem tapers gradually from the handle to the knob, the thickest part being equal in calibre to a No. 8 catheter, the portion near the knob being equal to a No. 3 catheter. The exploring half of the sound should be made of silver only mod- erately alloyed with copper, so as to permit of its being readily bent by the fingers. Some are made with virgin silver. This is too flexible, as it is apt to bend during use, especially in cases of flexion of the uterus. The stem is about nine inches long, and is graduated so as to indicate the depth to which it may penetrate. The graduation is marked in the figure. (Fig. 35.) There is one principal mark which is the most essential as a standard of comparison, made by an elbow or projection, just 2 J inches from the knob. This marks the normal length of the uterine cavity. When the sound has been introduced as far as this, resistance is commonly felt, and we know, by feeling the elbow on a level with the os externum uteri, that the knob is 2 J inches in the uterus. It is useful to have a mark between the elbow and the knob half an inch above the elbow. This is useful in giving precise measurement where the knob will not go the full distance. Below the knob the stem is graduated by inches. These secondary marks are best made by slight notches. There are different ways of making the index marks; but as Simpson rightly insists, the marks should be so made as to be readily felt by the finger in the vagina, so as to admit of being read oif when the instrument is withdrawn. The sound, as sold in the shops, is almost always bent at an obtuse angle at the 2J inch elbow, the two parts above and below being quite straight. It is more convenient in practice to give a slight curve to the part above the elbow. Yalleix, Huguier, and Kiwisch^ described forms of uterine sound differing from Simpson's chiefly in the mode of graduation. There are cases, notably those where the canal of the uterus is much deviated by tumors, where the use of the rigid sound is objectionable. In cases of this nature it is occasionally more useful to employ a flexi- ble bougie or sound. An ordinary male bougie is very suitable. Dr. Henry Bennet commonly uses bougies of soft material, which retain the impression of any constriction they may have passed through. Dr. Thomas uses^ a hard rubber sound, about 12 inches long, provided with a knob at the end similar to the figure (Fig. 36), taken from the 1 " Nnnvelle M^thode de Traitement des Ulceres de I'llterus." Paris, 1828. 2 " Klinische Vortrage." Prag, 1851. 3 •' Diseases of Women," third edition. Philadelphia, 1872. 124 UTERINE SOUND METROTOME. instrument which I use. This is made of whalebone, which is suffi- ciently flexible and durable, and is not likely, as the vulcanite one is, to break. My instrument is 15 inches long, not at all too long to Fig. 35. Fig, 36. Simpson's Uterine Sound. (Half size.) Fig. 37 Kiichenmeister's MetrotomeScissors. (Half size.) track the elongation of the uterine cavity produced by some cases of fibroid tumor. METROTOMES ECRASEUR. 125 The speGulum-force'ps should be about 12 inches long, and straight. It is sometimes made with an angle between the joint and the finger- holes, under the mistaken idea that when straight the handles and hand occlude the field of the speculum, and interfere with accurate manipulation. This objection is not real. There is a practical in- convenience in the handling of a bent forceps. It will not, for example, rotate handily, so as to wipe off adhering secretions, as the straight forceps will. The instrument should be toothed at the ends, and grooved longitudinally, so as to hold a rounded stick of nitrate of silver, or potassa cum calce. Metrotomes. — The instruments I employ to incise the cervix uteri are Simpson's metrotome, and either a scissors designed by myself or Kiichenmeister's. The reasons for this preference will be given when discussing the operation. Simpson's metrotome is really a bistouri cache, with a long handle. When closed, the blade and its guard or sheath form a rod about the size of a sound, which is easily passed into the cervix uteri. When there, by depressing the handle to an extent determined by a regulating screw, the blade is made to start from its guard, and cuts its way out. The guard is sometimes made double, so that the blade sinks back between the two parts. This is inconvenient. Wh^n the blade, after having cut, is allowed to fall back into its guard, the point is apt to pinch a bit of tissue in the guard, and the witlidrawal of the instrument is thus made awkward. A single guard answers quite as well, and is free from this little diffi- culty. (See Fig. 38.) - Barnes's 31etrotome- scissors. — This is a powerful scissors, having one blade probe-pointed to pass into the cervix. The blades are so made as to cut well at the points. They are worked, not by finger-rings, but by a spring between the handles, on the plan of the old-fashioned sugar-nippers. The handles are slightly curved, so as to enable the operator to see the cervix in the field of the speculum whilst working. Kiichenmeister's 3Ietrotome-scissors. — Ordinary scissors are not well adapted to make an incision clean through a rounded wedge-shaped body, which shall be of equal depth at every part. The blades are liable to slide away a little towards the finish of the stroke, leaving a spur of tissue uncut. To remedy this I have often completed the incision made by my scissors with Simpson's metrotome. But for some years I have used Kiichenmeister's scissors, one blade of which is provided with a small recurved hook. This buries itself in the tissue as soon as the part is seized, and holds it secure whilst it is being cut through. The instrument answers well. (Fig. 37.) Sims's Tenaculum Hook. — This is a very useful little instrument for seizing and holding steady the cervix uteri for examination, and during operations through the speculum. (Fig. 39.) The Wire-ecraseur. — Advancing experience has gradually proved the superior convenience of the form of ecraseur here illastrated. (Fig. 40.) For ordinary purposes, such as the removal of polypi, the single wire is far more convenient than the chain. The two ends of the wire are hooked on to the hook Mdiich travels in the screwed stem of the in- strument. The loop of wire, which has seized the body to be cut 126 METROTOME TENACULUM HOOK. through, is drawn through the flattened eye at the end of the stem with- out any sawing movement. This involves a considerable loss of power; but in the majority of cases this is of no importance. An advantage Fig. 38. Simpson's Metrotome. Fig, 39. Sims's Tenaculum Hook. possessed by this arrangement is that a much longer loop can be worked, since the loop comes down double ; whereas, when one end of the loop is fixed, and only one travels, the travelling end may be brought home ^CEASEUR TENT-CAERIEE. 127 too soon, that is, before the loop has cut through the tissues embraced in it. There is. however, the advantage of a half-sawing or cutting Fig. 41. Improved Wire Ecraseur Barnes's Instrument for Introducing Laminaria or Sponge-tents into the Uterus. (Half-size.) a. The hollow laminaria-tent. 6. The sponge-tent, c c. The stilets upon which the tents are mounted. action, which increases power. To obviate the inconvenience of the ends of the wire travelling home before the loop has done its work, 128 instrumejS'ts for treating diseased uterus. Messrs. Weiss have constructed a very powerful ^craseur, furnished with a windlass upon which the wire is wound as it is brought home. This gives practically an endless rope. It is a splendid instrument ; and iu some cases it will succeed where ordinary instruments will fail. To cut through large fibroid tumors a very powerful instrument is necessary. The Laminaria and Sponge-tent Carrier. — This is a very useful in- strument, contrived by me some years ago, to carry laminaria-tents into the uterus. It consists of a piece of elastic catheter having the end cut off, so that the stilet may project about two inches. Upon this portion of stilet the tent, which is hollow, is mounted. It thus makes one with the catheter, and can be passed into the uterus nearly as easily as the uterine sound. When the tent is in situ, which is ascertained by the guiding finger at the os uteri, the stilet is withdrawn ; the unsupported tent is then left in the uterine canal. This description shows that an efficient instrument can be improvised out of a catheter. But it is con- venient to have a special instrument. (Fig. 41.) Mine is provided with two sizes of stilets, which screw into the stem ; also with a pointed stilet to carry sponge-tents. These stilets are stowed in the handle, which is hollow. At the handle-end of the catheter or tube is a disk or shield which gives a point of resistance for the thumb, when the handle and stem are withdrawn. (Fig. 41.) The same instrument can be adapted to introduce Simpson's galvanic and other intra-uterine pessaries. The Intra-uterine Caustic Carrier. — My contrivance for the applica- tion of nitrate of silver to the os and interior of the uterus is an adap- tation of a plan which I learned, when a student, from Sir Benjamin Brodie. This illustrious surgeon used to arm the end of a silver probe by dipping it into fused nitrate of silver. With the probe thus armed he could cauterize a fistulous tract. I have had made a long probe mounted on a handle. The last three or four inches should be made of silver, platinum, or aluminium, so as to be flexible, as it is often con- venient to give a curve. The extreme end should be roughened so as to hold the fused caustic better. To arm it, proceed as follows : Fuse about half a drachm of nitrate of silver in a watch-glass or platinum crucible, over a spirit-lamp or small gas-flame ; dip into the fused caus- tic the end of the probe several times, so as to get several layers upon it. The probe should be moderately warmed in the flame before dip- ping, or the nitrate of silver will be apt to break off when cooled. (Fig. 42.) By means of this armed probe, caustic can be carried into the cervi- cal canal, and even into the cavity of the uterus, without any fear of leaving a piece behind. It may even be used without the speculum, although in doing this, unless it be guarded by a sheath, the caustic is liable to touch the vulva in passing, and to cause some irritation in con- sequence, and to blacken the surgeon's fingers. The Tube for Carrying Solid tSubstances into the Uterus. — To apply sulphate of zinc, chlorate of potash, and some other substances, it is Very convenient to fuse them into slender sticks of a given weight. To introduce these sticks into the uterus through a speculum by help of a forceps is a needlessly troublesome and sometimes difficult proceeding. INSTEUMEISTTS FOK TEEATING DISEASED UTERUS. 129 A far more simple way is to cut off the end of an elastic male cathe- ter, to place the stick in the end, and then to pass the catheter half an Fig. 42. }j a Fig 44. Barnes's Nitrate of Silver Cautery. (Half size.) Barnes's Tube for Depositing Fused Sticks of Sulphate of Zinc in Uterus. Barnes's Uterine Ointment Positor. The left-hand figure is full size. A, the sliding-piston, which, being pushed on after the catheter is in situ, expels the ointment. inch or more into the cervical canal, as you would a sound ; then by 9 130 INSTRUMENTS FOR TREATING DISEASED UTERUS. pushing up the stilet, the stick is deposited in the uterus, and the in- strument can be withdrawn. This can be done more easily without the speculum than with it ; and where an application of this kind has to be repeated once or twice a week, this is a great advantage, saving the patient annoyance and fuss, and the surgeon trouble. Instead of this improvised positor, it is better to have the special instrument figured. (Fig. 43.) This is a silver or nickel tube fur- nished with a stilet. The Tube for carrying Ointments, &c., into the Uterine Cavity. — It is often more convenient to make applications to the interior of the uterus in the form of ointment. For this purpose I have designed, with the assistance of Messrs. Weiss, a very handy instrument. It is a long silver, nickel, or vulcanite catheter, having two long eyelet- holes at the end, and a conical well-fitting piston or rod. It is easy to charge, by plunging the end of the catheter beyond the eyelets into the ointment, and wiping off the superfluity which hangs to the outside. The instrument is then passed like a sound into the uterus, and then the piston, being pushed forward, expels the ointment by the eyelets on either side, leaving it, of course, in immediate contact with the uterine mucous membrane. This is an especially useful way of treat- ing the uterine membrane affected by syphilis. The iodide of mer- cury ointment is thus readily applied. (Fig. 44.) An Intra-uterine Injecting Appay-atiis. — By means of the above con- trivances for depositing solids and ointments in the uterine cavity, the necessity for resorting to fluid injections is very much restricted. But an intra-uterine syringe is sometimes indispensable. A good form is a small vulcanite tube, having minute perforations at the sides — not at the end — so that fluid projected may escape in fine streams or drops. The propelling force is best obtained by a movable caoutchouc ball. Higginson^s Syringe for Vaginal Injection and Irrigatio7i. — There is no form of vaginal syringe more generally convenient for the patient's own use than that known as Higginson's. (Fig. 45.) It should be fur- nished with a vaginal tube four inches long. Barnes's Speculum for introduction of Cotton-ivool charged with Rem- edies into the Vagina. — The best way of introducing pledgets of cot- ton-wool charged with fluids or powders into the vagina is by help of the ordinary speculum. But this requires skilled assistance. To en- able the patient herself to carry out this treatment, I have devised the speculum figured (Fig. 46), manufactured by Krohne and Sesemann. It is made of vulcanite, a material not injuriously acted upon by the materials most frequently used. It consists of two blades, moving on a pivot about the middle, and a piston. The blades above the pivot are made to diverge by a spring inside; this divergence causes the blades below the pivot to come together, forming a hollow cylinder in which the pledget of wool is placed. The blades inclosing the pledget are further kept in contact by a strong elastic ring outside. When charged, the patient, by simply opening the vulva, can pass the in- strument into the vagina, directing the point backwards as far as neces- sary; then by compressing the external diverging blades, the internal ones are opened, and by pushing on the piston or rod, the pledget is INSTRUMENTS FOR TREATING DISEASED UTERUS. 131 deposited in the vagina. The speculum is then withdrawn by leaving off the compression upon the external blades. The action of this in- strument will be better understood by an illustration. It was suggested to me by the ingenuity of a lady whom I had advised to introduce pledgets of wool soaked in solution of bromine. She made use of a Fig. 45. Fig. 46. ll i^ /'\ Higginson's Vaginal Syringe. (Half size.) Barnes's Speculum (half size) to facilitate application of Med- icated Cotton-wool in the Va- gina. glove-stretcher to separate the labia vulvae, and then slipped in the pled- get with her fingers. My speculum is like a glove-stretcher, with the blades hollowed to protect the pledget whilst passing, and a piston to thrust it out into the vagina 132 DIAGNOSIS. The pledget of wool is tied round with a bit of string. This string hangs outside the vulva, and by means of it the pledget is easily with- drawn. No pledget should be worn longer than five or six hours. CHAPTER XVI. THE DIAGNOSIS OF DISEASES OF THE PELVIC OEGANS. THE TOUCH— THE SOUND— THE SPECULUM. The general knowledge we have now acquired of the value of sub- jective symptoms and of the instruments of diagnosis, will enable us to pursue with greater advantage those means which bring out the objective signs, and thus to gain all the possible elements of a complete diagnostic conclusion. One guiding rule should be impressed upon the mind of the young- practitioner, when he has a case of presumed disease of the pelvic organs under investigation. Do not concentrate all attention upon this one region of the body. Remember that the fault may be in dis- tant parts ; that disease in other organs may complicate disease in the pelvic organs. Do not, in short, fall into the deplorable snare of be- coming a specialist. Do not imitate the error of those physicians who, whilst rej)udiating the idea of being specialists, and who, when in the presence of a case marked by disorder of the nervous system, of the heart, lungs, or abdominal viscera, carefully explore the state of the organs contained in the skull, chest, and abdomen, yet scrupulously avoid exploring the not less important organs contained in the pelvis ; and that even although the symptoms point to disorder in this region. The great clinical rule should be : Interrogate all the functions ; examine every organ. In this way only can we acquire a well-founded confidence that important disease is not overlooked ; in this way only can we rightly estimate the relations of symptoms to disease, and the reactions of disease upon distant organs, and frame a rational plan of treatment. A work whose intention it is to illustrate the pathology of the pel- vic organs, must necessarily observe the limits of its design. The art of diagnosis, therefore, as applied to the pelvic organs, demands the most elaborate description. But in tracing this with almost exclusive care, as it must be done in a work ad hoe, it must not be supposed that general pathology or general diagnosis can ever be pretermitted in actual practice. DIAGNOSIS. 133 If it be admitted to be necessary to investigate all the functions of the body in connection with any presumed localized disease, ci fortiori it is necessary, in any case of presumed disease of one of the pelvic viscera, to examine the state of the rest, its immediate neighbors. Fig. 47. Skeleton diagram for recording alterations of size, position, and relations of pelvic and abdominal organs. We must then never neglect to inquire into the state of the bladder and rectum. These organs seldom escape all disturbance when the uterus, vagina, or ovaries are affected ; primary disease in them, in its turn, affects the uterus, vagina, and ovaries ; and not seldom, symp- toms seemingly indicative of disease in the uterus or vagina are really due to disease in the bladder or rectum. The order of clinical proceeding, then, may be laid down as follows : If a patient complain of distress referred to the pelvic organs, or disorder of their functions, note first the subjective symptoms ; 2, in- terrogate the functions of the nervous, circulating, respiratory, and 134 DIAGNOSIS. nutritive organs ; 3, elicit the history of the patient as to her general health, and the antecedents and course of her disorders ; 4, if the in- dications point to disease in the chest or abdomen, subject the organs contained in these cavities to physical exploration by sight, palpation, Skeleton diagram for recording alterations of size, position, and relations of abdominal and pelvic organs. percussion, measurement, auscultation, &c. ; 5, subject to physical ex- amination, by the methods hereafter described, the state of the pelvic organs, observing at the time, or reserving for chemical and micro- scopical analysis, the nature of the local secretions, or of solid sub- stances expelled ; 6, when all necessary information has been obtained, DIGITAL TOUCH. 135 compare the symptoms and facts in tlieir individual, relative, and aggregate significance, so as to work out the diagnosis which shall de- termine treatment. In taking down a case, it is well to follow the order indicated above ; and since " word-painting " can hardly be so graphic as actual drawing, it will be found of great service to attach to the notes diagrammatic memoranda of the position, shape, size, and other conditions of the organs under observation. These become extremely valuable as stand- ards of comparison during the future progress of the case, and by furnishing more intelligible records for other persons. To record these observations, outline or skeleton diagrams like those represented in Figs. 47, 48, will be extremely convenient. The idea of these will be found in one of the grandest memoirs on the diag-nosis of abdomi- nal tumors ever published, that of Dr. Bright, in Guy's Hospital Reports. I have, with the skilled assistance of Mr. Denison, librarian to St. Thomas's Hospital, designed these outlines. The physical exploration of the pelvic organs is conducted chiefly by the touch. The touch is applied either directly by the hand, or mediately through instruments. The touch is sometimes aided by sight, facilitated or not by the speculum or other contrivances for bringing concealed parts into view. The touch is also sometimes aided by the sense of smell. The touch takes precedence in importance and in order of appli- cation of all other methods. We may therefore usefully recall what Gooch said about the " tactus eruditus." " Some are of opinion that this art is a blind tact, to be gained only by practice ; but this is not true ; the period of my life when I improved most rapidly in the art of deciding by examination cases of doubtful pregnancy was that in which I gained clear and orderly notions of the objects of examination. The faculty of observation requires rather to be guided than to be sharpened ; the finger soon gains the faculty of feeling, when the mind has acquired the knowledge of what to feel for." The " tactus eruditus " may be defined as the " educated touch." How is the finger educated ? Greatly by practice in feeling the vari- ous conditions of form, size, consistency, and relations of the parts upon which this sense is to be exercised. But touch alone will never give perfection to the finger as an instrument of diagnosis. We must be content, if we would attain precision in its use, to imitate the ex- ample of children, who, in their earliest introduction to the study of external objects, correct the evidence of one sense by appealing to another. When they see a strange object they try to feel it also, and even to taste it. It is by this tentative method of cross-testing that children extend their knowledge of Nature. We must do the same. We too must correct touch by sight, and even call the senses of smell- ing, taste, and hearing to our aid. Those physicians who boast of possessing an " erudite tact " in vaginal exploration, and who have neglected the cross-testing by the eye, live in a fools' paradise, and must necessarily be frequently ^vrong in their appreciation of what they touch. Before the speculum and the uterine sound were brought to complete and correct the information given by the hands, a true " edu- 136 DIGITAL TOUCH. cated touch " could not exist. We should ridicule the physician who boasted of an " erudite ear/' and who, neglecting the cross-testing of dissection, ventured to pronounce dogmatically upon the existence and characters of vegetations upon the valves of the heart. So must we ridicule the pretensions of those who, relying upon their ignorant touch alone, venture to express an absolute opinion as to the presence or absence of uterine disease. Still more shall we be justified in ridi- culing those who venture to utter absolute opinions upon a given case, or upon general questions of ovarian and uterine pathology, without so much as using even their fingers. Their position is simply that of men who pretend to know what they have never taken the pains to learn. It is only, then, by an honest course of pathological study and the painstaking education of all our senses, separately and conjointly, that we can gain the true "tactus eruditis," "The mind, in short, must," as Gooch says, "first acquire the knowledge of what to feel for." It is with the hope of aiding the student in acquiring this knowl- edge that the preceding condensed estimate or analysis of the signifi- cance of the most ordinary symptoms and characters of ovarian and uterine disease has been worked out. Manual examination, or exami- nation by touch, embraces the following modes of exploration: In some, one or both hands only are used ; in some, the hand is aided by the sound or other instrument. 1. Simple vaginal touch, by one finger. 2. Ahdomino-vaginal. — The vaginal touch is aided by abdominal palpation with the other hand. 3. Simple I'ectal touch. 4. Recto-ahdominal. — The finger in the rectum is aided by abdomi- nal palpation. This mode is often useful in determining the size and relations of the uterus, the complication with uterine or extra-uterine tumors, or the existence of the uterus in vaginal atresia. 5. Recto-vaginal. 6. Urethro-vaginal. — The finger in the vagina is aided by the sound in the urethra. 7. Urethro-rectal. — The finger in the rectum is aided by the sound in the urethra; indispensable in investigating cases of vaginal atresia. 8. Simple abdominal palpation and percussion. 9. Uterine exploration by the sound, 10. Utero-abdominal. — The sound in utero is aided by abdominal palpation. 11. Utero-rectal. — The sound in the uterus is aided by rectal touch. 12. Examination by Speculum. — Here the sight is the main source of information. 13. Examination of the secretions, discharges, or substances expelled. Exploration by the Hands. Examination by the hand should always precede the use of instru- ments. Because — 1st. In many cases the information gained by the hands is sufficient. 2d. In some cases, notably in cancer, in which DIGITAL TOUCH. 137 sufficient information can be gained by the hands, instruments may do positive harm. The Mode of Making a Digital Examination. The patient is placed either in the lateral or dorsal decubitus. Each position has its advantages. In making a first exploration for diagno- sis, it is most convenient to place her first on her left side, the knees drawn up, the head and shoulders directed obliquely across the couch, on a level, or nearly so, with the nates, and the nates brought near the edge of the couch. This affords perfect facility for digital touch, also, for the sound ; and often for the specuhim. If the patient lies on her left side, the surgeon will find it best to use his left hand, for then his right hand is conveniently disposed for palpation above the pubes, and to examine in concert with the finger of the left hand in the vagina. If he can only touch with his right finger, he must cross his left hand awkwardly over his right to get at the abdomen. It would be better in this case to place the patient on her right side, when things will be disposed conveniently for the right-handed surgeon. But the obstetric surgeon, like his ophthalmic brother, ought to be ambidexter, and should sedulously cultivate the equal use of both hands. Supposing the patient lies on her left side, the usual obstetric position, the surgeon having anointed his left index with cold cream, olive oil, glycerin, or soap, arranges the bed-clothes or dress with his right hand. To lessen risk of infection, it is well to use carbolized oil. The radial edge of the left hand is then directed between the nates, and determines the relation of the parts by feeling the lower end of the sacrum and coccyx and anus; the finger then passing along the raphe of the perin- eum, comes necessarily to the edge of this structure at the posterior commissure of the labia, and therefore falls surely between the labia ; the pulp of the finger is made to enter at this spot, and its further progress is made by pressing the back of the finger against the distensi- ble perineum and onwards, following the curve of the sacrum. The reasons for this mode of proceeding are to save the patient the annoy- ance of touching the sensitive structures at the pubes, and to get at once between the labia, which it is not always easy to do, if the finger be directed more forwards. It is also much more easy in this way to follow the curve of the vao-ina. To reach the os uteri, Avhich often lies high up under the promontory of the sacrum, it is commonly necessary to press the perineum well back. The os uteri is found, then, by making the finger feel its way all along the posterior wall of the vagina to its roof, until the cervix is reached. It first takes note of the size, shape, firmness, and character of surface as to smoothness or roughness, of the vaginal-portion of the cervix ; of the character of the os externum as to patency or closure, of its form, whether a fissure or round. Having made these observations, the finger next takes note of the condition of the supra-vaginal-portion of the neck and of the body of the uterus. Feeling all round the vaginal-portion, pressing the finger lightly into the fundus of the vagina, in some portion of the circumference, the re- sistance due to the solid cervix or body will be felt. Following this. 138 EXAMINATION BY RECTUM AND BLADDER. the cervix is traced by continuity into the body. If the uterus is in normal position, the body is felt in front of the cervix through the upper and anterior wall of the vagina. Two other points may now be studied : the bulk, the sensitiveness and mobility of the uterus. The bulk is estimated by poising the cervix uteri on the tip of the finger, whilst the hand is pressed in above the symphysis pubis, until the solid body of the fundus uteri is felt. Thus, the uterus is caught in its ex- treme length between the two hands, and allowance being made for the thickness of the abdominal wall, a fair idea is obtained of its length and bulk. The necessary pressure will determine the sensitiveness of the uterus ; and the poising of it on the finger, alternating with depres- sion on the fundus, brings out the degree of mobility. If the uterus is in reclination, the solid resistance of cervix and body is felt through the vaginal roof behind the cervix. Again, by com- bined abdominal palpation, the body is caught between the two hands, not in its long axis, for the fundus lies under the sacral promontory, but across its body. The diagnosis is verified by bringing the examin- ing finger in front of the cervix ; and then when abdominal palpation is resorted to, the hands approaching each other, find no intervening body, i. e., no uterus between them. The finger next explores, by aid of abdominal palpation, the lateral regions of the pelvis. In this way, if there is deposit in the broad ligament, distension of the Fallopian tubes, or enlarged or prolapsed ovary, the abnormal condition may be made out. The Digital Reetal Touch. The lateral position of the jjatient is still the best for the examination by the rectum. The forefinger, lubricated, is passed into the rectum, and exploring as it goes the anterior wall, the uterus is felt through it. Commonly, the vaginal-portion is easily made out. If the uterus is strongly anteverted, so that the os is thrown backwards, this part will project into thg rectum. This position will account for the pain some- times suffered at stool, when the cervix uteri is inflamed and enlarged. One of the greatest advantages, however, gained by rectal touch, is the greater reach it gives one over the body of the uterus. If the uterus be retroverted or retroflected, the finger may usually reach the very fundus, and thus take a very accurate estimate of its bulk, form, posi- tion, and sensitiveness. The ovaries, again, which lie a little behind the uterus, may, in some of their abnormal conditions, often be explored with precision by the rectum. In the case of some uterine tumors and retro-uterine effusions, as hsematocele, or peri-uterine effusions, exami- nation by rectum supplements vaginal touch, giving often even more valuable results. Combined with abdominal palpation, rectal touch determines with great accuracy the bulk of the uterus. It can often be commanded more completely in this way than by vaginal touch. Examination by the Bladder. It is possible and sometimes desirable to explore the bladder by the finger in the urethra. This canal in the female is short and very dis- THE USE OF THE SOUND. 139 tensible. It may be dilated very quickly by Weiss's urethral dilator. But in the majority of instances, mediate exploration by the catheter or uterine sound supplies the information that is sought. The exploration of the abdomen by palpation and percussion is, of course, best conducted with the patient in the dorsal decubitus ; and this position is often also the best for the combined vaginal touch and abdominal palpation. The uterus in this decubitus is more easily grasped and pressed down into the pelvic cavity into contact with the finger in the vagina. Further information is gained by the sound. This is virtually a lengthened finger. It extends the sense of touch beyond the point which the finger can reach. If there be sufficient indication to use it, it should be introduced before the finger which has been making the observations already described is withdrawn, as it is desirable to avoid the necessity of having to repeat the vaginal touch. Fig. 49. Designed to illustrate diagnosis of early pregnancy. B, bladder, r, rectum, u, gravid uterus in anteversion. o, os uteri tilted up, and stretching the anterior vaginal wall from o to v, making this part tense and elastic. Before taking up the sound, one precaution is imperative. Be satis- fied that the patient is not pregnant. We may acquire reasonable as- surance of this negative if, by combined vaginal touch and abdominal palpation, we find the uterus not exceeding the normal bulk, and the 140 " THE USE OF THE SOUND. OS uteri hard and small. If, on the other hand, we feel the os uteri soft, tilted far back under the promontory of the sacrum ; if we feel what I have elsewhere described as " anterior vaginal roof-stretching," and the bulk of the uterus increased, the presumption of pregnancy is great. Then, do not take up the sound. Another rule is useful. Never use the sound unless you have trustworthy evidence that the patient has fairly menstruated within the preceding fortnight. As this rule in practice is exceedingly important, I introduce a spe- cial illustration in order to draw attention to the physical signs which afford presumption of early pregnancy. (Fig. 49.) The Mode of Using the Uterine Sound. The patient still lies on her left side. The examining finger on the OS uteri serves as a guide. The sound, held with its concavity forward, is carried along close to the examining finger to the os, into which it is . introduced. When it has passed an inch or so, an obstruction is com- monly met; this is the isthmus, or os uteri internum. At this point the direction of the cervico-uterine canal changes ; and a corresponding change must be given to the direction of the point of the sound. When the axis of the uterus is normal, the canal curves gently forwards, so that by carrying the handle of the sound lightly backwards the point will follow this curve. In giving the direction to the sound we are guided by the information gained by the digital touch. The body of the uterus has been felt in front of the cervix. As the point of the sound passes on, the finger on the os uteri takes note of the extent to which it passes, and when it feels the elbow or projection which marks off two and a half inches from the point, on a level with the os exter- num, a sense of resistance is communicated to the touch. The point has reached the fundus of -the uterus, usually the most sensitive part, and the patient will commonly complain of pain unless the utmost gen- tleness is used. The introduction of the uterine sound resembles the introduction of the vesical sound or catheter in the male urethra. It requires the like delicacy of touch ; the instrument is made to feel its way rather than to be propelled by force. When the sound has touched the fundus, by imparting light movement to the handle backwards and forwards, we ascertain more clearly the mobility of the organ, its rela- tion to neighboring parts, and especially if the form or bulk of the uterus is altered by fibroid or other tumor in its walls or outside. Whilst the sound is in situ supporting the uterus, the hand outside depressed above the pubes readily feels the fundus, and this pressure is commu- nicated through the sound to the hand which holds it. By this com- bined manipulation also a closer idea is formed of the size, form, and relations of the organ. The variations in the mode of using the sound required by different morbid conditions will be described in the appropriate places. It will be sufficient to add in this place a brief description of the mode of using it in retroversion or retroflexion of the uterus. If there be re- troflexion, the finger feels behind the vaginal-portion the angle of flexion, and then the body of the uterus. To get the sound into the THE USE OF THE SOUND. 141 Fig. 50. down-bent body, its curve must be increased, and when the point has reached the os internum, the curve must be reversed; that is, the con- cavity must be turned backwards to follow the curve of the uterus. The manoeuvre by which this is accomplished resembles the foitr de maitre, by which the male sound is made to enter the bladder after reaching the pubic arch. The point remains nearly stationary, merely turning on its axis, as the handle is made to describe a large radius. Unless this be neatly done, the point is apt to slip out of the cervix, and by describing a large radius to cause pain. The principle of this manoeuvre is made manifest by the following experiment. Lay the sound on a sheet of paper, and trace its outline on the paper (Fig. 50). Then keeping the point fixed by a finger, give a semi-rotation to the handle so as to re- verse the concavity of the curved end. It will be seen that the uterine end simply turns upon its axis without changing its position. The sweep of the handle is done with the minimum of force ; it is rather suffered to turn by its own weight than made to do so by force. When reversed, the point of the sound is made to pass the isthmus by a double consentane- ous manoeuvre ; the guiding finger runs up the posterior wall of the cervix, and lifts up the body of the uterus, straightening it a little so as to bring the extreme curve of the uterus more into agreement with that of the sound; at the same time the handle of the sound is car- ried forward under the arch of the pubes, so as to make the point take the direction of the uterine canal. When the sound has passed as ^'^ f^om c describes a large ra- /> •, m "j. •!! 11 1 J dius in reversal. B is a fixed lar as its elbow, it will commonly have reached • . ^ ■ .^ ■ ^ ^.■ ' , •' . point during the semi-rotation the fundus, ihe next object is to ascertain the of the instrument, and the end mobility of the fundus, and to restore it to its a performs a very small curve natural place. To do this the concavity of the ^" the uterine cavity, if a b be -.J- . -, 1 • 1 straight it will simply rotate, sound must be again reversed ; and again the and a a win coincide. same manoeuvre must be practiced as before passing the os internum. The handle is made to describe a still larger radius from before backwards, so as to make the point and the intra- uterine end rotate upon its axis. The effect of this will be to lift up the fundus a little. To bring it forward to its proper position of mod- erate anteversion, the handle is carried straight backwards. We can then feel the fundus supported on the sound by abdominal palpation above the pubes. Sometimes, after clearing the os externum, the knob is arrested before it has reached the os internum. The reason of this will be understood by looking at the structure of the cervical canal. The knob is liable to get caught in one of the crypts or furrows formed between the ridges of the arbor vitse. This hitching is likely to happen when the knob is too small ; a larger one will ride over the pits. But even with a well-chosen sound the accident may happen if the patient has Showing the reversal of the sound in utero. B corresponds to the os exter- num uteri. The handle extend- 142 DANGERS FROM THE SOUND. long suffered from chronic cervical leucorrhoea. Then the mucous membrane is hypersemic, swollen, flabby, and the folds of the arbor vitffi rise and overlap, so that the point of the sound is easily caught, as it were, in a pocket. Some remarkable accidents prove the necessity of exerting the utmost care and delicacy of touch in using the sound. The point of the in- strument has actually perforated the fundus of the uterus. Two such cases were observed by Schroeder. In both the sound went without force sixteen to seventeen centimetres deep, and its knob Avas felt through the thin abdominal walls. Both were puerperal women. No bleeding, pain, or other bad symptom followed. Professor E. Martin relates a case^ in which the perforation was verified by autopsy. Mr. Lawson Tait relates^ that Sir James Simpson was well aware of this accident, and regarded it as of no consequence. Mr. Tait refers to two cases under his own observation, in one of which he believed there was a fistulous tract through the fundus. Dr. Matthews Duncan suggests that the sound may have run along an unduly patent Fallopian tube. I believe this is quite possible, although Hoening denies that it is so. In some of the cases in which the sound thus perforated the uterus, notably in the two puerperal cases of Schroeder, it is probable that the uterine tissue was abnormally soft. However this may be, it must be borne in mind that the sound roughly used may wound the uterus, and even perforate it. I am unable to look upon the accident as of little impor- tance. The most careful and judicious use of the sound is sometimes attended and followed by intense pain. Metritis has occurred ; and this even when there was no reason to infer that the wall had been perfora- ted. That fatal accidents have occurred from the use of the sound can hardly be doubtful. I repeat, then, the injunction to avoid anything like force in introducing the sound. It is a question of skill, not of strength. If there be any obstacle to the progress of the instrument, it must be either evaded or turned, or the attempt to pass it should be given up. Some physicians are in so great dread of accidents from the uterine sound, that they condemn it altogether. This is unreasonable. Tlie surgeon does not abandon the male sound or catheter because inexpert people make false passages. The danger just described is avoided by using a flexible bougie in- stead of the metal sound. This instrument Dr. Henry Bennet prefers also, from its taking the form of the uterine canal, and gauging the calibre of the isthmus. These are advantages not to be disregarded in some cases. Where the canal is very much distorted by fibroid tumors, it is sometimes possible for a moderately firm flexible bougie to worm its way along the tortuous passage where a rigid sound could not travel. It is, however, open to the objection that the point being caught, the stem will double. up, and thus, perhaps, convey a false impression as to the distance it has penetrated. The flexible bougie, if not provided with a knob at the end a little larger than the stem itself, will become more likely to be caught in a cervical crypt than the metallic sound. ' NcigUTigen und Beugungen der Gebarmutter. ^ Lancet, 1871. USE OF THE SPECULUM. 143 Occasionally the sound is used through the speculum ; but as a rule this is a mistake. When this is done, we sacrifice the aid which the finger gives in guiding the sound, and facilitating its passage into the body of the uterus by tilting up the body so as to lessen any abnormal curve or angulation. And when the uterus is much bent, it is impos- sible to make the sound follow the flexion Mdthout imparting a corre- sponding, perhaps painful, inclination to the speculum. Moreover, when the sound is passed through the speculum, we lose much of the information which the sense of touch imparts. One use, however, the sound possesses in conjunction with the specu- lum. It serves to depress out of the field of vision projecting folds of vagina, to bring the os uteri more fairly into the axis of the speculum, and by passing the point a little way into the os, and pressing upon one or other lip, we may expose a considerable surface of the cervical canal. Before using the speculum, we have to consider the means of illumi- nation. Daylight is preferable, and the line of light should be hori- zontal or at a slight angle above the horizon ; the foot of the couch or bed, therefore, should be opposite a window. If a Fergusson's silvered speculum be used, even a dull light will commonly be sufficiently re- flected and focussed to give a good view at the field. But even well- polished metal valvular specula are not so well calculated for success when the light is bad. When the valves are expanded they diverge, and reflection and focussing are almost lost. It may then become con- venient to concentrate light by a mirror or convex lens. A slightly concave mirror may be so adjusted as to throw a stream of reflected light down the speculum ; or the light may be collected into a focus by a convex lens. The mirror or lens may be supported on a quaquaversal jointed rod attached to the couch. When daylight cannot be had, a gas-lamp, or even a candle may be used. In the consulting-room a movable- gas-lamp fed by a flexible tube is very convenient ; to such a lamp a reflector might be adjusted to throw the light into the specu- lum and screen the surgeon's eyes. I have seen and tried a mirror which was attached to the speculum ; I found it more convenient to use the mirror separated. The Mode of Introdueing the Tubidar Speeidum. As a general rule the dorsal position is the best; but it is a necessary condition that the bed or couch upon which the patient reclines be firm in the centre, so as to obviate sinking of the nates in a hollow. To maintain the nates at a proper elevation for the admission of a good stream of light, striking horizontally from an opposite window, or at most at an angle of 45° from the horizon, it is also essential to keep the shoulders and head of the patient only slightly raised above the level of the nates. A proper position of the patient saves her from unnecessary annoyance, and makes all the diflerence between success and failure to the surgeon in carrying out the examination. The patient takes then the dorsal position, as described, as near the edge of the couch or bed as possible. 144 USE OF THE SPECULUM. The surgeon, standing or kneeling at the side holding the speculum lubricated and warmed in one hand, explores with the index of the other hand to determine the exact position of the cervix uteri, the object being, of course, to get this part in the centre of the field of the specu- lum. Having settled this j)oint, he draws the finger back to the vulva, and brings up another finger to hold open the labia; the speculum, guided by these fingers, is then passed into the vulva by getting the end well over the perineal border first; then, before pushing the instru- ment onwards, its end is pressed backwards so as to depress the perineum. This manoeuvre carries the instrument away from the pubic arch, M^here it might cause pain by jamming the soft parts against the bones, and directs it towards the hollow of the sacrum in the direction of the axis of the pelvis. The further direction of the instrument is governed by the idea which was gained of the position of the os uteri by the explor- ing finger. When fully introduced, if the os should not be found in the field, the instrument must be withdrawn a little way, and the end shifted so as to bring the cervix within the field. Then note is taken of the aspect of the part, and of the character of the discharge. The surface is often bathed with secretion so that it cannot be well seen, and the secretion, moreover, would interfere with the application of remedies. This is removed by a small pledget of cot- ton-wool carried by the speculum-forceps. When visiting a patient at her own home it is often most convenient to examine in the lateral position. The bed or the source of the light may render a satisfactory examination in the dorsal decubitus impos- sible. The patient then is placed on her left side on the right side of the bed, the nates being drawn well up to the edge, the knees slightly drawn up, and the head and shoulders bent forward towards the mid- dle of the bed and laid low, so as to keep the nates high. Unless all this be done, great difficulty will be experienced in getting a direct line of light, as well as in introducting the speculum. The patient in position, exploration is made with the left index, and the speculum is inserted with the same precaution as in the dorsal position. An ad- vantage attending the lateral position is, that artifical light is more easily made to serve where sufficient daylight cannot be had. A candle — a short bit of wax taper is the most handy — can be so held as to throw its light well in the line of the speculum, whilst this is held by the left hand. The Introduction of Sims' s Speculum. The facility of introduction of Sims's speculum is one of its recom- mendations (Fig. 33). The patient lying in the semi-prone position on her left side, the right leg is made to cross in front of the left ; this brings the vulva well within manipulation, and makes it the highest point of the vaginal canal. The effect of this is, that by placing the uterus at a lower level, the intestines fall away from the roof of the pelvis, and the uterus tends to gravitate with them. Then when the speculum is in situ, the cervix uteri is drawn forward out of the hollow of the sacrum in front of the speculum, and the line of light being USE OF THE SPECULUM. 145 at a slight angle above the horizon, flows well down to the cervix at the bottom. This direction is also the most convenient for therapeu- tical manipulation. The mode of passing the instrument is easy. The exploring finger determines the position of the cervix uteri, and the capacity of the vagina and vulva. The larger or smaller blade is selected accordingly, and then holding open the vulva with one or two fingers, the end of the blade is slipped in as near the perineum as possible, first with the width of the spoon in a line with the vulvar fissure, and then, as soon as the end has fairly entered, the instrument is rotated so as to bring the back of the spoon against the perineum ; the guiding finger in the vagina then, aided by gentle pressure on the handle by the other hand, carries the point of the blade along the posterior wall of the vagina to its place behind the cervix. When in situ, in order to bring the cervix into view it is necessary to hold back the instrument firmly against the perineum, which being distensible and yielding permits the curved vagina to become straight, and thus the cervix to be seen. Sometimes when the vagina is large and lax, the anterior wall will bulge up against the speculum, and however much the perineum may be retracted, the cervix cannot be seen, until either by the finger, the handle of the sound, or a retractor made like a tongue-depressor, the anterior wall of the vagina is pressed up against the pubes. We then get virtually an inferior kind of Neugebauer. Sims further recommends the use of a fine hook (see Fig. 39) to seize the vaginal-portion, to pull it up into sight, and to fix during the application of remedies to the surface or to the interior of the uterine cavities. This hook, it is said, causes little pain, and the flow of a few drops of blood. But it appears to me that, although very convenient in some cases, it may be dispensed with as an habitual aid in examination and treatment. Introduction of Neugebauer^ s Speculum. The passage of the first blade is made exactly in the same way as Sims's speculum (Fig. 33). The patient lying in the semiprone posi- tion on her left side, the surgeon takes the larger blade in his left hand, whilst one fino-er of the rig-ht hand introduced through the vulva feels for the OS uteri ; this finger serving for a guide, the end of the blade is slipped in over the perineum in close approximation to the finger, and carried along it so as to get behind the os uteri. If this direction is followed, there will be no hitch against a fold of the vagina. When the blade has passed in, the handle is held well back so as to depress the perineum. An assistant then raises the right knee so as to enable the surgeon to introduce the second blade, which being a degree smaller than the first, fits into it as in a groove. The uterine end is adapted inside the handle-end of 'No. 1, held firmly with the left hand, and is then made to slide down in No. 1 until the handles of the two blades are on the same level. Then the two handles being brought forward, the two blades work as bent levers, upon the angle of junction of handle and blade, which serves as a hinge or fulcrum; the uterine ends 10 146 THE OVARIES: M EN STEU ATION. thus diverge like two valves, stretching the roof of the vagina, and giving an excellent view of the vaginal-portion (see Fig. 34). The w^ithdrawal of the instrument is very simple. The two blades must be treated as one whole. The handles are allowed to fall back, which brings the uterine ends of the blades together. The gentlest traction then upon one or both blades will bring the instrument out, the contraction of the vagina helping to expel it. CHAPTER Xyil. THE PATHOLOGY OF THE OVARIES. THE HISTORY OF MENSTRUATION AND ITS DISORDERS. The relation of the ovary to the function of menstruation has been referred to when describing the anatomy of this organ. A few further observations upon this subject are necessary to serve as an introduction to the study of the disorders of menstruation, and of the organic diseases of the ovary. The most important laws in this application to pathology are illus- trated in the following facts : The catamenia, the name given by Aristotle to the monthly discharge from the uterus, indicates the periodicity of menstruation. In all lan- guages, and throughout all ages, names indicating this periodicity have been adopted. The "menses," "les mois," "les regies," are examples. But this character of periodicity, so striking, was not traced to its true cause or connection until the present century. It was scarcely suspected, certainly not demonstrated, that the periodical monthly flow was dependent upon another periodical act, the ripening of ova. Dr. Power, a man of singular sagacity, seems to have been the first to seize upon this great fundamental fact. In 1821 he distinctly enunciated the theory. Girdwood, in 1826, brought new observations in proof of this theory. It was, however, warmly disputed in this country, es- pecially by Dr. Robert Lee, whose authority probably retarded its general acceptance, so that it was not until Negricr,^ in 1831, working as it appears independently, proved by adequate researches and ana- tomical preparations, that the outward and visible periodical discharge of menstruation was the expression, the consequence of an internal and 1 " Recueil de faits pour servir a I'Histoire des Ovaires." Angers, 1858. MENSTRUATION, 147 hidden, but superior function. Gendrin, Paterson, Raciborski, Bischoif, and others followed with fresh proofs which established the theory against all disputes. The preparations of Coste, preserved in the Col- lege of France, show the following points : A Graafian vesicle, the ripening of vvhich always coincides with the turgescence of the genital organs, pursues the course of its development during the various phases of menstruation ; and, according as the circumstances are more or less favorable, it may burst at the commencement, or towards the end, or at any moment of this periodical discharge. In a woman who died on the first day of the appearance of the menses, the ovarian vesicle was manifestly ruptured. In another, who died four or five days after the cessation of the menses, the right ovary presented a vesicle still intact, but so distended that the slightest pressure made it burst. Lastly, in a young virgin, who died fifteen days after menstruation, there was no recent trace of a yellow body, and it could not be doubted that the Graafian vesicle had been arrested in its development. The subjects of these observations had all died a violent death in the midst of health. Thus, we may conclude that at each menstruation a Graafian vesicle assumes a marked preponderance over the rest, arrives spontaneously at maturity, and, generally, bursts at an indeterminate moment of this period, in order to expel the ovum it contains ; but, nevertheless, in certain cases this vesicle may also remain stationary, or be totally ab- sorbed. The double phenomenon is analogous to what is observed in mammifera, during the rut. Roederer^ observed that the ovaries grew towards the epoch of com- mencing menstrual life and became atrophied at the menopause. He distinctly found that the atrophy of the ovaries was more marked and more closely associated with the cessation of menstruation than was the atrophy of the uterus. If the ovaries are absent or ill-developed, girls do not menstruate, the breasts are flaccid or defective in development, the characters of womanhood do not become manifest. This may be said to be experi- mentally proved by the celebrated case of Pott. A girl aged 23, of good constitution, went to Bartholomew's Hospital, in consequence of two tumors situated in the groins, which had for several months caused her so much pain that she could not attend to her work. She was healthy, and menstruated regularly. The tumors -were soft, uneven, easily movable, and lay externally to the tendinous apertures of the inferior abdominal wall. Pott determined to remove them. After dividing the skin, a thin membranous sac was found, in which a body was inclosed that was taken to be the ovary. It w^as removed, and the same operation was repeated on the other side. From this time forth she never menstruated, her breasts fell away, and the muscular system became developed as in man. If, then, the ovaries are extirpated or become atrophied, menstru- ation does not reappear. Raciborski says the menses may be a little postponed, but that this does not always prevent the follicles from pur- 1 " Icones Uteri Humani," 1779. 148 OVULATION. suing their regular course, and from accomplishing dehiscence. He has seen on ovaries of young girls one or two cicatrices, although they had never menstruated. Thus also women who had never menstruated have conceived. But these cases are very rare. The first dehiscence corresponds with the first appearance of the menses. Whitehead relates cases of conception in persons who had never menstruated ; and conception during lactation whilst menstruation is suspended is not uncommon. Dr. Ritchie^ also adduced evidence to show that ovulation may go on although there is no menstrual discharge. Negative observations, then, as to the menstrual flow do not prove that ovulation is also sus- pended ; and ovulation is obviously the condition of impregnation. Menstruation, then, is the natural epoch for the escape of ova ; and, consequently, it is the most favorable to conception. But a question of great interest is attached to this conclusion. Do the epochs of ripening and of the natural fall of the ova always and of necessity re- turn in a regular manner ? That is, are there not other influences besides the rut and menstruation, capable of hastening the epochs of maturation and fall of the ova ? This must be answered in the affirm- ative. Thus, the pigeon in its wild state lays eggs only once or twice a year, whilst in our pigeon-houses it lays seven or eight times. Hens, whose eggs are taken away from them to prevent their sitting, lay al- most every day for eight months in the year. The rabbit, which, in a state of liberty, has only one or two litters a year, has perhaps seven when its young are taken away at a suitable time. The period of maturation, then, far from being immutable, appears to depend upon certain con- ditions which may accelerate or retard it. Similar conditions exert similar influences in women ; and there is reason to believe that sexual intercourse may hasten the maturation of ova, and especially their escape from the ovary. Admitting, however, as we must, the occasional operation of dis- turbing circumstances, the general law is that these phenomena are reproduced periodically ; and that during the periods when they are manifested certain signs attend, which in the aggregate bear the name of menstruation. Consequently the ripening of ova, and most fre- quently their dehiscence, are revealed outwardly by the appearance of the catamenia. We may now conveniently study this function from a clinical point of view, fixing our attention mainly upon those phenomena which are open to direct observation. Pouchet^ has distinguished the different phases of menstruation with great precision, by defining its difterent periods, and by comparing, by help of the microscope, the discharges attending it with those of the intermenstrual period. Characters of the Menstrual Discharge. — The first sign of the advent of the menses is the manifestation of a particular odor imparted to the mucus secreted by the sexual organs. The second sign is a change of 1 " Ovulation during Amenorrhcea." Ed. M. & S. J., 1845. 2 " Theorio Positive de I'Ovulation Spontanec." Paris, 1847. MENSTRUATION. 149 color of the utero-vaginal mucus ; at first, dull white, it becomes brown- ish ; some blood-disks, mingled with numerous mucous globules and fragments of epithelium, floating in the liquid, account for this change of color. The first period lasts one or two days. Sometimes it imme- diately precedes the flow of blood ; sometimes the mucus becomes nor- mal again ; then, after an interval of a day, blood, almost pure, sud- denly escapes from the vulva. The flow of ruddy blood constitutes the second period. The fluid secreted is composed of blood, not cliifering from arterial, mixed with vaginal mucus. By the microscope we find mucous globules in various stages of development, thin fragments of transparent epithelial scales, mixed with innumerable blood-disks. This flow usually ceases in three or four days ; but in some women it is continued for seven or eight days, without obvious departure from the physiological condition. The menstrual blood diifers from pure blood, in not coagulating ; that is, under ordinary conditions. Dr. Whitehead explained this by showing that the vaginal mucus has an acid reaction, and that contact of the blood with this acid prevented its coagulation. Donn6 also says that menstrual blood is acid, containing phosphoric and lactic acids. Mandl, however, showed that the smallest quantity of pus or mucus stopped blood from coagulating. Now, the menstrual discharge is blood mixed with mucus. That admixture with mucus accounts for the flu- idity of the menstrual discharge may be admitted ; and so long as the quantity of blood is within normal bounds, the proportion of mucus supplied is sufficient ; but if the blood be in excess, and if it be re- tained a little while, it will coagulate. Thus it is that in menorrhagia clots are frequently passed. Clotting in the cavity of the uterus causes pain and contractions. The quantity of the blood exhaled becoming less and less abundant, its color changes from red to brown, the proportion of blood-disks diminishes, whilst that of the mucous elements increases ; at length the mucus itself becomes thinner. It is especially at the end of this period that the Graafian vesicles may burst spontaneously. When the menstrual discharge has ceased, the internal surface of the uterus, and especially that of the vagina, casts off numerous epithelial scales, at first nearly entire, but soon reduced to fragments of more or less tenuity. These scales or debris constitute during the first inter- menstrual days the greater part of the solid elements contained in the excretions of the vulva ; the rest is composed of a variable number of mucous globules. Virchow insists that the detachment of the uterine mucous membrane is more complete than is generally supposed, and that in normal menstrual blood heaps of cells are often met with, which by their structure reveal their origin in the uterine glands. Just as in women who have already menstruated, the menses are pre- ceded by a modification in the quantity and color of the normal sexual secretions ; so in the young girl, who, not having yet menstruated, has arrived at puberty, the menstrual hemorrhage is often preceded by a serous whitish or brownish discharge. This discharge may anticipate by several months the appearance of the blood, and may recur several times before this makes its appearance. Often also after the first san- 150 MENSTRUATION. guineous discharge in a young girl, several months may intervene be- fore the menses set in. The like phenomena are repeated at the disap- pearance of the menstrual discharge, when the privilege of fecundity is lost. This similarity of the phenomena attending the first advent and the climacteric cessation of menstruation is especially deserving of note. There is, 1. Irregularity as to periodicity, 2. Occasional excess of blood loss, amounting to hemorrhage. 3. Alternate enlargement and subsidence of the abdomen. 4. Pain and induration of the breasts. The quantity of blood discharged at each epoch varies in different women, and in the same woman under different circumstances. It usually ranges from three to four ounces. Generally it is more abun- dant in women living in luxury. And, according to Burdach and Brierre de Boismont,'^ it is more copious in hot than in cold countries. Our countrywomen in India are more subject to menorrhagia than when in England. A vulgar error still prevails that the menstrual blood has fetid or even poisonous projjerties. This is only true under the conditions of retention, of uncleanliness, or admixture with the products of disease. The Source of the Menstrual Blood. — Haller was aware that it came from the womb. Observations in point have been made under two different conditions ; that is, in the living and in the dead. First, the uterus, examined in cases of complete prolapsus, and where there is no prolapsus, by the speculum, blood is seen to issue from the os uteri ; and in cases where the uterus is turned inside out the menstrual blood is seen directly oozing from the mucous membrane of the body of the uterus. Secondly, on examining the bodies of women who have died during menstruation, Coste and others, myself among them, have seen the vascular apparatus of the uterus developed and injected in an ex- traordinary manner. The vascular structure of the mucous membrane, in particular, forms on the surface, under the fine layer of epithelium which covers it, a beautiful network, each mesh of which incloses a glandular tube. This vascular reticulation is so marked and rich that it gives a more or less deep violet tint to the inner surface of the uterus. According to all probability, it is through the walls of these ramuscules that the menstrual blood oozes. " In one case," says Coste, " death took place exactly at the moment when the blood began to ooze through the engorged vessels. There were seen in the course of these vessels an innumerable multitude of small red points, as if the mucous mem- brane had been pricked with a fine needle, each prick giving issue to a minute droplet of blood. Here and there, under the epithelium, were small ecchymoses, indicating that the hemorrhage, suspended by death, had not yet made a complete escape. In other women, the phenomenon being more advanced, the cavity of the uterus was found filled with red fluid blood, about to escape by the neck." Some experiments made by Matthews Duncan, to determine " the power of the uterus to resist a bursting pressure " (1868), seem to me 1 " De la Menstruation dans ses Rapports Physiologique et Patliologiqiie," Paris, 1842. MEjSiSTEUATION. 151 to find application here. Air was forcibly driven by a pump against a piece of uterus stretched over a tube. " It was curious," he says, " to observe the permeability of all the unruptured tissues to this fluid." The experiments being performed under water, the air bubbled up, or effervesced from the peritoneal surface by innumerable minute points. In all probability the mucous membrane of the uterus and the delicate coats of the bloodvessels offer even less resistance under the hydraulic pressure to which they are subjected by the increased turges- cence attending menstruation. This oozing from a free surface is a pro- tection against extravasation in deep structures, which could not fail to be injurious. This intense vascular engorgement involves the ovaries and Fallo- pian tubes as well as the uterus ; and there is no doubt that blood is effused from the whole tract of the tubo-uterine mucous membrane. Dr. Letheby [PMl. Trans., 1852) describes the microscopical characters of the menstrual fluid found in the tubes in the bodies of two young women who died whilst menstruating. Periodicity. — The typical periodicity is every twenty-eight days. In many women the return is exact to the day. There is, however, a range of variation in different women ; in some the interval from the commencement of one menstruation to the return of the next is less than twenty-eight days, in others more rarely exceeding thirty days ; that is, if strict periodicity be observed. In women whose intervals vary, being sometimes more, sometimes less than twenty-eight days, some pathological element probably exists. The Age at which Menstruation Begins. — In temperate climates, be- tween the ages of thirteen and fifteen, concurrently with the appear- ance of other signs of puberty, as the growth of hair on the genital parts, and the swelling of the breasts, the menses begin to flow. Here, again, there are considerable variations. Cases are recorded of men- struation beginning at ten, and even as early as seven or six years of age. These must be regarded as instances of quite exceptional pre- cocity. Retardation is more common; cases are not infrequent of the first appearance, or at least, of the fair establishment of menstruation, at sixteen or seventeen. In these there is mostly some pathological con- dition. Since the outbreak of this function of the uterus is a symptom or consequence of the entry into active function of the ovary, it may be concluded that whatever causes hasten or retard the evolution or ripening of the ova, will have a corresponding effect upon men- struation. Hence luxurious living and libidinous excitement, tend to forestall the ordinary period, whilst the contrary conditions of hard living and freedom from sexual emotion tend to postpone it. Climate has been said to have a powerful influence. The observa- tions of Brierre de Boismont and others seem to have pi'oved that the advent of menstruation is decidedly earlier in hot climates than in cold. And common observation proves that, tested by their physical and in- tellectual characters, girls pass into womanhood at a somewhat later age in cold and temperate climates; whilst the women in hot climates fall at an earlier age into sexual decrepitude. 152 MENSTRUATION. In Siarn, according to Dr. Campbell [Edin. Med. Journ., 1862), some girls arrive at puberty at twelve, but the more usual ages are fourteen, fifteen, and sixteen. Dr. Goodeve gives about twelve as the mean, and Dr. Leith, of Bombay, twelve and a half. But of a series of cases tabulated by him, the largest number menstruated after fourteen. The influence of cold is further seen in the character of the men- struation. Thus, Dr. McDiarmid, surgeon to Sir John Ross's Arctic Expedition, says that amongst the Esquimaux, menstruation is often delayed until the twenty -third year, and then only appears scantily during the summer. I also know women of feeble sexual development Avho menstruate in the summer only. Probably, race may have as much to do with the period of advent of menstruation as climate. Observation of the Jews, who are to be found in almost every climate,. might determine this question, and thus enable us to appreciate more accurately the influence of climate. Is the first appearance of menstruation amongst the Jews inhabiting dif- ferent countries uniform or not ? The period of disappearance of menstruation is more uncertain than that of its commencement. Usually about the age of forty to forty- five some irregularity begins. But the function often continues with complete regularity until forty-five and sometimes fifty, and even be- yond. The instances, not infrequent, in which periodical discharges of blood, not distinguished by the subject from ordinary menstruation, are continued much beyond fifty, may, with considerable confidence, be suspected to be due to some abnormal condition. This is especially true when the issue of blood is greater in quantity and lasting longer than the subject had been accustomed to observe ; and the presumption that some disease, local or remote, is present, is very great when profuse losses of blood, periodical or not, break out after the menstruation has ceased for some months. If it is difficult to determine the latest limit for the persistence of healthy menstruation, so is it to determine the earliest limit. It is a popular belief, that if a woman begins her menstrual life at an early age, she will cease to menstruate at an earlier ag-e than those wdio begin later. Another mode of expressing this theory is to say that the epoch of menstrual life, that is, of active ovulation, and hence, of aptitude for conception, lasts for thirty or thirty-five years. Negrier's observa- tions, however, seem to prove the reverse. He says : " It seems well proved that the ovarian function, creative of germs, is prolonged in life in direct ratio of the volume of the ovaries and of the precocity of ovulation ; thus, the girl, nubile at twelve, will continue menstruating until fifty, or even fifty-five ; whilst the girl who did not menstruate until eighteen or twenty, a fact which reveals feeble development and small energy of the organ, will cease to menstruate at forty — an early age." Considerable departures from this limit are probably due to some morbid disturbing element ; and in many cases the departures are more apparent than real. For example, at the commencement, although no sanguineous discharge may mark the onset or establishment of men- struation for several months, or a year or two, there is no doubt that MElSrSTRUATIOJSr. 153 ovulation, the essential motive of menstruation, goes on. This is proved by cases in which pregnancy has occurred without menstruation. Whitehead has recorded such cases. Dr. West relates the history of a lady who married at twenty, never having menstruated, but who became pregnant immediately. After childbearing, she menstruated regularly. In other cases, a leucorrhoeal discharge, " white menstruation " it might be called, returns periodically, attended by the usual indications of menstruation. In a third series of cases, even the white discharge may be wanting, and still a sluggish kind of ovulation may occur. This is observed in some forms of amenorrhoea. At the other end of the history we sometimes find menstruation ceasing at a comparatively early age, that is, before forty, even at thirty- seven or thirty-six. These can hardly be instances where the allotted thirty years have run out, from having begun prematurely. Most fre- quently the explanation is that ovulation, or its exponent, menstruation, has been prematurely arrested by some intercurrent condition of the ovaries or of the uterus. Sir James Simpson described a condition in which the ordinary involution of the uterus which follows delivery, seems to have passed the physiological bounds, and to have proceeded to positive atrophy, thus ushering in a premature senility. Whatever the explanation, I can attest the fact that a woman who has borne a child at thirty -six or thirty-seven has henceforth never menstruated or conceived again. In most of these women I have found the uterus reduced below its normal bulk, and presenting the other features of the senile uterus, whilst the breasts also, which obey so closely the impulse of the ovaries, have shrunk ; these women are overtaken by an early climacteric. In not a few instances, however, the explanation of N^grier holds good, namely, that the early cessation of menstruation is due to original feeble ovarian development. In these women the menstrual excretion is scanty and appears late ; their languid genital functions are exhausted long before the normal epoch. In other instances the premature failure is due to the exhausting in- fluences of disease. The most distinct evidence that healthy menstruation may be pro- tracted much beyond the age of forty-five is drawn from the undoubted fact that occasional pregnancy takes place after that age. Many cases of precocious menstruation are recorded. In some, the common signs of puberty appear to have been almost congenital. These cases form a class distinct in some features from the premature men- struation which appears at from nine to twelve years of age. In infantile menstruation, says Dr. Harris, of Washington [American Journal of Obstetrics, 1871), no matter how young the infant may be when the menses have made their first appearance, the mamrate are found unusually developed, and the pubes shaded with hair ] the sub- jects have menstruated regularly, have grown rapidly, inclining to obesity, and have not presented any sign of weakness ; it is little de- pendent upon climate ; there is generally no marked precocity of mental development; sexual passion is not marked. Sir Astley Cooper narrates the history of a child which commenced 154 MENSTRUATION. to menstruate at three years old, and was last noticed by him when seven years and five months old ; at this early age she had all the ap- pearance of a thickset stunted woman; she measured four feet one inch, and had so large a pelvis that she could no doubt have given birth to a child. {Lond. Med. and Phys. Journ., 1810.) Le Beau mentions a similar case [Annales d'Hygiene, vol. x). In the case of infantile puberty, the ribs and pelvis are excessively developed, and shortness of stature results. Where menstruation begins at eight or afterwards, the growth of the body is not usually interfered with. That early menstruation depends upon early ovulation is further proved by the occasional occurrence of very early jjregnancy. Several well-authenticated cases of girls being mothers at thirteen, or even twelve years old, are recorded. Dr. Roberton tells of a girl, working in a cotton factory, who was delivered of a full-grown child when only a few months advanced in her twelfth year. She had menstruated be- fore falling pregnant. Mr. Smith, of Coventry, relates {Record of Obstetric Medicine, vol. i) the case of a girl who at twelve years and seven months gave birth to a full-grown healthy child. She began to menstruate at the age of ten. Dr. J. G. Wilson reports {Edin. Med. Journ., 1861) the case of a girl who began to menstruate when twelve years and six months old in January and until April. She was deliv- ered of a full-grown child at thirteen years and six months. In several cases of premature menstruation, exhaustion and death have occurred (Clifford Allbutt, Med.-Chir. Trans., 1866). But this is not the rule. Vicarious or ectopic menstruation occurs when hemorrhagic discharges take place periodically from other organs than the uterus. The oc- currence of this remarkable phenomenon is evidence of the force of the periodical habit. It seems as if every month a state analogous to plethora, or an accumulation of blood arose, which must be relieved by evacuation. The active physiological process going on in the ovaries naturally determines the blood-current in especial force to the pelvic organs ; hence the uterus is the natural evacuant organ. It is a remark made by Trousseau, that all the physiological discharges of blood take place from mucous membranes. A happy provision, for mucous mem- branes all lead to external outlets. If serous membranes were equally liable to pour out blood, the blood must be imprisoned in close sacs, and pressure and inflammation would constantly imperil life. It Avill generally happen, then, when the mucous membrane of the uterus is not disposed to execute its functions, that some other mucous mem- brane will supplant it. The most frequent seat of vicarious menstrua- tion is the Schneiderian membrane. In young people especially, epis- taxis is easily excited. There can be no doubt that in many cases it is a beneficial safety-valve. Certainly menstrual epistaxis is a quasi- physiological phenomenon, which should be checked only with great circumspection. In some cases I have known epistaxis to accompany the ordinary menstrual discharge from the uterus ; thus supplementing, not supplanting it. Various parts of the alimentary canal may assume the work of the uterus. The stomach is perhaps the most frequently called upon. Thus we have menstrual hoimatemesis. VICAEIOUS MENSTRUATION. 155 Hcemoptysis is, I believe, occasionally a manifestation of vicarious menstruation. The right appreciation of this condition is obviously of great importance, lest it be misinterpreted as a symptom of tubercular mischief. Other parts may, however, do similar duty. Thus we occasionally see hemorrhage from the rectum. And towards middle age, when haemorrhoids are not uncommon, these bleed more freely at the men- strual periods. During pregnancy, when the uterine mucous membrane is barred against hemorrhagic response to the ovarian excitation, I have several times seen hsematemesis occur. The natural disposition to vomiting which attends pregnancy may to some extent account for the hemorrhagic molimen being determined to the stomach. I have notes of cases in which menstrual hsematemesis seemed to be hereditary. In some there is a distinctly hemorrhagic diathesis, as in the following instance : A young- lady, aged twenty-four, had several attacks of hsematemesis more or less profuse, and at last one which was so severe and protracted that she made a very narrow escape with her life. It appeared to be con- nected with menstrual deviation. She recovered fairly ; but six months later, just when menstruation was due, having felt sick, and oppression at the stomach, she vomited a small quantity of dark blood, the menses appearing at the same time scantily. She never suffers dysmenorrhoea. A sister, when sixteen, who had hitherto menstruated scantily, had hsematemesis at her periods. A brother, aged five, died of epistaxis after purpura. The father died of epistaxis at fifty -six, caused, his wife says, by intemperance, which produced epilepsy. Whenever he had a fit he had hemorrhage. The conjunctiva is another mucous membrane which evinces a par- ticular proclivity to pour out blood vicariously. I have seen a woman who every month suffered profuse ecchymoses of both eyes, some blood escaping from the surface, and some being effused under the conjunc- tivae, to be gradually absorbed, and passing through all the stages of ecchymosis of the eye from direct violence. Liebreich has figured in his magnificent Ophthalmoscopic Atlas (Plate VIII, English edition, 1870) an example of retinal hemorrhage after suppression of menstruation. He says he has several times seen the same appearances, and always in women. The iskin is not infrequently the seat of vicarious menstrual hemor- rhage. Sometimes the blood appears in the form of petechia or small ecchymoses on various parts of the body, but sometimes it has actually been seen to ooze in droplets from the surface, forming a true bloody sweat. There seems some analogy between these cases and the bumps of erythemo. nodosum, which are not uncommon on the legs of girls suffer- ing from amenorrhoea. In some instances the blood is poured out from a varicose ulcer or other sore. Dr. Mason relates {Edin. Med, Journ., 1866) a case in which menstruation began at eight, and continued to recur until eleven, then stopped until thirteen. A large abrasion then formed in the right cheek, suppurating in the centre, and inclining to bleed towards the 156 MENSTRUATIOIS'. circumference. The menstruation was now irregular. After a time this place healed ; blood then oozed from the skin of the face. Dr. Basset relates [Presse Medieale) a case of a woman who con- sulted him on account of periodical discharges of blood by the nipples. Menstruation, however, Avas also present, although scanty. The patient had borne three children. Mr. d'Andrade relates an interesting case.^ The subject was a stout, healthy Parsee lady, aged eighteen. She had menstruated regularly from thirteen to fifteen and a half, when the catamenia became first ir- regular, then ceased, being replaced by bleeding at the gums and nose, and vomiting of blood. Menstruation returned. No pregnancy. Mr. d'Andrade observed blood to ooze from the healthy skin of the left breast, and of the right forearm. The blood exuded showed red and white globules under the microscope. The skin-hemorrhage recurred every month or two. Subsequently blood oozed from the forehead. The following case,^ which occurred in St. George's Hospital in 1872, under the care of Dr. John Clarke, is so complete in its history, and so illustrative of several important points in physiology and pathology, that I am induced to quote it at length : "J. C , aged eighteen, was admitted into the hospital on May 30th, 1872. The history of the case is as follows : Her family were healthy. She was single, and had never seen any catamenial dis- charge ; but for three months before admission she had from time to time suffered pain at the lower part of the back and between the shoulders. During these attacks of pain she had bleeding from the nose and gums, which lasted about a week, and then ceased, returning again after the interval of one month. For two or three weeks before she came into the hospital she had had great irritability of her skin, to relieve which she had recourse to scratching ; but this gave rise to im- mediate bruising of the parts. For four months past she had complained of pain in the left side, accompanied with difficulty of breathing, cough, and spitting of blood. She had never had rheumatic fever ; but about five years ago she suffered from chorea. "On admission she was very ansemic, the lips and conjunctivae being almost bloodless. She suffered from shortness of breath, and had fre- quent bleedings from the nose, mouth, and skin. She said she had never menstruated. There were hemorrhagic spots on the tongue, in- side the lips, and on the gums. Some of the spots on the tongue Avere as large as half a split pea, and the tip was so covered with ecchymoses that it had the resemblance of a strawberry. The lips were cracked, and on the inner side were numerous ecchymosed spots. The surface of the chest was more or less marked with these hemorrhages, but here some of the spots could be picked off. At the places where scratching had been practiced there were distinct bruises. On the legs and thighs the spots had more the character of the hemorrhages seen in purpura. In many places the blood seemed to have actually exuded from the skin, as they could readily be lifted off; but there was no evidence ' Trans, of Med. and Phys. Soc. of Bombay, 1862. = Lancet, 1872. VICARIOUS MENSTEUATION". 157 that mechanical means had been employed to produce them. For four or five days she had suffered from epistaxis. On examining the chest, a loud mitral murmur, most marked at the apex, was heard, the heart's action being very irregular and rapid. The lungs were resonant, and air freely entered ; but the breathing was rapid and labored even after slight exertion. There was a troublesome cough, and occasionally the patient spat blood. There was no vaginal orifice; the small cavity rep- resenting the canal of the vagina ended in a cul-de-sac, and was not deep enough to hold a teaspoonful of fluid. The urethra was in the middle of this cavity. The labia majoria were well formed, but small, and there was an ordinary amount of pubic hair. The space between the rectum and the urethra measured about half an inch. On passing the finger into the rectum, no uterus could be discovered ; and, when a catheter was introduced into the bladder, it could be distinctly felt through the anterior wall of the rectum. jS'umerous ecchymoses were present on the inner side of the labia majora. The patient was ordered beef tea, milk, and eggs. " May 31st. — Breathing easier ; ecchymoses still come out ; bleeding from nose and gums about the same as above. Ordered two drachms of infusion of digitalis, and twenty minims of tincture of perchloride of iron, to be taken every four hours Avith some spirits of nitrous ether. At night to have a purge composed of ten grains of calomel and colo- cynth pill. " June 1st. Medicine to be discontinued and purgatives to be admin- istered. Tlie patient complained in the evening of feeling faint. " 2d. Bowels have acted freely ; epistaxis much diminished; complains of feeling sick ; has vomited. To have some hydrocyanic acid and soda mixture every four hours. " 3d. Spots gradually fading ; bleeding from nose and gums nearly stopped. Purgative medicine to be discontinued. " 8th. Gradually improving. "The patient continued to improve till June 11th, when the breath- ing became much embarrassed, and accompanied with severe palpita- tion of the heart, cough, and spitting of blood, death taking place at 3 P.M., consciousness remaining till the last. "Autopsy. — Body well nourished; limbs and trunk covered with ecchymoses. Mammse fairly well developed, but nipples small. Color of the hair light^brown. Oi\ opening the thorax the pleurae were found to be spotted with ecchymoses. The lungs were oedematous, and gorged with blood. The pericardial cavity contained a small quantity of light- red fluid, but the walls were dotted with hemorrhagic spots, especially the visceral wall. The endocardium at the upper part of the left ven- tricle w^as thickened and opaque. The aortic valves were thick, puck- ered, and inefficient ; the mitral valve thickened, and so contracted that the orifice would only admit the tip of the little finger. The muscu- lar walls of the right ventricle and left auricle much hypertrophied. The liver, spleen, and kidneys did not present any abnormal appear- ance. The ovaries were very well developed and congested, and con- tained a recent false corpus luteum. The uterus was absent (evidently 158 MENSTRUATION. congenitally), only a small nodule of fibrous tissue being found in the folds of peritoneum between the rectum and the bladder." Here we see exhibited in a striking manner the influence of ovula- tion upon the system. There being no uterus, the menstrual blood sought outlet in almost every direction, and the function failing, the patient died. The case is extremely valuable, as showing that absence of the uterus or its imperfect development does not imply defective development of the ovaries. Possibly an operation for the construction of a vagina to oj^en a communication with the rudimentary uterus might have been of service. These cases of vicarious menstruation prove how intense is the effort of Nature to seek an outlet for blood. They seem to show that the tension of the vascular system becomes general when the outlet by the uterine mucous membrane is not free. Tliis general tension is illus- trated by the frequent sensation complained of by sufferers from araen- orrhoea and dysmenorrhoea, of " those things flying to the head," evi- denced by headache, vertigo, and epistaxis. These phenomena of vas- cular tension suggest that the rational treatment consists in diminish- ing tension by purgatives and leeches, or by cupping. Two conditions in the healthy subject siispend menstruation, — Preg- nancy and Lactation. The arrest of menstruation is the most familiar presumptive evidence of pregnancy. The law is, that from the moment of conception menstruation is stopped, and does not return until the child is weaned. Many exceptions, however, occur. Some of these are apparent rather than real. When pregnancy occurs, the lining mem- brane of the uterus, being wanted for the new function of connecting the impregnated ovum with the uterus, undergoes a remarkable change of structure. If it were now to pour out blood, the relation of the ovum to the uterus would be disturbed, and abortion would ensue. In fact, this not seldom does occur. Notwithstanding the general truth of the theory of the Genesial Cycle, so well described by Tyler Smith, which expresses the law of the successive domination of the ovaries, uterus, and breasts in the woman, it is certain that, although during pregnancy and lactation the ovaries are comparatively subdued or qui- escent, ovulation occasionally, if not always, goes on. Negrier and Scanzoni have especially insisted that pregnancy does not arrest ovula- tion. If in the majority of cases we miss the common proof or expo- nent, menstrual discharge, yet the other signs of ovarian activity are frequently present. There is a monthly molimen or nisus, marked by greater turgidity and accumulation of blood in the pelvic organs. Hence the epochs when the return of the menses is due are those when abor- tion is most likely to happen. The influence of ovulation is also seen in the later months of gestation, markedly when the placenta grows to the loAver or cervical zone of the uterus. In this case liemorrhages are apt to break out at the menstrual epoclis. And generally premature labor is more likely to occur at these than at intermediate periods. But menstrual hemorrhage may occur, especially during the first three months of gestation, without interfering with the relations of the ovum to the uterus. This may be explained in two ways : First, the blood may be poured out from the free surface of the decidua vera lining the EFFECT OF LACTATION. 159 inferior zone of the uterus, and even from the free surface of the decidiia reflexa. Secondly, it may exude from the congested cervical cavity. This is especially likely to occur when there is ulceration or abrasion of the OS or cervix, or inflammatory congestion. 3Iensfruation during lactation is much more frequent than during ges- tation. Although, normally, the breasts are now in the ascendant, the ovaries are not always dormant. Many women really menstruate throughout lactation, and not infrequently, in spite of suckling, preg- nancy occurs. In the majority, perhaps, menstruation is in abeyance for nine, ten, eleven, or twelve months if suckling is kept up. Some women, hoping to postpone pregnancy, go on suckling for fifteen, eigh- teen, or even twenty-four months.- Only a certain proportion succeed in their object. After nine months the ovarian excitement usually be- comes too strong to be subdued by the more languid activity of the breasts, menstruation reappears, the milk dries up, and pregnancy often quickly follows. In other suckling w^omen, however, the menstruation is chiefly apparent. From imperfect involution of the uterus after labor, from congestion, from abrasions or ulcerations of the os and cervix uteri, or from disorder of remote organs, discharges of blood, which may or may not be periodical, occur. If these irregular hemorrhages are much protracted, excessive in quantity, and present marked deviations from periodicity in recurrence, it may be concluded that there is a mor- bid factor, local or remote, wdiich calls for investigation. In very im- pressionable or nervous women, the mere act of applying the child to the breast will cause a discharge of blood from the uterus, offering one example of the many of the intimate correlation between the ovaries, the uterus, and breasts. It is convenient here to notice the influence menstruation exerts upon the milk. It is generally believed that the milk is injuriously affected ; and common observation shows that the suckling is often griped, or has diarrhoea, at the nurse's monthly periods. Raciborski, indeed, says the milk is not sensibly altered in its properties ; it simply appears to be less rich in cream. I have, however, observed that co- lostrum-globules were reproduced at every menstrual epoch. And it must be borne in mind that the activity of the ovaries renders the nurses more susceptible to moral impressions and to emotions. The influence of emotion in disturbing the milk cannot be doubted. In the contention for supremacy the ovary is pretty sure to win. If the woman is exposed to sexual relations, active ovulation and menstru- ation are very likely to be quickly resumed. Thus, in spite of suck- ling, impregnation often occurs within two or three months of delivery ; and not a few women fall pregnant wdthin six months " wdthout seeing anything between." On the other 'hand, women who have become widows before or soon after delivery, and lived a single life afterwards out of a feeling of concentrated affection, keep up lactation for eighteen months or two years wdthout a return of menstruation. But this, perhaps, they could not have done had the ovaries been subject to the excitement of married life. As a rule, nursing women continue unfruitful until the activity of 160 MENSTEUATIOX. the mammary secretion has remitted, this remission being shown by the necessity of adding foreign substances to the infant's food. We may now attempt to trace the local and constitutional reactions, that is, the symptoms or concomitants of menstruation. First, the local conditions. There is congestion or hypersemia of all the genital system ; ovaries, uterus, and breasts swell and become turgid. Scauzoni had an opportunity of directly observing this. In a remarkable case of inguinal hernia, the contents of the sac included the uterus and ovaries. He found these organs to sw^ell and become painful to the touch at every menstrual period. Concej^tion took place twice whilst the uterus w^as in the sac (Beitrage, 1871). Many women are conscious of a sense of fulness, weight, and pain in the region of the ovaries, which points to the distension of these organs. Then there is the evidence of post- mortem inspection of the ovaries of women dying during menstruation, W'hich shows them to be full to the point of bursting with blood. In- deed, w^ien an ovum escapes there is an actual rent in the capsule of the ovary ; in some cases phenomena, in a certain sense traumatic, as severe pain, a kind of shock, are present. The state of the uterus has been partly described. The mucous membrane overgorged, actually allows blood to ooze from its surface. The bulk of the uterus is increased. This may be determined by its greater weight as ascertained by touch, and by examination between the two hands. The vagina also is more vascular and turgid. The breasts sympathize with the pelvic molimen. They swell visibly, become firmer, sometimes painfully hard. This is especially the case at the age when menstruation is being established. Under the ovarian stimulus the breasts, like the uterus, actually grow ; they assume their full development or evolution. So great is the activity thus provoked, that, occasionally, this rapid, almost sudden, action passes the physiological boundary ; the glands present nodular masses, extremely tender to pressure ; they may even inflame, and I have seen these phlegmons form abscesses in the breasts of virgins, produced apparently under this sole ovarian excitation. This is in strict analogy with the history of the production of phlegmons in the breast after labor. I have, however, suspected, in some cases, that libidinous ma- nipulation of the breasts was in some degree concerned. The forma- tion of abscesses is, indeed, rare ; but it is not rare to find at puberty nodular painful points in the breasts, which give rise to great anxiety as to their real nature. Howsoever rare and improbable cancer of the breast may be in young girls, it is not always easy to allay the appre- hension that it exists. Mere surgical examination is not always enough to establish a decisive diagnosis, affirmative or negative. At any rate, I have known surgeons of great experience at fault in these cases ; and it was only on further consultation that, in two instances, I rescued the patients from undergoing needless amputation of the breast. In con- sidering these cases, then, we must make great allow^ance for the physiological stimulus, and deliberate well, calling Time, which solves so many problems, into consultation. These local conditions are usually well marked throughout menstrual life. But the remote or induced phenomena are generally more strongly PHENOMENA OF MENSTRUATION. 161 characterized at the first appearance of the function. The following description, however, whilst it applies more strongly to the first men- strual periods, will serve, with modifications in degree, for the subse- quent menstrual history. The vascular excitement of the genital organs cannot fail to affect other parts of the body and the general system. The nervous centres, especially, feel and respond to and sympathize with the altered condi- tion of the genital system. In most instances, there are prodromata, forerunning signs, the sig- nificance of which is well known to the subject. These, like the signs which occur at later stages, will vary in different individuals. In women whose health is good, whose organs are perfectly adapted to the easy performance of their function, the prodromata are scarcely noticed, and all the phases of menstruation are gone through with little or no local or general disturbance. In such persons a slight sense of fulness in the pelvis, some little perturbation of the circulation, signs suggesting plethora, are speedily followed by the flow which brings complete relief. All sense of trouble passes away with a momentary lassitude that does not compel to the interruption of ordinary duties. Such persons are often more cheerful and animated at the menstrual periods ; their ideas flow more brightly ; their emotions are more kindly. But in a very large proportion of women, things do not run so smoothly. In many the function is performed with more or less diffi- culty, and causes more or less general disturbance. This may arise from one of two, or a combination of the two circumstances. The sub- ject may be of excessively impressible, nervous temperament, stirred too readily and immoderately by ordinary excitation. Or, secondly, there may be local, mechanical, or other hindrances to the fulfilment of the menstrual acts. Or the two conditions may be combined. In either of these cases, not only may the prodromata be severe, but the stage of menstruation itself will be attended with suffering, and even when the function is fairly completed, distress will not be altogether allayed. Amongst the prodromata are pain in the pelvis, a sense of fulness, backache, pain especially in one iliac region, and radiating down the thighs. The alimentary canal reveals the impression made upon the ganglionic centre by vomiting and diarrhoea. Lassitude, to the extent of prostration, seizes the patient. The mind is always more or less disturbed. Perception, or at least the faculty of rightly interpreting perceptions, is disordered. Excitement to the point of passing delirium is not uncommon. Irritability of temper, disposition to distort the most ordinary and best meaning acts or words of surrounding persons, afflict the patient, who is conscious of her unreason, and perplex her friends, until they have learned to understand these recurring outbursts. Despondency to the verge of melancholy, violence to the verge of mania, impulse ungovernable to the verge of monomania, false ideas, distorted judgment to the verge of delusion, and sometimes overstepping the boundary, render the sufferer for a time really irresponsible. Lunatic asylums offer numerous examples of comparative abeyance of the usual manifestations of insanity during the intermenstrual periods, and of their exacerbation ^vhen the catamenia return. Not even the 11 162 MENSTRUATION. best educated women are all free from these mental disorders. Indeed, the more preponderant the nervous element, the greater is the liability to the invasion. Women of coarser mould, who labor with their hands, especially in outdoor occupations, are far less subject to these nervous complications. If they are less frequently observed ; if they less fre- quently drive refined women to acts of flagrant extravagance, it is because education lends strength to the innate sense of decorum, and enables them to control their dangerous thoughts, or to conceal them until they have passed away. In other cases the ovarian excitation evokes a fit of what is called hysteria. This, too, is sometimes to a great extent kept in subjection by a determined will ; but when once this habit has grown, the attack is usually irrepressible. I, as well as other physicians, have observed cases in which a fit of eclampsia has ushered in menstruation. In some of these there existed an hereditary or other predisposition to this form of convulsion ; but still the exciting action of ovulation was clear. Sometimes stupor or lethargy is the prominent symptom, but this is more frequent as a result of hysteria or eclampsia. Associated occa- sionally with hysteria, or independent of it, erotic passion is the promi- nent symptom. When this occurs, the lapse into insanity is often near. After committing the grossest excesses, which may for a time be attrib- uted to moral depravity, the disorder passes, perhaps suddenly, into unmistakable mania, and seclusion becomes necessary. A remarkable fact amongst the phenomena of menstruation is the effect on 'pigmentation. The complexion is commonly changed ; it loses its clearness, becomes dull or sallow, and a dark, even black ring, especially marked in brunettes, is traced around the eyes. This is often so conspicuous as to reveal to the initiated what is going on. It is similar to the state of pigmentation wrought by pregnancy, and thus aifords evidence of the analogy or relation between the two states. Dr. Laycock says excessive pigmentation is brought about by imperfect oxidation of the carbon ; that by imperfect elimination of the carbon, in deficient menstruation, diseases of the liver and kidneys are induced ; and that these conditions are promoted by the excessive production of carbon from the use of highly carbonized food. PRIMITIVE AMENORRHCEA. 16' CHAPTER Xyill. DISOKDEKED MENSTEUATION (PARAMENIA, W. FAER)— AMENOPvEHCEA. The departures from the ordinary character of healthy menstruation are conveniently classified under amenorrhoea, including deiiciency of the flow; Menorrhagia indicating excess, and dysmenorrhoea, indicating that the function is performed with difficulty and pain. These terms, like so many others we are obliged to use in medicine, do not represent any definite disease, but are simply general descriptions of sym])toms. Under each of them the most widely differing pathological conditions, mechanical and systematic, are grouped. Many different pathological conditions may alike lead to one symptom that shall be more promi- nent than the rest. That symptom is the first thing that fixes atten- tion, and for which the patient seeks advice. It is the business of the physician to analyze the patient's condition, and to discover, if he can, what are the associated phenomena, and what is the cause of the lead- ing symptom. This is the method we are daily forced to adopt at the bedside. It is not so illogical as it appears ; it is eminently practical ; it exercises the diagnostic faculty in the most invigorating manner, and, if rightly pursued, leads to the soundest knowledge, at once the most satisfying to the physician, and the most profitable to the patient. We will, then, take the symptom, amenorrhcea, search out the condi- tions upon which it depends, and study the various forms it presents. Some authors associate with primitive absence of menstruation those cases in which the menses are retained by closure of the genital canal. Logically and pathologically, it is obviously more rational to consider these cases apart. They will be discussed under "Retention" and " Atresia." The amenorrhoea here is not real. There is secretion, but excretion is mechanically hindered ; menstruation is occult. The most rational division of amenorrhoea is into — 1. Primitive, that is, the flow has never taken place; 2. Accidental, or secondary, that is, the func- tion has at some time been established, but has subsequently been suppressed. Primitive Amenorrhoea. — The appearance of menstruation may be retarded for one or two years beyond the usual age without any obvious derangement of health. But in a large number of cases, concurrently with non-menstruation, a remarkable condition of the general system is observed, to which the name chloro-anosmia or chlorosis, vulgo, green- sickness, is given. A marked feature of this condition is a great dimi- nution of the red corpuscles of the blood, and a consequent exccessive proportion of water. A thin, pale blood, incapable of carrying on effi- ciently the functions of nutrition, respiration, or circulation, flows lan- guidly in the vessels. Every organ, every tissue feels the want of 164 AMEXORRHCEA. adequate nourishment and stimulus. The skin and mucous membranes present a peculiar pallor tinged with green. The patient is unwilling to make any exertion, and even the most moderate effort is followed by- mental and physical prostration, or an outburst of hysteria. The taste and appetite are often depraved. The ordinary diet, as meat or fish, is rejected with loathing. The craving is usually for fruit, cucumbers, jjickles, vinegar, or things in which sourness predominates. It is more than probable that the craving for these things is the cry of Nature for a supply of elements which the degraded blood is in need of; it should not, therefore, be too absolutely thwarted. In some cases earthy and alkaline substances chiefly excite the morbid appetite. The heart, ill- nourished, acts feebly ; it endeavors by increased frequency of beat to make up for the deficiency in quality of the blood it sends into the general system. It is easily excited to hurried action, which assumes the well-known character of palpitation, and which may on pushing exertion, such as ascending stairs or hills, too far, readily lead to faint- ing. Excessive irritability of the heart under emotion or physical ex- ertion is the characteristic condition. Severe pain, more or less fixed under the heart, is commonly complained of. Headache is very com- mon, and is easily induced by exertion or emotion. The watery state of the blood, the general laxity of all the tissues, including the walls of the capillaries, and the feeble power of the heart, lead to local stagnations and to effusions of serum into the cellular tissue of depending parts. The feet especially swell, are cold, readily affected by chilblains. The hands also swell ; and this would be fre- quently observed, were it not that they are subject to constant changes from the hanging position. The face gets puffy, bloated, especially so the loose tissue of the eyelids. The muscular system is flabby and feeble, incapable of bearing any strain ; and pains in the muscles are easily induced by even moderate exertion. Depending upon a similar systemic condition we occasionally see those nodules of limited hypersemia, ecchyraosis, and hyperplasia, which are known as erythema nodosum. These chiefly appear in the legs, but sometimes also in the arms. They indicate the extreme debility of the walls of the vessels, and of the surrounding tissues, which in their healthy state contribute so much to the support of the vessels. The normal flow of blood is not uncommonly replaced by a periodi- cal watery discharge. This must be regarded as menstruation. The vascular system yields under the ovarian stimulus the best substitute for healthy blood which it can afford. This may be called '^imperfect menstruation." In these and other cases it is not uncommon to note a persistent leucorrhoea. This form of leucorrhoea is one of those which are not the result of some physical lesion justifying local examination. The discharge seems due to relaxation or want of tone in the vessels and mucous membrane. It commonly ceases when healthy menstrua- tion is restored. In every case in which the deficiency of red globules is marked, a blowing sound, recognized as the ansemic hruit, is heard at the base of the heart, and extending along the arterial trunks of the neck. Where this deficiency is extreme there is commonly heard in the jugular veins CHLOEO-AN^MIA. 165 that peculiar and characteristic noise known as the hruit-de-diable, or the German " Nonnengerausch." This sound gives not only precise diagnostic indication of the maladv, but its intensity affords accurate estimate of its progress. In propor- tion as the quality of the blood improves under treatment the noise diminishes. It appears to be directly associated with the relative ab- sence of the red globules. When these are present in due proportion the sound is no longer heard. I have observed this sound in a marked degree in anaemia associated with menorrhagia ; and notably in some cases where there was suspicion of commencing tuberculosis. In some of these cases of associated chloro-ansemia and amenorrhoea it is not easy to determine which is the primary factor. Is the want of menstruation the cause of the degraded condition of the blood? Or, on the other hand, is the degraded condition of the blood the cause of the amenorrhoea? If we could tell which condition came into existence first, and which followed, the sequence, if constant, would settle the question. But the ovary is beyond direct observation; we are almost limited in our conclusions as to its activity by noting the subordinate phenomena of menstruation. One fact comes out prominently: the state of chloro-anasmia stands in constant relation to the menstrual function. It seems probable that at the age of puberty, ovulation, which ushers in such a striking revolution in the economy, stimulating, almost visibly, development of the whole system, and remarkably of certain organs, takes at least an indirect part in the function of blood-making. Or to put it in an- other way : that evolution of the system at puberty, that almost sudden bursting into womanhood, cannot be perfectly accomplished unless the ovaries give the impetus. This is illustrated by the occurrence of re- lapses. For example, a girl who has quite recovered from one attack of chloro-ansemia, may again fall into exactly the same condition, amenorrhoea attending. Chlorosis, says Virchow, is distinguished from leukaemia in this : the entire number of the corpuscles is smaller. In leukaemia, color- less corpuscles in some sort take the place of the red ones, and a real diminution in the number of the cellular elements in the blood is not produced. In chlorosis the elements of both kinds become less numer- ous, without the occurrence of any disturbance in the numerical rela- tion between the colored and colorless corpuscles. Anatomical obser- vations, he goes on to say, indicate that the foundations of the chlo- rotic ailment are very early laid ; for the aorta and the larger arteries are usually, and the heart and sexual organs frequently, found imper- fectly developed. To originate a new function, to bring to perfection a hitherto unex- ercised power, makes larger demands on the strength than are required for its continued activity. The feeble phthisical child fails, as the time of womanhood approaches, to menstruate, and the signs of chlo- rosis gradually manifest themselves. Numerous instances, however, are observed in which after menstrua- tion has been fairly established for months or even years, chloro-anaemia almost suddenly makes its appearance, and entails suppression of men- 166 AME]!fOEEHCEA. struation, partial or complete. In many of these cases emotion plays an important part. Jealousy, disappointment in love, the " sjiretse in- juria formse" are often the immediate antecedents. No one who has had a large experience can fail to remember numerous examples of the powerful influence of emotion in altering the quality of the blood. At the advent of puberty, organs hitherto existing only in a latent or potential condition, almost suddenly come into the foreground, and a new function that dominates the whole system appears, or ought to appear. The perfection of the ovaries undoubtedly entails the evolution of the breasts and uterus, and provokes a rapid development of the wdiole frame. To a certain extent this general physical development will take place, whether ovulation be perfectly performed or not. But, then, to carry out the full change in the ovaries, certainly a fair supply of healthy blood is requisite. If the sudden excessive demand for healthy blood requisite for this purpose, and for the attendant general physical growth, be not adequately met, menstruation will be hindered. And the continuing, although impeded, general growth, exhausting the blood supply, quickly induces the marked blood-degeneration wliich is so characteristic. Things once at this stage, a vicious circle of mor- bid action and reaction is established. The effect in its turn becomes a cause of further disease. On the other hand, it is observed that M^hen the quality of the blood has been improved under the use of suitable remedies and hygiene, menstruation usually returns ; and that when a degraded condition of blood is induced by defective nutrition, or subjection to bad sanitary conditions, menstruation is suppressed. The influence of the ovaries is at times strikingly manifested, as when, under the influence of marriage, ovulation being stimulated, the chloro-ansemia often disappears. We may, perhaps, best sum up the argument by stating these propo- sitions : 1. That the due action of the ovaries gives an important stim- ulus to innervation, sanguification, and the general well-being. 2. That the due action of the ovaries, as of other organs, depends upon their being duly nourished by a supply of healthy blood. We cannot always tell which factor is first in default; but whichever it be, a vicious circle of action and reaction becomes established as soon as the one condition has induced the other. It has been happily said that amenorrhoea is a cry of distress indi- cating something wrong in the organism. The opposite condition of plethora will sometimes delay menstrua- tion. Girls suddenly exchanging a poor vegetable diet for one rich in nitrogen, whilst neglecting exercise, are apt to fall into this state. A very frequent complaint attending amenorrhoea is acute pain un- der the left breast, in the intercostal spaces, in the sacral region, or in the temples. These pains have often been described as " hysterical ;" and the hysterical knee of Sir Benjamin Brodie might perhaps be classed under the same head. It is rather a form of neuralgia, induced by the waste of nervous force in wrong directions. Arsenic, iodide and bromide of potassium, are the most useful reme- dies. A sponge soaked in hot water held to the temples or other seat TREATMENT OF AM ENORIIHCE A. 167 of pain brings sensible relief, Simpson speaks highly of nickel, as sulphate or phosphate, in half-grain or one-grain doses. There are local causes of primitive ameriorrhoea. The most free from doubt are absence, defective development, or disease of the ovaries and uterus. Some of these conditions will be discussed under "Atresia." It is not easy to discover defective development of the ovaries ; it can at best be inferred from the existence of defective development of the uterus, and the defect of the menstrual functions. But this is far from being constant. A small infantine uterus may be recognized by the touch, and measured by the sound. The uterus is sometimes only an inch and a half or two inches long, the cervix or vaginal-portion is very small, the os uteri a small round aperture, and the body may be deflected to one or other side. In these cases there is commonly sexual indiflerence. Simpson's galvanic pessary is here of use. It stimulates the growth of the uterus, and I have several times seen healthy men- struation established. Cystic and malignant diseases of the ovarieg are rare at the age of puberty. And in a considerable proportion of those cases which occur at a later period, a portion of the gland, adequate to form ova, which run through the normal phases, and escape, evoking the attendant phenomena of menstruation, may for a long time resist the invasion of the disease. This residuum of efficient ovary may easily be overlooked; its possible existence must be borne in mind when we meet with cases in which menstruation has continued concurrently with even extensive ovarian disease. But it must not be concluded that absence or imperfect develoj)ment of the uterus is a certain exponent of absence or imperfect develop- ment of the ovaries. For proof that the ovaries may be well developed and perform their function, although the uterus may be wanting, I refer to a case observed at St. George's Hospital, and cited at length at page 156. When the chloro-ansemia has lasted some little time, a slow chronic feverish state sets in. The treatment of this form of amenorrhoea should be governed partly, at least, by the knowledge of the influence of ovulation. But here, as in almost every case which the physician is called upon to treat, we must treat the symptoms, alleviate the consequences of the disease, as well as attack the cause. The two indications can generally be followed out at the same time. Our first effort, then, should be to improve the condition of the blood, since we can hardly expect the ovaries to assume their function energetically until they are properly nourished. It is accepted as an axiom in medicine, that the blood being deficient in red globules, iron is the remedy jDa?' excellence. This is true ; but it requires more judgment in administering it than is often shown. Long clinical experience has taught me the general law, that in all states of blood-degradation, whether resulting from mal-nutrition, from wasting diseases, or from hemorrhages, iron is ill tolerated at the beginning. In all extreme anaemic states the febrile irritability I have adverted to is liable to be aggravated by iron, if rudely and precipitately " thrown in," as the phrase is. The tongue gets parched and brown, indicating 168 AMENOERHCEA. a like state throughout the alimentary canal, inducing constipation, and generally impeding nutrition ; violent headache ensues ; the pulse rises in frequency. The true indication is, first, to allay vascular irritability, so as to prepare the system to assimilate iron. This is best done by salines, of which I believe the best is the fresh prepared acetate of am- monia, the old spiritus Mindereri. If freshly made it is not only more grateful from containing a quantity of carbonic acid, but it is more efficacious. A little nitrate of potash may sometimes be usefully added ; and in almost every case the combination of some light tonic, as hop, cinchona, or calumba, will be of service. So marked is the benefit often arising from this exhibition of salines, that one cannot resist the conclusion that the blood is in want of salines as well as of iron, and that the saline material is the first want. This view is confirmed by what is observed in transfusion. In extreme anaemia, revival has fol- lowed the injection of saline fluids into the veins. When vascular irritability is subdued, when the secreting organs have been brought to a cleaner and healthier state by salines and aperients, iron may be cautiously tried. Nothing surpasses, probably, Griffiths's mixture. This also should be freshly made. There is a special virtue in nascent combinations. We can hardly trace the new forms, or estimate the loss sustained in stale preparations. But it is very nauseous ; and modern chemistry has supplied us with other ex- cellent preparations of iron. Almost every one has his favorite pre- scription. The citrate of iron and ammonia, which may be given in an effervescent state if desired, is an excellent medicine ; it is generally easily borne. I have long given with great advantage the solution of acetate of iron. This seems easily assimilable, and is, perhaps, the most agreeable of all ferruginous preparations. It is not desirable to give large doses. Iron should rather be regarded as an element of food than as a medicine. The blood wants it ; but it must be taken in such a way that the system have time to deal with it like other food-elements, to assimilate it and convert it into blood. Iron must, therefore, be given for a considerable time ; that is, until the return of color to the cheeks and mucous membranes, the vanishing of the hruit-de-diable and the ansemic souffle, and the establishment of menstruation announce that the system has regained the independent power of carrying on the function of blood-making. Coindet and Boinet extol the virtue of iodine in amenorrhcea. Trousseau also advises it, saying, however, that it comes in most usefully after iron. Ever since I followed the clinique and lectures of this admirable physician I have prescribed iodide of potassium in a con- siderable proportion of cases. But my observation, whilst confirming most distinctly Trousseau's opinion of its efficacy, has led me to prefer giving it before proceeding to the administration of iron. It seems to me to occupy an intermediate place between ordinary salines, wliich should be given first, and chalybeates. Iodide of potassium may be given in ten-grain doses, with or without ammonia and bark, two or three times a day. An old popular remedy is saffron. Trousseau extols it. I have tried TREATMENT OF AMENORRHGEA. 169 it extensively, but generally in combination with iodide of potassium, so that I am unable to speak positively of its independent virtues. The restorative power of iron is often much increased by the addi- tion of small doses of strychnine. Under this agent the nervous sys- tem especially acquires more tone. The digestive organs display the same sluggishness which oppresses every function. Constipation is frequent, and the peristaltic action of the Ijowels requires stimulation. Purgatives are generally necessary, and the favorite ones are aloes or rhubarb combined with myrrh or other stimulating adjuvant. Hoifman said he had seen better results from Rufus's pill — the " pilula de tribus" — consisting of myrrh, aloes, and saf- fron, given in repeated small doses, than from any other medicine. The concurrence of experience as to the efficacy of this pill should rescue it from neglect. Concurrently with the use of these medicaments, diet and exercise must be carefully studied. The diet should be generous. Milk is especially useful ; but a fair proportion of roast meat, vegetables, and fruit should be taken. Wine, of Avhich claret, Carlowitz, and Rhine wines are the best suited, or beer should be prescribed. Exercise, mental and physical, must be graduated to the strength and power of endurance of the patient. In the profound impairment of nutrition which affects every organ, the nervous centres cannot supply the requisite nerve-force, nor are the weak, pale, flabby muscles capable of strong, or sustained exertion. Every tissue has to be regenerated. This is a work of time, and during this period care must be taken to make exercise keep pace with, but not exceed, the growing strength. The aim being to create or to restore the " habit '^ of periodical men- struation, special care is indicated to favor any molimen that may re- veal itself by pain, sense of heat or weight in the pelvic organs, or by nervous or vascular phenomena elsewhere. This may often be success- fully done by the use of warm hip-baths — the addition of enough mustard to act as a slight rubefacient is sometimes useful — warm vaginal douches of plain water, or even with the addition of sufficient free ammonia to communicate a soapy feel to the water. One or two leeches applied to the anus or inside the thighs have often started the natural uterine se- cretion. These means act by derivation ; they determine the afflux of blood to the pelvic organs. As further means of following up this indication Schoenbein and Scanzoni recommend aloetic enemata. Golding Bird and Duchenne advised electricity. This agent has been, I believe, extensively tried ; but I am not aware that it has quite fulfilled the expectations that might primd facie be reasonably expected from it. Direct excitation of the uterus has been resorted to. Light applica- tion of nitrate of silver to the cervix uteri has undoubtedly been suc- cessful. The catheterization of the uterus has been said to be service- able. The wearing of an ivory or metal stem in the uterus has also been advised. The most effectual local remedy is probably the gal- vanic pessary of Simpson. But there are obvious objections to having recourse to these topical proceedings in single girls, and the cases are not many in which less objectionable means are not effectual. 170 A M E N O E E H GB A. I mention, but without approving, a proposal of Sir James Simpson to dry-cup the interior of the uterus. He described the proceeding as consisting of the introduction of a tube like a male catheter, furnished with numerous holes at the end, into the uterine cavity, and then being- attached to an exhausting syringe. The suction power attracts blood to the mucous surface. ' Probably these direct local excitants or derivants are the only true " emmenagogues." According to the old idea, an emmenagogue is a medicine possessing the property of causing the menses to flow, that is, of inducing a discharge of blood from the uterus. It is not clear that any known medicine possesses this property in a direct or immediate manner. But if we adopt the modern theory that menstruation is a function consisting essentially and primarily in the ripening and dis- charge of an ovum from the ovary, and secondarily of a discharge of blood from the tubo-uterine mucous membrane, we shall see still fur- ther reason to doubt the reality of emmenagogues. It is difficult to imagine how any agent we know of can in any direct or immediate way determine ovulation. Amongst the agents capable of exciting con- traction of the uterus, strychnine deserves a prominent place. But whatever influence it may have as an emmenagogue, it owes to its prop- erty as a tonic ; certainly it has no power of directly causing the men- strual flow. Iron, which enjoys the greatest popular reputation as an emmena- gogue, undoubtedly acts by first gradually restoring the quality of the blood, and improving general nutrition. If it occasionally acts promptly, it may be supposed that large doses of iron may produce temporary congestion in the pelvic organs. But I have not met with unequivocal evidence that it does so act, and I have known the exjjcriment to be repeatedly tried and fail. So in the amenorrhoea of phthisis, menstruation may sometimes return when, under cod-liver oil, iron, quinine, and suitable hygienic means, the disease is arrested, and a comparatively healthy hsematosis has been gained. But no one would call cod-liver oil an emmenagogue. It is interesting to observe that those agents which appear to exert a special influence upon the uterus are precisely those which have the property of checking hemorrhage from that organ ; indeed, the bleed- ing is checked through that very property of causing contraction of the muscular wall. Thus ergot, which possesses the most undoubted power to originate uterine contraction, possesses also the power of checking hemorrhage. It has no obvious action as an emmenagogue. The same observation applies, although in a less degree, to quinine and digitalis. I am informed by Mr. Cockburn, an eminent surgeon prac- ticing in India, that in that country, quinine is specially apt to cause abortion in women of delicate fibre. Dr. Fordyce Barker has given satisfactory evidence of its power as an oxytocic. Indian hemp again is credited, I believe justly, with oxytocic prop- erties; but its action in checking uterine hemorrhage is even more certain. To this rule galvanism may appear to be an exception. The powers of galvanism as an oxytocic, and even in originating uterine contrac- SECONDARY AMENOREHCEA. 171 tion, Dr. Radford and I proved some years ago. And it is regarded by some as the only direct emmenagogue. Many of the factors which account for primitive amenorrhoea will also induce secondary or accidental amenorrhoea. Thus, defective nutri- tion, unhealthy occupations in crowded, ill-ventilated rooms, blood- tainting from exposure to sewage-emanations, want of exercise in the open air, which implies privation of the wholesome influences of the sun, will all prevent the advent of menstruation. It is a matter of observation that girls verging on puberty, sent to boarding-school or into business in large town establishments, commonly fail to men- struate, whilst the function often is accomplished on their return to free life in the holidays, or on return to the country. In these cases the blame cannot always be assigned to insufficient food, for girls working in trades in cities often get a more substantial diet than they were pre- viously used to. What is wanting is outdoor exercise, and less rigor- ous strain upon the mind and body. Cretinism exerts a remarkable influence. Luuier ("Nouveau Diet, de Med. et de Chir. Pratiques," 1869) says "that puberty is almost always held back, or is only developed at the age of nineteen or twenty in girls, and later even in men. The cretin remains until puberty what he Avas in the first childhood, and very often there is nothing to distinguish the boy from the girl." Dr. Langdon Down tells me " that he is able to say with much cer- tainty that idiocy retards by quite two years the first appearance of the menses. In a large number of cases it is much more postponed, and sometimes never appears. Necroseopic inspection of idiots reveals, as a rule, want of development in the ovaries as to size. Associated with the non-appearance I have observed considerable increase of adipose tissue." The causes of arrest of menstruation are numerous. We exclude, of course, the physiological suspension during pregnancy and lactation. When an organ happens to be in a state of physiological activity, it is specially liable to suffer when the system is exposed to any physical or mental shock. Physiological activity implies hypersemia; under sudden excitation hypersemia readily passes the physiological boundary, and the function which was in progress is arrested. Hence, exposure to cold and wet during the menstrual flow will frequently check it. It is said that some women wilfully avail themselves of this deleterious in- fluence, in order to escape from the temporary abandonment of their pleasures which menstruation compels. They encounter a very serious danger. It is not to be expected that the effect will stop short just at the point desired. Ovaritis and pelvic peritonitis are very likely to attend this violent suppression, and permanent, even fatal, mischief has resulted. Dr. Whitehead relates a case in which menstruation was suppressed by cold which ended in fatal peritonitis. There was no eff'usion of blood. In another case the same physician found all the large sinuses of the brain distended to their utmost limit, gorged witli black, firmly-coagulated blood ; no extravasation. Menstruation had been suddenly suppressed by intense mental emotion. On the other hand, it must not be concluded that decided organic change in the 172 AMENORRHCEA. ovaries necessarily attends the sudden suppression of menstruation. Aran made minute examinations upon this jioint. His results were mostly negative. The absence of any serious organic lesion is further proved, in many cases, by the return of the menstrual function at no distant date. The arrest of the flow must therefore be regarded, in some cases, as a reflex phenomenon, the peripheral or centric irrita- tion which caused the suppression causing a diversion of nerve-force and of blood in other directions. It is analogous to the suppression of epistaxis under the application of a cold body to the skin. I have lately seen a remarkably well-developed young woman who never menstruated regularly after receiving a blow on the side. Abrupt suppression is, however, often marked by signs of local dis- tress. Pain, a sense of fulness in the pelvis and groins are felt. If examination be made by touch, the uterus is found to be tender, and even some tumefaction of the ovaries may be detected. The vaginal- portion is injected. Constitutional disturbance also reveals the local trouble. The pulse rises. Uterine and ovarian disease not seldom entails amenorrhoea. In- flammation may suspend it, but advancing degeneration of the ovaries is more likely to lead to complete suppression. That menstruation so often goes on notwithstanding the development of enormous ovarian tumors, is explained by the fact that commonly one ovary is healthy, or that where both are affected, yet some portion of one or both retains so much of its normal structure that the process of ovulation goes on, whilst the " habit " is so strong that even slight ovarian nisus provokes the customary flow from the mucous tract. Emotion, sudden, or that attending a great change in the mode of life, will often suspend menstruation. Thus it is not uncommon to ob- serve in young women absence of the menses for two or three months after marriage, naturally giving rise to the idea that pregnancy has begun. This is often nothing more than an emotional suspension. In like manner, under the still greater emotion of illicit connection, the same thing occurs. Passion, depressing news, domestic calamities, have often caused so great a shock that the menses have been arrested even permanently. Amenorrhoea frequently follows acute diseases, especially fevers. Thus I have seen girls who had exhibited all the characters of healthy development cease to menstruate for months after recovery from scar- latina or typhoid fever. I have known examples of amenorrhoea dating from simply nursing a scarlatinal patient. Exposure to the poison was sufficient, without the development of the fever. In some, the functions are for a long time irregular, imperfectly performed, and the constitution is manifestly impaired. In particular, the complexion seldom regains its original clearness, growth is checked, and the tem- per is more uncertain and irregular. Ague may have a similar effect. In some cases of arrested menstruation I have suspected the existence of disease of the supra-renal capsules. In these the arrest came on at ages between thirty and forty ; the complexion underwent the most marked dirty sallow change, freckles and spots becoming almost black ; SECONDARY AMENORRHCEA. 173 there was great mental depression occurring in fits, and great emacia- tion. Associated with amenorrhoea, probably as cause, there may some- times be found a general torpor or deficient innervation of the sexual system. This probably implies defective evolution of the ovaries. There is an original or acquired insensibility. There is no sexual feel- ing. This has sometimes been observed to follow a labor ; but in many cases it is original, and is attended by sterility. Attendant upon, or resulting from, this ovarian defect, there is commonly imper- fect development of the uterus. In amenorrhoea following labor, the suppressed ovarian function is accompanied by super-involution of the uterus. Diagnosis. — In studying this question we must bear in mind all the conditions associated with amenorrhoea; we must review the history of the patient, and of her present illness. To trace the circumstances under which the absence of menstruation commenced, we must inter- rogate all the functions, in order to detect disease in organs unconnected with the genital system. The exploration of the chest is especially important, on account of the frequent relation between amenorrhoea and phthisis. And in many cases it is necessary to examine the vagina and uterus to ascertain if there be any physical defect or obstruction to the excretion. This applies to married as well as to single women. The possibility of pregnancy must not be lost sight of. In women approaching the climacteric we must also consider how far the amenor- rhoea is natural. The signs of " Retention " will be discussed here- after. Prophylaxy. — Many of the causes of amenorrhoea are avoidable. Nevertheless great carelessness, even recklessness, is shown in en- countering them. It ought to be needless to insist upon the obser- vance of repose, physiological and physical, at .the menstrual periods, the avoidance of exposure to cold or mental disturbance. Adults may be expected to take care of themselves ; but young girls verging upon puberty require the Avatchful care of a mother. Serious mischief often arises from their being taken by surprise at the first appearance. Not being forewarned, in their alarm they may seek to check the bleeding by bathing in cold water, and they are apt to commit other imprudent acts which may suppress the natural floAV, and lay the foundation for serious protracted or permanent disease. Many girls, for example, have never menstruated again. They should be warned then to dress warmly, to avoid excitement, and to keep quiet when the period is approaching and during the flow. The course, duration, and consequences of amenorrhoea vary. Where there is no organic disease, as tuberculosis, and the subject is submitted to proper hygienic and medical treatment, the function is generally re- stored in a few months. But in those cases where amenorrhoea is com- plicated with, or dependent upon, disease in the heart, lungs, liver, kidneys, or ovaries, we can look with no confidence to the end of the symptomatic or consecutive disorder. On the other hand, where the defective action of the ovary appears to be inherent, or primary, its long continuance often entails such impairment of nutrition and in- 174 AMENOERHCEA, nervation as to give rise to distant organic disease. Where there exists hereditary morbid diathesis, especially tubercular, the evil which might otherwise have remained latent is very likely to be developed. The influence of protracted amenorrhoea upon the nervous system is almost always prejudicial, and is sometimes deplorable. The leading characteristic is want of power or tone. The general physical condition is lowered ; the patient is unequal to more than moderate muscular exertion ; the fits of irritable temper alternate with torpor ; headache is frequent ; it is difficult or impossible to sustain any mental effort ; memory is feeble; and in some instances mania or dementia has ensued. Amenorrhoea, especially if attended by marked chloro-ansemia, is very liable to merge into, to induce pulmonary consumption. The hygienic care is of great importance. Careful watch must be kept for the invasion of phthisis. Hence it is often useful in amenor- rhoea, whether there exist any special cause for apprehending the inva- sion of tubercular mischief or not, to winter in a mild, pure air, as in Torquay, Ventnor, or the South of France or Italy. The treatment of acute amenorrhoea from accidental suppression must be governed greatly by the nature of the cause of suppression. If it be the result of cold, a warm bath, rest in bed, sudorifics, as acetate of ammonia, ipecacuanha, a moderate opiate, or terebinthinate eneraata will be useful. But if there be evidence of pelvic congestion or inflammation, it will be unwise to seek to provoke the menstrual flow by local exci- tants. If there be much pain, increased on pressure, a quickened pulse with hot skin, some leeches applied to the groins or anus, hot fomentations to the stomach, salines, constitute the best treatment. When the pain has come on very suddenly, and with great severity, there is reason to fear that an effusion of blood has taken place from the turgid Fallopian tubes or ovaries into the peritoneum. This case will be discussed under " Hsematocele." Chronic amenorrhoea usually falls practically under the same rules as the primitive amenorrhoea. Iodide of potassium, iron, strychnine, suitable hygiene, are our chief resources. BETENTION OF CATAMENIA. 175 CHAPTER XIX. AMENORRHCEA FROM RETENTION— RETAINED MENSES FROM OC- CLUSION OR ATRESIA OP THE UTERUS, VAGINA, OR VULVA, OR FROM IMPERFORATE HYMEN— OCCULT MENSTRUATION— H^MATOMETRA. The study of those cases in which amenorrhoea is only apparent, in which the secretion is effected, but is retained in the cavities of the uterus or vagina, will, for clinical reasons, be most conveniently under- taken here. In its practical bearings it will be found naturally to take its place between amenorrhoea and dysmenorrhoea. The history and symptoms of retained menses very much resemble those of dysmenorrhoea. In some cases they simulate pregnancy. In other cases, for a considerable tira£, the negative sign of absence of the ordinary menstrual flow chiefly attracts attention; and they are looked upon simply as cases of amenorrhoea. The leading clinical feature is the combination of signs of dys- menorrhoea with amenorrhoea. And since retention commonly induces enlargement of the uterus, and hence of the abdomen, the combina- tion of amenorrhoea and this enlargement leads to the suspicion of pregnancy. When things have arrived at this point, the character of the patient, no less than the physical distress and danger, impera- tively point to the necessity of an examination. The usual history is as follows: A girl having arrived at puberty, does not menstruate. Month after month, perhaps for two or three years or more, pass by, and nothing is seen. But every month, perhaps with occasional intermission of a month, pains in one or other iliac fossa, such as commonly indicate difficult ovulation, are felt; pain in the centre of the pelvis referred to the uterus follows or pre- cedes, often of a forcing or bearing-down character, that is, uterine colic, such as occurs when the organ is struggling to expel something from its cavity; frequently the pain spreads to the abdomen, so that the patient cannot bear to be touched, and suggesting the presence of peritonitis. With these pains there is often flushed face, accelerated pulse, headache, vomiting, pains down the legs, irritation of the bowels and of the bladder. After a few, days these symptoms subside, seldom entirely ; and the patient is left to an interval of comparative ease. But her general health suffers. A degree of irritability of nervous system remains. Not seldom, occasional rigors appear, and these are followed by quickened pulse, increased temperature, nausea, muddy complexion ; in short, the usual signs of blood-infection. When irritative, hectic, septicaemic, or pysemic fever sets in, the case is commonly hastening to a climax ; and the physician is soon compelled to search for the source of the disorder. The periodical pelvic pains, the amenorrhoea, and the frequent compli- cation, with evidence of peritonitis, direct him to the uterus. 176 ATRESIA OF THE GENITAL, CANAL. In other cases, the irritative fever, although existing in a minor degree, is not the immediate cause of chief distress. This is due to the distension of tlie uterus, or vagina, or both, progressing so as to dis- tend the abdomen. The pain, causing vomiting and prostration, may be so great that the local source cannot be overlooked. The enlarged uterus may press the bladder forwards, and jam it against the symphysis pubis, causing retention of urine. The distress arising from this, and the added enlargement of the abdomen, admit of no delay. In other cases the enlargement of the abdomen is slow, and the pain is tolerated ; and it is only when amenorrhoea and enlargement of the abdomen excite suspicion of pregnancy that medical advice is sought. In some of these cases the history of the enlargement, extending over alonger period than the normal time of gestation, and other circum- stances, independently of the moral character of the sufferer, are enough to remove all doubt of her chastity from the minds of all but the censorious. The governing fact, then, is retention of the menstrual fluid in the uterus or vagina. There is secretion, but not excretion. Menstruation is non-apparent, but it exists. The proper term, then, is not amenor- rhoea, or amenorrhoea from retention, which is a contradiction in terms, but ^' occult, or concealed menstruation." The ovaries act, the uterus responds, the menstrual blood is secreted, but owing to some physical obstruction it cannot be excreted ; that is, it is retained. These cases may be divided into two kinds : 1 . There is retention ah initio ; there is some congenital defect, or some condi- tion acquired in childhood; 2. The retention has arisen after puberty, and most frequently after childbearing, and is the consequence of an obstruction acquired after maturity. We have, then, to examine the cases of Atresia of the Vulva, Vagina, and Uterus, and the other defects offorTMition which lead to retention of menstrual secretion. Atresia (from « rpy^fftq, a hole) of the genital canal may be congenital or acquired, primitive or secondary. The congenital conditions con- sist in abnormal formation from imperfect or defective or excessive development. Atresia or occlusion may be coraj)lete or incomplete, the degrees of incomplete atresia, of course, varying greatly. The incomplete occlu- sions, differing somewhat in their pathological and clinical history, will be discussed in succeeding chapters under otiier heads, as "Dysmenor- rhoea," &c. In this place I propose to describe the history of occlusion, complete, or so nearly complete, that the cases strictly fall under the same category. Atresia may affect any part of the genital tract from the vulva to the uterus, and even to the Fallopian tubes. It will be convenient to begin with the description of occlusion of the vulva, and to ascend from this point. Puech distinguishes three kinds of closure of the T^ufoa; 1. Adhesion •of the labia majora, always of accidental origin, the result of inflam- mation or injury ; 2. Adhesion of the labia minora, also the result of accident, and like the first, chiefly distressing from impediment to ATRESIA OF THE GEXITAL CANAL. 177 micturition ; 3. Hymenial atresia, the most common, and usually spoken of as imperforate hymen, generally congenital. It may come under notice before puberty from the collection of mucus in the vagina causing distension, or it may be detected soon after birth. I have several times incised an imperforate hymen in infants. The closure of the vagina may be congenital or accidental. The congenital kinds may be formed by transverse membranous septa, com- posed of the folds of mucous membrane with some connective tissue or muscular fibres between. In, some cases, imperforation of the cervix uteri complicates that of the vagina. The accidental closure of the vagina is far more frequent; it is almost always the consequence of cicatricial contraction after injury or inflammation. The walls cohere ; the vagina is more or less perfectly obliterated. True occlusion or atresia is commonly the result of a cicatricial pro- cess following upon ulceration, granulation, or laceration of the os uteri. The most frequent cause is laceration or sloughing, arising from severe labor, with or without instrumental aid. It has been caused by burns suffered during childhood ; by cauterization of the os uteri with potassa fusa ; from cicatrization following inflammation in small-pox, scarlatina, typhoid ; from sloughing of the mucous membrane of the .vagina, from use of a too concentrated solution of perchloride of iron (Tessier, Gaz. des Hop., 1869); after amputation of the cervix, for want of sufficient care to maintain the patency of the canal during cicatrization ; also from advancing senile atrophy, which produces a kind of concentric obliteration of the os. Rokitansky describes this last form. I have seen many examples of it. Ivlob describes a peculiar form of obliteration of the os externum as following upon prolapsus, with inversion of the vagina ; in these cases a small pit alone shows the seat of the os, and the atresia is caused by a milk-white membrane formed of several layers of vaginal epithelium. Closure of the uterus most frequently takes place at the os internum or OS externum. It may be the result of extrinsic causes, as from ex- ternal pressure of tumors ; froiu flexions of the uterus, more especiallv from bending of the body forwards or backwards upon the neck, so as to form an acute angle at the seat of flexion ; from tumefaction of the mucous membrane, as from catarrhal or other inflammation ; from the growth of cancerous or fibroid tumors in the substance of the neck ; from plugging by clots, membranous substances, or pseudoplasmata. These conditions may be diagnosed from true atresia, and sometimes may be relieved by passing the uterine sound. Another form of closure is due to the sealing of the os externum or internum by a false membrane, as described by Naegele. This has been observed to take place during pregnancy, so that at the time of labor no os uteri could be felt. Absence of uterus, according to Kussmaul, is very rarely complete. Even when exploration is made by finger in rectum and sound in bladder, a rudimentary uterus may evade detection by slipping on one side. Even on dissection, unless very carefully conducted, a rudimen- tary uterus may escape detection. In one case (Perkins, cited by How- 12 178 RETENTION IN DOUBLE UTERUS. ship) the uterus, containing two pounds of blood, was found behind the closed vagina. An apparently absent vagina is no proof of absent uterus. An artificial route has several times been made to the distended uterus. (Amussat.) In some of these cases of absent vagina the os uteri has opened into the rectum or urethra, and these canals being used by the intromittent organ, impregnation has occurred. According to Dr. Oldham, there is in many cases of closure or malformation of the vagina, an original dilatation of the urethra, a circumstance which has embarrassed the examining surgeon. This enlargement of the urethra has been com- monly supposed to be the result of accidental or voluntary substitu- tion of the urethra as a copulative organ ; but Dr. Oldham is, no doubt, right in recognizing it as pre-existing and independent of this use. Dr. Routh related a case {Obstetrical Trans., 1870) confirmatory of Dr. Oldham's view. It may, however, be due in some cases to surgical examinations. Uterhart^ relates a case of nearly complete occlnsion of the introitus vaginae by cicatricial degeneration, in which the function of the vagina was performed by the dilated urethra. The defect was cured by operation. The urethra then contracted to its normal state. Spencer Wells [Med. Times and Gaz., 1870) relates cases where the meatus was used for the vagina, although the vagina existed closed by hymen. In one case the vagina was apparently wanting, but menstru- ation was regularly performed through a small fistula between the urethra and anus. This being incised, an opening was made into a well-formed vagina above, the normal os uteri opening into it. It is remarkable that retention has frequently been observed where the uterus was tw^o-horned, or double. One uterus is occluded, and becomes the seat of retained menstrual fluid, whilst the other uterus performs its function normally, or is the source of metrorrhagia. Dec&s {Bull, de la Sog. Anat, 1854) tells a case in which retention in one uterus led to rupture of the horn, and fatal peritonitis. Leroy {Journ. des Connaiss. Med., 1835) published a case in which there was occlusion of the right uterine neck, retention of menstrual flux, and formation of a tumor reaching to the umbilicus and simulating preg- nancy. Rokitansky relates an important case {Zeitsch. d. Gesellsch. d. Aerzte, 1860). He dissected a woman who died under symptoms of pelvic inflammation. The uterus had a complete septum. The right half only communicated with the vagina, which was single. The left half was shut oif from the vagina, and expanded into a pouch con- taining a dirty ichorous matter. This pouch formed a fluctuating pro- jection into the roof of the vagina. The septum between the two uteri was perforated by ulceration. Rokitansky concluded that there had been imprisonment of menstrual fluid in the blind half of the uterus, causing, first, distension of the cervix, then inflammation and perforation of the septum, with consensual inflammation of the collat- eral (left) ovary, leading to abscess and peritoneal effiision. Dr. Be- 1 Berlin, Klin. Wochcnschrift, 1809. ATEESIA OF THE GENITAE CANAL. 179 rouius relates a similar case {Mon.f. Gehur^tsk., 1862). The distended half of the uterus was punctured ; but death ensued from acute peri- tonitis in thirty-six hours. Dr. Breisky relates the following case.* A girl, when sixteen years old, began to suifer from uterine colics every four weeks, no discharge appearing. The pain was most severe in the right side, and the abdo- men became gradually larger after every period. Constipation and extreme anssmia followed ; then difficult micturition. Suddenly she felt something burst, and a quantity of pale-red, thick, stinking fluid escaped, to her great relief. Discharge returned irregularly during a year, at times like thin pus. Breisky punctured by the side of the os uteri, and let out a quantity of pus. He concluded that the seat of the abscess was the right uterus. G. Simon relates'^ a case of congenital atresia of the left half of the vagina at the vulva, with duplex uterus. There w^as retention of men- FiG. 51. From a preparation in St. George's Museum. (Half size.) r, dilated uterus; v, dilated vagina above the seat of atresia, traversed by B, a piece of bougie. The Fallopian tubes are not dilated. struation in the closed half, and contemporaneous metrorrhagia from the open half. In the senile form of occlusion, pain of an acute kind ensues when- ever there is any secretion forming in the cavity of the uterus. In 1 Archiv fiir Gyniikologie, 1871. 2 Monatsschrift fiir Gebiirtskunde, 1864. 180 ATRESIA OF THE GENITAL CANAL. women in whom the menstrual function has ceased, there sometimes exists a form of catarrhal inflammation of the lining membrane of the uterus, giving rise to a mucous or muco-purulent secretion, which, being retained, produces symptoms resembling those from retained menstrual blood. If the fluid is watery, this is called hydrometra. The uterus seldom attains a size comparable to that observed in cases of retained menses ; but the cavity is always somewhat enlarged. On Fig. 52. From specimen in EadclifFe Museuna, Oxford— (case described by Dr. Tuckwell.) (One-third size.) u, cavity of vagina distended ; o m, os uteri, and cavity of uterus above it also distended. Complete occlusion of vulva. examining by the finger, the uterus is felt enlarged, often retroflected: the OS externum is sometimes difficult to make out, from the vaginal- portion of the uterus being atrophied, and so leaving the os flush with the roof of the vagina. Generally, however, the point of the sound will penetrate a little way; and by persevering with gentle pressure, sometimes a passage is gradually found into the uterus. There is a feature in the history of stenosis and atresia of the genital canal, which it is interestina: to describe, on account of its bearino- on RETENTION OF MENSTRUAL FLUID. 181 treatment. Under the condition of stenosis or atresia long persisting, this canal obeys the same law which rules over other canals or hollow organs. It undergoes retrograde dilatation above the seat of stricture. This is the almost inevitable consequence of the futile attempts of the muscular coat to expel the retained contents. This successive ascending- dilatation of vagina, cervix, body of uterus and tubes, is illustrated in Figs. 51 and 52, taken from preparations in St. George's and the Rad- cliffe Museums. This effect is seen in the most marked form in cases of imperforate hymen. The vagina being the most distensible part of the canal dilates first, forming a large pouch ; then the cervix uteri is distended ; then the cavity of the body of the uterus ; and lastly, the Fallopian tubes. This dilatation, conservative in its effect by accom- modating the contents which cannot be evacuated, has its limits. When these are reached, the danger of rupture or perforation at the weakest part is great. But before this comes to pass, there are two events which may happen. The first is transudation of the more fluid part of the contents under the concentric compression to which it is subjected. The experiments of Dr. Matthews Duncan, to which I have before referred, show that under a certain degree of hydraulic pressure, air or liquids penetrate the entire wall of the uterus. This is the old experi- ment of the Florentine metal globe applied to organic tissues. His experiments, of course, were performed on dead tissue. But it appears to me that there is good reason to believe that the force which the living uterus exerts in its efforts to expel what may be in it, whether it be a foetus or imprisoned fluids, is enough to drive fluid through its walls, in the form of a fine oozing or dew, which hangs on the peri- toneum. It seems to me probable that it is in this way that some cases of puerperal pelvic peritonitis are produced ; and I have seen cases of septicaemia and peritonitis occurring from retention of menstrual fluid, greatly resembling puerperal fever, in which there was no rupture, and no escape of fluid by the open ends of the Fallopian tubes. Supposing that the structures retain their integrity, it is natural that the concentric compressive force should drive the contents along any passage that may be pervious; hence the escape by preference along the tubes. This is rendered more likely by the dilatation which com- monly takes place at their uterine ends. This compressive force is exerted with most effect immediately after the puncture of the closed hymen. The sudden collapse of the walls of the uterus ensuing upon the partial escape by the opening excites the uterus to contract. This contraction drives the contents in all the three directions, and some will probably escape through one or other of the tubes into the peritoneal cavity. The more common event is the laceration of the tubes at the weakest place, caused by the sudden dragging upon them by the retreating uterus, the tubes being, perhaps, held back by adhesions. Other consequences of retention, if not relieved by operation, are : the distension of the uterus leads to perimetritis, with adhesion to the surrounding parts, especially of the Fallopian tubes to the ovaries and broad ligaments. The thinning of the uterus may proceed to burst- ing. The distended Fallopian tubes may burst, or without bursting,. 182 EETAINED MENSTRUAL FLUID. an overflow of blood may escape into the peritoneum, causing peri- tonitis. (Brodie, Kiwisch.) Beclard relates a case in which the uterus burst, discharging into the bladder. Scanzoni and Dr. Arthur Farre relate cases in which the distended hymen burst; in Dr. Farre's case death resulted. In other cases the obstructing membrane has given way under a process of ulceration, and a cure has resulted. (See cases in Puech.) The constitution suffers from hectic, the result of pain, and the absorption of the altered blood from the uterus. In some cases — Liz6 relates one [Union 3Iedicale, 1863) — the impossibility of evacuat- ing the collecting menstrual blood induces amenorrhoea; the ovaries and uterus give up their functions. Lize believed that in his case atrophy of the uterus was induced. Dr. Murray, of Newcastle, relates a case {Brit. 3fed. Journ., 1868), of a single lady, aged twenty-seven, whose vagina was closed by small-pox in infancy. Menstruation had been suspended for fourteen years. The vagina being opened up, no collection was found in the uterus, but exactly a month afterwards menstruation appeared, and recurred with, tolerable regularity after- wards. In this case it was clear that the ovaries were not atrophied, but that the uterus ceased to pour out menstrual blood. This is in accordance with what sometimes occurs in apparent amenorrhoea, with- out uterine obstruction. Ovulation may go on without exciting men- strual flow. This returns when a healthy state of the blood is restored. Simon relates [Mon.f. Geburtskunde, 1851) a case of complete closure of the vagina, with a distended uterus. Vain attempts w^ere made to establish a vagina. The patient maintained good health without the uterus being opened. I'he character of the retained blood is remarkable. It is dark-colored, deficient in fibrin, of treacly consistence, rarely containing coagula; it contains mucus, and often cholesterin scales. It is glutinous, in- odorous. The quantity varies with the duration of retention. Occa- sionally the tolerance and accommodation are surprising; the uterus may be expanded to the size of the end of pregnancy. Ten pounds of blood have been collected; I have collected forty ounces, and this per- haps LS an average amount. Puech deduces from comparison of quan- tity and time of retention that, as a rule, the quantity is less than the number of menstrual periods would have produced normally. Letheby {Lancet, 1845) analyzed forty ounces, which gave water, 875.4; albumen, 69.4; globulin, 49,1; hematosin, 2.9; salts, 8.0; fiit, 5.3 ; extractive, 6.7. There is another analysis of retained menstrual fluid by H. Miiller in Henle and Pfeuffer's Zeitsch-ift, 1846. Sometimes the fluid undergoes decomposition, and then gas mixed with the blood constitutes physo-hsematometra. The symptoms of atresia are those which might be expected from ob- structed functions. " Impediuntur coitus, conceptio, et purgatio." Until the advent of puberty, nothing may cause suspicion of abnormality. But with the onset of menstruation distress begins, due to retention of the menstrual fluid ; at first, perhaps, this is limited to passing attacks ,of uterine colic, marked by pelvic pain and bearing down or expulsive SYMPTOMS OF RETEXTION. 183 efforts. Vomiting often attends, as in all cases where the uterine fibre is suddenly stretched. These attacks, more or less periodical, are not attended by the expected appearance of the menses. Occasionally there is a vicarious discliarge of blood in form of epistaxis. In Fallen's case, one of absence of the vagina, there were marked menstrual molimina, but no accumulation of menstrual blood in the uterus or neighborhood. When an artificial vagina Avas made, menstruation took place periodi- cally by this channel, and the epistaxis ceased. Gradually the distress increases. A sense of fulness in the pelvis arises ; the hypogastrium enlarges ; the abdomen is visibly larger ; perhaps pregnancy is sus- pected ; there is sometimes retention of urine from the pressure of the uterus and vagina distended with the accumulating menstrual secre- tions ; defecation is difficult, and the digestive function is disturbed ; irritating fever, with a sallow skin, and vomiting — the result of ab- sorption of the watery part of the confined fluid — sets in. On exami- nation, a firm, even tumor is felt rising from the pelvis behind the sym- physis pubis, sometimes as high as, or even higher than, the umbilicus. The uterus gradually yields under excentric pressure ; as in preg- nancy, or when it contains a growing polypus, it then grows, its mus- cular walls as well as its cavity enlarging. This process meets to a certain extent the pressure of the accumulating fluid ; but the contained matter receiving fresh increments at every menstrual epoch, after a time requires more space : then other compensating processes bring allevia- tion, and stave oflP for awhile the critical moment when the strain can no longer be borne. The more watery element. of the contained fluid is absorbed, and to supplement the imperfect distension of the uterus, another cavity is formed by the distension of the vagina ; and the Fal- lopian tubes stretching, form further supplementary receptacles ; the uterine and vaginal cavities are commonly divided by a strait formed by the cervix uteri. This vaginal pouch may be very large, especially if the occlusion exists at the vulva, when it may so compress the rectum as to obstruct defecation (Tiickwell), or the bladder, causing retention of urine. The obstruction to normal menstruation is sometimes compensated by men- strual deviation, that is by fluxes from the intestines, bladder, nose, skin, &c. If the occlusion exists higher up the vagina, a pouch is still formed. And it is remarlvable that the vaginal wall undergoes hyper- trophy in the same way as the uterine wall. In a fatal case, Dr. Sutton {London Hosp. Reports, 1867) found the vagina so much hypertrophied that the walls at the upper part were quite. as thick as the uterine pa- rietes. Klob contends that in cases of obstruction at the vulva, it is the vagina that chiefly, or almost exclusively, forms the sac, the uterus scarcely contributing. This is certainly not always true; and it may be doubted whether it is even generally so. Dr. Tuckwell's case (see Fig. 52) exhibits manifest dilatation of both uterus and vagina ; and that this was also the case in two women whom I relieved by opera- tion, I had distinct evidence. The uterus certa;inly enlarges considera- bly, and the easily distensible Fallopian tubes become generally dis- tended, forming distinct tumors, readily felt on either side ; sometimes, as Bernutz remarks, mistaken for pelvic phlegmons. The Fallopian 184 EETENTION OP MENSTRUAL FLUID. tubes have been found distended, even when shut off from the uterine cavity ; but generally the uterine orifices of the tubes are expanded. A further stage leads to the escape of blood from the Fallopian tubes at their fimbriated extremities, or through rents into the peritoneum. This event, long ago pointed out by Brodie, has been amply confirmed by subsequent observers. The blood collecting in Douglas's pouch, con- stitutes retro-uterine hsematocele. The common eifect of this is pelvic peritonitis, sometimes fatal, at others resulting in segregation of the effused blood by plastic matter ; a later stage of which is a process of suppuration or necrosis of the posterior vaginal wall and possibly dis- charge of the hsematocele and care. As Bernutz says, and I venture to add my own testimony in support, the foregoing phenomena of ob- structed menstrual flow may result from uterine deviations, especially flexions, from spasmodic contraction of the cervix uteri, and, according to my own observation, from congenital narrowing of the os externum uteri associated with a conical vaginal-portion. The symptoms of ab- dominal shock and peritonitis following upon those of retention of menses, indicate the occurrence of effusion of blood from the Fallopian tubes into the peritoneum. These symptoms depending on the same accident are very liable to follow operations for the discharge of the re- tained fluid. The history of hsematocele will be fully discussed here- after. A tumor is formed, sometimes of considerable size, in Douglas's sac; at first, this is soft, fluctuating; it then gets harder under coagu- lation, and the effusion of plastic matter around it ; a firm tumor may be felt rising above the pubes, even to the umbilicus. The abdominal walls can be made to glide over it ; the limit of the tumor may be de- fined by percussion; inferiorly the tumor sinks into the pelvis. By the vagina we find the tumor pushing forward the roof and posterior wall of this canal, shortening it, and compressing it from behind forwards, so that the finger is guided to the os uteri driven forwards behind the symphysis. The os felt in this position, and a firm rounded mass ex- tending behind it, has been mistaken for retroversion of the enlarged womb, and this the more readily, because retention of urine has often been an urgent symptom. Sometimes the atresia, especially in the acquired cases, as when cica- tricial occlusion takes place after fevers, sloughing from severe labor, or frorn injury by instruments, is not quite complete. There may remain a narrow fistulous tract, communicating with the expanded sac, which receives the menstrual collection, and which affords an occasional, but rarely complete relief by oozing. Such a fistulous tract may act for a long time as a sort of safety-valve, by which extreme tension is re- lieved. It is liable to complete occlusion at times. This was the case in the following typical instance : Cicatricial closure of the Vagina following Labor ; at first partial, then complete retention of menstrual fluid — Dysmenorrhea — Operation — Care. In January, 1867, I met Mr. Powell at Wey bridge, in the case of Mrs. W. Twelve years before, she had been delivered by instruments CASE. 185 of twins after severe labor. From that time she had suffered more or less difficulty in menstruation. This had increased gradually, and in a marked degree during the last two years. During the last three months her condition has become very serious.. At each menstrual period, severe colic with expulsive pains set in. An enlargement has been felt rising considerably above the pubes. Partial relief has been obtained by the escape of blood, and a very offensive ichorous dis- charge. At times, retention of urine calling for the use of the catheter has occurred. The introduction of the catheter was difficult, owing to the urethra being compressed and deviated by the tumor. A period came round two or three days ago with increased suffering and com- plete retention of menses. The enlargement of the uterus was rapid ; it rose nearly to the umbilicus in twelve hours. There was great pros- tration and small pulse. We found the vagina quite occluded by con- tracted dense cicatricial tissue extending from the meatus urinarius to the anus, nothing but a scarred furrow marking the site of the vulva. There was a minute red point which seemed to be the opening of a fistulous tract; but not even a small probe would pass into it. It is probable that this had been really the opening of a fistula which had on previous occasions given difficult and partial escape to the accumu- lated fluids above, but had now become quite closed. I determined to try and open up the vaginal canal next day. She passed a bad night from severe colic and efforts at expulsion; and on the following morn- ing I found the uterine tumor just as large and firm as before. It was directed a little to the left. It was also felt per rectum, at a point j)rojecting within the pelvis. The patient was placed in lithotomy po- sition. I passed a flexible male catheter into the bladder, and one finger into the rectum. I could then feel the hard dense column of cica- tricial tissue between the bladder and rectum, which represented the obliterated vagina. I then, thus guided, made careful incisions in the cicatrix, and at about an inch above the outer surface struck the sac. A quantity of offensive ichor mingled with dirty-white clots escaped. I then felt a small dense ring at the bottom of my incisions, no doubt the upper part of the cicatrix. This I enlarged by a Simpson's metro- tome and a fine knife until I could pass my finger through it. Then I found beyond this ring a widely-distended pouch formed by the dilated fundus of the vagina; at the extremity of this pouch I felt the OS uteri slightly open, very soft. I could not reach into the uterus, but it was clear that the uterus also was distended, forming the supra- pubic tumor, as this gradually subsided as more and more of the ichor- ous discharge came away. The patient felt great relief. A compress and bandage being applied to the abdomen, she was put to bed com- fortable. Three days afterwards I had a letter from Mr. Powell say- ing "she was going on favorably; did not suffer much pain; the dis- charge was decreasing; she was very low; the catheter was used night and morning ; no sign of inflammation, but he feared pyaemia, in fact he thought she had been for some time past suffering from it to a degree." It was my intention at a later period to restore the vagina more com- 186 EETENTION FROM ATRESIA. pletely; but the patient being relieved, refused further treatment. She got quite well. The following case illustrates so many points in the history of ob- structed menstruation that I am induced to relate it : Mrs. W has been married three years without becoming preg- nant. She is well developed in frame. Two years ago she had yellow fever in South America. Her health has been indiiferent since then. She had always menstruated regularly ; at times in advance of the period due, and lasting four or five days ; not excessive in quantity. There had been dysmenorrhoea before marriage and since, but not constantly. But latterly, and especially since the fever, the dysmenor- rhoea has been very severe, and has evidently undermined her health, and wrought a serious degree of despondency, and other nervous symptoms. Under these circumstances she came to England for advice; saw two medical men in town, who told her there was nothing to be done. She came to me in October last, very discouraged, but determined not to go back to South America until she was either relieved, or well assured that her case was hopeless. I found the vagina was a wide shallow cul-de-sac, not an inch deep. There was no projecting cervix uteri, and no solid body in the roof of the cul-de-sac where the uterus might be expected to be found. About the middle of the cul-de-sac, however, was a small round hole, which just admitted the point of the sound. This had been taken to be the os uteri externum. The case looked unpromising, as no uterus could be felt in connection with it. I submitted her to further examination under chloroform. Then hav- ing passed a sound into the bladder and a finger into the rectum, I as- certained that for at least two inches above the vaginal cul-de-sac there was no uterus, nothing but the wall of the rectum and the wall of the bladder intervened. But about three inches beyond the anus I could feel a solid rounded mass, which I concluded to be the uterus retro- verted. On passing the sound through the small opening in the vagi- nal cul-de-sac I found it proceeded two inches along the septum, be- tween the bladder and the rectum, towards the solid body which I believed to be the uterus. I was now therefore in a position to con- clude that there was atresia, or closing of the vagina from a little above the vulva upwards along its whole extent. I am unable to determine whether this obliteration of the canal was congenital or acquired. It may possibly have been a sequel of the fever she suffered two years before. The position of things being recognized by Drs. Avcling and Hewer, who assisted me in the exploration, I determined to open up the ob- literated tract of the vagina so as to establish a free communication with the body above, which I took to be the uterus. This was done under chloroform, assisted by Dr. Aveling and Dr. Hewer at two dif- ferent sittings at an interval of a month. Starting from the miiuite opening in the vaginal cul-de-sac, I separated the bladder from the rectum, partly by incising, partly by tearing with my fingers until I could fairly touch the solid body through the new canal. When this was done I ascertained that this body was tlie uterus; it was more ATRESIA VAGIN.E. 187 rounded than natural, its fundus was directed forwards ; it was the cer- vix directed backwards which was felt through the anterior wall of the rectum. It was now clear that there had been a small cavity represent- ing the upper part of the vagina, into which the cervix uteri opened ; that this small cavity was closed in just below the cervix uteri by the fusion of the vaginal w^alls, if such had ever existed ; that a fine devious fistulous tract ran from this upper vaginal cavity to open into the lower vaginal cul-de-sac; that the menstrual discharge had with great dif- ficulty made its way along this fistula, wdiich was always in danger of closing. I have endeavored to give an idea of the state of the parts in Fig. 53. I did not succeed in getting a sound into the os uteri ; but this will probably be effected at some future time. To maintain the new vagina I have applied a small elongated Hodge's pessary, the upper arch of Fig 53 Atresia of Vagina. R, rectum ; b, bladder; L', uterus; v, eul-de-sac at vulva; a, dense tissue in place of vagina traversed by a narrow fistulous tract between v and uterus. Avhich, under the leverage which is the principle of the action of this most useful instrument, is constantly carried high up into the restored vaginal roof. A month after the last operation, the vagina was well 188 ATRESIA VAGINA. preserved, and examining by a Fergusson's speculum during a period, I could see the menstrual fluid being poured into the summit of the vagina. For the first time she was menstruating without pain, and her health and spirits were already improved. She menstruated healthily several times ; her health was fairly restored. But I believe there was at a later period some disposition to contraction, which would require another operation. Dr. Gardner^ cites from Professor Meigs " a case of unusual form of stricture of the vagina, which was the cause of an almost fatal error in diagnosis." The figure given represents the uterus of normal size, then a pouch formed by the dilated vagina, and the vagina itself nearly closed about its middle by a stricture half an inch long. The stricture was traversed by an extremely narrow fistula, just permitting of what has been called "stillicidium mensium." Professor Thomas^ describes a similar case. There was this " stillici- dium ;" but notwithstanding, the sac of the vagina, between the con- striction and the neck of the uterus, contained several ounces of thick tenacious blood. Simpson describes "a kind of adhesive or obliterative vaginitis" in adults, differing in some respects from the adhesive vaginitis of infants. In infants the inflammatory closure is usually limited to the orifice of the vagina, and produces complete occlusion. In adults it generally com- mences at the upper part of the vagina, sjd reads gradually downwards, and seldom produces complete occlusion. It is almost always attended with a circumferential contraction of the canal at the site of the disease, so that when it is limited, as it often is, to the top of the vagina, the os uteri is felt drawn up to the apex of a narrow conical or funnel-shaped cavity. But it occurs without this circular contraction, says Simpson; and I feel justified by observation in affirming that this funnel-shaped contraction of the upper part of the vagina may occur independently of inflammation. The adhesion is more agglutinative, like that which unites serous surfaces in the early stages of inflammation, than true fusion. The finger can separate the adhering surfaces. It is a remarkable circumstance in connection Avith the history of atresia, or absence of the vagina, where no uterus can be found, or at least only such a rudimentary one as to be incapable of performing the functions of a uterus, that the artificial formation of a vagina brings considerable relief. Of this I have seen examples ; one especially was that of a well-developed young lady, who had suffered from what may be called difficult ovulation; there was evidence of menstrual molimina, but there Avas no discharge. I dissected up a canal between the rectum and bladder ; a good vagina was maintained by Avearing a Sims's dilator or a Hodge's pessary ; and she recovered health, remaining free from pain, and married. This, and other cases, of AA'hich I may specify that of a young AA'oman lately under my care in St. Thomas's Hospital, prove that ovarian de- velopment may be good, and the uterus remain undeveloped. They also prove that the general frame may be AA^ell de\^eloped, notAA'ithstand- 1 Gardner on "Sterility," New York. * " Diseases of Women," Philadelphia, 1869. ATRESIA VAGINA. 189 ing the want of a uterus, and that the evolution of the general system takes its stimulus from the ovaries. Treatment. — In the case of apparent absence of the vagina there are three methods of proceeding. The first is to cut a channel through the tissues between the urethra and the rectum up to the uterus. The second, adopted by Fletcher (icmcef, 1830-1831) and Araussat {Gazette Medioale, 1835), is to tear or stretch out a canal by the fingers or other dilating instruments. The third may be called the mixed method, making use both of cutting and dilating. The last combines the ad- vantages of the two preceding, and at the same time reduces their dis- advantages. Whatever mode is adopted, the patient is placed in lithotomy position, the space between the urethra and rectum is care- fully examined, the index of the left hand is passed into the rectum, the sound is passed into the bladder, and feeling for it by the finger in the rectum, the amount of tissues available for burrowing, and the position of the uterine tumor are determined. Then the sound is held up under the pubic arch, whilst the finger carries the rectum away in the opposite direction. A transverse incision is made in front of the anus through the skin, then cautiously nicking with the knife or scissors and stretching out with the fingers, working from side to side, between the finger in rectum and the sound in urethra as guides, a canal is opened to the uterus. Care should be taken not only to make all inci- sions laterally, but to work backwards towards the rectum, as the chief danger is that of penetrating the wall of the bladder. If the os is felt, a sound should be tried first ; if the os be impervious, it may be per- forated by a trocar or by the knife. It may be desirable to carry out the proceeding at different sittings. It will generally be necessary to place a tent or bougie in the uterine opening to prevent closure ; and the artificial vagina must be preserved by plugging with lint steeped in carbolic acid oil, glycerin, or the glass or vulcanite dilator of Sims, or what I have found to answer better, a narrow Hodge-pessary. The tendency of the parts to contract and close again after operations for the restoration or formation of a vagina is very great. The operation may have to be repeated, unless great care is taken to preserve patency by artificial means. But I have known a good vagina to be maintained for a year after operation, when the subject married, and there was no further trouble. Where the closure of the vagina is the result of cicatrices from sloughs, the same cautious mode of dissecting and dilating may be adopted. Where the vaginal canal exists, and there is closure of the vulva by agglutination of the nymphse, or from imperforate hymen, the preponderance of testimony is in favor of making an opening into the vagina. The distended fluctuating membrane indicates the spot. This is pierced by a trocar, or better by a knife. It has frequently been discussed how the catastrophe of sudden escape of the retained fluid into the peritoneal cavity can best be averted. Some have contended that it is better to make a very small opening in the hymen and let the fluid drain away gradually, hoping that in this way the suddenness of the collapse of the uterus might be diminished. This is the plan I have hitherto followed. But others have preferred 190 IMPERFORATE HYMEN. making a free incision at once, and even proceeding to wash out the cavity. I am not sure that this is not the best plan. A free external outlet would make it easier for the contracting uterus to expel its con- tents by this route, and thus take off the pressure towards the tubes. On the other hand, the rapid retreat of the uterus would favor lacera- tion of the tubes, if held back by adhesion. The balance of advan- tages and of drawbacks of either plan is difficult to strike ; and it is to be apprehended that cases will continue to occur in which a fatal result will follow any method of treatment. A plan which I should be disposed to try is to draw off* a little at a time by the aspirator-trocar, so as to effect a very gradual diminution of the cavity before finally freely dividing the obstruction. In any case absolute rest should be rigidly enforced. On no consideration should even simple puncture of an imperforate hymen be done in the consulting-room. The patient should be in bed, and keej) her bed until the discharge has fairly ceased, and the disturbed uterus and vagina have assumed a natural condition. It is held that these dangers are lessened by letting the blood ooze out very slowly. The fact is that death has followed both methods ; and we are perhaps not yet in possession of certain means of rendering even the simplest puncture perfectly safe. I believe the opening should be sufficiently large to admit of easy evacuation, and that to prevent the entry of air a compress should be applied over the uterus and sus- tained by moderate pressure with a bandage. In some cases injections of warm water have been used to wash out the uterus. It is doubtful whether this is good practice at the time of the operation, but if there should arise decomposition, the gentle injection of a weak solution of permanganate of potash or carbolic acid will be desirable. After a few days it is proper to enlarge the opening in the vulva by removing a circular piece of the membrane, so as to fit the parts for all their func- tions. Absolute rest in bed for some days is a wise precaution, not- withstanding the histories of cases where impunity has followed its neglect. Symptoms of peritonitis, indicating that retained fluid has suddenly escaped into the peritoneal cavity, have set in on the third or fourth day. The contraction of the uterus leading to this catastrophe does not take place immediately after the operation. The greatest care, therefore, is necessary for some days afterwards. Dr. Ramsbotham collected several cases in which simple puncture of imperforate hymen terminated fatally. Simpson relates a case of occlusion of the vagina from adhesion causing a septum of no great thickness. Retention of menstrual fluid was going on, so a very small incision was made ; the patient remained well for two or three days, great quantities of the usual dark grumous fluid constantly escaping by the vagina. On the third day surgical fever set in, and in a few days she died. The autopsy showed that the interior of the distended uterus had become the seat of a very intense inflammation, which had spread thence, and led to a severe and fatal peritonitis. This was probably set up by air getting into the uterus and causing decomposition and septicaemia. It strengthens the argument for free incision and washing out the uterus. DILATATION OF FALLOPIAN TUBES. 191 In cases of occlusion of the uterus with retention of menses, the in- dication is to make a passage into tlie cavity. This may be clone by a trocar or by a bistoury. The fluid evacuated, it is necessary to intro- duce a tent — a metallic one is best — to preserve the opening, which would otherwise close, and lead to a repetition of the mischief. This liability is especially great in cases of contraction after amputation of the neck. Lefort cites, however, several instances where death followed the simple evacuation by puncture. The opening into the uterus is best made by a fine-pointed knife. After piercing in the central point, the natural seat of the os uteri, in- cisions may be made on either side, and by carefully dissecting upwards, a passage is made into the cavity of the uterus. Some have advised puncturing by the rectum in preference, and even puncture of the uterus above the symphysis pubis has been recom- mended. The experience of puncture of the rectum is not so favora- ble as to show any superiority over opening by the vagina. It is an imperfect operation, for the establishment of a vaginal canal would still be indicated when relief from hsematometra has been obtained. In cases where opening up the natural route is impracticable or too haz- ardous, it may be resorted to as a temporary expedient. Fatal peri- tonitis followed in cases treated in this way by Antoine Dubois and Dupuytren. Dr. Oldham {Gkiy's Re-ports, 1857) reports two cases in which punc- ture per rectum was practiced. In one there was congenital absence of vagina ; the os uteri was felt through the rectum, the trocar was made to pierce at this point. The operation was repeated on four occasions ; at last the opening continued patent, and menstruation took place by the rectum. In the other case the vagina was closed by dense cicatrix ; the OS uteri was felt by rectum, and was punctured; relief followed. A third case at Guy's is reported by Dr. Hicks (Iledical Times and Gazette, 1861 ) : here there was absence of vagina ; puncture by rectum was fol- lowed by relief, and, as far as the report goes, there was subsequent amenorrhoea. In striking for the os uteri by the vagina it is very possible to pierce the rectum behind the cervix. In such a case menstruation has thence- forward occurred per rectum. The time selected for the operation should be remote from the men- strual epochs ; during the epochs the uterus is more apt to resent interference. . When these cases of retention have been relieved, and have ap- parently recovered, it must be remembered that the Fallopian tubes do not at once, perhaps not for a long time, recover their normal calibre. Some degree of abnormal dilatation remains. This is certainly the case in the partial retention due to stenosis of the cervix and to retroflexion. The knowledge of this fact is of the highest importance in practice. The long-continued obstruction having entailed dilatation of the uter- ine cavity, and catarrh of its mucous membrane, with very often a disposition to metrorrhagia, the physician is tempted to inject astrin- gent fluids into the uterus. It is well known that fatal accidents have followed this practice, and much discussion has taken place as to the 192 DYSMENORRHCEA. immediate cause of these accidents. The prevailing idea is that the injected fluid is driven along the tubes by the force of the syringe, its return by the cervix being stopped by the injecting-tube which fills it. I am disposed to believe that where there is unusual patency of the Fallopian tubes, this may occasionally be the case. But the more common mechanism, I am convinced, is that which I have just ex- plained as occurring in retention from imperforate hymen. The as- tringent fluid thrown into the uterine cavity acts primarily as an irritant and constringent. This action is forcible and rapid. The cavity instantly contracts and pumps on the fluid along the patent Fallopian tubes. That this was what occurred in a case in which a solution of perchloride of iron was injected into the uterus, on account of hemorrhage from retroflected uterus, in the London Hospital, seems to me beyond doubt. The tubes were found patulous, and fluid had run along them into the peritoneal cavity. It is important then to recognize it as a general fact, that whenso- ever the uterus has long been subjected to stenosis or flexion, there will very probably be patency of the Fallopian tubes, and, conse- quently, facility for the transmission of fluids from the uterine cavity into the peritoneal sac. CHAPTER XX. DYSMENOERHCEA— NETTEALGIC; CONGESTIVE; FROM OBSTRUCTED EXCRETION; INFLAMMATORY. Dysmenorrhcea is the term used to express that menstruation is performed with difficulty and pain. It is a very frequent affection, being symptomatic of, or consequent upon a great variety of morbid conditions. These morbid conditions of course are mostly unknown to the patient ; she applies for relief of the functional distress. To give the sought-for relief the physician must form a clear idea of the causes of the distress. The method by Avhich this knowledge is ar- rived at is partly by clinical observation and study of the phenomena which present themselves, and of the condition of the organs involved ; and partly by observation of the effects of treatment. It may be ad- mitted that the means of treatment employed are sometimes empirical ; that is, they are not directed by a clear comprehension of the cause of the distress ; but if we find that these means are frequently followed by success, this treatment, empirical though it be at first, will lead us DYSMENOREHCEA. 193 to a clearer knowledge of the evil which it overcame, and thus in the end it becomes rational. By this double process we arrive at the conclusion that cases of dys- menorrhoea may be classified under the following heads : namely, 1. Neuralgic, or sympathetic. 2. Congestive, or inflammatory. 3. Me- chanical anomalies of the uterus. 4. Fallopian obstruction. 5. Ovarian disorder, constituting a distinct form of dysmenorrhoea. The simple study of the subjective phenomena will not enable us to distinguish cases of one kind from those of another kind. Indeed, so long as this very imperfect method was exclusively pursued, all cases of dysmenorrhoea were confounded together, or the distinctions made were necessarily arbitrary and fanciful, and treatment, being aimed at random, was generally unsuccessful. This is a logical necessity. For the practitioner who limits his observation to the subjective symptoms must perforce exclude from his resources those means which are sug- gested by the objective method of investigation. Not many years ago, dysmenorrhoea was almost universally looked upon and treated as a nervous affection of the uterus itself, or sympathetic with disorders of distant organs, or the expression of constitutional debility. And vague ideas of this kind still largely prevail amongst physicians who have not directed particular attention to the pathology of the ovaries and uterus. But in proportion as precise objective methods of investi- gation have been applied to the study, it has been discovered that in most cases the nervous phenomena are dependent upon distinct morbid conditions of the uterine tissue, or upon conditions which oppose a me- chanical obstacle to the proper performance of the uterine function, or upon disorder of the ovary. If, therefore, we still retain the term neuralgic dysmenorrhoea, we must do so on the understanding, that although expressing a really existing disorder, it is a convenient asylum ignorantioi, under which we may class a number of cases, the true pathology of which eludes our research. Extending observation Avill, however, certainly contract this asylum more and more, if indeed we may not hope to close it altogether. We may see a remarkable illustration of this in the history of what that admirable clinical physician. Dr. Gooch, called the '^ irritable uterus." The late Dr. Robert Ferguson, commenting on Gooch's de- scription,^ said : " This malady, I believe, is deeply rooted in the very essence of that complex organic function termed the generative; which, in its most comprehensive sense, includes no inconsiderable portion of the moral, as well as of the physical development of the female orga- nization." Ferguson recognized, it is true, the fact that various morbid conditions of the uterus and ovaries were sometimes associated with the so-called irritable uterus. He says there is a form of the disease not described by Gooch. " In this the purely nervous aspect of the malady is masked by some obvious change in the uterus and its appendages; but this change is by no means a constant one, either in its seat, extent, or nature. Sometimes there is a congested condition of the uterus, alter- ing its shape into that of a retort ; the enlarged and curved fundus 1 Prefatory Essay to New Sydenham Society's Edition of Gooch's Works, 1859. 13 194 DYSMENORRHQEA. being exquisitely sensitive of pressure. At other times the cervix or some portion of the uterine walls is the seat of congestion, of varying consistency^ and of pain The local changes have been the fluctuating, the nervous affection the constant element ; in it, therefore, and in no doctrine of a phlogistic origin, can I place the essence of this strange disease." Dr. West included' these cases under the " congestive " order ; Dr. Henry Bennet assigned inflammation as the real pathological condition ; Dr. Rigby thought many cases were due to a rheumatic diathesis ; and other authors have from time to time, impelled by the accidental nature of their experience, or the bent which preconceived theories had im- parted to their observations, given prominent or exclusive importance to some other complication. If we postpone theory, and carefully analyze a large number of cases, noting the complications and the effects of treatment, we shall find that the cases of " irritable uterus " resolve themselves into the following groups, viz. : 1. In which there is mani- fest enlargement from congestion of the uterus ; 2. Subinvolution with chronic inflammation of the uterus, following labor or abortion; 3. Reclination or flexion of the uterus, most frequently retroflexion ; 4. A projecting conical vaginal-portion, with very small os externum uteri ; 5. Lateral reclination, mostly associated with imperfect development of the uterus; 6. Disorder of distant organs, especially of the digestive organs, attended or not by one or more of the preceding structural faults, and almost always with impaired sanguification and nutrition ; 7. A morbid condition of the ovaries ; lastly, a residuum of cases in which, whether from not pushing investigation to the proper point to discover the associated fault, or because there really is no physical fault, we are obliged to conclude that the dysmenorrhoea is simply the ex- pression of nervous disorder. We may reasonably expect that advanc- ing knoM^ledge of uterine and ovarian pathology will still further diminish this residuum. The truth is, that difficult menstruation so exhausts the tone of the nervous centres, that general or local hyper^esthesia is almost certain to follow. Many women complain of a distressingly exaggerated sensi- tiveness all over the skin. In some, it takes the form of neuralgia of the face and breasts; in some, the seat is in the uterus, vagina, or vulva. I think observation warrants this general conclusion : The healthy, well-formed uterus is rarely an " irritable uterus," or associated with dysmenorrhoea. Or the case may be stated as follows : For menstrua- tfon to occur healthily and easily, the genital canal from its commence- ment at the fimbriated extremity of the Fallopian tubes to the vulva, must be pervious. This presumed purely neuralgic dysmenorrhoea we will now endeavor to describe. If we follow a chronological order, and consider first the dysmenorrhoea, which is observed at the very outset of the function, we find a number of cases from which we may fairly exclude the idea of inflammatory ulceration or other tissue disease, since these conditions very rarely occur in early girlhood. The reverence due to youth, and 1 "Diseases of Women," 3d edition. NEURALGIC. 195 pre-eminently to female youth, imperatively forbids physical examina- tion, unless under urgent circumstances and the failure of ordinary treatment. We are, therefore, precluded in most of these cases from determining in the first instance the presence or absence of uterine flexions and narrowness of the os uteri, which are, perhaps, the most frequent causes of primitive or initial dysmenorrhoea. Whether the pain be due to recognizable mechanical conditions or not, the phe- nomena observed are nearly the same. The disorder may be associated with an hysterical disposition ; it is generally associated with a highly susceptible nervous temperament, which may be defined as the hyperses- thetic temperament. Extreme susceptibility to pain is one of the penalties of high civilization, and of too luxurious rearing. Hence the neuralgic dysmenorrhoea chiefly affects the easier classes. It is not common, I believe, amongst the laboring agricultural population ; but it is by no means infrequent in towns, where, although girls and women may have to work for a living, they are nevertheless exposed to many enervating influences, hygienic and moral. The first onset of menstruation is generally late ; it is marked by pain coming on a day or two before the flow, sometimes so intense that the sufferer writhes upon the floor, and is compelled to take to bed. The pain begins in the pelvic region, radiates to one or both groins, and shoots down the legs. It is commonly paroxysmal, resembling colic — it is, in fact, uterine colic. It is often likened to labor. Often the whole abdominal surface is tender to the touch. At times it simulates peri- tonitis. This pelvic eccentric irritation, commonly involving, as it does, ovarian irritation, propagated to the nervous centres, may evoke other nervous phenomena, as hysteria, vomiting, hiccough, headache, even delirium, and in some cases, mania. The urgent symptoms sub- side in two or three days ; the patient recovers so much strength as to enable her to resume her ordinary mode of life. But as the period comes round the same series of painful phenomena is renewed. The pain is often diminished when the flow sets in, but it generally attends the whole period with more or less severity. It does not appear to bear any constant relation to the amount of the discharge ; but when this is so great as to deserve the name of menorrhagia, we may, I think, generally predicate with confidence the coexistence of a mechanical dif- ficulty. If there is no recognized organic change in the uterus, or dis- placement in the first instance, we may be very certain that some com- plication of the kind will appear sooner or later. I quite coincide in the statement of Scanzoni,' that long-standing dysmenorrhoea rarely fails to induce some change of tissue in the uterus, the most common being hyperplastic enlargement. The nervous phenomena described may attend all the forms of dys- menorrhoea. We are thus led to ask, is there any physical condition of the organs concerned that can account for the pain ? The colic, the spas- modic character of the pain, seems to indicate a contracting uterus seek- ing to expel contents that irritate it ; and this is often true. Bat not always. It is a well-recognized character of the nervous function that 1 Bcitrage, 1870. 196 DYSMENORRHCEA. its phenomena, or actions, have a tendency to periodicity, as if, like elec- tricity, it required a certain degree of accumulation of the vis nervosa before it can act. So in the case of pain we often see alternations of acme and of ease, of discharge and accumulation. The fact that the period of most intense pain is usually twenty-four hours before the appearance of blood, is held to prove that these uterine colics or paroxysms cannot be due to anything contained in the uterus, and irritating it to contract. This objection rests upon the assumption that there is nothing but blood, fluid or coagulated, that can be there. But this is overlooked, — the ra]3id preliminary development of the mucous membrane into men- strual decidua, the congestion of this structure, and of the uterus gen- erally. This is enough to cause tension of the uterine muscular fibre, and to excite it to contract, and this swelling of the mucous and muscu- lar walls may close the os internum, and lead to partial retention when the flow begins. The frequent vomiting at this stage favors this view. At the same time, there is the ovarian pain ; and to this the hysterical symptoms are most commonly due. The course and prognosis of neuralgic dysmenorrhoea. — The obsti- nate character of the affection is well known. It may be predicated with some confidence that a girl who starts with dysmenorrhoea is doomed to suifer for years, perhaps for life. It is said sometimes to wear itself but ; occasionally marriage, if fruitful, brings relief; but more frequently the recurring attacks of pain, even if unattended by other causes of distress, increase the irritability of the nervous centres, impair nutrition, destroy the harmony or correlation of the vital forces, and reduce the sufferer to the condition of a perpetual invalid, enjoying at the best, only comparative remissions of illness. If pain do not persist throughout the intermenstrual intervals, it is liable to be evoked by any fatigue or emotion, so that the state of the patient comes to be the chief care of the household. After a time, as R. Ferguson, who draws the most terrible, but not exaggerated picture of the affection, observes, the erotic element is in most cases entirely extinguished. " All intercourse is dreaded or loathed, at the very instant wdien the victim under the passion for sympathetic commiseration is ready to give up her whole soul to the first acquain- tance, nurse, or practitioner who will listen and pity. They who have been able to watch this real and most formidable malady through years have many a tale to tell — of husbands estranged, chiklren neglected, and home stripped of all its holiest influences, authority delegated to strangers and abused, ill-assorted marriages, expenditure stretched for health's sake to its extreme limits." Under the goading of repeated agony the occasional resort to stimulants merges into a confrmed habit of drinking. Happily the recent application of means of exploring the state of the organs primarily affected has, by enabling us to analyze the cases, shown that the majority at least are dependent upon physical causes which admit of remedy. The treatment has become far more success- ful than was contemplated as possible by Gooch and Ferguson. The first condition in which we are likely to be consulted is during the attack. We are called upon, as our first duty, to relieve pain ; and NEURALGIC. 197 during the menstrual flow our liands are commonly tied. We are driven to a trial of sedatives and narcotics. Where the agony is so intense as to induce delirium, it is justifiable to induce anaesthesia by chloroform or chloral, but the frequent recourse to these agents is apt to entail a terrible penalty. The patient who has once or oftener thus drowned her sufferings, is little able to resist the imperious craving to throw herself into the same treacherous oblivion on every return of pain. She soon falls into the habit of exaggerating her suffering so as to impose upon others, as well as herself, the necessity of getting relief even momentary at any cost. To say nothing of the fatal accidents which have occurred from the use or abuse of chloroform or chloral, even when skilfully administered, experience shows, it is said, that the repeated or habitual use of these agents is liable to induce epilepsy and mental prostration of a kind to justify apprehension of lapsing into dementia. There is no principle of conduct more imperative than this : so to direct our treatment as to preserve and encourage to the utmost the mental and moral integrity of the patient. When once we have lost the aid of her own will, when she has lost the precious gift of self- control, our task is a sad one. We are almost driven into becoming quasi-accomplices in a course that almost infallibly ends in moral anni- hilation, compared with which the original malady, still subsisting, sinks into insignificance. One of the best temporary sedatives is Hoffman's anodyne, the spiritus setheris sulphuricus compositus, which may be given in half- drachm doses. To this may be added tenor fifteen drops of liquor opii sedativus, and both act better if given with liquor ammonise acetatis. Indian hemp in half-grain or grain doses is often valuable ; it may be given alone or combined in pills with lupulin, or five grains of Dover's powder. Where there is a distinct hysterical character, musk, cam- phor, and assafoetida are often useful. Allied to sedatives in their effects are the bromides of potassium and ammonium. One or other of these may be given in scruple or even half-drachm doses, repeated every four or six hours. Bromine seems to possess a specific power in subduing ovarian excitation. If sedatives cannot be taken by the mouth, we may resort to subcutaneous injection of one-eighth or one- sixth of a grain of acetate of morphia; or half a drachm of laudanum may be thrown into the rectum ; or medicated pessaries containing opium or belladonna may be placed in the rectum or vagina. The local treatment in the purely neuralgic affection is restricted to the use of hot fomentations or cataplasms to the abdomen, foot-baths, and other external applications. Simpson recommended the injection of chloroform vapor or carbonic acid gas into the vagina, or the appli- cation of a small bit of lint soaked in chloroform and covered with a watch-glass over each groin. This produces a small blister. The diet should be simple, and the use of stimulants strictly regulated. Moral treatment is of great importance. During the intervals great care should be taken to cultivate habits of industry. Occupation, phys- ical and mental, is the great panacea. " Something to do !" is the great female cry. In no case is it more urgent than here. If these and other similar means, as well as Time, fail to bring re- 198 DYSMENORRHCEA. lief, a physical examination becomes necessary, and then we shall prob- ably discover some condition of the pelvic organs, on the successful management of which the hope of curing the dysmenorrhoea will rest. The Congestive Dysmenorrhoea may be either primary, that is, dating from the commencement of menstrual life, or secondary, that is, ac- quired at a later period. The primary cases do not differ essentially in their symptoms from the neuralgic cases ; and until examination by touch is made they can only be conjecturally distinguished. In addi- tion, perhaps, to the subjective signs marking the neuralgic kind, there is a greater sense of weight and bearing down in the pelvis, pain referred to one or other ovarian region, principally the left. It is difficult to derive any precise information from external palpation, because in congestive as well as in neuralgic cases, the hypersesthesia is often so great that the patient shrinks from that amount of pres- sure which is necessary to fairly depress the abdominal wall. Va- ginal touch, too, is often difficult for the same reason, and it may become desirable to conduct it under chloroform. We then ascertain that the uterus is somewhat enlarged, and on returning consciousness the patient complains of pain on pressure. There is also a peculiar sense of tension and heat. Of course, in the case of simple congestion we assume a normal uterus as to structure, form, and position. But this coincidence, I believe, is rare. A normal uterus will generally perform its function normally. The physiological bloodfulness, which is an essential condition of every menstruation, is different from con- gestion, which is a morbid process. The physiological state is relieved by excretion. The morbid state is only partially so relieved ; some of the blood-elements remain, keeping up more or less tension of the bloodvessels, and the serum is effused into the tissues. Hence con- gestion is liable to induce some degree of permanent enlargement, which may even lead to hypertrophy or increased growth of the organ. This enlargement is perceptible to the touch in the intermenstrual in- tervals. It induces relaxation of the pelvic tissues which support the uterus ; hence, from increased weight and lessened support, the uterus tends to sink lower in the pelvis. What is the cause of this congestion ? We can hardly conceive the idea of primary congestion. This condition is almost necessarily the consequence of some morbid process or injury. These are manifold, and will be discussed under their appropriate heads. But in especial reference to the present subject, it must be remembered, that an organ which performs its function with difficulty, is by that circumstance disposed to congestion. Thus the simple neuralgic dysmenorrhoea is pretty sure to merge sooner or later into the congestive form. We may go further, and affirm that the congestive dysmenorrhoea, if not primarily due to a mechanical impediment, is certain to produce a mechanical impediment, chiefly marked at the menstrual e]^ochs, and by the obstruction this opposes to excretion from the womb, increas- ing the pain. The tumefaction of the mucous membrane, which commonly exceeds the normal bounds, fills up and chokes the cervical canal, especially at the os internum. Here there is a mechanical ob- struction to excretion. If the disease continues, the body of the uterus, CONGESTIVE. 199 increased in size, and all the surrounding structures, upon whose healthy tonicity the uterus depends for maintenance of its form and position, being relaxed, is liable to fall back in retroflexion. This necessarily increases the obstruction at the angle of flexion, that is, near the os uteri internum. Although I believe this is the history of some cases of retroflexion, I am very sure that in the majority the retroflexion is the primary condition. We are thus by several routes led to the discovery, that mechanical obstructions to excretion are the most important factors in dysmenorrhoea. Obstructions, it is almost superfluous to say, vary in seat, extent, and kind. They are most frequent at one of the natural orifices of the genital canal. Thus, narrowing of the os uteri internum, as brought about by flexion or angulation, is not uncommon ; narrowing of the OS externum is very common. But like results may attend narrowing at any other part of the canal, as in the vagina. If the closure be complete, and menstruation take place, of course there wall be retention. If the closure be incomplete there Avill be partial reten- tion, the expression of which is dysmenorrhoea. This partial retention and dysmenorrhoea w^e know is extremely common. Its phenomena should, I think, be studied in connection witli those of complete re- tention. We shall find in this study endless illustrations of the prop- osition that one essential condition of dysmenorrhoea is retention of menstrual seeretion. There is another condition to which retention of secreted matter is not necessary. In many cases where there is con- gestion of the uterus combined with extreme nervous susceptibility, the jtain is most marked at the outset of the period, that is, in all probability, before any pouring forth of blood into the uterine cavity has taken place. The pain is explained by the sudden distension of the morbid uterine tissue by the gathering of the blood in the vessels pre- liminary to secretion, and the swelling of the mucous membrane. In both there is retention, the difference being that, in the one case the menstrual blood is retained in the cavity of the uterus after secretion, and that in the other case, the blood is retained in the tissues of the uterus. The point which brings both cases together is that there is difficult excretion, causing distension of the uterine fibre, and nervous irritation. The residua] cases, which do not fall under one or the other descrip- tion of retention, are rare indeed. I have seen many cases in which long-standing dysmenorrhoea was cured by incision of the os externum, relapse occurring when the os contracted again ; and a permanent cure was obtained when the os was kept patent. In cases of anteversion and anteflexion, without stenosis, dysmenor- rhoea has been from time to time relieved or averted by the passage of a sound a day or two before the onset of menstruation. By this means and rest the uterus was redressed for the occasion, and the ob- struction and retention were averted. If this measure was at any time omitted, the dysmenoi-rhoea was sure to come, and the body of the uterus became very sensibly enlarged. Permanent cure has constantly followed permanent restoration of the uterus to its proper position. 200 D Y S M E N O R R H CE A. Another cause of dysraenorrlioea, and often of menorrhagia, is the fixing of the uterus by perimetric deposits, coming on after labor or abortion, or other conditions. The fixing of the uterus, although commonly attended by patency of the cervix, seems to me to cause dysmenorrhoea by preventing the uterus from contracting, and also by favoring engorgement of its tissues. Dysmenorrhoea is a not uncommon attendant upon fibroid tumors, which either produce obstruction by twisting or compressing the cer- vical canal, or by keeping up a state of congestion, or by interfering with the effective regular contraction of the uterus. Dysmenorrhcea from the first cause is frequently relieved by dilating the cervical canal either by tents or incisions. Many other illustrations will occur of pain analogous to that of dys- menorrhoea, produced by the retention in the uterus of blood-clots, as after labor and abortion, of intra-uterine polypi, of the exfoliated mucous membrane in the dysmenorrhoea membranacea, or, in fact, of anything which distends and irritates the uterine cavity. The differ- ence in the symptoms, and the degree of severity, depend not so much on the nature of the substance retained, as upon the completeness of the retention and the nervous susceptibility of the patient. A further proof that dysmenorrhoea is due to retention lies in the changes the menstrual fluid undergoes, and the character it presents when discharged. In some cases, especially those in which there is such excess of blood as to deserve the designation of menorrhagia, the escape being impeded, and the mucous secretions of the cavity of the uterus being insufficient in proportion to preserve the normal state, clots form. In other cases, in which there may be no excess of quan- tity, the retention is so protracted, or the quantity of catarrhal mucus mixed with it so large, that the fluid when discharged closely resem- bles, in its syrupy consistence and dark color, that which is pent up by an imperforate hymen. This is markedly so in some cases of tempo- rary retention from compression of the ' cervical canal by a fibroid tumor. But it is not uncommon in obstruction from retroflexion, and from stenosis of the os externum. The discharge is also often offen- sive to the smell. I have given a series of illustrative cases in support of the proposi- tion that dysmenorrhoea, in most instances, is the exponent of obstructed excretion, in a memoir in the "Obstetrical Transactions" for 1872. AVith all this variety of illustration concentrated into one focus, we shall be justified in repeating the proposition with which we started, namely : The essential cause of dysmenorrhoea — at least, in the great majority of cases — is retention of the menstrual secretion. The ex- ceptions in my experience are very few. And yet among these few ex- ceptions there are some which I should hesitate to consign to the neural- gic asylum. We meet with cases, every now and then, in which the dysmenorrhoeal symptoms are very severe, although there is no obvious stenosis. In some of these I have found the uterus small, perhaps in- clined to one side, set in a short, non-distensible vagina. Sometimes the OS externum is preternaturally small ; but even after freely dilating this, the dysmenorrhoea persists. The subjects of this kind of impcr- BY OBSTEUCTION. 201 feet development — for such it is — are commonly of a highly nervous temperament, acutely sensitive of pain, and it would be easy to say they suffer from " irritable uterus/' or neuralgic dysmenorrhoea. But this refuge seems unsatisfactory. In some of tlie subjects it is certain that the hypersesthetic condition has been gradually develoj)ed, caused by the frequent pain and imperfectly performed function, and was not a primary condition. In some cases I have seen great improvement, even cure, from the use of Simpson's intra-uterine galvanic pessary. Dysmenorrhoea from Obstructed Excretion. We may then conclude that, in a very large proportion of cases of dysmenorrhoea, some distinct mechanical anomaly of the uterus will be found. Careful study of the history of these cases, supplemented by observation of the results of treatment, will leave little doubt that these mechanical anomalies act as real obstructions to the menstrual function, and that they are therefore the primary factors of the disorder, to the removal of which treatment should be directed. The principal mechanical anomalies associated with dysmenorrhoea are : Narrowing of the os uteri externum, with or without projecting conical vaginal-portion ; retroflexion or retroversion of the uterus ; anteflexion, or anteversion of the uterus ; lateriversion ; torsion of the uterus (see Fig. 23, p. 47); inflammatory and hypersemic states of the uterus; fibroid tumors in the walls of the body, and especially in the neck of the uterus ; polypi in the uterus ; tumors or effusions out- side the uterus, pressing upon it, such as pelvic peritonitis, or perime- tritis, and retro-uterine hsematocele, which impede its mobility, and keep up hypersemia in it. These conditions may exist simply, or two or more may be combined. I propose now to discuss, in relation to dysmenorrhoea, the narro^v os, and the displacements of the uterus. The other conditions will be studied under their appropriate heads. This doctrine has not, it is true, met with general acceptance amongst those who have not applied to the study of the diseases of the ovaries and uterus the same method which they might think necessary in the case of other organs. So long as they regard the ovaries and uterus from this exceptional point of view, so long must they be under the dominion of arbitrary hypotheses. If a patient suffers from dyspnoea, the first thought is to explore the organs of respiration. And in the great majority of cases a physical condition of these organs adequate to explain the distress in breathing is discovered. So in like manner, whenever any organ performs its function with difficulty, it is inferred that the organ is out of gear. But with a strange inconsistency they exclude the uterine and ovarian functions from this process of inquiry. I have sketched the most common forms of conical vaginal-portion and stenosis of theos externum in the following figures. They are mostly congenital, and may be traced back to imperfect development. The vaginal-portion may project into the vagina half an inch, an inch, or even as much as two inches. Sometimes the vaginal- portion is rounded, representing the half of a globe. In some cases the excessive projection is due to acquired hypertrophic elongation of 202 DYSMEIfOEEHCEA. the infra-vaginal-portion. In the ordinary construction the cervical canal communicates freely with the vagina by an open transverse fissure ; inclining, indeed, to the circular form in the virgin. The form Fig. 54. Showing one form of the conical vaginal-portion. Showing another form of the conical vaginal-portion. of the cervical cavity is thus a flattened cone or funnel, of which the base is open (see Figs. 10, 12). The vaginal-portion projects as a flattened hemisphere scarcely half an inch into the vagina, the vagina Fig. 56. Showing a third form of the conical vaginal- portion. Showing a common form of narrow OS uteri, attended by dysmenorrhoea and sterility. being reflected oflP from the cervix a little above the level of the os externum. Instead of the natural free communication between the cervical cavity and the vagina, the os externum is so contracted as to form a sensible obstruction. Indeed, sometimes the ordinary uterine sound can be passed only with difficulty ; and I have known the occlusion to be complete, requiring some little force to break down a thin membran- ous septum formed at the orifice. As soon as the os uteri externum is penetrated by the sound, it is usually found that the point enters into a sufficiently capacious cervical cavity. This cavity is, in fact, exactly spindle-shaped ; it narrows again towards the os uteri internum. In cases of protracted suflFering from dysmenorrhoea attending this ijeculiar form of cervix, I have, however, generally found that the sound passes through the os internum without difficulty. It is by this observation that I have come to the conclusion that in some cases the excessive projec- BY OBSTEUCTIOISr. 203 Fig. 58. Section showing conical cervix with small OS externum. tion of the vaginal-portion is simply due to the vagina being reflected off at a higher level than usual. The sound shows the entire length of the uterus to be normal. The seat of the obstruction, then, I believe to be most commonly at the os externum. The obstruction is due chiefly to the small round os itself; partly to the pointed elongated form of the lower part of the vaginal-portion ; and partly to an unusual rigidity of structure of this part, which impedes the expanding action natural to the healthily formed os uteri. When obstruction is experienced at the OS internum, I have almost always found it to be due to the flattening of the canal at this point, caused by ex- treme flexion or angulation of the body of the uterus upon the neck. The sound will generally pass, by giving it a mode- rate curve, by tilting up the down-bent body with a guiding finger, and carry- ing the handle of the sound well backwards in the case of anteflexion, and vice versa. Dysmenorrhoea from obstruction at the os uteri internum, or at some point below it, is closely allied in pathology and symptoms with occlu- sion of the uterus and complete retention of the menstrual fluid. It is, in fact, a minor or incomplete degree of occlusion. The consequences of the described obstructions take place in retro- grade or ascending order above the seat of obstruction. They are: 1. Congestion and enlargement of the body of the uterus, disposing to menorrhagia at first, and causing uterine spasm and colic ; 2. A similar condition of the Fallopian tubes, and tendency to undue patency of the uterine mouths of the tubes (see Figs. 20, 21, 22, 23) ; 3. Congestion, enlargement, inflammation of the ovaries, determining (a) intra-alar hemorrhage, (b) retro-uterine hsematocele, (c) limited pelvic peritonitis, with or without adhesions of tubes and ovaries to surrounding struc- tures ; 4. As an ulterior result, continued obstruction may entail, through the action of inflammation or long interference with function, atrophy of the ovaries, and extinction of the menstrual phenomena. All the above consequences may occur in single women. When the subjects of uterine obstruction enter upon married life, other consequences are added. These are : Increased congestion and inflammation of the body of the uterus ; increased liability to ovarian irritation ; increased tendency to menorrhagia ; acute and chronic cervicitis with leucorrhoea ; vaginitis ; vaginismus ; dyspareunia ; ster- ility ; or, in the rare event of impregnation, abortion, or dystocia. I have learned that a history of abortion is generally to be mistrusted. A presumed abortion is likely to have been nothing more than menor- 204 DYSMENOERHCEA, rhagia. The barren woman would fain console herself with the delu- sion of a blighted hope. Of course it is not intended to convey the idea that these consequences are, one and all, constant. But I believe it is rare for the subject of narrow os externum uteri, alone or com- bined, as it frequently is with retroflexion of the uterus, to escape from some of them. Dysmeuorrhoea, dyspareunia, and sterility will com- monly follow ; and, continued through the period of ovarian activity, will render life miserable, even if health be not utterly broken doM'n. The symptoms of dysmeuorrhoea from obstructed excretion ex])ress the several pathological conditions which are called into action. Pain is the most urgent symptom. This usually comes on as a heavy aching sensation, even before the flow appears. The seat is pelvic, spreads to the sacrum, loins, one or both iliac regions, and often extends down the thighs. As the flow appears there is sometimes relief from pain, but more commonly it assumes an expulsive bearing-down character. It rises sometimes to such intensity that the patient is obliged to take to bed. The constitutional reactions of this pain are often great. Pros- tration approaching to collapse may ensue, violent headaches, syncope, retching, vomiting are not unfrequent. I have witnessed marked stupor and hebetude, loss of memory, loss of energy, want of all power of fixing attention, delirium, even mania. These symptoms subside, or are mitigated as the flow ceases, but occasionally last for several days, leaving the patient so exhausted and depressed in body and mind that she has scarcely time to rally before the next period returns, when all her distress is renewed. That these symptoms depend chiefly upon the hypersemic state of the uterus seems proved by the observation re- peatedly made, that touching the cervix or fundus with the finger will produce the same phenomena, and that the uterus is really enlarged and painful. Enlargements of the abdomen from perverted nervous action, resembling those which occur at the climacteric period, are fre- quent at the menstrual periods. The breasts also frequently enlarge at these times, and become painful, in response to the ovario-uterine dis- tress. The effect upon the menstrual function varies. In one class of cases menorrhagia is induced, the result, no doubt, of the extreme hypersemia caused by the obstruction. In these cases the intermenstrual interval is often reduced to three weeks or less, whilst the flow nei'sists for a week or longer. Clots are frequently passed, indicating retention in the cavity of the uterus. The case then resembles abortion, and not seldom, patients believe they have aborted. This, as I have said, is rarely the case. There has been no conception. The menorrhagia is commonly followed by leucorrhoea, another means which Nature adopts to lessen the hypersemia. More or less pain often persists throughout the interval, and is liable to exacerbation on any exertion or emotion. This is due to the continuance of hyperremia, and even to some hypertro])hv of the uterus. When dysmeuorrhoea depends upon obstruction of the OS externum or retroflexion or anteflexion, it commonly begins with the first advent of the ovarian function, and continues in spite of all ordi- nary treatment. I have notes of a case which shows in a striking- manner the severity of the symptoms sometimes produced. A young lady had been married two years without pregnancy. Since marriage SYMPTOMS. 205 she had suffered from metrorrhagia, and several attacks considered to be, and treated as peritonitis. During the last six months she had a constant sense of swelling, ^vith pain in the left ovarian region; vomit- ing attended the pain. This had been relieved by leeching. When I saw her, metrorrhagia had lasted six weeks without cessation. Great prostration was present, with irritative fever, reminding me of pysemic puerperal fever. I found a small conical cervix, with an os so minute that it required considerable pressure to introduce the uterine sound ; the cervix was deviated to the left ; there was defined tumefaction and pain in the left ovarian region. I inferred tliat the narrowed os ex- ternum, impeding the flow of blood from the uterus, led to the forma- tion of coagula in the cavity ; that these coagula were broken up by decomposition ; that absorption of septic matter took place, causing constitutional symptoms, and possibly peritonitis or cellulitis in the left broad ligament ; that the tumefaction in the left broad ligament might also be due to hemorrhagic effusion, or to congestion of the ovary. I split the cervix with my scissors. The metrorrhagia, which had per- sisted for six weeks, and was abundant at the moment of the operation, ceased in a few clays, the pain abated, and recovery ensued. The escape of a muco-sanguineous offensive discharge, when the os externum is opened by incision, is a very common occurrence. This indicates that chronic endometritis or uterine catarrh is one of the con- sequences of this malformation. In another class of cases, arising either primarily or secondarily upon menorrhagia, the menstrual flow gradually decreases, and it may even end in amenorrhoea. In these cases it may be conjectured that the ovaries undergo some change of an atrophic character, the result or not of inflammatory processes in the organs themselves, or in the surrounding tissues. The association of painful menstruation, uterine hemorrhage, and ster- ility, with a peculiar formation of the os uteri, has long been recognized. Indeed, this fact in pathology appears to be simply a recovered legacy from the most remote epoch of medical history. There is a passage in Aetius, in which not only is the dependence of sterility upon a con- tracted OS uteri pointed out, but the supposed modern treatment of di- lating it by compressed sponge-tents is also described. The late Dr. Macintosh was mainly instrumental in reviving and applying this knowledge to practice. Professor Simpson in Edinburgh, Dr. Oldham, myself, and others, in London, accepted the doctrine. On the Conti- nent it has met with less favor. But in America it is almost univer- sally recognized. If we reflect upon the normal uterus, the characteristics of which are: a nearly straight axis from the fundus to the os externum, slight anteversion only, an os uteri externum consisting of a free transverse slit, a cervical canal admitting the ready passage of the sound nearly or quite straight, we cannot avoid the conclusion that these are condi- tions fit for the easy performance of menstruation. It might, a 'priori, be predicated that where these conditions do not exist, difficult menstru- ation must result. Clinical observation amply proves that this is so. But opinions differ as to the exact nature and seat of the obstruction. 206 DYSMENORRHCEA. Simpson thought the seat of stricture was often at the os internum, and this view has been adopted by several men of experience in London. The question is one of great importance to determine. It stands liter- ally at the very threshold of the subject. If the obstruction be always, or even often, at the os internum, it follows that treatment must be di- rected to the dilatation of this part. Now, dilatation of this isthmus by bougies or expanding tents is attended but with transitory results. The isthmus very soon regains its ordinary calibre. Dilatation by in- cision is not only of transitory result, for the isthmus quickly contracts again, but it is attended by great danger. The bloodvessels enter the cervix just about this level, some penetrate deeply into its structure, and the venous canals are maintained as, more or less rigid tubes. An incision half an inch, or even a quarter of an inch deep will be very liable to divide some of these vessels. Hence, as a first danger, we have to apprehend profuse, even "furious" bleeding; next, from the gaping of the divided veins and the injury to the tissues in which they run, there is great liability to pelvic inflammation and septicaemia. These are no theoretical dangers. Many cases, some fatal, are well known. To illustrate this point, I made many sections at the level of the OS uteri internum. The disposition of the vessels is shown in Figs. 59, 60.^ The same figures show, what almost every section at this level shows, that the natural calibre of the isthmus will just about ad- mit the passage of the uterine sound. This coarctation has been demon- strated to be normal by Dr. H. Bennet in the living, by Boullard in the dead, and is no longer disputed. No operation, then, is needed to make it larger. If the sound will pass, we may be satisfied as to the efficiency of the os uteri internum ; and in my experience it is very rare indeed to find serious difficulty in passing it. If it does not pass readily, by far the most common cause is excessive flexion, mostly retroflexion, of the body upon the cervix. The point of angulation is at or near the OS internum, so that the sound will not pass unless the body be lifted up so as to straighten its axis, or the sound be much curved. When these things are done, the angle or spur of flexion is overcome, and the calibre of the isthmus is found to be normal. What need, then, to en- large it by incision? Will incision help to straighten the uterus? If the incision be made into the spur of flexion, and the wound be kept from closing, we may, it is true, get a straighter passage between the cervix and body. But can we depend upon so keeping a wider canal ? Of this I think proof is required. The rational course is, where there is obstruction from angulation, and this is frequent, to attack the flexion. For these reasons I disagree from those who insist upon the frequency of stricture of the os internum, and apply their treatment accordingly. Before describing the operation of incision, it is proper to describe and to discuss the value of the methods of dilating by bougies and tents. This was first done in modern times by Macintosh, and has been largely followed. Various dilating materials have been used. One was to fashion a tent made of ivory out of which the bony matter was taken by hydrochloric acid. Such a tent, when applied inside the 1 On " Dysmenorrhcea," &c , " Obstetrical Transactions," 1866. SEAT OF STRICTURE. 207 cervix uteri, will swell to about double its ordinary size, and so distend the canal in which it is placed. Metal bougies have been applied of gradually increasing size, as for stricture of the male urethra. A steel sound provided with a mechanism for expanding its calibre after intro- duction into the cervix has been advocated by Dr. Priestley and others. Fig. 60. Sections of uterus made at os internum — (ad nat.). Showing the normal size of the os internum, the circular disposition of the fibres around it, and the bloodvessels in proximity. Of late the favorite agents have been compressed sponge and laminaria-' tents. The sponge is made into a conical form and waxed over. Tents of this material, when introduced, soften and swell by imbibition of the fluids secreted. The patient should be undressed, in bed, and lie on her left side, knees drawn up. To introduce the sponge-tents, first of all pass the uterine sound to determine accurately the dimension and direction of the canal ; then the tent mounted on a stilet is introduced, and when in situ, it is well to plug the vagina below by pledgets of lint soaked in carbolic acid oil. After a few hours it will have expanded to its full extent, and may be removed. If it be found that the dilatation ob- tained is insufficient, another tent may now be passed. The laminaria-tents are now usually made about two inches long and hollowed out, that is, tubular. I have contrived a very convenient in- strument (see Fig. 41, p. 127) to carry them into their place, which has been sold by the London instrument-makers for several years. Re- cently, my friend Dr. Charles Godson has so modified my instrument, that the tube-bearing stilet may be set at any convenient angle. A suitable laminaria-tube is mounted on the stilet, when it virtually forms part of the equivalent of a uterine sound, and is almost as easy to introduce. The forefinger of the left hand, serving as a guide, is applied to the edge of the os uteri, whilst the instrument carrying the tent is handled by the right hand. The tent end is carefully slipped up, until nearly the whole length has passed the os externum. By 208 DYSMElSrOREHCEA. this, and also by a sense of resistance overcome, we know the os in- ternum has been passed. Then, keeping the forefinger on the os, with- draw the handle of the instrument, whilst the catheter is kept steady against the os. The stilet thus withdrawn from the laminaria-tube, this is left in situ. To secure it here, until it swells, when it will hold itself, plug lightly with lint soaked in carbolic acid oil. The tent takes about six or eight hours to swell to its full extent. If the constriction be rigid, or the patient very susceptible, it is not un- common for vomiting and pain to come on when the excentric pressure stretches the uterine fibre ; it is therefore desirable to give a sedative an hour or two after the application. The necessary time taken for the action of the tent suggests a practical rule in the selection of the hours for introducing it. It will combine the least distress to the patient with the greatest con- venience to the surgeon, to introduce the tent in the evening, and to visit her early in the morning to remove it ; or, it may be introduced in the morning and removed in the evening. The os internum yields with most difficulty. Sometimes the tent is gripped at this point so forcibly, that a deep furrow or circular constriction is formed, and the part of the tent over this point having expanded freely, considerable resistance is opposed to the removal. What is the effect of these measures ? The immediate effect is un- doubtedly to expand the cervical canal. A laminaria-tube, the size of a No. 8 bougie, will so expand the canal that it will admit the finger. The irritation produced by the presence of the tube causes a free secre- tion of mucus, which lasts for a day or two. But does the canal re- main enlarged ? It does not ; in a very few days it has contracted to its old diameter, and matters are in statu quo. To meet this, the operation has been repeated time after time, either until the patience of the suf- ferer was exhausted, or until serious accidents arose. That the cervix possesses the property of contracting again after simple mechanical stretching is amply proved by its occasional com- plete return to its previous diameter after parturition, during which a far greater force than that exerted by tents is applied. The accidents attending the process are not inconsiderable, and have been too much underrated by those who prefer dilatation by tents to incision, on the mistaken presumption that incision is more dangerous. Numerous cases have occurred of pelvic cellulitis or peritonitis, and some of septicsemic fever after the use of sponge-tents ; and similar acci- dents, although less frequently, have followed the use of laminaria-tents. Marion Sims relates several such cases, some so severe as to threaten to be fatal. Dr. L. Aitken^ relates others, and one in which retro- uterine hseraatocele also occurred. He insists upon the very proper caution that they should not be used when there is any inflammation. We may then conclude that the use of tents to dilate the cervix uteri is not efficient, and does not possess the advantage of being safer than incision. I entirely agree with Marion Sims that incision properly performed is less dangerous, less painful, and far more effective than 1 Edin. Med. Journ., 1870. USE OF TENTS. 209 any mode of dilatation by plugs or tents ; and this is the testimony of patients who have gone through both operations. The operation of Dilatation by Incision. — To combine the conditions of least danger, least pain, and greatest success is the object to aim at. I have already pointed out the objections to dividing the os uteri internum. By eliminating this proceeding we greatly lessen the danger, and do not, I believe, diminish the benefit of the operation. Further to lessen the danger we must eschew a class of instruments which must be regarded rather as machines than as surgical instruments. I am very unwilling to underrate the ingenuity which has been dis- played in the contrivance of the various two-bladed metrotomes. It is, however, against these that my objection is urged, and especially against the most ingenious in its mechanism of all, that of Dr. Green- halgh. This is adapted to divide the os internum, and therefore is already excluded by the reasons advanced against this proceeding. It moreover exceeds the rest of the two-bladed metrotomes in its automatic character. The two blades, as in all the contrivances of their class, are concealed in a narrow sheath open at both sides, so that they can be introduced into or through the cervix before being allowed to cut. When introduced thus guarded to the desired extent, by a mechanism in the handle, the blades spring out, one on either side, and make their incisions whilst the instrument is being withdrawn. With some in- struments the extent of divergence of the blades, and therefore the depth and place of the incisions, is regulated by the pressure of the operator's hand. In this respect the instruments are good. It is, however, dif- ficult to insure perfect accuracy in this way, and there is really no ad- vantage in cutting both sides simultaneously. But Dr. Greenhalgh's instrument does not possess the advantage of being controlled in its work by the operator. The blades are set beforehand, so as to diverge to a given extent. The sheathed blades are then passed through the cervix, when the mechanism by which they are opened is set at work, and from this moment the operation is performed by automatic ma- chinery. The blades cut as they are set, beyond observation of sight or touch ; the incisions they make cannot be regulated according to indi- cations obtained during the operation. Now, the thickness of the cer- vix uteri at the place of incision, and the nearness to which the vessels may approach the inner surface, are not absolute invariable quanti- ties. Setting the blades to diverge one-eighth of an inch only beyond the limit of safety — a limit which it must be borne in mind we are unable to determine — will involve the dangers of hemorrhage and septi- caemia. Two other serious objections tell against the double metrotomes. I have frequently observed, in cases requiring incision, that there is ob- liquity of the uterus. The axis of the uterus is often inclined to the right or to the left. A two-bladed instrument will not respect this ob- liquity, but will be in danger of cutting the two sides of the cervix un- equally. The side nearest the median line will be cut imcompletely, because it stands at a higher level, whilst the other side, being on a lower level, will be caught in the sweep of the knife at a higher point, where the vessels enter the uterine neck (see Fig. 61). 14 210 DYSMENOERHCEA. Fig. 61. The otlier objection has been pointed out to me by Dr. Aveling him- self, the inventor of the best double metrotome. Examining the action of the metrotome on a number of uteri taken out of the body, he ob- served that the thickness of the two sides of the cervix often varied considerably, so that the two blades, although diverging at an equal angle, would cut to a dangerous extent on one side. For this reason he has abandoned two-bladed instruments. The governing idea, then, of this mechanism rests on the assumption that the conditions of the part to be cut are constant as to disposition of vessels, thickness, and relations. But no such constancy exists in nature. Cases vary infinitely. The surgeon, then, here, as in every other operation upon the body, must be able to adapt every step of his proceedings to the peculiarities of the case in hand. He must use tools that will do his bidding with nicety from first to last. The objections stated apply, although with less force, to all two-bladed metrotomes, even when designed to cut the lower or vaginal- portion of the cervix only. The degree to which this portion projects into the vagina varies greatly. Thus, in some cases the vagi- nal-portion forms a conical mass, projecting an inch and a half into the vagina, whilst in others there is hardly any projection, the os uteri being almost flush with the vaginal roof. It is difficult to work two blades simultane- ously with the required precision in all cases. It is generally quite safe to divide all that part which projects into the vagina. But where the cervix is entirely supra-vaginal, a degree of nicety is required which it must be difficult to secure with two blades working at once. I do not condemn these instruments with- out having tried them. I had used them fairly before the objections expressed were re- vealed to me. The operation sometimes is attended or followed with an amount of nervous disturbance out of all proportion to its severity. This is greatly emotional, and depends upon the de- gree of apprehension excited in the mind of the patient, of her sus- ceptibility, and of the degree of mental tension sustained before and during the operation. The consequence is generally restlessness, sometimes hysteria. Pain after the operation is not commonly com- plained of. In the event of sleeplessness, nervous disturbance, or pain, it is proper to provide a sedative to be taken at night. The after-treatment is simple. To avert the risks of hemorrhage and inflammation, the patient should keep her bed for four days, and not be allowed to leave her room under a week. If there be any bleeding to cause uneasiness, the vagina may be plugged with strips of lint soaked in oil. The ordinary diet may be given. The sound may Eepresenting the aclion of the two-bladed Metrotomes in cutting the os internum. (Half- size). A, B B, c, the dotted lines di- verging from A to their extreme distance at b b, and converging again at c. At b b the os inter- num is divided, perhaps to an unequal depth, according to the thickness of the uterus at this part. INCISION OF THE CEEVIX. 211 be passed on the fourth day, to lightly part the freshly-cut lips of the Avound, and secure against reunion. When the operation has been performed as described, and these precautions have been observed, I have never seen any serious symptoms arise. Where symptoms of peritonitis have occurred it has generally been from getting up too soon, from exposure to cold, or undue excitement. The simple passing of the uterine sound for the purpose of diagnosis, has been followed by pelvic cellulitis or peritonitis. It is not, therefore, possible to pre- dict absolutely that in even the most favorable condition, such a result may not follow the operation under discussion. But I am warranted by very considerable personal experience, in affirming that with due care the risk of danger from the operation is infinitely small, and not to be compared with the protracted and repeated suffering and danger attending the obstruction which the operation is designed to remove. In the event of secondary hemorrhage occurring, as it sometimes will, within the first twenty- four hours, it is well not to trust to ordi- nary plugging. The most satisfactory plan is to introduce the specu- lum, to bring the os uteri well into view, to wipe away all blood, to seize one lip with a Sims's tenaculum-hook, so as to open the os, and steady it ; then to insert into it a small strip of lint, soaked in per- chloride of iron. This direct application of the styptic is generally eifectual ; it avoids the risk of continued bleeding. When the styptic plug is applied, the vagina may be packed below by strips of lint, soaked in carbolic acid oil. Immediately after the operation, or on the next day, it is generally useful to insert a Wright's intra-uterine stem. This instrument con- sists of a small perforated disk, on which are mounted two stems about two inches long, which are brought together by means of a tubular carrier. When so united the stem and its holder form virtually a sound, and is as easy of introduction. When the stem is passed into the uterus as far as the disk, the finger pressed upon this, retains it in situ whilst the holder is withdrawn. The two parts of which the stem is composed then diverge, and, adjusting themselves in the uterine cavity, hold the instrument in its place. The use of this instrument is twofold : it keeps the os externum open during the healing of the wound, and it straightens the uterus. It may be removed after four or five days. This may be done either by catching the stem with the holder, as for introduction, so as to bring the two parts together again, or by simply drawing it down by the tip of the finger. Besults and Appreciation of the Operation. — The operation as de- scribed, or as modified according to the views of different practitioners, has certainly now been performed some thousands of times. The acci- dents that have attended it are almost all explained by the imperfection of the methods adopted, or by the neglect of proper precautions. At one time Professor Simpson and some others regarded the operation as so slight, that they did not hesitate to perform it in their consulting-rooms, sending the patients home in cabs immediately afterwards. Bleeding and peritonitis were not uncommon results of this practice. I have seen several cases of chronic pelvic cellulitis arising in this manner; and some cases of fatal bleeding are known to have occurred. 212 DYSMENOEEHOEA. The wished-for result is not always immediate. In a certain number of cases, indeed, the next ensuing menstruation is perfectly easy, and future imnmnity is attained. But not unfrequently, the first period or two after the operation are even more painful than before. This may be accounted for by the congestion which remains after the operation, and by the extreme nervous irritability of the subject. The sympa- thetic distension and pain in the breasts, a frequent concomitant of dys- menorrhoea, is commonly relieved or removed after the operation. That relief should not be immediate is not surprising, when we con- sider the state to which protracted suifering and impaired nutrition have usually reduced the patient. The balance of the nervous system has to be restored; every tissue in the body wants regeneration. For this, time is essential. In the great majority of cases, relief more or less complete is gradually established within six or eight months, and ultimate entire disappointment is quite exceptional. One benefit is im- mediate. Where there has been great congestion or inflammation, this is almost instantly relieved by division of the vessels. Success is in proportion to the earliness of treatment. If carried out whilst the patients are comparatively young, and within two or three years of marriage, the prospect of complete relief is very great. But even after the age of thirty, success more or less decisive is still the rule. The important point is to operate before secondary changes in the uterus and ovaries have been established. As already stated, opinions are not unanimous as to the value of the operation. Before discussing adverse opinions, I think it not unreason- able to submit that the vast number of times the operation has been per- formed aflPords prima facie presumption that it has often been beneficial. Had it been no better than one of the numerous new remedies for intrac- table diseases, continually surging up and falling speedily into oblivion, because they failed to cure, it is almost certain that incisions of the con- tracted OS uteri, for relief of dysmenorrhoea and sterility, would long since have shared the fate that waits upon failure. But there is reason to believe that the operation is gaining favor. And if I may trust my own observation, it is not because of any excessive pertinacity of medi- cal men in recommending it, that it is so frequently performed, as because many patients being relieved by it, others are led to hope for similar benefit. Amongst those who have criticized the operation with most minute- ness and authority, stands Dr. Scanzoni.^ His objections are partly theoretical, partly clinical. They are aimed at the operation as a remedy for sterility, and as a remedy for dysmenorrhoea. Those conditions are so frequently associated in nature, that it is not easy to discuss them apart. One argument for the division of the narrow os uteri lies in this, that the narrow os obstructs alike the outward excretion of the menstrual fluid and the ingress of the seminal fluid, and hence the corol- lary that enlargement of the os may be expected to remove both diffi- culties. Now, Scanzoni admits that the dysmenorrhoea is frequently relieved, but contends that the sterility persists notwithstanding. 1 H. Scanzoni's Beitrage, 1870> INCISION OF THE CERVIX. 213 Thence, he urges that far too exclusive importance is attached to the mechanical hindrances to the meeting of the semen and ova. He says, we know as yet little as to the influence of the various morbid condi- tions upon the fertility of the semen and ova. Diseases of the testicle, it is known, sometimes lead to the absence of spermatozoa. May not the frequent diseases of the ovaries lead to the production of diseased or defective ova ? Manifold experience proves that, during extreme anaemia, conception does not take place. Here is a proof that in the case of the ovaries, as in that of other glands, a bad condition of the blood leads to bad secretions — ova incapable of fructification. Another series of diffi- culties arises when we consider the indispensable locomotion of the semen and of the ovum. It is only necessary to call to mind the fre- quent abnormities of the Fallopian tubes met with in autopsies, such as congenital or acquired shortenings, dislocations, adhesions, which are completely beyond clinical diagnosis. Scanzoni then puts the case of typical dysmenorrhoea with narrow os uteri and sterility. The os is split, the dysmenorrhoea is relieved, but the sterility continues; and asks, must it not be admitted that there is here a cause of sterility which lies in other and unknown conditions? This may be freely granted. The cure of the sterility is not nearly so frequent as the cure of the dysmenorrhoea. Impregnation is a far more complicated process than menstruation. But is the cure of dys- menorrhoea unimportant ? The suifering attending this condition it is which urges by far the greater number of patients to seek advice. The sterility is with many a secondary consideration, or does not so much as enter into their minds. In a considerable number of cases — I have had in my own practice not a few — conception does follow ; and the chance, if only a remote one, will be esteemed worth taking. It may, then, be assumed as in the highest degree probable, that the narrow os uteri is one cause of sterility. It is perfectly logical and good practice to remove this cause, giving the patient the possible benefit of its being the only cause. Sound clinical reasoning dictates that we should elimin- ate all the known complications of a morbid state, and not leave them to harass a patient because there may be others which we cannot relieve. A further reply to Scanzoni's objections is justified by observation. He insists upon the frequency of abnormities in the Fallopian tubes and ovaries, met with in autopsies, which are completely beyond diag- nosis. Now, it is in a high degree probable that some, if not many of these very abnormities, especially inflammatory adhesions and altered conditions of the ovaries, are the consequence of the narrow os uteri, and might have been prevented, had this obstruction to menstruation been removed at an early period of life. This opinion is based upon three orders of facts which have come under my observation. First, the removal of sterility, as well as of dysmenorrhoea, is probable in proportion to the early removal of the obstruction. I have repeatedly seen women who had passed one, two, or three years of married life without pregnancy conceive within two or three months after the opera- tion, whilst women who had remained sterile for ten years or more were cured of the dysmenorrhoea only. The second clinical fact is, that I 214 DYSMEISrOERHGEA. have frequently observed symptoms of peritonitis attending dysmenor- rhoea ; occasionally I have seen retro-uterine hsematocele, both of which conditions will leave adhesions. The third fact is, that in single and married women who had suffered some years from dysmenorrhoea at first attended with menorrhagia the menstrual discharge gradually tended to disappear, sexual indiiference set in, the uterus underwent marked atrophy ; in short, that premature sexual decrepitude had beeu produced, depending probably upon atrophy of the ovary, which itself was probably the result of inflammatory adhesions, or of the protracted struggle against impeded function. It would carry us far beyond reasonable limits to pursue the dis- cussion, or to describe minutely the difterent proceedings that have been advocated. It is desirable, however, to refer to the operation per- formed by Marion Sims, and to some modifications which are thought important. Dr. Skinner^ thinks incision should be preceded by dila- tation by metallic sound. Several practitioners concur in this practice. Dr. Skinner also contends "■ that the vaginal-portion ought on no ac- count to be split through and through." Dr. Gustav Braun^ divides the vaginal-portion with Kiichenmeister's scissors. He then cuts the OS internum by a blunt-ended, lancet-shajaed knife. He reports sixty- seven cases. The result was favorable in fifty -three; in eleven un- known ; in four interrupted by subsequent affections of the abdomen ; in eleven pregnancy followed. Braun's proceeding seems based upon Marion Sims's. The American surgeon places the patient on her left side ; introduces his duck-bill speculum ; hooks up the os uteri by a small tenaculum (Fig. 39, p. 126), and thus draws the uterus gently forwards ; he then passes one blade of a pair of curved scissors into the canal of the cervix, until the outer blade comes almost in contact with the reflection of the vagina ; the portion thus embraced is divided by one stroke of the scissors. The opposite side is then divided in like manner. A narrow-bladed, blunt-j^ointed knife is then used to divide the spur of tissue left on either side by the springing back of the scis- sors, so as to complete the lateral incisions " up to the very cavity of the womb." When the bleeding has been stopped, two or three small pieces of cotton, wetted with perchloride of iron, are pressed in between the lips of the wound, and the vagina is tightly plugged below. That this is an effective operation, I do not doubt; but it is unnecessarily severe. Sims says the hemorrhage is sometimes profuse. It is true this can be stopped by plugging and styptics, but I believe the extent of the hemorrhage is an index of other dangers. It shows that the vessels entering on the level of the os internum are divided, and when this is done there is greater danger of pelvic cellulitis and pya?mia. The scissors is a good instrument. For some time after I abandoned the two-bladed metrotomes, I used a pair of scissors, which I had specially designed for this purpose.^ It is the safest of all instruments, because it can only cut the infra-vaginal-portion caught between the 1 Liverpool Med. and Sure;. Reports, 1865. 2 Wicn Med.-Wochenschrift, 18fi9. ' '' Obstetrical Transactions," 1866. VARIOUS OPERATIONS. 215 two blades. I would still recommend it to those who have not ac- quired by practice skill in handling the single-bladed metrotome. In cases where there is decided flexion of the cervix, as well as con- traction of the OS externum, Dr. Sims modifies his operation. Suppose the case be retroflexion, bilateral incision will not materially strengthen the uterus, and there will remain constriction at the os internum at the angle of flexion. To bring the axis of the uterine cavity into a direct line with the vagina, he splits up the anterior lip of the os uteri in the central line. This, by laying open the lower part of the cervix uteri, brings the os internum into direct relation with the vagina. In the case of anteflexion, of course it is the posterior lip which is divided. Connected with flexions, and as a presumed cause of them, Sims in- sists upon the frequent existence of small fibroid tumors in the anterior or posterior wall of the body of the uterus. This splitting up of the anterior or posterior lip seems to be a rational proceeding ; but I have been accustomed to treat the flexion in a different manner. The com- plication, in my experience, is very frequent, and retroflexion greatly predominates. To meet this, after the bilateral division of the vagi- nal-portion, I use a Hodge pessary, occasionally passing the uterine sound. It has been objected that the new lips made by dividing the vaginal-portion occasionally roll back so as to cause a gaping con- dition of the OS. This is apt to follow when the splitting is excessive. It is a reason for not laying open the cervix quite to the roof of the vagina. Another objection specially urged by the advocates of dilatation by tents is, that the opening made by incisions frequently contracts again, whereupon the object of the operation is frustrated. This contraction does sometimes take place. When it does, it is desirable to repeat the operation, and to obviate the tendency to contraction by wearing a Wright's intra-uterine pessary for a day or two during the healing of the wound. And these objectors should be reminded that contraction always recurs after the use of tents and bougies. The operation, as I now perform it, is as follows : The necessary instruments are, — a specu- lum, the best for the purpose being my modification of Neugebauer (see Fig. 34, p. 121) ; a uterine sound, a Kuchenmeister's (see Fig. 37, p. 124) or my metrotome scissors, or Simpson's (see Fig. 38, p. 126) single-bladed metrotome, and a Sims's single tenaculum-hook (see Fig. 39, p. 126). The patient lies in bed, undressed, the nates drawn well up to the edge of the bed, the thighs flexed, the head resting on a pillow in the middle of the bed, the shoulders being kept low. I have not usually induced ansesthesia. The operation, although annoying, is not protracted, and only in rare cases very painful. Where, however, the patient is very nervous, it is better to give chloroform or ether. The sound is introduced to take exact survey of the direction of the cervix and uterus. The speculum is then introduced so as to bring the vaginal-portion well into the field. The advantage of my speculum is here seen in its bringing the vaginal-portion forward, so that in almost every case it can be touched with the finger. The speculum being held by an assistant, although I have often performed the operation 216 DYSMENOEEHGEA. Fig. 62. without assistance, the plain blade of the scissors is passed into the cer- vix from half an inch to an inch, and the part intervening between the blades is divided by a quick stroke. The blades are then reversed, and the opposite side of the cervix is dealt with in like manner. Generally, if Kiichenmeister's scissors are used, the hooked blade having secured the part so as to prevent it slipping back under the stroke, the operation is now completed. But if other scissors are used, it is desirable to hold the vaginal-portion steady by Sims's tenaculum during the cut. The operation may be done with Simpson's metro- tome instead of scissors, and sometimes when it is found that the scissors have not cut suffi- ciently, Simpson's instrument may be used to complete the incisions. The operation, if scissors alone are used, is thus necessarily limited to the vaginal-portion ; that is, it is by the very conditions of the opera- tion kept within the bounds of safety. It is not often necessary to divide the vaginal-por- tion quite up to the angle of reflection of the vagina. It is enough to make a good transverse slit, or os tincse, which shall give free communication between the cavity of the cervix and the vagina. The part thus divided is not very vascular, and it is rare that bleed- ing of any importance occurs. The parts should be swabbed with bits of sponge till bleeding has fairly stopped, which it generally does in a few minutes. If it continue, a small swab of sponge, mounted on a whalebone or other stem, or carried by forceps, and steeped in a solution of perchloride of iron, may be pressed between the lips of the wound. The vagina is then to be lightly plugged with strips of lint, soaked in olive oil, containing one part in ten of carbolic acid. It is convenient to attach a bit of string to each strip of lint, to facilitate removal. The plugs should be taken out next day. When there is decided flexion of the uterus, it is useful to insert a Wright's expanding intra-uterine pessary. This may be worn during the few days which the patient spends in the recumbent posture. Shows the action of Kiich- enmeister's scissors in enlarg- ing the OS uteri externum. — (Half-size.) OVAEIAN DYSMENOERHOEA. 217 CHAPTER XXI. OVAEIAN DYSMENOKRHOSA ; DYSOOTOCIA ; OOPHORIA (HYSTERIA); TUBAL DYSME]SfORRH(EA. When we reflect upon the importance of the ovary in the function of menstruation, upon the structure of the organ, and the activity of the processes going on in it, we shall not be surprised to find that dys- menorrhoea is sometimes due to conditions of the ovary. The ovary is, as we have seen, the primum mobile of menstruation ; the first and most important part of the function takes place in its structure. This part of the twofold function is ovulation or ootocia; the uterine part consists in the secretion of blood. Difficulty in the ovarian part of the function, then, means difficult ovulation, a distinct thing from difficulty in the secretion and excretion of the menstrual blood, which is the duty of the uterus. It is very important to keep this distinc- tion in mind. Dysmenorrhoea fails to express the idea of difficult ovulation ; and, thus failing, we are apt to lose sight of the clinical fact that in many cases the source of the distress lies in the ovary, I have therefore sought to designate difficult ovulation by a term in accordance with medical nomenclature. After consultation with my colleague, Dr. AY. H. Stone, I venture to propose the word " Dyso- otocia."' There is no doubt about the function nor about the difficulty with which it is occasionally performed. I hope, then, that I shall be held to be justified in projiosing a word to describe it. The clearest cases of ovarian dysmenorrhoea are those where there is pain at the menstrual periods, and no uterus, or only such an im- perfectly-developed uterus as to be unfit for its function. In these cases the cause of distress seems, ex necessitate rei, concentrated in the ovaries. I have observed signs of local fulness with pain ; but the chief distress has been in the nervous centres ; severe headaches, with such mental disturbance, marked by prostration, as to lead to fear that the mind would give way. Strange to say, I have known two cases of this kind to be almost completely relieved when a vagina had been made by dissecting up, although no menstrual flow was established. But when the uterus and entire sexual apparatus is well developed, the ovaries still may exhibit the only signs of periodical activity. There is the monthly pain in one or other iliac region, the increased nervous irritability, perhaps general vascular excitement or tension, leading possibly to Schneiderian epistaxis ; but the uterus takes no obvious part in the effiDrt. These cases show that an attempt at ovulation is often made, and that the menstrual effi)rt is exhausted in this attempt, no uterine men- 1 Erom Svg and uotokeu, to lay eggs. 218 DYSMENOREHCEA. struation occurring. These cases are usually classed under amenorrhcea ; but, strictly, they should be called cases of imperfect or abortive men- struation. They are really very common. A form of ovarian dysmenorrhoea which I have noted, occurs in con- nection with commencing ovarian disease. In many cases of ovarian dropsy I have ascertained that for some time preceding the develop- ment of the tumor, or the suspicion of it, dysmenorrhoea has been com- plained of. In some cases I was able to ascertain that there w^as no complicating uterine abnormality to account for the trouble. It seems to me, therefore, reasonable, to infer that the dysmenorrhoea was due to the morbid process going on in the ovary. In other cases where the ovarian tumor began at the end of sexual life, dysmenorrhoea was not complained of But no doubt there are exceptions to both these rules. The cases described by Dr. Priestley,^ under the title "Intermen- strual or intermediate dysmenorrhoea," should, I think, be classed as cases of ovarian dysmenorrhoea. Severe pain is felt midway between the periods, and commonly ceases before the flow sets in. The suifering is referred to one or other ovarian region ; and in three cases out of four referred to by Dr. Priestley, marked tumor, or thickening from old adhesions, was found in that locality. He conjectures that the pain is due to commencing ovulation-process, in ovaries affected by thickening of the indusium. I have seen a considerable number of similar cases. In some there was uterine complication, which may, however, have been secondary. The existence of adhesions or marked tumors, observed by Dr. Priestley in his cases, is by no means necessary to the production of ovarian dysmenorrhoea. At least, in the majority of cases which have come under my observation, no such coniplication was present. Swell- ing, indeed, sometimes considerable, of the ovary commonly attends the process even of healthy ovulation ; but this is not necessarily in- dicative of recent or old inflammation. Sometimes ovarian dysmenorrhoea is the expression of some form of oophoritis, more especially of that form which N^grier called ''vesic- ulite" or inflammation of the follicle. In other cases there is conges- tion, swelling, tension of the entire ovarian shell or capsule, producing a kind of strangulation more or less painful in the organ. In these cases the local symptoms are soon subdued or masked by various ex- traordinary nervous phenomena, usually designated as hysteria. The work of ovulation, like that of pregnancy, excites, first, a higher degree of irritability of the cerebro-spinal centres ; secondly, exalted tension of the vascular system ; thirdly, if the investment of the ovary, or the follicle itself, present any obstacle to the free swelling and burst- ing of the follicle, or if there be any morbid condition, as subacute inflammation in the ovarian structure, then, ovulation being impeded, disordered, there is a source of irritation. These conditions combined will not unfrequently issue in the phenomena called " hysteria." If the jjhenomena of dysmenorrhoea, that is, of the complex form, in 1 Proceedings of Med.-Chir. Soc, 1871. OVAEIAN. 219 which there is difficult ovulation as well as difficult secretion and ex- cretion, be observed and recorded with precision, it will as a rule, be found that the so-called hysterical phenomena occur early. They coin- cide with the first part or stage of menstruation, that is, with the ova- rian difficulty. They appear before the uterine or hemorrhagic stage begins ; and often subside when secretion and excretion are established. This history implies two things : first, hysterical phenomena find their source or their exciting cause in the ovary, not in the uterus ; secondly, the ovary having discharged its function soon undergoes involution, returning to quiescence. An objection, it must be said a superficial one, has been urged, that even the most severe and palpable diseases of the uterus and ovaries, such as cancer and ovarian dropsy, do not evoke marked nervous phe- nomena; and hence, by a false a fortiori argument, it is concluded that disorders of less severity cannot evoke them. It is quite true that dis- eases of the uterus, not only those which are severe, but also those which are comparatively slight, rarely of themselves call forth hysteria or other nervous disorders. During the ordinary state the uterus is a passive organ ; it has no great sensibility. It may be cut, cauterized, and otherwise manipulated. It may be eaten away by malignant ulcera- tions, without producing severe nervous phenomena. During men- struation its sensibility awakens, and if the escape of the ovum be hin- dered, there will be increased and prolonged hypersemia and hypertes- thesia of the uterus. Difficult ovulation is almost always attended by increased afflux of blood, marked by increase of bulk of the ovary. The ovario-uterine vascular system is so entirely one, that increase of uterine afflux neces- sarily attends. It may, therefore, be expected that increased menstrual flow should be a consequence or symptom of difficult ovulation. Gen- erally this is so. Menorrhagia is often the exponent of ovarian dysmen- orrhoea. And whether menorrhagia be produced or not, some degree of pain referred to the uterus is often experienced. Thus we have com- bined the two forms or elements of dysmenorrhoea, the ovarian and the uterine. If we seek to analyze such cases, to resolve them into their component parts, wx find no great difficulty. The ovarian distress al- most invariably manifests itself first. Pain is complained of in one or other iliac or inguinal region, often for days before the flow appears, and before the uterine distress is felt. In many cases there is little or no uterine pain ; and when the flow appears, the ovarian pain subsides. In the case of uterine dysmenorrhoea, the pain complained of is central, pelvic, and lumbo-sacral. In connection with ovarian dysmenorrhoea I may cite some views of Negrier which he deduces from striking clinical observations. He describes what he calls the " ovarian temperament." It depends upon large size and enei'gy of the ovaries disposing to early menstruation, to profuse menstruation, to the persistence of the function to a late period of life, and to excessive sexual passion. He finds evidence of this ovarian predominance in the hypersesthetic temperament ; in the persistence of menstruation during the early months of pregnancy ; in the quick return of the function after childbirth ; and in dysmenorrhoea, 220 DYSMENOERHGEA. characterized by a sudden attack of acute pain in an iliac fossa, confined to a space which may be covered by the pahn of the hand. This pain is not in paroxysms, but permanent ; it does not resemble intestinal colic, but more that of nephritis. There is no acceleration of pulse. These phenomena recur at every ovarian rupture. It is not within my scope to trace the history of hysteria or oophoria in a systematic manner, through all its phases. Although I believe it is next to im- possible for any but those who practice obstetric medicine to appreciate correctly the causes and concomitant conditions of this malady, I am far from maintaining that it is to be looked upon exclusively in its relations to the generative organs. I think no one, even amongst those who neglect the study of the disorders of these organs the most, denies that the association of hysteria with disordered conditions of these or- gans, is frequent. Possibly, those who devote themselves almost ex- clusively to this study may exaggerate the importance of this associa- tion. There may be too much absolutism on both sides. I hope to have an opportunity of discussing this interesting and intricate subject elsewhere. My present object is simply to show the primary influence of the ovary in evoking certain nervous phenomena. Iliac pain has long been recognized as a frequent attendant on hys- teria. There -is some divergence of opinion as to the actual seat of this pain. Schutzenberger, Piorry, Negrier, and Romberg insist that it lies in the ovary. Briquet says it is only a muscular pain, a " myo- dome." The pain of the pyramidal portion of the inferior extremity of the rectus muscle has been mistaken for a uterine pain ; and the pain of the lower portion of the oblique muscle answers to the pretended ovarian pain. Such is Briquet's opinion. That muscular pain often enters as an element in these cases, I do not doubt, but that this ex- plains the whole case appears to me quite untenable. Sometimes the pain is very intense ; the patient cannot bear to be touched by the bed- clothes. It is obvious that in these cases the muscles and skin play a part. There is general hypersesthesia. But in many of these cases, emotion plays a part too ; the patient shrinks and cries out before she is touched ; and this shrinking and this superficial pain are commonly only indications of an instinctive effort to protect the deeper structures, really the seat of pain, from injury. This is only one illustration of a general law, that suffering internal organs are protected by the muscles over them contracting in such a manner as to screen them from outward disturbance. At other times, however, the pain in the iliac region is not com- plained of spontaneously, and there is little or no superficial muscular pain. The muscles, when relaxed, may be pinched without evoking pain. "VVe must feel deeper. The pain is nearly fixed in one spot, that spot being the seat of the ovary. Pressure here will, as Dr. Charcot says, when brought to bear upon the ovary, which can be felt and dis- tinguished under the touch, cause a characteristic pain, inducing painful radiations towards the epigastrium, complicated sometimes with nausea and vomiting ; and then, if pressure be continued, palpitation, with extreme frequency of pulse, soon follows ; and lastly, the sensation of globus hystericus is developed in the neck. Charcot goes on to say OVAEIAN. 221 that various cephalic phenomena succeed ; such, for instance, as when the left ovary is compressed, intense wheezing noises in the left ear, and loss of sight of the left eye. If the right ovary be compressed, the head- symptoms are noticed on the right side. If pressure be pushed beyond this point, convulsions would break out. The following case related by N^grier is so apposite as a typical illustration, that I cite it in detail. A lady, aged twenty-one, of ovarian temperament, had hysteria from fourteen to eighteen ; married at nineteen ; had abortion at fifth month of pregnancy, after riding on horseback at a menstrual epoch ; free hemorrhage two months later. Suddenly violent muscular contractions, with throwing back of the spine, set in ; sharp involuntary cries, sufiPo- cating sensations attended. Energetic pelvic projection as often as the hand is applied to the hypogastrium. She had not menstruated since abortion. Pressure in the right iliac region reproduced a nervous irradiation towards the diaphragm. This sensation, said the patient, was exactly like that which precedes the nervous attacks. She recovered after dry cupping and cupping blood in the iliac fossa. The "pelvic projection" mentioned by Negrier, consists in the throw- ing forward of the pelvis. It is a frequent and remarkable symptom of oophoria. Charcot confirms the conclusion drawn from JSTegrier's and Schutz- enberger's experiments, which show that pressure in the ovarian region only reproduces artificially the same series of phenomena which is spontaneously developed in hysterical subjects. Charcot points out that the hemi-ansesthesia, the paresia, and contraction occupy the left side when oophoralgia is left, and vice versa. In several cases Charcot demonstrated that the convulsions of hys- teria could be controlled, resolved by firm pressure upon the ovary. Willis, it appears, in the seventeenth century, was aware of the power of firm pressure by the two hands in the abdomen in stopping a fit of convulsions. Chairou says he knows a young person in whom an hysterical fit can be produced by compression of the left ovary ; and Dr. Tilt says he knows a patient in whom similar pressure is followed by uncon- sciousness. I have myself on several occasions witnessed similar sequences of nervous phenomena. I feel a strong conviction that close observation wdll tend more and more to establish the fact, that iliac pain is the most constant and the primary feature in hysterical attacks. Opponents of the ovarian theory have too often indulged in what seemed to them the unanswerable fact, that there is no relation between hysteria and indubitable diseases of the ovary. It is true that severe organic disease of the ovary is not often attended by hysteria. It is even probable, that since severe dis- ease commonly tends to suppress the function of ovulation, it would thereby tend to suppress hysteria. It is not organic disease of the ovary that causes hysteria, but that disorder, that difficulty in the per- formance of its function, which is so common in young persons. Perfect coincidence as to time in the occurrence of ootocia, and of the development of hysterical symptoms, is not wanted to establish the 222 DYSMENORRHOEA. truth of the ovarian theory. Clinical observation, however, proves conckisively that the iliac pain, which is the expression of dvsootocia, in an immense number of instances, is the first condition. When once the hysterical temperament has been thoroughly established by several attacks, the excitability of the nervous centres induced is so great, that it will respond to the slightest peripheral or emotional irritation. The attacks then occur at other than the menstrual periods. It must, more- over, be remembered that menstruation, that is, the flow of blood, does not always coincide exactly with ovulation or ootocia. This process certainly often begins several days before the uterus pours forth blood ; and in very susceptible persons, the proclivity to excito-motory dis- turbance is so great, that even the trouble of the early stages of dyso- otocia is enough to bring forth the hysterical fit. When the hysterical habit has once gained force, any physical or mental fatigue, or ordinary emotion, may induce such exhaustion of the nerve-force that the balance is disturbed, and the control of the will, which undoubtedly is often sufficient to keep down a fit, is lost. It is, however, a serious error, because, if acted upon, it may lead to cruel treatment, to look upon hysteria, as some do, as essentially a mental disorder characterized by moral perversion. Some such element certainly, in some instances, enters into the field; and a certain degree of counteractino: moral force from without must be exerted in the treat- ment. But intimate knowledge of the constitution and character of many sufferers from hysteria leaves a settled conviction on my mind, that the attack is utterly beyond their voluntary control; that they look upon it with a sense of pain and degradation; that they would willingly conceal their infirmity from others. In persons of feeble character, of little self-reliance, eager for sympathy, especially where the ovarian excitement gives rise to an erotic feeling, no doubt the attack is often promoted and encouraged by a perverted will. It is difficult when witnessing a case of this kind to repress the feeling that a decided treatment of coercion would be the most appropriate. But it would be neither true in science, nor morally justifiable, to carry this feeling into the treatment of the numerous other cases in which the patient can no more suppress her illness than can the subject of puerperal convulsions. Lately it has been proposed to employ terror — the terror of being strangled by violent compression of the vessels of the neck — as a means of dealing with these cases. I cannot look upon this revolting practice — for I believe it has been practiced — with- out shame and humiliation that such ignorance and brutality should be so far recognized as to be discussed. Tracing the nervous phenomena usually summed up as "hysteria" to ovarian influences, Xegrier proposes to substitute the word "ovarie" for " hysteric." Agreeing in great measure with Xegrier's views, I see serious practical objection to the particular word he has selected. Even in its French form the word "ovarie" is scarcely distinct enough from "ovaire" or "ovarite," and in English the word "ovaria" is excluded by its he'nv^ in common use as the plural of ovarium. I therefore propose the word "oophoria," which is more correct etymologically, and convenient in relation to oophoritis or inflammation of the ovary. OVARIAN. 223 N^grier says the ovaries perform alternately. 1. He finds in one ovary a recently-rnptured follicle, and in the op- posite, one coming forward. 2. In cases of dysmenorrhoea the suffering is sometimes every other epoch, the pain being one-sided, and in that side which at other times has evinced local disease. 3. In women having double uterus and vagina, the menses have come from each side alternately. The diagnosis of ovarian dysmenorrhoea is made out by the history, the subjective signs, and the objective signs. Pain occurs in one or both iliac regions, limited to a small space, before the menstrual flow appears ; if the region which is the seat of pain be touched externally, the abdominal muscles become tense, so as to screen the deep structures beneath ; if pressure be made on the opposite side, although often the patient shrinks, either from dread or from a generally diffused hyper- aesthesia, the pressure is borne with comparative ease ; if examination be made by the vagina very tenderly, so as to touch the os uteri with- out exerting pressure on either side of the uterus, no marked pain is elicited ; but if the uterus be pressed upwards or towards the side where the affected organ is situated, acute pain is produced ; if the finger be pressed deeply in the vaginal roof towards the affected ovary, avoiding the uterus, pain is also elicited ; if the abdominal muscles can be re- laxed, and sometimes an opportunity is found on deep expiration with the thighs well flexed, the hand outside can be pressed down towards the finger inside, so as to grasp the tender ovary between them ; if the like manoeuvre be repeated with one finger in the rectum, the ovary may often be felt enlarged, tumid, tender, a little lower than its usual position, and a little more central. There is another sign characteristic of ovarian congestion which I have almost constantly observed. It is this : the body of the uterus is drawn towards the affected ovary in lateri version, so that the vagi- nal roof on that side is more tense and full than on the other. This drawing together of the uterus and affected ovary is no doubt due to the greater tumefaction of the intervening tissues, caused by the more active vascular process. It is curious to remember that Galen says lateral displacement of the womb is often associated with hysteria. A frequent, if not constant, phenomenon in ovarian dysmenorrhoea is a swelling of the lower abdomen, which takes place about the time of the menstrual effort. It is due to distension of the intestines, and is the result of a disturbance or metastasis of nerve-force, by which the intestines for a time lose their tone or contractile energy. The symptoms above described will, in many cases, be found almost alone, that is, as far as pelvic symptoms are concerned. They will in almost every case be attended with nervous phenomena, generally of the so-called hysterical order, sometimes by vomiting, occasionally even by convulsions, generally by headache. The pulse is seldom much accelerated ; there is no marked heat of skin. But in a considerable number of cases the symptoms of ovarian distress are accompanied by those of uterine distress. Uterine ob- 224 DYSMENOREHCEA. structive dysmenorrhoea, as it is commonly called, but to which I pre- fer the term, dysmenorrhoea from retention, complicates the ovarian dysmenorrhoea. But even in these cases the ovarian symptoms take precedence in time. The treatment of ovarian dysmenorrhoea: The indications are, to allay general and centric hypersesthesia, and to moderate the local ovarian pain. The two indications are carried out at the same time. It is important to clear out the bowels, so as to take oif any pressure upon the ovaries which a loaded rectum may cause. When the pain is very great, and especially if the pulse rise, and the skin be hot, ten or twelve leeches to the iliac region will give great relief. Two or three leeches applied directly to the fundus of the vagina are more effectual ; but this treatment is open to serious practical objections. Indeed, when we consider that the affection is one that tends to return every month, the remedy may be found as distressing as the disease ; and if often repeated, the consequent anae- mia and debility will increase the hypersesthesia by lowering the general strength. Now and then, however, the affection has been cured in a comparatively short time by the application of leeches out- side. Fomentations, to which turpentine is added, or slight vesications by chloroform, may always be used with advantage. The general remedies consist chiefly in sedatives. Hoffman's ano- dyne, acetate of ammonia, chloride of ammonium, bromide of potassium, chloral hydrate, and opiates, give valuable aid. Opiate suppositories, or vaginal pessaries, are often serviceable. If convulsions appear, the inhalation of chloroform should be resorted to, with great discretion, however, lest we engender a desire for its frequent use. Here, again, as generally in the diseases of women characterized by marked nervous phenomena, alcoholic stimulants should be allowed only in the most rigorous moderation, or even absolutely cut off. Dysmenorrhoea from Ohsti'uction of Fallopian Tubes. Bernutz relates a case which seemed to be of this nature. A lady at twenty-eight enjoyed good health till some months before death ; she then had metrorrhagia, and was thought to have a miscarriage. During a time of severe mental trial she was seized suddenly with violent pains in the abdomen, fainting, and vomiting. There was then no discharge. She soon sank with symptoms of internal hemorrhage. Much blood was found in the abdomen and pelvis. The left tube presented a tumor the size of a pigeon's ^gg', on its surface was a small transparent cyst, covered with filaments of the tube. At its junction with the uterus, the tube was rendered impervious by a small fibrous tumor. MEMBRANACEA. 225 CHAPTER XXII. INFLAMMATOKY DYSMENOERHCEA ; DYSMENORRHEA MEMBRANACEA. Inflammatory dysmenorrhcea is not common in single women. The clearest examples are those in which dysmenorrhoea follows on suppressed menstruation, as from the sudden shock of cold, injury, or emotion sustained during the flow. Under this circumstance, metritis, or at least intense uterine congestion, is very likely to arise ; and an inflamed organ necessarily performs its function, if it be performed, with pain. Not uncommonly in these cases, pelvic peritonitis and oophoritis complicate the metritis ; and these conditions in themselves will make menstruation painful. The history of the case, the evidence of primary pelvic inflammation, and of secondary dysraennorrhoea, ex- plain the nature of the affection. In some of these cases there is not only some degree of chronic metritis persisting, but as sequelae of the peritonitis, adhesions may remain which impede the mobility of the uterus, and even drag it out of place. Local examination confirms the diagnosis supplied by the history. In these cases the appropriate treatment is to apply six to ten leeches to the groin, or two to the cervix uteri ; to use warm hip-baths con- taining Vichy salts ; to administer salines and sedatives. If the peri- tonitic complication be severe, it is desirable to give small doses of calomel and opium for two or three days. The rectum should be cleared out by an enema of gruel and olive oil; but all purgatives which disturb parts which ought to be at rest, should be carefully avoided. Inflammatory dysmenorrhoea is well exemplified, although not per- haps in its purest form, in those cases where metritis, with perimetritis and soDie degree of fixing of the uterus, spring up, and persist after labor or abortion. In many of these cases there is a clear history of freedom from dysmenorrhoea until after labor; henceforth the menstrual function is performed with pain. The pain comes on with the flow, which is often profuse and hemorrhagic, lasting for six days or even a fortnight. The pain is referred to the seat of the uterus, whence it radiates to the back. The treatment resolves itself into that of the abnormal condition of the uterus, and surrounding structures. The further history, then, of this form of dysmenorrhoea will be discussed when describing the conditions of which it is a symptom or consequence. The Dysmenorrhwa memhranacea may be classed under the inflam- matory kinds. It is often a very obstinate affection. The pathogno- monic feature is the discharge of a membrane, sometimes in shreds, sometimes representing a cast of the cavity of the body of the uterus. A case is graphically related by Morgagni. The real nature of these 15 226 DYSMENOEEHCEA. r membranes was not clearly understood until it was described by Dr. Oldham.^ They had long been regarded as casts formed by exudations of lymph, like those of croup. They are so described by Montgomery, R. Ferguson, Churchill. Oldham distinctly enunciated the proposition that these membranes were formed under the ovarian stimulus ; and that they were formed by the uterine glands — that they were, in short, menstrual decidua. Oldham's observation was speedily confirmed by others. Professor Simpson^ described the membrane as resembling the decidua vera.^ Bernutz cites three cases from Boivin and Duges, in which casts or cysts were expelled from the uterus, in order to prove that the affection described by Oldham had been previously known in France. But we have already seen that a case of a shed membrane, exactly resembling a cast of the uterus, had been accurately described by Morgagni ; and the other authors, whose names are cited above, distinctly refer to the disease. It is not, then, the discovery of a particular variety of dys- menorrhoea, distinguished by the shedding of a membrane, which con- stitutes Oldham's merit ; it is the discovery that this membrane was not simply an exudation-cast of the lining membrane of the uterus, but the lining membrane itself. Oldham's priority in this respect still re- mains untouched. But here, as is constantly happening in the history of medicine, we have an instance of the disposition, at once and absolutely to exclude the hitherto existing theory of a disease, and to replace it as absolutely by the last new theory brought forward. It is too often forgotten that both may be true, as expressing the nature of certain cases ; and that neither may be true, as expressing the character of all cases. The new fact, that the membrane expelled is the mucous membrane of the uterine cavity, is undoubtedly true, but I am in a position to affirm from my own observation that the membrane expelled in some cases of dysmen- orrhcea consists essentially of fibrin and mucus, and does not contain the elements of mucous membrane. It is important then to bear in mind that the membranes associated with dysmenorrhoea are not ail of one kind. The first kind may be defined as the exfoliated mucous membrane of the uterus. All the elements of this membrane may be recognized by the microscope. When voided they may be entire, in which case their source and nature are easily recognized. They are then seen as three-cornered bags, somewhat longer in one direction, having an irregu- lar opening at each angle, the opening at the smaller end or space being larger than the two others. This lower opening corresponds with the os internum uteri, the other two with the ostia of the Fallopian tubes. The membranes are rough, ragged on the outer surface, and smooth on the in- side. In size they are about an inch long, and a little less in width, that is, generally somewhat in excess of the normal proportions of the cavity 1 London Medical Gazette, April 17th, 1846. 2 Edinb. Monthly Journ. of Med. Sc, Sept., 1846. 3 It is to be regretted that even in the collected edition of Professor Simpson's works, published in 1871, his memoir is reprinted without any reference to Dr. Oldham's prior publication. MEMBEANACEA. 227 of the body of the uterus. Under the microscope, the distinctive element of the uterine mucous membrane, namely, the utricular glands, is made manifest. It may be said that the identification of this membrane as mucous membrane was a natural consequence of the identification of the decidua of pregnancy as mucous membrane. This decidua had already gone through the same phases of theory, that is, it was long looked upon as a simple exudation from the inner uterine surface, analogous to the fibrinous effusions of inflammation or croup, and it was ultimately recognized as the highly developed mucous membrane. The applica- tion of this knowledge of the true nature of the decidua gravida to the study of the deciduous membrane of dysmenorrhoea, might be directly suggested by the demonstration of Coste that the uterine mucous mem- brane at the epoch of menstruation assumed a development strictly an- alogous to that which it assumed on the advent of gestation. This similarity suggested to Virchow the name " decidua menstraalis" for the dysmenorrhoeal membrane ; and this name, although rather indica- tive of a constant or normal state, than of a pathological one, it is con- venient to retain. The decidua menstrualis, then, may be expected to present characters like those of the decidua of early pregnancy. And this similarity is so close that some observers have impugned the existence of the decidua menstrualis, and contend that all membranes presenting the characters of decidua are really the jjroduct of concep- tion ; that, in short, the so-called dysmenorrhoeal membrane is nothing but the issue of an early abortion. This view was distinctly enunciated by Dr. Hausmann,^ who based his conclusions on the examination of specimens furnished by Martin and Virchow. The discharge of the membrane at the menstrual epoch is not, he says, constant ; it is often a few days in arrear ; the expulsion begins, as a rule, from six to twenty- four hours, sometimes several days, after the beginning of hemorrhage, and always under forcing pains. The several causes of this abortion and of the consequent expulsion of the decidua, are not yet known, but probably the premature destruction of the embryo is the first factor. The logical prophylactic deduction from this theory is simple abstinence from sexual intercourse for several months. Hausmann cites, amongst other arguments, a case from Tyler Smith, which if it be admitted as typical, would indeed furnish strong evidence in favor of the abortion theory. A woman whilst single was healthy; from the time of mar- riage to the death of her first husband she passed membranes at irreg- ular intervals ; became free whilst a widow ; and again discharged these membranes six months after second marriage. To accept this theory, that the menstrual decidua is simply an abor- tion, may be to subject the patient to an impeachment of her character. If the membrane be the result of sexual intercourse, the discharge of one by a single woman, or by one living apart from her husband, must be taken as proof of unchastity. It therefore behooves us to examine the subject with the utmost care before coming to a final and absolute conclusion. 1 " Monatsschrift fiir Geburtskunde," 1868. 228 DYSMENOREHCEA. Has the dysmenorrhoeal membrane ever been observed where absence of sexual relations is undoubted ? In attempting to reply to this ques- tion, it is essential that the structure of the membrane have been accu- rately determined by the microscope. Premising this condition, we may put the question in another form — Has a case been observed in which, there being absence of sexual relations, a membrane has been expelled bearing the distinctive character of uterine mucous membrane? I put the question in this form, because I think it may be admitted, in limine, without prejudicing the main question, that membranes, of which the chief constituent is fibrin, are passed quite independently of impregna- tion. Some of these fibrinous casts are blood-clots which, compressed in the uterine cavity, have lost more or less of the red-globules ; and on the surface, especially, have assumed a pale and membranous appear- ance. Generally, however, these altered blood-masses are more or less solid ; that is, they present no cavity, or if there be one, it is filled with blood, fluid or coagulated. These casts or clot-moles are not very un- common accompaniments of dysmenorrhoea. There is no doubt of their being shed independently of impregnation, or even of sexual connection. But they are certainly more common in women who have had children, and who continue to be subject to sexual connection. The natural monthly shedding of the uterine mucous membrane, instead of taking place, as in the usual way, by disintegration, so that the elements escape gradually as detritus, mingled with the menstrual blood, may be effected by a more rapid and violent process. In this case we shall find distinct shreds, perhaps an entire cast, composed of fibrinous fibrillse, of fibre- cells, numerous mucous-globules, and epithelium-cells. In the case from which the figure (No. 64) is taken, the subject had had children, and suffered severely from menorrhagia and dysmenorrhoea. I believe this form of membrane is restricted, not indeed absolutely, but with rare exceptions, to women leading a married life. It is quite conceivable that the uterine mucous membrane, having undergone an unusually full menstrual development, may be cast off even more completely than in the preceding case. We should then have the typical contested decidua menstrualis. The inner side would exhibit the fine points or holes of the orifices of the utricular glands, and the outer side, the ragged flocculent appearance which is commonly, but not always, seen in early aborted ova. It does not consist of the entire mucous membrane of the uterus. The outer layer of the mucous membrane, with the blind extremities of the uterine glands, remains behind. The decidual membrane contains the normal elements of the mucous membrane, the ciliated epithelium, the glands, the vessels and connective tissue ; the vessels and connective tissue are hypertrophied ; the glands are elongated and widened. If it be admitted, and observa- tions in point are now so numerous and authentic that it can scarcely be disputed, that the mucous membrane, under simple ovarian menstrual excitation, does undergo a high degree of development not distinguish- able from the decidua of early pregnancy, it must also be admitted as possible that the mucous membrane so developed may be cast off. Moreover, that the presence of an ovum in the uterus is not necessary for the development of a membrane having all the characters of the MEMBRAXACEA. . 229 decidua of pregnancy, is proved by the formation of a decidua in utero in cases of tubal gestation. Rokitansky distinctly says, when describing the characters of a membrane submitted to him by Mandl, "The development of the mucous membrane is in excess of its usual menstrual degree. It is not, however, connected with conception." It does, hoAvever, occur in women who have had children. Courty relates in full a case of a girl who passed membranes at her periods. On one occasion he extracted one from the os uteri by forceps, through a small speculum carefully manipulated, so as not to break down a virginal hymen. This seems an unequivocal case. Another form of cast appears to consist purely of fibrin. These come in shreds, or in one piece representing the shape of the uterine cavity. Under the microscope, nothing but the fibrillar arrangement of fibrin, interspersed with mucous corpuscles, is seen. In some cases of endometritis it would seem eitlier that a layer of fibrin may be effused, or that the raucous secretion, rendered more tenacious by retention and by fibrinous matter, may form a distinct layer on the surface of the Qiucous membrane. Such a membrane may be independent of impreg- nation, but being associated with chronic metritis, it is rarely seen in women not subject to sexual connection. At the menstrual epoch the chronic metritis is intensified, and may deserve the name given to it by H. Huchard^ of " menstrual metritis.''^ In some cases the albuminoid secretion from the cervix uteri, which is especially copious in endocervicitis, may, entangling a lesser propor- tion of epithelium, produce a tenacious membrane less solid than the preceding, but of a similar character. This may occur in single as well as in married women. The mucous plasma thus condensed, assumes very much the appearance of fibrillse. Shreds of membrane, mostly very small, are frequently passed when there is malignant disease of the uterus. These are the result of super- ficial disintegration or necrosis of the diseased structures. They are not likely to be mistaken for dysmenorrhoeal membranes. They differ in being mostly minute in size, and in being attended by the turbid, greenish, watery discharges characteristic of cancer. I have seen shreds of this kind brought aAvay from the interior of the uterus by the small sponge-probang when the disease affects the cavity. Raciborski points out^ that the mucous membrane of dysmenorrhoea may be distinguished from the decidua of early abortion. The dys- menorrhoeal membrane is generally in shreds, thin and membranous, triangular, and showing the orifices of the tubes and os internum uteri. It is always expelled at a menstrual epoch. On the other hand, the aborted decidua is generally thicker, blood being extravasated in the substance ; in shape it is more ovoid ; the tubal orifices are not easily made out; and it is generally passed after a period has been suspended. Shreds of a membranous appearance may be passed from the vagina at intermenstrual periods, which do not necessarily come from the uterus. Thus the ordinary exfoliation of epithelium which takes place ' Gazette des Hopitaux, 1870. 2 Ti-aite de la Menstruation. 230 DYSMENORRHCEA. from the os uteri may, under a condition of subacute inflammation, be so rapid, that the throwing off of epithelium-cells exceeds the propor- tion of mucus necessary to maintain fluidity. In such a case there is formed a layer of whitish material which covers the mucous membrane, resembling a diphtheritic membrane. When analyzed by the micro- scope, this is seen to consist almost entirely of pavement epithelium- cells and mucous globules. I have not seen this in virgins, but the possibility of its occurrence cannot be excluded. Under peculiar puerperal states also, the vulva, vagina, and perhaps the uterus, may be covered with a diphtheritic membrane, closely re- sembling that which covers the fauces in diphtheria. I mention one circumstance, to warn against a possible fallacy. When women suffering from leu corrhoea are using astringent injections, as of zinc or alum, the albuminoid mucus is coagulated by the injec- tion, and comes away in shreds. The patients say it brings away "bits of flesh or skin." Dr. Arthur Farre has described' cases in which complete casts of the vagina were passed. These were distinguished from uterine mem- branes by their having the exact form of the vagina, by the absence of the characters of the uterine mucous membrane, and by not being cast under symptoms of dysmenorrhoea. The drawing, Fig. 63, is taken from a specimen of this kind in St. Thomas's Museum. It should be borne in mind also that the superficial layer of the vaginal mucous membrane is liable to be exfoliated under the applica- tion of perchloride of iron. Thus, I possess a very complete cast of the vagina, showing all the rugae, which was shed after several intra-uterine injections of this styptic to arrest obstinate metrorrhagia. This mem- brane, like other compressible substances in the vagina, was not ex- pelled, but got rolled up in a ball in the posterior vaginal cul-de-sac, whence it was brought away by the finger. It escaped detection by the speculum. The surface of the vagina and os uteri were pale, and very smooth. A single injection is not likely to cause this exfoliation, unless it be used of nearly concentrated strength, as in a case related by Dr. Tessier, who, in a case of profuse non-puerperal flooding, in- troduced into the vagina a piece of charpie, charged with pure per- chloride of iron. The plug was removed in forty-eight hours. On the seventeenth day a piece of mucous membrane was discharged. The patient had a slow convalescence, and great contraction of the vagina iollowed. The perchloride had acted as a powerful caustic, producing a slough of the mucous membrane.^ To avoid this caustic action, two things are necessary : first, use solutions not stronger than one in ten ; secondly, thoroughly oil the vagina before injecting. We must then, a 'priori, admit the possibility of the casting of a menstrual decidua, in the form of a membrane. But it must be re- served for extended clinical observation and critical research, to de- termine the frequency of the detachment of the menstrual decidua en masse, independently of sexual relations. I must declare that the greater number of membranous structures ' Beale's "Archives." 2 Gazette des Hopitaux, 18G9. MEMBRA NACEA. 231 discharged in dysmenorrhoeal eases which I have seen, occurred under the conditions specified by Hausmann, that is, the subjects were lead- ing a married life, and the menstruation had been some days in arrear. At the same time we must bear in mind that no aggregate of cases, however large, in which this association was verified, can absolutely exclude the possibility of the discharge of a dysmenorrhoeal membrane by virgins. Recognizing this possibility, we must, I think, go further, Fig. 63. Fig. 64. Fig. 63.— Exfoliated mucous membrane of the vagina. (G. G. 5, St. Thomas's Museum— ad. nat.) Fig. 64. — Uterine mucous membrane shed entire, laid open, showing interior cavity smooth. (St. Thomas's Museum, G. G. 4, nat. size.) At upper part are seen numerous points, the openings of glands; on the outer surface are slight ragged projections. and affirm that we cannot, without imminent risk of falling into sci- entific error and unjust suspicions of the chastity of the patient, admit that any structural character of a membrane cast from the uterus, short of the detection in it of chorion-villi, is proof of impregnation. And it must be remembered that chorion-villi may be simulated by the ducts of the utricular glands ; and that it requires some experience and care to distinguish them. The epithelial cells of the utricular glands difPer from the cells which surround the chorion-villi ; the outline of the gland-casts is less defined; and these do not present the pyriform buddings which are so characteristic of the early chorion. The Symptoms.— The presence of inflammation as a necessary ele- ment has been doubted. But there can be no doubt as to the general presence of congestion and hyperplasia. It may be doubted whether a single case has occurred in which some morbid condition of the uterus was not coincident. There is almost always extreme tenderness of the 232 DYSMENOERHOEA. uterus, on touching the vaginal-portion or the body of the organ ; and increased bulk of the uterus is discovered by combined intra-vaginal and abdominal palpation. Dyspareunia and sterility are almost con- stant complications. The tendency to rapid morbid hyperplasia of the uterine mucous membrane seems to unfit this structure for the forma- tion of healthy gravid decidua, while the morbid congestion and irri- tability of the muscular wall dispose the uterus to premature contrac- tion, and to cast off its contents. The process of detachment of the morbid mucous membrane is vio- lent, and not the slow result of gradual exfoliation. Exudation of fluid, serum, sometimes blood, takes place between the inner uterine wall and the layer of mucous membrane which is to be thrown off; then, spasmodic contractions or colics of the uterus being set up, the detachment and expulsion are completed. The symptoms are in harmony with this view. Pain, pelvic, abdom- inal, and inguinal, precede the menstrual flow by several days. There is bearing-down pain, with sense of increased fulness and weight in the rectum, frequently causing tenesmus both of the rectum and of the bladder. A painful sensation of gnawing, extending to the umbilicus and epigastric region, has been complained of in several cases. The pain is intensified, assuming an expulsive labor-like character when the flow sets in, and is so continued from twenty-four to forty-eight hours, when the membrane is usually expelled. The pain then abates; but frequently the discharge of blood is profuse, and lasts for some days longer. When this has ceased the patient rallies for a time, to be again cast down by the recurrence of a similar train of events. It is not, however, every menstrual period which is attended by the expul- sion of casts. Sometimes a period, marked by less severe pain and less hemorrhage, occurs. It deserves to be carefully observed how far these intermissions correspond with the suspension of sexual intercourse. Dr. Rigby says oophoritis is not seldom the result or concomitant of this form of dysmenorrhcea. According to the degree of nervous susceptibility and general impairment of health of the individual, various degrees and forms of hysterical and other nervous derange- ments will manifest themselves. The treatment of dysmenorrhcea membranacea will of course be greatly governed by the view we take of the pathology of the affection. If we conclude that the essential factor is sexual intercourse, especially if involving im])regnation, the main treatment is obviously prophylactic. Abstinence, that is, physiological rest for a time, should be dictated. We then gain time and opportunity for treating the morbid conditions of the system and of the generative organs. The survey we have taken of the affection almost precludes the idea that the menstrual membranes are cast by the healthy uterus. It fol- lows that we must carefully study the physical condition of the uterus, and direct treatment to the removal of the complicating diseases. What are the best local applications? It is clear that the origin of the membranes being the lining membrane of the cavity of the uterus, our remedies must be applied there. We can only act very slowly in- deed, if at all, if we trust to the principle of derivation by limiting the MEMBEANACEA. 233 application of remedies to the cervix. If there is a syphilitic taint I would advise the use of a mercurial vapor-bath, using a bath-speculum to enable the vapor to enter the vagina. To the inner cavity of the uterus we may apply nitrate of silver, iodine, bromine, or sulphate of zinc. These are best applied in the solid form. By using the instru- ment I have devised for this purpose, a stick of sulphate of zinc or other remedy can be readily passed into the uterine cavity without the aid of the speculum, and without any exposure ; or the iodide of mer- cury may be applied in the form of ointment by my instrument. (See Fig. 44, p. 129.) The application should be repeated every five or six days. Mandl speaks favorably of chlorate of potash, as this remedy is known to possess a decided influence on the liquefaction, degeneration, and resorption of epithelial growths and pseudo-membranous exuda- tions of the mucous membrane. In the case he narrates, benefit at- tended the use of this substance. If nitrate of silver be used, it should be reduced by using three- grain sticks, made by fusing together equal proportions of nitrate of silver and nitrate of potash. If there be retroversion or retroflex- ion, as is not uncommon, this must be corrected, by the use of a suit- able pessary. When there is considerable turgidity of the cervix, from congestion or active inflammation, two or three leeches applied to the cervix uteri may be useful. Constitutional treatment, hygienic, and including the exhibition of remedies by the stomach or skin, is often essential. In some cases I have been satisfied that the unhealthy condition of the uterine mucous membrane, leading to the casting of shreds and membranes, was due to syphilitic disease. Inquiry in this direction, by examining the skin and the state of the mucous membranes elsewhere, as well as by weigh- ing the history of the patient, is important. A succession of early abor- tions or dead children aifords highly presumptive evidence. The severe suflering attending the dysmenorrhoeal paroxysms may be mitigated by opium, Hoffmann's anodyne, chloroform, chloral, In- dian hemp, or other sedatives. The liquor ammonise acetatis is valu- able by itself, and is the best menstruum for opium. Trousseau recom- mended turpentine, in twenty-drop doses, continued for three months, and the prolonged use of warm baths. C. Braun prescribed small doses of arsenic, to allay the attendant painful excitement. Tonics, as iron, quinine, strychnine, arsenic, and the mineral acids, are almost always serviceable, as adjuvants to local treatment. The bowels require special care, as accumulation in the rectum is a serious aggravation of all uterine affections. Prognosis. — But with all possible care we must be prepared to find these cases rebellious to treatment for a long time; sterility may be re- garded as a consequence ; for when pregnancy occurs, and is carried on for some months, the disease may be considered to be cured. 234 CLIMACTEEIC. CHAPTER XXIII. THE MENSTEUAL IRREGULARITIES OF THE CLi:SIACTERIC EPOCH. In connection with the deviations from healthy menstruation, it is convenient to trace the history of menstruation at the climacteric epoch. This epoch is sometimes called the " menopause/' to indicate the ces- sation of the function of menstruation. There is no fixed uniform period for this event. Some women cease to menstruate at forty ; others go on till fifty or even later. In some the transition is, if not abrupt, at any rate well marked ; in others the transition is protracted, inter- rupted by occasional suspensions, or the missing of a period or two. The flow appears irregularly, both as to periodicity and quantity. This uncertainty has earned for the climacteric age the expressive term of "the dodging time of life." Often it is called "the change;" and a great deal is implied in these expressions. The transition-period, from active ovario-uterine life to the stage of sexual decrepitude or degeneration, is seldom effected without some disturbance; and in many cases the local and constitutional disorders that attend it are numerous and severe. Physicians do, indeed, talk of the climacteric in man ; but the analogy is more fanciful than real. In the male sex there is no epochal limita- tion of sexual life. There is nothing to compare Math the almost sudden decay of the organs of reproduction which marks the middle age of woman. Whilst these organs are in vigor, the whole economy of woman is subject to them. Ovulation and menstruation, gestation and lacta- tion by turns absorb and govern almost all the energies of her system. The loss of these functions entails a complete revolution. And before the new regime ib established, an interregnum of trouble has commonly to be passed through. For thirty-five years or more, the pelvic organs have been the seat of active periodical congestions, and determinations of nerve-force. When ovulation ceases, this nerve-force and local activity of the circu- lation are suddenly called upon to find other outlets. The transition frequently entails symptoms that partake of a pathological character. These symptoms are chiefly referred to the circulation, to digestion, and to the nervous system. Menstruation, instead of ceasing gradually, not seldom assumes the form of hemorrhages, more or less periodical. These are sometimes the result of abortions. The last effort of menstrual life is to propagate. The ovaries retain their function of maturing ova perhaps a little longer than the uterus retains its capacity for gestation. As in the outset of menstruation so in the cessation, the uterus may be found unfit : in the first case it is immature; in the second there is commencing atrophy. Generally, however, atrophy of the uterus follows that of the ovaries. PSEUDOCYESIS. 235 When hemorrhages do not occur, or are not substituted by vicarious discharges, as hsemorrhoids, epistaxis, or leucorrhoea, severe headaches, and cerebral congestions are liable to take place. Vertigo, epilepsy, apoplexy are more likely to happen. The headache is peculiar ; it is chiefly occipital, involving the nucha and spinal cord ; and invokes distressing mental phenomena. Minor, moral, emotional, and intellec- tual aberrations arise. A desponding, gloomy state, verging upon hypochondriasis, is not uncommon. These are often controlled by a well-regulated will ; but sometimes they break out. Fretfulness, irri- tability, forgetfulness, indecision, are the earlier signs. There is nothing so frequently complained of as the want of power of attention, and consequently of loss of memory. The nervous disorders which so often attend dysmenorrhoea and amenorrhoea, are reproduced at the climacteric age with exaggerated force. The subject of them is gener- ally perfectly aware of her condition ; she feels acutely the distress her waywardness occasions to others ; and when she is unable to control it, she will seek to hide it in seclusion until it has passed away. This is often the explanation of conduct which, to the unobservant, appears motiveless or wilful. This power of comparison, of judgment is, as Conolly insists, that Avhich distinguishes this condition from insanity. It is a shallow saying that women can give no reason for what they do. They justly claim the privilege of weakness by declining to give one. They rather incur the reproach of being illogical or unreasonable, than wound their sense of delicacy. Woman's decision, then, is to be re- spected, not questioned. Disorder of the Alimentary Function is one of the most common attendants upon the menopause. The habit of constipation has, per- haps, already been acquired. It becomes aggravated. It would seem that there is a metastasis of nerve-force to the intestines. They become the seat of severe spasms. This is due in some cases to loss of tension of the abdominal walls, the result of pregnancy ; to loss of tonicity from defective nutrition attendant upon invalidism and want of exercise; to obstruction to the action of the bowels from pressure on the rectum, as from retroversion or prolapsus of the uterus. From these and other causes, especially from the tendency to adiposity, the intestinal canal, wanting its normal contractile property, becomes liable to distension from flatulence and the accumulation of fecal matters. Hence irrita- tion, exciting spasm, and other irregular actions of the intestinal mus- cular walls. The distress arising from this source is often very great ; and in many cases where the nervous centres are involved in the climacteric confusion, the sensations arising in the belly are misinter- preted, and are the immediate occasion of mental phenomena verging upon, and not seldom passing into insane delusions. One of the most remarkable yet familiar illustrations of this condition, is the conviction entertained by the sufferer that her abdominal symptoms are due to pregnancy. In some cases there is enough evidence, 'prima facie, to impose upon others, even upon the medical attendant. This state is known as "Fake or Spicrious Pregnancy" a term which has been Hellenized by Mason Good into " Pseudocyesis." It is sufficiently marked to merit special attention. Although arising chiefly at the 236 CLIMACTERIC. climacteric period, there is hardly any limit to the age at which these symptoms and the subjective belief in pregnancy may occur. Thus, I have seen several examples of women long past sixty, whom it was difficult or impossible to convince that they were not pregnant. Some of these were married, some were single. In the latter case there had been a clandestine intercourse. The mental perturbation consequent upon the sense of error, and the dread of exposure, rendered more vivid the perception of the local phenomena, and completely overthrew the mental faculty by which they were judged. We easily believe what we wish or fear to be true. So strong is the delusion in some cases, that no amount of reasoning or authoritative decision will dispel it. I have dealt with them in this way. I have got the patient to fix the date of presumed conception ; the ordinary term at which gestation would be completed is thus determined ; and I have told her to come again for examination at a period of one or two mouths after the expi- ration of that term. Then, the appointed time having gone by without fruit, the dreaded phantom has sometimes been exorcised. Even then, perhaps, not without reluctance ; for in spite of shame, of self-reproach, of the fear of ridicule and loss of position, the dear delusion has been hugged as a proof of sexual capacity. Thus, still in some cases the delusion is cherished in spite of time, and of every argument. In these cases the narrow boundary-line between san- ity and insanity has been passed. Analysis of the mental condition will commonly reveal other evidence of aberration from the healthy standard. Dr. Crichton Browne relates^ a remarkable case in illustration of the influence which the mind can exert over the uterus and ovaries. A woman long past the climacteric, whose last child was fifteen years old, was admitted into the West Riding Asylum, declaring she was two months pregnant. To this assertion she held firm ; and at the end of seven months informed the attendants that she was in labor. She persisted resolutely during four days in going through the performance. At last when exhausted, as one who had gone through a protracted labor, the catamenia, which had been suspended for years, appeared. In many other cases where insanity could not be said to exist, the delusion has been carried to the extent of imitating or pretending labor. An analogous form of pseudocyesis occurs in young women who have secretly incurred the risk of pregnancy. Sexual and emotional excitement, and fear of consequences, have been attended by suppres- sion of menstruation, enlargement of the abdomen, disorder of digestion involving nausea and flatulence, swelling and pain in the breasts. Imagination strengthened by fear does the rest. And occasionally the conviction of pregnancy persists, although the menstrual function is regularly performed. Again, a woman marries within the age when pregnancy is to be expected. A similar train of symptoms quickly follows. The strong- est evidence on the other side is unwillingly received. The regular return of the catamenia, the stationary size of the abdomen, the absence of many subjective signs of pregnancy, the assurance of tlie physician 1 Brit. Med. Journal, 1871. PSEUDOCYESIS. 237 that the decisive objective signs also are wanting, are all held of little account. Here imagination is strengthened by hope. The doubting physician is himself doubted ; and he must often be content to appeal to time, the great solver of mysteries. The phenomena of pseudocyesis, however, most commonly occur at the climacteric epoch. And they are often very puzzling. Many things concur to put on the semblance of pregnancy. First, there is the probability of pregnancy. The social condition, the history, an existing family, a hitherto normal ovario-uterine life, the age not yet beyond the liability, all concur to strengthen the patient's belief. The irregularity or suspension of menstruation, the contemporane- ous enlargement of the abdomen and breasts, all collected, make up an imposing aggregate of symptoms, easily accepted as decisive proof of that which is hoped or dreaded. To this array of symptoms, slight nausea and various nervous phenomena are frequently added. There is much that is real to lend color to the belief in pregnancy. Imagi- nation does the rest ; it supplies the missing links in the chain of evi- dence, and binds all signs, real and imaginary, together into one whole, which is confidently affirmed to be beyond the possibility of dispute. So vivid indeed is the emotional and mental force, that it creates the symptoms which are wanting. The woman who has been pregnant before, calls upon her memory ; and so keen is the edge set upon per- ception by fancy, that feelings counterfeiting those she really experi- enced in earlier years arise as it were at her bidding. And by a similar process the woman who has never been pregnant, conjures up into seeming existence the signs which are suggested to her eager mind by hearsay or reading. It will often appear cruel to break down the fond delusion, by ex- plaining these ambiguous phenomena by another theory. But it must be done. About the age of fifty there is, as Gooch said, a torpid state of the uterus, with a flatulent state of the intestines. The omentum and parietes of the abdomen often grow very fat, forming what Baillie called " a double chin in the belly." Wind and fat combine to form the tumor which simulates the gravid uterus. Air moving about in the bowels gives the sensation which is taken for the move- ments of the child. The enlargement of the breasts is also due to fat. The diagnosis ceases to be puzzling when we carry out the proper physical exploration, that is, when we substitute scientific objective inquiry for the patient's description of her subjective sensations. Obesity is rarely limited to the abdomen and breasts ; it is seen in the limbs and face also. And it is an aphorism generally true, that when a woman is getting fat she is not pregnant. Although the breasts are large, they want the characteristic changes of pregnancy. The abdominal enlargement is felt to be doughy, yielding before firm pressure, nowhere giving the sensation of a defined firm globular tumor, and consequently not giving the peculiar feeling of a wavy or living impulse under the hand, which marks the peristaltic movement of the uterine wall, or the movements of the foetus. Percuss, and where the pregnant uterus ought to be, you hear nothing but empty resonance. Auscultate, and you hear the rolling of confined air, bor- 238 CLIMACTERIC. borygmi, instead of the foetal heart. Give chloroform, as Simpson recommended, and the "phantom-tumor" disappears; the relaxed ab- dominal walls allow the hands to sink freely down upon the spine and into the pelvis. There is nothing solid. All that is not fat has vanished into thin air. Examine by the vagina, the finger touches a hard os uteri, probably low down, and near the centre of the pelvis ; not, as in pregnancy, soft, and directed backwards. There is no large solid mass in front of the cervix, but a small uterus, freely movable, which, under chloroform, and sometimes without, may be defined be- tween the finger in the vagina, and the hand pressed in above the symphysis. Treatment. — Although we may have proved the patient to be in error as to the existence of pregnancy, we must not hastily conclude that she requires no care. Her distress is often real. The nervous symptoms forming an element in the general climacteric disorder will be discussed in connection with this subject. I will only stop here to say that in many cases, a well-adapted abdominal belt will give great relief, by supporting the distended bowels, and the omentum and ab- domen weighted with fat. So much, however, depends upon tlie belt being well made that I think it not out of place to observe that, to design and construct abdominal belts and other mechanical supports, requires a special skill, which every instrument-maker cannot be ex- pected to possess. After the menopause, uterine diseases, especially of an inflammatory kind, are more rare, and are less active. The general character is rather that of passive congestion and catarrh. The menstrual flow must also be regarded in the light of a safety- valve, whose function is to restore the equilibrium of the circulation. The uterine evacuation takes ofP the turgescence of the utero-ovarian system of vessels. If this be not done there will probably be deter- minations of blood, local hsemostases, where there is no provision for throwing off the excess with safety. It is only mucous membranes having a convenient communication M'ith the external surface, which can discharge blood with safety ; and the uterine mucous membrane is pre-eminently fitted for this purpose. By this evacuation vascular tension is relieved, and a great source of nervous irritation is removed. In conjunction or not with the phenomena of pseuclocyesis, other disorders of the chylopoietic organs are frequent. That the menstrual flow is an excretion performing to some extent a cleansing or depurat- ing oflfi.ce, can hardly be doubted. The manifest relief obtained from distressing symptoms on the appearance of the flow, so often felt, is evidence of this. When this excretion is suppressed, it is natural to infer that the system will feel the want of an accustomed depuratory channel. The liver, the kidneys, the skin will have more to do ; and the consequent defective excretion is aggravated by want of exercise. The difficult or imperfect action of the liver and kidneys is pretty sure to entail local stases in the circulation, and consequent disposition to loading of the heart and great vessels. Hence there is a disposition to metrorrhagij^. This is sometimes so profuse as to induce a marked NERVOUS PHENOMENA. 239 degree of ansemia. The hemorrhage may be alternated with serious offensive discharge, and the suspicion of cancer not unnaturally arises. The sallow skin and offensive discharge may be simply due to degra- dation of the blood and decomposition of matters retained in the vagina. In a considerable number of cases a copious flooding seems to be, if not salutary, at any rate not injurious. I have seen cases of aged women, that is, sixty and even seventy years old, in which sudden profuse vaginal hemorrhage occurred without a trace of disease, recov- ery following. These cases seem strictly analogous to those of senile epistaxis, which call for plugging of the nostrils. But in too many cases, disease of a serious character is the cause. Amongst these, unhappily, cancer is the most common. Fibroid tumors and polypi may be found. Hemorrhages at this period of life are, however, always the subject of just anxiety. It is eminently desirable to analyze carefully the various conditions associated with these symptoms. In many cases there is no discoverable morbid condition of the uterus. The cause lies in remote organs, or in the state of the organs of circulation, or of the blood ; as in the cases just referred to. An outburst of hemor- rhage, under these circumstances, is sometimes beneficial. If modern medicine had not too absolutely condemned venesection we should take a hint from this clinical fact, and imitate the practice of nature. True eclamptic convulsions followed by a stage of semi-coma and delirium, sometimes occur. There may be only one attack ; but gen- erally there is a tendency to recurrence at more or less regular inter- vals. The immediate exciting cause is in some cases the habit of peri- odicity, stimulated or not by remains of ovarian activity. There seems to be a gradual accumulation of blood and nerve-force, which, when a certain tension is reached, breaks out in the way described. If it should happen that a discharge of blood takes place, the nervous phenomena are generally mitigated. These attacks are commonly followed by periods more or less pro- longed, during which the cerebral functions are impaired. Perception rarely suffers so much as other facalties. Attention is commonly im- paired. The patient finds it difficult to follow a conversation, or to keep up a continuous train of thought. Aphasia is a frequent phe- nomenon. Articulation may be impaired ; but the main difficulty con- sists in finding the word that is wanted. The patient is quite conscious that she is using the wrong word, and tries by signs, or relies upon the knowledge or intuition of those whom she is addressing, to correct and fill up what she wants to express. The mind is essentially right; but the organ of expression is at fault. The patient is at first stunned by the shock of the attack. Recovery is gradual, sometimes slow. Headache is a common symptom ; pains in different parts of the body are felt : there is often a marked disposi- tion to sleep. The want of rest is attested in many ways. She is easily exhausted by exertion, bodily or mental. In some cases the phenomena may be described as epileptoid only. There is not complete loss of consciousness, but a degree of vertigo. 240 CLIMACTERIC. The face becomes pale, cool ; and irregular movements of the limbs are enacted. In another class the symptoms are syncopal in character. For some time there is almost complete loss of consciousness. At least in many- cases there is no subsequent recollection of what occurred during the attack; — nothing but a confused notion of the circumstances attend- ing the beginning and the recovery from it. The patient may fall down, suffer injury, and yet be unaware of what has happened. Associated with this kind of attack, and no doubt to a great extent accounting for it, there is often a weak condition of the heart. The organ is badly nourished, loaded with fat deposit, if not also degenera- ted in fibre ; it is dilated, and incapable of acting efficiently under the call of sudden excitement or exertion. All these nervous abnormalities, and the disposition to hemorrhage, are unfortunately liable to be seriously aggravated by the frequent re- sort to alcoholic stimulants. Under the immediate depression induced by nervous exhaustion or flooding, relief is sought from wine or brandy ; necessarily so perhaps in many cases. But the habit of flying to this ready and tempting aid is easily acquired ; and then, the ills of alco- holism being added to those already existing, a vicious circle of morbid reactions is set going, and gathers strength with every revolution. I have already observed that apoplexy and eclampsia are more likely to happen at the climacteric period. But the cases are more frequent in which these diseases are simulated. Many women complain of a partial hemiplegia, chiefly of sensation. This is not preceded by coma or convulsion ; the mind is unaffected ; the patient can walk nearly as well as usual, and without any perceptible dragging of one leg. She describes various subjective symptoms, as numbness, coldness, tingling in the arm and leg. No difference in temperature of the two sides can be detected. With or without these apparent paralytic phenomena, there are fre- quent alternations of flushes in the face, and chills. These are apt to come on on the slightest fatigue or emotion, and constitute one of the most frequent conditions which harass women of a certain age. The flushes are often visible to others ; the face becomes red, or even empurpled, and there is a feeling of giddiness or vertigo. These are no doubt the result of that extreme tendency to sudden aberrations of nerve-force and of blood-supply, so characteristic of " the change." It seems as if the equable distribution of health were replaced by irregular supplies sent in excess to particular organs, or vascular and nervous systems. The treatment of disorders of the menopause. The principle of dealing with these, flows from the observation of their natural history. Our care must be directed to counteract the sluggishness of the liver, and the imperfect action of the other digestive organs ; to regulate the circulation of the secretions ; and to guide aright as far as possible the nervous functions. In the disorders attended by plethora, florid complexion, tendency to embonpoint, and convulsions, abstraction of eight or ten ounces of blood from the arm will often be of signal service. If this be consid- ered too great an outrage upon the exsanguineous therapeutics of the TREATMENT. 241 present day, we may compromise the «iatter by applying four or six leeches to each temple or behind the ears. I have frequently seen the greatest benefit from cupping, taking by this means eight or ten ouncas of blood from the nucha or between the shoulders. The loss of a small quantity of blood will often act in the most remarkable manner. That I have seen lives saved by this practice, that conditions threatening cerebral congestion or apoplexy have been averted by it, I have no manner of doubt. I have seen women con- ducted over the greatest perils of the critical age by occasional leeching and cupping, combined with judicious medicinal and hygienic manage- ment. These abstractions of blood, small as they are, produce good results out of proportion to their quantity. They act as derivatives as well as evacuants. By taking off the tension of the vascular system, and diverting the current of the blood to the surface, they equalize the circulation, and free the central organs, which are gorged with blood approaching to stagnation. They act, in short, as the most direct and eifective substitute for the wanting menstrual bleeding. The regulation of the secretions is best effected by occasional resort to alterative remedies, as blue pill with colocynth or aloes and bella- donna ; podophyllin ; salines, of which the best is acetate of ammonia ; a little colchicum is often of signal service. The habitual use of Pullna or Friedrichshall waters is often of great service. Patients have ex- pressed themselves as highly pleased with the use of the galvanic belts in exciting the action of the bowels, and in enabling them to dispense with purgative medicines. The skin should be kept in working order by exercise and baths, and often the addition of Vichy salts to the baths will be useful. The nervous centres are calmed and regulated by occa- sional sedatives, as the acetate of ammonia with Battley's solution, or chloral. But the most valuable remedy is the bromide of potassium. This may be given in ten-grain doses or larger, two or three times a day for a considerable time, with occasional intermission, taking care to resume it whenever the nervous symptoms threaten to return. To equalize the action of the heart and counteract local stases, salines are again of value, and their good effect is often enhanced by digitalis. Where there is deficient tone, as is often the case, quinine and strych- nine with mineral acids are indicated. Amongst other useful proper- ties, these agents possess that of improving muscular tone, and thus of counteracting the sluggish condition of the intestinal canal. The establishment of an issue in the back of the neck, or on the arm, operates as a valuable derivative. I have known women kept free from nervous seizures so long as an issue was open, and be again subject to them when the issue was healed. Attention to the diet is of the utmost importance. Many things which have come to be looked upon as necessaries, but which are really luxuries, must be given up, or taken with the strictest moderation. The food should consist of fish, meat, poultry, game, carefully but plainly cooked, bread, vegetables, and fruit. The allowance of meat should be restricted to one meal a day. Spirits generally should be avoided, port should be shunned absolutely, and sherry taken rarely ; sparkling wines mixed with soda or seltzer, claret, carlowitz, or hocks, 16 242 MENSTRUATION. may be alloAved to the extent of two or three glasses daily. Beer, as a rule, is unsuitable for climacteric women. I/ithiasis is especially apt to arise at this period, and may give rise to those attacks of excruciating agony characteristic of the irritation of graved in the urinary track. These attacks must be distinguished from the pain which attends some forms of uterine disease. GalMones also are apt to be troublesome under the same conditions. The loaded portal system, the sluggish liver perhaps undergoing some organic change, easily engender disorder. The gorged state of the portal system, and the pressure upon the kid- neys, are shown in the turbid urine, loaded with lithates and phosphates, and occasionally containing albumen and biliary matter. Vomiting not uncommonly attends this condition. Alkaline salines steadily ad- ministered oiFer the best means of relief. Sometimes the troubles of the menopause subside gradually and en- tirely. But they rarely disappear altogether in less time than two or three years. The woman then seems to take a new lease of life. She resumes her physical and mental power. Sometimes, however, these troubles persist and merge into those w^hich mark the period of decrepi- tude. CHAPTER XXIV. THE EELATIONS OF MEISTRTEUATION TO VARIOUS DISEASES— THE INFLUENCES OF OVULATION AND MENSTRUATION IN EVOK- ING MORBID INFLUENCES. In discussing this subject it would be convenient to consider, first, the influence of disease in other organs or in the system generally, upon the function of menstruation; and secondly, the influence of ovu- lation and menstruation in producing diseased action in other organs, or in the system at large. In a considerable number of cases this could be done. But there are other cases in which the action and reac- tion are so close, that it is scarcely possible to get at the first factor. So we are compelled by clinical necessity to study some cases from both sides, that is, to observe the reciprocal influences of ovulation, and men- struation, and diseased actions. In some diseases, menstruation is diminished or altogether arrested. This is especially the case in chronic wasting diseases which induce degradation of the blood. Phthisis is a marked example of this kind. Ovulation, indeed, is not arrested, but the ordinary menstrual dis- RELATIONS OP MENSTRUATION. 243 charge gradually diminishes, and generally ceases altogether. This is partly due to the waste of red corpuscles ; partly to the diminished force of the circulation; partly to the morbid process causing deriva- tion of blood away from the uterus ; and partly from impaired nutri- tion of the ovaries. Louis observed that cessation of the menses was seldom delayed beyond the onset of the tubercular hectic. Acute lung inflammations do not entail much interference, menstruation usually appearing notwithstanding. In the great majority of affections of the spinal cord, menstruation is not suspended. When menstruation makes its appearance in the course of a disease, especially in fevers, it has been looked upon as critical, and as exer- cising a favorable influence. There is little evidence of the truth of this theory. Perhaps the case is, that when the disease is going on favorably, there is more probability of menstruation being restored. At the same time a useful indication may sometimes be drawn from the manifest relief which follows the appearance of the menstrual flow in many morbid conditions, to solicit or promote the floM^ or to establish an equivalent for it, by a topical or general bleeding. In exanthematous fevers, as small-pox, scarlatina, measles, or typhoid, sanguineous discharge occasionally takes place from the vagina. Sometimes this is undoubtedly menstrual. But in most instances it is to be regarded in the same light as the epistaxis which occurs under similar circumstances. These fevers, especially small-pox and typhoid, induce a state of blood favorable to extravasation from the mucous surface and skin. The utero-vaginal tract is of course likely to be the seat of this effusion ; and if menstruation be impending, the flow will probably be profuse. In studying the etiology of pelvic hsematocele we shall see that under these circumstances, blood may flow back from the Fallopian tubes, and escape into the peritoneum. We have another example of hemorrhage from the genital tract in " malignant jaundice," or "acute yellow atrophy of the liver." Here, also, there is no special tendency to metrorrhagia. The genital hemor- rhage is simply the result of a general alteration in the blood which disposes it to exude from all the mucous membranes. As this subject has not attracted the attention it deserves, I am happy to have the opportunity of embodying the results of extensive observation and inquiry, kindly made, at my request, by my colleague, Dr. Clapton. Phthisis, he says, in nearly every case stops menstrua- tion; in the majority, abruptly, but sometimes after gradual diminu- tion. Not uncommonly phthisis appears to be developed in conse- quence of emansio mensium, but in almost all these instances there is evidence of scrofulous diathesis. In Scrofula, there is great irregularity as to time, quantity, and character. As a rule there is delay, deficiency, or suppression. In Bronchocele menstruation is generally scanty and pale. In Neuralgia it, as a rule, diminishes. Neuralgia is often asso- ciated, either as cause or effect, with dysmenorrhoea. Malarious affec- tions diminish the secretion ; the color is pale. Chorea is not common after puberty, except in pregnant young women; but when it does occur it is generally associated Avith either dysmenorrhoea or emansio mensium. The influence of Epilepsy is uncertain; menstruation is 244 M E X S T R U A T I O X. generally regular, but if not, there is a tendency to excessive or too frequent flow. Hysteria is sometimes cause, sometimes effect of amenorrhoea; it is usually associated with dysmenorrhoea ; more rarely with menorrhagia. Inflammatory and congestive diseases of the brain and spinal cord tend to increase the menstrual flow, the degenerative tend to diminish it; 'paraplegia, if from hypersemia, increases, if from anaemia decreases the flow. 3Iania generally increases the discharge ; melancholy diminishes it; dementia usually occurs after cessation of catamenia; in idiocy, in the majority of cases, menstruation is regu- larly performed, in others there is emansio mensium. Surgical inju- ries, attended by shoch or concussion, generally check menstruation if occurring during the flow, but tend to induce it, if occurring during the intervals. Pycemia at once suppresses the discharge. In secondary syphilitic affections there is no alteration. (This I would qualify by observing that where the uterine mucous membrane is aflected, as it often is, there is a tendency to menorrhagia.) Purpura disposes to uterine hemorrhage. Typhus and enteric fevers and exanthemata retard, and sometimes suppress for a long time after the attack. In some of the worst cases there is uterine hemorrhage at the time. Rheumatism and gout have little apparent effect, except that in rheumatic fever men- struation is generally delayed. After one attack of acute rheumatism, menstruation is usually suppressed for a month or two. Congestive liver diseases often for a time increase, whilst the atrophic diseases di- minish or suppress it. Chronic diarrhoea or dysentery tend to diminish or suppress. Of kidney diseases, the inflammatory or congestive gene- rally increase menstruation, whilst the fatty and amyloid diminish or stop it. Diabetes diminishes, and after a time stops the secretion, but in some cases there is no change. Heart diseases: distension of the right cavities, and affections of the mitral valves tend to increase, whilst aortic diseases generally diminish or stop menstrual flow. In ephysema and asthma as a rule there is no change ; if any, there is dysmenorrhoea. In chronic bronchitis and pneumonia there is no change. The above conclusions agree very closely with my own observations. Some of them will be discussed or illustrated hereafter. Acne is one of the forms of skin affection induced or influenced by disorder of menstruation. At least an eruption of this form has been noticed at every month when menstruation has been suppressed, and has ceased when the function was restored. The internal administra- tion of arsenic is often useful in these cases. The acne pustules may be touched with butter of antimony by a camel-hair pencil, taking care to neutralize the caustic immediately with a little solution of bicarbon- ate of soda. The influence of ordinary menstruation upon the breasts has been already alluded to. Of the influence of obstructed menstruation upon morbid conditions of the breasts I have seen several remarkable illus- trations. Some years ago a single lady came to me from the country, suffering so much from dysmenorrhoea that her health was breaking down. She had, besides, a suspicious hard tumor m the left breast, for which she consulted the late Mr. C. H. Moore, surgeon to the RELATIONS OF MENSTRUATION. 245 Middlesex Hospital. The dysmenorrhoea I concluded was due to ex- treme narrowing' of the os uteri. I dilated this by incision, and almost complete relief from dysmenorrhoea ensued ; and whereas the tumor in the breast had previously been progressing unfavorably under monthly exacerbations of pain and s^A^elling, it now became quiescent, and scarcely gave any distress. Several years have now elapsed, and the tumor is still dormant. Mr. Moore was himself so struck witli the beneficial effect attending the relief of the utero-ovarian distress, that he read a paper on the case before a meeting of the British Medical Association. It is one amongst many proofs constantly observed in practice, of the wisdom, when cases of complicated diseases come before us, of elimin- ating any one of the complications that may be within our power, in the assurance that, generally, the remaining diseases wall be mitigated, and the load borne by the patient be so much lightened. Menstruation seems to induce a state of hypersesthesia or nervous erethism, under which, evils that in the intervals lie dormant or quies- cent are brought into prominence. Thus I have a lady under my care for endometritis folloAving abortions induced, I have no doubt, by a syphilitic diathesis, and who has also a stiif knee with chronic synovitis, for which she saw my colleague, Mr. Le Gros Clark. At every period pain came on in the knee, and her lameness was worse ; and at the same time an old syphilitic eruption on the chest would reappear. In numer- ous instances I have known intense facial neuralgia occur at every period. The influences of chronic nervous disorder upon ovulation and men- struation is not often very clearly marked. But sudden strong emo- tions, acting as it were by shock, often exercise an unmistakable influ- ence. In some cases, profuse flooding is produced ; in others the secretion is checked, and even protracted amenorrhoea is induced. Negrier says, " Softening of the brain does not always suspend men- struation." The ovaries receive their innervation from the ganglionic system. For the like reason chronic affections of the brain do not usu- ally interrupt ovarian functions. On the other hand, ovarian function exerts great influence upon diseases of the brain, especially when the ovaries are unusually developed. Thus, ovulation sensibly aggravates intellectual disorders, and frequently stamps them with an hysterical character. Treatment tending to moderate ovarian action would be useful. In tracing the history of *^ the menstrual irregularities of the climac- teric period" in the preceding chapter, we have seen illustrations of the relations of menstruation to various nervous phenomena. I may men- tion in this place, that very similar nervous disorders are often mani- fested in connection with disordered menstruation at the onset of sexual life. Thus, vertigo, syncope, epilepsy, neuralgia, mental aberrations varying in degree, are not uncommon. A young lady came several times under my observation in consultation, at the age of sixteen and afterwards. She never had fits in infancy or childhood. At fourteen menstruation began ; it soon became arrested or irregular, and epileptic fits appeared. The epochs were indicated by pelvic uneasiness ; the fits generally occurred a week after the menstrual effort. Her aspect was 246 MENSTEUATION. heavy, but she was not wanting in intelligence. There was a scrofulous diathesis. By the application of leeches to the inside of the thighs at the epochs, and the use of bromide of potassium, she greatly improved, and when menstruation was properly restored, she had no more fits. Marotte,^ in a special memoir, adduces interesting illustrations of the relations of epilejisy with menstruation. Leuret relates a case of mania recurring at every period, and subsiding with the ap^iearance of menstruation. The following case from N§grier deserves special attention. Epilepsy under Ovarian Irritation and Flow to Head. X , aged twenty-one, of general good health, never menstru- ated, felt for first time, ten months ago, violent lumbar colics. After several of these attacks, she suddenly fell down seized with convul- sions, and loss of sight ; sensibility and intelligence remained ; could not articulate. She afterwards related that, at the beginning of the attack, the blood flew to her throat, and she felt a sudden choking. During the convulsive state the face was at times red, at times pale and greenish. From this time, on the 11th or 12th of each month, this girl was seized with tremblings and flushes in the face, soon fol- lowed by convulsive attacks like that described. The " lumbar colics" always preceded the attacks. She never had vaginal hemorrhage. She was virginal ; only a rudimentary uterus the size of a walnut could be felt. This case, like the one observed at St. George's Hos- pital (see page 156), affords another proof that ovarian development may exist with defective development of the uterus. My observations of epistaxis with menstruation show that blood does fly to the head. The relations of the sexual functions to the various forms of insanity, form a subject of the highest clinical interest. The occasional outbreak of insanity after childbirth unequivocally demonstrates the influence of childbirth upon the nervous system. Phenomena scarcely less strik- ing are not seldom seen in connection with disorders in the menstrual function. There is evidence to show that disease of the ovaries is occasionally the exciting cause of mental disease. With the view of obtaining some precise information upon this subject, I have asked for the experience of my former colleague. Dr. Down, formerly resident physician at the Asylum for Idiots, and my old pupil. Dr. Davis, superintendent of the Burntwood Asylum. Dr. Down says that idiocy tends to diminish the quantity of the flow. Menorrhagia does some- times occur, but it is veiy rare. Great irregularity as to periodicity is also noticed. In the great majority of cases the commencement of menstrual life is attended by no marked results. Occasionally, how- ever, acute mania, or acute melancholia, becomes engrafted on the idiocy, and disappears on the completion of the change. Dr. R. A. Davis says : " In all the cases, whether puerperal mania, ordinary mania, or melancholia, during menstruation, the symptoms are mostly aggravated. In the cases of melancholia and of those 1 Kapports de I'Epilepsie avec la Menstruation. (Revue Med. Chir., 1851.) RELATIONS OF MENSTRUATION. 247 having a suicidal disposition, extra watching is required lest they should commit suicide during the menstrual periods. I find in nearly- all cases on first admission, that the menstruation is either very irregu- lar, or suppressed for some time beforehand." Negrier relates the following amongst other interesting cases : X , aged seventeen, menstruated at fourteen, was seized with hysteriform symptoms coinciding with menstrual derangement. After several closely succeeding convulsive attacks, this girl, well brought up, and very intelligent, became insane, exhibiting erotic delirium, obscene talk and acts. Secluded in an asylum, under most cruel treatment, she recovered after a year, married at nineteen, and had six children, all of which she suckled. She gave no further sign of mental disorder. " Pregnancy exerts a happy and powerful derivation in insanity, especially if this state of the encephalon has for cause a nervous dis- order of hysterical form." The condition being that the ovaries are kept in abeyance during the temporary rule of the uterus. This is strikingly shown in the following case of N^grier : X was hysterical from nubility, was seized with insanity almost imme- diately after marriage ; always recovered her intellect during her nu- merous gestations, and during the first months of suckling. She re- lapsed into her mental alienation as soon as the ovarian function mani- fested itself. Dr. Crichton Browne, medical director of the West Riding Asylum, bears decided testimony to the inter-reactions of the ovario-uterine and nervous systems : "A condition of mental agitation may, he says, de- range the menstrual discharge, and ideas may modify the nutrition of the sexual apparatus." He gives a remarkable illustration of this, which has been cited at length under " Pseudocyesis." Under the in- fluence of imaginary labor, a discharge simulating the menstrual was brought on in a woman long past the menopause. It is, Dr. Browne observes, in the close and subtle relation between the bcain and the pelvic viscera, which is so curiously exemplified in the case just de- scribed, that the source of hysterical mania must be sought. The one constant element in all cases of this disorder, is a disturbance of the balance of action and reaction which subsists between the nervous centres and the reproductive organs. In every instance of it, the brain and the uterus have their functions constantly deranged ; for whatever may be true of simple hysteria as encountered in general practice, it would not hold good of hysterical mania as seen in asylums, that it may accomplish its whole course without the involvement of the generative system. The morbid process may originate in the brain or in the uterus ; but in either case it spreads from the one to the other, and upsets that harmony and proportion of function in which health con- sists. "As the result," Dr. Browne further says, "of large experience of hysterical mania, I am satisfied that it is, without exception, pre- ceded or accompanied by some derangement of the reproductive system, the existence of which is most frequently indicated by alteration or obstruction of the monthly discharge. Even where, however, neither amenorrhoea, leucorrhcea, nor menorrhagia can be discovered, other 248 MENSTRUATlOJSr. signs of disorder in the functions of the reproductive organs can be found, if carefully looked for." I venture to affirm that in the great majority of cases of so-called "simple hysteria" met with in ordinary practice, the intimate associa- tion between the reproductive organs and the nervous disorder, which Dr. Browne so constantly found in the case of hysterical mania, will be discovered if looked for with intelligence. The rapid, almost sudden bursting into womanhood, attests the influ- ence of the complete evolution of the sexual organs. The nervous system especially, is profoundly affected ; sentiments, disposition, pursuits are changed. Menstruation, a function compounded of ovulation, an effort at reproduction, and of a periodical discharge of blood, exercises a two- fold influence upon the general system. The relations of the discharge have chiefly attracted attention, whilst those of the higher antecedent function of ovulation have been comparatively overlooked. Although the menstrual discharge may, by its variations in character, frequently give note of what is passing in the ovaries, we must be careful not to conclude that this is always so. It would, indeed, be convenient for the clinical observer, if he could depend upon the menstrual discharge as a constant index of the state of the ovary. In studying the rela- tions of menstruation, we are mostly compelled to take the function as a whole, including the discharge and the ovulation ; for v/e can rarely assign the effects we witness to the one factor, independently of the other. Whenever an organ is the seat of a secretion, it is endowed with a particular mode of vitality in relation with the function it has to fulfil. When this secretion is periodical, there are alternations of action and of repose, which preserve the equilibrium of action of the different organs. When the activity is spent upon one point, there is derivation at the expense of other parts, and every exaggeration of this activity is a dis- turbance of the general equilibrium ; in the same way as the sudden cessation of the functions recalls the activity to another organ, which becomes the seat of a movement of fluxion appropriate to its structure. It is thus a dynamic metastasis rather than a transmigration of fluids. This is so true th^t, when it does not appear in its ordinary, that is, critical form, it is upon the nervous system alone that this deviation of activity is concentrated, and some disorder of nervous function is manifested. So long as the function of menstruation is accomplished normally in all its conditions, there is nothing, quoad this function, to disturb the harmonious balance of the nervous system. But let the function be attended with pain, shock to the nervous centres is inevitable; and it is henceforth only a question of time, how long the brain and spinal cord will withstand the irritation of continuous or intermittent pain- ful impressions, before the healthy equilibrium is overturned, and before morbid deviations of nervous energy become manifested. The time of resistance will vary with the absolute and relative force of the two factors at work. If we look upon the nervous centres as the resist- ing or -conservative power, and the aberration of the menstrual function .as the assailing power, it is obvious that, wliere the nervous system is SENILE DISORDERS. 249 robust, pain will make less severe impressions and slower inroads ; and that, on the other hand, where the nervous centres are very susceptible, pain is felt more acutely, and will sooner break down the conserva- tive resistance. In practice we may see frequent illustrations of this proposition. Dysmenorrhoea, at first, leaves but an evanescent depres- sion ; after a time, the prostration and nervous irritability are continu- ous, only remittent in degree ; later still, attacks of hysteria, neuralgia, and other nervous disorders are developed, and the general health breaks down under the continual wear and tear and perverted dis- tribution of the nervous power. The subject of the connection of hysteria with ovarian influence has been discussed in Chapter XXI, on " Ovarian Dysmenorrhoea." CHAPTER XXV. THE DISOKDEKS OF SENILITY OR DECREPITUDE. Following upon the description of the disorders of the climacteric period, we may most conveniently notice some of those which more especially arise in advanced life. As the ovaries and uterus pass into atrophy, and shrink, the woman may be said to become asexual. The economy is no longer dominated by the sexual apparatus. Some women continue to lay up fat, and in these the gastric troubles increase. Others emaciate, the fat is absorbed ; and as the " padding " disappears, the pelvic organs, wanting their external support, tend to fall through. Hence the " senile prolapse," which is especially prevalent amongst women who are compelled to lead a laborious life. The atrophy of the uterus not seldom involves the obliteration of its cavity, or more frequently, atresia at certain points of the canal. This closure is especially liable to happen at the os internum, and at the os externum. This last condition is not at all uncommon. The vaginal- portion shrinks away ; the os contracts to a point, sometimes closing altogether. At the same time the vagina also undergoes a kind of atrophy ; the roof is contracted, and gives to the examining finger the sensation of a funnel-shaped cul-de-sac, in the centre of which the small dimple-like os uteri is felt. The mucous membrane is often pale; the tissues have lost elasticity. The uterine mucous membrane is now liable to what may be called 250 SENILE DISORDERS. senile catarrh. There is a chronic secretion of mucus which, when moderate in quantity, and not impeded in excretion, may entail little distress. But it not infrequently happens that through the atrophic atresia of the os externum, the mucus secreted in the uterine cavity is retained. In this case, colic and other consequences similar to those which characterize retention of menstrual secretion arise. The remedy is similar. It consists in dilating the closed os by incision or by lami- naria-tents ; and then astringents can be applied to the uterine mucous membrane. This chronic senile catarrh is very often a continuation of catarrh which began at an earlier period. The discharge is sometimes muco- purulent. In this case there is often some persistent hypertrophy of the vaginal-portion. The margin of the os uteri commonly shows a ring of intense red color. This, says Whitehead, is a sure sign of endometritis. There are various troublesome affections of the skin which appear at and after the climacteric period. Alibert observed many skin-eruptions only twice during life ; that is, before the appearance of menstruation, and after its cessation. The predisposing cause appears to reside in the unhealthy state of the blood and nervous system, which underlies so many of the climacteric troubles. Amongst other evidences of this we see a greater disposition to gout, rheumatism, and neuralgia. A transient form of erysipelas is not uncommon. Eczema of the vulva is almost peculiar to the critical age. It succeeds sometimes to intertrigo, the result of prolonged contact and chafing of skin-surfaces. Hence this is most frequent in adipose women, in whom great accumulations of fat cause overlapping dependent rolls of skin. Thus, "■ the double-chin in the belly" produces a large surface of contact at the lower abdomen, groins, and upper part of the thighs ; between the labia majora and the thighs a similar condition occurs; the large flabby hanging breasts cause similar chafing surfaces on the chest; another seat is the arm-pits ; another behind the ears. This affection is in many respects analogous to that which is seen in very fat infants not carefully treated. The immediate causes are : the screening of the skin from its wonted exposure to the air, and consequent tendency to assume the characters of mucous membrane ; the friction of the opposed surfaces leading to shedding of epithelium scales, retention of dirt, and increased heat. The principle of treatment is clear. Prevent the contact of the skin- surfaces ; observe perfect cleanliness and dryness. A good belt to lift up the lower abdominal fold is essential. During the stage of acute inflammation, marked by red raw surface and secretion, lotions of lime- water with olive oil, bismuth, oxide of zinc, lead, glycerin, applied on pieces of smooth lint, so as to preserve the opposing folds from contact, offer the most relief. Eczema of the vulva sometimes succeeds to intertrigo, these depend- ing on similar conditions. But the most troublesome form of it is in- dependent of this antecedent. It affects chiefly the folds between the labia majora and the thighs. In its acute stage it entails a burning itching sensation and thickening of the labia majora. The part is deep- red, often purple, and covered with minute dark spots caused by SENILE DISOEDERS. 251 scratching. There is commonly a serous oozing from the surface. The affection is exceedingly distressing ; obstinate under treatment owing to its situation, the heat of the part and the difficulty of maintaining cleanliness if the subject be very stout. It is not seldom aggravated, if not greatly induced by an acrid discharge from the vagina. This condition is often attended by a fulness of the pelvic vascular system, giving a dark-red or purple hue to the luucous membrane of the vagina. There is chronic hypersemia, a degree of stagnation in the vessels, owing, no doubt, to engorgement of the portal system, of the venous system generally, and an enfeebled heart. This local vascular hypersemia often aggravates the preceding and following affections. Pruritus of the Vulva. — This most distressing and obstinate complaint is sometimes due to disorders of nutrition. In many cases it is ac- companied by a gouty diathesis (Gueneau de Mussy) ; in others (Dr. Charles West) by diabetes. In such cases it is obvious that we must not rely upon local remedies alone ; we must treat the complicating diseases as well. Arsenic, in small doses, is often eminently useful. In the acute stage, emollient baths with poppy-heads, laurocerasus, belladonna, aco- nite may be tried. Now^ and then, pulverized water, charged wdth belladonna, will be found useful in allaying irritation. Weak solutions of bichloride of mercury, alkalies, especially lime-water with oil, glycerin w"ith calomel, tannin, or benzoin, borax, bismuth, or oxide of zinc will all in turn or in some cases be serviceable. In the chronic form, strong sulphur baths or some hyposulphite baths, as those of Aix, are useful. Dr. Thomas Chambers tells me he has seen great benefit from the application of a pasma formed of flowers of sulphur and w^ater. Pomade made with mercury and belladonna is sometimes of service. Dr. Gueneau de Mussy extols an ointment of bismuth, bromide of potassium, calomel, and extract of belladonna, made up with glycerinum amyli. The painful excrescence of the meatus urinarius is a disease chiefly observed during the ages of the climacteric and of decrepitude. It is during the period of the atrophic process, or often before it has fairly set in, that the uterus is so peculiarly exposed to the invasion of cancerous degeneration ; and it is chiefly at this period that malignant disease of the labia vulvae arises. In treating of the Diseases of the Ovaries, Uterus, and Vulva, these affections will be more fully described. Women, even to extreme old age, may be subjects of uterine hemor- rhages, which cannot be traced to any local disease. This has been already referred to in a preceding chapter. The fact is important to bear in mind, since hemorrhages at this period of life always give rise to the fear that malio-nant disease exists. 252 OVARIAN DISPLACEMENTS. CHAPTER XXYI. OVARY: ABSENCE OF ABNORMAL CONDITIONS OF, DISPLACEMENT; HERNIA. Both ovaries are hardly ever absent, unless when there is defect of the whole sexual apparatus. They commonly exist well developed when the uterus is absent. Deficiency of one ovary is rarely observed when the rest of the sexual organs are well developed. When an ovary is wanting, the Fallopian tube of the same side is also wanting, or is only represented by a solid cord running from the uterus. Occasionally, says Rokitansky, an ovary may be missing from having been twisted off by a process of atrophy, through dragging upon its attachments, and then sometimes a bit of the tube has gone with it. Atrophy of the ovaries, independently of the normal involution at the climacteric, is not seldom observed within the period of childbearing as the result of exhausting diseases. The existing follicles shrink away, new ones are not formed, and the stroma retracts ; on the surface all trace of recent scar is wanting. Displacements of the Ovary. The ovary is subject to various displacements. These arise : 1. From changes in its own condition, as of bulk, the result of in- flammation or other disease. 2. From pressure of other organs or structures upon it, as tumors. 3. From dragging of the uterus. ■ 4. From inflammatory adhesions binding it down in unnatural posi- tions. 5. From relaxation of the vagina and other structures, which support the uterus and ovaries in situ. 1. Displacements of the Ovary from its altered bulk. — The most fre- quent, or at least the most familiarly known, are the displacements which ensue upon enlargement of the ovary from cystic disease. I must refer to the chapters on Ovarian Dropsy for further description of the displacements from this cause. Slightly increased bulk and weight, acting concurrently with the re- laxation induced by morbid action, may cause the ovary to drop ; and if it drop, it must fall into the recto-uterine pouch, tending to get be- hind the uterus. This movement from the lateral position towards the median line is the necessary result of its attachments. The ovary is suspended at the side of the uterus on a plane posterior to this organ by a cord represented by the Fallopian tubes and ovarian ligament. As the ovary descends it describes an arc, of which this cord is the radius; and thus, unless the uterus desceuds pari passu, the ovary must come behind it. OVAHIAl^r DISPLACEMENTS. 253 This has been called prolapsus of the ovary by Rigby and others. It gets between the rectum and the uterus. It is, says Kigby, of great practical importance, producing intense suffering. There is a peculiar sickening pain about the sacral region extending to one or other groin, and coming on in paroxysms of agonizing severity. Sometimes there are intermissions ; at others only remissions. The source of the pain is connected with the rectum, the passage of faeces being difficult and painful. The patient describes it as a sense of obstruction up the rectum. Rigby likens it to orchitis. There is throbbing, sense of bursting, aggravated by menstruation and coagula; the stomach is irritable, vomiting being frequent. Great pain is felt on touching the os uteri, but this is owing to pressing the cervix back upon the ovary. If the finger is pressed behind the os, either by vagina or rectum, it touches the painful spot directly ; the oval movable ovary is then felt. It is almost necessarily enlarged by the strangulation caused by the dis- placement. The ovary may be fixed in this abnormal position by adhesions. The symptoms above described are mostly due to inflammation, which may be either primary or secondary upon the displacement. Whether there be inflammation or not, dyspareunia is an almost con- stant consequence. Simple prolapsus occurs in women of lax fibre, prone to constipa- tion, to passive menorrhagia and leucorrhoea. An essential point in the treatment is to rouse the liver, to clear the intestinal canal by salines and occasional alteratives. When the pain is great on touch, opiate suppositories or sedative pessaries should first be tried, unless we are satisfied there is inflammation. In this event leeches to the posterior fundus of the vagina will probably be useful. 2. Displacements from 'pressure of other structures. — Enlargement of the uterus from a tumor in its walls may displace the ovary in various ways. The ovaries naturally follow the uterus in many of the displacements of this organ, as when a retro-uterine hsematocele pushes it forwards against the symphysis pubis. But as their relative position to the uterus may be preserved, this change of position does not of itself involve any particular symptoms, although the displacing cause may exert such pressure upon the ovaries as to cause pain in them. 3. Displacement^^ of the Ovary from dragging of the Uterus. — If the uterus descend, the ovaries must follow, unless we imagine the Fal- lopian tubes and ovarian ligaments to stretch. In prolapsus of the uterus the ovaries will be drawn down, preserving their relative posi- tion behind the uterus. They are thus brought more within reach of the finger examining by the rectum. The uterus may be carried up into the abdomen, as in pregnancy. The ovaries then follow, dropping, however, a little to the sides of the uterus. The uterus may also rise out of the pelvis, owing to enlarge- ment from tumors in its cavity or walls. Retroversion and retroflexion of the uterus, by dragging on the Fal- lopian tubes and broad ligaments, must pull somewhat upon the ova- ries, and in some cases the displacement thus effected is considerable. 254 OVARIAN DISPLACEMENTS. The effect of displacement of the fundus uteri is well seen in cases of inversion. The descending fundus drags upon the tubes, tends to draw them into its inverted cavity, and the ovaries are drawn inwards to- wards the same centre. Hernia of the Ovary. — When the ovary enters into the contents of a hernial sac it is generally the result of a congenital vice. The most common form is the inguinal, but the ovary has been found in crural, abdominal, vaginal, subpubic, and even ischiatic hernise. Observed cases permit the following conclusions to be drawn : The pain which attends these hernise extends from the seat of the strangulation to the uterus, and thus, if by the finger in the vagina we move the uterus, this movement is transmitted to the contents of the hernia. In one- sided ovario-inguinal hernia, the fundus of the uterus is slightly in- clined to the side of the hernia, and Seller has drawn attention to the fact that the pains in the hernial sac increase, and are attended by a feeling of dragging, when the patient lies down on the opposite side. The ovaries may be felt to swell and become more tender, as was di- rectly observed by Scanzoni, in the remarkable case already referred to under "Menstruation" (see page 160). Boivin and Duges feared that ovarian hernia would either induce sterility or lead to extra-uterine gestation. Since Mr. Curling has shown that hernia of the testicles induces sterility in the male, the first conjecture seems strengthened. But Scanzoni's patient became pregnant. Treatment. — When the hernia is reducible, the taxis and a suitable bandage should be applied. But if the ovary be fixed by adhesions it may be wise to follow the example of Pott, whose case I have also re- ferred to under " Menstruation," and of Deneux.^ Enlargement of the ovary is mostly the result of textural disease. To this category belongs the excessive growth of the follicles, resulting in cysts. 4. Anomalies of relation are frequently seen in the form of 'pseudo- membranous adhesions of the ovaries. The most common is the adhe- sion with the tube ; next in frequency is the adhesion of the ovary, either with or without its tube, to the hinder wall of the uterus, and the neighboring parts of the ligamentum latum down to the bottom of the recto-vaginal pouch. These adhesions frequently result from puer- peral peritonitis at a time when the uterus is above the usual size, filling the pelvic cavity, and when its appendages are thrown back to its posterior surface. Adhesions of the ovaries also take place to the sides of the pelvis, to the rectum, to the sigmoid flexure, in conse- quence of pelvic peritonitis to which anomalous maturation and morbid processes in the ovaries or tubal catarrh has given rise. Peritonitis determining adhesions of this kind may also be caused by retro-uterine hsematocele. When the blood-tumor disappears, the relation of the ovaries and uterus may thus remain altered for a time. Rokitansky says the ligamentum ovarii may undergo stretching and separation in childhood, and even in the foetal state, in consequence of adhesions then acquired, and that separation of the ovary from the 1 " Kecherches sur les Ilernies de I'Ovaire." Paris, 1813. ovary: cystic degeneration. 255 uterus may thus result. It will then degenerate, and may be fixed at its place by adhesion, or loose. Sometimes it vanishes, leaving no trace behind. When the ovary has contracted adhesions it is subject to dragging from the rising gravid uterus, or from the uterus growing together with the developing pelvis, also from the development of the bladder, sigmoid flexure, or rectum. This dragging commonly causes atrophy of the ovary. CHAPTER XXyil. OVAKY: HYPEE^MIA, HEMOREHAGE, AND ANOMALIES OF THE CORPUS LUTEUM. Hyperemia of the ovary attends the normal as well as the ab- normal ripening and extrusion of ova and the results, and especially affects the stroma surrounding the peripheral follicles, and their fibrous cavities. The involution of the follicle following on the completion of the menstrual antecedents is also often marked by a considerable vascularity of the surrounding tissues. Menstrual, as well as extra-menstrual, congestion excites in the pe- ripheral, as well as in the deep-lying follicles, an excessive growth and cystic degeneration. Very often it leads to hemorrhage, principally in the large peripheral follicles ; then there are found one or more pro- jecting sacs filled with lightly coagulated blood, and varying in size from a bean to a nut, or even to a fist. They shrink after the manner of corpora lutea, and sometimes after the resorption of the extravasated blood they remain as cysts and continue to grow. The anomalies observed in the corpus luteum are, according to Rokitansky — 1. Dendritic protrusion of the corpus luteum outwards through the rent of the follicle. This appears as a villous, soft, reddish-yellow outgrowth continuous with the mass of the yellow body, or as a leaf-like excrescence connected by a branched stalk, on which are small linseed-formed white fibrous bodies. 2. Duplication of the corpus luteum, which Rokitansky explains thus : A fresh hemorrhage takes place prematurely from the wall of a follicle after the formation of one corpus luteum, which detaches the yellow body, pushing it inward, and hereupon a second corpus luteum is formed in the wall of the follicle. Rokitansky describes the following degeneration of the corpus luteum, 1. Cystic degeneration. The cyst in the periphery of the ovary is 256 OVARY. found retaining traces of the structure of the corpus luteum, including the scar of the rent, although it may be as large as a walnut. With these cysts there is occasionally seen the remarkable appearance of a primitive communication of the cyst with the fimbriated extremity of the Fallopian tube, resulting from the process of extrusion of the ovum from the follicle and its reception into the tube. These are the so-called tuho-ovarian cysts which have been described by Richard. (See Fig. 79, from Carswell.) 2. The degeneration to a fibrous tumor, which consists in the excessive growth of the yellow body and its persistence m the form of a more or less plainly visible sheath inclosing round fibrous knots the size of a walnut, and a cavity filled with serum. Showing a blood coagulum in a cyst of ovary. (Guy's, 2228^.) " The ovary forms a cyst with thick waBs, and contains what appears to be a coagulum of blood as large as a chestnut." — (Catalogue.) The specimen figured (Fig. QQ) seems to be an example of this fibrous degeneration of a Graafian follicle. 3. The degeneration to carcinoma may ensue upon the preceding fibrous degeneration. " Oophoralgia,'^ "neuralgia of the ovary,'' "ovarian irritation," is an aifection so often mistaken for inflammation that it is desirable to dis- cuss it in the same connection. It is an extremely distressing disorder, apt to last for years, and to embitter existence. It occurs in the single as well as in the married, but more frequently in the married. It is often associated with tlie hysterical temperament, and almost always with an induced increase of irritability of the nervous centres. It is OOPHORALGIA. 257 marked by intense exacerbations at the menstrual periods. The pain in the ovarian region is then so acute as to simulate oophoritis or peri- tonitis; the pulse rises in frequency and the skin in temperature. But mere pain is enough to induce these conditions. Local examination Fig. 6G. Fibrous tumor of ovary from a woman set. 50. (St. George's, XIV, 140. Nat. size.) The uterus also contaiued a fibrous tumor. reveals a swollen condition of the ovaries, often considerable, that is, to twice the ordinary size, or even more; the patient complains of ex- quisite pain when the ovary is compressed between the finger internally and the hand outside, and also by mere digital touch on its side of the uterus. Touching; the neck of the uterus in such a manner as to lift up the body of the organ, or to move it to either side evokes pain. This is partly due to concomitant congestion and tenderness of the uterus itself, this organ becoming more sensitive in consequence, and partly to the moving uterus disturbing the ovaries. Touching the ovarian region will sometimes induce hysteria, sometimes vomiting as W'cll as pain. The monthly repetition of these attacks rarely fails to induce such a state of nervous irritability and exhaustion that the sufferer loses appe- tite, nutrition is impaired, and she is compelled, or thinks she is com- pelled, to abandon all exercise, and comes to regard herself as a con- firmee! invalid. Dyspareunia is a never-failing consequence, and this adds to the mental and physical distress. The character of the menstrual flow varies. Not seldom it is in ex- cess, but sometimes it is not so. Dysmenorrhoea is a frequent, but not a constant concomitant. In many cases it may be said to arise out of dysmenorrhoea. The ovarian irritation is the expression of difficult ovulation. 17 258 OVARY. That these cases are especially apt to pass into inflammation is highly probable. There is congestion of the ovaries, tubes, and uterus beyond the physiological measure, so that escape of blood into the peritoneum is not unlikely to occur. But that the symptoms related indicate in- flammation it would be wrong to assume. The intensity of the pain is not evidence of inflammation. I have known an ovarian cyst burst, discharge its contents into the peritoneal cavity, and death ensue under the most excruciating agony ; yet examination has not shown a trace of inflammation. Again, in these cases we find the uterus remaining movable, entire absence of any thickening or perimetric swellings, even after years of suffering. It may be true that the ovary proper may be inflamed alone, but it is hardly conceivable that repeated attacks of oophoritis should always fail to involve the peritoneal investment. It is, moreover, scarcely in accordance with the history of inflammation to return in an organ every month, to run its course in a few days, and to leave the organ essentially sound, that is, in a condition ultimately to perform its functions. Yet I have seen cases where this oophoralgia lasted for years, was cured, and healthy menstruation ultimately estab- lished. The ascertained conditions are extreme local hypersemia, or conges- tion, and exquisite sensibility of the ovaries, combined with great irri- tability of the nervous centres. These conditions furnish the indications in treatment. It is very important to eliminate the idea of inflammation where the thing does not exist, because antiphlogistic treatment will in the long run aggra- vate the disease, and reduce the general powers. Thus I have several times seen great prostration, increase of local hyperesthesia and of gen- eral local irritability produced by the repeated application of leeches to the groins or to the os uteri. It is true that in some of these cases the patients expressed relief at the time ; but the relief could hardly be said to be real ; it was not attended by cure, and seemed to me to do more harm than good. Counter-irritation in the form of blisters, or chloro- form-embrocations to the iliac regions, has appeared to be beneficial. Another proceeding very apt to be carried to a mischievous excess is lying down. Nutrition must suifer, and, as a consequence, the nervous centres become more irritable. The true course to adopt is to follow the three indications given by — 1. The general depression of the system ; 2. The exaggerated irrita- bility of the nervous centres ; 3. The excessive congestion and hyper- sesthesia of the ovaries and surrounding parts. It is superfluous to enumerate the medicinal, dietetic, and hygienic remedies which help to fulfil the first indication. The task of allaying the extreme irritability of the nervous centres will be made easier in proportion as the general tone is improved. The nervous centres Avill also recover power as the third indication, that of tranquillizing the ovaries, one source of irritation, is effected. Rest in the physiological sense, that is, abstinence from " married life " is imperative. To subdue the hypersesthesia, the wearing for a few hours every day one of the forms of " vaginal-rest " will be found of great service. If there is any displacement of the womb this must INFLAMMATION. 259 be corrected by suitable means. Abrasion, congestion of the cervix uteri, must be cured. I liave found it useful to eiFect a derivative action in the cervix, by making a small eschar on the vaginal-portion Avith potassa cum calce. This is far less painful and more efficacious than blistering the groins. Bromide of potassium acts in some degree as a sedative of ovarian excitement ; but it is not to be depended upon alone. The bowels must be well regulated to prevent accumulation in the rec- tum. Salt-water or Vichy baths, tepid or cold, according to the season, are often eminently useful. The treatment must be pursued steadily. Time is required to bring about a healthier innervation, and to improve the nutrition of all the tissues. The case under discussion not seldom falls under the category of dysmenorrhcea, and the treatment, of course, is directed by the indica- tions arising in this connection. Great relief is often obtained by the use of sedative pessaries contain- ing opium or belladonna applied to the fundus of the vagina a day or two before the advent of the exacerbation due to the menstrual epoch. Inflammation of the Ovary. It is not within the scope of this work to describe the diseases of the puerperal state. I pass over therefore those forms of oophoritis with which pathological anatomists are most familiar. The oophoritis of childbed is seldom met with, perhaps never, apart from complication with inflammation, extending from the uterus, tubes, and broad liga- ments. The ovary is not affected primarily, but is caught secondarily in the spread of an active inflammation which invades most or all of the pelvic structures. It is difficult so to isolate the oophoritis in these cases as to extract any trustworthy facts to illustrate the history of pure oophoritis. Nor do we derive a much larger amount of precise informa- tion, ad hoe, from the examination of subjects who have had oophoritis apart from childbed. Here, too, the oophoritis is not often simple, but a part of an inflammatory process involving other structures. Simple oophoritis is rarely fatal ; so that the opportunities of seeing the condition of the ovary under the influence of acute or recent in- flammation are necessarily rare. I cannot help thinking that the precise division of oophoritis into four degrees given by Boivin and Duges is drawn rather from theoretical reasoning than from observation. Rokitansky declares that apart from childbed oophoritis is very rare. But this statement must be taken as expressing the experience of the dead-house. I believe that simple, or conjoined with metritis, it is not uncommon. But as the cases recover more or less perfectly, dis- tinct evidence of the inflammatory action to which the ovaries have been subject is rarely seen. All such evidence had disappeared during life, or had become confounded with the results of complicating diseases. One of the most frequent conditions found is fibrinous adhesions of various age uniting the ovaries to the sides and posterior surface of the uterus, to the broad ligament, or other neighboring structures. These are often found in women who have never borne children. We are 260 OVARY. thus driven to the conekision that women are liable to frequent pelvic inflammations aj)art from pregnancy. These adhesions of course are the residua of peritoneal inflammation, and commonly extend beyond the ovaries to other parts of the pelvic peritoneum. The ovarian implication is often secondary. But it cannot be doubted that there are cases of primary oophoritis proper. An organ performing a function so important as ovulation, and stimulating the Fallopian tubes and uterus to share in the work of menstruation, can- not be expected to enjoy immunity from inflammation. All active function involves determination of blood to the organ performing it ; but there is no organ whose functional activity attracts blood in such profusion as the ovary. It goes beyond simple transient hyperaemia ; the rush and work are so violent that actual extravasation of blood and laceration of structure take place. It cannot then be surprising that under certain conditions interfering with the normal accomplish- ment of this function, activity so great should pass the narrow physio- logical boundary, and terminate in inflammation. Obstruction to the due discharge of the menstrual secretion, sudden suppression of the secretion, undue excitation of the uterus and ovaries whilst in the exe- cution of this function, as from excessive exertion, sexual relations, or exposure to cold and wet, may easily determine inflammation. Some- times the uterus, tubes, and pelvic peritoneum will be seized along with the ovaries, but at other times the ovaries are chiefly, if not ex- clusively affected. Scanzoni describes the post-mortem appearances in what appears to have been a typical case of acute oophoritis. The subject died of pneumonia, the result of cold, and with symptoms of peritonitis in the right ovarian region. In this situation was found a mass of coagulated fibrin, the size of a fist. On removing this the right ovary was seen two inches long, nearly as much across, and one and a half inch thick. It was ovoid, considerably enlarged, as the measurements show ; its surface was violet-blue, covered with numerous dilated veins, and near the inner angle of the jDosterior surface was a black spot, the seat of recent rupture of a vesicle. The organ was pasty, almost fluctuating in parts. On incision there escaped a considerable quantity of blood, and the section showed the same violet color, and some veins strongly congested. The ruptured vesicle still held some liquid black blood. Towards the other extremity of the ovary, where the congestion was less intense, there was an abscess in the i^arencliyma ; and at the side were other smaller abscesses, all deej) in the parenchyma. This case shows that there is combination of all the forms of oophoritis. Causes. — Oophoritis may be said to be almost strictly limited to the reproductive period of life. It is accordingly found to arise under conditions which offer obstruction to the ordinary course of the ovarian function. Impressions, physical or emotional, occurring during men- struation may goad the physiological congestion into inflammation. Cold, excessive sexual indulgence, esjiecially during menstruation, arc not uncommon causes. It has followed operations on the os uteri, and intra-uterine injec- tions, and the spread of blennorrhagic inflammation along the Fallo- INFLAMMATION, 261 pian tubes. Ricord described this last form as analogous to the orchitis arising from blennorrhagia in the male. Its origin in obstructed men- struation will account for the fact of oophoritis being more frequent in virgins than inflammation of the uterus, which as yet has only entered upon the subsidiary function of menstruation. It is often secondary upon disease of the uterus, tubes, and broad ligaments. The intimate vascular communications between these organs offer a ready channel of extension for inflammation from the uterus. The dysmenorrhoea resulting from a contracted or nearly impervious OS uteri, seldom exists for any considerable period without inducing chronic inflammation of the ovary. Retroversion is a frequent cause of swelling and great tenderness of the ovary, not unfrequently amounting to oophoritis, from the fundus of the uterus pulling the ovary backwards, and thus by the tension of the broad ligaments producing obstruction to its returning circulation. Sexual intercourse for the first time, especially if there have been previously an irritable state of the ovary, with dysmenorrhcea, is not unfrequently followed by oophoritis. Early abortions also will, sometimes, lead to the same condition. Oophoritis, arising otherwise than in childbed, is often single. But the ovaries appear to be subject, like the eyes and other double organs, to consensual suffering. Thus, inflammation of one ovary is likely to be followed by inflammation of the other. It is in some cases difii- cult to explain the attack upon the second ovary by any other than the consensual hypothesis. But in some cases it is easy to observe that common predisj^osing and exciting causes act upon both ovaries alike, although one may be affected earlier and more severely than the other. Inflammation of the Follicles of the Ovary. — Apart from the ordinary peritoneal inflammatory action proceeding from the ripened and burst follicles, one may see one or more ripe follicles with injected walls, red, softened, easily torn, with turbid, flocculent, puriform contents, and the surrounding parenchyma infiltrated. This leads to atrophy of the follicle, or causes its degeneration to a cyst. Negri er describes " Vesiculite'^ simple. In most cases the trouble remains local. A point of the ovary becomes tumefied and torn, an inflammatory areola has surrounded the little wound, sometimes has invaded the peritoneal investment, and even the pelvic peritoneum. Vesiculite is "simple" when easily stopped, and ending in resolution. V^siculite is "grave," when ending in suppuration, or when the in- flammation has spread widely to the pelvic peritoneum. Kiwisch says the inflammation of the follicles is commonly confined to one Graafian vesicle. An indication of the inflammatory process is seen in the menstrual metamorphosis of the follicles. The products of this inflammatory condition are more or less plastic, and in general much infiltrated with blood ; the follicle is distended to the size of a pea or a cherry. When several follicles are implicated, the surround- ing stroma participates in the inflammatory condition, and is found in a state of hypersemia, serous infiltration, or inflammatory softening. 262 OYARY. Pai^enehymatous Ovaritis. — This very rarely runs to suppuration. It often, however, leads in young persons to peritoneal false membranes and adhesions, to increase of bulk and thickening (sclerosis) of the stroma, thickening of the tunica albuginea, with atrophy of the fol- licles, especially of the peripheral ones, and enlargement of the ovary, with tuberose surface. Inflammation of the stroma is rare in the non-puerperal state. Kiwisch relates two cases in which the entire organs were aifected, both ending fatally in a short time; in the one by acute abscess, in the other by a sanious disintegration. In both consecutive peritonitis was the cause of death. Simple peritoneal oophoritis can hardly be said to exist. It is peri- tonitis, not oophoritis; and the inflammation will rarely be limited to the surface of the ovary. Ovarian peritonitis is commonly a part of the widespread pelvic peritonitis of childbed, or other forms of gen- eral pelvic peritonitis. Primary ovarian peritonitis is more frequently limited to one side, and is the result of, or attended by traumatic or other lesion proceeding from the bursting or disease of a Graafian fol- licle. But even in such a case the inflammation is very apt to spread to the peritoneum beyond the ovary. Symptoms and Diagnosis. — When oophoritis is complicated with metritis and pelvic peritonitis, its special symptoms are lost or con- founded in those of the attendant inflammation. The peritonitic sym}> toms especially preponderate, and govern both diagnosis and treat- ment. Where ovaritis is simple, or the chief morbid condition, the symptoms being more concentrated, ought to be more characteristic. But they are not free from ambiguity. The local symjitoms attending many severe cases of dysmenorrhoea are referred by the patient and traced by the physician to the ovary. Intense j)ain in the ovarian region, swelling and tenderness of the ovary under touch, burning, shooting pain in the pelvis, pain in defecation, febrile movement, in- cluding hot skin and quickened pulse, suggest inflammation, and seem to fix that inflammation in the ovary. But these symptoms subside in a few clays, as menstruation passes off; and if we now examine the ovary we may find little or no tenderness or swelling. If, then, in- flammation attended the painful menstruation, it was an inflammation of a very transient character. We can hardly conceive an inflamma- tion of the ovary which recurs every month throughout thirty years, and which is, nevertheless, compatible with the continuance of the ovarian function. These symptoms, then, Avhich outside the menstrual epoch would be considered to indicate inflammation of the ovary, may be produced by temporary hyperemia and hyper^esthesia of the organ. Pain in the region of one or other ovary, even if increased by pres- sure, is not sufficient evidence of oophoritis. Pain of this character is a frequent, almost constant, attendant upon inflammation of the neck of the uterus. It arises with this disease and subsides with it. It is in like manner a frequent attendant upon obstructive dysmenorrhoea or the dysmenorrhoea of retention. In these cases the pain must be regarded as reflex or sympathetic. On the other hand, ovarian disease is very liable to be overlooked. INFLAMMATION". 263 because attention is likely to be concentrated on attendant uterine disease. Before concluding that the ovary is inflarued, we must continue our observations during the intermenstrual ]3eriod. The history of the onset and progress of the aifection will oflPer different points. If in- tense pain referred to one or other ovarian region supervene quickly on exposure to cold, excessive venereal excitement, emotion, in the course of blennorrhagia, or after operations on the uterus, or intra-uterine injections, the state of the pelvic organs should be explored by internal and external palpation. It is probable that the uterus will be found to share in the tenderness and swelling which afPect the ovaries; per- haps, too, the broad ligaments and pelvic peritoneum will be involved. Where this is the case, it will be difficult to get at the ovaries, which will be surrounded by swollen and tender structures. But where the ovary is principally affected, or when the concomitant affection of the uterus and other structures has subsided, the state of the ovary comes into prominence. Palpation supplies the only trustworthy evidence. In every examination per vaginam, the finger is first directed as a point of departure to the os and cervix uteri. On touching this part, pain will in all likelihood be caused, and we may conclude that the uterus is the organ at fault. The pain may, however, be due to the pressure of the uterus upon the inflamed ovary.. We therefore seek to elimi- nate the uterus by pressing the finger gently against the vaginal roof in front, at the sides of, and behind the uterine neck. When pressing at one or both sides upwards, the pain will be greater, and we may possibly, by conjoint external pressure on the abdomen, embrace the painful structures between the two hands. This deep pressure in the sides of the pelvis on the abdomen alone causes pain, and there is a feeling of resistance, caused partly by the swelling of the parts, and partly by the muscular tension exerted instinctively to ward off the dreaded pressure. But the clearest evidence of the state of the ovary is to be attained by the recto-abdominal touch. As Lowenhardt pointed out, the ovaries, especially if inflamed, can commonly be reached by the finger in the rectum ; and this the more surely if they be pushed on to the examining finger by the hand pressed firmly down upon the uterus through the abdominal wall. We may then recognize the ovary by its form, position, mobility, and tenderness, and judge by its increased size, and pain on touch, whether it is inflamed or not. But the ovaries, even much enlarged by inflammation, may be insensi- ble to considerable pressure — a proof, says Schultze, that oophoritis need not necessarily implicate the peritoneum. Other signs, chiefly subjective, concur in throwing light upon the case. Accumulation of fecal matter in the csecum will increase the pain of inflammation in the right ovary, whilst the movements of the rectum in defecation will have the like eff'ect when the left ovary is inflamed. But after all, a rigorous method of exclusion of inflamma- tions in neighboring structures is necessary to justify a positive diag- nosis of ovaritis. My experience coincides with that of Schultze, who says that he has often observed that an inflamed ovary, in Douglas's pouch, lies in front 264 OVARY. of the uterus to the side, and that after it has recovered its normal vol- ume and sensibility, it has returned to its normal position. In other cases after recovery it maintains its abnormal position, and in one case an ovary which had been closely adherent to the uterus after inflam- mation, was several months before it became movable again. So many of the symptoms supposed to indicate an oophoritis may really depend on some form of metritis or pelvic peritonitis, or some flexion or other change in the uterus, that we may agree with Veit that the diagnosis of oophoritis can only be made out with certainty when the swollen and painful ovary can be distinctly felt as a circumscribed swelling. It is not necessary that it should be movable; although it may be exceedingly difficult to recognize an ovary when fixed, by adhesions. The morbid follicle, according to Aran, may be distinguished from the normal follicle under menstrual hypersemia by its position; it is often more or less central, not peripheral ; it does not cause so marked a projection on the surface of the ovary; its walls are equally thick, showing no evidence of absorption at any part preparatory to de- hiscence; nor is there any ihcrease of vascularity as in a follicle pre- paring for dehiscence; it does not exhibit the corpus luteum or the corrugated foldings of the normal ovisac; its contents are generally a collection of dark coffee-grounds matter, resulting from admixture of decomposing blood-corpuscles, fragments of membrana granulosa, inter- mixed with a dirty fluid. An inflamed ovary seldom exceeds twice its ordinary size. There are many examples in medicine of treatment becoming an ele- ment in diagnosis. But the conclusions drawn in this manner are sometimes fallacious. Thus it is frequently observed that ovarian pain and other symptoms taken to indicate oophoritis are cured by cauteriz- ing the OS and cervix uteri, which may at the same time exhibit marks of disease. It seems rational to infer that the ovarian symptoms were only symptomatic, or dependent upon the affection of the uterus; and in the majority of cases this, I believe, is true. But it is also true that the treatment applied to the uterus may really have cured ovarian dis- ease, first, by acting on the principle of derivation or counter-irritation, and secondly, by removing uterine disease, which was the source of disease in the ovary. Symptoms and Course. The pain is chiefly .due to peritonitis, which is almost certain to ensue. Tumefaction is so inconsiderable in recent inflammations that it can hardly be the cause of marked subjective symptoms, and it is not easy to measure it even by physical examination. Menstruation may be suppressed, or there may be an increased flow. In very rare cases the affection proves fatal in a few days. This termination is due to sanious decomposition of the ovary, or to acute perforation by an abscess. Where it commences with unusually severe symptoms, and particu- larly when it leads to extensive degenerations of the ovary, or causes INFLAMMATION. 265 much peritoneal exudation, it may continue for weeks or months with more or less marked remissions. In other cases perfect intermissions occur, aud the paroxysms are synchronous with the catamenial periods. In the most favorable cases, which are also tlie most common, after a short time the exudative process is arrested, and the exudation is either removed by absorption, or undergoes the usual metamorphosis into cel- lular or stringy strata, which bind the ovaries to the surrounding struc- tures. Sometimes a fibrous condensation of the exudations takes place, and dense capsules are formed round the ovary, leading to atrophy of its tissue. The exudations into the follicles also lead to various meta- morphoses, with shrivelling and atrophy of the aifected vesicle. When the course is less favorable, a new morbid process starts from the inflammation, and abscesses and various chronic tumors of the ovaries are developed. Professor Faye' relates a case of abscess in the ovary in a pregnant Avoman. She had been delivered by forceps. During pregnancy (her first) she suffered much from vomiting ; and towards the end she had a fixed pain in the right side of the abdomen, and several convulsive fits. On the night after delivery she had severe pains, mistaken for after-pains. Next day, the pains were more bearing-down in character ; the abdomen was tender and tympanitic. She died fifty-three hours after delivery. Douglas's sac was found filled with a thin purulent sanguineous exudation. An abscess in the right ovary had burst ; the remains of the organ had changed into a mere pulpy detritus. There was considerable degeneration of the cortical substance, of the kidneys, and there were many extravasations of blood under the serous mem- brane covering the kidneys, liver, and lung. Associated with abscesses, although probably different in origin, is the case narrated by Dr. Farre, " in which the ovary was entirely re- duced to a diffluent pulp of a yellow or brownish-green color, of the consistence and having somewhat the appearance of very soft putty, immiscible with water. Of this morbid condition, which may, how- ever, be cancerous, I met with a striking example in a case of sudden death occurring in the seventh month of pregnancy. Both ovaries were of the size and form of a bullock's kidney, their natural structure was entirely destroyed, and was replaced by the soft substance just de- scribed. The circumstance that both ovaries were thus affected renders it evident that the disease could not have existed in any great degree at the time of impregnation." Most of the recorded cases of large abscess holding from one to twenty pints of pus, are probably instances of suppuration taking place in the cavities of ovarian cysts. When, says Matthews Duncan, suppuration has occurred in the ovary or around it, it may be easily made out by the attendant phenomena. These are, increase of pain, sometimes throbbing, once or twice daily attacks of fever, hectic. The feeling of fulness is supplanted by hard- ness, which has more or less of a resistant character. But all these features may be the expression of inflammation and suppuration outside 1 Schmidt's " Jahrbuch," 1860. 266 OVARY. and around the ovary, the condition of this organ being concealed by the surrounding disorder. The terminations of suppuration or abscess of the ovary are : 1. The ovary may burst into the peritoneum, causing abdominal shock, collapse, or peritonitis ; 2. Small perforations may take ]jlace, exciting more cir- cumscribed peritonitis, and leading to plastic effusions surrounding the diseased ovary ; 3. Adhesions may be formed with the bladder or in- testine, and a fistulous communication be established, by which the pus may be more or less completely discharged ; 4. The suppurating ovary, being the focus of a pelvic cellulitis or peritonitis, may terminate after the manner of this form of pelvic inflammation, by discharging into the rectum, vagina, or externally above Poupart's ligament. The treatment must be conducted on the same plan as that which is laid down for pelvic peritonitis which has proceeded to suppuration. The exit of pus should be favored when there is distinct evidence of an eliminatory process. Chronic oophoritis is characterized by a sensible deformity of the affected ovary ; the surface is knobbed, its consistence harder than nor- mal. This induration results from the hypertrophy of the parenchyma, which in its turn proceeds from the transformation of the effused matter into the cellular tissue. Possibly also there is thickening of the tunica propria. Henkel and Virchow compare this to the interstitial hyper- plasia of other glands, for example, the cirrhosis of the liver. The thickened capsule prevents the external dehiscence of the vesicles. The ovum perishes in the effused blood in the vesicle. On several occasions Scanzoni found the sanguineous effusion had taken place not only in the interior of the vesicles, but also in their immediate neighborhood ; it thus became evident that the friability of tissue which sometimes accompanies chronic oophoritis is an important cause of what is called apoplexy of the ovary. Chronic oophoritis may succeed to the acute form ; it may be a con- tinuation of oophoritis of childbed, or it may arise in a subacute man- ner. The causes will be similar to those which induce the acute in- flammation . It is extremely probable that cystic disease in some cases, if not in many, takes its origin in a slow inflammation of the follicles. The early stages of cystic disease are often attended by intense pain, and the other signs of dysootocia. The menstrual flow in the early stages of the disease will generally be increased in quantity and protracted in duration, and irregular hem- orrhagic discharges may occur. At a later period, when probably the follicular structure has become impaired, diminution or suppression of menstruation may be observed. The disease very often affects one ovary only, so that menstruation, or rather ovulation is not necessarily always attended by dysmenorrhoeic phenomena. Not seldom, one or two periods may pass without pain. This may be explained by Xegrier's theory of the alternate action of the ovaries. AVhen there is no pain, the healthy ovary is at work. In other cases, every period is attended by severe dysmenorrhoea, and then we may infer either that both ovaries are affected, or that the general pelvic hyperremia of ovulation may involve the healthy as well as the inflamed ovary. INFLAMMATION. 267 Leucorrhoea frequently attends, but can hardly be regarded as symp- tomatic, although the discharge may in some measure be a means of unloading the engorgement of the ovario-uterine vessels. Impregnation may take place, since one ovary only may be involved ; and even where both are involved, there may still remain some follicles in a condition to bring forth healthy ova. Sterility, however, is com- mon, partly because the ovaries are really disabled by obliteration of the follicles, or by external adhesions, and partly also because pain forbids eifective intercourse. It may terminate in cure by resolution. But it may undoubtedly go on to destroy the proper structure of the organ. The vesicles may become compressed and atrophied, the result being incurable araenor- rhoea and sterility. It may proceed to suppuration, and then the symptoms described under Abscess of the Ovary will be observed. Aran says the great danger of chronic oophoritis is the constant liability to peritonitis, which may prove fatal. He says he has never seen peritonitis supervene on chronic metritis, whether parenchymatous or mucous. I cannot indorse the latter statement; but certainly as a general proposition Aran is right in affirming the far greater risk of peritonitis attaching to chronic oophoritis. It has been said that chronic oophoritis may run on for years, or for any length of time, without the ovary becoming fixed by adhesions, and without causing suppuration in the neighborhood. That this happy negation may occur may be admitted ; but I think the escape is excep- tional, and that the danger indicated by Aran is not exaggerated by him. It is not unreasonable to suspect that many of the cases relied upon as evidence that chronic oophoritis may persist for years without inducing mischief beyond the ovary are examples of oophoralgia without inflam- mation. There is a fibroid degeneration of the ovary which is attended by complete disappearance of the follicles. There is a remarkable speci- men of this kind in St, Thomas's Hospital. Both ovaries are enlarged to twice or thrice the normal size ; they are deeply furrowed or con- voluted, and sections through their substance present smooth surfaces. This is probably the consequence of chronic inflammation, the contract- ing parenchyma gradually obliterating the follicles. Chronic oophoritis is marked by dull, heavy pain in the seat of one or both ovaries, more or less constant, but aggravated by menstruation, by coitus, by standing or exertion in the upright position, sometimes by a loaded rectum or bladder. The pain radiates from the ovary as a centre to the bladder and surrounding organs. Constitutional symptoms, marked in some cases, attend. There is some degree of fever, accompanied by hectic, if suppuration have taken place. Nervous symptoms, indicating exhaustion, irritability from constant pain, will generally show themselves. But, except in the very early stages, when the disease is likely to be confounded with ordinary dysootocia, the nervous symptoms do not often put on the hysterical form. To establish a diagnosis, pain, as described above, must exist. And 268 OVARY. besides ascertaining this, we must exclude other pelvic diseases. Where the ovary only is affected, we may by touch determine its increased bulk, sensitiveness, and perhaps prolapsus. Touch, single and bimanual, vaginal, rectal and recto-abdominal, must be performed in the same manner as for the detection of the acute form. Since the inflamed ovary is commonly enlarged, and is disposed to drop behind the uterus, it may be felt in the situation assumed by the body of the retroflected uterus. The sound will lift up the body of the uterus, and the ovary, if adherent to it, as is not unlikely, will be carried up along with it. But by a little care the uterus may gen- erally be isolated from the ovary. The Treatment. We must rely mainly upon rest, physiological and physical, and derivation. Bromide of potassium, sedatives, occasionally leeches to the iliac region, chloroform-blisters on the same spot, iodine-painting, or when pain is acute, fomentations or poultices. A valuable means of derivation may be pursued by setting up a small issue or eschar on the vaginal-portion of the uterus by potassa cum calce. This makes a healthy granulating surface which heals with some cicatricial contrac- tion. If the uterus were perfectly healthy one would hesitate before resorting to this remedy ; but in many cases there is so much compli- cation of uterine disease as will alone justify the application. I have in several cases seen great relief obtained by wearing a Hodge- pessary. It gives relief probably by maintaining the ovary at its probable level, thus favoring disgorgement of its vessels, and by favor- ing rest of the organ. CHAPTER XXVI ri. OVAET: TUBERCLE— CANCER— SOLID TUMOES. Tubercle in the Ovary is considered to be extremely rare. Rokitansky knows but one case of tuberculization of the ovaries ; there were round yellow knots in the ovaries, and also tuberculosis of the tubes and peri- toneum. And Kiwisch says tubercle is not met with in the ovary ; he has only found some tubercular granules in the stroma in intense peri- toneal tuberculosis. There is, however, no lack of examples of what CANCER. 269 must be presumed to be invasion of the ovaries by tubercle. Possibly an unequivocal instance of tubercle limited to the ovaries has yet to be demonstrated. But tuberculization of the ovaries in association with tubercle elsewhere, especially in the uterus, Fallopian tubes, and neigh- boring glands, is not rare. Thus in St. George's Museum (No. XIV, 78) is a preparation exhibiting scrofulous disease of the uterus, tubes, and ovaries. Both ovaries were converted into cavities, and contained remnants of a thick semi-fluid, tubercular matter. They were greatly enlarged, and their walls much thickened. There was extensive tuber- culization of the lungs and pleurisy ; also scrofulous ulceration of the right sterno-clavicular joint. No. XIV, 79, in the same museum, is another example. The uterus, tubes, and left ovary are involved. The left ovary was converted into an abscess containing scrofulous pus. The subject, a girl, aged eigh- teen, died of psoas abscess and scrofulous disease of the medulla ob- longata. Some may question the tubercular nature of the matter contained in the ovaries of these and similar specimens; but the probability that the ovaries thus involved should be aifected by disease diflFerent in character from that w^hich invaded so many other structures in the body is infinitely small. In the case of cancer being diffused through various structures and organs, the cancerous nature of similar disease found in the ovary is not questioned. Baillie described " scrofulous ovaria." " The ovaries," he says " are sometimes changed into a true scrofulous matter, intermixed with cells." Dr. Bristowe demonstrated (Path. Trans., vol. vi) the tuberculous nature of an ovary, diseased in common with the tubes and uterus. The Fallopian tubes were filled with soft tubercular matter. The cavity of the uterus was distended by a mass about as large as a pigeon's egg, of softish, opaque, yellowish-white cheese-like tubercle. The mu- cous membrane of the fundus was wholly deficient, and the subjacent muscular tissue was irregularly destroyed, the tubercular deposit at many parts extending into the substance of the muscle. The os and cervix uteri were somewhat congested ; they were otherwise healthy. The right ovary M'^as healthy. The left ovary contained two masses of tubercular deposit, one about as large as a horse-bean, the other as large as a Spanish nut. The deposit exactly resembled that in the uterus and tubes. Bristowe says the same thing has been satisfactorily demon- strated by Dr. Ogle. Bernutz and Goupil also describe an autopsy, in which, with much other disease, including tubercular lungs, they found both ovaries containing crude tubercles, just like those met with in the testicle. The course run by tubercle in the ovary, the disease in this organ being generally secondary, and of minor import than its concomitant presence in the lungs or other organs, scarcely calls for independent consideration. Advancing disease elsewhere, and attendant exhaustion of the whole system, preclude the idea of directing any special treatment to the ovary. Where, however, the ovary is converted into a sac con- taining tuberculous pus, it is conceivable that tliis may burst, and thus precipitate death, by causing peritonitis. 270 ^ OVARY. Cancer of the Ovary. Cancer resembles tubercle in being a diffusive disease. More fre- quently than tubercle it is primary in the ovary. But, still, in the majority of cases, by the time at least that it attracts attention in the living, and almost always as it is seen in the dead, cancer has invaded other organs as well. It is frequently consecutive upon disease of the uterus and the pelvic and abdominal glands. The secondary invasion of the ovary by cancer was accurately made out in a specimen exhibited by Dr. Bristowe to the Pathological Society. In this case innumerable cancerous nodules were attached to the peri- toneum. There was also an ovarian tumor showing cancerous disease. The ovarian tumor was essentially unilocular. It was originally an ovarian cystic tumor, the parietes of which had become secondarily in- volved in cancerous disease from its peritoneal connection. Next to cystic disease, cancer is the most frequent disease of the ovary. It is often combined with the cystoid formation. Every form of cancer may be reproduced in the ovary. It frequently appears as medullary carcinoma, in the form of a distinct mass, or of a roundish tuberous tumor completely supplanting the ovary, and growing to the size of a fist, or of a child's head, or bigger. In some places it resembles, in its firmness and the preponderance of its framework, the fibrous can- cer ; in others it is soft, very juicy, fluctuating, encephaloid. The de- generated ovary is sometimes free, but mostly united to surrounding structures by adhesion. In some rare cases, says Rokitansky, carcinoma of the ovary arises from the degeneration of a corpus luteum. Often the medullary cancerous degeneration is, in size and form, symmetrical. It occurs especially in young persons as a primitive dis- ease. It is also associated with cancer of the uterus, breast, liver, peri- toneum, stomach, intestine, and lumbar glands ; and appears as a part of a general widespread cancer formation. How cancer may invade an ovary in the midst of active function is illustrated in a specimen (No. 2640) in the College of Surgeons. It consists of a uterus, with ovaries and appendages. " There is a well- formed foetus, of about five months, with its membranes and placenta within the uterus. The ovaries are both extensively diseased — enlarged. The tissue of the left is soft, flocculent, and vascular ; that of the right is replaced by a collection of cysts, most of which are filled with soft, laminated, and apparently medullary substance." In St. Thomas's Museum is a similar specimen (No. FF, 51). Both ovaries are of ovoid shape, much nodulated on the surface, and not pre- senting in any part the appearance or structure of ovary. They appear to consist entirely of medullary (encephaloid) matter. The same disease was found in the mammse and liver. The woman was five months pregnant with a well-formed foetus. Medullary cancer occurs upon the cyst-walls and the cyst-cavities, especially in the form of villous cancer. The gelatinous cancer thus appears in the cystoid growths. On the inside of the cysts, here and there, are seen flat, rounded, medullary knots ; or villous, cauliflower- like excrescences. Both grow from all points of the cyst-wall, until CANCER. 271 they fill the cavity ; and at length the growth may penetrate the wall, so that the medullary carcinoma grows free in the peritoneal cavity, seizing neighboring structures, and the whole cystoid-formation becomes fixed in all directions. This cysto-carcinoma also often occurs sym- metrically in both ovaries — more commonly so in the more mature periods of life. Cancer of the ovary is most frequently seen in the encephaloid form. It may attain considerable size, forming a globular mass, with spher- oidal knobby projections. Courty relates a case in which a tumor of this kind, weighing about eleven pounds, left the corresponding tube quite unaifectecl, whilst there was congestive hypertrophy of the uterus, and return of hemorrhages simulating the menses in a woman who had passed the menopause. The encephaloid masses, diffluent in several places, appeared to have arisen in the Graafian vesicles, so encysted were they ; they even seemed, as Rokitansky pointed out in other cases, to have sprung up on the internal membrane of the vesicle, preserving there an areolar or alveolar aspect, whilst the centre was filled with liquid, chiefly blood. Several of the cysts were distended with blood, the result of internal hemorrhage. In some of the cysts some black pigment was accumulated in the walls. Cancerous tumors of the ovary sometimes come under the category of solid tumors. Thus, the specimen (No. 2246^^) in Guy's Museum shows " both ovaries affected by carcinoma, which has converted them into solid tumors, about the size of the human kidney. The subject, aged 40, was under Dr. Gull for carcinoma of the brain, breasts, and various other parts. She was delivered prematurely of a child in hos- pital, a few weeks before her death." " The most remarkable examples of hard cancers with fibrous tumors that I have yet seen," says Paget, " have been in the ovaries of certain patients with common hard cancers of the stomach or breast. In these cases the place of the ovary on either, or on both sides, is occupied by a nodulated mass of uniformly hard, heavy, white, and fibrous tissue. The mass appears to be generally of oval form, and may be three or more inches in diameter. Its toughness exceeds that of even the firmest fibrous tumors, and its component fibres, though too slender to be measured, are peculiarly hard, compact, closely and irregularly woven. With these I have found only few and imperfect cancer-cells, with more numerous nuclei, elongated and slender. They are not mingled with elastic or other ' yellow-element ' fibres." The following case (No. 31.76) in St. Bartholomew's Museum sug- gests how narrow is occasionally the line of demarcation between malignant disease of the ovary and the presumed fibrous disease of that organ. The specimen exhibits the uterus and ovaries : " The place of each ovary is occupied by a large, hard, oval tumor, nodulated on its external surface. The tumors consist of a very dense and hard, obscurely fibrous tissue ; and upon the surface, as well as in the interior of each, there are small membranous cysts, which contained a serous fluid. The uterus was healthy. The subject was 38 years of age ; her breast had been removed three years before for hard cancer." But for the 272 O Y A R Y. histor}^. the general appearance of the ovaries might be taken for the result of fibrous transformation. 3Ielanosis resembles other forms of malignant disease in its diffusive property. I have not met with example or- record of melanosis limited to the ovary. Like other forms of malignant disease, it probably almost always attacks the ovary secondarily. There is a good example (No. 31.16) in St. Bartholomew's Museum : "The ovaries are altered in form ; their natural structure is removed, and its place occupied by a very soft melanotic matter. There are also some small circumscribed deposits of melanotic matter in the peritoneum covering the uterus. Taken from a young woman in whom melanosis existed in many other organs." In St. George's Museum (XIV, 112) is a specimen of "simple cysts in each ovary. The following note is probably written by Sir B. Brodie : The cysts contained a thick, black, unctuous and nauseous substance of the consistence of tar. A small polypus is attached to the cervix ; a small ulcer is seen in the interior of the fundus. The woman had her knee amputated for fungus hsematodes by Sir Benjamin Brodie, and the disease of the organs of generation Avas not known. Is the color of the ovarian fluid owing to the same substance as melanosis ?" In the College of Surgeons (No. 2642) is a specimen of melanosis of the ovary. There was similar disease over the peritoneum, omentum, pleurae, and lungs. The sternum, ribs, cranial bones, &c., were black, brittle, unusually soft. The uterus appeared healthy. This specimen came from the museum of Robert Liston. No. 2642a is another mela- notic ovary. The disease involves the uterus and other parts. The specimen was presented by Lawrence. The frequent transition from the cystic tumor to colloid cancer sug- gests the suspicion that some forms at least, esj)ecially the proliferous, partake of the cancerous character. If this be assumed, then the pri- mary origin of cancer in the ovary must be admitted to be frequent. The history of pathological processes does not, I believe, lend much confirmation to the hypothesis of the ready convertibility of one form of morbid product into another. For example, if I may appeal to my own observation, I should say that fibroid tumors of the uterus are not greatly more liable to the invasion of cancer than is the normal tissue of the uterus. Cancer of the uterus begins as cancer, and not as any other disease. So far, then, as analogical reasoning may be trusted, that which in its advanced stages is obviously cancer, in the ovaries, as elsewhere, is cancer ah initio. That cancer of the ovary preserves, for a comparatively lengthened time, its exclusive habitat in the ovary before spreading to other parts, may be explained by the comparatively isolated terminal position of the ovary. Cancer certainly appears to linger longer in the ovary without con- taminating other parts tlian it does in the uterus. These considerations must weigh greatly in favor of regarding the compound proliferous cysts of the ovary practically as non-malignant, and therefore as being suitable for extirpation. The strong innate disposition of the ovary to develop cystic forma- TUMORS. 273 tions may deterinine the frequent assumption, by the original cancerous element, of the cystic or alveolar form. Cancerous disease of the ovary, as elsewhere, occurs more frequently in middle life and later life ; but it may arise in childhood. When cancer has existed some time in its pronounced forms, and es- pecially when the broad ligaments and glands of the pelvis and abdo- men are involved, ascites is a frequent complication. The course of ovarian cancer is frequently involved in that of ma- lignant disease elsewhere ; but it not uncommonly takes the lead in producing the cachexia and peritonitis which cause the fatal issue. The colloid cancer grows rapidly, and to a large size; but does not quickly tend to destroy life by contaminating the system. The oppor- tunities of examining the primary stages of its formation are therefore rare, except in cases where the affected ovaries have been removed by operation. Mr. Heath exliibited to the Pathological Society (Path. Trans., vol. xvi) a specimen of cancer of both ovaries, in which death was produced by obstruction of the bowels. The circumstances which, according to Dr. T. Gaillard Thomas, who has written a valuable memoir on Malignant Diseases of the Ovaries,^ most prominently point to the development of the disease, are: "1. The rapid development of a solid tumor in an ovary, with 2. Marked depreciation of the strength, spirits, and general condition. 3. The oc- currence of oedema pedum and spansemia at an early period, and con- sequently dependent upon a general blood state, and not the consequence of pressure. 4. Lancinating and burning pains through the tumor. 5. Cachectic aspect. 6. The occurrence of ascites without evidence of cirrhosis or other hepatic disease; organic disease of the kidneys, or heart, or chronic peritonitis ; the fluid accumulating in such large amounts as to force aside the supernatant intestines, and produce dul- ness in place of resonance on percussion in dorsal decubitus." These signs must, however, be taken with some qualifications. OEdema of the legs and ascites are not constant, even at stages when the disease has produced marked ravages upon the general system. I have, moreover, found it in practice difficult to distinguish solid malig- nant ovarian tumors from malignant disease around the caput coli. It is not, indeed, very important in a therapeutical point of view to make the diagnosis, since in either case the treatment would be the same. Solid Tumors of the Ovary. — For want of more precise pathological materials for discrimination, it is convenient to group certain tumors of the ovary under this general term. On clinical grounds this dis- tinct recognition of solid tumors of the ovary is of great value. The solid tumors include not only fibrous or fibro-cystic tuniors, but tuber- cular and malignant tumors of the ovary. Solid tumors in the ovary then, frequently, are a local expression of diffusive disease which in- volves other organs as well. This consideration of the characters of solid tumors, will strengthen the rule not to attempt the extirpation of solid ovarian tumors. Of what use, for example, would it be to re- ' American Journal of Ub-tctrii'S, 18 274 OVARY. move a cancerous ovary, when it is in the highest degree probable that the disease has extended to other organs ? A. Fibrous or Jibro-muscular tumors of the ovary are so rare that their existence has been doubted. In some instances where it has been concluded that one or both ovaries had been the seat of fibrous tumors, it is reasonable to conjecture that the tumors really arose in the uterus, and, becoming pedunculated, pressed upon the ovaries, whose proper structures became obscured. At the same time, since fibrous and non- striated muscular elements form a natural constituent of the oxslyj, there is sound histological reason for admitting the possibility of tumors being developed from exaggerated extension of these elements. There is a specimen in the London Hos^jital Museum described by Dr. Ramsbotham (No. Ea. 27) as " a large fibro-muscular tumor pro- jecting from the fundus uteri. The ovaries are as large as a hen's egg, nodular surface, and converted into dense fibrous masses." Cruveilhier had drawn attention to the fact that fibrous tumors were found implanted upon or in the substance of the ovary, which by their structure could not be distinguished from fibroid tumors of the uterus. He observed that they were often found at the same time in both organs, as in the specimen referred to of Dr. Ramsbotham. Dr. Baillie also was struck with the identity of structure, and observed that these tumors of the ovary ran the same course, and were liable to the same cartilaginous and bony transformations as the fibroids of the uterus. In Guy's Museum is a specimen (No. 2246) consisting of uterus and ovaries. " The latter are converted into large tumors, each the size of a cocoauut, by the production of a fibro-plastic material. The stomach was aifected in the same way by a growth which resembled that seen in the recurrent fibroid tumors." There is a specimen in Guy's Museum of both ovaries converted into solid tumors (No. 2225). Both ovaries are uniformly enlarged to the size of one's fist, smooth externally, and compact internally. The growth is seen to consist of fibro-plastic material, rather than cancerous. The woman had borne children. The tumors commenced after cessa- tion of menstruation, and caused a swelling above the pubes. The case is alluded to by Dr. Bright, who says it is difficult to determine whether the tumors are malignant or scrofulous. The tumors are quite smooth externally, and the section exhibits a perfectly homogeneous appearance. Guy's Museum also contains another specimen (No. 2246'''*). The ovaries are converted into solid hard oval tumors composed of fibro- plastic material. Each weighed about three pounds. One contains •three or four cysts. They are smooth on the surface. The patient was admitted for ovarian disease, took pleurisy, and died. Scanzoni says he has known only four cases in which autopsy verified the fibrous nature of a tumor diagnosed during life. The smallest was the size of a goose's egg; it was spherical, elongated, hard as cartilage, and almost without vessels. The biggest had exceeded the size of a man's head ; its section showed a concentric disposition of its fibres around several centres; its tissue was loose, inclosing numerous vessels, and in some places the veins presented an organization resembling that of the corpora cavernosa; it weighed about twenty pounds; it was irreg- TUMORS. 275 ular, as if formed of several tumors compressed against each other. There remained no trace of the normal tissue of the ovary, and in the other ovary were several dropsical vesicles, some as large as a pigeon's egg. The patient had died of Bright's disease. A specimen in St. George's Museum (No. XIV, 140) seems to offer the clearest features of a fibrous tumor of the ovary. It is represented in Fiff. 66. It is described in the catalogue as "A fibrous tumor of the ovary from a woman aged 50, who died of disease of the heart. The uterus also contained a fibrous tumor in its walls." The position of the tumor in this case in the centre of the ovary excludes the objec- tion urged against other cases, that its origin might be uterine. The coincidence of fibroid tumor in the uterus so often observed, points to a general disposition in the fibro-muscular elements of the uterus, broad ligaments, and ovaries to undergo like transformations. This tissue, it is known, is intimately connected throughout all these organs. The affinity of these tumors with fibroids of the uterus is illustrated by a specimen M'hich Mr. Wells exhibited (Path. Trans, vol. x) of a fibrous tumor of the ovary found after death. It was of the size of a large cocoanut. A section of the tumor showed that it was composed of fibrous tissue, the denser parts being calcified by a deposit of car- bonate of lime. A specimen was exhibited at the Obstetrical Society last year, which was examined by Dr. Wilson Fox, who described it as a " loculated fibroid ; as having in the more central and transparent parts of the loculi a great number of non-striated muscular fibres." Mr. Wells says he has seen only two instances. He removed "two tumors which were really fibrous tumors of one ovary, the right in both cases. One weighed nine ounces, the other four pounds and a half. In both cases there was a large quantity of fluid in the peritoneal cavity. One pa- tient was in the third month of pregnancy. Both recovered. One of these tumors is now in the Museum of the College of Surgeons." In St. Thomas's Museum is a specimen (No. FF, 47) showing " the half of a large, fibrous, kidney-shaped tumor of the right ovary, with the uterus attached. The entire tumor weighed five pounds and a half; it is deeply fissured on its external surface ; and in parts, is covered by a false membrane, where it had adhered to the abdominal parietes. When recent, it was highly vascular, and of fleshy consistence; its structure is throughout closely intersected by dense fibrous bands. From a woman aged 22." Another specimen in St. George's Museum (XIV, 139) further illus- trates the subject. It consists of the uterus and ovaries. The latter are observed considerably enlarged, and have undergone transformation into dense fibrous structure ; a small mass of calcareous matter has been deposited in the left ovary. Two of the Nabothian glands of the cer- vix uteri are slightly enlarged. This calcareous degeneration is pre- sumptive evidence of the fibro-muscular nature of the tumor. In most of the presumed fibrous tumors the cystic cavities have been the most noticeable features. The cysts may be more or less ob- literated by the hyperplastic condition of their walls. These over- grown partitions are made up of a fibrous vascular mass, not in any 276 OVARY. way distinguishable from that usually seen in cyst-walls. This kind of fibro-cystic tumor grows very rapidly, and has a strong hemorrhagic disposition, causing also in some cases effusion of blood into the cyst- cavity. A specimen is thus described by Dr. Ritchie. " On making a section through this, it was found to be invested on every side by a firm fibrous capsule, about two lines in thickness. This capsule sent projections into the interior of the tumor, and these projections met and crossed each other at different angles, so as to form a network. From the interstices of the network projected a number of thin-walled trans- lucent vesicles, containing a colorless fluid. The largest did not exceed the size of a small plum, whilst the smallest were mere specks. Most of the larger ones had been forced into an elongated oval shape, and as they projected from the fibrous network, the latter formed a sort of col- lar which embraced them. Some of the vesicles were very vascular, receiving little trunks of vessels, which run along the fibrous bands. The vesicles could be enucleated entire. They appeared to be formed by a basement-membrane, epitheliated internally, and covered exter- nally with shreds of fibrous tissue." It appears then to be highly probable that most of the apparent fibrous tumors of the ovary differ from undoubted cystic tumors, chiefly in the greater relative proportion of the fibrous walls, and the lesser development of the cysts. Scanzoni's larger specimen referred to above seems to confirm this view. Dr. Wilks, reporting on three tumors of the ovary exhibited to the Pathological Society,^ says, " The specimens referred to afford examples of the various grades of disease which the ovaries may undergo. We may see in them the connection between a hard fibrous tumor and the simple cystic disease. We may have in the first place a multilocular cystic disease ; then a similar disease with the addition of solid fibro- cellular growths between the sacs ; thirdly, a disease made up of the same parts, but where the solid predominates ; fourthly, a uniform fibrous tumor ; and lastly, a hard dense fibrous growth resembling the analogous tumor in the uterus." Dr. Bristowe and Mr. Hutchinson, who also examined the specimens, confirm the opinion of Dr. Wilks, that one of them was of the same nature as ordinary cystic ovarian tumor, but that the intercystic or solid tissue has been developed in a far greater proportion than usual. Dr. Bristowe and Mr. Hutchinson suggest that the absence of mus- cular fibres in ovarian tumors distinguishes them from the uterine tumors. They admit that large fibrous tumors may grow from the ovary. B. Enchondromatous Tumors. — Kiwisch says he has observed two examples of this tumor. In one, cartilaginous concretions surrounded the ovary in the form of numerous scales or rounded protuberances. In the other case the right ovary was entirely transformed into a tumor the size of the fist, surrounded with false membranes of which the external layers inclosed cartilaginous nodules, coarse and hard, whilst the interior of the tumor resembled a cartilaginous mass, hyaline and of less density. ' Pathological Traneactions, vol. ix. CYSTIC DISEASE. 277 CHAPTER XXIX. OVAKIAN CYSTIC TUMORS; THEIR NATURE— SIMPLE ; MULTIPLE; PROLIFEROUS; CYSTO-SARCOMATOUS ; TUBO-OVARIAN— CON- TENTS OF OVARIAN CYSTS: DERMOID CYSTS. Tumors of the ovary may, for clinical purposes, in the first place be divided roughly into solid and cystic. The solid tumors have been described in the preceding chapter. The cystic are the most common, and practically the most important. Ovarian cysts are distinguished by Paget as 1. Simple or barren, containing fluid or unorganized matter; and 2. Compound or proliferous, containing variously organized matters. They may further be usefully distinguished as Malignant or benign. All these tumors, on account of their glandular origin, are grouped together as adenoid. In association with ovarian cysts proper it is convenient, and even necessary, to study certain extra-ovarian or pseudo-ovarian cysts. For example, there are cysts which are developed in the broad ligaments, or which are formed in structures so close to the ovaries that they easily simulate ovarian cysts in the living, and are not always easily distinguished by dissection in the dead. These will be described in the chapters devoted to the Pathology of the Broad Ligaments, and of the Fallopian Tubes. 1 . Simple Ovarian Cysts. — The most simple idea of an ovarian cystic formation is derived from the observation of certain specimens of dis- tension or enlargement of Graafian sacs in the early stage. By ex- amining, for example, such a specimen as that represented in Fig. 67, which represents a section of an ovary in St. Bartholomew's Museum, one cannot help being struck with the appearance of the cysts arranged in a row close to the free border of the ovary, just as the Graafian sacs are disposed in the normal ovary. These are, in fact, morbidly-dilated Graafian sacs. In different specimens we may see similar appearances, the cysts being larger and larger, until their distinct existence is lost by the septa between them being absorbed by pressure and atrophy. That such is the real history and nature of the ordinary simple ovarian cyst is proved by the following observations. 1. The structure of its walls is identical with that of the Graafian sac. 2. Rokitansky^ has found ova in cysts of this kind ; and this very interesting, if not crucial fact, was verified by the late Dr. Ritchie, in 1864, in the ovaries of a woman operated upon by Mr. Spencer Wells. Both tumors contained a number of small cysts, which were evidently enlarged Graafian fol- licles. Mr. Wells submitted the specimens to Dr. W^oodham Webb for examination. Dr. Webb reported^ as follows : " Both the tumors you 1 Wochenblatt d Zeitschrift d. kk. Gesellschaft d. Aerzte zu Wien, 1855. 2 Mr. Spencer Wells, '' Diseases of the Ovaries," 1872. 278 OVARY. sent to me, after their removal from a woman 54 years old, were growths in excess of true ovarian structure. The multilocular character was produced by clusters of ovisacs of various sizes. Ova, with the other Fig. 67. Section of ovary. Early stage of cystic disease. (Nat. size.) natural contents, were to be found in all the small sacs. The fibrous coats of the larger sacs were thickened, and had many secondary sacs develojDcd in them. The interior was lined with epithelium, which in some instances had, by parthenogenetic enlargement and successive bud- FiG. 68. Outer surface of ovary, shovring prominences of dilated Graafian follicles. (Xat. size.) Same spec. as Fig. 67. dings of the cells, given rise to bunches of grape-like growths — re- peated generations of imperfect ova. The whole, therefore, was nothing more than a reproduction in the human subject of conditions which are natural in some of the lower creatures." 2. Dr. Ritchie further says •} "Since Augu,st, 1864, 1 have succeeded in finding ova in a large number of ovarian cysts. Some of the ova were perfect, with a sharply-defined zona pellucida, a germinal vesicle, and a germinal spot ; others were more or less imperfect, many having the appearances mentioned by Rokitansky. I have never found an ovum in a loculus larger than a cherry, and never in a loculus which contained jelly-like contents." ' " Ovarian Phvsiologv and Pathology," 1865. CYSTIC DISEASE. 279 3. Cystic disease of the ovary rarely begins except during the period of normal ovarian activity. Cysts have indeed been found in young girls, even under ten ; but menstruation sometimes is premature ; and some cysts springing from the broad ligaments may have been errone- ously regarded as ovarian. 4. Cysts are more frequent in the ovaries than in any other organ ; and in many respects they differ from the cysts seen elsewhere. The Fig. 69. Showing incipient cystic enlargement of the Graafian follicles in both ovaries. (Middlesex Museum.) small cysts sometimes seen on the peritoneal investment of the ovary and of the uterus are different in nature from the true ovarian cyst. Although it is frequently the case that several, if not many Graafian sacs are affected together, this is not always so. Even in cases where one or more sacs have become so large as to have called for removal by abdominal section, menstruation has continued, and portions of healthy ovary have been found. Frequently the degeneration of the follicles is symmetrical, both ovaries being affected in a similar manner as in the specimen figured (Fig. 69) in the Middlesex Hospital. There is an excellent " Hunterian" preparation in the College of Sur- geons (No. 2616), showing incipient ovarian cystic disease. It is "an enlarged ovary, in the interior of which are numerous small oval, smooth-walled cysts, with distinct thin walls, all probably enlarged Graafian vesicles." Up to a certain point several follicles may enlarge wdth tolerable uniformity, as in Figs. 67, 69. But after a while, one generally takes precedence of the rest, and growing more rapidly compresses them, so 280 OYAEY. that they either remain small, or their walls becoming atrophied and thinned under the compression of their nutrient vessels, the cysts hitherto distinct are fused into one. By a kind of natural selection one obtains predominance, absorbing the others, or destroying them. Sometimes portions of the minor cysts remain in the form of projecting processes, constituting chambers or loculi, communicating with the large cyst. In this way what are called multiple cysts are formed. They are really simple in their nature. Although multiple in number, they are nothing but agglomerations of simple cysts, and do not, collectively any more than singly, possess the distinctive property of the compound or proliferous cyst, that of self-multiplication by endogenous gemma- tion. In some cases there appears to be one, or chiefly one, follicle affected, and when this happens this follicle may be found not at the periphery of the ovary, but deeply imbedded in the stroma. In these cases it is reasonable to surmise that the ovum was prevented by the thickness of the surrounding structure from making its way to the surface at the proper time ; that the effort would result in distension of the sac, the outpouring of an excessive quantity of blood into it ; and hence, if the epithelial lining retained, as it is likely to do, its proliferous virtue, the gradual formation of a cystic tumor. In University College Mu- seum (T f ) is a good specimen of hemorrhage into the ov^ary. In Guy's Museum is another specimen (No. 2231^"), showing " an ovary much distended, having been filled with blood." (See Fig. 65.) Dysmenorrhoea is in my experience a frequent antecedent of ovarian dropsy, when this disease begins during the period of ovarian function. This observation corroborates the opinion that some obstruction to the due maturation and escape of ova is one cause. It has often been con- jectured that a single life, by suppressing one ovario-uterine function, led to abnormal action of the formative-force. Out of Mr. Spencer Wells's 500 cases, 221 were unmarried and 18 were widows. On the other hand, the complication of ovarian dropsy with pregnancy is not very uncommon. What is the beginning of this transformation of the Graafian folli- cles ? The formative-force is peculiarly active in the ovary. If inter- rupted or hindered in its ordinary progress, it may be supposed that, still persisting, it will reveal itself in abnormal results. In University College Museum (No. 866) is an interesting specimen, which may serve to illustrate the effect of obstruction to the healthy course of menstrua- tion. It exhibits cysts in the ovaries and tubes, and a fibroid tumor of the uterus inside, which probably obstructed the uterine openings of the tubes. Rigby says he traced in one case an ovarian dropsy from its beginning in oophoritis. Scanzoni says there is no doubt that dropsy of the Graafian follicles is sometimes caused in this way : the menstrual congestions in the ovaries do not attain sufficient intensity to effect the bursting of the follicular wall, and the result is that an increase of secretion and its accumulation in the cavity thus takes place. The follicular wall is thus gradually hypertrophied, and by the formation of new vessels causes a permanently increased secretion. The com])ara- tively great frequency of these follicular dropsies in women who have CYSTIC DISEASE. 281 long suffered from chlorosis or other diseases, combined with amenor- rhoea, speaks in favor of this view. The principal varieties of the complex or 'proliferous ovainan cysts have been described, as Paget truly says, "to the very life" by Dr. Hodgkin, to whom we are indebted for the first knowledge of their true pathology. Hodgkin divides them into two principal or extreme forms of endogenous cysts : namely, those which are broad-based and spher- oidal, imitating more or less the characters of the parent cyst, and those that are pedunculated, clustered, and thin-walled. Between these forms many transitional and mixed forms may be found. A typical example of the first is in the Museum of the College of Surgeons (figured p. 417, Paget). It is a large cyst, with tough, compact, and laminated walls, polished on both their surfaces. On its inner surface there project, with broad bases, many smaller cysts, of various sizes and variously grouped and accumulated. These nearly fill the cavity of the parent cyst ; many of them are globular ; many deviate from the globular form through mutual compression ; and within many of them are similar but more thickly-walled cysts of a third order. Respecting tlie mode of generation of the endogenous cysts, they appear to be derived from cell-germs, developed in the parent cyst- walls, and thence, as they grow into secondary cysts, projecting into the parent cavity ; or disparting the mid-layers of the walls, and remaining quite inclosed between them ; or more rarely growing outwards, and projecting into the cavity of the peritoneum. Dr. Wilson Fox^ says, " All the forms of cysts met with in the ovary originate from the Graafian follicles, and that the multilocular forms are not the result of any special degenerations of the stroma of the ovary, but are due to secondary formations from the interior of parent cysts thus formed." He divides them into three classes. The first and most frequent manner in which secondary cysts are formed is the result of the production of a series of glandular structures, presenting a tubular type, on the inner wall of the parent cyst. Dr. Fox describes the mode of formation of these glands as differing from those of other glands, which for the most part originate in the embryo as diverticula from surfaces. The process in this case commences with a stratification of the epithelium, into which project papillae formed of the stroma of the wall of the parent cyst, each papilla carrying a delicate vascular loop. Villi more or less densely clustered are thus formed, which may persist as such, and these, according to Wilks, Friedreich, and Luschka, may become covered with ciliated epithelium ; but in a large number of cases they become converted into tubular structures of the upward growth of the stroma around their bases. Cysts may be formed while they are thus situated on the surface, from the occlusion of their orifices by mu- tual pressure ; but most commonly the growth of the stroma, by which this tubular character was first determined, continues until they are completely imbedded in the wall and covered by a fresh layer of the stroma, the surface of which may again become the seat of a new and similar growth of glands and villi. Masses of glands thus imbedded Medico-Chirurgieal Transactions, 1864. 282 OVARY. are dilated into cysts by their own secretion, and from the semi-solid masses which project into the interior of the parent cysts, and in them similar processes may be repeated indefinitely. Dr. Fox believes that he has traced in the variations between the relative growths of the stroma and these glands, which Mr. Wells described as " fibro-epithe- lioma," or "alveolar adenoid tumor," the source of those varieties in the density of these masses which have given rise to the names of " alveolar disease of the ovary," or " cysto-sarcoma of the ovary." The histology of these tumors is well illustrated in Figs. 70, 71, for which I am indebted to Mr. Henry Arnott. Fig. 70 represents three thin sections from the solid stromal portions of a multilocular cystic tumor, removed by Mr. Croft, in jN'ovember, 1872. The specimens were fresh and stained with carmine. All show varieties of developing fibrous tissue. a. Dense connective tissue, studded with irregular rod-shaped nuclei ; the outlines of the cells not discernible. b. Delicate connective tissue, with slender cells at rare intervals. c. Rapidly-growing connective tissue, rich in nuclei, plump and oval, which can be seen here and there, to be contained in lai'ge spindle- cells. Fibrous stroma or compound cystic tumor of ovary. — (By H. Arnott.) Fig. 71 shows epithelium from the inside of the same compound cystic tumor. a. Detached flakes of columnar epithelium, viewed sideways. 6. Part of a large surface of epithelium, lining a small cyst ; showing the polygonal aspect of the columnar cells as seen from above, and CYSTIC TUMORS. 283 showing, besides, dilatation of the wall, in which the cells appear swollen and partly out of focus, rendering their nuclei less distinct. Cysto-sarcoma of the ovary. — Miiller applied this name to those tumors in which the fibrous iiitercystic substance equals or exceeds in quantity the contained fluid. However, all degrees may be observed in different tumors, and we cannot therefore venture to separate ab- ruptly ovarian cystic tumors into diflFerent classes. Good typical ex- amples of all of them— a, the simple; b, the simple but multiple cyst; c, the proliferous or compound cyst ; d, the proliferous or compound cyst, with colloid contents ; e, the proliferous, with large sarcomatous formation — may frequently be met with; but in a large majority of instances, ovarian tumors share the characters of two or more of these varieties. The more active the proliferous tendency, the further the departure from simplicity of organization, the more nearly does that tumor approach in its relations to malignancy. Whether, however, any form of ovarian tumor, excepting the fungoid (medullary) is truly cancerous in its tendencies, is a matter of much doubt; and practically all must be treated as if it were proved that they are not so, unless they are solid. Brodie called these sero-cystic sarcomata. Fig. 71. X 220 Epithelial lining of a compound ovarian cyst. — (H. Arnott.) Alveolar or colloid tumor of the ovary is a not infrequent form of the compound cyst. It contains very numerous loculi, which are filled with a semi-solid tenacious substance resembling gum. It, however, often complicates tumors in which many cysts contain fluid, and which resemble those of the common compound form. There is much reason to doubt whether the usual tendencies of true cancer are ever mani- fested by it. 284 OVARY. Fig. 72, taken from a specimen in University College Museum, pre- pared by i)r. Fox, exhibits a section of the colloid or alveolar tumor. Fig. 72. Univ. Coll. Mus., No. 5054 (from nat. half-size.) Section of an ovarian tumor showing the alveolar structure. Fig. 73, also from a preparation in University College Museum, exhibits a form of proliferous cyst. Both ovaries are affected. In one the cyst is perforated by a dendritic proliferation. By eccentric pressure, the result of endogenous growth, the capsule of the ovary has given way, so that the dendritic processes project on the surface. Tubo-ovarian Cysts. — Adolphe Richard^ first described a form of cyst, into the composition of which both the Fallopian tube and the ovary entered. He detailed five observations, and cited analogous cases from Morgagni, Frank, Chambon, Boivin and Duges, Kiwisch, and others. He demonstrated that ovarian cysts may open into the uterus by the tubes ; that after having received the fluid of the cyst, the tube con- tinues to undergo a pathological action, by which its calibre in- creases, its length being doubled, its walls thickened, the folds of its mucous membrane smootlied out ; that lastly, the dilatation extending gradually to the internal part of the oviduct, the communication be- tween the canal of the dilated tube and the cyst remains, and there is thus made up a cavity or cyst compounded of dilated tube and the ovarian cyst. My former colleague at the Western General Dispensary, Mr. An- derson, described a clear case of tubo-ovarian cyst. A woman who was waiting to be tapped began to pass an excessive quantity of urine, and 1 Memoires de la Society de Cliiniririe, 1856. CYSTS. 285 her distress subsided. The fluid passed was albuinenized serum, with cholesterin plates. After six months the woman died from a sudden outburst of haemoptysis. A large empty cyst was found lying, col- lapsed and loose, in the belly ; it had thick walls, and included some lesser cysts. A good-sized staff passed with the greatest facility from Univ. Coll. Mus. (from nat. two-thirds size.) Both ovaries affected with proliferating malignant disease. Dendritic processes perforatinQ the investing structures. the cyst along one of the Fallopian tubes into the uterus and vagina. The supposed urine did not come from the bladder, but was cystic fluid which escaped by the tube, uterus, and vagina. Boinet relates a case interesting in its bearing on this subject, A young married lady, some months after her last labor, and after exces- sive excitations, felt acute pain in the ovary, simulating local peritonitis. The ovary swelled considerably, and soon became as big as a fist ; all. the signs of acute ovaritis of the most intense degree existed, and Boinet feared rupture of the ovary, or the formation of an abscess in the iliac fossa. She had fever, shiverings, vomiting ; a fatal issue was apprehended. Something burst, and there escaped by the vagina a quart of watery fluid, albuminous. The symptoms subsided ; but for three years afterwards, fluid of the nature described escaped from the vagina. It is conjectured that in this case a Graafian follicle burst into the adherent tube. We may conclude then, that tubo-ovarian cysts may be formed : 1. By the establishment of a communication between an ovarian cyst and the Fallopian tube, the outer end of which dilates to form one 286 OVAEY, cavity with the opened ovarian cyst ; 2. By the bursting of a Graafian follicle, diseased or healthy, under circumstances which provoke peri- tonitis and the formation of adhesions uniting the fimbriated extremity of the tube to the ovary, the communication with the Graafian sac being maintained or not ; 3. It is possible that a tubo-ovarian cyst may be formed in a different way from the two preceding. The tube may be distended from carrjdng pus or irritating matter, and set up inflammation, which gives rise to plastic eifusions binding the fimbri- ated extremity to the surface of the ovary. Most frequently the matter escapes into the peritoneal cavity, and the peritonitis is widely diifused ; but it may be wholly or in great part surrounded by the rapid throwing out of plastic matter, which forms a cyst of the kind described. It is possible that the cysts represented in the annexed drawing (see Fig. 74) from Carswell's Pathological Anatomy are of this kind. (Half-size.) — Carswell. a. Uterus, h. Fallopian tubes, d. Tubo-ovariau cyst. The characteristic of these cases is their rapid formation under symp- toms of ovaritis or peritonitis following upon sudden escape of ovarian fluid by the vagina, where there had previously existed a tumor, or symptoms of acute ovaritis or peritonitis with rapidly-forming swelling. CysU from Development of ivandering Ova. — That ova impregnated, and especially non-impregnated, occasionally fall into the abdominal cavity, not being caught by the Fallopian tube, there is every reason to believe. When discussing the pathology of retro-uterine heemato- cele, and of extra-uterine gestation, this accident will be again referred to. In this place it is only necessary to refer to an hypothesis of Boinet, that ova which have gone astray in this manner may give rise to cystic growths : " May not," he asks, " that happen for the forma- tion of cysts of the ovary, which happens for fecundated vesicles ? These are sometimes developed in the ovary itself, or in the Fallopian tube, or in the peritoneum, constituting abnormal gestations. May it not, then, liappen that the non-fecundated ovum, diseased through causes referred to, may be pathologically developed either in the ovary CYSTS. 287 where it remains fixed, or in the tnbe wliich it has reached, as at the moment of fecundation, or lastly in the peritoneum, into which it has fallen f Contentu of Ovarian Cysts. In the following condensed sketch of the contents of ovarian cysts, I borrow freely from the more minute accounts given by Scherer and Mr. Wells. Beginning with the normal Graafian vesicle, as a point of departure, we find it to contain a minute quantity of a slightly viscid, whitish- yellow albuminous fluid resembling the serum of blood. It is alkaline, of pale whitish-yellow color, and transparent. It is not ropy nor viscid, but limpid, readily separating into minute drops. It contains a small quantity of a substance which Avill coagulate with alchohol, or when exposed to a raised temperature. It holds in suspension spher- oidal, nucleated epithelial cells, and shreds of epithelium from the membrana granulosa of the ovisac. Under certain pathological conditions, by which either the Graafian follicles enlarge or new cavities are formed, the contained fluids are altered, and may conveniently be arranged into three groups, according as they resemble the normal fluid of the ovisac, or as they become more or less ropy and viscid, or as in consistence they resemble mucus. The fluids of the two last groups are frequently met with in multi- locular cysts, and in the alveolar and colloid tumors. The contents of the simple cysts consist commonly of a clear, limpid, pale-citron or straw-colored fluid, which flows in a stream as readily as blood-serum, or even more so. Scherer demonstrated the presence of paralbumen and metalbumen, as albuminates peculiar to ovarian fluids. Fibrinogen is also a constituent, and may be demonstrated by applving Dr. A. Schmidt's test, which is the addition of a few drops of blood to the fluid, when a distinct clot will form in from twenty -five to ninety minutes, involving the blood-corpuscles which had been added. The clot is generally so firm that it can be raised unbroken, and if squeezed in the hand a quantity of fluid issues, leaving a loose Ijundle of fibrillated substance. Cholesterin crystals are sometimes seen in the fluid of simple cysts, and may be detected by their glisten- ing in the stream as it flows through a canula in tapping. After standing a while, these crystals form a pellicle on the surface of the fluid. Scales of epithelium are almost always found floating in it. It must not, however, be assumed that even in simple cysts the fluid is always clear. Pus or blood is occasionally found ; and pus is occa- sionally apt to be found on a second or subsequent tapping, although the flaid drawn by the first tapping was perfectly clear. Admixture of pus and blood will aflect the color variously, according to the period and quantity of the eifusion. Thus it may be yellow, green, brown- ish, or red. The turbidity of the fluid generally depends upon the admixture of these secondary matters. The greatest variety of contents, however, is found in the compound cysts. It is no uncommon thing to find clear thin fluid in one cyst, turbid greenish or brownish fluid in another, purulent matter in a 288 OVARY. third, and colloid or gelatinous or syrupy tenacious matter in other cysts. When a compound cyst has once been tapped, as it refills the contents are pretty sure to alter in character, becoming mixed with pus and blood. Mr. Wells observes that the more consistent colloid sub- stances are occasionally distributed in a very peculiar manner. They form conical columns, with their broad bases directed out-wards. Be- tween these almost isolated columns a whitish or yellowish-white mat- ter, consisting of epithelial cells in a state of degeneration, is placed without any definite arrangement. Such cysts have probably been formed by the confluence of smaller cysts, of which nothing remained but the epithelial investment, undergoing fatty decay, and so tracing out the former lines of separation. The chemical and microscopical characters of ovarian fluids have been elaborately described by Eichwald.' The first group oi abnormal fluids, very liquid^ are generally found in molecular cysts with a smooth internal surface invested with a layer of pavement-epithelium. Their specific gravity ranges from 1003 to 1006. They have no odor, and are either neutral or slightly alkaline. The following analysis repre- sents the average composition : Water, 98'2.5 Minrral suits (sulphates, chlorates, pliosphates), . ll^.O Organic salts (lactates), ..... 4.0 Chcilesterin, occasionally traces. Alhuniinose, ........ 1.5 1000.0 These fluids are devoid of fat and albumen. In the clear slightly ropy fluid of some of the small cysts in the broad ligament, minute flakes are occasionally found. They are granular, with a minute round or irregular cumulus of fatty granules in the centre. The Second Group of Liquid but Ropy Ovarian Fluids. — They are of the consistence of oil or syrup, and frothing when shaken. They are clear amber or lemon-colored, or pinkish like the peritoneal fluid. The reddish fluids, after standing, deposit the red blood-corpuscles to which they owe their color. These fluids may become turbid, and of gray- ish, yellowish-green or whitish color, from the presence of cells and oil- globules, which they hold in suspension. Their reaction is alkaline; specific gravity, 1009 to 1018. Heat, alcohol, and nitric acid will coagulate them like blood or ascitic fluid. Baedeker, Thudichum, and others have found leucin. In the fluid will generally be found epi- thelial cells, principally the pavement-epithelium, which lines the cavity of the cysts. Besides these, there will be always white blood- corpuscles, sometimes red blood-corpuscles, due to capillary hemor- rhage from the inner surface of the cyst. The fluid in very old cysts becomes thicker, and assumes the consistence and color of cofl'ee- grounds. It will also contain granules of htematosin from disinte- grated blood-corpuscles.' ^ Wiirzburg ^Mediziiiische Zeitschrift, 18(34. CYSTS. 289 Third Group — Viscid and Ropy Fluids. — These fluids or substances are generally clear, colorless, or of a grayish tint, and semi-transpar- ent. They are viscid, adhesive, resembling the vitreous humor of the eye, or are jelly-like, breaking up into lumps. They will not pass, or only with difficulty, through a canula. They are alkaline or neutral; specific gravity 1010 to 1015 : in colloid cysts it is as high as 1040 or more. They coagulate when exposed to high temperature, just like the white of egg, to which they sometimes bear a great resemblance. The variations depend upon the conditions of the principal components, the colloid bodies and the mucus, and the intermediate stages of meta- morphosis from one to the other. Epithelial cells and blood-globules are also found. They contain certain quantities of mineral salts, crys- tals, or crystallizable principles of organic origin, as fats, and certain principles nearly allied to alkaloids, viz., urea, creatin, leucin, crea- tinin, &e. The microscopical analysis shows fat-granules and globules, large colorless colloid globules, with delicate margins and a large transparent centre, either perfectly homogeneous, or dotted with fine black spots. Some colloid globules inclose one or more granulated aggregations. There may also be found a large quantity of small circular corpuscles, clear, with a dark margin, containing a varying number of fine dark molecules, and sometimes, also, several larger granules of high refract- ing power. They appear to be identical with the pyoid bodies of Le- bert, or the exudative cells of Henle. Cholesterin crystals are found in great quantities. Pigment, of dark brown, reddish-black, or black color in granules of different sizes, is found. The Structure of the Alveolar or Traheculated Framework of Cystic Tumors. — The walls of the alveoli, near the base of the tumor, con- sist mostly of an areolar tissue, interwoven with elastic fibres. The stroma will be found undergoing a retrograde transformation in various stages of fatty metamorphosis. The majority of the alveoli are lined with a columnar or pavement-epithelium. The epithelial lining is generally covered with a layer of semi-opaque matter, consisting of exfoliated cells, colloid globules, granulated cells, horn cells, or pyoid bodies. The trabeculse of the alveolar stroma consist of areolar tissue in various stages of development. The intercellular substance of the trabeculse possesses the chemical properties of mucin; when treated with acetic acid it coagulates into threads. In some portions of the denser stroma alveoli may be found occasionally, the walls of which consist of fasciculi of genuine fibrous tissue. Some of the alveoli are so densely filled with cells that intercellular substances can scarcely be discovered ; others may be found entirely devoid of cells. They con- tain instead a mucous substance, rendered more distinct by the addition of water, which makes it contract. It coagulates into membranous threads when treated with acetic acid, and dissolves in alkalies. The inner surface of the walls of alveoli of considerable size is in- vested with a layer of epithelium, Avhicli gives the character of true cysts. In large colloid cysts fatty decay is a very common occurrence, and 19 290 OVARY. portions of the walls and septa are destroyed. It presents itself to the nal?ed eye in irregular patches of dirty brown or yellow color, bordered by the raised edges of the surrounding healthy tissue. They are brittle, and easily broken up. The lining epithelium has also undergone fatty metamorphosis. These changes are due to the compression and obliter- ation of the capillary vessels. In some cases these vessels may be traced filled with a brown finely-granulated substance. Hemorrhage frequently takes place from such partially-destroyed vessels. The contents of the alveoli are mixed with and suspended in a semi- fluid medium, consisting principally of modified mucin, which seldom contains albumen coagulated by heat, free albumen or septon, but oc- casionally traces of albuminate of soda. It is a thick creamy fluid, of greenish-white color, not unlike the sputa in chronic bronchitis. Its reaction is alkaline. CHAPTER XXX. CUTANEOUS PKOLIFEEOUS CYSTS; OE, DEEMOID CYSTS OF THE OVAEY. Lebert gives the name of "dermoid cysts" to those structures, either in newly-formed or in pre-existing spaces, which show on the inner surface of a sac, new formations, whose identity with the struc- tures of the skin is unmistakable, as bone, cartilage, teeth, and hair. The walls are generally very thick. The inner surface is either smooth, or in places there are prominences. The superficial layer of the inner surface consists of thick layers of pavement-epithelium. Indeed", elements representing all those of skin are found. Hair, fat- glands, sweat-glands, are recognizable; so that along with hair we find the contents of the cyst to be a yellowish, fatty unguent, made up of free fat, cast-off" pavement epithelial cells, and cholesterin crystals, which sometimes distinctly glisten. The general likeness of the interior of the cysts to skin had been often noticed. Kohlrausch demonstrated it. It was at one time thought that these dermoid cysts were the result of an incomplete fructification of an ovum. But Baillie found them in children wlio had never menstruated ; and anatomists now gener- ally agree that they are quite independent of conception. Brain-matter has been discovered in cysts of this kind by Gray, Chalice, Friedreichs, and Rokitansky. Friedrciclis even found recently- DERMOID CYSTS. 291 formed strong cords of broad nervous branches, and unipolar and bipolar pigmented ganglionic cells. Virchow has seen a similar case ; and the same pathologist has also described muscular fibres. Bone is sometimes developed. It is found in small scales or lamellae in the areolar tissues beneath the skin-formation. These, as they grow larger, acquire the most extraordinary shapes, with branches and spiculse. The osseous structure itself is that of genuine bone, the Haversian canals and bone- cells being arranged in lamellae. There is little doubt that in the living body the fat often exists in the fluid state. Thus there is a specimen in Guy's Museum (No. 2237-") which, when opened, poured forth fluid fat, which immediately solidi- fied. In another specimen (No. 2235) the fat was wholly soluble in ether. The hairs were imbedded in the usual way in the sheaths ; and abundant, large, well-formed sebaceous follicles opened into the hair- tubes. The source of the fat in these cvsts is therefore clear. A dermoid cyst of the ovary. From specimen in St. Thomas's Hospital Museum. (Half-size.) Mr. Wood exhibited a tumor removed from the body of an old woman, which contained hairs, and fat, no doubt fluid during life, as it melted readily on being exposed to heat equal to that of the body. (Path. Trans., vol. x.) Dr. Hare mentioned another case where solid fat was found in an ovarian cyst after death, but which melted at 85°. (Path. Trans., vol. iv.) Dr. Ramsbotham (Path. Trans., vol. iv) describes a case of labor obstructed by a tumor in Douglas's space. The tumor was punctured by a long trocar through the vagina; a large teacupful of thick, yel- lowish matter, like thick custard, ^yas collected ; it became solid when cool, and consisted of fat-globules. As shown in tubes it looked like butter. The tumor before puncture felt quite solid, no doubt from tension. Two cases, quoted from Ingleby, gave the same characters. 292 OVAEY. Hence, Rarasbotham says, every tumor impeding labor should be punc- tured. His patient recovered. They do not grow exclusively in the ovaries. There are two kinds. Those which grow in the ovaries, which are the most frequent; and those which grow in other parts. Both kinds, says Paget, may be regarded as diseases of the same general group with the cutaneous pro- liferous cysts. The great formative power which they manifest is con- sistent with their occurring only in embryonic life, and in the ovaries, in which, even independently of impregnation, one discovers so many signs of great capacity of development. This active formative power is remarkably illustrated in the follow- ing case, presented to the Pathological Society (Path. Trans., vol. viii) by the late Mr. Moore. The abdomen was larger than at full period of gestation. An opening formed near the navel, and discharged pus. The opening was enlarged by incision, and about seven pounds of stuff like putty was removed. Vomiting came on, and the patient died. There was one vast cyst adherent at every part of its surface, except near the bladder. The wall was tough, in part cretaceous. It contained hair, adherent and loose, and perfectly-formed teeth. The right ovary and tube were a little enlarged. Uterus healthy, but elongated. Left ovary not discovered. Among the peritoneal adhesions were many small cysts, some of which were attached by slender pedicles to the main cyst, whilst others were entirely unconnected with it, but like it contained soft, cheesy, yellow epithelium, mixed with hairs. These cysts were either formed from the principal ovarian cysts, or they sprang up in the places in which they were found. Either the cysts, now separate, were once parts of the primary cysts, and loosening themselves by the lengthening, and then by the rupture, of their pedicles, they started in independent life ; or, though formed in the wall of the main cyst, they were cast loose at their first extru- sion from it. Now, an inspection of the interior of the large cyst shows that sec- ondary, or rather smaller, cysts had burst into it. Others, likewise, may have burst outwards into the peritoneum, and forming adhesions, nourished themselves at the expense of the adhesions in which they were lodged. These tumors are often the seat of inflammation ; and by ulceration or wasting of their walls, communications are established either with the exterior through the abdominal walls, or with the internal hollow viscera ; and hair, fat, and bones being discharged, give rise to the suspicion of an extra-uterine gestation. Dr. Gibbes^ relates a remarkable case, in which labor being termina- ted by the forceps on account of syncope, the patient was harassed by the most intractable after-pains. A tumor was discovered above and behind the pubes, distinct from the uterus, and movable. On a sub- sequent day this tumor was felt per vagi nam in the anterioi' cul-de-sac. It then increased rapidly to the size of the largest shaddock ; and it was considered necessary to remove it. This was done, as by the operation for ovariotomy. It grew from the left broad ligament. About three 1 Amer. Journ. of Med Sc, 1869. DERMOID CYSTS. 293 inches of the Fallopian tube were included in the ligature. The cyst contained pus and a mass of tine black hair. Menstruation occurred at several successive monthly periods through the wound. The patient ultimately recovered. When these cysts are of ovarian origin the symptoms they produce are generally similar to those which attend other ovarian growths. They spring from the same seat; they extend in a similar manner. But they differ in several respects. Their rate of growth is usually much slower. They often date from an earlier age. They are mostly more solid and irregular in shape. Fluctuation is rarely so distinct or diffused ; this symptom indeed is not often developed, except as the result of suppuration. Dermoid cysts rarely attain so large a size as the dropsical tumors do. They more commonly terminate by setting up inflammation between some part of their walls and neighboring structures, and in this way effect communications with the hollow organs, as the intestinal canal, or the bladder, or else they form fistulous openings externally through the abdominal wall. In all these respects they more resemble the abdominal cases of extra-uterine gestation. For these indeed they are often mistaken. If foetal bones are discharged, it may be concluded that the case is one of extra-uterine gestation. It is rare, however, that this formation of fistulous outlets is attended by a cure. It is undoubtedly an attempt at elimination, but one which is only partially successful. The attempt is towards the surface; the wall of the tumor forms adhesions with the abdominal wall; inflamma- tion attacks the skin, an erysipelatous blush appears; the skin is thick- ened, tender ; fluctuation appears ; an abscess points and bursts, if it be not opened by the surgeon. The elected seat is generally near the um- bilicus on one side. Nothing but pus may be discharged ; the swelling undergoes little diminution ; suppuration goes on ; the signs of hectic or irritative fever set in. Sometimes masses of hair, matted together, and quantities of fatty matter, may be present and be dragged out from the opening. This may go on for a long time, emaciation proceeding, and exhaustion ending in death. Teeth usually remain adhering to the w^alls of the cyst. When these tumors form a communication with the bowel or bladder, the course of events is similar. Pus, mingled wdth hair, escapes from time to time, producing attacks of severe pain. When these cysts form a communication with the bladder, as they not infrequently do, the most puzzling symptoms are apt to arise. Dysuria may harass the patient for years ; generally cystitis supervenes, and sometimes attacks of retention of urine occur. When fatty matter or hairs make their escape, the diagnosis is pretty clear, especially if a tumor be observed in one or other groin or at the pelvic brim. The cyst occasionally relieves itself partially at intervals, and then may be felt to diminish in size. The symptoms set up may be so severe, either by threatening life by acute inflammation or by obstruction to the blad- der, or by exhaustion from irritative fever, that an operation for removal of the tumor may be indicated. The operation for extirpation must be conducted on the same principle as that for extirpating ordinary cystic 294 OVARIAN TUMORS. tumors of the ovary. But to relieve the bladder it may sometimes be enough to dilate the urethra, and bring away the offending matters. That their course is sometimes slow, that their developmental .power may be very languid or suspended, is proved by their being occasionally found of moderate size on making autopsies in persons who have died of independent diseases, their existence during life having been unsus- pected. In a considerable proportion of cases the termination seems to be accelerated by pregnancy and labor. The pressure of the gravid uterus and of the child during labor probably injures the cyst, and disj^oses it to inflammation. These tumors are exceedingly apt to contract intimate adhesions with the viscera amongst which they are imbedded. Treatmoit. — When there is evidence by pointing of working towards the surface, it is wise to open the abscess by a bistoury. This should be done cautiously, to a limited extent, in the first instance. The in- cision may be subsequently extended, perhaps crucially, and the cavity of the cyst explored by sound and finger. In this way we may facili- tate the evacuation of the contents ; masses of hair may be seized by forceps. The cavity may be washed out with Condy's fluid, or weak carbolic acid. Generally a fistulous opening remains for an indefinite time, leading to hectic fever. It is therefore desirable to make tentative incisions with a view to extirpation. The adhesions they are so apt to contract will, however, often frustrate the attempt. It might be justi- fiable to lightly cauterize the inner surface of the cyst with the galvanic cautery, to modify its character. It is scarcely probable that much inflammation would be excited in surrounding healthy structures, and when the sloughs had been discharged, the cyst M'ould contract and the fistulous opening close. CHAPTER XXXI. NATURAL COURSE AND TERMINATIONS OF OVARIAN TUMORS. The terminations of ovarian cystic tumors are various ; but the progress is generally towards a fatal issue. 1. They tend to go on growing by accumulation of fluid until the distension is too great to be borne. The cyst pressing in all directions, and not al)le to extend backwards or much into the pelvis, stretches the abdominal walls in front, and the diaphragm above, driving the intestines backwards and even encroaching upon the cavity of the chest. COURSE. 295 The circulation is impeded by the pressure upon the aorta and vena cava. The functions of the viscera, abdominal and thoracic, are im- peded by pressure. The viscera undergo a degree of shrinking or atrophy. Nutrition and respiration and circulation being imperfect, in the end exhaustion ensues. In cases of long standing, some amount of compensation is effected by dilatation of the superficial veins of the abdomen. Sometimes, but by no means commonly, relief is sought by serous effusion in the legs. More or less oedematous thickening of the integuments of the lower abdomen, where the overhanging of the tumor is greatest, is not infre- quent. Probably the effusion into the cyst itself acts as an accom- modating process. 2. Sometimes death occurs rapidly or suddenly from asphyxia, owing to the pressure upon the heart and lungs. Mr. R. F. Battye relates a case of this kind in a girl aged 13. (Obstr. Trans., vol. ii.) 3. As Dr. Bright says, some state of unexpected collapse, for which no reason can be assigned, takes place, and the jaatient sinks. I have seen several such instances. One lately occurred at St. Thomas's. A young woman w^as admitted with a large ovarian cyst which had formed rapidly. Tapping was contemplated, but before it w^as performed, death took place almost suddenly under symptoms of lung distress. It was conjectured that rupture of the cyst might have taken place; but the cyst w^as found so universally adherent that there was no spot whence effusion could take place. The diaphragm was driven up so as to confine the heart and lungs within the narrowest space. The lower lobes of the lungs were so compressed that they presented a foli- aceous appearance, resembling the atelectasis of new-born infants. In this way a considerable portion of the lungs was disabled. I concluded that under the impetus of some excitement or exertion, the heart and lungs were suddenly taxed beyond their feeble powers of adaptation, and that thus asphyxia was induced. In these cases of very large tumors there is not only encroachment upon the space naturally per- taining to the thoracic organs, but the chest-walls are nearly fixed. The proper respiratory movements are restricted, so that on any sudden impetus to the circulation or respiration, the balance is destroyed and asphyxia results. 4. The cyst being free from adhesions, and tolerably firm, may roll over on its axis. This may happen from the enlargement of the uterus tilting it over, or from overexertion, when one part of the tumor being more pressed upon than the opposite part, it rolls over. The effect of this axial twdsting is to strangulate the pedicle ; the bloodvessels can- not return the blood from the tumor, so congestion and bursting of the vessels follow. Hemorrhage into the cyst, leading to sudden dis- tension, causes shock and anaemia sufficient to cause death, without rupture of the cyst and hemorrhage into the peritoneum, which may, however, also happen. Should the patient escape the more immediate danger of death from shock, hemorrhage, and peritonitis, the strangulation of the tumor is almost sure to lead to gangrene. But when the strangulation takes place very gradually, or when the 296 OVARIAN TUMORS. tumor is not very vascular, atrophy taking place slowly, and the pedicle being constantly stretched, complete separation has taken place, the tumor becoming loose ; or the tumor may shrink without being detached. I have related two cases of this axial twisting in St. Thomas's Hos- pital Reports, 1870. In one case the rotation was caused by the growth of a gravid uterus ; in the other there was no pregnancy, and the rotation was in all probability caused by severe bodily exertion. Dr. St. John Edwards of Malta relates a case (Lancet, 1861). The subject had gone through one labor M'ithout mishap, notwithstanding the complication with a movable ovarian tumor ; in a second preg- nancy labor supervened at the seventh month, collapse and death ensued ; the tumor was found twisted and strangulated. Mr. Lawson Tait relates another case. Dr. Kidd (Dub. Quart. Journal, 1870) relates one in a non-pregnant girl. On this subject much valuable in- formation may be gathered from a memoir by Rokitansky (Allg. Wiener. Med. Wochenschr., 1870). He describes many dissections which show: 1. Atrophy and twisting of a Fallopian tube, through the dragging of its ovary, as by an ovarian fatty cyst or serous cyst, which in its growth may pull, stretch, and rend the attached tube. 2. Tearing asunder of a tube through the dragging of pseudo-mem- branous adhesions, as through adhesion of the right tube to the small intestines. 3. Tearing asunder of a tube or corresponding ovary, as w^hen the tube and ovary adhere in the recto-vaginal space ; the tear- ing being caused by the uterus enlarging in repeated pregnancies. 4. Axial twisting. Professor Turner also has contributed a valuable memoir " On Separation and Transplantation of the Ovary due to Atrophy of the Broad Ligament and Fallopian Tube." (Edin. Med. and Surg. Journ., 1861.) But twisting of the pedicle may lead to a more happy result. The compressed vessels supplying no nutriment to the tumor, atrophy and shrivelling may take place, and thus a spontaneous cure. The remains of such tumors have been found sometimes in Douglas's pouch as a hard, solid, partly cartilaginous substance. 5. Simple dragging of the stalk may lead to the same results as twisting. This dragging may occur from a growing uterus pushing the tumor up ; from adhesions being formed, fixing the ovary in the pelvis, when the growing uterus will drag out the ligament ; or the ovary has contracted adhesions higher up, so that when the uterus re- treats again to the pelvis, the ligaments are stretched. (Klob, Roki- tansky.) 6. It is probable that some cystoids of the ovary .undergo a kind of atrophic involution, which may be regarded as a spontaneous cure. In old women the ovaries are sometimes found as agglomerates of smaller or larger degenerated cysts, seated in an extremely hard thick stroma. On tlieir inner surface are seen papillary outgrowths, likewise converted into hard knots. Such formations, says Rokitansky, must be regarded as involved shrunken cystoids. 7. Small tumors getting into Douglas's si)ace may push the uterus forward ujion the bladder so as even to cause retention of urine. In COURSE. 297 the case of large tumors, the neck of the bladder is sometimes pulled up along with the uterus, so that the control of the sphincter is im- paired. Hence enuresis. This trouble is also created at times by the pressure of a large tumor downwards upon the bladder. Bladder dis- tress is even more likely to arise when the tumor is the centre of a mass of adhesions impeding the mobility of the pelvic organs. Cystitis and uraemia may even be induced, and thus cause death. Or the tumor may so press upon the kidneys and ureters, as in a case told by Wells, that the kidneys may be almost obliterated, and thus produce ursemia. 8. In like manner ovarian tumors may encroach upon the rectum, causing at times obstruction to the passage of fseces. A fatal case of obstruction of the rectum by an enlarged ovary is re- lated by Dr. Parker (Ed. Med. Journ., 1863). Dr, Parker's patient suffered periods of constipation prolonged to several weeks. A dense tumor occupied the space between the vagina and rectum, almost filling up the upper two-thirds of the pelvis. It could not be dislodged. The gum-elastic catheter could not be passed beyond the mass to the promontory of the sacrum. Fluctuation was detected in the mass, and projecting cysts were tapped per vaginam. A few ounces of fluid escaped. The patient ultimately died from the effect of the disease. 9. Another mode in which ovarian tumor may cause rapid death is by ileus. Vomiting, perhaps of stercoraceous matter, and the other symptoms of intestinal obstruction, come on and carry off the patient. On examination after death no adhesions or other obvious cause of con- striction of the intestinal canal are found. It can only be conjectured that, owing to the extremely small space into which the intestines have been squeezed, they get thrown into angular contortions which, when any unusual pressure from without, or distension of a part by flatus or otherwise supervenes, the peristaltic action is disordered, and there occurs a virtual obstruction. In one case Rokitansky found a fatal constriction of the intestines caused by the rotations of the tumor, a dermoid one. 10. In other cases adhesions have been found which were sufficient to account for the intestinal obstruction. 11. The disappearance of the disease by spontaneous resorption of the fluid and shrivelling of the cyst, is not proved. The lining mem- brane of the cyst has the property of throwing fluid into the cyst with extreme facility, but not in the converse direction. So long as the fluid is confined in the ovarian cyst it is beyond the influence of absorption. So much at least is true as far as sure clinical experience proves. Cases do, however, occur in which considerable accumulations, believed to be in ovarian cysts, disappear more or less completely, either spontaneously or under the use of diuretic and other medicines. A little time ago there was a woman in St. Thomas's Hospital, under the care of Dr. Gervis and myself, whose history gave support to this hypothesis. She then carried a very large ovarian cyst seemingly single ; two years be- fore, she said, she had one nearly as large, and the swelling disappeared under medicines, water passing freely by the bowels and bladder. I cannot help suspecting that in this and similar cases, the fluid escaped 298 OVAEIAN TUMOES. first into the peritoneal cavity by rupture or a small perforation, or else by a fistulous channel directly into the bowel. 12. When it escapes into the peritoneum, the fluid, if of the limpid kind, may be taken up into the circulation and discharged rapidly by the excreting organs. Numerous cases are on record of the spontaneous or accidental bursting of ovarian cysts, followed by cure in this way. If the walls are thin, and the tumor tense, under gradual or sudden pressure or violence rupture may take place. In this way cysts have burst under the rapidly accelerated pressure caused by the simultaneous growth of the pregnant uterus, under sud- den exertion, under direct violence as of a blow, or under concussion as from a fall. A remarkable case occurred in the temporary St. Thomas's Hospital. A woman under my care was descending in the lift to take the air in the grounds, when the machinery gave way and the lift came down the last few feet with a run. The concussion burst the tumor ; large quantities of watery fluid were discharged during the next few days by the bladder, and she completely recovered, the tumor not returning. The recovery, however, is not always complete. After bursting and absorption of the fluid, the tumor may form again, just as we see after the operation of tapping. Thus W. F. Soltau relates a case (Medical Times and Gazette, 1862) in which the cyst burst three times into the peritoneum ; the fluid was voided by diuresis. She was also tapped thirty-seven times. She died after the bursting. Disse relates a case (Monatsschr. fiir Geburtsk., 1860) in which the patient recovered from one bursting, the fluid being discharged by the kidneys. After a few years the tumor burst again. The second rupture of the cyst was verified by autopsy. Obstinate constipation followed the accident, then copious watery discharge by rectum ; in two days eighteen quarts were measured. When this ceased, profuse discharge of urine occurred ; during five days eight quarts were passed daily. She sank exhausted. Huguier expressed a doubt whether cases of this kind were really bursting of an ovarian tumor, and suggested that they were more likely examples of simple cysts of inflammatory origin attached to the uterus. Matthews Duncan indorses this view, " regarding cures of ovarian cysts by spontaneous bursting or by simple puncture in a high degree doubtful, and considers that at all events whilst post-mortem verifi- cation of such cures is absent they are partly explained by supposing that instead of ovarian dropsies, inflammatory serous cysts, cases of serous perimetritis were the subjects of treatment." I tliink we must accept this explanation for some of the cases of presumed cure of ovarian cysts following rupture or simple puncture. But certainly the possibility of some ovarian cysts being so cured seems free from doubt. In the case at St. Thomas's, above referred to as having been caused by the shock of a fall, the ovarian nature of the cyst had been verified by repeated examinations. And the possi- bility of an ovarian cyst healing after rupture is proved by two speci- mens in Guy's Hospital Museum, of ovarian cysts, which had burst spontaneously, the rent cicatrizing. These specimens supply the post- mortem verification which is said to be wanting. Tlie first specimen, COURSE. 299 No. 2246^* is " a large ovarian cyst, which had burst spontaneously^ and had become repaired." Within it an inverted portion of the old wall is seen, and a reduplication of the cyst is indistinctly seen in the section. The case was that of Ann B., aged 46, under I)r. Addison, in 1836. When first seen, in March, 1834, she stated that she had had children at an early age, and had menstruated regularly since ; that five years before she observed a swelling in the right iliac fossa, that the tumor increased, although her health remained good until ten days ago, when she fell, and struck her abdomen. She was seized with violent pain, sickness, and fainting, and then perceived that the swelling, which was before local, had diffused itself over the abdomen. On admission she was suffering from acute peritonitis. She soon per- fectly recovered, and again entered into domestic service in 1836, only a small tumor in the left iliac region being distinguishable. She died in August, 1836, and the sac was removed. There were adhesions in various parts of the abdomen ; the ovarian cyst occupied the pelvis, and was closely connected to surrounding parts. It contained about two quarts of a reddish thick fluid, and the lining membrane was covered with thick layers of albuminous matter. Upon the front of the tumor was a band, formed by the folding of the walls upon them selves as the cavity shrank. The Avails were so firmly united that the reduplication was only clearly seen when a section was made. The rupture had been about eight inches in length. The edges of the rent had not united, but the inferior lip was found floating free within the cavity, whilst the superior lip of the rent was glued over the opening to the cyst below. The other specimen, No. 2239^*, is equally decisive. It is "a ute- rus and a portion of a large cyst from the left ovary. It is of a com- pound serous kind, and had burst spontaneously during the life of the patient, from which accident she recovered, and survived several months. The cicatrix appears in the portion of cyst preserved. The patient died from malignant disease of the stomach." The specimen was presented by Mr. May, of Tottenham. There is a third specimen in the same museum, No. 2231^^, which although less striking than the foregoing, affords evidence to the same point. In St. Bartholomew's Museum is another specimen (No. 31.31), which illustrates this point. It " is a portion of a cyst that arose from the left ovary. It communicates with the ileum by a small aperture, between four and five inches above the ileo-coecal valve. Some weeks before death, after the discharge of a large quantity of fluid per anum, the abdominal tumor had diminished in size, and the dulness to per- cussion over its region had been replaced by tympanitic resonance." These cases place the possibility of cure of ovarian cystic disease, by rupture or perforation, beyond dispute. In anotlier class of cases, perhaps more frequent, the patient dies quickly, killed by the shock ; or if she rallies from shock, peritonitis sets in, which is most likely to prove fatal. This danger appears to depend in great measure upon the qualities of the fluid effused. If clear and watery the fluid itself may cause little irritation ; the peri- 300 OVARIAN TUMORS. toneum tolerates it well. If it act injuriously, it is probably chiefly because it is voided suddenly in large quantity, so as to disturb the balance of circulation greatly. It is the shock that is dangerous ; the fluid itself is harmless. But where the fluid is gelatinous or puriform it is clearly not favorable for absorption, and it may even possess acrid or irritating properties. Hence there is added to the simple shock, re- tention in the peritoneum of an irritating fluid. Peritonitis is inevita- ble ; and since the cysts which yield fluid of this nature are commonly multilocular and incurable by simple tapping, the progress of the tumor is not stopped. If the patient survive the shock and peritonitis, the ovarian disease will pursue its natural course notwithstanding. Mr. Spencer Wells relates a case (Medical Times and Gazette, 1861) in which, after ovariotomy, the serum found in the peritoneum must have con- tained a very active animal poison. He himself suffered from absorp- tion. Sometimes when a cyst bursts, vessels in its walls are torn, and blood to a considerable extent may be effused into the peritoneum along with the ovarian fluid. This complication increases the danger of peri- tonitis, and adds that of anseraia. 13. Bleeding from the surface of the cyst or into its interior may take place without rupture. In such an event death may be rapid under symptoms resembling those of rupture of an extra-uterine gesta- tion cyst. The patient may bleed to death. In one case Mr. Wells says the blood escaped through the Fallopian tube and uterus from a large cyst in the ovary. 14. The cyst may contract adhesions witli the bladder or bowel, and bv bursting or ulcerative perforation into one of these viscera, its con- tents may be discharged. Communication thus established with the exterior is more favorable than rupture into the peritoneum. The bladder and the bowel — the latter especially — are less liable to injury, and can, moreover, readily get rid of the offending matter. In this way even fluid of tenacious or gelatinous nature may be discharged. Thus Ulrich (Monatssch f. Geburtsk., 1859) relates a case in which a large quantity of thick fatty matter was emptied by the bladder ; it was ascertained to be pure elain ; several quarts were passed. For a long time the urine contained pus and fatty matter. The patient re- covered, some remains of tumor being still felt. The London museums contain several interesting examples of ovarian tumors opening into the hollow viscera. At Guy's is a specimen (No. 2228^-^) from a woman, aged 36, under Dr. Gull, in 1861, for Bright's disease. At the same time there existed in the abdomen a remarkable tumor, being a cyst containing fluid and air. On striking it a loud splash was heard, and at the same time it was resonant on percussion. After death, on opening the tumor, a fetid gas escaped, and at its lower part was a turbid purulent fluid. The intestines were adherent to it, and at the bottom was an opening communicating with the upper part of the rectum. Dr. Murchison (Path. Trans., vol. xviii) relates the following: E. C, aged 37, for eight years had been liable to general dropsy and attacks of erysipelas of the face. About eighteen months before admission to Middlesex Hospital she first noticed a swelling in the lower part of the COURSE. 301 abdomen. On admission, the abdomen was distended by a tumor rising above the pubes. The urine contained albumen. The patient began to suifer from diarrhoea ; the stools contained blood. This continued for sixteen days, during which time there was no diminution in the size of the abdomen. Then the stools contained a quantity of pus, which went on for three days, and in a week all signs of the tumor had disappeared. The patient sank two or three days later. The liver, spleen, and kidneys were very large. A collapsed cyst, the size of a cocoanut, was seen in the situation of the uterus. This was a cyst of the left ovary, which had emptied itself by an opening the size of a fourpenny piece into the rectum four inches above the anus. In St. Thomas's Museum is a specimen (FF, 45) of a fecal abscess communicating with an ovarian cyst. The lower end of the rectum, the vagina, and the uterus with its appendages are included in the specimen. The lower end of the rectum is very much constricted, and its inner surface is very irregular ; above are two sinuses which lead into fecal abscesses situated in the cellular tissue external to the rectum. One of these abscesses is seated between the rectum and uterus, and communicates superiorly with a cyst about the size of a walnut in the right ovary. From a woman, aged 40, who died of phthisis. When pregnancy intervenes, the risk of a fatal issue is vastly in- creased. I have discussed this subject at some length in my work on "Obstetric Operations," second edition, 1871. Perforation must be distinguished from bursting. Perforation is a gradual process, and is more likely to occur in the glandular cystomas than in the simple cysts. An opening may be effected direct into the peritoneum, but more commonly into a hollow organ. The causes of perforation are : 1, a wearing-through of the cyst-icall by partial pressure of the growths from within of a papillary cystoma. The dendritic cauliflower growths, springing from any spot, advance to the opposite side, and if large, cause perforation by pressure. They may then grow on unhindered in the peritoneal space, and sooner or later, cause fatal j)eritonitis (see Fig. 73). 2d, suppuration, which is the most frequent cause of perforation. In this case the opening is seldom into the peri- toneum; it mostly opens externally or into a neighboring hollow organ. Dr. O. Spiegelberg relates some good illustrative cases (Arch. f. Gynakologie, 1870.) Dr. Bristowe described these perforations (Path. Trans,, 1853, vol. v), having several times seen perforations of ovarian tumors into the peritoneum, precisely resembling those between the cysts themselves, and (vol. xii) says it is extremely common. Adjoining cysts are con- stantly opening into one another ; and cysts are almost as constantly rupturing into the abdominal cavity. In both cases the steps of the process are identical : first, the outer surface of the wall yields at iso- lated points, in consequence of the distension due to the accumulating fluid within, and circular or oval depressions of various sizes are pro- duced; secondly, these enlarge in area, and deepen, and finally per- forate ; thirdly, the contents of the cyst escape, the cysts collapse more or less, atrophy, and ultimately (in consequence of the growth of new 302 OVARIAN TUMORS. cysts in their walls, of the enlargement of neighboring cysts, and of their own shrinking) form irregular crescentic or sinuous folds. Most commonly these perforations are attended by adhesions which, uniting the cyst with a hollow organ, form a substance through which a fistulous tract is gradually made. In this way the abdominal cavity is protected. I believe that it is through small perforations occurring that the frequent attacks of peritonitis are produced; and that we may thus look upon the adhesions so commonly found, as the effect and evidence of a conservative process enacted to limit the mischief. No sooner does a minute perforation take place than the opening is glued up by plastic effusion. But sometimes adhesions do not form in time. Then the perfora- tion allows the contents of the cyst to escape into the peritoneal cavity, and the result may be quickly fatal. In St. Thomas's Museum (No. FF 32) is an example of spontaneous perforations in an ovarian cyst. The perforations allowed free com- munications with the abdominal cavity ; their edges were well-defined, and bevelled off at the expense of the outer edge. The following speci- men (No. FF 33) is another example of the same kind. Occasionally adhesions form to the diaphragm, and the ulcerative process, continuing in an upward direction, the pleurae and lung may be attacked. In the College of Surgeons is a specimen (No. 2623) consisting of a portion of diaphragm, with part of a large ovarian cyst firmly adherent to its peritoneal surface. On the inner surface of the cyst there are numerous smaller cysts and tumors connected with it, and with one another by pedicles and bands of false membrane. A portion of lung adheres to the corresponding pleural surface of the diaphragm. The cyst had been tapped several times, but could not be completely emptied, for it was sacculated. It adhered firmly to most of the ab- dominal viscera. (From MSS. of Geo. Langstaff.) Sometimes the ulcerative process works from the intestines towards the cyst. Dr. Bristowe (Path. Trans., vol. xiv) presented a case of communi- cation between an ovarian cyst and the rectum. There was an exten- sive ulceration of the mucous membrane of the large intestine. The patient suffered from phthisis. In this case, the ovarian cyst had not opened into the bowel, but the intestine ulcerated and opened into the cyst. Fecal abscesses had first formed, one of which had perforated the ovarian cyst. Ovarian cysts may also discharge through the Fallopian tubes. Richard cites cases of cysts which had involved a considerable portion of a tube, through which their contents could be forced into the uterus. The portion of tube implicated had become increased in lengtli and thickness, and the folds of its mucous membrane were partly effaced. A distinct aperture between cyst and tube was found. In these cases the a])erture was no doubt effected by a gradual perforative process, not by bursting. Apart from bursting, if not from perforation, intercurrent attacks of peritonitis are common in the progress of ovarian tumors. Such an COURSE. 303 attack may prove fatal, but more commonly recovery takes place, leaving adhesions of tumors to the walls of the abdomen and viscera. 15. Inflammation in the interior of the cysts also not seldom occurs. It is of a low kind, and suppuration is often the result. This process may be limited to one or more of the cysts, others retaining their pristine condition. There is reasonable presumption that suppuration has taken place inside a cyst, if symptoms of hectic or irritative fever set in after acute pain in the seat of the tumor. "When," says Mr. Wells, "the temperature of the patient is high, ranging from 100° or 101° F. in the morning to 103° or 104° at night, and emaciation is progressive, appetite lost, thirst troublesome, sleep disturbed, nausea or vomiting distressing, and the abdomen tender on pressure, with hurried pulse and respiration, it is extremely probable that one or more cysts may contain pus ; and when these symptoms are present in an extreme degree, or have lasted for a considerable time, the pus has become fetid." 16. The roof of the vagina may burst, and allow the ovarian tumor to protrude through it. (See Mr. Berry's case, p. 304.) Luschka also (Monatsschr. fiir Geburtsk., 1867) relates a case of rup- ture of the vagina, and protrusion of an ovarian tumor. The rate of growth or natural duration of ovarian cysts varies with the kind of tumor, and other circumstances, one of which is the age of the patient. The simple non-malignant cysts generally go on steadily increasing, attaining a size that entails distress of breathing and danger to life, in about two or three years from their first attract- ing attention. But it is almost certain that the earlier stages of growth may extend over a considerable time before, either by bulk or pressure on the abdominal viscera, the tumor is noticed by the patient. We have, then, an unknown quantity to add to the known; and this cir- cumstance frustrates all attempt to arrive at a precise estimate of the rate of gro^vth or duration. Not seldom there are alternations of in- crease, and of standing still. After remaining passive for a consider- able time, a stage of rapid accumulation may set in. Scanzoni believes menstruation stimulates the growth. The partly solid non-malignant tumors may last many years, growing very slowly, thus admitting of gradual adaptation of the compressed organs, and of the system gener- ally, to the inconvenience, before distress becomes intolerable, or a fatal result ensues. I have known distinct evidence of ovarian tumors to extend over twenty and even thirty years. The malignant and proliferous forms proceed more rapidly. The history of many of these cases is brief. It is measured by months rather than by years. In cases of long standing, oedema of the legs is a frequent conse- quence. It is caused either by pressure on the renal vessels, inducing hypersemia of the kidneys, by independent or induced Bright's disease, by pressure on the pelvic veins, or by thrombosis in the pelvic and femoral veins. In the latter case the prognosis is bad, as it generally indicates malignant disease spreading into the broad ligaments, and matting the pelvic structures together. If ascites be added, the proba- bility of malignant disease extending to the abdominal glands and other structures is much increased. 304 OVAKIAN TUMORS. The eifects of ovarian cystic disease upon the proper ovarian func- tions are various. We have seen that in many cases ovulation may go on. Even in a diseased ovary a portion may remain unafiected, and suffice to stimulate menstruation. And, although in many cases it ls found that both ovaries are invaded, yet it is rare that the proper struc- ture of both is entirely destroyed. In some cases, perhaps exceptional, and only for a time, there is menorrhagia. INIore frequently menstrua- tion becomes scanty, and at last ceases. This undoubtedly is often the consequence of general dyscrasia. That menstruation may go on is p'rimd facie evidence of the possibility of conception. It is a fact that in many cases pregnancy does take place. It may even go on to the natural term, and delivery take place without accident. I have known examples of several successive pregnancies thus being accomplished. Bat the risk is serious. In another class of cases the uterus is unable to pursue its full development, and abortion or premature labor sets in. Fatal injury to the tumor has been sustained during labor from the pressure of the child, or from the necessary operations to effect deliv- ery. The tumor has on many occasions burst during the pregnancy or labor, generally with a fatal result. There is an extraordinary speci- men in St. Bartholomew's Museum (No. 31.34) contributed by Mr. Berry, of Bu-mingham. It is an ovarian cyst which had protruded through the external parts by rupture of the vagina during labor, and which was afterwards removed by ligatures with success — a singular instance of ablation of an ovarian tumor by this route. On the other hand, the uterus may rupture from the obstruction to labor caused by an ovarian cyst. (Ogier Ward, Path. Trans., vol. v.) The breasts are often affected. In some cases they become tumid, even yield a little milky fluid, and the areola is darkened. This chiefly happens during the earlier stages of the active tumors. Gener- ally when the disease is of long standing, the breasts become flaccid, and shrivel. This may be an indication that the follicular structure of the ovary has been destroyed. The origin of ovarian cystic tumors is frequently so little marked by recognized symptoms that the date when they began cannot be de- termined. Many proceed insidiously, without causing distress or at- tracting notice, until they have made some perceptible enlargement of the abdomen. On the other hand, in many instances, dysmenorrhoea has preceded the development of the tumor; and in many, attacks of severe pain in the ovarian region have been noticed, suggesting that the initial condition was an inflammation of the ovary. In some cases, the tumor, whilst of small size, gets into the retro-uterine pouch, pushes the uterus forwards against the bladder, and causes re- tention of urine. DIAGNOSIS. 305 CHAPTER XXXII. DIAGNOSIS OF OVARIAN TUMORS. The Diagnosis of Ovarian Tumors involves the analysis of all ab- dominal tumors. The recognition of an ovarian tumor really involves very often the decision between life and death. Whether an operation of a most severe, possibly fatal, nature shall be performed or not, de- pends upon the diagnosis. And if we do not operate for want of an accurate diagnosis, the patient may equally incur the penalty of death. The pregnant uterus has been tapped or opened in mistake for an ova- rian tumor. An ovarian tumor has been often mistaken for pregnancy ; and this latter error may subject the patient to an imputation of dis- honor,, than which death itself will, to some minds, appear more toler- able. The first point to determine is the presence or absence of pregnancy. Dr. Peaslee, in his excellent work on "Ovarian Tumors" (1872), ob- serves that the diagnosis of pregnancy in the early months does not come into practical consideration, since it is only when ovarian tumors have attained the size of the gravid womb at five months or more, that the question of extirpation arises. But there are other reasons for form- ing a diagnosis at even the earliest stage. A proper weight must be given to the evidence of history. This may or may not be useful ; but it is not safe to rely upon anything but physical exploration. We must, then, make a systematic search for the objective signs of pregnancy. We must examine the breasts ; observe the degree of tension, the veins running to the areolae, the pigmentation and area of the areolae, the de- velopment of the follicles, the presence or absence of milky secretion. Then, examining the abdomen by careful palpation, we search for uterine and foetal movements ; by stethoscope in the groins and oyer the abdom- inal tumor we listen for uterine and foetal sounds ; by vaginal touch we determine the softness or hardness of the cervix uteri, the patency of the OS, its relative position in the pelvis ; the presence or absence of what I have described as vaginal roof-stretching, that is, the tense in- clined plane formed by the enlarged body of the uterus pressing upon the roof and anterior wall of the vagina — (see Fig. 49, p. 139) — and through which, if the uterus be pregnant, we may feel its rounded solid bulk. Place the patient on her back, with the shoulders a little raised, then strike upon the rounded mass of the uterus in front of the cervix with the tip of the finger, to elicit the phenomenon of ballottement ; or, if the OS be patulous, perform this experiment cautiously through the OS. If we thus get positive evidence of pregnancy, we have gained an important step in the diagnosis of the case. But it must not be hastily conckided that because there is pregnancy there is not ovarian tumor Both may coexist. And if we fail to bring out any of tlie absolute signs 20 306 OVARIAN TUMORS. of pregnancy it must not hastily be concluded that the woman is not pregnant. It is not a very uncommon thing, even in an uncomplicated case of pregnancy of three, four, or even five months, to miss the une- quivocal signs. And there are cases, rare it is true, in which the preg- nant womb is sunk out of reach in a large accumulation of ascitic fluid. This mostly happens in connection with albuminuria, when there is anasarca as well. BcdlottemeM, usually considered so conclusive a test of pregnancy, is sometimes fallacious. Spencer Wells relates two cases in which this phenomenon was marked, although there was ovarian tumor and not pregnancy. In one there was a rather solid tumor, complicated with ascites. Ballottement was produced by the floating of the tumor in the ])eritoneal fluid ; in the other case there was a large, semi-solid tumor, which, through the vaginal roof, felt like the head of a child, and could be moved by the manipulation which produces ballottement of the foetus in utero. This became more marked, when subsequently some ascitic fluid collected ; but this helped rather than obscured the diagnosis, as it enabled the observer to isolate the tumor from the uterus. I have seen several similar cases. Before discussing the special or particular cases for diagnosis, it will be convenient to describe summarily the general principles of proceeding l)y which we determine the presence of an ovarian tumor. These flow partly from the knowledge acquired of the nature and progress of these tumors, and partly from the application of means of physical exploration. The means at our command are : 1. Inspection of the Abdomen. — The patient should be on her back, with the abdomen, and at least the lower part of the chest, bare. We tlien note the shape, size, and position of the tumor. An ovarian tumor generally gives the abdomen an arched form, sometimes uniform, espe- cially if the tumor be mainly monocystic; sometimes there is oblique or sloping form, one side being prominent, another depressed ; this in- dicates polycystic tumor. Very large tumors may rise under the ribs, push up the liver, and make place for themselves by everting the false ribs and cartilages. It is not uncommon to find the xiphoid cartilage protruded forwards. The i-ecti muscles are sometimes parted ; and the tumor, falling forwards, may even find a resting-place on the thighs and knees. Generally the abdomen is in full tension, the skin is shining, and even marked by scar-like cracks, as in pregnancy. In the depending ])arts, especially that which hangs over the pubes, the skin becomes thick and doughy from infiltration of serum into the cellular tissue. This is sometimes so great as to give a brawny or hypertrophied char- acter to the skin. Furrows and ridges are thus formed. The form of the abdomen depends upon the form of the tumor. If tiie cyst be single and its wall thin, so that it has yielded easily and uniformly to distension, it will tend to arch out in the direction of least resistance ; that is, forwards, protruding the abdominal wall. The um- bih'cus, as in pregnancy, is pushed out, but the arching of the abdomen from below the xiphoid cartilage to the pubes, is even more prominent, generally, than is the bow produced by the pregnant womb. It even DIAGNOSIS. 307 seems sometimes to point above the umbilicus. The Avails of the uterus are not merely stretched, like an ovarian cyst; they grov\ and the uterus always preserves, more or less, its original shape, that is, it is compressed or flattened a little in its anterior wall. If the cyst is multiloeular and the cysts be distended unequally, the form of the abdomen will be un- equal ; but still, as one cyst, and that one which enlarges in the direction of least resistance, is sure to be most anterior, the general form is like that of the monocystic tumor. In the early stages there is commonly more prominence on one side of the abdomen, one iliac region being visibly more tumid than the other. By inspection, also, we observe the peculiar expression of countenance which attends so many cases of ovarian disease. This is often so striking as to be alone diagnostic to the trained eye. ]Mr. Spencer Wells^ gives a drawing, taken from a pho- tograph by the late Dr. Wright, which represents this very graphically. He calls it the "fades ovariana." The emaciation, the prominent or almost uncovered muscles and bones, the expression of anxiety and suf- fering, the furrowed forehead, the sunken eyes, the open sharply-defined nostrils, the long compressed lips, the depressed angles of the mouth, and the deep wrinkles curving these angles, form together a face which is strikingly characteristic. 2. Mensuration gives more precision to what the eye has observed. Carry a tape from the spinal column round on either side to the um- bilicus or linea alba. If the two semi-circumferences are unequal, this raises a presumption in favor of ovarian tumor. Another measure- ment is perhaps more useful. Measure from each anterior superior spinous process of the ilium to the umbilicus, and also to the xiphoid cartilage. These comparative measurements will show clearly the greater protrusion of one side, if it exist. Mensuration is more valua- ble as a means of keeping a precise record of the increase or diminution of the size of the abdomen, 3. Palpation. — By feeling with the outstretched hands, we get infor- mation as to the size, form, and solidity or waviness or penetrability of the abdomen. If the hands can be made to sink in a marked manner towards the spinal column below^ the umbilicus, the presumption against ovarian tumor, unless a very small one, is strong. If an ovarian tumor lie behind the abdominal wall, this is impenetrable. By carrying the open hands all round the swollen abdomen, by gentle pressure M^e can often determine the outline of the underlying tumor ; we make out the rounded cyst or bag which contains and confines, within definite limits, the fluid which is felt waving in it. This sense of a waving fluid is QaWeA fluctuation. It is most clearly brought out by placing one hand spread out, or one or two fingers lightly, at one point of the tumor, whilst with a finger of the other hand we lightly flip in another part. By shifting the positions of the observing and the striking hands, we explore the area of fluctuation and its degree in different parts. If the fluctuation be felt freely in all directions, of equal force, transversely, obliquely, longitudinally, along the extreme breadth and length of the tumor, the inference is justifiable, not that the tumor is strictly Diseases of the Ovaries. 308 OVARIAN TUMORS. raonocystic, but that the main volume of the fluid is contained in one If we find there is fluctuation in one part of the tumor and not in another ; if we find the fluctuation is different in force in different parts ; if we find the wave propagated from one point is wholly or par- tially arrested in its spread across to another part of the tumor, we may infer the presence of septa or solid parts. Plain as fluctuation often is, this sign is not free from ambiguity. I have known a solid fibroid of the uterus communicate a sense of fluctua- tion that imposed upon skilful observers. And we may have what may be called double fluctuation. There may be ascites as well as ova- rian tumor. Or the fluctuation may be due to ascites. The latter case will be diagnosed by and by. When, as not unfrequently hap- pens, there is fluid in the peritoneal cavity as well as in an ovarian tumor, if the tumor be large, the peritoneal fluid will be diffused as a thin layer all over the tumor. Thus, when we first flip the abdomen, we may see and feel a light wave run along the surface. By pressing the fingers rather firmly and suddenly into the abdomen, we may dis- place the thin peritoneal stratum, and come down upon the resisting bag of the tumor ; then, by a giving a rather smart impact to another part, we may elicit the feel of another deeper fluctuation, that proper to the tumor. In pregnancy, also, where the uterine and abdominal walls are very thin, and the quantity of liquor amnii excessive, fluctuation may be as distinct as in some cases of ovarian dropsy. We may also make the phenomena of fluctuation available in deter- mining the limits of the sac. Thus, by applying two observing fingers spread out, so as to leave a space of two or three inches between their tips, to one flank, whilst impact is given by the other hand, we may feel fluctuation by the upper finger, and not by the lower one, showing that the boundary of the cyst is between the two fingers. Intra-vaginal touch may be considered as a form of palpation. By this touch we determine some of the physical signs of pregnancy, if this condition exist; and, in the contrary event, we determine the posi- tion and other conditions of the uterus, and some of the relations of the ovarian tumor. The conditions found in some very early cases : will be described under the head of "Special Diagnosis of Early Cases." In advanced cases, where the tumor has assumed the balloon shape, and even the loAver pole of it is too large to enter the pelvic brim, the uterus is often dragged up a little, and tilted on one side, generally to the opposite side of the tumor; the os is generally directed backwards, the fundus fi)rwards. The vaginal roof is mostly covered in by the spherical pole of the tumor ; it feels elastic if the tumor is monocystic, and sometimes fluctuation may be transmitted to it by flipping the abdominal wall. The upward dragging of the uterus tends to obliterate or conceal the vaginal portion of the uterus ; it is draAvn out of the vagina, so that the OS uteri is often felt almost flush with the vaginal roof The vaginal roof itself is sometimes drawn up into a cone. In the opposite class of cases, in which the tumor, or a part of it, descends in Douglas's space, DIAGNOSIS. 309 this space is much enlarged, the posterior vaginal roof is distended and made to protrude, sometimes so as to be prolapsed beyond the vulva. The touch is extended by the uterine sound. But before using it we must first clearly exclude pregnancy. This instrument, passed into the uterine canal, determines — 1, the length of the uterus; 2, its in- clination or position ; 3, its mobility or freedom from the tumor. If the uterus is easily moved, and of its ordinary size, it may be inferred, not only that the tumor is extra-uterine, but also that the pedicle is long. It must, however, be remembered that the uterus is sometimes greatly elongated by the pressure of an ovarian tumor ; and if the tumor should be solid, M^e might easily fall into the belief that it was uterine. Vaginal and rectal touch is further of great service in determining other questions, especially that of complication with malignant disease. This point will be discussed hereafter. The information obtained from inspection and palpation is corrected and supplemented by that obtained from 4. Percussion. — This is, jjerhaps, the greatest test. It may be said to be but a form of palpation, but it brings out information that mere palpation could not supply. By percussion we determine the areas of dulness and of resonance. In ovarian cystic tumor the relation of these areas is characteristic. The tumor, arising from one iliac fossa, pushes the hollow intestines over towards the opposite side. Whilst the tumor is small, that is, not so large as to reach the level of the umbilicus, the contrast between the dulness of the side where the tumor lies, and that where the intestines are driven to, is marked. When the tumor is so large as to reach the scrobiculus cordis this contrast is not so obvious ; but it may almost always be traced. The intestines lie laterally and inferiorly in the space between the last false rib and the crest of the ilium and back to the spinal column, because the cyst, occupying the opposite side of the abdomen, has left only this space for the intestines to retreat to ; and has not driven them directly and all upwards, because it grew, always occupying a more or less lateral position. The con- trary of this happens in pregnancy and ascites, in which conditions the intestines are driven straight and gradually upwards, the gravid womb rising from the centre, and ascitic fluid filling the lower parts, to rise with its level uniformly upwards. Hence we have in cystic tumors resonance on one side, between the last false rib and the crest of the ilium, whilst on the op]:)osite side the dulness is more extensive, because the cyst is there. So much may be taken as generally true, but we must guard against fallacies. In pregnancy, as in ovarian »tumor, the intestines are so crowded back that, whatever the position of the patient, the dulness is heard all over the front of the abdomen, whilst there is an area of resonance in both flanks. In advanced pregnancy there is often marked obliquity of the uterus; it inclines so much to one side that the area of resonance in one flank may be notably smaller than in the other. And in ovarian tumor we almost invariably find some resonance in both flanks, although the resonant area will be greater on one side. 5. Auscultation is chiefly of use in determining the presence of preg- 310 OVARIAN TUMORS. nancy. It is true that by it we may detect a friction-sound, produced by the ascent and descent of the tumor under the respiratory move- ments ; and sometimes a blowing-sound in one groin, which might impose for the souffle of pregnancy. But these signs are of minor clinical value. Some variety of vascular murmur is much more common in uterine tumors than in ovarian. It is synchronous with the pulse. The practiced ear will distinguish it from the souffle of pregnancy. Practically, it is not necessary in every case of suspected ovarian tumor to go systematically through all the above cases, with a view to their successful elimination ; or, at least, the experienced clinical phy- sician performs this elimination so rapidly as to be almost unconscious of the process. But in a considerable number of instances, it is neces- sary to enter minutely into the differentiation between some two of these cases before we can decide which it is that is present, , Nor does the difficulty end here. Two or more of the above cases may coexist. After discovering the existence of some one of the con- ditions enumerated, we may overlook a complication which is masked by the prominence of that which we have discovered. For example, just as ovarian tumor may be complicated with pregnancy, so it may be complicated with uterine fibroid, or with ascites. Nor is it enough to determine the presence or absence of complicating tumors or fluid collections. When we have settled that there is an ovarian tumor and nothing else, it is still important, with a view to forming a prognosis and the selection of the mode of treatment, to determine — 1, Whether the tumor be monocystic or polycystic; 2, whether it be benign or malignant; 3, whether or not adhesions have been contracted with the abdominal walls and viscera ; 4, whether the uterus be enlarged, or in any way involved ; 5, the condition of the general health, and espe- cially the presence or absence of diseases of other organs, as of the heart, lungs, liver, kidney. A sound judgment as to these points will greatly influence the choice between tapping, extirpation, or expectation. Diagnostic research must be applied to the solution of the following problems : a. Is there a uterine pregnancy ? 6. Is there an extra-uterine pregnancy ? c. Is there an extra-ovarian cyst ? d. Is there enlargement of the uterus from fibroid tumor or fibro- cystic tumor? e. Is there enlargement of the omentum and intestines ? /. Is there enlargement of the spleen, liver, pancreas, or kidneys? (/. Is there pelvic cellulitis or peritonitis or hsematocele? h. Is there ascites or encysted peritoneal dropsy or abscess? i. A re there adhesions ? j. Is the tumor benign or malignant? k. Is there distension of the bladder or fecal accumulation ? It follows from the foregoing discussion that to enter pro])erly jn-e- pared upon the task of diagnosing ovarian tumor, the inquirer nmst have a good clinical acquaintance with thoracic and abdominal path- DIAGNOSIS. 311 ology. A most masterly memoir bearing directly upon this point will be found in " Guy's Hospital Reports," by the late Dr. Bright.' a. Is tha^e a uterine pregnancy f This initial question has been already discussed. 6. Is there an extra-uterine 'pregnancy f This question trenches to some extent upon the first, a ; but it involves many points quite dis- tinct from uterine pregnancy. Extra-uterine pregnancy is rare ; but Fig. 7G. Ovarian tumor aud pregnancy. O T, the tumor lifted out of tlie pelvis by the uterus, u, which is pushed over to the side and over the brim of the pelvis ; r h, spot where festal heart may be heard. for this very reason, and also because the seat of the tumor which it forms is more nearly identical with that of ovarian tumor, the diag- nosis is more difficult. . It must not be lost sight of that ovarian tumor may be complicated with pregnancy, uterine or extra-uterine. In the case of uterine preg- nancy we may expect to make out the positive signs of pregnancy ; but these will be likely to mask those of the ovarian tumor. One characteristic of the double condition is that the abdomen is moi'c widened out than in either of the single conditions ; and we may usually define by palpation, percussion, and auscultation the limits of each tumor. There is commonly a marked sulcus or depression of the ' See also Now Sydenham Society's edition of " Bright's Memoirs," vol. vi, 1860. 312 OVARIAN TUMORS. upper part, where the two spheres diverge, as is exemplified in the diagram, Fig. 76, taken from my work on " Obstetric Operations," second edition, 1870. In ovarian solid tumors it almost always happens that the tumor is of irregular form. There are projections, angles, sometimes simulating limbs of a foetus ; but they do not move ; nor do we feel that peculiar vermicular movement characteristic of the gravid uterus. We may succeed in isolating the uterus from the tumor by the sound. If the uterus be at all fixed, and any hardness be felt around it, examine by rectum as well. If malignant, projections, hard and irreg- ular, will probably be felt more plainly here. c. Is there an extra-ovarian cyst f When by internal and external examination, no nodular hardening of the cyst-wall can anywhere be detected, where the cyst is uniformly smooth and elastic over its whole surface, where the wave of fluctuation is equally perceptible in all direc- tions, the inference is clear that the cyst is practically unilocular ; and if in a young person it is either flaccid and of long duration, or exces- sively tense and of recent formation, the inference is, says Wells, almost equally clear, that the cyst is extra -ovarian and the contents limpid. It is a good practical rule in any case presenting the above charac- ters to tap in the first instance, as this simple operation will probably be sufficient to cure. d. Is there enlargement of the uterus from fibroid tumor or hydrometraf This is one of the great practical questions. Under the belief that an ovarian tumor existed, the abdomen has many times been laid oj)en, only to discover what should have been known before, namely, that the tumor was uterine. The diagnosis is not seldom extremely diffi- cult, and especially so when the tumor is fibro-cystic, that is, containing fluid so superficially placed as to yield the phenomenon of fluctuation. The uniformly solid tumors ought rarely to deceive, so far as to carry one into the practical error of opening the abdomen. Uniformly solid ovarian tumors are so rare, whilst uniformly solid uterine tumors are so much the rule, that if I were disposed to be aphoristic, I would sub- mit no aphorism with less hesitation than this : If you find a smooth, solid tumor, beware : it is uterine. If a solid tumor of the ovary be rare, a large solid tumor, so large as to give rise to question of operating, may be said to be amongst the curiosities of pathology. In seeking to determine whether a tumor be uterine, we must be governed greatly by what vaginal and rectal exploration teaches as to the condition of the uterus. The great point is to determine whether the tumor felt above the pubes is continuous or identical with the uterus. This is done by the immediate touch by finger in vagina, by mediate touch by sound in utero, separately and combined with palpa- tion by hand outside on the abdomen. If, by these means we ascer- tain — 1, that the uterine cavity much exceeds two and a half inches in length ; 2, that the course of the uterine canal is tortuous (a flexible bougie, which will worm its way along a tortuous canal, is sometimes better than the metal sound); 3, that the body of the uterus is directed backwards; 4, that the bulk of the tumor moved by the hand outside communicates a continuous movement to the cervix, as felt by finger or DIAGNOSIS. 313 sound — we may fairly infer that the tumor is uterine. This inference will be strengthened if the tumor be of very long standing; if frequent metrorrhagia have been suffered. But it is right to declare frankly that we cannot always elicit these phenomena, although the tumor is fibroid ; and that some of them, when elicited, are not absolute proof that the tumor is ovarian. I have pro- nounced a tumor to be ovarian, influenced by the apparent separate mo- bility of the uterus, in a case where the tumor proved to be uterine. This sign is very deceptive. The great bulk of the uterine tumor may be connected with the uterus by a comparatively narrow portion below. At this narrowed point the portion of the uterus below it may easily move upon the great mass above, which is comparatively fixed by its volume and solidity. The most trustworthy signs are the increased length of the uterus, as determined by the sound, and the solidity of the tumor. How the cervix uteri may be elongated is illustrated in a case described by Dr. Bristowe (Path. Trans., vol. v). The patient, aged 24, single, had been tapped several times for ovarian dropsy, in St. Thomas's. The body of the uterus was slightly tilted by the ovarian growtli ; no os uteri could be detected at first. The cervix was three and a half inches long, and formed a cylindrical band, about half an inch broad and one- third of an inch thick, extending between the os and the uterus, which was somewhat atrophied, but otherwise healthy. The recto-vaginal pouch had become much distended, pressing the posterior wall of the vagina forward like a hernia. This had exerted a certain traction upon the OS uteri, and through the latter on the anterior wall of the vagina, and by long continuance caused the excessive elongation of the cervix uteri. It is not very uncommon to find a complication of fibroid of the uterus with ovarian tumor. In such a case we must carefully weigh the evidence showing that both organs are implicated. An ovarian tumor of moderate size, especially if in great part solid or semi-solid, may closely simulate a uterine fibroid, if there be great thickness of the abdominal wall. A thick mass of fat intervening be- tween the examining hands and such a tumor will often effectually mask the two great distinctive features of an ovarian tumor, namely, fluctua- tion and irregularity of surface. We must depend upon careful exam- ination of the uterus by the vagina, isolating, if possible, this organ from the tumor, aided by abdominal palpation under chloroform, to establish a diagnosis. Dr. C. C Lee has collected nineteen cases of fibro-cystic tumor of the uterus, and has analyzed them, with the view of establishing grounds of diagnosis between it and ovai'ian tumor.^ As proof of the difficulty of diagnosis, it is stated that in one only was the true nature of the tumor ascertained before operation. Koeberle, however, thinks the diagnosis may be established by the following signs : 1. The discolored hue and dejected expression of the face, the so-called fades uterina of the patient. 2. The variable consistency of the tumor, as made out by abdominal palpation. 3. The results of tapping. If the trocar touch a fibrous spot in the tumor- wall, blood will flow ; even when the cyst is 1 New York Journal, 1871. 314 OVARIAN TUMORS. reached the fluid never presents the clear viscid character of ovarian cystic fluid, but is either yellowish, thin, serous, and rich in lymph or cholesterin, or it is brown, muddy, sero-purulent, or bloody, and the tapping leaves only partial collapse, 4. The indurated or nodular feel of the tumor after tapping. 5. The uterine connections of the growth, as made out by vaginal uterine examination, by aid of the sound. The uterus is more displaced than in ovarian tumor. The history, although liable to deceive, must be taken into account. The rate of development of ovarian tumors usually gives less than two years, whilst that of flbro-cystic tumors is generally much slower. But I have known ovarian tumors last forty years. Ovarian tumors begin early, uterine late. But the variations are numerous. The fluctuation in flbro-cystic tumors is confined to certain regions, generally to the upper part, and the solid portions preponderate; whilst in ovarian tumors having solid elements, the fluctuating parts predom- inate, and the solid element is almost always at the lower part. We must, however, be prepared to flnd all the above signs giving, at best, ambiguous indications. The signs most common in flbro-cystic tumor may be present, or appear to be so, in ovarian tumors, and vice versa. Where doubt is unavoidable, error is excusable. Hence we are occasionally driven to the exploratory incision, and to the direct exam- ination of the tumor. This gives another order of signs. If the tumor be uterine, the exposed mass is dark, vascular, thick, and frequently fasciculated with fibrous bands. If it be ovarian, the sac is usually pearly white, or blue and glistening. But these appearances again I have seen interchanged. More than this, even after removal from the body, tumors believed by the operator to be ovarian have turned out to be fibroid outgrowths from the body of the uterus, more or less pedun- culated. Mr. Spencer Wells,^ discussing this question, says, some of the largest abdominal tumors he has ever seen have been fibroid or flbro-cystic tumors of the uterus ; and more than a hundred cases are on record where the abdomen has been opened with the object of remov- ing an ovarian tumor, when the operator discovered that it was uterine. The aspirator-trocar will in many of these doubtful cases prove of signal value. By it we can draw off some of the fluid from the cystic portion for examination. e. Is there enlargement of the omentum and intestines f At the climac- teric age, a woman, falling off' perhaps in health, notices with alarm that she is increasing in size. She fears that it is due to a growing tumor. The phantom-tumor or pseudocyesis of the climacteric period has been already discussed. We have now to eliminate flbroid and ovarian tumors. Where there is nothing but fat and inflated intestines, we may always exclude large fibroids and ovarian tumors by palpation and per- cussion. Resonance in front may be dulled, but still the sound is dif- ferent from the dead sound returned on percussing over a solid or fluid tumor. The hands will sink in towards the spine, on firm pressure, especially if the abdominal muscles are made to relax under chloroform 1 A fourth series of 100 cases of ovariotomy, with remarks on the diagnosis of uterine from ovarian tumors. " Med.-Chir. Trans.," vol. liv. DIAGNOSIS. 315 or under expiration. The sensation to the hands is doughy, not resist- ing. The condition of the uterus can commonly be determined by vaginal examination and by sound, so as to leave only the possibility of ovarian tumor to investigate. And here we come to the practical difficulty of excluding a smcdl ovarian tumor. This may be buried in one iliac region, so much masked by surrounding fat, that neither by external nor by internal touch can we get at it so as to bring out dis- tinctive characters. It may help us to remember that women who are storing up fat do not commonly have ovarian dropsy or pregnancy. These states usually cause emaciation. /. Is there enlargement of the liver, spleen, pancreas, or kidney f Tu- mors of the stomach, liver, spleen, or pancreas, may in most cases be eliminated by evidence showing that they grow from above downwards. This may generally be obtained by percussion. If dulness prevail from the ribs downwards, leaving an area of resonance below the tumor, that is, between its lower margin and the pelvis, the inference that the tumor is not of pelvic origin is nearly certain ; and this probability is greatly increased if the tumor be solid. The hydatid of the liver is the condition most likely to deceive. Here we may have fluctuation and dulness over an area sometimes very similar to that occupied by an ovarian tumor. The history and the peculiar features of the disease will supply diagnostic indications. We shall generally have a resonant space below the tumor. The hydatid tremor or thrill may be felt. Spiegelberg relates' a case of echinococcus of the right kidney, mis- taken for ovarian tumor, and operated upon with a fatal issue. The tumor extended from the ribs to the pelvis, and was felt by the vagina. In reading this case, it appears to me — it is so easy to criticize after the event — that the tumor was more strictly confined to one side than is usual in ovarian tumor. It extended all along the right side from ribs to pelvis, but did not much overlap the median line. Cystic disease of the kidney has given rise to mistakes. So long as the tumor formed by this disease is comparatively small, danger of mistaking it for an ovarian tumor is not great. The dulness and fluc- tuation are more limited to one lumbar and hypochondriac region; and an area of resonance will be made out between the tumor and the pelvis. But when the cystic enlargement is very great, extending across the abdomen and below to the pelvis, the diagnosis is not easy. E,enal tumors growing from behind press the intestines forward, so there is resonance in front. Babington and Bright pointed out that in renal disease we may expect changes in the urine, especially an abun- dance of phosphates and lithates. A very small ovarian tumor, with a long pedicle, might be mistaken for a floating kidney. I have known a considerable area of resonance between the pelvis and a tumor seated under the liver, which proved to be ovarian. This had been carried up and rolled over on its axis, the pedicle stretching and twisting under the pressure of a growing gravid uterus. g. Is there pelvie cellulitis or peritonitis or hcematocelef Here a his- tory of sudden or rapid development under symptoms of local and 1 " Archiv fiir Gynakologie," 1870. 316 OVARIAN TUMORS. general distress will, when given, generally be sufficient. But often cases come before us with no history, or only a misleading one. In these it requires great care to distinguish a consolidated mass of omentum or intestines found near the pelvis from an ovarian tumor. This condition has frequently deceived, even to the extent of inducing the surgeon to open the abdomen. The distinction will rest mainly upon the more solid character of the inflammatory consolidation, the absence of fluctuation, and perhaps the presence of deadened resonance from intestine entangled in the mass. Here again the aphorism which warns to be suspicious of a solid tumor finds useful appli- cation. It is also necessary to remember that peritonitis or hsematocele may supervene upon ovarian cystic disease. In the first case, that of peri- tonitis, it is singular to observe how an area previously yielding dis- tinct fluctuation, becomes hard, almost solid, from the effusion of plastic matter on the surface of the tumor. Where there has been no oppor- tunity of examining before the inflammation set in, it is not easy to avoid the error of concluding that there is a solid tumor under the hand. In the absence of antecedent knowledo'e of the real nature of the tumor it is only by waiting until the inflammatory complication has to a great extent disappeared, that we can be sure of our diagnosis. In the second case, that of hsematocele, the sudden access of grave symptoms at once arrests attention. Where there is an ovarian tumor the source of the effused blood is likely to be the tumor itself. Its walls, or large vessels on its surface, may have burst. Abdominal shock is the first result. If the patient survive this, peritonitis, diffuse or limited to the pelvic region, follows. This will give rise to a firm tumor felt projecting into the rectum and vagina, probably rising out of the true pelvis in one or both iliac fossae, and pushing the uterus forward against the symphysis pubis. For the distinctive characters of retro-uterine hsematocele I must refer to the chapter on this subject. Pelvic cellulitis may be confounded with ovarian tumor under two conditions : first, where there is tumor only ; and secondly, where there is a tumor which has burst, and is discharging purulent matter. In the first case, the history is important. Pelvic cellulitis is usually of recent formation. It has come on with acute symptoms after labor, abortion, suj)pressed menstruation, surgical treatment, or other acci- dent; it sets the uterus fast in a collar or framework of hard effusion, in the brim of the ])elvis, so that the body of the uterus cannot be dis- tinguished. The uterus is not so affected in ovarian tumor. If there be fluctuation, there is commonly redness of the skin and the peculiar oedematous feel of the tissues where the fluctuation is due to abscess. The pelvic distress, including dysuria, is marked in cellulitis, rarely so in ovarian dropsy. Where there is escape of pus, this may be due to the perforation of a suppurating ovarian cyst. But this is a rare event ; whilst it is a frequent issue of pelvic cellulitis. And it usually occurs within a few weeks of the commencement of pelvic cellulitis ; whereas it is extremely rare for an ovarian tumor to suppurate and discharge, until it has at- DIAGNOSIS. 317 tained a large size, that is, until it is of considerable duration. But these features, clear enough when the whole course of the disease has passed under our observation, are not so clear if we are called to a case of long standing. For example, although pelvic cellulitis usually runs a tolerably definite course within a short time, cases occur where ab- scesses burst after some moiiths, or at least in which suppuration goes on, and matter is discharged for months together by the vagina or rec- tum. It is not always easy, under such circumstances, to decide that the source of the pus is not an ovarian cyst; especially as a cyst, dur- ing the process of suppuration and perforation of the vagina, is likely to liave set up pelvic peritonitis. This complication may be very puzzling; and we shall often be driven to the history for data upon which to found a presumption one way or the other. The necessity, however, of forming a precise diagnosis in such case is of minor urgency, since even if we attained to the certainty of its being ovarian, the high probability of extensive pelvic adhesions would forbid the attempt at extirpation. h. Is there ascites, or peritoneal encysted dropsy, or abscess f The distinction between pure ascites and pure ovarian dropsy is rarely so difficult as to induce error. But the two conditions are so frequently associated that the subject demands discussion. The grand character- istics of ascites are : that in the intestines, floating, anchored to the mesentery if the patient be on her back, there will be clear resonance in front, where in ovarian dropsy, pregnancy, and fibroid of the uterus there is dulness ; that the dulness will be in the lumbar regions be- tween the false ribs and the crests of the ilia, where the fluid gravitates, and where there is resonance in ovarian dropsy and pregnancy ; that the areas of resonance and dulness will shift on changing the position of the patient, because the hollow intestines float to the surface, whereas in cystic dropsy and pregnancy these areas do not shift. If percus- sion be performed, the patient lying on her back, the fluid in ascites gravitating to the flanks, and the intestines floating up to the front, the areas of resonance and dulness will be as in Fig. 77. In ovarian Fig. 77. A. Ascitic dulness. i. Intestinal resonance, l. Liver. dropsy, the areas of resonance and dulness will be exactly the reverse, as in Fig. 78, and will not vary under change of posture. 318 OVARIAN TUMORS. A striking contrast between ascites and ovarian tumor may also be demonstrated by percussing in the erect posture. In ascites the line O T. Dull area of ovarian tunior. I. Intestinal resonance. L. Liver. of demarcation between dulness and resonance is concave, whilst in ovarian tumor it is convex. This contrast is seen in diagram, Fig. 79. Fig. 79. Differential characters of ovarian and ascitic droiDsies in upright posture. Again, ascites is the consequence and therefore a symptom of disease of the heart, liver, or kidneys. The history and other symptoms of these diseases will guide to a right appreciation of the dropsy. There is a form of encysted dropsy, the result of peritonitis, in which the peritoneum of the pelvic organs may or may not be involved. Peritonitis may be greatly limited to a portion of the omentum, and of the small intestines covered by it. Plastic matter may be so thrown out as to form a cavity or cyst between these parts in which serum is imprisoned. I saw a case which I concluded to bo of this kind some years ago in consultation with Dr. Clapton and Mr. Litchfield of DIAGNOSIS. 319 Twickenham. There was a large tumor in the riglit flank, passing across the median line, and giving fluctuation, which could be traced downwards to the iliac fossa. It had been looked upon as certainly ovarian. The circumstances that made me doubt were the rapidity with which the tumor had formed ; the severe attendant pain and history of fever ; a certain singular thickness and doughiness of part of the walls ; and the more marked lateral site of the tumor than is usually found in ovarian cysts. I punctured the cyst ; and in doing so it required some confidence in one's diagnosis, for the trocar had to be made to penetrate considerably deeper than is usually necessary in the case of ovarian cysts which lie close behind the abdominal wall. A quart or more of horribly stinking putrid serum escaped, so that we suspected there had been a perforation of the intestine into the perito- neum as the cause of the inflamipation. The entire disappearance of the tumor and recovery of the patient lent confirmation to the diag- nosis arrived at. In encysted dropsy the serum drawn off will coagu- late by heat, or sometimes without. Encysted dropsy may also exist as a reliquium of retro-uterine haematocele. Encysted peritoneal abscess may simulate ovarian dropsy. Thus a case was recently admitted under my care at St. Thomas's, in which a tense, obscurely-fluctuating tumor was traced from the right side of the pelvis, rising as high as the umbilicus, and passing the median line to the left. The uterus was three and a half inches long ; its fundus deflected to the left by the swelling in the right of the pelvis ; the cervix was pushed forward near the pubes. In the fundus of the vagina, on the right of the cervix uteri, was a tense, stretched, elastic, smooth depression. The tumor had, the patient said, all formed within a month. Its onset was not marked by any acute symptoms. But when admitted there were signs of irritative fever; the pulse was about 100, the temperature ranged from 100° Fahr. to 104° Fahr. The physical signs could hardly be distinguished from those of ovarian tumor ; but the rapidity of formation, and the signs of irritative fever, pointed to the diagnosis of a perimetric abscess. I accordingly punc- tured by the vagina with the aspirator-trocar. Fifty-eight ounces of ofi^ensive pus were drawn off; the tumor subsided, and the uterus re- turned to its normal position. More pus formed, which w^as again drawn off. The woman died of peritonitis and septicaemia. The diagnosis was verified, in so far that an encysted abscess was found. But a small ovarian cyst, which appeared to have ruptured, was im- bedded in the abscess. In connection with ovarian cysts it is desirable to refer to certain cysts occasionally found on the external surface of the uterus, and described by Huguier. Two cases he described were the result of metro-peritonitis. Dr. Matthews Duncan, in his work on " Perime- tritis and Parametritis," describes " an example in the autopsy of a case of ordinary cancer of the neck of the uterus, where two little serous bags of the size of hazelnuts were, without adhesions, lying in Doug- las's pouch attached to the lower part of the posterior wall of the uterus by a base narrower than the breadth of the cysts at their middle 320 OVAEIAN TUMORS. parts." I have seen several similar examples, mostly in connection with malignant disease, and where obvious indications of recent or old peritonitis existed. I have, however, seen other examples of cysts containing serum seated on the peritoneal surface of the uterus, on the broad ligaments and ovaries, in which association with inflammation or cancer could not be proved. Dr. McClintock also has referred to cysts behind the uterus. Another form of ascites is that which attends upon malignant disease inducing peritonitis. Here the evidence of malignant disease will commonly be marked ; and we shall miss the characteristic signs of encysted dropsy. It is the complication of ascites with ovarian cystic disease which is so often puzzling. If the ovarian tumor be small, and the ascitic col- lection large, the tumor is easily overlooked. On the other hand, if the tumor be large and the ascitic collection small, the tumor alone may attract attention. In the latter case the practical consequences of mistake may not be serious, because the ovarian tumor is the disease that rules the choice of treatment, the ascites being secondary. In the first case, if there be urgent distress from accumulation of fluid, tap- ping by the aspirator-trocar would be indicated ; and then, the fluid removed, the tumor would come under manipulation. i. Are there adhesions f This is often an exceedingly difficult point to determine. I have seen extensive adhesions where it was confidently foretold that there were none. Accurate diagnosis is not so important as it was at one time thought to be. Abundant experience has now proved that moderate adhesions offer no serious difficulty in carrying out ex- tirpation, and do not jeopardize the recovery. Mr. Wells says his results, in cases where there are adhesions, are as good as in those where there are none ; and that, therefore, practically in determining whether ovariotomy should be performed or not, adhesions to the ab- dominal wall may be altogether disregarded. Extensive and intimate adhesions, especially to the lower surface of the liver, to the intestines, and to the pelvic cavity, will sometimes altogether frustrate the opera- tion, or the injury inflicted in overcoming them may be so great as to prove fatal. But adhesions at these points cannot be diagnosed, so that in practice we are often compelled to disregard the possibility of their presence. We can but abandon the pursuit of extirpation, when the operation having been begun, it is found that the adhesions are in- surmountable without undue violence. The tumor may be presumed to be free from adhesions if — 1 . There be no history of antecedent severe pain pointing to attacks of peritonitis. But this cannot be trusted. 2. If we can pinch up folds of the abdominal wall, or make the ab- dominal wall slide over the tumor. 3. By inspection in the semi-prone position, watching the effect of respiration, if, on inspiration, the tumor is seen to glide downwards beneath the alDdominal wall, and to glide up again on expiration. 4. If on moving the patient, first to one side then to the other, the tumor be seen or felt to fiill to the dependent side. DIAGNOSIS. 321 5. If the uterus move freely under examination by finger and sound,, the presumption is against pelvic adhesions. 6. If we can make out a thin layer of ascitic fluid, giving a wave superficial to the tumor, we have, perhaps, the best evidence of absence of adhesions. 7. Adhesions are less likely to be present if the tumor is benign ; more likely if the tumor is malignant. Owing to the free peristaltic and other movements of the small in- testines, adhesion of them to the ovary is comparatively rare. All the signs of free movement of the tumor may be found, and yet there may exist extensive adhesions. These may have become gradually drawn out by the advancing growth of the tumor, have become elon- gated, partly atrophied, so as to admit of free movement, but yet to give some trouble to separate when an attempt at extirpation is made. j. Is the tumor benign or malignant f In seeking to determine this question, we shall derive assistance from the history, aspect, and con- stitutional condition. If the aspect be clear, and the general health not impaired beyond what can be attributed to the mere bulk and pres- sure of the tumor ; if there be free fluctuation ; if the uterus be capable of being isolated from the tumor ; if we find the tumor free from ad- hesions, it may be presumed that the tumor is benign. It is not easy, however free and universal the fluctnation may be, to predicate that the tumor is monocystic. Indeed, monocystic tumors are so rare that it is scarcely worth while to contemplate the probability of any given tumor being of this kind. It is almost always a safe prophecy to say that it is polycystic. A single cyst will, ex necessitate rei, be perfectly uniform on its surface, and of spherical or ellipsoid form. Deviations from these characters, or variations in degree of fluctuation, or in the rate of growth in different parts, are conclusive against a single cyst. The tamor is probably malignant, if it have grown rapidly ; if the aspect be earthy, sallow, and of characteristic malignant cachexia ; if emaciation be very great ; if very irregular, knobby in form ; if the uterus be found fixed to it ; if irregular protrusions be found behind the uterus; if on rectal examination — which should never be omitted where malignancy is suspected — these projections into the rectum be more plainly felt ; if the vaginal or other glands within observation be enlarged and hardened ; if there be any considerable amount of ascitic fluid, and especially if there be oedema of the legs, with or without phleg- masia dolens. The recognition of ovarian tumor in the earliest stage is especially dif- ficult. Very little distress may attend the early growth. Practically, it rarely happens that the case comes before us until a tumor of consid- erable size has formed. The first inconvenience that attracts attention is the increased size of the abdomen ; and this is often more annoying for moral than for physical reasons. An unmarried woman is visibly increasing in size, and censorious people whisper away her character ; and if dependent upon her own exertions, she is unable to find employ- ment. But sooner or later physical distress from pressure is pretty sure to follow. 21 322 OVARIAN TUMORS. When a small cyst containing fluid has formed, we may feel a smooth, rounded, tense body stretching the roof of the vagina on one side of the cervix, or a little behind. Small cysts get into Douglas's pouch, caus- ing some amount of prolapse of the vagina. By bimanual palpation we may possibly define the tumor, and even make out fluctuation. In this stage, a cystic ovary may be mistaken for a Fallopian gestation, or a dropsy of the tube. In either event the uterus may be so pushed for- wards by the tumor as to obstruct the bladder and cause retention of urine, as in the following case: A young woman applied as an out- patient, complaining of retention of urine. In accordance with our practice in such cases, she was at once sent to bed. I found the os uteri pressed close behind the symphysis pubis : after drawing off the urine I passed the sound into the uterus ; it went in the normal direction forwards, and the fundus was felt just above the symphysis. This made it clear that the uterus of normal size was pushed bodily forwards by something behind it. Exploring with the finger to the sides of, and behind, the uterus, the vaginal roof was felt stretched out, and a tense, elastic, de- fined swelling with fluctuation was made out by vagino-abdominal touch. The swelling did not rise above the pelvic brim, and except bv the two-handed mode of examination it could hardly have been distinguished. I concluded that it was an incipient ovarian cystic tumor ; and since it was causing serious, even dangerous, pressure upon the bladder, I punctured it through the roof of the vagina by the aspirator-trocar, and drew off about six ounces of limpid lemon-colored serum. The uterus then retreated to near the centre of the pelvis, leaving the bladder. No bad symptom followed ; but after some days there was again retention ; the uterus was again pushed forwards against the pubes. I repeated the operation, this time drawing off about two ounces of fluid, and injected an ounce of tincture of iodine, hoping that a cyst so small might contract and be cured. For a time the patient seemed to be doing well ; but irritative fever set in, and ended fatally. Unfortunately a post-mortem examination could not be made. We have since had another case in the hospital of retention of urine caused by a small ovarian tumor. Difficulty of diagnosis between early cystic tumor of ovary, tubal gestation, and dropsy of the Fallopian tube, is the less to be regretted, because puncture by the aspirator-trocar is probably the best treatment in all these cases. A rare instance of difficult diagnosis arose in a case related by Disse {Monatsschrift fur Geburtskmide, 1857), in which an ovarian cyst formed part of a femoral hernia. Puncture by the aspirator or needle-trocar should be preferred in all cases where the prevailing character of the tumor is solidity, and where the fluctuation is obscure and limited. The fluid drawn off should be carefully examined. It sometimes gives diagnostic evidence. Spencer Wells says, in the case of uterine tumor, it is not the viscid mucoid fluid of multilocular ovarian disease, but a thin serum containing 5, 10, or 15 per cent, of blood intimately mixed with it. If we get fluid of this character or none, the idea of gastrotomy should DIAGNOSIS. 323 be abandoned, unless, indeed, we are prepared to undertake the extir- pation of the uterus. It will be convenient to discuss the therapeutical value of tapping and of iodine injections, whilst we are discussing the diagnostic value of tapping. Tapping and Exploratory Incisions. — After exhausting all ordinary- diagnostic methods, the indication to relieve from distressing symptoms and danger to life may still be so urgent that we are justified in resort- ing to certain operations in order to attain the precise knowledge nec- essary to direct ulterior proceedings. These operations are tapping and exploratory incisions. Tapping is indeed an operation of old standing ; for long it was the only proceeding employed to relieve the distension and other urgent symptoms. The operation was looked upon simply as a palliative, and occasionally it turned out to be curative. Now there is added to its palliative value a diagnostic element. When a tumor, apparently raonocystic, is emptied of the greater proportion of its fluid, the cyst which contained this fluid collapses, and the operator can press his hand down upon the base of the tumor and feel what remains. Sometimes, but rarely, we may feel nothing; the tumor has to all evidence gone. In these cases the doubt is reasonable that the cyst was not ovarian, but a simple cyst of the broad ligament. In such a case the tapping may prove curative as well as diagnostic. The cyst-walls may shrivel up, cease to secrete, and finally become atrophied. It is in such cases that the injection of iodine is likely to be followed by cure ; and it must often remain doubtful whether the iodic injection was not superfluous. Or we come to the conclusion that there is no cyst at all ; that the case is one of ascites. The peritoneum emptied, we can now examine the state of the liver and other abdominal viscera more easily ; we may find tubercular or other disease of the lumbar and pelvic glands. It is not always easy to determine that there is no cyst. Its walls may be so thin, and be adherent to the abdominal wall, that incision may go through the cyst- wall without this being identified. In other cases, and these by far the most numerous, when fluid ceases to run by the canula, we come down to a residual tumor more or less solid, more or less bulky. If there remain a considerable mass bulging up behind the abdominal wall on one side, or near the pelvis, and pre- senting fluctuation, we may diagnose another cyst, and the trocar may be used to puncture this, and even another in succession, or we may explore through the canula by a sound to ascertain the condition of the tumor. Here the polycystic character is beyond .doubt. And the therapeutical conclusion may confidently be drawn that neither by iodine injection nor by any means, short of extirpation, will a cure be obtained. In these cases the fluid isoft^n gummy or colloid, sometimes puriform. Once opened, these tumors are liable to run a rapid down- ward course. Suppuration in the cysts is very likely to occur. Injec- tion of iodic or other irritants will only accelerate mischief. The prac- ticability of extirpating the mass should be earnestly considered. In another class of cases, also numerous, when the .fluid ceases to run, the great bulk of the swelling has disappeared. But by deep pressure 324 OVARIAN TUMORS. through the now flaccid abdomen, we come upon a solid residuum in the pelvis, which may sometimes be grasped in the hand, and which may always be defined between the hand outside and a finger in the vagina. In these cases also it is of no use to inject iodine. The solid residuum almost certainly contains smaller cysts, whose development, repressed by the preponderant activity of the one which has been emp- tied, will quickly take its place, if indeed the first cyst do not fill again. When the tumor has thus grown again, it is generally advisable not to repeat the tapping, but to proceed to extirpation, which holds out the only trustworthy hope. Exploratory Incision. — Before proceeding to this measure, the call for relief should be so serious as to justify extirpation, should this ultimatum be found practicable. Exploratory incisions are not, it is true, so dangerous as the major operation; but a fatal issue has with considerable frequency occurred. It properly claims consideration when other means of diagnosis, including puncture or tapping, yield no results, or are contraindicated. It is generally advisable on begin- ning the operation to have all things prepared for proceeding to extir- pation. The patient should be in anaesthesia. A small incision, an inch or two long, is made with a bistoury, midway between the umbilicus and pubes. This is very cautiously made, so as to avoid all risk of incising the tumor, which may not be ovarian. The incision should be just large enough to admit the finger to feel the tumor, and to sweep round in a short radius, so as to ascertain if there are adhesions. This will generally be large enough also to enable one to inspect the surface of the tumor.. The uterus, or uterine fibroid, presents a dark-reddish fleshy appearance, which, if not absolutely difterential from the usual pearly-blue aspect of an ovarian cyst, should serve as a warning not to proceed to ulterior measures without further investigation. For clinical purposes, Kiwisch, Scanzoni, and Hutchinson divide tumors of the ovary into two classes, namely, those which contain cavities, and those which form solid and compact masses. To the first belong the simple or multiple cysts, the cysto-sarcoma, the colloid tumor, and the cysto-careinoma ; whilst the second comprises the fibroid bodies, the enchondromata, and the cancerous tumors without cavities. This division is certainly useful. But there is another division which, not displacing this one, I think is even more useful in practice. Ova- rian tumors may be divided into benign and malignant. It is not indeed easy in all cases to tell, in the living subject, to which class a particular tumor belongs. But in many cases we can form a reason- ably good opinion. For example, we may often negative malignancy. When we can do this the course of treatment to adopt is more easily decided, and the prognosis is more hopeful. On the other hand, we can often affirm malignancy ; and in this case we know the treatment must be more circumspect, and the prognosis be more grave. h. Two other conditions, which may possibly give rise to error, are distension of the bladder Mdth urine, and fecal accumulation. The error of overlooking a distended bladder will be avoided, if the rule of passing the catheter before proceeding to abdominal examina- tion be observed. TAPPING. 325 CHAPTER XXXIII. TREATMENT OF OVARIAN CYSTIC DISEASE: MEDICINAL; TAPPING BY VAGINA, AND BY ABDOMEN. The experience of a century has but confirmed the conclusion arrived at by William Hunter, that ovarian dropsy was an incurable aflPection, and that tapping was the only palliative. The methods by which nature or accident effects spontaneous cure of ovarian dropsy are so uncertain in their result, and so unforeseen, that the expectation of seeing relief occur in this way cannot influence the conduct of the surgeon. Rupture, perforation, or twisting of the tumor may, indeed, effect a cure ; but they are far more likely to cause death. It may with confidence be said that if a woman is to be rescued from the dangers of an ovarian tumor, the only reasonable prospect lies in extirpation. The following are the proceedings for the treatment of ovarian cystic tumor which especially call for discussion : 1. Medicinal. — The Pharmacopceia has been ransacked in vain. There is no trustworthy evidence that any internal remedy has the slightest effect in arresting the growth of an ovarian cyst. If, in a few instances, a cyst have seemed to diminish or to disappear under bro- mides, iodides, chlorates, or other medicines, further trials in other cases have signally failed. Dr. Peaslee " has, however, in several in- stances of late apparently arrested the growth of ovarian cysts in the early stages by the application, per vaginam, of ointment of iodide of lead. But," he adds, "further trials must demonstrate how permanent is to be the benefit thus obtained." Although the surgical proceedings which have successively been tried for the relief or cure of ovarian cystic tumors have yielded for the most part only unsatisfactory results, a brief review even of those which have most unequivocally failed is useful. In the first place, this review may save us from repeating operations which experience has con- demned. In the second place, these proceedings may be regarded as experiments calculated to give us useful knowledge as to the constitu- tion and behavior of cystic tumors. Thirdly, some of these proceed- ings, although they have lost claim to be regarded as generally appli- cable, may still prove valuable in exceptional cases. 2. Surgical. — Tapping and iodic injections have to some extent been discussed under " Diagnosis." Many simple cysts may be cured by simple tapping, or by tapping and injection of iodine. The difficulty is to determine whether a cyst be simple or compound. Sometimes tapping itself proves fatal. It is of course less hazardous than ovari- otomy, but it is not free from danger. In the great majority of cases . 326 OVARIAN TUMORS. the cyst will quickly fill again ; and the operation must be repeated. Sometimes tapping is followed by inflammation and suppuration of the tumor. And although tapping will commonly give immediate comparative relief, it has been thought that the disease is often acceler- ated by it. Tapping hy the Vagina. — The argument for this proceeding rests upon the anatomical fact, that the ovary always occupies the lowest position in the pelvis. It is in direct relation with the roof of the vagina, and below the intestines. A fair amount of success has at- tended the operation; but there is not sufficient reason to conclude that it is more favorable than tapping by the abdomen. There are two forms of tapping: the one is simple tapping; in the other the tapping is supplemented by other proceedings, as keeping the cyst open, and throwing irritant or other fluids into the cyst. Simple tapping consists in puncturing the cyst, letting the fluid con- tents drain off, and then letting the opening close. This proceeding may be adopted as a palliative, with a view to cure ; or as tentative with a view to obtaining information to guide further treatment. It is useful only in a limited order of cases. Our first care then is selec- tion. The favorable conditions are : a small "cyst which descends fairly behind the uterus, bulging out the posterior wall and roof of the vag- ina ; distinct fluctuation ; absence of solid masses at the most promi- nent point where puncture must be made. The cases in which vaginal tapping is most likely to be useful are the monocystic. But this condition can hardly be determined before tapping; and thus tapping comes to be experimental as regards treat- ment, and exploratory as aiding diagnosis. I would therefore strongly advise that the first or diagnostic tapping be made by the aspirator- trocar. Comparatively little risk attends this method. The Operation. — No matter what the instrument employed for tap- ping, the chief difficulty, of course, consists in selecting the point for puncture. This should be determined with precision. The cyst, it is assumed, occupies by its most dependent part the peritoneal sac between the uterus and rectum. Occupying this space, it causes the uterus and rectum to diverge, the uterus is pushed forwards and a little to one side, the rectum is compressed or flattened backwards. The perforating in- strument must therefore strike between these two organs. First, pass a catheter into the bladder, to empty this organ, to insure its safety, to remove it from all interference, by collapsing. Secondly, feel for the position of the uterus by touch and by the sound. In front of the os uteri through the anterior vaginal wall, we may feel the body of the uterus ; by passing the sound, the position and relations of the uterus are made still more clear. This is one great landmark. We must keep behind this. Thirdly, pass the forefinger into the rectum, the sound being still in the uterus. You will then ascertain the position and re- lations of the rectum at the level of the tumor and os uteri. There will probably be a space of one or two inches or more between the os uteri and the anterior wall of the rectum. It is within this space that the puncture must be made. The anterior wall of the rectum is the other great landmark. Fourthly, your finger quits the rectum and TAPPING BY VAGINA. 327 returns to the roof of tlie vagina behind the cervix uteri ; tlien, feel- ing the cyst here, press firmly down towards it the cyst from above by your other hand in the abdominal wall above the pubes. You thus get evidence of a fluctuating point. Tapping being resolved upon, you place the patient in position. It is scarcely desirable to give chlo- roform. The lithotomy position is very convenient ; but it is often quite as easy to operate, the patient lying in bed on her left side, the nates drawn well to the edge. An assistant presses the tumor firmly down into the pelvis ; the forefinger resting on the tumor an inch or so behind the cervix uteri guides the trocar, which is thrust in perpen- dicularly to the surface, and carried in the direction of the axis of the pelvis for about an inch, or until the sense of resistance is suddenly lost. Then, the fluid ought to flow either spontaneously, or under the vacuum produced by the pump. The exhausting pressure should be kept up as long as fluid flows. Then explore to ascertain what remains of the tumor. Withdraw the trocar. Enough has been done for the occasion. Time must be allowed to observe the subsequent course of events, before the diagnosis can be absolute, and before determining on further operations. As yet we cannot be certain that the cyst is not formed by a tubal gestation, or by dropsy of the Fallopian tube. In either of these cases it would not be desirable to enlarge the opening or to inject fluid into the cyst. Simple exhaustion of the fluid contents may be sufficient for cure of either of these affections, and also of a simple cyst of the ovary or of the broad ligament. It is obviously, then, sound practice to take the benefit of this possibility of cure. If the cyst be ovarian it will probably fill again. By repeated tapping by vacuum, a small ovarian cyst may gradually become smaller, shrivel up, and be obliterated. This process may be accejerated by iodine injection. A few drachms may be turned on w^hen the cyst has been emptied. Firm pressure by compress and binder should be applied imme- diately after operation, and sustained for some days. The double use of this is to obviate the vacuum that might otherwise form, favoring suction of air into the cyst ; and to promote the reduction of the cyst by maintaining its walls in contact. Rest in bed for a week, salines and sedatives are to be recommended as after-treatment. If, aided by this preliminary tapping, the tumor be found to be ova- rian, and be of the size of a foetal head, or somewhat larger, we may then consider the expediency of tapping by the vagina, and keeping the cyst open, so as to allow continuous drainage to go on. The pre- paratory steps are the same as those already described. It is best to use a long curved trocar, after the manner of Kiwisch. The canula is connected with an elastic drainage-tube, to carry off the fluid. The next step is to widen the orifice. To do this a long director, correspond- ing exactly to the curve of the canula, is passed through the canula as deeply into the cyst as it will go. The canula is then withdrawn, and a long probe-pointed bistoury is guided along the director into the cavity. By this the wound is enlarged, to allow the forefinger to pass 328 OVARIAN TUMORS. into the collapsing sac, to ascertain the condition of the internal surface. On withdrawing the finger, a long curved uterine tube is inserted into the opening, so as to project well into the cavity, and its outer end is fastened with a T-bandage in front of the pubes. The uterine tube should be furnished with a flexible tube, to drain off into a convenient vessel. This vessel should always contain water enough to cover the open mouth of the tube. This will prevent the sucking-in of air into the cyst. On the second or third day, symptoms of inflammation of the cyst, with severe reaction, commonly set in. A discharge of ichor- ous fluid takes place, and there is great pain in the pelvic region. In favorable cases, says Kiwisch, these symptoms gradually gave Avay to a purulent discharge, which ceased in from five to seven weeks, and then shrivelling and perfect obliteration of the cyst took place. As long as any secretion goes on it is desirable to inject lukewarm water through the tube twice a day. Scanzoni' is an advocate for vaginal tapping, in preference to ab- dominal tapping, generally, when the cyst can be reached by the vagina, amongst other reasons, because it secures more perfect draining of the cyst. If this could be always performed, he says, abdominal tapping would disappear from the rank of recognized operations. Our expe- rience of this method is, perhaps, insufficient. But it is certain that the advantages of it are not without a drawback of danger and of failure. There is always an element of uncertainty, owing to the varying char- acter of these tumors, complications, and the idiosyncrasy of the patient. The operation is, therefore, of an experimental kind. The inflamma- tion, the suppuration, may extend beyond the wished-for limits. Then there is an objection which especially applies to tapping through the vagina. The wound is necessarily made at the base of the tumor, where solid elements are most commonly found, and where the bloodvessels which feed the tumor are largest and most abundant. Kiwisch him- self, the chief advocate for the measure, says it is only of use in mod- erately-large simple cysts, because in very large cysts the extensive decomposition must be very exhausting to the system, and compound cysts do not allow of a full shrivelling-up of the sac. Now here is the difficulty ; we can rarely be certain that the cyst is not compound. Some cases are related by Mr. Wells. His conclusion is, that "sim- ple tapping is more hazardous than tapping followed by drainage, and that drainage should be so complete, that no reaccumulation of fluid can take place, the cavity being kept open until the walls collapse and unite, so that it is completely obliterated." I am disposed to qualify this view. Assuming that only those cases are suitable for vaginal tapping, in which there is strong presumption that the cyst is single, I would first practice a simple tapping; and if the cyst refilled I would combine the second tapping with drainage. Tavignot proposed tapping by the rectum. Where the tumor pro- trudes more within reach by this canal, it may be preferable to tapping by the vagina. But whilst open to all the objections urged against tapping by the vagina, there is a special danger attending it, from the ^ " Maladies des Organes Sexuels de la Fenime." French ed., 1858. TAPPING BY ABDOMEN. 329 greater likelihood of foul air getting into the cyst from the rectum. The sphincter ani converts the rectum into a pouch, often filled with air, and may even by its contraction help to force air into the cyst. And dysenteric tenesmus has been caused by the irritation produced. Tajipivg by the abdomen is an operation often of necessity to relieve urgent distress of breathing. It scarcely merits the rank of an opera- tion of election ; since, except in rare and unforeseen cases, it is at best a palliative only. But as a palliative it is exceedingly valuable. It is applicable to a large class of cases, and especially to those large tumors which are admittedly unfit for vaginal tapping. It is a legitimate resource in most cases where, for any reason, extirpation of the tumor is excluded. It possesses the great advantages over the vaginal opera- tion, that it is easier of performance, that it is done at a distance from the base of the tumor, so that we are more likely to avoid wounding solid and vascular parts ; that tlrere is, further, a considerable area of space within which we can select the point for puncture. The following dangers attend tapping by the abdomen : 1. It is possible to wound a vessel in the abdominal wall large enough to cause serious bleeding. This is no real bar, because all serious bleeding may be avoided by selecting the linea alba for piinc- ture, and by dividing the skin by a scalpel, by which precaution we can secure any injured vessel before plunging in the trocar. 2. The risk of wounding some large vessel in the wall of the sac is more serious, and can hardly be secured against. This risk is, however, small in cysts presumed to be singl-e, and in which free fluctuation in- dicates that the walls are thin. In the case of tumors partly solid, and whose walls, even at the fluctuating parts, are thick, the risk is very great, so great in fact, that if things generally are not adverse, the major operation of extirpation should be at once preferred. The hem- orrhage is dangerous in two ways : blood may be slowly poured out into the peritoneum, setting up peritonitis; or it may pour into the cyst to such an extent as to cause augemia, as well as inflammation of the cyst. If, after tapping a thick-walled cyst, symptoms of internal hemorrhage arise, the operation for extirpation should be immediately undertaken. By this means, and only by this means, can the bleeding be arrested by tying the pedicle, and the effused blood be removed. 3. The rapid emptying of the cyst may be followed by collapse, just as prostration sometimes follows too rapid delivery. This is our reason for compressing the abdomen by bandages as the fluid escapes. 4. Some of the contents of the cyst may run into the peritoneal cavity and set up inflammation, which may prove fatal. This accident may be avoided by using a sharp well-made trocar, by dividing the skin of the abdomen first by a scalpel, oiling the trocar, and piercing the remains of the abdominal wall and the cyst-wall with a decided stab, so as to carry the canula a good inch or more through into the cavity of the cyst, before withdrawing the trocar. To accomplish this the trocar should be much longer than the old-fashioned instruments. 5. Air may be sucked into the sac. When this accident happens, decomposition and suppuration are very likely to ensue. Irritative fever will set in, and the result may be fatal. This risk should be 330 OVARIAN TUMORS. guarded against by using a trocar so constructed as only to permit flow from the cyst outwards, by keeping the delivery end of the drainage tube under water, and by steadily following down the emptying sac by pressure. 6. In the case of compound cysts, especially if malignant, mere tapping, where precaution against letting in air has been successful, may be still followed by suppuration and fatal septicaemia. Indeed, in most cases, it is observed that after several tappings the nature of the fluid changes, becoming turbid, more viscid, or puriform. Where evidence of suppuration in the cyst is obtained, the feasibility of extir- pating the tumor should be considered. 7. By repeated tapping the system is exhausted by the drain caused by the diversion of material to the cyst. This is probably often in- creased by tapping, which takes off the pressure that restrained ex- halation. Even where no untoward accidents follow tapping, the relief obtained is often very transient. Fluid rapidly collects again, and the opera- tion must be very soon repeated. It has been supposed that tapping accelerates the progress of the disease, — that it is, in fact, the beginning of the end ; that, once performed, the necessity for having recourse to it again and again recurs at a constantly accelerated ratio. There appears to me to be a fallacy lurking under this belief. Tapping is rarely performed until the symptoms are so urgent that relief is im- perative. This implies that the disease is in high activity, and that things have reached a climax. From this time it is not surprising that the course should be down-hill, whether tapping be performed or not. And it can scarcely be doubted that in most cases, tapping does afford a respite more or less prolonged. It certainly, in some cases, averts apparently imminent death. In some cases, unforeseen, it must be admitted, it is followed by complete cure. I think the matter may be summed up as follows: Tapping has its own immediate dangers, but these are limited to a small proportion of cases; tapping postpones death from the secondary effects, such as pressure of the tumor upon the viscera and bloodvessels, and allows the sufferer to sink under the })roper effects of the progress- ing disease. Even simple tapping, then, cannot be urged upon a patient as an operation free from danger. A considerable proportion of patients die very quickly after its performance. It is often objected that tapping lessens the chance of success of ovariotomy, should this operation subsequently be performed. This objection is not borne out by experience. It may even in many cases be regarded as a useful auxiliary to extirpation, giving means for more accurate diagnosis, and giving time for the patient to recruit her gen- eral health by relief from the pressure before the extirpation is under- taken. Dr. Fock published a memoir in 1856, in which it is stated that out of 132 cases of ovarian disease tapped for the first time, twenty-five died within some hours or a few days. Kiwisch lost nine patients out of sixty-four within twenty-four hours after the first tap- TAPPING BY ABDOMEN. 331 ping. Mr. Southam, of Manchester, collected twenty cases of tapping from various sources; of these four died within a few hours. I think, however, these figures give an exaggerated idea of the danger of tapping, if the operation be performed with proper circumspection. Still it must be admitted that tapping is attended by considerable risk. The Operation of Tap])ing by the Abdomen. A trocar made on Mr. Wells's plan, modified from that of Mr. Charles Thompson, of Westerham, designed for paracentesis thoracis, secures against most of the accidents liable to attend the use of ordi- nary trocars. The edges of the canula should not be thin, but perfectly smooth and well rounded oif. This best obviates the risk of injury to large veins on the inner surface of the cyst ; and the maker should be careful, when sharpening the cutting part of the hollow trocar, to leave one half of the lips quite blunt. If sharpened all round it would act as a punch, and cut out a ciruclar hole in the skin. If the instrument is properly finished, only a semilunar cut is made in the skin and cyst, which closes much more readily than the triangular puncture made by the old trocar. To the trocar, a long elastic tube is attached, which can be made to act as a syphon, exerting suction-power fi'om the cyst. In piercing the cyst, care is taken that the point of the instrument is maintained at a lower level than the commencement of the tube, so in fact that the canula makes the short leg of the syphon, whilst the conducting tube makes the long leg. Thus the moment the canula enters the cyst, the rush of fluid into it drives the air in the canula and tube before it, and running along the tube or long leg of the syphon, a strong outward suction-power is at once at work. The far end of the tube may be kept under water. This is especially desirable towards the end, when the cyst is nearly empty. In withdrawing the instrument it is always well to press the abdominal wall well down upon the cyst, and with the finger and thumb of the other hand so to press the abdominal wall together behind the escaping canula, as to prevent the entrance of air. Should any bleeding follow, and not be stopped by a little pressure, a harelip pin should be passed completely across the opening, deeply enough beneath the skin to compress any injured vessel. Two or three turns of silk twisted round the pin make sufficient pressure to stop any bleeding. In ordinary cases a small pad of lint and a slip of adhesive plaster suffice to close the opening. It is often useful to apply pads or com- presses of lint or napkins in the flanks to fill up the spaces left flaccid and hollow by the withdrawal of the fluid. The abdomen may then be supported by a binder over all. The best position is the semi-recumbent in bed. Empty the bladder by catheter. It is important to puncture low down. A firm thick linen binder, having a long slit in the middle, is applied round the abdomen so that the slit corresponds with the linea alba below the umbilicus ; the two ends are then crossed behind the back and brought out in front, one on each side. The incision and puncture are made as 332 OVAEIAN TUMORS. already described in a selected part through the slit, and compression is kept up as the fluid escapes by assistants pulling upon the ends of the binder. If the canula gets choked, it may be cleared by hooking out the obstructing matter with a wire. If the flow stops while the tumor is only partly collasped, this may be due to the existence of other cysts which do not communicate with the one tapped. It may then be de- sirable to pass a sound through the canula to feel for these other cysts, which may be punctured and drained like the first. Or there may be a solid residuum which precludes all further benefit from tapping. Sense of fainting or actual syncope often attends the evacuation, so that stimulants should be at hand. One effect following upon tapping is a temporary revival of the secre- ting power of the kidneys. The quantity of urine thrown off is often considerably increased for a time. Tapping Gomhined with injection into the Cyst of iodic or other irritating fluids. The success attending the injection of wine or iodic solutions into the sac of hydrocele of the testicle naturally led to the imitation of this practice in the treatment of ovarian cysts. But the analogy between the cases is only apparent. A simple serous sac which can be perfectly surveyed and commanded is in reality widely different from the imper- fectly accessible and probably proliferous ovarian cyst. The difference in size alone alters the conditions materially. Still the method of in- jecting has been taken up with enthusiasm, especially by Boinet, who in a valuable work' details several cases in which it was successfully employed. He urged that, when the cyst was unilocular, filled with a limpid, lemon liquid flowing easily, and the patient otherwise of good constitution, it should be tapped and an iodic injection made immedi- ately afterwards. When the contents were drawn off he passed an elastic catheter, of size just fitting the canula, through the canula, which was then withdrawn, leaving the catheter in its place. Through this the injection was made. He used equal parts of tincture of iodine and water, adding a little iodide of potassium. Of this solution he threw in about three ounces. The cyst was then kneaded, and the position of the patient changed so as to insure free contact everywhere of the solution ; it was then, after five or six minutes, withdrawn, if necessary, by aid of the syringe. The catheter was then removed, and the abdo- men well compressed and supported by a bandage. If fluid collected again in the cyst he would repeat the injection several times, anticipa- ting refilling and distension. In multilocular cysts containing a thick liquid, flowing with diffi- culty, further care is necessary. A large trocar was employed, and after letting all the fluid that could, run, a catheter was passed, and a syringe applied to draw out all the thick viscid matter remaining. The rest of the proceeding was the same as in the simple cysts. But in complicated cysts it was sometimes necessary to keep the catheter in. ' "lodoth^rapie " Paris, 1855. KEEPING OPEN THE CYST. 333 This was to be done when the cyst showed no tendency to obliteration. In these cases the catheter was plugged, fixed by a bandage, and unstop- ped two or three times a day to let oiF the gathering fluid. Washing out the cyst with tepid water or weak solution of iodine was practiced occasionally to prevent decomposition, and to clean out the cyst. When the fistulous opening formed by the catheter was well established, so that all escape into the peritoneal cavity was prevented by adhesions, the catheter was replaced by an ivory canula furnished witli a stop- cock. Then iodic injections and washings were performed from time to time. The result was slow, the cysts taking months to contract and shrivel up. Since the publication of Boinet's work I have practiced iodic injec- tions a good many times. In three, perhaps four, cases, the cure was complete and permanent. These were apparently monocystic tumors. Possibly they might have been simple cysts of the broad ligament ; and possibly, also, simple puncture without iodic injection might have cured them. In other cases, undoubtedly polycystic, I could not satisfy myself that good was effected. Suppurative inflammation of the cysts set in, and a fatal result, not visibly accelerated by the treatment, fol- lowed. In other cases the sac refilled, the patients left the hospital, or were submitted to ovariotomy. Acute pain and a degree of collapse not seldom set in during or soon after the injection. In all the cases it was easy to detect iodine in the urine ; in one case a strong iodic odor was given off from the patient. I detected iodine in the perspiration and in the breath. In another case, as well as in the foregoing, the signs of iodism were marked. But I have not seen a case in which it could be said that the patient was fatally poisoned by the iodine. Scanzoni and others think iodic injections ought to be rejected alto- gether. Since simple tapping may prove fatal, it can hardly be expected that tapping, plus iodic injection, should be free from danger. Dr. R. L5w- enhardt^ relates a case in which oiv of a mixture of equal parts of tincture of iodine and water, with gr. x of iodide of potassium, was injected. Death followed in fourteen hours. The cyst was found col- lapsed ; there was no trace of inflammation ; in the cyst was a small quantity of clear-brown weakly iodized fluid. Death was ascribed to shock, Legrand^ relates the case of a woman aged fifty-six, in whom a puncture, followed by iodine injection, was made. Little reaction en- sued ; in eight days the patient was up ; the dropsy quickly returned. The operation was repeated, and twelve to fourteen pints of fluid were let out. At the instant of injection the patient sank into syncope ; a strong shivering, vomiting, peritonitis set in, and death followed in sixteen hours. In this case, probably, some of the injection escaped into the peritoneum. It is better, I think, to use the concentrated tincture of iodine. There must always remain fluid enough in the cyst to dilute it, and if ' "Monatsschr. f. Geburtsk," 1860. 2 " Gazette des Hopitaux," 1861. 334 ovARiAisr tumors. used already much diluted, its caustic action on the cyst-wall is lost, whilst absorption into the system is promoted. In performing the operation, the patient should be on her side in bed. Tapping must be performed in the usual Avay ; and when the cyst is nearly emptied, a flexible catheter, closely fitting the canula, should be passed quite through it, so that the end shall project two or three inches beyond the canula into the cyst. Then the remaining fluid should be allowed to drain from the cyst. When no more can be obtained, four ounces of tincture of iodine should be injected through the canula, and allowed to remain about ten minutes. It may then be dramed ofl" as far as possible. I would then advise that an ounce or two of water be injected through the catheter to clear it of iodine before removal. The catheter and canula may then be with- drawn together, taking care to keep the thumb over the end of the catheter, to prevent the escape of iodic fluid into the peritoneum during the passage of the instrument through the wound. I have described Boinet's method with care, because, although it is very far from having realized the expectations at one time formed of it, I still think it would be unwise to reject it altogether. It may fairly claim to be adopted in certain cases where circumstances exclude ovariotomy, such as refusal of patients to submit to this operation, or the complication of severe disease, as phthisis. Tapping and keeping open the Cyst — By this plan it was hoped that the fluid, being allowed to escape as quickly as it formed, tlie cyst would go on contracting gradually to complete obliteration. It was also expected that the irritation set up in the cyst-walls would promote the attainment of this result. A favorable case is reported by Ollen- roth (1843). Mr. Alexander Anderson, my colleague, when obstetric physician to the Western General Dispensary, treated two cases in this way, leaving a canula in the cyst. One woman recovered completely after long suffering, suppuration having gone on through the canula, attended with hectic and great emaciation. I saw this case several times, and could not help forming the opinion that her power of re- sistance against exhausting influences Avas exceptional. The other woman died a few weeks after the tapping, from constant vomiting. Mr. Anderson abandoned the practice. It is not, I apprehend, likely to be revived, unless in very exceptional cases. Cases have, however, occurred in which, after simple tapping, the punctured wound has kept open spontaneously, giving vent from time to time to cystic fluid. In this way a slow cure has been effected. Incision of the Cyst. — Ledran advised and practiced the following operation.^ When the liquid is thick, and contained in several cysts, he made an incision in the most dependent part of the tumor, and, according to its position, either in the median line, or outside the recti muscles ; he then divided the cyst in the same direction, and broke down the internal septa, which could be reached. He placed in the wound a strip of soft rag, for which, at a later period, he substituted a tent, and at last a canula, to preserve free vent for discharges and for ' See Malgaigne, " M<5decine Op^ratoirc," 4eme ed., 1843. OVARIOTOMY. 335 detersive injections. By this proceeding the cysts empty themselves, their walls suppurate, cleanse, and contract. Sometimes a fistula, diffi- cult to close, remained. It was found that owing to the retraction of the cyst, the opening in it getting below the level of that in the abdom- inal wall, fluid would escape into the peritoneum. To obviate this accident, E.6camier and others sought to effect adhesion between cyst and abdominal wall before incision by caustics ; Trousseau by repeated insertion of several long needles ; Begin by cutting through the ab- dominal wall, so as to bare the cyst, and waiting until adhesion had formed all round the wound before tapping and incision of the cyst. The results of the operation have not established for it a claim to a recognized place in the rank of elective proceedings. It is now chiefly known as a pis aller, as the best thing to do in certain cases where the attempt to perform ovariotomy breaks down, either from insurmount- able adhesion or other complications. In this way some most unex- pected recoveries have taken place. It scarcely differs in principle from the preceding operation, of keeping open a fistulous canal after tapping. The dangers attending it are greater, and therefore it falls, d fortiori, under the like condemnation. A modification of this proceeding was proposed by Deneux and Sacchi. It consists in cutting away portions of the wall of the cyst. Malgaigne advises it as a resource when extirpation cannot be carried out. In a case recently operated upon by Dr. Chambers, at the Chelsea Hospital for Women, Dr. Aveling and myself assisting, adhesions ren- dered it unwise to proceed with the intended extirpation. The cyst was compound ; all the contents that could be easily removed were taken away ; and the cyst-wall being included in the sutures through the abdominal wall, the wound was closed, all but a small part at the lower end. Several weeks later the wound only gave vent to a slight oozing of pus, and the patient was in a fair way to recovery. The excision of a part of the exposed cyst, and then closing the ab- dominal wound, was proposed by Mr. Baker Brown. It is a deliberate imitation of those cases of accidental rupture of the cyst in M^hich the fluid effiised into the peritoneum has been absorbed and excreted. The abdominal cavity was opened by a small incision, a part of the cyst was laid bare, then punctured by a trocar, and the nature of the contents ascertained. If limpid serum was found, a part of the cyst-wall was drawn through by a sharp hook, and excised. The abdominal wound was then closed. The cyst would thus continue to discharge into the peritoneal cavity, whence it would be removed by absorption and ex- creted. The operation has not, I think, been often practiced. Repeated simple tapping would appear preferable. It is better to get rid of the fluid directly, than to let it flow into the peritoneum. Encouraged by the fact that many cures have followed the accidental bursting of an ovarian cyst, and discharge of its contents into the peri- toneal cavity, whence they have been removed by absorption. Dr. Blun- dell and others have been led to hope that ovarian dropsy might be successfully treated by deliberate imitation of this accidental process. Gu^rin, Bainbridge, and others attempted to carry out this idea by 336 OVAEIAN TUMORS. making a subcutaneous incision in the wall of the sac by means of a small tenotomy-knife. But this mode of proceeding is open to the grave objection that it is working in the dark. Many tumors have large vessels ramifying on the surface, which, if divided, might give rise to fatal hemorrhage. Mr. Bainbridge operated by cutting down on the tumor, and excising a piece of the cyst-wall. But this plan, like Gu6- rin's, is open to the objection that the fluid which is to be thrown into the peritoneal cavity may be of a viscid and irritating character. It is true that by his plan Bainbridge avoids the risk of wounding vessels ; and as it gives the opportunity of seeing the nature of the tumor and its contents, the operation need not be proceeded with. It might be treated thus far as an exploratory operation, the information gained from which would govern ulterior measures. The late Professor Simpson thought the proceeding might be use- fully modified by making a preliminary tapping, with the view of as- certaining the nature of the fluid; and if this were found to be benign, to allow it to escape into the peritoneum. In this way, he says, hav- ing made sure that the fluid was innocuous, he stopped the tapping by shutting up the cutaneous orifice, and allowed the last part of the fluid to run into the cavity of the abdomen. To provide for the escape of subsequent secretion into the abdomen, it is necessary to keep the lips of the puncture in the cyst from closing by first intention. This is the great difficulty. To gain this object, he sometimes made use of a large quadrangular trocar. He then forcibly compressed the tumor daily, so as to break down the adhesions which tended to close the cyst. In this way, at least, one cure was effected. Ovariotomy, or Extirpation of the Diseased Ovary. This operation has slowly made its way against prejudice, and the many failures necessarily attending the tentative operations performed whilst the conditions of success were unknown. It may at last be said to be admitted to a recognized place amongst the legitimate resources of surgery. Acting on this assumption, I may conveniently omit much historical and argumentative matter. Ample details will be found in the works of Wells and Peaslee. The operation was suggested by William Hunter; its practicability, and the mode of performing it, were taught by John Bell ; it was first practiced, and that successfully, by an American, Dr. McDowell, a pupil of John Bell. But it is mainly to the enterprise and skill of British surgeons that it has attained its present position. Up to this day, the operations in Great Britain alone form a very large proportion, if not an actual majority, of the total. Ovariotomy has been contrasted with tapping. The fallacy that deprives this comparison of all practical application is of the same kind as that which invalidates all absolute doctrines in medicine. There are cases for which ovariotomy is best ; there are cases f(5r which tapping is best. The great distinction between the two operations is, that the first kills or cures; whilst the second hardly ever cures, and can, at best, prolong life. Looking to cure, we should prefer ovariotomy, if the OVARIOTOMY. 337 case admitted of this operation ; looking to mere palliation, we must in many cases resort to tapping. The first is more an operation of choice, the second rather one of necessity. It has been urged against tapping that it lessens the chance of ovari- otomy being successful by promoting the formation of adhesions. This objection has been disposed of by experience. The moderate parietal adhesions following tapping rarely present any serious obstacle to the execution of ovariotomy. On the other hand, tapping is often useful in clearing up the diagnosis ; as a means of gaining time for the pa- tient's general health to recover ; or of lessening the shock by remov- ing the flnid a few hours or days before removing the solid portion of an ovarian cyst. Thus, it may be affirmed, that tapping promotes the success of ovariotomy, instead of being antagonistic to it, PreGcmtions before Operating. 1. It is needless to say that a good diagnosis is the first point. 2. If there is much anasarca or oedema of the legs, it is well to tap some days previously. The eftiised fluid becomes absorbed and ex- creted, thus removing what might be an injurious complication. If this be not done, the absorption process must go on simultaneously with the wished-for process of healing from the operation. In this case the quality of the blood is impaired by having thrown into it, just at the wrong time, a large quantity of watery and effete material. 3. Examine the urine for albumen. The presence of albumen is not indeed an absolute contra-inclication, for it may dej^end upon tem- porary congestion of the kidneys, the immediate consequence of pres- sure by the tumor. The tumor removed, the kidneys may recover. But if the albumen be accompanied by casts, by persistent oedema of the legs, hands, and face, and be thus traced to permanent Bright's disease, the operation will be likely to fail. Brodie used to insist upon this condition as being highly adverse to the success of capital operations. Mr. Wells insists further that a small quantity of highly concen- trated urine, depositing mixed urates in abundance, indicates a state of hepatic and renal disorder which should be corrected before operating. For this purpose saline purgatives, as sulphate of soda, carbonate of magnesia, and lithia water may be given with advantage. 4. The state of the heart and lungs should also be examined as to their soundness and fitness for work. If there is advanced phthisis it may be of doubtful advantage to operate. 5. The Season. — Where there is a choice it is wise to follow Brodie's advice as to avoiding operating during an east wind. The wind is of more importance than the mere season of the year, the only point usually noted in statistical tables. An east wind in June may bring more hazard to a severe 023eration than a west wind in March. 6. If there be evidence of malignant disease in the abdomen or else- where it will rarely be advisable to operate. 7. Ovariotomy should not be practiced whilst the tumor is small, nor until the constitution has undergone some degree of impairment 22 338 • OVARIAN TUMORS. from pressure, and the other effects of the disease. It was at one time very naturally thought that a patient would have a better chance if the operation were performed whilst she was in robust health, and the tu- mor was small. But experience has not borne out this a 'priori reason- ing. Wells prefers waiting. Keith says, "I prefer operating when the tumor is large, and when the patient has suffered a good deal." The place chosen for the operation is a matter of vast importance. It should be fairly spacious, light, well-ventilated, and the furniture should be limited to what is necessary. Carpets covering the entire floor are objectionable. A strip on either side of the bed, and a piece or two in places much used, to prevent noise, and Avhich can be taken out of the house to clean, is an infinitely preferable arrangement. The nurse should be specially qualified by training ; be able to pass the catheter; keep utensils perfectly clean by disinfectants; and able to exercise efficient yet gentle control over the room. She should have nothing else to do. This is a matter of course in a private house; but it is still more imperative in an hospital. A nurse attending an ovariot- omy patient should not come into contact with any other patient ; above all, she should not be exposed to the risk of contact with infectious or surgical patients. This touches closely upon the great question whether this operation should be performed by surgeons in ordinary hospitals. As a general fact it may be urged that all serious surgical operations are exposed to an increased element of danger in large hospitals ; but that this is not held to be an adequate reason for not performing them there. The circumstances of the patient may leave her little choice; whilst the practiced skill of the hospital surgeons, and the excellence of the general arrangements of the hospital, may be thought to outweigh the attendant disadvantages. This much being admitted, it will be asked, Is there any special condition attached to ovariotomy, which makes this operation an exception to the general rule, which turns the scale the other way? I think there is. Ovariotomy in some respects has analogies with parturition. The sudden removal of an enormous growth feeding upon the system leads to a constitutional revulsion, and suddenly altered dynamic and constituent conditions of the circulation, which, as in a woman after labor, render her peculiarly susceptible to external impressions, and, especially, to the deleterious action of mor- bific poisons. To this risk is added the exposure of the peritoneum, a structure remarkably obnoxious to toxical influences, and easily absorb- ing any contaminating matter which the operating surgeon or his as- sistants, who are constantly working, as Sidney Smith would say, in the midst of " pus and miasm," are so likely to contract. This danger, I believe, might be materially lessened by careful adaptation of the anti- septic methods which have been so successfully applied in other depart- ments of surgery. It is a little singular that an operation requiring such care beyond all others should hitherto be the most neglected in this respect. With all possible precautions, however, I do not believe that ovariot- omy in large general hospitals will ever give results that shall compare favorably with ovariotomy done in private houses or small special hos- pitals. In this country, at least, where the rights of the humbler classes OVARIOTOMY. " 339 are respected to a degree unknown elsewhere, it is practically admitted that to deliver women in lying-in hospitals or in general hospitals, is a proceeding justifiable only under peculiarly exceptional conditions. Recognizing this unreservedly, I have felt it my duty steadily to resist the extension of lying-in hospitals, notwithstanding the great tempta- tions these institutions offer for scientific observation and teaching. The passion for study must be kept in subordination to the claims of humanity. Instruments required. — The necessary instruments for a simple case are few. A scalpel, to divide the abdominal wall; a director, to pro- tect the cyst as this division is completed ; a trocar, to empty the cyst ; a clamp, to secure the pedicle; needles and silk, to close the wound; with forceps and ligatures, to secure any bleeding vessels, complete the list. But there is no surgical operation where the surgeon may be so met by difficulties where he least expected them, so that it is a safe rule to take to every case a full supply of instruments to meet every possible emergency. Clamps of different sizes, cautery clamps, and cauteries for cases where the clamp is not applicable; ligatures and needles of differ- ent shapes and sizes, for cases where neither clamp nor cautery effectu- ally deals with the pedicle; large hare-lip pins, or acupressure needles, for cases where simple ligature cannot be trusted; clamps with screw fastenings, for temporarily securing separated omentum or torn vascular adhesions; artery forceps of different lengths, torsion forceps, bull-dogs, vulsella specially adapted for holding large cysts; a chain and wire §craseur; drainage-tubes of glass, vulcanite, or india-rubber; and per- chloride of iron should always accompany the operator. The Operation. I shall describe the operation very nearly as it is performed by Mr. Spencer Wells, whose experience and success may fairly be said to be unequalled. Prejjaration. — A strong narrow table is placed conveniently for light and access. It is covered with a firm squab, over which is laid a blanket, and then over all a waterproof sheet. Two or three pails are ready to receive the fluid and the tumor. A small table is placed within reach of the operator's right hand, so that he can help himself to the instruments laid out on it. Iron or copper cauterizing imple- ments are kept in the fire. On the fire also is a kettle of water boiling. A nurse has cSarge of basins, cold water, several sponges, and pieces of thin flannel steeping in hot water, ready to wring out when wanted. The room is kept well ventilated by a fire ; but it is not found neces- sary to keep up a heat of 90° Fahrenheit, as it was at one time thought to be. The patient is clothed in flannel drawers, stockings, and night-gown, it being important to prevent long exposure of a large surface of the body to cold. She is rendered insensible by chloroform, bichloride of methylene, or ether, in her bed, and then removed to the operating- table. Mr. Keith prefers sulphuric ether, as less liable to cause vomit- ing. The legs are strapped to the table by a belt like a horse-girth. 340 ■ OVAEIAX TUMOfiS. The hands should also be secured by straps. This avoids the necessity of supernumerary assistants. It may be laid down as an axiom, that every additional assistant brought into contact with the patient is an additional element of danger. A waterproof, having a slit in the mid- dle large enough to permit of the operation being done within it, is laid over the patient. The adjustment of this obviates all overflow and mess on the patient and the floor. An assistant stands at the operator's left hand ; another opposite on the other side of the patient. The as- sistant in charge of the anaesthetic apparatus stands, of course, at the patient's head. In making the incision, the following structures are successively divided: 1. The skin; 2, the subcutaneous areolar tissue, with fat of varying thickness ; 3, the interlaced fibres of the aponeuroses of the abdominal muscles constituting the linea alba ; 4, layers of the fascia transversalis, with more or less fat (the uppermost layer adheres closely to the linea alba : the deepest layer is only very loosely connected with the peritoneum) ; 5, the peritoneum. The peritoneum may be raised with a hook or forceps. The double sharp hook of Mr. Adams answers well. The membrane is then di- vided by horizontal touches with the knife, and an opening made large enoagh to admit the insertion of a broad director. Upon this the peri- toneum should be slit up. It is desirable to keep the incision as short as possible. If the tumor will not come through the short incision first made, it can afterwards be lengthened. The incision is made with a scalpel in the linea alba from below the umbilicus towards the pubes, three or four inches long at first, pro- ceeding very carefully as the peritoneum is approached, lest the cyst be penetrated, and its contents escape into the peritoneum before the wound is completed. The peritoneum may be protruded through the wound by some ascitic fluid behind it, and impose upon the operator for the cyst. The touch will commonly correct this by feeling the more solid cyst behind it. The peritoneum is then opened. The cyst comes into view. If ovarian, especially if simple, it is recognized by a glistening, pearly, smooth aspect. If it be a compound cyst its surface may be uneven, it may be redder, vascular, and even hard. If it be a fibroid or fibro-cystic tumor of the uterus tlie appearance is dark-red, fleshy, and firm. The incision is made just large enough at first to admit the hand, which should be passed in dean, and carried round between the abdominal wall and the cyst to feel for adhesions, and if there be any to separate them. This is best done all over the front of the tumor, whilst the cyst is full and tense. The cyst is then punctured by a smart stab with Wells's hooked trocar, to wliich a large flexible tube is attached to carry the fluid into a receptacle on the floor. As the cyst is collapsing, its walls are seized in one or two places by forceps, so made as to hold a good fold of the cyst-wall without tearing it. N6la- ton's forceps is the best for this purpose. It is constructed on the principle of my craniotomy forceps. The holding part of each blade is deeply furrowed (not tootlied), so that the two blades brouglit into apposition grasp the cyst evenly, and hold by their perfect parallelism OVARIOTOMY. 341 rather than by direct force. Such a forceps will retain firm hold of even delicate cyst- walls, whereas ordinary hooked and toothed vulsella tear the cyst. Mr. Sydney Jones has also contrived a good forceps for this purpose. Whilst an assistant supports the sides of the wound with flannels wrung out of warm water, with the double object of preventing the protrusion of intestines and the escape of fluid into the peritoneal cavity, the cyst is drained as far as it will flow freely. At the same time gentle traction is made on the cyst, to see if it will turn out of the abdomen. If this does not occur readily the evacuation goes on, and the hand is passed in to explore all round the tumor, breaking down adhesions, if necessary, and ascertaining the existence and extent of solid portions, which may by their bulk oppose the removal of the tumor. If, during this proceeding, the cyst-wall be kept well drawn out, and over one side of the patient, the opening made by the trocar will be clear of the iibdominal wound, and no fluid will escape into it. If there are no adhesions, or only such as are easily broken down, and if there is little or no solid element in the tumor, it will easily turn out. As this is done, the assistants, with warm moist flannels, carefully press up the abdominal wall behind the tumor, so as to keep the cavity closed. Care is taken, especially at the last stage, to prevent the tumor falling suddenly, lest it drag injuriously upon the pedicle. When it is fairly out, and well supported, the operator examines the pedicle. The Pedicle. — If the pedicle is of sufficient length to permit of the stump being secured outside the abdominal wound, this method should be preferred. This, the so-called extra-peritoneal method of dealing with the pedicle, stands in contrast with the method of tying the pedicle, and leaving it in the abdominal cavity, closing the wound over all. That many successful results have been obtained by the intra-peri- toneal method of dealing with the pedicle is true, but the proportion of recoveries after the extra-peritoneal method is, I believe, larger. Mr. Hutchinson's introduction of the clamp to facilitate the extra-peritoneal plan has been very generally admitted to be one of the most substantial improvements acquired for ovariotomy. It is now very extensively used. Securing the stump outside the wound possesses the following- signal advantage : The surface, which may bleed or yield noxious discharges, is always kept in sight, and all discharge escapes externally. It has been urged that the seclusion of the stump within the abdominal cavity places it in a like position to a subcutaneous wound, and that it is consequently less likely to undergo decomposition than if exposed to the air. The stump, it is affirmed, will be surrounded with benignant plastic effusions, and thus occasion no trouble. These propositions are to a great extent true. But experience proves that the method does not guard against danger so surely as that of keeping the stump outside. The ligature which is necessary to secure the pedicle must be very strong ; it must be drawn very tightly to close the vessels in it ; some- times two or three stout ligatures are necessary. Tliese themselves will often be a source of irritation. Then, after a while, the tissues embraced in the liagatures shrink a little, the ligatures become looser, and under returning reaction bleeding takes place into the abdomen. Mr. Spencer Wells has also observed that on the return of menstruation, blood is 342 OVARIAN TUMORS. poured out from the surface of the stump. It is, of course, as likely that the stump should menstruate in the cavity of the abdomen as out- side. For these reasons it appears to me clear that the stump should be kept outside, M'here it can be observed, if this course be possible. This depends upon the pedicle being long enough to afford a good hold for the clamp, and for this to rest upon the abdominal wall without serious strain or dragging upon the broad ligament and uterus. This dragging is the source of great pain, and may lead to inflammation. If it is found to occur after the clamp has been applied, it may be wise to tie the stump below the clamp and let it drop into the cavity, either cutting the ligature close, or keeping the ends hanging out of the wound. If the stump be found so short in the first instance that the clamp can only be got round it with difficulty, tying or the cautery must be resorted to. Extreme care will be necessary to secure all arrest of bleeding. If the pedicle is too short for a clamp, Mr. Wells seizes it by a long screw forceps fenestrated ; and through the fenestrse a strong whij)-cord is carried on a needle through the pedicle, and then tied. One end of the ligatures should be brought out of the wound. Where the pedicle is too short even for the ligature to give a secure hold, it should be grasped by a clamp, and the tumor severed from it by the actual cautery. A danger attending the clamp is that the pedicle strangulated in it, may slough and fall back into the abdomen. This happened in a case at the London Hospital. The patient was doing well until the clamp was removed. As soon as the pedicle is secured, search for the other ovary, to as- certain if it be not also affected in a manner to require removal. If a fibroid tumor be found projecting from the uterus, it is better to leave it alone. Clean out the Abdominal Cavity. — Kemove by sponges all ovarian fluid or blood which may have found its way in. This is an object of paramount importance, and especially so if the contents of the cyst be viscid or puriform. But too great pains cannot be taken to prevent fluid getting into the peritoneum. If it be found, from the cyst being rotten or other cause, that the fluid will run over, turn the patient on her side, so as to give a dependent drainage away from the abdomi- nal cavity. Closing the Abdominal Wound. — Every variety of suture has been employed, and possibly the choice has not much effect upon the result of the o])eration. Most o]3erators use the silver-wire. The following is Mr. Wells's plan : " Silk about eighteen inches in length is threaded at each end on a strong straight needle. Each needle is introduced from within outwards, through the peritoneum and the whole thickness of the abdominal wall. The sutures are placed at intervals of about an inch. The ends of the sutures are held up by an assistant, who draws up the lips of the wound until all the deep sutures have been applied. Then the lips of the wound are held ajxu't again, in order that the operator may convince himself that no further bleed- OVARIOTOMY. 343 ing has taken place into the abdominal cavity, which, if required, has to be sponged again. This done, the sutures are tied, and the ends of the threads cut oif. If the abdominal wall is very thick, superficial su- tures may be required between the deep ones. If the pedicle has been secured by the clamp, a suture should be passed close to the latter, in order to bring the lips of the wound so precisely around the pedicle that the peritoneal cavity is accurately closed. The including of the peri- toneum within the stitches is of the utmost importance. The two peri- toneal layers adhere very rapidly. At the post-mortem examination of patients, who died after twenty-four hours, the edges of the peritoneal incision have been found firmly united by the first intention. Thus, pus and other secretions are prevented from entering the peritoneal cavity, adhesion of the omentum or intestine to any part of the inner aspect of the wound not covered by peritoneum is prevented, and such firm union is secured that a ventral hernia scarcely ever occurs after recovery." The clamp is then warded ofP from the skin and wound by a pled- get of lint dry or soaked in carbolized oil laid beneath it. Mr. Wells uses pledgets soaked in carbolic acid absorbed in calcined oyster-shell. The surface of the stump is sprinkled with dry perchloride of iron. The Dressing. — Pledgets of lint are laid on the wound. Pads of cotton-wool are disposed on each side; broad strips of plaster are passed over; and lastly, a flannel belt secures all. The cautery-clamp is used for the temporary compression of the pedicle. It was devised by Mr. Clay, of Birmingham, in order to stop bleeding from vessels in the omentum which had been adherent to the cyst. It is to him we owe the principle of combining compression and cauterization in the suppression of hemorrhage. Mr. Baker Brown next applied this principle to the pedicle. Dr. Skoldberg, of Stock- holm, and INIr. Wells improved the instruments for this purpose. But the most efficient one I have seen is that of Dr. Thomas Chambers. The blades are perfectly parallel, so that equal pressure is applied along the whole length of the blades, compressing even a large pedicle with great nicety. Dr. Lloyd Roberts bears his testimony to the effi- ciency of this instrument in practice. After-treatment. Rest is the great principle to be observed. To help this an opiate suppository, or an opium pill, should be given two or three times a day, to tranquillize nervous excitement and restrain action of the bowels. If vomiting occur, or indeed to anticipate it, give the patient ice to suck; bismuth or oxalate of cerium may be combined with the opium. The diet should be highly nutritious, not stimulating: beef tea, milk, eggs, constitute nearly all that can be given with safety. Wine or spirits must be given very sparingly, and rather as means of restoring the system if it show signs of flagging, than as a recognized part of the diet. The bladder should be emptied by catheter every eight hours. Unless local distress arise, the wound need not be disturbed for three days. On the fourth day the stump may be exaniined. It will com- monly be found shrivelling up, sometimes even dry. The clamp may 344 OVARIAN TUMORS. now be removed. If there be any discharge, wash lightly with weak carbolic acid, and dress with lint steeped in carbolic oil. The abdominal wound is often firmly united in four or five days ; but the sutures may usefully remain until the seventh or eighth before being cut and removed. It is desirable to keep a flannel belt or binder on for some days after this. Certain complications may render it expedient to modify the above proceedings : 1. The eyst may be so friable or rotten that it breaks down under the most careful handling. Great pains must be taken to bring away the cyst without leaving pieces of it or the contents in the abdomen. 2. If the cyst is multiloGular, so that after tapping the main cyst the tumor is still too large to come through without enlarging the abdomi- nal incision, the septa should be broken down by the hand, and any semi-solid contents brought away. It is only when accommodation cannot be got in this way that the incision should be extended. 3. Extensive firm adhesions may be found in front. These can gener- ally be broken down by the flat hand working under the abdominal wall. But it may be necessary to enlarge the wound and evert its lij)S, so as to be able to divide the adhesions by the handle of the scalpel, by its edge, or by the adze-edged cauterizing iron. The latter is perhaps the best plan, as it stops bleeding. The bands of adhesion are first embraced by a clam, such as the one proposed by Mr. John Clay ; the hot iron is then applied to the cyst-side of the clam, which protects the visceral side from injury. If divided by knife it may be necessary to tie with silk or wire or fine catgut small bleeding vessels. When this is done the ends of the sutures should be cut oif short, as they have to be kept in the abdomen. If obstinate adhesions to the intestines are found the same means must be employed to divide them. It has been found occasionally necessary to leave portions of the cyst adhering. If there be adhesions to the omentum these must be carefully detached as far as possible. The omentum itself must then be carefully spread out on a clean napkin, and examined for bleeding points. Wherever these are found a silk ligature is put round them, the piece of omentum is cut off, and the ligature cut short. If adhesions be found insiirmoun table, the attempt to complete ex- tirpation must be abandoned. We may then fill back upon the plan of keeping the cyst open as in Ledran's operation, trusting to the ob- literation of the cyst under drainage and inflammation. The after- treatment will consist in occasionally washing out the cyst Avith water or some detergent fluid, as Condy's or weak carbolic acid. Mr. Hutchinson calls attention to a special dijficulty caused by ad- hesions in front. Great difficulty may occur in distinguishing the cyst. The operator may mistake the cellular interspace between the transver- salis fascia and the parietal peritoneum for that between the cyst and the latter. If not quickly discovered this error may be the cause of ffreat damaoje. In endeavoring; to avoid it the suro;con mav commit another; he may incise the visceral peritoneum of the cyst, and proceed to separate it. In many cases the exterior of the cyst deprived of its peritoneum is smooth, white, and glistening, the adhesions are cellular OVARIOTOMY. 345 and easily broken through, so that there is nothing to apprise the oper- ator of his mistake. One plan there is in case of perplexity to avoid all risk of these two errors : it is to enlarge the wound upwards until the peritoneal cavity is opened at a part where no adhesions exist. When once the operator's finger has touched the intestine he knows where he is, and may proceed to detach adhesions without any fear of mistake. In cases where the detachment of the cyst would be dangerous or impossible. Dr. Atlee has solved the problem by a very ingenious plan. He leaves the peritoneum with its adhesions, by separating it from the fibrous wall of the cyst, so that the adherent portion peeled off is left in contact with the viscus to which it was attached. " Dr. W. L. Atlee has practiced this," says Peaslee, "for many years past. In his 215th case adhesions seven or eight inches long were thus left attached to the transverse colon." When bad symptoms follow ovariotomy, as pain, vomiting, fever with abdominal distension, there is evidence that some fluid, blood, serum, or pus is collecting in the peritoneal cavity. It may collect in such quantity as to give rise to sensible fluctuation from one side of the abdomen to the other, or it may gravitate to the bottom of Doug- las's space, and form a tense swelling behind the uterus. If the pedicle has been treated by ligature the ends of the ligature passing outwards then serve as drainage-conductors, and a very free discharge of fluid may go on for several days. Whenever fluid can be detected by vaginal examination in the neigh- borhood of the uterus, it is usually in such quantity that it must be removed. This may be done by a long rather fine trocar. The seat of puncture should be where there is free fluctuation behind the uterus, so as to strike a dependent part of Douglas's pouch. A drainage-tube may be inserted. If, when the pedicle has been returned into the abdomen, signs of internal hemorrhage arise, it is proper to open the wound to get at the stump, tie it afresh, and cleanse out the abdomen. It seems reasonable to think, what experience indeed proves, that it is less dangerous to do this than to leave the patient to the hazards of hemorrhage and perito- nitis. Untoward symptoms must be encountered according to their indica- tions. A survey of the causes of death under ovariotomy will supply the best guidance. The first and most immediate cause is commonly shock and collapse. A considerable proportion of all the deaths, I am convinced, occur from shock. Recovery from this is greatly a question of individual power of endurance. We can hardly foretell what this power is in any particular case. Women recover from the severest operations attended by all the complications considered the most for- midable; others sink after the easiest and simplest operations. Women comparatively robust succumb, whilst the apparently fragile recover. In many cases the unexpected result is not due, at least appreciably, to difference in skill. It can only be referred to difference in innate power of resistance. This is an unknoAvn quantity, and is the chief cause of the uncertainty which surrounds the operation. No doubt the shock 346 _ OVARIAN TUiMORS. can be lessened by care and skill during operation, and the patient can be to some extent supported through it. Shock bears some rela- tion to the length of the operation. Koeberle found the mortality in- creased with the time spent in the operation. The patient should be carefully watched and supported during the stage of depression which follows the operation. A free supply of wholesome, fresh, warm air, without draughts, should be secured. If the surface is cold, warm- water bottles must be applied to the feet and legs; light stimulants, as a little brandy and water, or ether, or sal volatile, may be ad- ministered. Hemorrhage. — Internal hemorrhage may proceed from two sources — the vessels torn across in separating adhesions, and the stump. The modes of avoiding or diminishing this risk have been described. If hemorrhage to an extent to produce serious symptoms occur, it is better, desperate as the expedient may seem, to open the wound, search for the source, and stop it by styptics, cautery, or ligatures. Peritonitis is a frequent cause of death. It may be purely trau- matic, the result of the violence necessarily done during the operation. It may be due to the injury inflicted in separating adhesions. But it has often been remarked that those subjects in whom a large extent of peritoneum has been altered in character by previous attacks of inflam- mation, leaving adhesions to the cyst, are not so prone to peritonitis as are many subjects in whom there were no adhesions, the peritoneum retaining all its natural liability to injurious impressions. A more serious form of peritonitis is one that seems analogous to the puerperal form. Here there is commonly septicsemia, or inflammation is propa- gated from the seat of the pedicle, in which some unhealthy action is going on. It will, of course, be especially likely to occur in the in- complete operations, where a portion of cyst has been left behind. It is also seriously promoted by the escape of the fluid of the cyst into the abdomen, and its imperfect removal. The fluid has been shown in certain cases to possess a peculiarly noxious, even poisonous, property. The earliest signs of peritonitis are pricking and shooting pain in the abdomen ; or according to Mr. Hutchinson, a peculiar pallor of the cheeks and an anxious expression of countenance, with frontal head- ache. The pulse becomes quicker and smaller, the skin hot, the tongue a little dry, and there is almost always more or less sickness. At a later stage the face may become flushed, the skin painfully hot, whilst at the same time the pulse is rapid and very small. Distension of the abdomen with flatus is a common and distressing symptom ; and at a later stage the intestines become involved, and the abdomen is full and tympanitic. The peritonitis may be local or general. If limited to the parts adjacent to the pedicle and to the pelvis, it is protective rather than otherwise, since it tends to exclude irritating matters from the general cavity. In cases, however, in which the peritonitis is encysted, very profuse discharge may take place, and the patient may sink ulti- mately from exhaustion. If from the first the whole peritoneum be in- vaded, recovery is rare. The treatment: Locally, leeches in the earli- est stage are useful. The abdomen should be covered with a liot lin- seed-meal poultice. The relief thus given is not less marked than it OVARIOTOMY. 347 often is in puerperal peritonitis. But ice has been used with apparent advantage. My own opinion agrees with Mr. Hutchinson's as to the vakie of mercury and opium, at least in the initiative stages. But salines are also serviceable, the best being the acetate of ammonia. Where the peritonitis is of a low or erysipelatoid type, twenty -drop doses of solution of perchloride of iron should be tried. Septiccemia may occur although not commonly, without much peri- tonitis. The symptoms then are very similar to those of septicsemie puerperal fever, and should be treated in a similar manner. Embolism and Th'ombosis. — Some deaths have occurred from these conditions. Obstinate vomiting or hiccough may attend peritonitis. But some- times they can only be referred to irritation of the ganglionic system, the irritating cause being pain starting from the structures included in the clamp or ligature, or other injury. The vomiting started by the inhalation of chloroform may persist. This danger is regarded by Mr. Keith as so serious, that he has abandoned chloroform for ether. Wells says, after ovariotomy, the most frequent cause of death is peritonitis, or some form of fever or blood-poisoning so often associated with peritonitis; then collapse or exhaustion. He has never lost a patient from hemorrhage. In two cases tetanus proved fatal. In some, obstructed intestine, and in others superfibrination of blood and deposits of fibrous coagula in the heart, were the immediate causes of death. Two or three further questions in connection with ovariotomy call for discussion : 1. How to deal with a case in ivhich the cyst has rujAured, or has given rise to effusion of blood, to peritonitis, or to septicaemia. This literally vital question has already been partly answered by anticipation. The argument may be stated as follows : The case is, that the patient is in the most imminent danger from the sliock, irrita- tion, and loss of blood attending the injury. The shock may be re- garded as a blow struck at the vital powers. We cannot lessen the shock given by this blow ; but we may, in some cases where there is some rally, do good by removing that which is the cause of protracted shock. This cause consists in the irritation arising from the contents of the cyst, or the blood eifused in the peritoneum, which irritation is quickly followed by inflammation. Of course the patient may sink rapidly under the primary shock, and thus defeat all idea of giving relief by operation. But, in not a few cases, the primary shock does not kill. The patient, however, will hardly pull through the secondary dangers of hemor- rhage and peritonitis, unless these be arrested in their course. There is the opportunity of trying to give relief to obviate these dangers. Here then is a case for the decisive application of the great law in medicine : Remove the offending cause. If extirpation of a diseased ovary, which is slowly sapping the vital powers, be recognized as a justifiable opera- tion, a fortiori must the operation be conceded as necessary when the diseased ovary is the source of instant danger to life. It would be dif- ficult to answer a priori reasoning like this, except by urging that how- 348 OVARIAN TUMORS. soever plausible in theory, it would be useless in practice. But even this answer, which until recently was still urged, is now deprived of force by the results of experience. When the irritating cause has been removed, the patient has recovered. Mr, Wells says,' "In several of my cases the operation has been performed after the cyst has burst, and its contents has escaped into the peritoneum. The peritoneum has been found intensely red, thick, soft, or villous, and occasionally covered by loosely adherent flakes of lymph. Yet the result has been surprisingly satisfactory. Tw^enty-four times has this complication presented itself out of the last 300 of my opera- tions. Five of the patients have died, so that the ordinary rate of mortality does not seem to have been much augmented. At any rate the bursting of the cyst, or the filling of the peritoneum by oozing from the puncture made by tapping the cyst, is no bar to the operation, but rather a reason for doing it without delay." In addition to the cases in which ovariotomy is resorted to deliber- ately as the best means of rescuing the patient from a more or less lingering death, it is justified under certain accidental circumstances of extreme urgency. Some of these are rupture or strangulation of a cyst, attended with intei'ual hemorrhage and shock. Thus Drs. Wiltshire and Watson have published a case, where a w^oman dying from bleed- ing into an ovarian cyst, was saved by immediate operation. 2. How to deal with ovarian cystic tumors complicated laith pi^egnancy. Ovariotomy during jjt^egnancy has been performed several times, the operator not suspecting the pregnancy before the operation. What should be done when a pregnant uterus is discovered during some stage of ovariotomy ? Wells says, " Let it alone," that is, the uterus. Dr. Atlee performed ovariotomy in the second month of pregnancy. It was followed by such great irritability of stomach, in consequence of the state of pregnancy, that the woman could not be nourished, and she died, thirty days after, of starvation. In a case related by Mr. Burd, of Shrewsbury, in 1847, of ovariotomy performed by him in the third and fourth months of pregnancy, abortion took place two days after operation, and was followed by alarming symptoms, lasting several days. Dr. Marion Sims performed ovariotomy in the third month, not detecting the pregnancy until the ovarian tumor had been removed. The patient recovered well, and was delivered of a fine child at term. Mr. Wells says, " If inadvertently the uterus be penetrated, if any conclusion can be drawn from the case in which I made this mistake and emptied the uterus, aiid two other cases in Avhich the some mistake was made by other surgeons, who did not empty the uterus, but closed the puncture in its wall by wire sutures, both patients having died after aborting, while mine recovered, it would appear to be the safer practice to empty the uterus." Wells relates four cases, in one of which ovariotomy was performed at the fourth month of pregnancy, after rupture of the cyst and peri- tonitis; in the second, third, and fourth the operation was a matter of 1 " Diseases of tho Ovaries," 1872. OVAEIOTOMY. 349 election to avoid other clangers. The result was successful, in all three giving birth to living chiklren at term. When pregnancy supervenes on ovarian dropsy, there are three, perhaps four, courses out of which to select. 1. We may leave things alone, simply watching, prepared to act, if urgency from rupture of the cyst, axial twisting, or hemorrhage or ex- cessive pressure arise. In a cpnsiderable proportion of cases pregnancy goes on to term, and the labor is completed happily. Is it wise then to stand by and trust to the chance of this issue ? If we determine to anticipate danger, we may 2. Tap the cyst. This will, of course, at once lessen the inconveni- ence of pressure, and the danger of bursting. 3. Or we may act upon the uterus. We may lessen the distension and risk of rupture by drawing oif the liquor amnii; that is, by induc- ing labor, postponing the question of dealing with the tumor, until the case is reduced to its simplest expression, by eliminating the pregnancy. I have discussed this question in my work on "Obstetric Operations," and have there given the reasons which appear to me to ^veigh in favor of this course. The opposite view, that of acting on the ovarian tumor by tapping or extirpation, is well argued by Mr. Goddard (Obstr. Trans., 1871). No doubt in certain cases, either proceeding may be preferable to the other. But, as a general rule, I believe experience will show that it is better to act first upon the pregnant uterus. Mr. Wells refers to five patients whom he has tapped during preg- nancy, one of them three times, once twice, and three once. In all these women great relief was afforded by the tapping, no ill effect of any kind was observed to follow it, and in all the children were born alive, after labors of moderate duration. There is a peculiar state of nervous and vascular tension produced by pregnancy which should be taken into account. Pregnancy induces great irritability of the nervous centres, spinal and cerebral. This irritability accounts for the greater risk of abortion, of vomiting, if in- terference be resorted to. It also is a source of danger if accident or complication arise, as rupture of cyst, inflammation, &c. And as this complication may be more serious than the operation, the operation may become justifiable as the lesser danger. Believing, as I do, that a woman in whom pregnancy is complicated with an ovarian cyst, is in a position of imminent peril; that her life is threatened at any moment by some catastrophe which may strike so suddenly and so violently as to leave no time for action, my opinion is decidedly in favor of eliminating the pregnancy. I have acted on this principle on several occasions with a successful result, not counterbal- anced by a single unsuccessful one. 4. If the cyst actually burst, or give rise to hemorrhage or periton- itis, there should, I think, be no hesitation in attempting removal of the tumor, which is the cause of immediate danger. 350 FALLOPIAN TUBES. CHAPTER XXXIY. THE FALLOPIAN TUBES: ABSENCE OF; SEPAEATION ; CYSTS CARCINOMA; TUBERCLE; FIBROID TUIVIORS; HYPERTROPHY ELONGATION; DILATATION; INFLAMMATION (SALPINGITIS) CATARRH; H.EMATOMA; OCCLUSION; CYSTIC ENLARGEMENTS DROPSY. The pathology of the Fallopian tubes deserves more attention than it has commonly received. The diagnosis of the diseases to which the tubes are liable is not so difficult as it may at first sight appear to be. The natural issue of some of these diseases is in sudden death ; and this catastrophe may, in many cases, be averted by timely treatment. The tube of one side may be wanting if the corresponding side of the uterus is wanting. In many cases the tube is represented by an im- pervious string. In some cases there is only seen a small rounded stump attached to the horn of the uterus. This last condition, says Rokitansky, is mostly the result of a twisting and separation of the tube. As conditions of excessive development, we sometimes see super- numerary fimbrise, and accessory openings into the abdominal cavity. Appended to the fimbriated extremity is often found a small clear pyriform vesicle hanging by a peritoneal stalk, which Rokitansky says is the remains of a pinched -oif portion of a Wolffian duct. The tubes are not very subject to new formations; small tumors, fibrous or fatty, sometimes occur, but possess little clinical importance. Cysts, however, often occur in great numbers in the broad ligament, and have their seat especially on and near the tubes, and on the ovaries. They are generally small, and contain a colloid moisture. The smallest appear as delicate vesicles formed out of a fibrous capsule. They occur only in mature and advanced life. They bear no relation to the par- ovarium. In some cases the cysts are much larger. There is a speci- men in St. George's Museum (No. xiv, 130) of a cyst as large as a walnut. Carcinoma occurs as an extension of the same disease from the uterus or ovaries. Kiwisch once saw a case in which the tube burst from distension of the walls with cancerous tissue. Tubercle most frequently occurs in association with tuberculous de- posit in the uterine cavity; but it may occur in the tubes alone. Such a case is preserved in St. Thomas's Hospital Museum. The tube is there filled with a cheesy, soft mass ; the tube is swollen, distended, re- sembling in outward form the distension from fluids. Generally both tubes are symmetrically affected. Rokitansky says tubal tuberculosis generally occurs as a primitive affection, and is afterwards complicated with tubercle of the abdominal DISEASES OF FALLOPIAN TUBES. 351 glands. It is also associated with tubercle of the lungs and mucous membrane of the intestinal canal. It appears sometimes in childhood, sometimes in the age of decrepi- tude, but usually in the period of puberty. Often it becomes devel- oped in consequence of childbed. Rarely, the tuberculous mass goes into calcification. In St. George's Museum are two specimens of "scrofulous disease" affecting the mucous lining of the uterus and tubes. In one, both ova- ries were also affected, " containing the remnants of a semi-fluid tuber- cular matter ;" in the other, one ovary was converted into an abscess containing scrofulous pus. Both had tuberculosis of other organs as well. Two specimens in Guy's Museum (jSTos. 2251 and 2251"^) show tuberculous matter in the tubes of children. One of the children died of strumous inflammation of the brain. There were also tubercles in the lungs. But it may happen that, although tubercle in the Fallopian tubes is generally of secondary importance as a cause of death, the func- tion of the tube being of little comparative moment, the disease in this part may be the immediate cause of death. Perforation of the tube may outstrip the fatal march of tubercle in the lung. Specimen No. 2251^° in Guy's Museum exhibits " the tubes and ovaries invested in adventitious tissue, forming part of a general tubercular peritonitis. The tubes were greatly distended with thick white grumous matter. The subject, aged twenty-two, died of phthisis and peritonitis." Fibroid tumors, or myomas, similar in character to the tumors so named, of the uterus, may occur in the Fallopian tubes, Baillie de- scribes "a hard tumor growing from a Fallopian tube, which exhibited precisely the same appearances as the hard tubercle (fibroid) of the uterus." They are developed out of the muscular coat. They may attain a considerable size. Professor Simpson describes one as large as a child's head; but probably this was of exceptional size. They are rare, or, at least, have been rarely identified as distinct from uterine fibroids or solid ovarian tumors. Arising on one side of the uterus, that is, in a situation very close to that of ovarian tumors, and being at first movable, the difficulty of discrimination must be almost insur- mountable during life. And even after death there is room for doubt, for a fibroid tumor, taking its origin in the external strata of the uterine wall, may be gradually cast off so completely that the pedicle even be- comes atrophied and no longer traceable ; the detached tumor then may lie between the folds of the broad ligament in such close proximity- with the tube, that appearances may support the idea that this was its true origin. They would differ from ovarian tumors in their progres- sion. Comparatively inert, they annoy chiefly by mechanical pressure; they may get jammed in the pelvis, and displace the uterus, and press upon bladder or rectum. If of large size, and situated above the pelvic brim, their bulk and weight would cause inconvenience, perhaps peritonitis. In the event of symptoms severe enough to indicate the expediency of removing the tumors, the operation as for ovariotomy might be performed, with a fair prospect of success. It is also possible 352 FALLOPIAN TUBES. that small ones dipping low in the pelvis by the side of the uterus might be removed by the vagina. Anomalies of size, that is, of calibre and length. The tube mav undergo elongation to a greater or less extent tliroiigh dragging of the uterus, as in prolapsus ; or upwards, as when enlarged bv fibroid tumors. But the most marked elongation is produced bv the dragging of an ovarian tumor. In this case the whole tul^e be- comes hypertrophied, its canal is widened, especially towards its fim- briated extremity, which sometimes stretches out, grasping a large sur- face of the tumor. Sometimes the stretching of the tube produces a marked thinning at one part, which undergoes atrophy. The dilatation of the tube is produced by accumulations of mucus and of pus, which, when the two ends are closed, constitute in its extreme states hydrops tubce. This affects more especially the outer end of the tube. It may also be dilated by collections of blood, and notably by the development of an ovum in it. Deposits of tubercular matter also produce dilatation. In all these cases, excepting that of gestation, the form assumed by the tube is very similar. The accumulation and dis- tension take place along the greater part of the length of the tube, so that there is formed a vermiform or contorted cylindrical or conical swelling, the greater calibre of the swelling, or its base, being usually towards the fimbriated end. Both tubes are commonly aifected alike. In this enlarged state they find no room in their natural place in the sides of the pelvis; they therefore rise out of the brim of the pelvis, and get directed somewhat forward towards the groins, occupying the hypogastric space. They may then be felt behind and above Poupart's ligament. Sometimes, however, they get imprisoned in the upper part of the pelvis by adhesions. The dilatation or enlargement of the calibre of the tubes is a subject of great importance in its relation to the practice of injecting fluids into the uterus. It so haupens that some of the morbid processes which give indications for injecting styptic or astringent fluids into the uterus, also entail undue patency of the uterine mouths of the tubes and of the tubes themselves. The mechanism by which this patency is produced, as well as the morbid processes which bring this mechanism into action, are therefore of special interest. We may take as a t}'pe a case of dys- menorrhoea from obstruction at some point of the uterine canal, as at the OS internum 1)y flexion. In such a case there is, as I have ex- plained under "Atresia," a degree of retention of menstrual fluid, asTorravated bv formation of clots. The retained matters irritate the uterus, excite reflex action, and thus cause uterine colics or exi)ulsive pains; that is, the body of the uterus contracts, trying to expel its con- tents. There is obstruction at the natural outlet; hence, following the general dilatation of the uterine cavity, there is retrograde dilatation of the uterine mouths of the tubes. All this is seen in a marked degree in cases of complete retention; but I believe ii is rarely absent in a minor degree in cases of partial retention. The pathological and thera- peutical consequences of this state are: secretions of blood, mucus, or INFLAMMATION. 353 pus formed in the uterus may be driven backwards by the contraction of the uterus along the tubes, distending the tubes, exciting inflamma- tion in them, and perhaps leading to discharge into the peritoneal cavity. In a similar manner fluids injected into the uterus excite con- traction, and this contraction drives the fluid along the tubes, if its exit be impeded at the neck, either by flexion, or by the canal being filled too closely by the injecting-tube. This accident may be avoided by the use of remedies in a solid form or as ointments, or of fluids carried on a swab. Dr. Matthews Duncan^ refers to this condition. He passed a probe with the least possible pressure, feeling certain that it went beyond the uterus; it always took a decidedly lateral direction. He concluded that it must have passed through a dilated tube into the abdominal cavity. The tube is liable to inflammation — salpingitis — and suppuration, independently of childbed. This may extend from the uterine cavity ; and this, according to Scanzoni, is its common origin. But it may arise in, and be confined to, the tube. Aran relates a case of suppura- tion of both ovaries and tubes, supervening on menstrual disturbance, without metritis. When suppuration occurs, the collection of pus pro- duces similar eflfects upon the form of the tube as other fluids. It does not escape readily by either end, but being retained and accumulating, forms a cylindrical, somewhat tortuous, dilatation of the middle part of the tube. Then comes the special danger attending distension. The tube may burst, or be perforated, and oifending matter, in sufficient quantity to irritate the peritoneum, suddenly escapes into the abdomi- nal cavity. Peritonitis may result from salpingitis in three ways: 1, by extension of inflammation through the fimbriated end; 2, through perforation of the tube ; 3, through pouring of pus through the open end. The physical signs Avill be the same as those of dropsy of the tube. There will be similar fluctuating, bent, cylindrical rolls felt behind Poupart's ligament, and in the vaginal roof. The diagnosis is very important, because this condition must fall under the same rule of treatment by puncture as other affections of the tube, namely, tubal gestation and dropsy. Fig. 80, after Hooper, is a good illustration of inflammation of both tubes. It shows the immediate effects of acute inflammation of the mucous membrane. The peritoneal investment is very vascular. The substance of the tube is much thickened and softened, and dilated into a sac. The mucous surface is covered with a flocculent albuminous layer. A quantity of fluid albumen escaped when the sac was opened. The fimbriae are destroyed ; and the openings into the cavity of the abdomen are obliterated. Tubal catarrh is probably most commonly the result of extension of inflammatory action from the uterine cavity. This may be acute or chronic. The acute form may be due to blennorrhoea. The chronic 1 " On a hitherto undescribed disease of the uterus, namely, unnatural patency of the Fallopian tube."— Edin. Med. Journ., 1856. 23 354 FALLOPIAN TUBES. form may result from the acute, or it may, ah origine, have been of a subacute kind. Catarrhal inflammation of the uterus and tubes entails, for one of its eifects, a degree of laxity of tissue and dilatation of cavity, as the mucus formed in the tube will naturally tend to discharge itself into the uterine cavity, and commonly this action is favored by the dilatation of the ostium uterinum. If escape by the ostium abdominale were common, catarrh would be a very dangerous affection. As it is, accumulations in the tube rarely take this route. It is only when the fluids secreted are large in quantity, formed rapidly, as in blennorrhoea, that the risk of retrograde overflow is serious. But when the openings of the tubes are obstructed, the fluids accumulate and distend them, Inflammation of the Fallopian tubes (half-size). — (After Hooper.) a. Uterus. 6 b. Tubes. c c. Saccular dilatations laid open. and, by and by, perforation or bursting takes place. This closure is easily produced. At the outer end, catarrhal inflammation often leads to adhesions of the fimbriae; and, at the inner end, the swelling of the tubes contorting it, forms angular spurs or valve-like bendings, which shut off the communication with the uterus. There is no reason to doubt that the lining membrane of the tubes is liable to inflammation which may lead to suppuration. The gonor- rhoea! inflammation is an example of this. But it must be remembered, that in the tubes, as well as in the uterus and vagina, fluids may ac- cumulate which the naked eye could not distinguish from pus, and which, on microscopical analysis, is resolved into epithelium scales float- ing in plasma. This was the case in a young woman who died of chorea in St. George's Hospital. The vesicles of the ovaries contained coagula. The Fallopian tubes were full of milky fluid, like pus, which proved to consist of columnar epithelium.^ This fact must be borne in mind in estimating the significance of puriform matter in the tubes. The tubes may be distended by accumulations of blood. One cause of this is menorrhagia. Usually, the uterine opening gives it passage; ' See Catalogue, St. George's Museum, XIV, No. 5. H^.MATOMA. 355 but sometimes, if this opening be obstructed, as by a clot, the blood continuing to be poured out by the tubal mucous membrane may over- flow by the abdominal end, and give rise to retro-uterine haematocele. The like event may occur in the hemorrhage of abortion. Another form of blood-accumulation, and one especially dangerous, is that which re- sults from atresia, or closure of the uterus, vagina, or vulva, leading to retention of the menstrual fluid. The Fallopian tubes in these cases commonly undergo extreme dilatation, and are liable to bursting or perforation. This subject is discussed more fully under " Atresia." In other cases the obstruction takes place at the ostium uterinum. When this occurs, it does not follow that the tubes will give up their part in the function of menstruation ; blood will be poured out into the tubes, and, if it do not escape by the ostium abdominale, must accumu- late as tubal retention. When we look at the contorted shape of the tube, it is not difficult to conceive how easily, under distension of one part of the tube, further contortion, producing angular flexion, may occur, so as to shut in the contents. The closure at the extremities of the tubes, especially of the abdominal extremity, is further very likely to be effected by inflammation of the tube and peritoneal investment. This inflammation may by caused by a minute perforation under an ulcerative process, permitting a little of the retained fluid to escape into the peritoneum; or it is, I believe — although there is no distinct clini- cal proof of this — more likely to happen through transudation, or oozing through the walls of the tube under the combined pressure of ac- cumulation and the excited contractile efforts of the walls of the tube. The contact of the unhealthy moisture thus bedewing the peritoneum would be pretty sure to set up inflammation in this susceptible mem- brane. But retention of blood or mucus in dilatations of the tubes may ter- minate in another way. Peritonitis may or may not supervene ; after a time there is no further increment of blood or mucus ; the watery part of that already in the tube may be absorbed, and the tube, not re- covering its pristine form, may assume the condition of cysts. There is a good illustration of cystiform dilatation of both tubes from tubal menstrual retention in the " Obstetrical Transactions," vol. viii, described by Dr. Meadows. The history of the subject is interesting. She had had fifteen pregnancies, but only one had gone on to term ; menstruation had generally been profuse, and latterly became clotty and painful. She died of extensive peritoneal inflammation, involving the uterus and tubes. The tubes presented cystiform dilatations ; no communication Avas found between these dilatations and the fimbriated extremities, and on the left side the ostium uterinum was quite closed. The dilatations were " all filled with a dark, thick, grumous fluid of a prune-juice color." This resembled the retained menstrual blood in the uterus, and was no doubt of like origin. Wagner' describes a case of hasmatonia of the Fallopian tube. There was also an old blood-mass in the pelvis, ft)und after death. The tube 1 Monatssehrift fiir Geburtskunde, 1869. 356 FALLOPIAN TUBES. was dilated only at the seat of the- hsematoma. There was nothing abnormal in the ovary or uterus. It seems probable that the closure of the tube at the uterine end or at the fimbrise is one of the dangers of gonorrhoea, or of those attacks of metritis or peritonitis to which prostitutes are so subject. These attacks, which give rise to the symptoms known as colica scortorum, commonly involve the tubes as well as the ovaries. Closure of the tubes almost necessarily is the first condition of retention, and thence of hemorrhagic and dropsical accumulations. Drojjsy of the tube is probably a secondary phenomenon of various affections, as of inflammation or effusion of blood. Effusions cause distension ; these being preceded or followed by closure of the extrem- ities of the tubes, saccular dilatations readily form, and the outlets being closed, sacs of considerable size may form. Baillie describes " dropsy " of the tube, and quotes Portal as having referred to it. Baillie says the tube terminated in a cul-de-sac. Hooper gives an excellent engraving of a case which exhibits very clearly the charac- teristic contortions and dilatations of the tubes, the maximum of dila- tation being on both sides at the abdominal end. Both tubes are generally symmetrically affected, although unequally. The cyst is not necessarily single, but may be subdivided by tight fibrinous bands, the product of peritonitis, encircling and constricting the tube at various points. The muscular wall is thickened. The mucous membrane is changed from its natural appearance; it becomes smooth or roughened by papillary vegetations from the submucous connective tissue. In many of these cases the disease is only recognized by dissection, death being, in some instances, brought about by other causes. The contents of the tube may be mucous, purulent, watery, sanguin- eous, like serum, or thick. Boinet says he found in a Fallopian tube thirteen pounds of water mixed with pus. Simpson, recalling the intimacy and extent of the adhesions often formed with the ovary, and the ease with which the diseases of the tube may thus be confounded with those of the ovary, doubts the accuracy of Boinet's conclusion. The quantity of fluid which constitutes the hydrops tubce is not usu- ally very great, but Dr. Peaslee' relates a case in which the patient had been tapped twice for ovarian dropsy, in whom there was found on the right a true ovarian cyst, and on the left a tumor of the Fal- lopian tube of very large size. The tube had become occluded at the very commencement of the uterus ; accumulation took place beyond, until the tube was distended into a sac with the capacity of eighteen pounds. The whole was adherent to everything in its neighborhood. Sometimes dropsy of the tubes is associated with, probably depend- ent upon, general dropsy, as in a case, No. 2254*^, in Guy's Museum. This specimen shows the uterus and appendages. The right Fallopian tube is greatly dilated. It came from a woman, aged forty-five, ad- mitted for renal dropsy. In a considerable number of cases, obstruction at the uterine orifice of the tube, as by a fibroid tumor, seems to have been the cause of ac- 1 New York Medical Journal, 1870. D E O P S Y. 357 cumulation of jfluid in the tubes. This is seen in specimens Nos. 866, University College, and 2643, Royal College of Surgeons. No. 2261^, in Guy's Museum, shows " a fibrous tumor of the uterus. Dr. Oldham dilated the os to get at the tumor. Whilst under treatment, the patient was seized with acute peritonitis, and died. An abscess in the left tube, in which the ovary was involved, had burst." The symptoms produced by dropsy of the tube resemble those arising from other enlargements of the tube or ovary up to a certain point. There is, says Simpson, an uneasy sense of weight in the side affected, and a feeling of pressure in the limb ; usually the limb is rendered more or less numb from the pressure of the tumor on the nerves passing through the pelvis, and this may even extend to lame- ness, as in pelvic cellulitis. In some cases the swelling acts chiefly on the bowels, keeping them loaded. More rarely there is a certain de- gree of dysuria. Intercurrent at some period of the history, signs of local peritonitis will probably appear. Diagnosis. — Dilatation of the Fallopian tube may be diagnosed from small cystic enlargement of the ovary by the shape of the tumor, its position, and by its relation to the uterus. It is of essential importance to clear the way by emptying the blad- der, and by determining the exact position of the uterus by the sound. A small cyst of the ovary gets behind, and a little to one side of the uterus, pushing the uterus forwards against the symphysis, pro- ducing probably irritation of the bladder or retention of urine ; there is only slight obliquity imparted to the uterus. The shape of the tumor is more or less spherical. It is felt better by the rectum than in the roof of the vagina. Fluid distension of the tube produces an elongated, contorted, cylin- drical swelling. Its position is more forward than that of the ovary ; it does not, therefore, push the uterus forward, but pushes the fundus towards the opposite side ; there is greater obliquity of the uterus. The swelling also may commonly be felt behind Poupart's ligament, and can be defined between the hand outside and the finger in the vagina. Vaginal touch will enable the observer to detect the swelling on one side of the cervix uteri. Except in the case of tubal gestation, affections of the tube are com- monly symmetrical, that is, both tubes are alike distended. This condition itself would be greatly diagnostic from ovarian disease, which is not nearly so often double, and very rarely, indeed, symmetrical, one ovary, where both are affected, being more advanced in disease than the other. When both tubes are involved, they will keep the uterus straight between them, and a cylindrical contorted roll will be felt on either side. Fig. 81 gives an ordinary form of the dropsical tube. It comes from a girl, aged nineteen. Both tubes are tortuous, and each forms an elongated and somewhat conical cyst. The dilatation begins about an inch and a half from the uterus, and gradually increases until it attains a diameter of an inch. The parietes are thinned in proportion to the dilatation. The fimbriated extremities have become adherent to the ovaries and other parts, and thus have become closed. In the living 358 FALLOPIAN TUBES. subject these distended tubes would occupy the iliac fossae, lying in a right line with the fundus uteri. Another specimen in the same museum, No. FF 55, shows each tube dilated into a globular cyst. The cyst on the right side was filled with bloody fluid, and some laminated coagula still remain adherent to its upper part. The other cyst is distended with white fatty matter, con- tained in numerous cells. The tubes at a short distance from the uterus Dropsy of Fallopian tube, nat. size. (St. Thomas's Museum.) are completely clo.sed. The uterus is healthy. The specimen was taken from a woman, aged twenty-one, of dissipated habits, who died of phthisis. The treatment of dropsical distension of the Fallopian tubes consists simply in puncturing the cysts through the vaginal roof. If a tense fluctuating swelling be found in this region attended by local distress, there ought, I think, to be no hesitation in tapping it by the aspirator- trocar. This instrument combines in a high degree the merits of the sound and speculum, namely, in being diagnostic and curative. The TREATMENT OF MORBID CONDITIONS. 359 range of liability to error in diagnosis lies between dropsy of the tube, cysts of the broad ligament, cysts of the ovary, cyst containing an extra-uterine gestation. Now, in all these cases, the same indication exists to puncture the cyst, so that absolute precision of differential diagnosis is not imperative. The diagnosis may become clearer after the tapping. Thus if the cyst be tubal, or in the broad ligament, it is not likely to fill ; there is reasonable prospect of complete cure. But if the cyst be ovarian, it is not unlikely to fill again. The mode of operating is described under the " Treatment of Early Ovarian Dropsy." An incidental consequence of most morbid conditions of the Fallo- pian tubes is sterility. There may be mechanical obstruction to the passage of the ovum and spermatozoa ; or, if the canal be pervious, the condition of the lining membrane or of the secretions in it may be destructive to the vitality of the male and female elements. Another incidental consequence, we shall see, is the proneness to extra-uterine gestation. The Treatment of Morbid Conditions of the Fallopian Tubes. Salpingitis being generally a part of an inflammatory process, of which the chief seat is the cavity of the uterus, the treatment merges in that which is indicated for the principal affection. If it lead to the escape of irritating matters or blood into the peritoneum by rupture, perforation, or overflow, the case must be treated on the principles laid down when discussing the subjects of Menstrual Retention and Tubal Gestation. The secret of preventing many of the tubal diseases, and of curing some, lies in securing patency of the uterine ends. But there are points of special interest in the dealing with tubal dis- tension. We know the danger of rupture, perforation, or overflow. We know that this danger is averted or greatly lessened, if the con- tents of the tube can be evacuated by the natural route into the uterus. Can nothing be done to turn the discharges into this, their natural drain? To accomplish this object. Dr. Tyler Smith proposed "Fallo- pian catheterization.'' He devised and demonstrated the practicability of passing a fine whalebone probe into the tube. The proposition when originally made, and since, encountered considerable criticism ; it was said to be rash, dangerous, and impossible of execution. The real ob- jection is that it is new and difficult. I think the operation will be established in spite of the ridicule and the arguments aimed against it; and that the difficulties of diagnosing the cases proper for its applica- tion, as well as of carrying it into execution, will be greatly lessened. Many of the reasons which are recognized as justifying catheterization of the uterus, apply to catheterization of the tubes. The obstacle to the onward discharge of mucus or pus from the tube commonly exists in the uterine portion, which is naturally contracted, and may be occluded by a plug of clotted blood or condensed mucus or pus. A very slight force would remove this impediment, and the passage of a flexible probe through this part would not be difficult. Whether it would be easy or feasible to pass a probe to any considerable distance along the canal, following its sinuosities, is a matter for experience to 360 CYSTS OF THE BEOAD LIGAMENT. determine. It will, I think, rarely be necessary. I can, indeed, imagine that a tubal gestation-sac might be ruptured in this way, and the gestation so brought to an end. But, as will be shown when treat- ing of tubal gestation, the tapping of the sac may be accomplished through the roof of the vagina. CHAPTER XXXV. THE BEOAD LIGAMENTS; DROPSY; INFLAMMATION; PHLEG- MASIA DO LENS; PHLEBOLITHES; FIBROID TUMORS. The principal affections of the broad ligaments are : dropsy, inflam- mation, and obstruction of its bloodvessels and lymphatics. Inflammation will be more conveniently described in connection with pelvic peri- tonitis and cellulitis, and obstruction of the vessels in connection with phlegmasia dolens. Dropsy of the Broad Ligament. Extra-ovarian cysts, or cysts of the broad ligament and of the Fallo- pian tube, are chiefly of two kinds. One kind of cyst is a dilatation of the terminal bulb or vesicle of the Fallopian tube (see Fig. 2, p. 21). In the form and size figured, they cannot be called pathological. They rarely exceed in size that of a pea or nut, but occasionally are found as large as an egg. They usually have thin walls, are covered by peri- toneum, and hang by a long slender pedicle. They may probably burst, but the small quantity and innocent nature of their contents in- duce no great irritation in the peritoneal cavity. The other variety of cyst is found between the folds of the broad ligament, at least in its original stages. It is a development of the tubules of the parovarium (see/, b, Fig. 2, p. 21). These cysts occa- sionally grow larger than the so-called terminal hydatid of the Fallo- pian tube. They may even grow as large as a man's head, and indeed may attain the full dimensions of ovarian cysts. The walls may be- come thickened by development of fibrous tissue, but still they remain comparatively thin ; fluctuation is usually very distinct in every direc- tion. As these cysts are strictly simple and innocent, and not likely to fill again if emptied, there is no sufficient reason, supposing the diag- nosis be clear or even presumptive, for subjecting the sufferer to the CYSTS OF THE BROAD LIGAMENT. 361 grave risk of an operation for extirpation, or even to that of injecting tincture of iodine. Simple tapping is often enough for their cure. There can hardly be a doubt that some cases of presumed cure of ovarian cysts by injections of iodine or by vaginal tapping were really cysts of the broad ligament. At least I have no doubt that such was the true nature of some cases which have occurred in my own practice. The possibility of a cystic dropsy being of this kind dictates the ex- pediency of executing a preliminary tapping in cases where the fluctu- ation is very free and universal. The features of a cyst of this kind, when greatly enlarged, are illus- trated in a case operated upon by Mr. Wells. " A lady, aged twenty, had observed an increase of size for a year. The abdomen was occu- pied with a fluctuating tumor which extended upwards two or three inches above the umbilicus. The uterus was far backwards, a little to the left, and freely movable; the right side of the vagina was de- pressed, giving rise to the impression that the connection was with the right side of the uterus and rather close. The disease gave so little uneasiness that all interference was postponed for some months. In the meantime the increase had been rapid. The cyst was then re- moved, and the adjacent ovary along with it, as it felt hard and appeared larger and more corrugated than is usual in unmarried women ; though from its being quite apart from the tumor, it would have been easy to remove the cyst and leave the ovary. The pedicle was not thicker than a finger. Another cyst, the size of a walnut, in the left broad ligament near the ovary, was laid open and emptied. Dr. Wilson Fox reported the removed cyst when distended as about twice the size of an adult head. The Fallopian tube flattened out is seen to course along its external surface. The fimbriae are, however, non-adherent and distinct. The ovary is found in a fold of the broad ligament distinct from the tumor, and presenting the natural appearance. It contains no cysts. The cyst itself has a smooth external wall. It is lined internally by a flattened polygonal epithelium. No villous or papillary growths can be discovered on its inner surface. This was of a delicate rose color. The vascularity of the cyst was not very great. Xo other cysts could be found in the broad ligament." Fibroid tumors or fibro-myomas may be developed in the broad liga- ments by aberrant growths of the cognate tissues inclosed between their folds. Some tumors, apparently belonging to the broad ligament, may really have had their origin in the uterus, from whose walls they have been extruded. The vessels in the broad ligaments are a favorite seat of phlebolithes, or stony transformation of blood-clots. The vessels, slenderly sup- ported by the flaccid tissues through which they run, liable to great variations of fulness and tension, and embraced between layers of peri- toneum extremely liable to inflammation, are subject to dilatations and formation of thrombi. These vary in size from that of a pea to nearly that of a cherry. Undergoing hardening they may become calcareous. As in the case figured in Carswell (see Fig. 91), the ensuing obliter- ation of the vessels may lead to atrophy of the uterus. 362 EXTEA-UTEEINE GESTATION. CHAPTER XXXVI. EXTKA-UTERINE GESTATIOiN" : TUBAL; OVARIAN; TUBO-OVA- EIAN; ABDOMINAL; INTEESTITIAL; ONE-HORNED UTERINE GESTATION. Tubal Gestation. Under various conditions the Fallopian tube may rupture or be- come perforated, when its contents suddenly thrown into the peritoneal cavity may cajise shock, or peritonitis, and death. The best known of these conditions is the tubal form of extra-uterine gestation. The ovum may be arrested in any part of the tube. If caught in the fimbrise, a sac is formed partly out of the dilated mouth of the tube, and partly by attachments to neighboring structures, especially the ovary, thus forming the tubo-ovarian gestation. The sac in this case usually as- sumes a rounded shape. If the ovum be caught in the middle of the tube, the shape of the sac is more ovoid. It may be caught in the uterine portion of the tube, and the gestation is then called " intersti- tial" or "intramural." It may be said, generally, that the sac bursts the earlier the nearer its seat is to the uterus. Thus the tubo-ovarian sac may not burst until near the ordinary term of uterine gestation ; whilst the tubal sac or the interstitial sac usually bursts at dates vary- ing from six weeks to three months. Kiwisch saw a case which burst at four weeks. Gestation may, however, go on for four, five, or even six months. Spiegelberg relates one case in which it went to term. The tube, although consisting of a mucous and a muscular coat like the uterus, is ill adapted to keep pace in growth with the rapid devel- opment of the ovum. The adaptation is not simply, as in the case of uterine gestation, obtained by growth of the tube -pari passu with its contents; the tube is stretched as well ; and there comes a time when, the stretching exceeding the distensibility of the tube, the sac bursts, and the contents escape into the peritoneal cavity. Along with the ovum, or at least the embryo — for frequently the chorion and decidua remain attached to the sac — there almost invariably is poured out a large quantity of blood, which proceeds from the torn vessels of the tube. The injury sustained is a compound one. There is the trau- matic violence attending the rent, producing shock ; and hemorrhage, producing ansemia. The symptoms are also twofold. Shock induces collapse. There is sudden intense pain following on a sense of some- thing having given way in the lower part of the abdomen. The im- mediate effects of the shock are coldness, prostration, near extinction of the pulse, vomiting ; deadly pallor supervenes, and in a short time, often not exceeding a few hours, the patient dies. To this assemblage of symptoms I have given the name "Abdominal Collapse." It is distinguished from the collapse which attends sudden injury or rup- EXTEA-UTEEINE GESTATION. 363 tures in the head by the preservation of the mental facnlties, and from the like injury in the chest by the absence of that terrible anxiety of respiration which marks the chest collapse. The symptoms, coming as they do suddenly and destroying a woman, who up to the moment of the attack was in the enjoyment of good health, have often given rise to the suspicion of foul play by poison or mechanical violence. If the patient survive the shock, and reaction set in, the signs of hemorrhage become manifest; the anaemia is marked by the pallor of the body, the w^hiteness of the tongue, lips, and conjnnctivte, the hemorrhagic pulse, the distension of the lower abdomen, and sometimes by semi-fluctuation in a mass behind the uterus in Douglas's pouch, constituting what I have ventured to call a cataclysmic form of retro-uterine lisematocele. Again, at this stage the patient is likely to sink under the exhaustion of the shock and loss of blood combined. But if she survive this stage, she has still a third and formidable danger to encounter. This is peritonitis. It usually supervenes rapidly. A few hours' time is often enough to light up almost universal peritonitis. Intense pain continues, the patient can hardly bear the slightest touch or the weight of the bedclothes on the abdomen ; the abdomen swells, becomes tense, the pulse is rapid and small, the temperature rises two or three degrees above the normal standard, the countenance puts on the anxious drawn expression characteristic of abdominal injury. Still the case may issue in recovery. The shock and liemorrhage may be not greater than the patient can bear, and the inflammation may be limited to the pelvic peritoneum ; plastic lymph may be so thrown out as to surround and encapsulate the blood-mass. When the physician is called to a woman suffering from an injury of this kind, reference to her previous history for the purpose of diagnosis, is but trifling in the presence of a great emergency. Nice diagnosis of the cause of the injury and source of the bleeding w^ould afford little help in treatment. The present state of the sufferer demands all our care. Historical investigation may be postponed. This is far from saying it should be neglected. What we want is such a perfect knowl- edge of the nature and course of a disease — and tliis remark applies with especial force to the case under discussion — as will enable us to detect it in its incipient stages, to understand the changes that are in progress, and thus to acquire indications for treatment in anticipation of the disasters which attend the climax. The hints we get that a tubal pregnancy is going on are commonly so obscure that they are easily overlooked. The subject herself may feel no disturbance of health, or observe no sign so unusual, as to lead her to seek medical advice. She may be satisfied that she is pregnant in the ordinary way. The phy- sician rarely indeed has the opportunity of studying these cases during their progress. He sees only the catastrophe. But phenomena some- times present themselves which, although not conclusive as to the ex- istence of tubal gestation, are yet sufficiently important to dictate a careful local examination. I will not insist upon the suspension of menstruation, and the presence of the common subjective signs of preg- nancy, further than to call to mind that if examination of the uterus lead to the conclusion — and this is not easy to arrive at — that the 364 EXTEA-UTERINE GESTATION. uterus is not the seat of the presumed pregnancy, we should consider the possibility of an extra-uterine pregnancy. One difficulty in gain- ing the first step in diagnosis — that, namely, of excluding uterine pregnancy — lies in the fact that the developmental force working in the tube extends to the uterus, causing considerable enlargement of this organ. Another obstacle is imposed by the hypothesis of pregnancy, which forbids the use of the uterine sound. Two signs, singly or concurrently, justify exploration. These are pain and hemorrhage. These signs, of course, are far more likely to be connected with ordinary abortion, some disease of the uterus, or with dysmenorrhoea. But this probability does not detract from the expediency of examining. On doing this we may be able to exclude uterine causes. This is one step. The next is to obtain evidence of abnormality outside the uterus. If we find fulness of the vaginal roof on one side of the uterine neck, the os uteri pushed over to the opposite side, if we can, by finger in rectum, and hand depressing the abdominal wall above the pubes, define a swelling between them, the presumption rises that there is extra-uterine pregnancy. Tubal gestation is dis- tinguished from encysted abscess of the broad ligament or pelvic peri- toneum by its smoothness, uniformly round or oval form, and by its mobility. The long axis of the oval tumor is parallel with Poupart's ligament. The presumption of tubal gestation is strengthened in pro- portion as we increase the evidence of ]3regnancy. Thus Huguier says, the violaceous coloration of the vagina has always been to him an in- dication of pregnancy, uterine or extra-uterine. Vaginal pulsation may be felt. Evory Kennedy in one case detected the placental souffle} Analysis of numerous cases proves one thing, namely, that in many, • perhaps in most, distinct symptoms which may be regarded as pre- monitory, do occur before the final catastrophe. The pain, Goupil says, is constant. It is due, no doubt, to the stretching of the tube chiefly, and in part to the pressure of the enlarging sac upon neighbor- ing structures. Kennedy's cases, my own,^ and many others, show that pain occurs early and continues. The hemorrhage is not less constant. I have several times pointed this out in discussions at the Obstetrical Society. Goupil says, metror- rhagia is an almost constant phenomenon. _ Lesouef, in the most valu- able monograph on extra-uterine gestation with which I am acquainted, declares that hemorrhage is the initial fact of the fatal accidents, and that when the fcetal sac bursts, blood had already for a long time been poured into it, distending its walls. Lesouef does not insist clearly upon the escape of blood externally in the form of metrorrhagia. But I believe this phenomenon is so frequent that it may be regarded as in- dicative of what is going on in the sac. The blood which flows by the vulva is to a certain extent the overflow. It no doubt postpones the climax in rupture. It should serve as a warning of the impending danger. 1 See a most interestiiis; memoir on cases of extra-uterine fcetation detected at an earl_y stae:e. — British Medical Journal, ]8G9. * See St. Thomas's Hospital Keports, vol. i, 1871. TUBAl. GESTATION. 365 A point deserving of the most earnest attention is that in many cases the fatal catastrophe does not come in one single stroke. One or more minor attacks, evidently marked by rnpture and effusion of blood, occur several days before the final blow is dealt. The symptoms of these preliminary strokes are those of hsematocele. The first rupture is prob- ably small, the ovum perhaps remains entire. If we could seize this moment to puncture the sac we might avert the fatal rupture.' The physical signs taken alone might not enable us to distinguish an early tubal gestation from a small ovarian cyst or a tubal dropsy. But add to these physical signs, so similar in both cases, the history and signs of pregnancy, the pain and the hemorrhage, and we get an accumulation of evidence which in some cases at least amounts to a very high degree of probability in favor of tubal gestation. Three conditions there are which are most likely to be a source of difficulty. Retroversion of the gravid womb ; a small ovarian cyst ; retro-uterine hematocele. The first and third of these conditions will commonly cause retention of urine, an accident which seems compara- tively rare in tubal gestation. In the first, almost constantly there is a history of pregnancy, and the characteristic signs of it ; in the third also there may be a history of pregnancy. Retroversion may be dis- tinguished by tracing the firm rounded body of the uterus by vaginal and rectal touch and by its other characteristic signs.^ Retro-uterine hsematocele may be the result of abortion. It will, like tubal gestation, be attended by external hemorrhages. But the mass of blood behind the uterus will have followed on severe symptoms suddenly produced, and the uterus will present a degree of development much less than that commonly observed in tubal pregnancy. A small ovarian cyst may also cause retention of urine, but it does not, or at least veiy rarely, cause suppresssion of menstruation. We may always negative preg- nancy. Lesouef cites a case in his Memoir (No. vi) of an extra-uterine ges- tation mistaken for a retroversion of the womb at the fourth month. Puncture was made, and attempts at reduction. Two days later the foetus passed by the rectum. There had been almost complete sup- pression of urine, and stoppage of fseces. The case was seen by Du- puytren, Antoine Dubois, Lisfranc, and Maygrier. I have also seen a case of gestation in Douglas's pouch which gave rise to the same symptoms and erroneous diagnosis. Fig. 82 is a good illustration of a tubal gestation, the cyst bursting at about the third month. The uterine decidua is dissected up, and is remarkably developed. Causes of Tubal Gestation. — These are interesting, as illustrative of the morbid conditions to which the Fallopian tube is liable. It is remarkable that, in a considerable majority of cases, it is the left tube which is the seat of gestation (Campbell, Hecker). This may possibly be explained by the fact that the left tube is more liable to 1 See case No. 6,' in the Author's Memoir on "Pelvic Hsematocele." — St. Tho- mas's Hospital Keports, 1871. 2 See my Lectures on " Obstetric Operations," 2d edition. 366 EXTRA-UTEEINE GESTATION. displacement and compression by the sigmoid flexure, which lies in close relation to it, and is often disturbed by feculent accumulations. The essential condition of tubal gestation is obviously arrest of the impregnated ovum in the tube. We have, therefore, to consider what Fig. 82. (St Thomas's Musi urn, H. H. 19, nat. size.) Gestation in the left Fallopian tube. The sac ruptured ; the embryo suspended by its cord ; the uterine mucous membrane developed to a thick decidua. are the conditions which may lead to this arrest ? Naturally we look to some mechanical obstruction, and in some cases this is found. Amongst these are — 1. Inflammatory Adhesions. — Hecker^ believes this to be a common cause. He supports this opinion by eight dissections, showing ad- hesions impeding the free course and connection of the tubes with the ovaries ; by the fact of the frequent sterility antecedent to tubal ges- tation ; by the well-known sterility of prostitutes which follows upon colic — the colicu scorforum. It has been remarked, tliat in many in- stances the subjects of tubal gestation had, up to the time of such ges- tation, been sterile. There is sufficient reason to admit this as a ' Monatsschrift fiir Geburtskunde, 1859. CAUSES. 367 frequent cause, but many cases are known in which the course of tlie tubes appeared to be free ; and in some cases, in which adhesions have been found, these Avere probably not antecedent to, but the consequence of, the tubal gestation. 2. Obstruction of the Ostium Uterinum by Polypi. — Breslau^ relates two cases in which polypi were found at the uterine end of the tube. In one, that of a woman aged thirty, who died of abdominal hemor- rhage six months after marriage, a tubal cyst, containing chorion and blood, occupied the left tube. The cyst was close to the uterine mouth of the tube. Inside the uterus, close to the mouth of the tube, was a mucous polypus, not quite obstructing the passage of a small sound. This position of polypus is not very uncommon. I dissected a uterus in which a polypus the size of a filbert was attached to the mouth of each tube and occluded it. Fibrous tumors in the uterus have been found in several cases. A very interesting one is related^ by Dr. Magrath, of Jamaica. In Uni- versity College Museum is a specimen (No. 4275) of tubal gestation, the sac having burst at the fifth month. The uterus contained several large fibroids. These tumors so distort the form and relations of the uterus, that obstruction to the passage of the ovum may readily occur. Extra-uterine gestation, then, may be looked upon as one of the penal- ties a woman having fibroid tumors in tne uterus may incur if she marries. It has struck me as remarkable, how often, in tubal gestation, twins have been found. May it not be that the two ova may obstruct each other in their passage along the tube ? 3. Another fact deserves notice. In the great majority of cases of extra-uterine gestation, the subjects have been w^omen exposed to hard work. In many cases the women themselves have assigned this as the cause of their misfortune. It is quite possible that great bodily exer- tion during the first days after conception, may so alter the relative position of the ovaries, tubes, and uterus, as to impede the due transit of the ovum ; or great congestion of the organs may be induced, caus- ing tumefaction of the mucous membrane. 4. Oldham was, I believe, the first to observe this very remarkable fact, that occasionally the corpus luteum was found in the opposite ovary to the tube in which the ovum was developed. How could this contradiction be explained ? The ovum must have travelled by an unusual route. The problem has given rise to the theory of the trans- migration of the ovum. This theory offers two routes which the ovum may take. 1st. The Extra-uterine Transmigration. — Oldham and Wharton Jones found, in a left interstitial gestation, the corpus luteum in the right ovary ; the right pavilion was obliterated, and both observers believed that this obliteration was of old date, so that the ovum could not have passed by it. The uterine portion of the left tube was drawn towards the posterior wall of the uterus by false ligaments, which were also 1 Monatsschrift fiir Geburtskunde, 1863. * Obstetrical Transactions. 368 EXTRA-UTERINE GESTATION. found at the far extremity of this pavilion, which was thus brought into contact with the right ovary, and had directly received the ovum from it, Rokitansky found in a woman who had died after a uterine preg- nancy, the yellow body on the left ; the abdominal portion of the left tube, for a space of two inches, was thinned, impervious, its pavilion adherent to the sigmoid flexure above the brim of the pelvis ; the right tube was mobile. He believes that the conception took place after these adhesions had been formed, and that the ovum had passed into the uterus from the left ovary by the right tube. In these two cases, then, it seems difficult to avoid the conclusion that the fertile ovum travelled from its ovary to the opposite tube. Klob and Kussmaul showed, what any one may see on the dead body, how easily the fimbriated extremity of the right tube may be applied to the surface of the left ovary, and vice versa. But Kussmaul does not regard this contact as necessary. Hq invokes observations made on amphibia, in which it is certain that actual contact between tube and ovary does not take place. And Miiller and Becker have de- scribed a vibratile current running from the ovary to the tube, which may sweep the ovum over the intermediate space into the tubes. Maurer's case is another illustration of the extra-uterine transmigration. A case that seems decisive as to the possibility of the extra-uterine Gestation in a rudimentary horn of the uterus — front view.— (After Luschka.) A, the developed horn of the uterus (right) ; b, the rudimentarj' horn with a rent, through which the fcetiis has escaped (left). 1, the Fallopian tube (right); 2, the Fallopian tube (left); 4, 5, right ovary and corpus luteum ; 6, round ligament. transmigration, is related by Luschka.^ A woman died under the usual signs of rupture of a fruit-sac when about ten weeks pregnant. It was found that the fruit-sac was in the rudimentary horn of a one- horned uterus, Avhilst the corpus luteum was in the opposite ovary. 1 Schwangorschaft i- d, rechten riidimentiiren Horne, &c., M. f. G., 18(53. MIGRATION OF OVUM. 369 ISTo communication could be found between the sac of the rudimentary horn and the cavity of the developed half of the uterus, so that intra- uterine migration is necessarily excluded in this case. It is convenient to. give Luschka's figure here; the reader can refer to it when studying the subject of pregnancy in a rudimentary horn further on. In several other cases in which the corpus luteum was found in the ovary of the same side as the fruit-sac, the rudimentary horn contain- ing it had no communication with the cavity of the developed horn. Here we may conjecture that the spermatozoa found their "svay through the developed horn and its tube, being thus conveyed across outside the uterus to the ovary of the opposite side ; unless, indeed, we con- clude that, at the time of the conception, a communication between the cavities of the two horns did exist, which became closed during gestation. Schultze^ relates a case of a tubo-uterine gestation, carried to term. The gestation was on the right side, the corpus luteum on the left. The right tube was impervious at both ends. This would appear a case of extra-uterine transmigration. In the London Hospital Museum (E. h. 28) is a specimen in point. It exhibits the uterus and ovaries of a woman who died very suddenly, and was suspected to be poisoned. There is a tubular conception and ruptured sac on the left side ; the corpus lut'eum is on the opposite side. Indeed, cases of this kind appear to be not very uncommon. 2d. The Intra-uterine Transmigration. — Tyler Smith, I believe it was, who started the hypothesis that the ovum might be received into its appropriate tube, enter the uterus, cross the cavity, and penetrate the opposite tube, where it might become developed. There are facts which support this idea. That the ovum does wander in the uterine cavity is proved by the cases of placenta prsevia, where the ovum gets to the cervical zone, and also in some rare cases even into the cervical cavity, constituting cervical gestation. Klob,^ however, disputes the possibility of intra-uterine migration. But it must be remembered that in a considerable proportion of cases of tubal gestation, the corpus luteum is on the same side as the embry- onic sac, and that no obstruction by adhesions or tumors can be found. Here we may suppose that a temporary flexion of the tube may pre- sent a spur or valve at some point on the uterine side of the ovum and block its onward course. Coste conjectured that a shock — moral or physical — occurring within some days after coitus, might cause extra-uterine gestation. I will now describe what I believe is the exact order and course of events in the greater number of cases of tubal gestation. The ovum is impregnated either in the ovary, as Coste thought probable, or after its reception in the tube. Arrested there, it grows, developing its chorion into placenta, and distending the walls of the tube into a sac, until the time arrives — seldom postponed beyond three months — when the growth of the ovum outstrips the growth and stretching of the tube which con- ' Wurzbur2;er Med. Zeitschrift, Band iv. 2 Wochenblatt d. Ztschr. d. k. k., Ges. d. A. in Wien, 1861. 24 370 EXTEA-UTEEINE GESTATION. tains it. The great majority of cases terminate in rupture within eight weeks (Hecker). Mr. George Roper observed that the rupture occurred at a menstrual period. This increases the analogy I have pointed out between tubal gestation and placenta prsevia. The tube does not burst at once ; if it did there would be no premonitory hemorrhage. This hemorrhage I account for on the same hypothesis as that by which it seems to me certain that the hemorrhage in placenta preevia is explained. In both cases the gestation is ectopic, that is, proceeding in an abnormal locality which is unfit for the office imposed upon it. The Fallopian tube, like the lower segment of the uterine cavity, has only a limited capacity of growth. This is soon overtaken by the growing ovum, which, not finding the room it requires, excites spasmodic contractions of the sac. Hence partial detachment of the ovum is caused, and some hemorrhage ensues. In the case of tubal gestation, partial detachment is very easy, owing to the scanty development of decidua. This hem- orrhage, in both cases of placenta prsevia and of tubal gestation, may escape externally. In the first case, the os uteri offers a ready exit ; in the second case, the exit is not so easy, and the sac is comparatively feeble. Hence a large proportion of the blood poured out by the severance of relation between placenta and sac is retained in the sac. The distension becomes extreme. Renewed spasmodic action of the muscular Avail is excited, and the sac bursts. The ovum itself does not always burst, and, probably, rarely does until the sac has done so. The accumulated blood in the tube, together with fresh blood pro- ceeding from the torn vessels of the tube, is now poured into the ab- dominal cavity, causing the shock and other phenomena that mark the climax. The influence of extra-uterine gestation upon the uterus is an im- portant point to consider. The remark of Velpeau that the sexual organs show little departure from their ordinary state when the foetal sac is not in the tube, and do not contract adhesions with the uterus, is generally true. But in every museum which can show specimens of tubal gestation will be found ample evidence of enlargement of the uterus, and of the development of the mucous membrane into decidua; and this is entirely in accordance with physiological knowl- edge. The uterine mucous membrane, as we have already seen, swells and undergoes development into decidua under the mere stimulus of ovulation. This development is a necessary preparation for the recep- tion of the ovum. It is not a necessary condition for its formation that the ovum should reach the uterus. But why, it may be asked, is the decidua so constantly found in tubal gestation preserved so long as three months when it is not wanted ? And why is it not ob- served in many cases of abdominal gestation? The explanation is found in the remark, before-cited, of Velpeau. In tubal gestation, the engorgement of the uterus and the physiological stimulus are main- tained by the proximity of the foetal sac; whilst in abdominal gesta- tion the developmental stimulus and the vascular system supplying the sac are remote from the uterus. Still, in many cases where the sac adheres to the uterus and ])resses upon it, this organ is greatly enlarged, and its mucous membrane is highly developed. As to the formation TREATMENT. 371 of decidua in the tube itself, it might be, a 'priori, supposed that the tube having a mucous membrane, and the physiological necessity for a decidua being present, a decidua would be formed. But Oldham,^ Ki- wisch, and Virchow have shown that it is not so. The mucous mem- brane in the tube is deficient in the utricular glands which the uterine membrane possesses. A careful examination of specimens confirms Virchow's observation. The chorion villi seem to be implanted di- rectly upon the mucous membrane. The condition of the mucous membrane of the tube has been investigated by Poppel,^ who says that even if a decidua vera be formed, there is certainly no serotina. Hen- nig has also studied the question.^ He shows greater similarity be- tween the behavior of the uterine and tubal mucous membranes under gestation than was before suspected. If, he adds, there be no serotina in tubal gestation, the placenta is developed on a different plan to that of the normal uterine placenta; it is developed according to the plan which governs the normal gestation in rabbits, cats, and dogs. This slender attachment may serve to explain the facility with which separation and hemorrhage take place. Also, in abdominal gestation, there is no true decidua. The placenta is attached directly to the sur- face of the uterus or of some abdominal organ. The body of the uterus is commonly enlarged when the sac is in any way attached to it. The Treatment. — A careful study of the history, course, and premoni- tory symptoms of tubal gestation, will encourage the hope that we may in some cases at least avert the ultimate catastrophe. In the early stages, before hemorrhage has occurred, if pain and local distress have led to an examination, and the detection of fulness in the vaginal roof a little on one side of the uterus, which we conclude to be, on grounds, described under "Diagnosis," due to a tubal cyst, we have, I think, a sufficient indication to act decisively. Lesouef has rightly said that every woman who has become the subject of an extra-uterine gestation, is doomed to more or less speedy death. This is eminently true of tubal gestation. Error of diagnosis is the only justifiable ground for hesitation. And for what is a tubal gestation likely to be mistaken ? Most likely for a small ovarian cyst. Now here is a case of which we have many analogous examples in medicine. Whichever view be right, the same treatment applies ; and hence the error entails no harm. The indication in both cases is to arrest the growth of the cyst. This can be done by tapping it ; and tapping through the vagina or rectum by means of the fine aspirator-trocar is infinitely less dangerous than letting the disease go on to its ordinary and almost inevitable ter- mination. In the case of tubal gestation, there being no available outlet, we are precluded from the induction of labor. But the embryo may be killed, and thus the development of the sac cut short. Electricity. — Dr. Bac- chetti* described a case in which two needles were passed into the tubal 1 Guy's Hospital Report, 1843. 2 Monatsschrift fiir Gerburtskunde, vol. xxxi. 3 Ibid., 18«9. '' Gazetta medica toscana, 1853. 372 EXTRA-UTEEINE GESTATION. sac, and then a current of electricity was passed through by means of a Bunsen's pile. Two shocks were administered. The growth of the tumor was arrested, and the patient did well. Of course it may be doubted whether there was really a tubal gestation ; but in any case it is proved that the puncture may be safely made. Duchenne, consulted by Lesouef, suggested resort to electricity in the state of tension by a Leyden jar. He ascertained that the discharge of a Leyden jar pro- duced a profound local stupor, and that for a certain time the capillary circulation and calorification were diminished in the tissues operated on. The method he recommends is, to cover the stem of the exciters with a thick coating of wax, leaving only the terminal ball bare. One excitor is then passed into the rectum, endeavoring to place it in contact with the postero-superior side of the tumor. The lumbo-sacral plexus must be avoided, else the mother will receive the shock. The second excitor is passed into the vagina, and the ball is applied to the antero- inferior wall of the cyst. Thus arranged, the rectal excitor is put in communication with the external armature by a chain suitably isolated. It then only remains to bring the internal armature in contact with the vaginal stem by a glass stem excitor. The electricity will recom- pose itself across the foetal cyst, and it seems inevitable that the stream must traverse the embryo. This mode of applying electricity seems preferable to that of Bac- chetti, inasmuch as no wound is inflicted. Indeed, Bacchetti's plan may be excluded on the ground that, having made the puncture, elec- tricity is superfluous. Drawing off the Liquor Amnii. — The sac deprived of this element will naturally collapse, the ovum will in all probability perish, and atrophy by absorption ensuing, cure will be attained. If the aspirator-trocar be used, the liquor amnii can be easily drained off. It had already been proposed by Basedow to puncture the cyst through the vagina, to drain off the liquor amnii, and thus to kill the embryo. This method was advocated by Kiwisch,^ who recommended to pass a small trocar into the cyst by the vagina. Professor Friedreich^ of Heidelberg relates a most interesting case in which, having detected a tubal cyst which gave rise to great pain, and was increasing so rapidly that bursting was apprehended, he made three injections of a solution of morphia into the cyst. He based this proceeding on the known susceptibility of the infant organism to opium. Complete success followed. The tumor shrank to a small hard knot, and all the distressing symptoms vanished. It is not, however, clear whether the same result might not have been obtained by the punc- tures alone, the morphia injections being superfluous. Some degree of inflammation is pretty sure to follow puncture, and this, no doubt, will insure the death of the foetus, and arrest the growth of the cyst. Dr. Greenhalgh^ describes a case in which he arrested the develop- ment of a tubal gestation by puncture through the vagina. Professor E, Martin^ relates an interestmg case in which he pursued 1 Klinische Vortra<;e, Prae;., 1849. 11 Abtheilung. S. 275. 2 Virchow's Archiv., 29, 1863. 3 Lancet, 1807. * Monatsschrift fiir Geburtskunde, 1868. TREATMENT. 373 the same method. The subject was about three months pregnant when she had symptoms of pelvic injury, with hemorrhage externally, sug- gesting rupture of a gestation-sac. A small spindle-shaped tumor was felt above the left horizontal pubic bone. The body of the uterus was pushed over to the right side, the os uteri to the right. In the left side of the roof of the vagina the same spindle-shaped tumor was felt. Examination at intervals had shown that this tumor increased rapidly. Martin punctured it through the vagina with an exploratory trocar. A few drops of bloody serum escaped. Some constitutional reaction ensued ; the woman quite recovered. The tumor disappeared, and the uterus regained its normal position. The late Professor Simpson^ related a case in which a patient who had suffered rupture of an extra-uterine cyst was punctured by the vagina " to evacuate the liquor amnii, to effect death of foetus and sub- sequent decomposition and expulsion." Death occurred through peri- tonitis. The sac was formed by the enlarged uterus, broad ligaments, pelvic walls, and sigmoid flexure. The foetus was of six months' de- velopment. In such a case gastrotomy would be preferable. Mere puncture could do no good. Dr. Rupin'^ relates a case of twin-pregnancy outside the uterus. A cyst was felt projecting in the roof of the vagina, which was punctured, and liquor amnii drained off; a foetus of four months escaped. The patient died of violent hemorrhage three days afterwards. On autopsy, a second foetus was found in a sac deep in the pelvis. Probably this was not a tubal gestation. Can we an'est embryonic growth by means of agents introduced into the blood f M. Delfrayssc'^ relates instances of retardation of the growth of the foetus by continued doses of iodine. Many attempts in ancient and modern times have been made by starvation and drugs to accomplish this object. I do not insist upon them, because I have no faith in their efficacy. It is possible, however, that strychnine carried so far as to pro- duce minor toxical symptoms in the mother, might destroy the embryo. Syphilis has more power than almost any poison we are acquainted with over the foetus, almost always either killing it, or impeding its develop- ment. Might it not be justifiable in such a case as we are discussing to practice syphilization ? I do not dwell upon this repulsive method, because I believe simple puncture of the sac is the right course to adopt. If the opportunity of treatment during development has been passed by, and rupture has taken place, what is the course to be adopted ? The question has often been discussed, whether it is not advisable to perform gastrotomy with a view to removing the embryo and effused blood, and checking further bleeding by tying the Fallopian tube on the proximal side of the sac, and cutting away the sac ? I can liardly imagine that this idea will ever be successfully carried out in these cases of early tubal rupture. In the first place, the greater number of sub- 1 Edinburgh Medical Journal, 1864. 2 Gazette de Hopitaux, 1860. ^ Comptes rendus de I'Academie des Sciences, 1850. 374 EXTRA-UTERINE GESTATION. jeets die within a few hours from the primary shock of the injury and hemorrhage. Removal of the blood by gastrotomy must add to this shock, and cannot restore the lost blood. And, secondly, to discover the source of the bleeding and to remove the blood is by no means easy. I have found considerable difficulty in tracing the parts with all the advantages incident to a post-mortem examination. Thirdly, if we could tie the Fallopian tube, and amputate the sac, the pain caused by the ligature would probably be so intense as by itself to exhaust the vital power. I fear the actual state of science has no resource beyond the old one of rallying the patient from collapse by cautious ad- ministration of stimulants, of ]jrocuring rest by opium, and by control- ling inflammation, if the patient survives until this conservative pro- cess sets in. If this fortunate event should be reached, the case may resolve itself into one of encysted pelvic hsematocele, and must be treated on the principles laid down for that condition. But this issue by cataclysmic rupture is not invariable. I agree with Lesouef 's observation that extra-uterine gestation is a far more frequent accident than is supposed, and that if it be so rarely observed, it is because the embryo in the greatest number of cases is destroyed in the first days of its development. No appreciable symptom then is manifested, or if the physician is called in, it is impossible for him to refer what he sees to its true cause. When a tubal, ovarian, or ab- dominal gestation is brought to an end in the first days, the hemor- rhage may not be fatal, and the rational signs of gestation not having yet appeared, the source of the resulting hsematocele escapes detection. In these cases the hemorrhage may escaj)e from the surface of the tube or from its open end. There is not necessarily rupture of the tube ; but the embryo perishes, and a hsematocele is formed. I have related cases, upon my interpretation of which of course it is easy for criticism to cast a doubt, l)ut which I nevertheless believe to be of this nature. In yet another order of cases, rupture of the tubal sac takes place early, the hemorrhage is not fatal, and the impregnated ovum escaping into" the abdominal cavity may graft itself upon the peritoneum, when a sac will be formed by false membranes. Lesouef, (quoting Bernutz, says : " If the rupture of the tubal sac takes place on a level with the attached border of the tube, the blood will find its way into the cellular tissue of the broad ligament, and thus find difficulty in effusion, whilst the ovum will insiimate itself in the route made between the folds of the broad ligament, and become developed there. For it must be remembered that the ovum itself rarely ruptures, its envelopes remain intact, and its vitality is not necessarily destroyed." The tubal gestation may go on to term. This issue is exceedingly rare ; so rare, that a case which Spiegelberg- relates he believes to be singular. Convulsions came on in a woman at term, with signs of labor ; copious albumen Avas found in the urine. She died after three •days, the convulsions and albuminuria having ceased on the death of the child. The cause of death was perforation of the sac. Examina- 1 Archiv. f. Gvnalvologie, 1870. TREATMENT. 375 tion showed that the sac was tubal ; a sound passed from the uterus into it ; muscular fibres were found over the surface ; the sac was in- closed between the two layers of the broad ligament ; the ovary was found entire. I am unwilling to hint a doubt of the accuracy of so excellent an observer as Spiegelberg ; but it appears possible, even in this case, that there had been at an early stage rupture of the tube at its lower margin, which had given opportunity for the ovum to extend its sac by opening up a space between the folds of the broad ligament. The question of performing gastrotomy to extract a foetus developed outside the uterus will be more conveniently discussed after the de- scription of the other forms of extra-uterine gestation. It will be convenient here to refer briefly to the other forms of extra- uterine gestation. These are the ovarian, the tubo-ovarian, the abdom- inal, and the interstitial. Ovarian Gestation. — The reality of this form has been_ doubted. Velpeau and Arthur Farre especially contend for the negative. The reasons adduced are twofold : 1st, the physiological one, which is based upon the assumption that the ovum must have escaped from the ovary before it can be impregnated ; 2d, the anatomical one. It is urged that there is no clear evidence of a foetus or foetal membranes having been discovered in the ovary. Professor A. Willigk^ advocates this view, and criticizes the alleged cases. He has carefully dissected several, and failed to find foetus or membranes in the ovary. It is needless to sav that the microscope is necessary to identify presumed chorion villi."' On the other hand, there are cases which it is hypercritical to set aside as being imperfectly observed. And the physiological objection falls to the ground if we"^ accept the conclusion of Bischoff and Coste that impregnation does take place in the ovary. Thus Duverney^ re- lates a case given by De Saiut-Morissey, of a lady who, pregnant for the ninth time, at three months fell ill with collapse from severe colic in the right groin. She died in nine or ten hours. The abdomen was full of clots, and a small foetus was found in the midst. The right ovary was torn longitudinally, and in the half of the side not attached to the tube its whole capacity was filled with clots. Every one present was satisfied that this was the spot where the foetus had been formed. Goupil cites a case from Ucelli. A. Avoman who had had three prem- ature labors, was pregnant for the fourth time. At the third month she passed a fleshy vesicular mole the size of a hen's egg. Pain, vom- iting, syncope, were followed by death. A small foetus was found in the right iliac fossa, attached to the ovary of the same side by its funis. This ovar}^ was of the size and form of a goose's egg, and had an opening by which the foetus escaped. The uterus was enlarged. Dr. P. U. AA^alter,^ of Dorpat, discussing the question, relates a case minutely dissected, and of which the parts are represented in draw- ings, in which the foetus was developed in the ovary for some mouths, when the cyst burst, and further development proceeded in the abdomi- 1 Prag. Vjhrt^^chr.. Ixviii, ^ ii (Euvres Anatomiques," 171. ^ Monutsschrift. fiir Geburtskunde, 1861. 376 EXTEA-UTEEINE GESTATION. nal cavity. Aud Hecker, whose authority is great, relates^ a case which he believed to have been one of ovarian gestation. Kiwisch, whilst admitting that ovarian gestation is not proved by observation, contends for the possibility of its occurrence. A case is related by Uhde^ of a young woman who died under the usual signs of "abdominal collapse." Blood was found in the perito- neum. The right ovary was enlarged and emphysematous ; at its lower and hinder part was a sac formed of chorion, which had burst. It was the size of a large plum, and contained an embryo 1'" to 8'" long. The right tube was hanging quite free, its fimbrise loose. The prepara- tion is preserved, and affords a good means of testing the reality of ovarian gestation. It is, prirnd facie, unphilosophical to affirm an absolute negative. It is, then, wise to admit that ovarian gestation may happen, but safe to affirm that it is very rare. During life it would be difficult, if not impossible, to diagnose it from tubal gestation. If detected before rupture, it would be right to treat it by puncture in the same way, for the histories of the few cases narrated show that the ovarian sac, like the tubal one, is apt to burst early. Probably a more frequent issue is the merging into the tubo-ovarian or abdominal forms. The tubo-ovarian form is not very infrequent. Probably its history commences with arrest and development of the ovum just within the fringes of the pavilion of the tube, so that this structure supplies part of the sac, the rest being made up by adhesions contracted with the ovary. It may also arise from original tubal gestation, early rupture of the tubal sac, and fusion of this with the surface of the ovary by adhesions. The occurrence of signs of pelvic inflammation at some period in the history of these cases supports the probability of this event. The tubo-ovarian gestation, like the abdominal form, differs from the tubal by the greater probability of the gestation going on to the full development ojp the foetus. What then happens will be consid- ered under " Abdominal Gestation." Abdominal Gestation. — It appears to me doubtful whether abdominal gestation is ever primary, that is, whether the impregnated ovum attaches itself ab initio to some part of the peritoneum. It can scarcely be doubted that ova, impregnated or not, frequently are missed by the morsus diaboli, and fall into the abdominal cavity, there to perish. Kiwisch and others, who disl^elieve in ovarian impregnation and ges- tation, insist that spermatozoa also find their way into the peritoneum, and may there meet the stray ovum, and give rise to primary abdomi- nal gestation. Such a fortuitous concourse of atoms resulting in gesta- tion must be very rare, and rests at present on conjecture. It seems hardly possible for a floating ovum to graft itself upon the smooth free surface of the peritoneum, and there to find the conditions for its devel- opment. Probably, then, abdominal gestation is always secondary upon tubal or ovarian gestation. After these latter forms have proceeded a little way, the sac, as we have seen, gives way, but the ovum is not cast out of its original habitat; it maintains its vitality by retaining part of 1 Monatsschrift fur Geburtskundo, 1859. ^ ibid., 1857. ABDOMINAL. 377 its original attachments. Inflammation of the peritoneum is excited by the rupture and effusion of blood ; neighboring organs get connected by adhesions with the sac ; the embryo and its envelopes grow into the new space ; fresh effusions of lymph are thrown out surrounding all; and thus a new sac is formed, in which it is difficult to trace the original tubal structure. It is only when the opportunity occurs of dissecting the parts at an early stage of gestation, that we can expect to unravel the structures involved in the sac. JSTo loug time elapses without the complication of inflammation and false membranes impli- cating neighboring organs, whilst possibly a process of atrophy of the original structures forming the cyst has altogether confounded analy- sis. That the original gestation may be ovarian and not tubal seems proved by a case related by the late Dr. Dyce, of Aberdeen. A woman died after having carried an abdominal gestation eight years, and hav- ing had two uterine pregnancies in the meanwhile. Both Fallopian tubes icere found entire, but no trace of one ovary could be detected. In abdominal gestation the same course may be observed as in oixli- nary gestation up to a certain point. But intercurrent attacks of pain, the expression probably of attacks of peritonitis, are apt to occur. The cyst may burst, as in a case related by Dr. Thormann (Wien. Med. Wochnschr., 1853). The cyst projected into the retro-uterine pouch, and under expulsive efforts it burst through a rent in the posterior wall of the vagina, an arm of the foetus protruding. In most cases, however, the cyst is too tough to burst. After labor- pains have persisted for some time, the foetus dies. Death may happen through exhaustion under the efforts at labor, and from compression of the foetus upon the abdominal organs. The peritonitis may prove fatal, and the cause may escape detection unless a post-mortem examination be made. Peritonitis may be the result of rupture or perforation of the sac, and it may precede or follow the death of the foetus. In one case of this kind which I liave related,^ a fluctuating swelling was formed behind the uterus. The uterus was driven forwards and above the symphysis pubis, and con- siderably elongated, I believe by the pressure to which it had thus long been subjected. The absence of uterine pregnancy was first established by the uterine sound, and by dilating the cervix to facilitate explora- tion of the interior. Then the swelling behind the uterus was punc- tured. Fluid in part resembling liquor amnii escaped. Death Avas caused by the peritonitis. In most cases, probably, the sac will en- croach upon the pelvic cavity, getting behind the uterus. The sound will isolate the uterus; the finger exploring by vagina and rectum will detect the fluctuating mass, perhaps make out parts of the foetus, or foetal bones. When this is done, puncture by rectum or vagina should be made. In many cases, the sac-walls being formed in part by some portion of the alimentary canal or the abdominal wall, or at least only sepa- rated from these by adhesions, a process of ulcerative absorption takes place, by which a fistulous perforation is made into the intestines, or 1 St. Thomas's Hospital Keports, 1871. 378 EXTEA-UTERINE GESTATIOIST. through the abdominal wall. This process is attended by hectic or irritative fever and emaciation. It is rarely that the opening thus made is large enough to permit the easy or complete evacuation of the foetus. The attempt at elimination is a long, tedious, and exhausting process, under which the patient commonly sinks. When such an opening is formed through the abdominal wall, it is advisable to enlarge it by incision with a bistoury, so as to give free exit to the remains of the foetus, which should even be extracted by the lingers or forceps. The opening may be safely dilated to the neces- sary extent for this purpose, because the sac will almost certainly have contracted large adhesions for some distance around. In the case of pointing and perforation into the rectum taking place a similar course should be pursued ; but the extension of the opening must be more limited. In either case, during the voiding of the foetal bones, and after they have been all collected, if an oiFensive discharge continue, the cavity of the sac may be washed out from time to time by injecting a weak solution of permanganate of potash or carbolic acid. Occasionally, but less frequently, elimination takes place by the bladder. In this case it may become necessary to dilate the urethra, which is easily done, so as to admit the finger or a lithotomy forceps, to facilitate removal of bones. Another issue of abdominal and tubo-ovarian gestation is the carry- ing to term, when signs of labor supervene. The phenomenon offers points of remarkable ])hysiological and clinical interest. It ought to throw considerable light upon the vexed problem — What is the cause of labor ? If unmistakable labor-effort occur when the foetus is inclosed in a sac quite independent of the womb, we are entitled to exclude the womb as the primary seat of the cause of labor. And, as we cannot ascribe to the artificial womb in which the foetus happens to be con- tained, greater virtue than the natural womb possesses, we are driven to conclude that the primary cause of labor lies in the foetus, unless Ave imagine some power resident in the mother. But this last hypoth- esis seems difficult to admit. I rather incline to the opinion that when the foetus has attained its full development, when its organs are pre- pared for external life, some change takes place in its circulation which involves a correlative disturbance in the maternal circulation which excites the attempt at labor. Sometimes, even, a sanguineous show takes place from the vagina. The seat of the labor-pains is not even clear in these cases. Velpeau believed the seat of the contractions to be the foetal cyst. If the cyst be formed by the Fallopian tube, its muscular wall may be so de- veloped as to possess true contractile power. The same remark applies if the sac be developed between the layers of the broad ligament. Dezeimeris thought the contraction was in the uterus, which, in tubal cases at least, is sufficiently developed. In a tubo-ovarian case which had passed into the abdominal form, the constitution of which I in- vestigated with Dr. Hall Davis and Dr. Cayley, abundant smooth muscular fibres were found in the walls of the sac. ♦> ABDOMINAL. 379 Whenever the sac takes its origin in or involves the tube, broad lig- ament, or ovary, we may expect to find muscular fibres in its walls. Whatever the initial cause of labor, the attempt is necessarily abor- tive. The pains subside, notwithstanding all the help derived from a duly irritable nervous centre, excited by impressions emanating from the foetus or its sac, and often vigorously seconded by emotional and voluntary actions. Under these the sac may burst. Perhaps the at- tempt is renewed at several intervals. Under these circumstances, what is the best course to pursue ? It is not necessary to say, that in the first place, accurate knowledge should be obtained as to the state of the uterus. Is it certain the uterus has no concern in the pregnancy ? It is proper, I think, in all cases, to dilate the cervix, so as to permit full exploration of the cavity. And this exploration should be especially circumspect and deliberate, for although we may be sure that the cavity so examined is empty and has nothing to do with the pregnancy, the uterus may be double ; the unexplored cavity may contain the foetus ; or the gestation may be interstitial, that is, in one horn of the uterus. The foetus dies in many cases probably of asphyxia ; in others from hemorrhage into the placenta. Large clots were found in the placenta by Koeberle.^ Supposing that we are able to exclude all forms of uterine gestation, ought we to undertake to deliver, and how shall we do it? It will help us to answer this question if we examine the results that may occur if nothing be done. The foetus dies, the vascular system which was brought into activity for its support becomes atrophied ; the sac assumes the character of an inert mass ; the system accommodates itself more or less to the burden, and things may go on for an indefinite time. There are instances of women having carried an extra-uterine gestation for forty, even fifty years, ultimately dying of independent disease or old age. The sac may become calcareous, or retain its soft structure ; but it is almost always found intimately adherent to ab- dominal viscera. The foetus may undergo one of several changes ; for several years the fleshy parts may be preserved, the skin retaining much of its original character, and the muscles also. The surface, however, is generally converted into adipocere. After a further time, the soft tissues having first undergone this fatty metamorphosis, break down, leaving the bones bare. These next Become separated. The cyst-walls inflame and suppurate, and a fistulous communication is opened with the exterior of the body, or with the bowels. If the attempt at elimination be towards the surface by the abdomi- nal wall, the skin becomes red, a tumor forms which becomes fluctu- ating ; there is, in fact, an abscess, which will burst if it be not opened. Considerable irritative fever attends the process ; pus escapes from the opening at first, and it may be long before any part of a foetus is recog- nized. A probe should be introduced to feel for solid substances ; and the opening should be eidarged by the bistoury to permit the freer exit of the bones. Every bone should be carefully preserved to re- 1 " A Memoir on Extra-Uterine Gestation," by Keller. Strasburg, 1872. 380 EXTRA-UTERINE GESTATION. construct the skeleton if possible, and thus to satisfy ourselves as to the progress of the case. If the attempt be made by the bowel, commonly some distress in defecation arises, perhaps obstruction of the bowel, then sanguineous discharge or dysenteric symptoms. Pelvic inflammatory symptoms attend. If examination be made by the rectum, a projecting tumor may be felt, and through its walls we may make out solid bones. If this be clearly established, it is advisable to puncture the sac at once by a bistoury or large trocar, and to aid the exit of the bones by fingers or forceps. There is a great advantage in the rectal elimination, if a sufficiently free opening be made. The drainage is more easy and perfect from the most dependent part of the sac being opened, and there is a greater tendency to contraction and obliteration. Accord- ingly, a fair proportion of recoveries have followed this issue. Still, a great hazard of exhaustion by purulent discharges and septicsemia is incurred. Or, in other cases, the foetus undergoes a calcareous metamorphosis. This seems the change most compatible with long life of the mother. There is a specimen in St. Thomas's Museum, for which I am indebted to Mr. R. W. Watkins, of Towcester. The foetus had been retained for forty-three years. It is an admirable specimen of what is called " Lithopsedion," or conversion of the foetus into stone. (See " Obstet- rical Transactions," vol. viii.) But this conversion of the foetus into a harmless mass must be re- garded as a rare and fortunate accident. Various circumstances may arise to disturb the tran(][uillity of the sac, light up inflammation, and bring about dangerous, even fatal changes. A not uncommon circum- stance thus acting, is a subsequent uterine pregnancy. The enlarged uterus may press upon the foetal sac, and thus mischief may arise even during pregnancy. But the period of labor is especially perilous. During the expulsion of the uterine child, the extra-uterine sac is ex- posed to severe pressure. Possibly, this sac may be fixed low down near the pelvic brim, and be a direct obstacle to labor. Accordingly, the histories of many cases show, that a supervening uterine labor has kindled the dormant mischief, and caused death. Cases are however known, in which women, carrying an extra-uterine foetus, have gone through a second and even several labors. They rarely escape in the long run. The danger is so great that it ought to influence our course of action. I have stated my opinion that rupture of a tubal gestation-sac is not necessarily fatal. The blood effused may flill into the retro-uterine pouch, become segregated there, whilst the remains of the sac, with or without the embryo, may be shut off from the general peritoneal cavity by plastic effusions, and shrivel up. This view is confirmed by a re- markable case published in the '^ Obstetrical Transactions," 1864, by Dr. Haydon, tlie specimen being reported upon by Drs. Tyler Smith and Braxton Hicks. A young woman became i3regnant, and was sup- posed to have aborted, but no foetus was seen. She was at the time dangerously ill, and not expected to live. Four or five years later she again incurred the risk of pregnancy, and six months afterwards died ABDOMINAL. ' 381 under symptoms of internal abdominal rupture. A gestation-sac in the right tube had burst, and a foetus of three months' development had escaped : and appended to the edge of the rent was a small irreg- ular solid mass, which proved to be a small foetus packed very tightly within a membrane. Tlie conclusion drawn was that the patient had had two distinct tubal gestations ; that the first ended in rupture and isolation with shrinking of the embryo ; that the second, occurring some years afterwards, ended by fatal rupture of the sac six months after conception, the embryo having died three months before the rupture. Diagnosis of Abdominal Gestation from Ovarian Tumor and Normal Gestation. The recognition of freely fluctuating ovarian tumors is easy ; but I have several times experienced great difficulty when the tumor was in great part solid. Ovarian tumors are occasionally irregular in shape, and present hard projections which, if the mind is occupied with the idea of pregnancy, are readily mistaken for foetal limbs. After the utmost pains have been expended in order to arrive at a conclusion, an exploratory incision may offer the only satisfactory information. As to the diagnosis of one form of extra-uterine gestation from an- other, Scanzoni declares that this is impossible during life. This must be taken witli some qualification. The abdominal form at least may commonly be distinguished from the tubal by its greater development, by its longer history, and by its terminations. The abdomen is generally less tense than in normal gestation ; it is expanded transversely; the umbilicus is often strongly drawn in. The foetal movements may be felt very distinctly, and are often more vio- lent than in ordinary gestation. The placental souffle is very rarely heard. The os uteri may feel like that of the pregnant uterus, the cervix being open. The body of the uterus is likely to be deflected to one side, and possibly fixed by adhesions. This fixing of the uterus, infinitely rare in uterine gestation, would raise a strong presumption in favor of extra-uterine gestation. In almost all these cases the uterus is elongated. This elongation and the direction imparted to the organ will be defined by the sound, if the circumstances seem to justify the use of this instrument. When the foetus is dead, the abdomen sinks; the breasts fall; the uterus resumes its ordinary state, remaining, however, somewhat above its normal length. The history will help. The subject will have been conscious of being pregnant. There will, in all probability, have been indications of attacks of peritonitis. The question of treatment has to be discussed under four different aspects. 1st. Under the condition of early rupture, gastrotoray might, as we have seen when dealing with tubal gestation, be resorted to with a view to stopping the hemorrhage. Velpeau, Duparcque, Kiwisch advised it. Koeberl^ says he would not hesitate to do it. 382 EXTEA-UTEEINE GESTATION. 2d. When the stage of danger of rupture has passed; that is, after the fourth month. 3d. When labor supervenes at term. 4th. When hibor has passed over and the child is dead. What is to be done daring the life of the child ? Shall we wait, pursuing simply an expectant course, or shall we take means to kill the child, so as to stop the developmental stimulus, trusting to the reduc- tion of the sac, to isolation from the general system, and atrophy, or shall we resort to abdominal section, or other sure way of opening the foetal cyst so as to extract the child? The decision is extremely diffi- cult. During the developmental stimulus, the sac and surrounding structures are full of blood. To make incisions into them at this time, or even to puncture them, is attended with serious danger from hemor- rhage. If the opportunity of tapping the sac at an early date has gone by, I think it will be better not to disturb the sac until the full term of pregnancy has arrived, when labor-effort is present, or when we know the child is dead. In one case^ Dr. B. Hicks having felt a foetus of about three and a half months in a cyst between the rectum and the vagina, tried to destroy it by passing a strong galvanic current through it. Although the foetal movements ceased during the admin- istration, the embryo survived. A month later Dr. Hicks passed a small trocar into it. On the fourth day the patient died under symp- toms of internal hemorrhage. Two pints of fluid blood were found in the peritoneum. Duchenne's plan of giving a shock from a Leyden jar might have answered better. What is to be done when the natural term of gestation arrives, the child being alive? New dangers now arise. The cyst may burst. There is renewed danger of hemorrhage, and of peritonitis. And, not seldom, accidents follow quickly on the death of the child. The cyst has on several occasions burst during the early days following false labor, and acute peritonitis has pro vecl fatal. To obviate these dangers, Levret advised gastrotomy. So did Gardien, saying the placenta might be left. Yelpeau and Kiwisch also advised it. Keller, who repre- sents the opinions of Koeberle, is in favor of the proceeding. He cites nine cases in which this, the primary operation, was performed, seven children and four mothers being saved. He adds an account of eight other cases, in which the operation might have been performed with ad- vantage, the opportunity being lost. It must, however, be remembered that in a large proportion of cases the labor subsides, the dead child is tolerated, and for a time at least the mother goes on without serious distress. It is true another phase of danger succeeds, but the period for this may be remote. Looking first to the mother's safety, I think we must decide that this is best attained by not resorting to any operation to remove the child. The rule of action maybe expressed as follows: If the labor-symptoms subside without sign of grave injury or hemorrhage, do not interfere. If, on the other hand, there arise evidence of severe injury, which, if 1 " Obstetrical Transactions," 1866. ABDOMINAL. 383 left alone, would probably be followed by fatal shock, peritonitis, or exhaustion, open the abdomen and remove the foetus. A weighty objection against opening the sac to remove the child whilst alive or recently dead, rests on the uncertainty as to the nature of the sac. In some abdominal cases it can hardly be said that a true sac with defined walls exists; the placenta may adhere directly to the back of the uterus, to the surface of the intestines, even partly to the kidney, or, as in a case of Koeberle, to the anterior abdominal wall, so that it was divided in the incision necessarily made to open the cyst. It may be almost impossible to cut down upon the foetus without dis- turbing attachments to such an extent as to produce hemorrhage that would probably be fatal. The case differs essentially from that of the Caesarian section. The extra-uterine sac does not possess the conserva- tive contractile property of the uterus. In gastrotomy for extra-uterine gestation none of the favorable con- ditions proper to the Caesarian section are present. The jDlacenta is almost always much spread out, and sometimes very adherent More- over, if the extraction of the placenta were possible, would it be pru- dent to eifect it ? The placental insertion is not endowed with con- tractility as in uterine gestation ; the maternal sinuses will remain gap- ing, and hemorrhage will be great. This objection to gastrotomy whilst the child is living, loses some of its force if the attachments of the placenta are religiously respected, as the greater number of operators have understood the necessity for doing. Its elimination is then effected slowly, and the maternal vessels have time to contract and to become obliterated. The most serious dangers of gastrotomy performed at term are those which the elimination of the afterbirth may provoke, that is to say, secondary hemorrhage, peritonitis, and septicaemia. But are these as great and real as they appear at first sight? In the first place the peritoneum is not always opened; the cyst has contracted adhesions Avith the abdominal walls. Thus argues Keller. If an expectant plan be followed, if opium and perfect rest be em- ployed, the vascularity of the sac and the organs connected with it gradually diminishes, menstruation returns, a degree of contraction takes place, and after a time probably further adhesions tend to com- plete the isolation. Still the patient's life may be said to be at the mercy of accidents, of which we may have no sufficient warning. The cyst may still rupture, or fatal peritonitis may ensue. If uterine preg- nancy supervene the situation may quickly become critical. If it be decided not to operate during labor, what is the alternative ? Shall Ave operate soon after the child's death? If the mother is suffer- ing, exhausted, in great pain, and adhesions be diagnosed, it may be Avise to operate witiiin a few days. The placenta soon ceases to be a source of much danger. Its circulation has ceased. The blood coagu- lates in its villosities as was observed by Koeberle. If Ave decide to wait, the patient should be kept under A'igilant ob- servation. We should be ready to act the moment any sign of rupture or shock occurs. When an eliminative process begins, the propriety of interfering is clear, especially if irritative fever, set in. The seat' for 384 EXTE.A-DTEEINE GESTATION. operative measures will commonly be indicated by the seat of the elim- inative molimen. If there be pelvic distress, such as obstruction or irritation of the rectum, crowding the uterus forwards upon the blad- der, causing retention of urine, with or without local inflammation, and if we can detect parts of the foetus or a prominent fluctuating tumor between the rectum and the vagina, this is the place to select. An opening may be made first with a large trocar, and any fluid contents of the sac be allowed to drain off. A sound, or the finger introduced through the opening, may detect the foetus or bones. Opportunity may first be aflbrded for the spontaneous evacuation of the foetus piece- meal. If this does not proceed satisfactorily, no great time should be lost before enlarging the opening with a bistoury ; and, if feasible, of extracting the foetal parts by finger or forceps. In some cases the eliminative eifort is directed to the roof of the vagina. In this event we equally adopt the route offered by nature. If the eifort be directed to the abdominal wall, the usual signs of abscess mark the point selected. The most common places are the neighborhood of the umbilicus, one or other flank about midway between the umbilicus and the anterior superior spinous process of the ilium, or a groin. In some cases a perforation may have taken place into the bowel or vagina, and there may also be eliminative effort towards the abdomen. The communication with the bowel may be at a point quite out of reach of examination by the rectum. In such cases the indication is to operate through the abdominal wall. It is not constant that an inflammatory process takes place between the sac and the abdominal wall. But there is almost universally increase of prominence at some part of the abdomen. If air get into the sac from the abdomen, and I suspect sometimes without, decomposi- tion proceeds rapidly, putrefactive gases distend the tumor, suppura- tion proceeds; and we then get resonance over the projecting part of the tumor, and fluctuation at other parts. Probably pus may be dis- charged by the bowel. With these local symptoms there will be hectic marked by rigors, sweats, diarrhoea, perhaps vomiting, a quick, Aveak pulse. When this concourse of symptoms is found, there can be no doubt as to the expediency of trying to relieve the patient. Extraction of the foetus and giving issue to the offensive contents of the sac may save her life. Accordingly, there are many instances where this course has been successfully pursued. Mr. Hutchinson, who has studied this question with great care, and based his conclusions upon the comparison of all the cases he could collect,^ is of opinion that what may be called the primary operation by abdominal section should not be jierformed, but that the secondary abdominal section, i. e., at a time remote from the death of the foetus, when inflammation of the sac has occurred, is strongly indicated. Camp- bell, who collected eighty-five cases of extra-uterine gestation, showed that sixty-two recovered, whilst twenty -three died as a direct conse- quence of the abnormal pregnancy. Of the sixty-two in which recovery took place, in twenty-one tiie foetus remained quiescent through life for 1 Medical Times and Gazette, 1860. ABDOMINAL. 385 periods varying from four to fifty-six years, and in the rest its removal had been effected by ulceration. In a not inconsiderable number of the latter, the natural processes had been materially assisted by the surgeou, as by extracting bones, enlarging the opening, and so forth. Campbell advised that abdominal section should not be performed until " after the system had been restored to its unimpregnated condi- tion, and nature had evinced a disposition to remove the extraneous mass." Study of the facts published since Mr. Hutchinson made his collec- tion, confirms me in the opinion that he is right in his conclusion, that "the longer the operation is deferred, and the longer continued the in- flammation of the cyst has been, the more likely is it that the incision will open merely an abscess cavity, from which the peritoneal sac will be shut off;" and that the prospect of the operation being successful is pro tanto increased. At the same time it does not seem desirable absolutely to condemn the primary operation ; still less the operation at a time remote from the death of the foetus, even when no inflammatory or elimiuative effort has presented itself. I do not think the risk of danger from subse- quent uterine pregnancy is sufficiently weighed. At all events the subject of an extra-uterine gestation should be emphatically cautioned not to incur the risk of another pregnancy. In the event of this com- plication occurring, the case should be treated on the same principle as those laid down when discussing the treatment of ovarian tumors complicated with pregnancy. Very eminent men have advised the primary operation. Thus Lev- ret, Gardien, Velpeau, and Kiwisch urged it, and that at a time when abdominal surgery was imperfectly understood, when its dangers were really greater than now, and when they were thought to be even greater still. In recent times, Koeberle, whose authority is especially to be valued on account of his great experience and success in ovariotomy and in gastrotomy for extra-uterine gestation, pronounces himself de- cidedly in favor of the proceeding. Dr. Keller, the author of an ex- cellent memoir on extra-uterine gestation,^ after carefully weighing the arguments, for and against, decides in favor. He calls to mind that dangerous accidents may ensue quickly upon the child's death ; that the cyst has on several occasions burst during the early days of false labor ; and that hemorrhage and peritonitis may quickly prove fatal. Mr. Lawson Tait, who has recently performed the operation three months after term, found the child's head in the pelvic cavity adherent to the cyst. He urges the probability of this accident as a reason for operating before term, or as soon as possible after it. His patient re- covered quickly after the placenta was discharged. On the other hand, it must, I think, be admitted that the risks attending the primary operation are greater than those attending the secondary operation. Whilst the child is alive, the cyst and placenta are in the full vigor of vascular communication ; the cyst has probably 1 " Des Grossespes extra-uterines, et plus specialement de leur traitement par la gastrotomie." Paris, 1872. 25 386 EXTRA-UTEEIXE GESTATION. no contractile property ; the placenta is likely to be widely diffused, its attachments projecting amongst intestines, perhaps deep in the pelvis ; or it may, as occurred in a case operated upon by Koeberle, grow to the anterior wall of the abdomen, so that it must necessarily be cut through by the incision made to open the cyst. The cyst itself has probably not formed extensive adhesions to the abdominal wall, so that incision will be likely to open the peritoneum. There will thus be greater danger of secondary hemorrhage, of suppuration, of septicaemia, and of peritonitis. On these and other grounds the primary operation has been opposed by Gerdy, Delpech, Hutchinson, and others. It is premature, I think, to lay down an absolute rule. Generally, the primary operation is certainly more dangerous than the secondary. But this is not all we have to consider. The question would be fairly stated as follows: Are the dangers of the primary operation greater than those of the secondary operation, plus the dangers immediately and soon following the neglect to perform the primary operation ? It is clear that the catastrophes, as rupture of the cyst, hemorrhage, and peritonitis attending false labor, must be taken into account, and added to the dangers of the secondary operation. It is also right to throw into the same scale at least a certain proportion of the more remote dan- gers, as peritonitis, exhaustion from suppuration, subsequent uterine pregnancy, and so on, to which the woman is exposed. If rupture occurs, if the w^oman is obviously suffering intensely, when the gestation is at term, there ought, I think, to be no hesitation in operating in the hope of removing the source of irritation. The Operation of Gastrotomy to Remove an Extra- Uterine Foetus. — The general preparations are the same as for the Csesarian section ; but there are important modifications in the execution. The seat of the incision will generally be in the linea alba. It is, however, determined somewhat by the point of greatest prominence of the tumor, or by the position of the foetus. A smaller incision is commonly necessary than for the Csesarian section. The central j)oint of pain and prominence is the most likely to be the centre of the ad- hesions formed between the sac and the alxlominal wall. A longitudi- nal incision, not exceeding two inches in length in the first instance, is then carried carefully through the abdominal wall, and a small open- ing is made in the sac. The finger is passed through this to feel for the limit of the adhesions, and guide the further extent and direction of the incision. This should be just large enough to permit the ex- traction of the foetus ; and it is better, if there be any difficulty in extracting the foetus whole, to bring it away piecemeal, than to extend the opening much, lest we open the peritoneal cavity. If the cyst have not contracted adhesions with the abdominal wall, care will be necessary to prevent the protrusion of intestines and the escape of blood and other offending matters into the peritoneal cavity. To ob- viate this, the cyst, at the point where it opens into the peritoneum, should be carefully stitched to the edges of the abdominal wound, so as to shut out the communication. The extraction of the foetus may appear a simj:)le matter, but it re- quires some obstetric skill to do it without unnecessarily increasing ONE-HORNED GESTATION. 387 the opening or disturbing the sac. I have seen a surgeon pull at the arms as soon as the fcetus came in sight, and thus, not reflecting that he was really making a transverse presentation, fail to extract the foetus througii a very liberal opening. It was instantly deliv^ered with perfect ease by the late Dr. Ramsbotham, who seized the feet, perform- ing the equivalent of version. The same consummate obstetrist, Mdio had had considerable experi- ence in cases of extra-uterine gestation, insisted upon the rule now generally adopted, of not removing the jjlacenta, if it in any degree adhere. It is advisable to tie the funis, and let its end hang out of the wound. If omentum interfere, the obtruding bit may be cut ofF, and the vessels tied, or, better still, removed by cautery-clamp. Re- frain from all curiosity as to the attachment of the placenta and other matters, if it cannot be indulged without disturbing the parts or ex- tending the opening. If the placenta do not come away on gentle traction, leave it. In some cases it wnll already have melted down, and its remains will come away with the pus and other discharges. In other cases it softens and breaks down within a few days after the operation, and will come away in lumps or small debris. In other cases its attachments have yielded in a few days as the sac shrank, and it has come away entire. Marked improvement commonly follows the discharge of the placenta. This last source of irritation gone, the rally is often quick. Where attempts have been made to remove the placenta or the cyst, the result has generally been disastrous, and that, whether the case were primary or secondary, whether the child were alive or dead. The wound may be closed with two or three sutures, leaving a suf- ficient opening for the funis and ligatures, if any vessels had been tied. If discharge continues, the sac may be lightly washed out now and then with a solution of permanganate of potash or carbolic acid. In such a case, when the sac adheres throughout the extent of the open- ing, the operation is, as Mr. Hutchinson remarks, scarcely more serious than opening an abscess. Primary Opening of the Sao hy Caustics. — A case is related' of a woman who had carried an extra-uterine foetus ten months. Blachet opened into the sac by five applications of caustic. No blood was lost ; and the foetus was extracted. The patient nearly lost her life from the bleeding which ensued on removing the placenta. Interstitial or Intramural Gestation, Gestation in One Horn of a Tido- Horned Uterus, and Gestation in the Horn of a Single-Horned Uterus. It is convenient to discuss these conditions together. They approach each other so nearly in locality and other characters, that they hardly admit of distinct clinical demonstration. The seat of these varieties, lying between those of tubal gestation and uterine gestation, must also occasionally give rise to difficulty in discriminating them from the 1 Gazette des Hopitaux, 1856. 388 EXTEA-UTEEINE GESTATION. latter. I entertain little doubt, for example, that some cases of pre- sumed " missed uterine labor," a part of whose history is the subse- quent discharge of foetal bones by the os uteri and vagina, were really cases of interstitial gestation, or of gestation in one horn of a two- horned uterus. Ulrich,' however, relates a case, which seems a genuine instance of retention of foetus in utero for long after its death. The foetus died at five months ; discharge of placenta in pieces took place by vagina four months later, and then bones came by the same passage. A year after this, all escape of bones by vagina having ceased, bones passed per anum. The patient died exhausted. The uterus was found adherent to intestine ; some bones were encapsuled in the wall of the intestine ; a direct communication existed between uterus and intestine. The cavity of the uterus was empty. It was concluded that the pregnancy was uterine, and that the discharge of bones into the intestine was the result of a fistulous opening established from the uterus. Halley^ relates a case of a pluripara, who, in the middle of her third pregnancy, discharged offensive water and bones by the vagina. He found the uterus anteverted, the cervix shortened and widened, the os slightly open. The cervix was dilated by laminaria, and twenty-eight pieces of bone were removed. The discharge then ceased, and men- struation returned naturally. Ramsbotham prefers the term " parietal " to " interstitial." It is re- markable, that when gestation takes place in the uterine portion of the tube, the dilatation, as a rule, affects solely the space between the inner and outer openings. The reason, Kiwisch suggests, may lie in the cir- cular disposition of the muscular fibres around these openings. The sac enlarges most freely in an outward direction, and forms a promi- nence with a broad basis on the side of the body of the uterus. It is surrounded by the uterine substance, which at first undergoes an eccen- tric hypertrophy, and later, as the sac grows rapidly, is stretched, thinned at its apex, and then bursts. Interstitial gestation may, says Rokitansky, in rare instances like tubal gestation, merge into abdomi- nal gestation. As in gestation in a rudimentary horn, it is often im- possible to trace an opening from the tube into the sac. This becomes obliterated on either side as the sac is developed. But a peculiar modi- fication at times occurs. The uterine mouth of the pregnant portion of tube may be dilated, so that the sac expands into the uterine cavity, constituting tubo-uterine gestation, or the tubal mouth dilating, the sac enlarges in the direction of the tube, constituting interstitial tubal gesta- tion. The first variety may end in normal labor, whilst the latter is likely to burst into the abdominal cavity. The illustration of tubo-uterine or interstitial gestation (Fig. 84) is taken from Dr. Poppel.^ A pluripara died suddenly under symptoms of abdominal collapse and internal bleeding. She had been unaware of her pregnancy. The uterus measured from fundus to os 18 centini., at its greatest width 13 centim. The right side of the fundus was more 1 Monatsschrift fiir Geburtskunde, 1857. '■' Lancet, 1867. 3 Monatsschrift fiir Geburtskunde, 1868. INTEESTITIAL. 389 protuberant than the left, and shoM^ed at its hinder part two rents, through which were seen portions of placenta and a foetus. The uterus, opened longitudinally along its fore aspect, showed two cavities. The lower one {a in Fig. 84) was clothed with a thick decidua. This was the proper uterine cavity. The upper cavity (c) was divided from the lower by a septum of muscular structure, all but a small opening of communication. It contained a fresh foetus, w^hich corres])onded to the fifth month of gestation. At the point of the rupture the wall of the sac was very attenuated, but at cZ British Med. Journ., Oct., 1872. ATROPHY. 403 could be felt under the abdominal wall, two inches above the umbilicus. It might be conjectured that the sound went through the fundus of the uterus ; but repeated examinations, varied in manner, by Dr. Thor- burn, Dr. Lloyd Roberts, and Mr., Windsor, corroborated the conclusion drawn by Mr. Whitehead. The following drawing (Fig. 91) taken from Carswell's "Morbid Fig. 91. Atrophy of the uterus ami ovaries from ossification of the arteries After Carswell. a, a. Uterus laid open : b, b, tubes ; c, c, ovaries ; d, d, d, the principal arteries, and several of their smaller branches completely ossified and nearly impervious ; the substance of the uterus e, contain- ing a multitude of small arteries in the same state ; a tumor/, composed of dilated veins and cellulo- fibrous tissue, occupying the fundus of the uterus. Anatomy," represents a form of atrophy of the uterus connected with calcification of the ovario-uterine arteries. Some forms of atresia and stenosis have been described in Chapter XIX. Obliteration of the uterine cavity is sometimes the result of concentric atrophy ; it often results from adhesions following accumulations of mucus, mucous polypi, or connective-tissue tumors. Obliteration of the cervix uteri and of the orifices is commonly caused by closure from pullulating ovula Nabothi. More often the os inter- num is closed by flexions. Occasionally it is the result of longitudinal dragging of the cervix. The os internum may be closed by cicatrices from lacerations and bruisings, from ulcerative loss of substance, from amputation of the vaginal-portion, from the action of cauteries. In aged women, it not unfrequently closes by a process of concentric atrophy, the margin of the ring of the os uteri getting glued up by dense epithelial scales resembling a membrane. 404 UTERUS. Fig. 92, from a specimen in the London Hospital, put up by me, represents closure at three different points of the uterine canal. Fig. 92. . London Hospital, Ea. 56, from nat. size (Dr. Barnes), stenosis ; atresia ; dilatation of uterus. This uterus came from a woman aged 43, married, barren. It is divided imperfectly into three cavities. The upper two, a, b, are hour- glass shaped ; the lowest, c, about three-quarters of an inch long, is separated from the middle one by a nearly complete fold of mucous membrane. In the middle cavity, the uterus is deeply furrowed, and studded with large gaping follicles. The atresia was no doubt due to endometritis with follicular inflammation. Abnormities of Shwpe of the Uterus. — As a congenital anomaly, there occurs the congenital obliquity in connection with the uterus bipartitus, unicornis, bicornis, and bilocularis. Tlie most marked form of this is seen when one horn with its tube stands higher than the other, and the vaginal portion is correspondingly oblique. This uterus lies ob- liquely in the pelvis, inclining to one or other side of tlie vaginal roof. (See Fig. 85 from Tiedemann.) The broad ligament of this side is narrower, and the ovary lies nearer to the uterus. Sometimes this uterus is bent in an angular form on that side which is highest. Often the higher side is more dense and bigger. There are asymmetrical forms of the uterus caused by excessive de- UTERINE PATHOLOGY. 405 velopment of one half of the body of the uterus. When there is bending on this side, the retort form is produced. Among acquired malformations, there is obliquity from one-sided dragging of a fibrous tumor, or an ovarian tumor, from dragging in hypertrophy of the vaginal-portion, from scars, from various accumu- lations in its cavity, and from inflammatory adhesions in one broad ligament. CHAPTER XXXVIII. GENERAL OBSERVATIONS ON UTERINE PATHOLOGY; EFFECTS OP LABOR AND LACTATION; INVOLUTION IN DEFECT AND EXCESS. In studying the pathology of the uterus, it is especially necessary to keep in constant view the peculiarities of structure and the physiology of the organ. No organ in the body undergoes such remarkable jjhysiological changes. At each menstrual period there is increased vascularity, increased volume, increased muscular energy, the develop- ment of new tissue, followed by a retrograde process of involution, which effects the return to the ordinary state. At every pregnancy the changes wrought are more wonderful still. Under its physiologi- cal influences, the uterus is thus continually subject to alternate hyper- trophy and atrophy, or more strictly speaking, involution. The mucous membrane is endowed wdth extraordinary regenerative power. And these active reproductive and solvent forces inherent in the uterus are constantly ready to be called into action on any abnormal stimulus. Thus, if a fibroid tumor form in the uterine wall, or project into its cavity, the vessels and tissues respond just as they do to the stimulus of impregnation. Interruptions, then, to the fulfilment of the organic changes evoked by function will account for a large proportion of the cases of uterine disease, especially congestion, engorgement, hyperplasia, hypertrophy, atrophy. Continually recurring functional acts will also exert an in- fluence, generally injurious, sometimes beneficial, upon morbid con- ditions. Perhaps there is no organ in the body so prone to hypertrophy as the uterus. Its functional hypertrophy has often been likened to in- flammation, notably that hypertrophy of the mucous membrane which results in the formation of the decidua. The diatheses also must not be overlooked. "When one of these exists, it may be the primary cause of the development of disease in 406 UTERINE PATHOLOGY. the uterus ; or, if one of them happen to complicate uterine disease which has arisen from other causes, it will impress its stamp, will greatly increase the difficulty of cure, and will, therefore, dictate largely the course of treatment. The strumous, dartrous or herpetic, rheu- matic or gouty diatheses, or the syphilitic, tuberculous, or cancerous cachexiee often play a most important part in the production, continu- ance, and curability of uterine diseases. The uterus is liable to alteration of structure and disturbance of function from causes external to itself. Some of these may take their rise in distant organs, some in neighboring organs ; and the uterus, as an integral part of the whole organism, is subject to the constitutional disorders which affect the body, and to the disorders ensuing upon the multitudinous varieties of toxaemia. Thus the uterus is liable to tu- bercle. The blood dyscrasiae which dispose to hemorrhages from the mucous membranes are perhaps more likely to induce hemorrhage from- the uterus than from other organs. This is especially true during the period of sexual activity. Thus scurvy, small-pox, measles often cause uterine and tubal hemorrhages. Certain medicinal substances or poisons circulating in the blood act with special intensity upon the uterus. The uterus is remarkably susceptible to nervous impressions, emo- tional, reflex, and so-called sympathetic ; and through these nervous impressions it is certain that functional and even structural disturb- ances are produced. The uterus stands in the most intimate correla- tion with the ovaries and breasts. With the ovaries it is directly associated by its vascular supply, which may be said to be common to both organs. The vessels supplying botli so freely anastomose that it is impossible for hyperemia to exist in the one without involving the other in a similar condition. This is most strikingly manifested in the uterine hypersemia evoked by the ovarian menstrual nisus ; but it is almost equally clear that what is called ovarian dysmenorrhoea reacts ujjon the uterus also. The application of the suckling infant to the breast often causes con- traction of the uterus. I have often known it cause uterine hemor- rhage. Many women are conscious of pain in the uterus when suckling. The application of leeches or blisters to the breast has brought on menstruation. Obstinate pruritus pudendorum, by keeping up a constant excess of blood and local nervous disorder, not seldom brings about a congestion, enlargement, or infarctus of the uterus. The uterus in its turn is the starting-point for manifold affections of the distant organs, and of the general system. I do not in this work more than glance at the influences which the pregnant womb exerts. Those which spring from the non-pregnant womb are scarcely less striking. The uterus is especially liable to change of structure and disturbance of function under the influence of changes affecting its neighboring organs. Floating, as it docs freely, between the bladder and the rec- tum, it is subject to constant change of position, according to the vary- ing conditions of fulness or emptiness of these organs. Of course, so EFFECTS 'of LABOR AND LACTATION. 407 long as these conditions are within physiological limits, the uterus adapts itself readily to them ; but if the natural mobility of the uterus be impeded, as by plastic deposits about the broad ligaments, by blood- masses and plastic deposits in the retro-uterine pouch, by tubal ges- tation, or by any body becoming attached to it, uterine hypersemia proceeding to infarctus or hypertrophy is sure to follow. In every case of pelvic peritonitis, or so-called pelvic cellulitis, the uterine walls are found thickened. This is a frequent cause of secondary puerperal hemorrhage, and of hemorrhage continuing for months after labor as menorrhagia. This, it may be said, is due to arrested involution from the state of pregnancy, this form of inflammation commonly arising after labor or abortion. But I believe this is only one particular instance of a general law. The same state of engorgement and hyper- plasia is observed, no matter Mdiat the cause which fixes the uterus. This fixing and the attendant changes in the circulation of the organ account in great part for the enlargement of the body of the uterus, which takes place when cancer invades the neck. If inflammation begin in the broad ligament, or in Douglas's pouch, not spreading to the uterus, but fixing it by external deposits, enlargement equally follows. The uterus also, I have observed, is liable to hyperplastic enlarge- ment, as the result of oft-repeated or long-continuous hypersemia pro- duced by disorder of the liver, kidneys, or heart. We shall find the history of the natural changes ensuing upon men- struation, pregnancy, and labor to be a necessary introduction to the right appreciation of engorgement, inflammation, hypertrophy, pro- lapsus, versions and flexions of the uterus, and of other uterine and peri-uterine afifections. This history, then, which really includes the study of the etiological relations of so many disorders, will here be briefly traced. Effects, Local and Constitutional, of Labor and Lactation. A very large projDortion of the cases of uterine disease which come under treatment are the result, more or less immediate, of parturition. To understand this aright it is necessary to study Avhat are the effects of parturition upon the uterus. Parturition is a violent process. Even in ordinary labor the dilatation of the cervix uteri is effected in great part by the direct pressure of the head or other part of the child. In many cases the pressure thus exerted amounts to severe bruising, con- tusion of tissue, attended by a partial sliding, a glacier-like movement of the mucous membrane, away from the subjacent tissues. This trau- matic process necessarily involves the rupture of many small vessels, producing ecchymosis and serous effusion in the connective tissue, and even in the wall of the cervix. That the edge of the os externum uteri is almost constantly torn in first labors is notorious. Lmpeded Involution. — The first in time, if not in importance of the results of labor, is the persisting enlargement of the uterus, which marks the failure of the process of involution. Within a month the uterus ought to complete its return to the ordinary state ; that is, it ought to 408 IMPEDED INVOLUTION. recover from a bulk represented by one and a half pounds weight or more to two or three ounces. This wonderful change is brought about chiefly by two processes. The first is one of active and tonic contrac- tion of the muscular fibre, which, by diminishing the bulk of the organ, squeezes out of its vessels all superfluous blood. The second process is a compound one of absorption and excretion. The now useless solid tissue is first converted into granular fat, then absorbed into the circu- lation, and lastly ejected from the organism by the glandular apparatus. Both these processes are liable to be impeded. The first and most essen- tial act, that of vigorous and persistent muscular contraction, is often badly performed. A degree of hsemostasis remains, which keeps up congestion, disposing to hemorrhage and inflammation. The excessive bulk and weight of the organ occasion local distress. This condition, moreover, retards the second essential process of absorption. And if to this be added, as is too commonly the case, feeble glandular action and weak nutrition, involution is seriously retarded. Besides mere want of power, other causes may concur in frustrating the due involution of the uterus and vagina; and these it is desirable to enumerate. Associated under the general terra, want of power, we of course include the influence of accidentally complicating diseases, as fevers, phthisis, and of the cachexise, as struma and syphilis. Under the influence of these diseases involution rarely goes on well. A marked excess of bulk, with chronic endometritis, may be observed for weeks and months. Flooding during and after labor, by weakening general power, and especially by impairing tonicity of muscular fibre, retards involution. The occurrence of perimetric inflammation during child- bed, especially if attended by effusions which impede the mobility of the uterus, surely retards involution. Indeed, I think it may be laid down as an aphorism that whenever the mobility of the uterus is arrested, whether the cause be external or internal, a degree of hyper- plasia is the result. Thus, as in the case just mentioned of perimetritic adhesions, imperfect involution and a process of slow infarction follow. In the case of extra-uterine gestation, where the foetal sac comes into adhesion with the uterus, the primary development of the uterus under the stimulus of conception is maintained, and even exaggerated. When peritonitis and adhesions form from maligant disease, the uterus is always increased in bulk, and this increase is greatly due to this cause, not alone to the direct influence of the malignant disease. The inevitable injury inflicted upon the cervix, and especially upon the vaginal-])ortion, may evoke such an active process for repair that general involution may be impeded. Displacements of the uterus also impede involution ; and displace- ments are very apt to occur after labor. The most common displace- ments are retroversion, retroflexion, and prolapsus. When one of these occurs the free circulation through the uterine vessels is neces- sarily interrupted. The arteries may pump in blood, but the return by the veins is obstructed by the tortuous course and angulations produced by the displacement. Hsemostasis, frequent metrorrhagia, arrest of involution, and continuous infarction are the result. Fibroid tumors, or polypi in the uterus, retard involution, by IMPEDED INVOLUTION. 409 keeping up a developmental attraction of blood. It is a kind of spuri- ous gestation. I am disposed to fix the normal period required for complete invo- lution as one month. But this applies to persons in health, and placed in favorable circumstances. Hospital air is an unfavorable condition ; and I am told that in the lying-in hospitals abroad six weeks is the time usually required. The reduction in size which the uterus has to undergo, and the brief space within which this change has to be effected, constitute one of the most striking facts in physiology. At the full term of pregnancy the cavity of the uterus, says Simpson, contains above 400 cubic inches; and in the non-pregnant it can hardly be said to be equal to one cubic inch. Yet to this latter capacity the uterus must be reduced in a month. The extent of involution of the uterus after labor may be accurately traced, by observation, by touch, and by measurement with the sound. The following diagram (Fig. 93), from Simpson, gives an idea of the Fig. 93. The outer outline represents the bulk of the uterus arrested in its involution after pregnancy, inner one represents the bulk it ought to attain. (After Simpson.) The ordinary difference in bulk of the uterus in which involution has been arrested, and that of the uterus in its ordinary state. Dr. Snow Beck showed to the London Medical Society (1851) a 410 IMPERFECT INVOLUTION. specimen of arrested involution, under the title " A New Disease of Uterus." The structure of the hypertrophied uterus showed no in- flammatory or heterologous deposits; but the tissue of the organ was similar in its histological characters to the tissue of the uterus at the ninth month of pregnancy, except only that its component fibres were smaller in size. The evidence of the traumatic injury sustained in labor remains in the indented cicatrices round the margin of the os, which are char- acteristic of the vaginal-portion in women who have borne children. But if the parts be examined soon after labor, much more striking marks of the injury they have sustained will be witnessed. Imme- diately after labor the vaginal-portion is large, flabby, pulpy, so as to be almost indistinguishable to the touch. It is some days before it re- tracts to any considerable extent, or regains much firmness of texture. The tissue of the cervix and of the connective tissue surrounding the vessels at their entry from the broad ligaments is infiltrated with serum, which has to be absorbed. The entire thickness of the vaginal- portion, as I have repeatedly seen in post-mortem examinations, at the end of a week or even ten days after labor, is still soft, large, and black from ecchymosis. It must also be remembered that the vagina during pregnancy and labor undergoes changes analogous to those which affect* the uterus. During pregnancy the extreme vascularity of the vagina gives a char- acteristic test of this condition. Its walls grow in length and breadth ; its tissues become softer, and more distensible. To the touch this is veiy perceptible. During labor it is subjected to enormous distension, and even violence. Involution will be arrested under the same condi- tions as those which arrest involution of the uterus. The vagina then remains larger and looser; folds may even project through the vulva. Thus we get a heavier uterus, which has to be supported by a vagina of less than usual power. Under favorable circumstances, the process of repair is rapid and complete. But in a great number of instances, the conditions are not favorable. Repair is retarded by a weakly state of the constitution, by the intercurrence of various morbid actions, by imprudence in getting about too soon, and the too early resumption of ordinary duties. I am persuaded that rest, 'physical and physiological, for at least a month after labor, is essential to complete the repair of the injuries sustained, and the involution of the pelvic organs. This proposition will, perhaps, appear overstrained in the opinion of those ^\'ho advocate a generous diet from the day of labor, and removal to the drawing-room in less than a week. I have so frequently seen pernicious effects, immediate and remote from this practice, that I cannot hesitate to condemn it. It is easy to adduce any number of cases of women who have been thus treated, and have made good recoveries. But the practice is not thus justified, if the exceptions also are numerous. It is true, that many women return to their ordinary mode of life within a fortnight, and continue with more or less success to perform their duties. But the frequent penalty is uterine and constitutional disease. The speed and completeness of recovery from labor depend also greatly upon the CAUSES. 411 health and physical power of the individual. Women accustomed to hard work, hard living, and exposure to the weather, complete the pro- cess of repair much more quickly than those who are nursed in luxury, and whose first experience of hard work is acquired in the task of bringing forth a child. In the first class of women, the muscular, vas- cular, and glandular systems are in vigorous working order. Effete matter is quickly got rid of. Every organ soon returns to its wonted state. In delicate and pampered w^oraen, on the contrary, the muscular fibre is lax, the glandular organs, especially those of the skin, are im- perfectly developed, they do their duty feebly, and are easily over- powered when an unusual strain is thrown upon them. The nervous system is stimulated beyond measure, and acquires predominance over the rest. Under these conditions it is not surprising that the extra- ordinary revolution in the system, and the im]3ortant local changes which have to be effected after labor, are accomplished with difficulty, imperfectly, and are the point of departure for various constitutional and local morbid processes. Neglect of the due period of " rest " for repair is especially apt to retard the restoration of that part of the uterus to which the placenta adhered. The changes that have to be effected here are more extensive than in the rest of the internal surface. It is no uncommon thing to see in women dying, a month and more after labor, a rough area, marking the site of the placenta. This is often covered with a muco-purulent secretion, showing that the return to the ordinary condition is not com- pleted. It is easy to understand that to tax the uterus in this condition with the premature resumption of functional work, will start endometri- tis, which will readily assume a chronic, and even permanent character. Analogous conditions follow abortion, although the actual violence inflicted upon the cervix is not so important an element. Abortion .also differs from labor at term in this respect: the development of the uterus is brought to a sudden termination prematurely ; that is, before the tissues and the system have attained the conditions favorable to rapid and complete involution. Within the first three or four months, for example, the muscular contractibility of the uterus — a prime agent in starting healthy involution — is not nearly so effective as at term; and, in addition to this, the transformation of the mucous membrane into decidua, is arrested at a stage when the adhesion to the uterus is much more intimate, more vascular, and embraces a relatively much larger area. Its separation is a far more violent process ; and if, as is not unlikely, the mucous membrane was unhealthy before conception, its separation will be apt to leave a subacute endometritis, with un- healthy new mucous membrane. Rest is as essential after abortion as after labor. The indifference with which many women in every rank regard "a slight miscarriage," is a source of much future trouble. A miscarriage is looked upon as slight in proportion to the earliness in pregnancy at which it occurs. But it is a grave error to measure in this way the importance of an abortion. The earliest abortion may entail consequences far from slight, if due hygienic precautions are not observed. Now, one of the surest means of inducing some one or more of the 412 IMPERFECT INVOLUTIOJSr. foregoing involution-retarding conditions, is premature exchange of "rest" for exertion. The upright posture within the first week or fortnight will surely increase the local vascular tension, and promote disiDlacement of the uterus. To add the influence of gravity, and of increased hydraulic pressure in the vessels whilst the uterus is still of inordinate weight, and its supports are disabled, cannot fail to be injuri- ous. The most healthy stimulus to uterine involution is the natural function of lactation. If this duty — this physiological complement to parturition — be neglected, involution will not go on smoothly. The application of the infant to the breast causes contraction of the organ. It is injurious to lose this. Lactation, moreover, causing a derivation of physiological activity to a distant organ, tends to promote rest in the pelvis. Indeed, one of the beneficent purposes of this alternative or cyclical action of the generative organs, is to give each in its turn the rest that is necessary for restoration. This natural order cannot be broken with impunity. The penalty, or rather one of the penalties of suppressing the function of the breasts, by depriving the uterus and ovaries of their allotted respite, is the resumption of work before they have had time or opjjortunity to recover their fitness for the task. It is to this evil that women of the easier classes are more especially exposed. The increasing neglect of the function of lactation is, I be- lieve, a prolific cause of uterine disease. This neglect does not, how- ever, entirely arise from indifference to maternal duties, or the fancied more imperative duties of social life. The inability to suckle is, in numerous cases, real. The system, the breasts want the power, the capacity, to secrete milk. After honest endeavors, it is too often found that after a few weeks of scanty secretion and painful suckling, the child and mother alike show evidence of the futility of the effort. Nothing can lend stronger confirmation to the theory I have expressed, as to the relative unfitness of women nursed in luxuiy to carry out in its completeness the function of reproduction, than this failure of the breasts. The breasts are glandular organs developed out of the skin. They are closely analogous in structure to the sebaceous glands of the skin. Their activity and degree of development may be taken as a measure of the activity of the skin and other glandular organs. All show the same kind and degree of incapacity. Unless the general system have been duly exercised and called into activity by the whole course of life, the glandular system, like the rest, will remain imper- fectly developed. It is unreasonable to exj)ect the breasts to become all at once competent to their work. On the other hand, there frequently occur amongst the working classes and others, cases where involution of the uterus is arrested by lactation. This is because lactation is a task that exceeds the strength. Deficient food, bad health, and hard work combine to exhaust the struggling mother. The process of repair is arrested, and a chronic endometritis, with engorgement, abrasion of epithelium from the os uteri, and leucorrhoea, sometimes tinged M'ith blood, or even alternating with metrorrhagia, always more or less prolapsus or retroversion, result. The worn, thin, pallid aspect of the subject attests exhaustion. The pulse is small, accelerated ; nutrition is feeble ; the muscles are flal^by ; CAUSES. 413 at one point muscular debility is invariably marked, the dorsal muscles, especially between the scapulae, are always painfully aching ; they are in fact overstrained by the heavy burden of carrying the child. The nervous system in many ways suffers from imperfect nutrition ; vertigo, syncope, are the sure signs of anaemia, and show how the brain is starved ; dimness of sight, musc£e volitantes, every degree of amaurosis commonly attend. Mr. Jonathan Hutchinson has investigated this subject with a sagacity pointed by an unsurpassed range of pathological knowledge. He rightly says that dimness of vision during suckling may be merely an indication of the existence of hypermetropia, and does not neces- sarily indicate retinal disease. Until weakened by lactation, many hypermetropic women experience no inconvenience, being able to bear the accommodative strain necessary to overcome the error of refraction ; but during lactation they find it difficult to keep the ciliary muscle up to its unusual exertion. He says it is' well to examine if spectacles are not requisite. Any nervous affection to which the subject retains a predisposition, from antecedent attacks, or from hereditary transmission, is now ex- tremely apt to break out. Thus, overlactatiou induces a recurrence of epilepsy, chorea, hysteria, ague : affections from which the subject might otherwise have been freed. Another jjoint of suffering is the lower lumbar and sacral region. This is partly the indication of reflex distress, proceeding from the diseased uterus, partly of pressure of the enlarged organ on the pelvic nerves, and partly of spinal exhaustion from the constant wear and tear occasioned by the irritation of a diseased organ acting upon an imperfectly nourished nervous centre. These subjects will also frequently complain of pain referred to the seat of one or other ovary, most frequently the left. This Dr. Henry Bennet has long insisted upon as characteristic of irritation jiropagated from the inflamed cervix. It may, according to him, and I am dis- posed to agree with him, be regarded as a consensual pain. Others, however, regard it as an indication of actual ovarian inflammation. The period when overlactatiou may be said to have begun cannot be fixed. It is determined by the relative strength of the individual. Whilst it may be said that few women are able greatly to transgress the normal period of nine or ten months with impunity, it is certain that many show all the signs of overlactatiou much earlier than this. We must, then, look to the symptoms, and not to the time the patient has been suckling. In a considerable proportion of cases, the functions of the ovary cannot be suppressed beyond a few months, if at all. It is in vain that the attempt is made to keep ovulation, with its consequences — menstruation and pregnancy — in abeyance by taxing the breast. The ovary is the dominant organ, and sooner or later will assert its suprem- acy. Accordingly, we often find one of two things taking place in the course of lactation. First, menstruation returns, sometimes in a few months after labor, and generally within a year, except, indeed, phthisis or other exhausting disease intervene, or premature atrophy 414 OVERLACTATIOX. of the ovaries and uterus be induced ; or, secondly, unless a new preg- nancy occur. This may, or may not, be preceded by a menstrual ap- pearance. Some women " never see anything from one pregnancy to another." Whilst suckling, they fall pregnant, without exactly know- ing when. The position of a woman in this predicament is indeed trying. She is laboring to support three beings at the same time. She is goading into simultaneous work the breasts and the uterus, which ought to relieve each other. No wonder if, under this double outrage to nature, her own strength break down, and if the welfare of the child at the breast, and the existence of the embryo in the womb, be equally imperilled. Accordingly, we often observe that abortion occurs under these circumstances. This accident is the com- bined result of the degradation of the mother's blood, which becomes unfitted to carry on the nutrition of the embryo and of the structures which bring it into relation with the mother ; of the reflex irritation constantly starting from the breast, and promoting congestions and contractions in the womb ; and of displacement, such as prolapsus or retroversion and chronic metritis. The condition of the uterus after the exhaustion of overlactation is usuall}" characteristic. Its bulk is somewhat excessive; its canal is patulous, easily admitting the sound; the cavity of the body is a little dilated, so that its walls are not in apposition, as in the healthy uterus ; the appearance of the vaginal-portion is peculiar: its aspect is pallid, partaking of the general anaemia, its lips are swollen out in lobes sepa- rated by the scars resulting from the slight rents which were produced during labor; to the feel and sight the tumid os is flabby, soft, as if oedematous; all round the os, and some way inside the cervical cavity, the epithelium is often abraded ; tenacious viscous mucus fills the canal ; the sound always causes a little oozing of blood; and metrorrhagia is usual. Such is a common condition. Sometimes there is great con- gestion and appearance of vascularity. The abraded portions present little granulating elevations, secreting a semi-opaque mucus. The mar- gin of the abrasion is well defined; Avhere the structure retains its epi- thelium investment the color is bluish or purple. This color becomes much deeper if pregnancy has supervened. Although ready to sink from physical exhaustion, the mother still clings to the burden which is dragging her to the ground. It often requires the most decisive authority the physician can exert to_ induce these poor women to give up the unequal struggle. The most effective argument often is to point to the child, which is generally pale, thin, deficient in the firmness of healthy nutrition. We may thus more easily persuade the mother to give up a course which, whilst surely sapping her own health, is doing her child no good. To wean, then, is generally the first injunction. The other indica- tions are to restore the general health, to improve nutrition, to bring back the proper proportion of red-globules to the blood, and at the same time to cure the local disease. In these cases quinine and iron are of inestimable value ; strychnine is of scarcely less. They almost take rank as food. The doses should not be large, especially at first. One, or at most two, grains of quinine OVERLACTATION. 415 two or three times a daj^, and one-thirtieth of a grain of strychnine is enough. More will not be tolerated if the exhaustion is great. Qui- nine has a special beneficial action beyond that as a general tonic. It has a distinct property in causing contraction of the uterine fibre. In this way it promotes involution, the diminution of congestion, and the tendency to metrorrhagia. To produce this action, larger doses are useful. Strychnine possesses a similar property in a marked degree. That the diet should be as generous as can be digested, it is needless to sav. Alcohol should form a moderate, strictly limited ingredient. The light wines of France, the Khine, and Hungary are the best stimu- lants and aids to digestion. But where it can be digested, good stout or ale to the extent of a pint or two pints daily is to be preferred. Cod- liver oil is often of great use. Under this regimen, the blood is speedily enriched in quality, and the eifect is seen in returning strength, in im- proved nutrition, and more vigorous performance of all the functions. We shall thus have gained one necessary condition for the repair of local mischief Without this improved constitutional power, mere local treatment would probably fail. The local treatment required is generally simple. One condition is rest. This is partly attained by keeping the prolapsed uterus at its proper level by means of a Hodge's pessary. This brings singular aid also by relieving the local hypersemia, by facilitating the return of blood from the uterus. Once every four or five days the abraded sur- face of the vaginal-portion and the interior surface of the cervix uteri should be lightly touched with solid nitrate of silver. Or a stick of three grains of sulphate of zinc may be introduced every third or fourth day into the cervix. A vaginal injection of oal^: bark, tannin, or sul- phate of zinc, or alum, should be used daily or even twice a day. The cold douche, if it can be borne without pain, is often useful. In sum- mer the cold hip-bath may be employed. Under this treatment the abraded surface will commonly heal over, the congestion disappearing, the bulk of the cervix becomes reduced, the tendency to prolapsus is lessened by this diminished weight of the organ, and by the recovered tonicity of the vagina and other uterine supports. If at this time, when all active inflammation has ceased, any marked degree of enlargement of the vaginal-portion and bearing down remain, we find a useful remedy in the potassa cum calce or Vienna paste. This should be rubbed gently across the most enlarged lip of the OS uteri, so as to produce a small eschar. This sets up a moderate degree of local irritation which stimulates to healthy granu- lation, and excites absorption. The raw surface will cicatrize within a week or ten days, and the bulk of the vaginal-portion will commonly be reduced. This treatment, although limited to the vaginal-portion and the canal of the cervix, exerts a beneficial action upon the enlarged body of the uterus. It is certain that the congested, inflamed state of the vaginal- portion keeps up a similar condition of the whole organ ; and it is also a matter of experience that remedies applied to the vaginal-portion act not only by removing the irritation of contiguous disease, but also by derivation. The eschar, for example, set up by potassa cum calce upon 416 INFLAMMATION OF THE BREASTS. the OS uteri, acts by derivation upon the body as a bh'ster does upon internal organs. To set invohition going, when the case is acute, Simpson recommends local antiphlogistics. This treatment is especially indicated where any trace of inflammation remains. ■ But in cases where all inflammatory action seems to have died out, he says, a local antiphlogistic course has the effect of setting up absorption in the enlarged organ. If the patient is not very weak, he advises the application of a dozen leeches to the vaginal-portion of the uterus or to the perineum. In these more acute cases, and in all the more chronic cases, he in- sisted on the use of counter-irritants. Antimonial or croton ointments, or the cantharides blister applied to the hypogastric region, or painting this region with tincture of iodine until it produced vesication, were amongst his remedies. At the same time he kept the vaginal-portion of the cervix uteri immersed in ointments of mercury or iodide of lead, or bromide of potassium introduced as vaginal pessaries. As internal remedies he relied upon iodide and bromide of potassium. Scanzoni recommends the introduction into the vagina every night of a sponge saturated with a solution of iodide of potassium in glycerin, in the proportion of one in eight, or of an ointment consisting of five grains of iodo-chloride of mercury in an ounce of lard. I have found the iodine and glycerin decidedly useful. The patient may apply it herself by the aid of my speculum. (Fig. 46, p. 131.) Dr. Grustavus Murray recommends the use of the galvanic pessary. I have also seen reason to think favorably of the use of the bromo- iodic waters of the Woodhall Spa. One is frequently asked " How long will it take to get well ?" To this the physician can give no definite answer, unless all the conditions of cure be placed fairly within his control. Whilst the patient is pur- suing more or less actively her usual course of life, and the treatment is often interrupted, the disease may linger for any length of time. But take her into hospital, where all the necessary measures, negative and positive, hygienic and medical, are systematically carried out, and a cure within two or three months may with confidence be predicted. Closely associated with this subject is that of inflammatory engorge- ment and abscess of the breast. This condition is commonly the result of, and bears evidence to, constitutional debility, and unfitness of the breast for its function. It occurs at two distinct periods. The most common is at the onset of the attempt to suckle. The other period is after lactation has been kept up for some months. Strumous women, who are especially liable to glandular and connective-tissue engorge- ments, are particularly liable to early abscess of the breast. The con- stitution and the organ at once rebel. If the attempt to force them be persisted in, phlegmons and abscesses are sure to form. It is not within the scope of this work to discuss the physiology and pathology of preg- nancy and chiklbed. I refer to lactation only in reference to our pres- ent subject. Much as, both in the interest of mother and child, it is desirable to suckle, it is better, where the function is not likely to be successfully carried on, not to make the attempt. It is rare for abscess to form where no attempt to suckle has been made. The constitutional SUPEEINVOLUTION OF UTERUS. 417 conditions which contraindicate lactation are general debility, ansemia, a strumous diathesis ; the local conditions are, depressed, undeveloped, excoriated nipples, or evidence of phlegmons in the breasts. These conditions, and others, lead to retention of milk. The secreted milk. clogs the milk-ducts, and this condition leads to stasis, and inflamma- tion in the capillary network surrounding the acini. When it has been determined to abandon lactation, it is a common practice to apply bel- ladoinia to the breasts under the belief that this drug possesses the property of drying up the milk. I very much doubt its efficacy. I have more faith in the internal use of iodide of potassium. To check secretion. Dr. Altstadter extols conium, given in one or two-grain doses four or five times a day. The distinct indication is to avoid stimulat- ing or exciting the breasts. If it be desired not to promote the secre- tion of milk, the breasts should be kept in perfect rest. It is in carry- ing out this indication that the physician will experience the greatest difficulty. It is a conviction rooted in the minds of nurses with all the tenacity of prejudice, that friction, and that not always gentle, and " drawing the breasts," are necessary. This inflillibly keeps up irrita- tion. Engorgement and inflammation are too apt to follow. One con- dition of rest is repose in bed, another is gently supporting the breasts, so as to obviate any tendency to hanging down ; they should be kept well lifted up from below and from the sides ; the easy return of the blood from them thus diminishes the risk of stagnation ; another way to promote rest is to use the arms as little as possible. If there be any engorgement, it is well to keep the arm of the affected side in a sling. Cooling lotions, as of acetate of ammonia and alcohol, are useful. It is only when there is great tension, that the overflow should be gently abstracted by a breast-pump, or, better still, by the soda-water bottle heated by hot water and then applied empty, so as to draw by vacuum. This is far safer in the hands of an ordinary nurse than the breast-pump. Saline purgatives, and moderate unstimulating diet, especially postpon- ing the conventional stout, are essential adjuncts. When mammary abscess occurs after lactation has been carried on for several months, this is almost certainly because the system has been so reduced that it is no longer fit to keep up the function. Simpson described (Med. Times and Gaz., 1861) sujjerinvolution of the uterus as a morbid state the opposite of subhwolutlon. It is pro- duced when the disintegrating process set up after delivery goes on to such an excessive degree as to reduce the uterus to a size decidedly be- low its normal dimensions in the unimpregnated state. He relates a case of a woman aged 20, who liever menstruated after her first labor. Two years after labor she was admitted to the Edinburgh Infirmary. There was amenorrhoea, great constitutional disturbance, frequent at- tacks of diarrhoea, which she believed to be most severe at recurring monthly intervals, the dejections being sometimes tinged with blood. The mammse were shrunk and flat. The uterus was small ; its cervix much atrophied, OS contracted. Sound penetrated 1.5''. Albuminuria and dropsy preceded death. The uterus was one-third below the natu- ral bulk ; the ovaries were atrophied, showing no Graafian vesicles. 27 418 IKJUEY TO CERVIX UTERI. Sometimes atresia from cicatricial closure of the uterus is followed . by a true amenorrhoea — not simply retention. Dr. Liz6 reports such a case in the "Union Medicale," 1863. The uterus seems to become atrophied from obstruction to the performance of its functions. In various parts of this work, this process of hyperinvolution is referred to. I believe it is far from uncommon. Sometimes, as in the ease quoted from Mr. Walter Whitehead (see p. 402), it may go to the extent of removing the uterus altogether. I have encountered it sometimes with partial success by the use of Simpson's galvanic pessary. Results of Injury to Cervix Uteri during Labor. If Ave pursue the clinical, and, in this instance, the historical order, in the study of the most common morbid conditions of the uterus, we shall find succeeding the first stage of tumefaction, ecchymosis, and congestion of the mucous and submucous tissues of the cervix, and the sliedding of the bruised epithelium, the following condition : The whole cervix, especially the vaginal-portion, is sensibly enlarged, tumid, gorged with blood, oedematous ; for a definite area around the OS, tlie part is bared of epithelium, giving a pulpy granulating appear- ance to the part; this part is further divided into lobes or prominences, the result of the small lacerations which took place during the passage of the child ; this bared part is red, angry-looking from the villi being full of blood, bathed with viscid and purulent-looking secretion; the part of the vaginal-portion, beyond the line of epithelial denudation, looks bluish-red, owing to the gorged bloodvessels being seen through the epithelial investment. The vaginal-portion in this state easily bleeds under examination, under coitus, and under any exertion or emo- tion. Leucorrhoea is generally copious. Lumbar pain is constant. General prostration certainly attends. Some degree of prolapsus is rarely absent. A similar state exists throughout the cervical canal. The rugae are prominent, bared at least in part. The surface is bathed in viscid, clear, or turbid mucus. The canal is more patulous than usual. In- tensely vascular, and the vessels badly pi'otected by delicate new epi- thelium, which is being shed as fast as formed, the intra-cervical sur- face easily bleeds, so that metrorrhagia is common. All this can be easily seen through the metroscope, or even in part through the bivalved speculum, whose blades, made to diverge, open the os ex- ternum. Some of these objective conditions are fairly illustrated in Fig. 94, drawn from nature from a case observed about a month after labor. This drawing shows also the enlarged relaxed state of the fundus of the vagina which attends this stage of the afPection. The microscopical condition of such a case is represented in Fig. 95, which should be compared with Fig. 24, p. 52, which shows the villi bared of epithelium by maceration. By some this condition is called "inflammation;" and the state of the OS uteri, bared of epithelium, is called " ulceration." In some ULCERATION .r " 419 cases, undoubtedly, inflammation intervenes; and the question of ulcer- ation is one of doctrine. What is ulceration? If Ave consult the most recent authorities for an explanation, we find Simon (Holmes's "System of Surgery ") defining ulceration as a destructive process of inflamma- SIiows condition often observed a month after labor. Congestion of vaginal-portion. Epithelial denudation around the os (From nature. E. B.) tion: " It is the process by which holes are made through the surface- textures of the body (cutaneous, mucous, articular, or serous), and hence perhaps into deeper parts; a process which differs from gangrene mainly in the fact that it proceeds more gradually and molecularly. At the place where an ulcer exists, the absent texture perished as truly as by gangrene ; but while gangrene would have occasioned its abrupt separation in mass, ulceration permitted its progressively shedding as detritus. The discharge from any spreading ulcer, if examined under the microscope, invariably exhibits particles of disintegrating tissue; and the so-called foulness is but gangrene on a smaller scale." Macleod (Cooper's "Surg, Diet.," 1872) gives a similar explanation. He says, "Ulceration is a result of inflammation, and consists in the molecular death and removal by minute disintegration and solution of the superficial vascular particles of the inflamed part. There is a mi- nute atomic division of the particles of the affected tissue, and these 420 ULCEEATION. molecules are removed in the ' ichor ' or discharge which escapes from the surface of the sore or ' ulcer ' which forms. The terms desquama- tion^ or excoriation, or abrasion, are applied to the removal of epithe- FiG, 95. (After Hassall and Tyler Smith.) Showing loss of epithelium, leaving villi of os uteri bare, and partially eroded. lium alone, while ulceration implies a deeper penetration of the de- structive action." If we next examine Avhat is meant by inflammation, we find Simon givino; the following account of what takes place in this process : " The capillaries allow fluid to sweat through their coats from the liquor sanguinis to the tissues. In this way they minister to growth. If the membrane be ruptured or dissolved, normal transudation is at an end, and capillary hemorrhage takes place. " The arteries are more relaxed, carry a profusion of blood. The veins carry more blood than usual ; but not all that the arteries carry into the tissues : something is left behind in the tissues." Now, in the typical case before described, is there not greater relax- ation of the arteries ? do they not visibly carry more blood ? do not the veins carry more blood ? and is there not something left behind in the tissues ? It is impossible not to answer all these questions in the affirmative. And so of ulceration : is there not gradual shedding of tissue as detritus ? does not the discharge exhibit particles of disinte- grating tissue ? is there not a hole through the mucous surface-texture ? Or is this breach of surface the result of gangrene? According to the historical and clinical points of view from which I have regarded the condition, it appears to be a combination of the two processes of gan- grene and ulceration. The first step is traumatic ; the mucous mem- brane is really killed by the bruising it underwent, and the partial severance from the deeper textures upon which it grew. Hence it is "ulceration." 421 cast oif by a process which cannot be distinguished from gangrene. It is remarkable that the area of epithelial denudation is almost always strictly limited. There is a more or less indented irregular line of demarcation Avhere the epithelium stops abruptly at a distance of about half an inch from the centre of the os uteri. This line represents accurately the extent of the mucous surface which fell under the crushing of the passage of the head. The fissures seldom or never go beyond this line. iSTor does the area of denudation tend to spread beyond it. In this respect the case differs from that of surface-ulceration. If there be ulceration it must be by destruction of tissue within this circumscribed area; that is, in depth. Of such action, however, there is usually very little. Prob- ably the eroded appearance of the bared villi accurately, as I know it is, represented in Hassall's drawing (Fig. 95) is also due, like the cast- ing of the mucous surface, to traumatism and necrosis. I do not think that the destructive process is commonly progressive in depth any more than it is in superficies. The process is essentially and truly one of re- pair ; often, indeed, arrested by the excess of congestion of the part and by the general blood-degradation of the system. But still it is a rare event for this process of arrested repair to pass into the 0]>posite condi- tion of extending destruction. The hypothesis of ulceration has been favored by the aspect of the denuded part, which strikingly simulates that of a granulating ulcer on the skin. But the observations and figures of Dr. Hassall, in Tyler's Smith's " Memoir on Leucorrhoea," conclusively show that the apparent granulations are really the project- ing villi jutting out irregularly on the surface, having lost the protecting epithelium which bound down smoothly all surface inequality. After all, it may be said, this is a dispute about words. A condition which so closely corresponds to the classical definition of ulceration may fairly be called ulceration. This might be conceded, were it not that the common, vulgar as well as professional, conception of ulcera- tion embraced the idea of a spreading, eroding action ; and that thus the word bears a more formidable significance to the patient than the reality justifies. Now, we all know that the morbid surface is not so aflFected. There is a bared, secreting, easily bleeding surface trying to heal. It is often slow to heal. It may take weeks and months to recover its normal investment of epithelium ; but during all this time ulceration cannot be said to go on, otherwise than in the most languid imperceptible form. But another process is certainly going on. This is exudation. The gorged vessels, through which their contents are only imperfectly pro- pelled, leave something behind in the tissues. " Exudations," says Druitt (Article "Inflammation," Cooper's "Surgical Dictionary," edi- tion 1872) "cannot remain dormant. They rapidly undergo changes either in the way of development or degeneration." In this case the tendency is towards development. This means hyperplasia and hyper- trophy. The connective tissue, or fibrous tissue of the cervix especially, becomes increased in quantity ; the cervix becomes after a time denser; it elongates. This latter part of the process, the conversion of exuda- 422 ULCERATION. tion into permanent tissue, may be averted by subduing the vascular engorgement, and healing the denuded surface. The treatment of this condition has been described in the preceding chapter. It consists essentially in " rest," tonics, good diet, and local astring^ents. Epithelial abrasion after labor. Tendency to hypertrophy. (Ad. nat.) If a cure be not effected at this stage, the case will often become more obstinate. The natural tendency to heal can hardly be trusted to if the powers of the system are sensibly reduced. If there be evi- dent anaemia and attendant impairment of nutrition, repair cannot be expected to proceed in a part exposed to constant disturbances, and peri- odical fluxes of blood. Generally, the vaginal-portion loses in bulk ; some degree of contraction takes place, owing to the absorption of the fluid element of the exuded material, and the condensation of the plastic element ensuing upon its conversion into fibrous tissues. The abraded area looks smaller, and, in fact, is smaller, but this is often not so much the result of acutal healing, as of the general contraction of the vaginal- portion. There is still a free secretion of mucus, viscid, coming from the cervical cavity. There is still more or less vascular engorgement, and some infiltration of tissue, with recent exudation. The denuded area looks red, granular, like a strawberry or raspberry. The vagina is still relaxed, and some degree of epithelial shedding goes on from its mucous membrane. The lumbar and dorsal pains persist. There is often pain in the seat of one or other ovary, generally as Bennet says, in the left. The treatment is still the same as for the earlier stage. The denuded surface should be lightly touched every five or six days with nitrate of silver, and the like application should be made to the interior of the cervical canal. If this cause much pain or bleeding, the solid sulphate of zinc should be substituted. Vaginal lotions of zinc, alum, bark, or tannin should be used daily. If there be any prolapsus, a Hodge pessary will be of essential service in maintaining '' rest," and diminishing the local engorgement. Under this treatment, the denuded surface will often get covered in in a few weeks, and the excessive vascularity will be reduced. But exudation has taken place; and exudation has been followed by new FLUXION. 423 growth. This hypertrophy, even altliough not attended by much in- crease of bulk, so as to induce prohipsus, or dragging, or pressure upon surrounding organs, is ahnost always attended by irritation, which keeps up increased attraction of blood, hypertrophy of the elands, and free leucorrhoea. Pain continues to wear the nervous ... centres. Healthy nutrition is prevented. At this stage, the application of potassa cum calce or the actual cautery to one or the other lip of the os uteri will often exert the most beneficial influence. The mode of applying these agents will be de- scribed under the treatment of chronic metritis. The further history of hypertrophy, or fibroid degeneration of the cervix uteri, will be traced in connection with that of prolapsus. CHAPTER XXXIX. CONDITIONS MAKKED BY ALTERED VASCULAKITY OR BLOOD- SUPPLY: FLUXION; HYPEREMIA; CONGESTION; INFLAMMATION. The vascular system of the genital organs and the proportion of blood supplied may be in excess or deficiency. The conditions characterized by excess may be distinguished as — 1. Fluxion or simple determination of blood. 2. Hyperoemia. 3. Con- gestion or Engorgement. 4. Inflammation. The conditions character- ized by deficiency are summed up in Anaemia. Whilst fluxion, hypersemia, or congestion may each stop short, in- flammation implies the previous existence of fluxion and congestion. It may be regarded as the climax of the first three conditions. 1. Fluxion in its simplest form may be defined as a transitory flow of blood to the parts. One example of it may be compared to the rush observed in the cheeks under the emotions of shame or anger. The uterus and ovaries are certainly subject to similar determinations of blood under the influence of various emotions, as the sexual passion, and of reflex irritation, as that produced by the child sucking at the breast. This fluxion is of course perfectly physiological ; and, if oc- curring in healthy organs, entails no ill eifects, unless it be artificially and inordinately stimulated. An example of simple fluxion is the physiological determination of blood excited by ovulation at the menstrual periods. 424 FLUXION. The vascular fulness determined by the developmental attraction of pregnancy may be regarded as an example of fluxion. Analogous to this is the fulness dependent upon the abnormal developmental attrac- tion produced by the growth in the uterus of fibroid tumors. One diiference which exists in the two cases, is that in the first, the fluxion is more uniformly persistent, less disturbed by the periodical molimen of ovulation ; it is a steadily maintained active hypersemia. In the second, the persistent hypersemia induced by the developmental stimu- lus is further liable to the periodical molimen of ovulation. Hence the tendency, where fibroid tumors, polypi, or cancer exist, to metror- rhagia. Fluxion has its pathological as well as its physiological significance. Using the term in this relation, it takes the place of those states com- monly described as " active hypersemia," and " active congestion." As Billroth observes,^ the vessels dilate or suffer themselves to be dis- tended, under the influence of some irritation, and then quickly dis- gorge themselves when the irritation has ceased. It may be difficult to discover the true cause, but it is generally easy to observe the phe- nomenon. The exafffferated afflux of blood is the reaction or the response of a vascularized jaart excited to irritation : " ubi stimuhis ibi Jluxus." If the ovaries and uterus be in an abnormal condition, whether from congestion, inflammation, displacement, from being the seat of new formations, their liability to fluxes is increased. The diseased organs will commonly be even more susceptible than the healthy to irritations which provoke the afflux of blood. If the uterus be imperfectly involved after pregnancy, or engorged, or its tissues relaxed from other causes, this fluxion, otherwise harm- less, may give rise to hemorrhages. And it is probable that the hem- orrhages so arising act in some cases as an evacuant, saving the uterus from passing into congestion or inflammation. Fluxion, then, may occur in healthy organs, and in diseased organs. Therefore, when studying the pathology of the ovaries and uterus, we must bear in mind not only their actual or essential morbid conditions, but also the influence, beneficial or injurious, of accesses of fluxion to which they are liable. These fluxions, in fact, form a most important element in the history of uterine and ovarian diseases. They are the immediate occasion of some of the most distressing and dangerous phe- nomena. By being prepared for them, by moderating their intensity, or by preventing their recurrence, we shall often accomplish the most useful therapeutical results. It may be doubted whether simple physiological fluxion, howsoever frequently repeated, will often produce inflammation of the uterus, ovaries, or their investing peritoneum. It is true that peritonitis and oophoritis are common in prostitutes, and that these events are attribut- able to sexual excesses. But it is certain that in many of these cases the determining cause has been the propagation of gonorrhoeal inflam- mation, or exposure to cold or other form of violence. 1 " Elements dc Pathologie Chirurgioale Generale," 1868. FLUXION. 425 The chief symptoms of simple fluxion are subjective. The patient feels a sensation of local heat and fulness, depending upon the turgidity of the organs affected, and the tension of the j^lexuses and erectile por- tions of the vascular system. The fluxion may subside as quickly as it arose; and it mostly leaves the organs exactly in their previous condition, unless they were dis- eased ; in which case the fluxion, especially if often repeated, may pro- dace injurious consequences. Should varicose veins exist in the legs, thighs, or groins, the effect of fluxion is seen in a marked manner at the menstrual periods. The veins visibly swell, become tumid, deeper colored ; and the patient is conscious of the increased turgidity. When fluxion occurs in morbid structures, the symptoms are com- monly more severe. Pain is more marked ; the sense of fulness, of weight, is more oppressive ; dragging pain is felt in the loins and groins ; and often, sharp colic spasms in the stomach in the region of the umbilicus. In the more severe cases, and depending somewhat upon the kind and degree of the local morbid condition, the fluxion develops all the symptoms of congestion. The vascular fulness seeks relief in discharges ; these present themselves as hemorrhage, leucor- rhoeal or mucous discharges, and escape from the mucous membrane of the uterus, vagina, bladder, or rectum. These are sometimes accom- panied by dysenteric and dysuric pains. Certain general symptoms precede and attend the local phenomena. The premonitory signs may be defined as an exaggeration of those which mark the approach of the ordinary menstrual molimen. There is a state of tension marked by a chill or even by a rigor, by spasm, vague nervous phenomena, irritability or depression of temper, rest- lessness, perhaps hysteria. The attendant signs are the reactionary phenomena which reveal the participation of the organism in the distress of the uterus. There is an exasperation of the nervous erethism, circumscribed pains in certain parts, neuralgia, gastric disturbance, headaches ; and, lastly, when the fluxion is often repeated, or has continued an unusual time, there occur what seem to be blood-determinations to the heart and lungs. The objective dgns are : distension of the hypogastrium, increase of heat, and slight development of pain on pressure. The vagina is re- laxed, perhaps secreting mucus ; the uterus is increased in bulk, lower in the pelvis, and is tender to the touch. The variation of volume ob- served in the uterus is at times very great. For example, in a case of anteversion I have felt the uterus, at the time of the menstrual fluxion, assume twice its usual size, and return to its ordinary bulk as the fluxion subsided. The neck of the uterus feels softer, swollen. For the time the mucous membrane of the uterus and vagina is of a deep- red color. Courty describes a chronic fluxion. But it appears to me that the essence of the idea of fluxion is an active transitory flow. When the vascular tension of a part becomes permanent, there is either hyper- semia or congestion. The treatment of fluxion will, of course, be determined by the degree of the affection, and by the condition of the organs to which the flux- 426 FLUXION. ion is determined. Even the ordinary physiological fluxion of the menstrual period requires some management, for influences, otherwise harmless or even beneficial, may, as is well known, act at this time injuriously. The treatment consists in the observance of hygienic precautions, and these may be also summed up in the one word, " Rest." The treatment of fluxion in diseased organs resolves itself in part in the special treatment adapted to relieve the disease. But the fluxion itself demands special management. The periodical fluxions of men- struation we ought to be prepared for. " Kest " here is even more important than in the simple fluxion. But the irregular fluxions, pro- voked by accidental emotional and local irritations, cannot always be foreseen or guarded against. Familiarity with the idiosyncrasy and surroundings of the patient, however, will often enable us to avert some of these irritations. We have the indication of one natural mode of relief of fluxion in the hemorrhage of menstruation ; and of another in the quiet subsi- dence of the local vascular excitement. If the fluxion occur at a menstrual epoch it will be pretty sure to seek relief in hemorrhage by an exaggeration of the normal menstrual flow. It will rarely be neces- sary to take measures to excite or to increase the flow. It will more often be necessary to moderate it ; for it is one of the remarkable phe- nomena of hemorrhage that when once begun, fluxion is determined with increased force towards the organ whence blood finds a ready escape. The bleeding organ seems to acquire the faculty of attracting more blood from the aorta, only to pour it out of the system. The heart becomes excited, and acts with greater force and frequency. The chain of the circulation is broken. The blood escapes at the capillaries instead of being carried on to the veins ; and in some cases, perhaps many, there is reason to believe that the raptus towards the accidental outlet is so active that blood is even drawn towards it in a retrograde course from the veins. These phenomena are nowhere so well marked or so easily observed as in the hemorrhage of the gravid, puerperal and diseased uterus. The treatment of hemorrhage is considered else- where. Our only point here is how to manage the fluxion. There is one very effective agent in turning away the fluxion from the organ predestined to be its seat, which it is almost hopeless to recommend at the present time. The doctrine of revulsion teaches that we may divert the torrent of the circulation from an organ towards which irritation conducts it, by setting up an artificial fluxion to another part. This is most certainly effected by venesection. This principle of controlling the circulation was, perhaps is, in great repute on the Continent. I have frequently seen it most beneficially acted upon by Lisfranc. A small bleeding from the arm, timely practiced, may not only save a greater effusion, by turning aside the current from the morbid surface, but by lessening the vascular activity in the diseased organ, may check the progress of the disease. The condition of usefulness from bleeding depends upon the observ- ance of the principle of revulsion. The bleeding must be practiced at a distance from the organ we want to relieve. It need not be large in amount. A few ounces drawn from the arm by venesection or from HYPEREMIA. 427 the temples or nuclia by leeches, will commonly suffice. It should, however, be remembered that all fluxions are not alike benefited by this treatment. It is especially useful in young plethoric persons ; and when the fluxion is recent or only im2)ending. It is also useful in some cases of more languid fluxion in women laboring under hepatic difficulty, or heart disease disposing to retrograde portal obstruction. Another form of revulsive treatment, less powerful, and more likely to commend itself to current ideas, consists in causing derivation to the skin or intestinal canal. By epispastics, by blisters, or fomenta- tions, we can excite some degree of local afflux to a distant j)art of the body. By purgatives we can cause a derivation to the intestines, and take off some degree of vascular tension, by exciting the flow of the watery ingredients of the blood. A revulsive recommended by Hippocrates, is the application of dry- cupping to the breasts. The illustrious father of medicine well knew the sympathy which existed between the breasts and the ovaries and uterus. This idea has in recent times been applied by the Germans, and the late Dr. Rigby, to excite the uterus to contract after labor, and by Scanzoni, who sought to provoke labor by thus stimulating the breasts. Courty speaks highly of the efficacy of dry-cupping the breasts to obtain the revulsive effect we are discussing. I am able to give a qualified approval to the practice of Rigby. That of Scanzoni has been condemned by the results of observation. The irritation of the breasts, whilst not always fulfilling the purposes in view, not sel- dom caused inflammation and abscess. I should fear similar accidents from Courty's practice, especially as he insists that the method, to be useful, must be kept up for several hours, even days. It is further open to the objection that irritation of the breasts is likely to excite fluxion to the uterus, and thus to cause the very accident it is sought to avert. Again, it is not desirable, for obvious reasons, to irritate the breasts in young women. Certain medicines possess the valuable property of allaying and reg- ulating vascular excitation. Of these the most useful are tlie acetate of ammonia, nitrate of potash, tartarated antimony, aconite, digitalis. A very useful formula is — I^. Liquoris ammonise acetatis, 5iij ; ni- tratis potassffi, gr. xv ; vini antimonialis, 5j ; infusi digitalis, 5ij ; aquae, .5j- M. This dose may be taken every three or four hours. It determines to the skin and intestinal canal ; it may possibly provoke nausea or vomiting, but this has a powerful influence in checking hemor- rhage. 2. Hypercemia must, I think, be distinguished from fluxion on the one hand, and from congestion on the other. It is a continuous or chronic fulness of the vessels of a ])art which does not necessarily imply morbid action in that part, but which at most leads to languid, passive, changes. Hypersemia occurs especially in connection with excessive menstrual congestion ; the uterus is full of blood, dark-red, swollen, softened ; the mucous membrane is injected, red, swollen, with a spongy flocculent aspect from the development of its uterine-tubular glands, softened and bleeding. 428 CONGESTION OF UTEEUS. The development of the uterine glands is at times quite extraordi- nary. Rokitansky saw in the body of a girl, who died in course of typhus whilst menstruating, the raucous membrane, especially on the posterior uterine wall, dark-red, and converted into a thick stratum of villous-looking folds packed together, in which the uterine glands were elongated to Q" or more. I have specimens of dysmenorrhoeal decidua showing the same thing. In the course of typhus, cholera-typhoid, the exanthemata, scurvy, ypersemia of the uterine mucous membrane occurs. The uterus becomes hypersemic and swollen when the pelvic system of veins is overloaded, and especially when flexions or displacements of the organ exist. In the latter cases, the hypersemia is most marked in the anterior or posterior wall. New formations cause and keep up hypersemia, sometimes more marked in the uterine substance, sometimes in the mucous membrane. It also occurs in heart disease, in obstructions to the return of blood through the vena cava. Often, it principally aifects the lower segment of the cervix and the vaginal-portion. Persisting hypersemia leads to persistent secretion of mucus, and to hypertrophy of the uterus, commonly of the eccentric form ; to hyper- trophy of the vaginal-portion, Avith predominance of the connective tissue ; and thence to induration, the so-called infarctus. Hyperasmia disposes to oedema of the tissues and to hemorrhage. The hemorrhage takes place from the mucous membrane into the uterine cavity as the expression of the hyperemia. The outpoured blood flows away, or sometimes, even without marked obstruction of the canal, forms clots, or one, which compressed takes the form of the uterine cavity. There is often a chronic pelvic hypersemia in aged women, leading to hemorrhage. The hypersemia is mostly due to portal obstruction and to the general vascular want of tone arising from obesity and want of exercise. This state may induce softening, fragility of the uterine substance, and fragility of its vessels. Its seat is the fundus, and especially, almost exclusively, says Roki- tansky, the posterior wall. The soft uterine substance looks black- red, infiltrated with blood so as not to be recognizable, and blood is seen in variable quantity in the tissues when section or rent is made. The mucous membrane is commonly in the same condition ; and often blood is found in the uterine cavity (the apoplexia uteri of Cruveil- hier). If the vaginal-portion be examined by the speculum it is seen to be swollen, dark-red, and the whole vagina commonly exhibits the same appearance. There is a sense of weight and heat ; often some degree of prolapsus ; and also a troublesome form of pruritus. Considerable improvement sometimes follows a spontaneous hemor- rhage ; and hyperemia being essentially a passive condition due to su- perior obstruction, a few leeches applied to the os uteri will occasionally be serviceable. But our chief effort should be directed to correcting the condition of the central organs of circulation and digestion, to re- storing the general health, and to removing any uterine complication. 3. Congestion or engorgement of the uterus and ovaries. This con- CONGESTION OF UTERUS. 429 dition implies a moi'e prolonged fulness of the vessels than mere fluxion ; it rarely exists without some amount of retardation of the blood in the vessels, that is, hypereemia ; and this retardation almost certainly en- tails more or less effusion of the serous or aqueous elements of the blood into the tissues of the organs affected. This implies swelling or tume- faction. Once set up, this condition is extremely liable to persist. The frequently dependent position of the organs favors the accumula- tion of blood in them, whilst their liability to fluxes, under the influ- ences already mentioned, is a constant source of aggravation and imped- iment to cure. Congestion may arise from many causes. If the organs are caught whilst under the influence of physiological fluxion by constitutional shock, by exposure to cold, or protracted fatigue, fluxion may pass into congestion. Congestion of the uterus very frequently takes its rise in the state of imperfect contraction and involution following pregnancy and labor. The relaxed tissues -and dilated vessels form a ready receptacle for the blood, and the want of tone and contractility obviously favors its reten- tion. Whatever the cause of congestion, it is soon aggravated by displace- ment of the womb. Implying, as congestion does, increased bulk and weight, and attended, as it almost necessarily is, by relaxation of the structures which ought to support the womb, this organ almost invari- ably sinks lower in the pelvis, or its body falls backwards or forwards. On the other hand, an abnormal position of the womb may predis- pose to congestion. Retroflexion or anteflexion may be primary. Under the repeated rushes of ovulation, of sexual relations and other causes, congestion is brought about by the obstruction which the dis- placement interposes to the return of blood. The effect of displacement is almost surely to add to the congestion. Take, for example, the case of ante version or retroversion. The body of the uterus rolled over on its transverse axis in the broad ligaments, twists, distorts, and compresses the vessels at the point of entry and exit. Blood still enters the uterus by virtue of the propelling vis a terc/o through the arteries ; but the veins, thin-walled, flaccid and valveless, rendered tortuous and compressed, afford but a difficult return. This state gives rise to what French authors distinguish as engorgement, but which it seems more convenient to describe as a phase or consequence of congestion. It is difficult to imagine that pure congestion can long exist without giving rise to the infiltration of tissue which constitutes engorgement. Uterine congestion complicates, or plays an important part in, a large proportion of cases of uterine disease. It constitutes one of the most serious obstacles to their cure. It tends, by its very conditions, to per- petuate itself. It exhibits little or no tendency towards spontaneous recovery. The organ in which it occurs is rendered permanently larger, its tissues are infiltrated with serum or semi-plastic extravasa- tions, its contractile force, the tonicity of its vessels are impaired ; the blood brought to the uterus, either by the ordinary distribution or by intermittent fluxions, is delayed ; a kind of hsemostasis is induced ; 430 CONGESTION OF UTERUS. and these conditions are aggravated by time, by the increasing mechani- cal impediment to the course of the pelvic circulation, which displace- ment of the uterus in relation to the broad ligaments induces. Uterine congestion may be primary, and for an indefinite time con- stitute the chief morbid condition. As, however, we have had fre- quent occasions to observe, it rarely exists long without inducing dis- placement, as prolapsus of the uterus; and sooner or later, it is likely to lead to other evils, as hypertrophy and inflammation. It may be secondary upon other conditions. There is one which in my experience almost infallibly induces congestion. That is the fixing of the womb ; whether this be from perimetric adhesions, from com- pression of tumors, from pressure against the symphysis pubis by retro- uterine hffimatocele, or other cause. The symptoms of congestion are essentially the same as those which mark the combination of fluxion and hyperBemia; the diagnostic test being the persistence of the symptoms, and the accidental intermittent character of the fluxions which may or may not complicate this con- gestion. There is also more pain than in bypersemia. The enlarged uterus, by its proximity to the bladder and rectum, irritates these organs, keeps up hypersemia or congestion in the surrounding pelvic tissues. The reflex excitation, or the proximate irritation, causes fre- quent desire to void urine, and dysuria ; the same causes induce dys- chezia, tenesmus, straining, at times diarrhoea. Expulsive efforts are caused, at first involuntary, afterwards perhaps intensified by the semi- involuntary bearing-down excited by the sensation that there is some- thing to be expelled. The contraction of the abdominal walls, as in the act of defecation, of sneezing, of coughing, is attended by indirect pelvic pain, more or less acute. A frequent consequence of congestion is dysmenorrhoea. This symp- tom, when not accounted for by obstruction from stenosis or angu- lation of the uterine canal, is, I believe, most commonly due to the accumulation of blood in the uterine cavity, its coagulation there, and retention, which is favored by the quantity poured out. It has time to clot, partly because its quantity is in excess of the mucus which helps to keep it fluid, and partly because it is allowed to rest by the uterus, whose power of contraction is enfeebled by the congestion. Retention means irritation, and irritation means uterine colic, that is, dysmenorrhoea. This symptom is the more certain to follow in pro- portion to the degree of displacement of the uterus. The difficulty which congestion occasions to the uterus in the per- formance of its functions becomes a source of aggravation of the con- gestion. It not uncommonly happens that the menstrual function is disordered in its periodicity, as well as in its other characters. The patient often becomes irregular, sometimes she even loses the reckoning so as no longer to know when her periods are due. The menstrual flow is merged in hemorrhage. It may last for a week or a fortnight, leaving a fortnight or three weeks interval only ; or a flow of blood, which it becomes difficult to distinguish as menstrual, appears at irregular intervals. Not seldom, however, the menstrual discharge CONGESTION OF UTERUS. 431 becomes scanty, or ceases to be noted otherwise than doubtfully in the shape of irregular discharges of blood. Leucorrhoea is an almost constant effect of congestion ; the gorged vessels of the uterus seek relief by secretion of mucus ; and Rokitan- sky has shown that the glands, under hypersemia and congestion, undergo enormous development. The local signs are the increased bulk and weight of the organ, in- volving diminished mobility, and more or less displacement expressed by prolapsus, anteversion, or retroversion, and sometimes flexion. By the speculum the vaginal-portion is seen swollen, deep red. The vagi- nal-portion and cervical cavity easily bleed on examination by touch, speculum, or sound. Congestion is often more or less limited to the vaginal-portion when there is stenosis of the os uteri externum. This condition is discussed under the head of " Dysmenorrhoea." Congestion of the vaginal- portion also occurs in prolapse with hypertrophy of the vaginal-portion. In this condition the vaginal-portion is liable to get constricted by the circular compression of the vagina, and between the bowel and bladder. This constriction retards the circulation in the lowest part of the vagi- nal-portion, makes it tumid, and increases the disposition to liyper- trophy. This is exemplified in a figure from a preparation in King's College Museum. (See Prolapsus : hypertrophy.) Congestion may affect the whole uterus ; or it may affect the body or the cervix only. In all cases the congestion bears most obviously on the mucous membrane. The treatment of congestion and engorgement must be determined greatly, in most instances primarily, by the indications for the removal of the complicating conditions. Thus, attending prolapsus, version, or flexion, demands special care. The displacement corrected, the as- sociated congestion will almost certainly be relieved, if not removed. The management of the complications is described where they are treated of as primary or essential disorders. It is necessary to remember that congestion or engorgement of the uterus is curable, whilst old-standing hypertrophy is not. Again, many women who have passed the climacteric, scarcely need to be treated for .congestion. This condition, when existing, is no longer so liable to exacerbation by fluxions; it becomes more passive; the pain subsides ; and tolerance is acquired. But, on the other hand, youth is favorable to cure ; the activity of the circulation and of all the functions facilitates the absorption of effused matters; and the very functions of the uterus, as menstruation and pregnancy, by virtue of the retrograde involution which seizes upon the uterus when these functions are completed, may involve the morbid hyperplastic struc- tures, and thus dissolve them. A remarkable example of this process is seen in the occasional diminution or even disappearance of fibroid tumors after labor. The question of local depletion when there is congestion is important. Its action is powerful, and resort to it requires discretion both as to the selection of the cases and the method to be employed. If the con- gestion is liable to periodical aggravation, especially if attended by 432 LEECHING. hemorrhages, from menstrual fluxion, the principle of derivation and revulsion already discussed, should be invoked. Where the congestion is accompanied by intense pain and sense of weight, the bulk of the uterus being sensibly increased, benefit will sometimes be derived from local depletion. This may be practiced either by leeching or scarifi- cation. Leeching has been extensively employed in the treatment of uterine disease ; and if one may be permitted to judge from the obser- vation of cases where it has failed to do good, or has done harm, under the advice of other practitioners, I should say that it is employed much too often. The effect of the suction of leeches on the lower seg- ment of the uterus is often to attract blood to the pelvic organs. The free anastomoses of the branches of the internal iliac, the numerous plexiform structures, the numerous valveless veins constitute a peculiar formation unfavorable to local bleeding by exhaustion. The vascular system of the pelvis has been likened, not inaptly, to a sponge. Draw blood from any one part, and it is immediately replaced by a new sup- ply ; the vessels can hardly be emptied ; you may attract any quantity of blood through this channel, producing marked systemic effect, but the local engorgement may be little diminished. That this is often the effect of leeching the os uteri and upper part of the vagina I am very confident ; and, therefore, I now resort to this practice with very great circumspection. The method of scarification is not open to the same objection, at -least not to nearly the same extent. Superficial scratches or incisions made on the vaginal-portion will give vent to the blood gorging the part operated upon, without entailing a fresh fluxion to the organ. The most marked benefit from incisions in the vaginal-portion, is often seen when the os externum is divided on account of stenosis and dys- menorrhoea. In this condition the mucous membrane is often intensely gorged ; and when cut, it is left pale and less swollen by the very moderate loss of blood which attends the operation. The mode of applying leeches to the cervix uteri is to introduce a Fergusson's or other tubular speculum, bringing the cervix well into the field ; wipe off any secretion with a bit of cotton-wool or sponge ; then put the leeches, three or four in number, into the speculum, and push them down upon the cervix by a pledget of cotton-M^ool. The operation is often troublesome, and this is another objection to it. The leeches at times refuse to bite, and worm their way out most insidi- ously between the wool plug and the speculum, and easily escape alto- gether unless carefully watched. One leech at a time may be more conveniently applied by means of a long glass tube open at the uterine end, and provided with a piston to push the leech onwards. In London there are several nurses who take charge of this little operation for a moderate fee. Scarification is to be preferred to leeching for the reason assigned, and also because it is more convenient to carry out. The operation is performed through a speculum. The most suitable specula are Sims's, Neugebauer's, or Cusco's. These have the advantage of bringing the OS uteri nearer to the outlet, of exposing it more freely and under greater tension, than the tubular speculum. Almost any bistoury long METRITIS. 433 enough, may be used, but it is most convenient to employ such a scari- ficator as that designed by Dr. Routh. It is a small lancet carried by a forceps and kept fast by two pins which go through the forceps. It gives stabs into the vaginal-portion rather less than half an inch deep. The number and depth of the stabs will be determined by the nature of the case, and the flow which follows the first one or two punctures. CHAPTER XL. METRITIS : ENDOMETRITIS ; FOLLICULAR EXCORIATIONS ; / APHTHOUS ERUPTIONS; VARICOSE ULCER. In practice what is called endometritis or uterine catarrh, meaning, more or less precisely, inflammation of the mucous membrane of the uterus, is the form of metritis the most frequently met with, and that presumedly as a distinct disease. It might on this ground be con- sidered desirable to describe it separately. But regarding the fre- quency of its com^^lication with inflammation of the parenchyma, either in its origin or in its course, it appears to me on the whole more useful to study metritis and endometritis together. In discussing the treat- ment, it will not be difficult to point out the modifications which the predominance of one or the other form may especially indicate. Metritis may be analyzed as follows : 1. There is the puerperal metritis springing from convection of foul matter in the venous and lymphatic channels, from the cavity of the uterus. This usually runs a rapid course, and when fatal, it is rather by general infection of the circulation and peritonitis, than from the simple metritis. This puerperal metritis may be: a, general, or b, limited more or less to that portion of the uterine wall which corresponds with the attachment of the placenta. Both forms are likely to be attended by peritonitis. Both may be- come chronic. In either case, the normal involution will be retarded, and the uterus will remain larger than normal. 2. Very similar conditions may follow in the non-pregnant state, from the slow necrotic inflammation to which polypi and fibrous tumors are prone; from necrotic or inflammatory changes in cancerous growths; from peculiar fungoid or other morbid conditions of the uterine mucous membrane. 3. We are, perhaps, most familiar with acute metritis, apart from 28 434 METRITIS. the puerperal state, as the result of injury or irritation produced by surgical treatment. Thus, operations upon the uterus, as incision of the cervix : scraping, or cutting, or tearing away of iibroid tumors ; the application of caustics to the interior of the uterus, especially in the form of injections ; the use of tents, laminaria or sponge ; and above all the wearing intra-uterine pessaries, may induce metritis. In all these cases there may be absorption of foul matter by the vessels which permeate the walls of the uterus. In all these cases, the inflammation mostly invades all the tissues of the uterus, mucous, muscular, vascular, and peritoneal, and almost invariably spreads to the cellular tissue on either side of the neck, involving the broad ligaments. Generally, the extra-uterine inflam- mation predominates over the metritis proper. Metritis may he simple or complicated. The inflammatory complica- tions are : inflammation of the ovary, of the tubes, of the perimetric cellular tissue, of the pelvic peritoneum, perimetric phlegmons or abscesses, lymphangitis, phlebitis, phlegmasia dolens. All these com- plications, or some of them, may arise not only as consequences of labor, but also from suppressed menstruation, cold, local injury, conditions arising out of uterine tumors, or of tubercular or cancerous disease. Dr. West has described as ''metritis hsemorrhagica " the intense acute inflammation which occurs when a piece of nitrate of silver falls into the cavity of the uterus. In such a case, free hemorrhage is very apt to arise. The diflFerence of structure and of function of the cervical portion of the uterus confers upon it pathological liabilities distinct from those of the body of the organ. It may be true that by continuity of tissue, and by receiving its blood supply in great part from the same vascular system, inflammation of the cervix is apt to spread to the body, and vice versd ; but practically, we often have to deal with cases in which one or the other part is so much more profoundly affected than the other, that it demands special attention. This consideration, and the advantage of avoiding much repetition, have led me to curtail in this place the description of inflammation of the cervical portion. The complement of this subject will be found in the section devoted to the changes consequent on labor, and in that on prolapsus and hypertrophy. Inflammation of the Substance of the Uterus. Metritis. The inflammation of the submucous stratum which occurs in acute endometritis spreads sometimes to the whole uterine substance, and rises to such a height that the uterus swells to the size of a goose's egg, becomes softened, reddened, unusually succulent and infiltrated with small extravasations. This acute metritis next invades the peritoneal covering of the uterus and of the neighboring organs. In some rare cases the issue has been in suppuration, and the formation of abscesses in the walls of the uterus, AS'hich, like the puerperal abscesses, lead to various secondary destructive actions. Chronic metritis proceeds from the acute form, or is developed out of METRITIS. 435 persistent hyperseraia. It not uncommonly arises slowly, even insid- iously, out of irritation produced by other morbid conditions, as tumors or cancer ; and that without being preceded by any condition that can rightly be called acute inflammation. It leads to hypertrophy of the uterus, with preponderance of the connective tissue, which affects the whole organ or prevails in the body, cervix, or vaginal-portion. Its most frequent foundation is undoubtedly laid in retarded involution after labor. Much, therefore, of what might, in strict order, be dis- cussed in this place, has been anticipated in the chapter on the conse- quences of labor ; and which should, therefore, be read in connection with the description of metritis. Chronic metritis thus takes its rise in hypersemia. Whatever pro- duces retardation and accumulation in the uterus or in the utero-ovarian system of vessels, leads to chronic metritis. Scanzoni^ says the influ- ence of heart disease in producing chronic metritis is underestimated. Stenosis and insufficiency of the mitral valves, by inducing retrograde venous stagnation, causes hypersemia of the uterus. He also insists that chlorosis and other forms of anaemia, by favoring pelvic hyper- semia, frequently lead to chronic metritis. Scanzoni has distinguished two stages of metritis ; namely, 1, a stage of infiltration or softening, in which is observed more or less extensive hypersemia, a sero-sanguinolent infiltration of the uterine tissue, which in consequence becomes soft, relaxed, thickened ; and 2, a stage of thickening or induration, in which general or partial anaemia of the organ, dryness, firmness, and hardness of tissue are the principal lesions. In the first stage, that of softening and hypereemia, there may be excess or alteration in the secretions of the mucous follicles ; especially, new formations may arise, or there may be general hypertrophy of the organ. In this stage the softened uterus is flaccid, so that it can be bent backwards or forwards, and pressure of the finger leaves a depres- sion. The surface of the organ often exhibits stringy peritoneal adhe- sions to the neighboring structures. When a section is made with a scalpel, there is absence of that crying sound which is heard when the healthy dense tissue is cut through. It is like cutting through an ordinary muscle. Fluid blood flows from the cut vessels, and serum from the tissue. The cut vessels are seen of larger calibre, gaping in places, but not universally. In intervening spaces the vessels may, to the naked eye, show no alteration. The parenchyma itself has lost something of its resistance, it is more succulent and friable. The in- crease in thickness of the wall at this stage, Scanzoni says, is not demon- strably due to increase of muscular fibre, but mainly to the serous infil- tration. It is more swelling than new growth. He has also observed advanced fatty metamorphosis of the muscular bundles, and in the interposed connective tissue a great number of free fat-globules. This more especially applies to the upper part of the organ. The mucous membrane is almost invariably the seat of chronic catarrh. In the second stage, that of thickening or induration, there is a gen- eral or partial anaemia of the organ. The tissue is dry, tough, and 1 Die Chronische Metritis, 1863. 436 METRITIS. hard. This hardness strikes the observer as the next feature after the increase of volume. The hardness resembles that of dense fibroid tumors. These characters are very clearly seen when the hypertrophied vaginal-portion is amputated. This tissue-change, Scanzoni says, is more evident in the posterior than in the anterior wall, and he attrib- utes this to the fact that the hinder wall is the more frequent seat of the placenta. The indurated places look pale, yellow, or yellowish- red, and this appearance is made more striking in those cases where these places are surrounded by others still in the stage of infiltration, and which will be soft and red. But cases are frequently observed in which the whole organ is thickened and indurated. In the hardened parts the vessels are contracted. The chief contribution to the increase of volume of the tissue is made by excessive growth of the connective tissue, although the muscular element may to some extent contribute. As far as I can trust my own observations made upon the hypertrophied vaginal-portion after amputation, I must concur in this statement. The same operation also gives evidence of the contraction of the ves- sels. Incision made with the knife divides no large vessels ; there is at most an oozing from the "surface. The greatest part of the blood comes from the divided mucous membrane. Chronic metritis, although it may predominate in the body or cervix, almost invariably affects the entire uterus, more or less. Scanzoni has taken great pains to verify the statements of those pathologists who contend that the anterior or posterior wall or the fundus may be the especial seat of hypertrophy from chronic inflammation. He has occa- sionally found a part more thickened than the rest ; but invariably the entire body of the organ is enlarged. The growth is outwards; it leaves the cavity expanded, impairing more or less its triangular shape, so that it becomes more ovoid. The mucous membrane is swollen, softened ; the glandular orifices are prominent, open, visible under water. The gland-tubes themselves are much elongated. Mucus, stained with pus, is generally found in the cavity. The origin of the increase of bulk, undoubtedly, in many cases, lies in acute metritis. The effused fluids not being entirely absorbed, that which remains becomes organized. But there are many cases in which it is difficult to prove the existence of inflammation. Under simple hypersemia fluids are efFused into the tissue, and the non-absorbed ex- cess may undergo the same change into dense tissues. It is thus that, during long-persistent hypersemia, there may be intercurrent attacks of metritis. But this is not shown to be necessary — the process is one of disordered nutrition. The changes produced in the cervix uteri by chronic inflammation involving the whole uterus have been partly described in a preceding chapter. Those which are necessarily dependent upon antecedent preg- nancy are the following : The foUiGular excoriations of the cervical canal arise, according to C. Mayer, in the following manner : There is an inflammatory process in the mucous membrane, so that the follicles being involved, their excre- tory orifices are closed. Then three several pathological changes pro- METRITIS. 437 ceed : 1. The follicles swell gradually to the size of a millet-seed, and form round, smooth, elastic cysts, containing a delicate, viscid, stringy matter, known as ovula Nabothi. Often the contents assume a pur- ulent condition ; and at length the follicles burst, and leave round fol- licular ulcerations. 2. The follicles do not reach the above-described development, but stop as it were on the way, as small, roundish bodies with thickened investments, and scanty contents, like hard knots on the surface, and so persist. 3. Or the follicles project more and more out of the mucous membrane, like ovula Nabothi, become bigger, and hang down, stalked, like scarlet-red pearls, out of the os uteri. These are called mucous polypi. These three forms give rise to three distinct forms of follicular erosions and ulcerations, different in their symptoms and in their ap- pearance. In the first form the os uteri is nearly always large, gaping, its scarred borders everted ; its whole surface feels rough, uneven. The profuse secretion is often yellowish, puriform, not seldom mixed with blood, and offensive. The lips are dark-red, even purple, hypei-semic. The prominent smooth follicles are easily recognized ; they have a tur- gescent, often finely granular surface. A thick stream of opaque, yel- lowish-white secretion flows from the cervix. Where the follicles have burst, roundish ulcers remain. The condition is not limited to the OS uteri, it extends to the interior of the cervix. These follicular affections, C. Mayer says, are almost always asso- ciated with chronic metritis. Scanzoni associates them with retarded involution of the uterus. The mucous membrane, with its glandular apparatus, hypertrophied during pregnancy, remain stationary, and give rise to the affections described. That this is in many cases true, 1 do not doubt. But the explanation I have given in the chapter on the changes the cervix undergoes after labor is, I am equally sure, more generally true. The mucous membrane, at least its epithelial ele- ment, falls by a necrotic process ; and one does not usually see in the post-puerperal cases distinct rounded follicular ulcers, but a large sur- face bared of epithelium ; the granular aspect being due, not so much to the enlarged follicles, as to the swollen villi, no longer bound down by their epithelial investment. The roundish erosions, resulting from burst follicles described by Maver, are often seen independently of pregnancy, that is, years after the last pregnancy, and even in women who have never had children. There is another form of erosions described by Scanzoni and others, which ought not to be confounded with the foregoing. These result from aphthous eruptions. Partly in the immediate proximity of the os uteri, partly scattered at some distance, are small vesicular points as big as a pin's head. The epithelium is easily rubbed off by a brush, leaving a small vivid red spot. Sometimes several of these vesicles run together, and give rise to a large erosion. This kind of erosion is distinguished from the preceding one, in the absence of follicular swelling of the cervical mucous membrane, by the thinness of the superficial wall of the vesicle, by the ease with which the vesicles burst, and in their leaving, not a sharp deep ulcer, but ^ superficial, perhaps irregular. 438 METRITIS. erosion. This appears to be the herpetic, dartrous or eczematous ulceration of Huguier and Courty, terms, which I think Aran rightly finds fault with, since they imply a connection with herpetic disorders of the skin, of which there is no proof. On the other hand, Scanzoni relates a case of an otherwise healthy woman who suffered from aphthae of the mouth, who, whenever she had a fresh eruption here, always had attacks of pruritus vulvae and slight leucorrhcea, attended by vesicular eruption on the mucous membrane of the vaginal-portion. These were speedily cured by light touches with nitrate of silver ; but a relapse always followed the formation of aphthae in the mouth. The 'papillary erosions I have described under the changes follow- ing labor under the name of " villous." I believe they are more fre- quently the cause than the consequence of chronic metritis. Dating from the act of labor, arising in traumatism, they precede metritis. Although the metritis may, and often does, arise out of the hyperaemia attending retarded involution, yet even in cases where involution has proceeded fairly well, the raw surface left by the fall of the epithelium keeps up irritation and attracts an undue flow of blood to the part ; maintaining a condition constantly liable to merge into subacute in- flammation. In connection with chronic metritis, it is not rare to find a form of erosions to which the name of "cock's-comb ulceration" has been given. It appears to be a transition-form from the papillary or villous erosion to the cauliflower-excrescence. When this occurs, the tume- faction and enlargement of the whole cervix as well as of the vaginal- portion are considerable. There is intense hyperaemia, and often some degree of loss of mobility of the lower segment of the uterus. This appears to be due, at least in those cases where evidence of malignant disease is not pronounced, to infiltration of serum, with some inflam- matory process in the cellular tissue immediately outside the cervix. These cases are difficult to deal with. Absolute rest is essential. Local applications of chromic or nitric acid answer the most effectually. Scanzoni, in 1856, described the "varicose ulcer" as a form of dis- ease of the cervix uteri -arising in this way: Some time after the exist- ence of a marked increase of volume of the uterus, and of a profuse secretion from its cavity, a bluish-red coloration is developed on the vaginal-portion and the adjoining part of the vagina ; some dark blue spots gradually appear, upon which, after a time, numerous varicose venous branches become manifest. Upon these spots the mucous mem- brane softens, and forms elevations recognizable by sight and touch. The epithelium is thrown off", and an erosion is the result. At a fur- ther stage the loss of substance extends deeper, usually giving rise to free hemorrhage. The surface of the sore looks remarkably pulpy, so that the sound easily penetrates it. Scanzoni has only seen these vari- cose ulcers in women who had borne children, and in whom there had long existed obstruction to the portal circulation, or in the subjects of heart disease. I have, however, notes of a case taken at the London Hospital, in which there was a vascular naevus-like growth on the OS uteri of a woman who had never had children. She was said to have had three abortions ; but tlie cervix and os uteri had the features METRITIS. 439 which I have almost invariably found significant of sterility. This woman had frequent metrorrhagia. Under applications of nitrate of silver the varicose mass disappeared, and the hemorrhage ceased. Chronic metritis sometimes brings about a papillary swelling of the ' mucous membrane of the vagina. This was at one time called "fol- licular." But since Hassall, Henle, Mandl, Kolliker, and others, have shown that the mucous membrane of the vagina is nearly destitute of glands, the papillary nature of the affection has been recognized. It is generally attended by a profuse milky or creamy leucorrhoea. This papillary hypertrophy is often observed in the course of pregnancy, which condition must be regarded as its chief cause. After labor it is sometimes so marked as to resemble a papilloma. The Course of Metritis. — Inflammation, if it does not terminate in resolution, may become chronic, and lead to hypertrophy, or it nlay tend to softening and liquefaction. This termination is, I believe, not very uncommon in women past the climacteric. In such cases the whole organ is enlarged. It feels flaccid, swollen, pulpy, between the internal and external examining fingers. The body falls either for- wards or backwards, or may seem to squat down on the vagina. The sound passes the os internum easily, provided there is no flexion, or when the downbent body is tilted up. It penetrates usually rather more than two and a half inches before resistance is encountered ; and the wall of the uterus is so pulpy, that the point might easily penetrate into or through its substance. More or less oozing of blood commonly follows the examination. By the speculum the os externum and vagi- nal-portion are seen deep purple or dark red; the mucous membrane is villous-looking ; it easily bleeds. If there be a tubercular element complicating this metritis, recovery is hardly to be expected. It may be doubted whether, even apart from such complication, recovery takes place, if the softening be gen- eral or far advanced. Abscess in the uterine wall is, I believe, rarely seen unless in the puerperal state ; and in this case it does not, unless exceptionally, arise in the parenchyma, but may be traced from the foci formed in the venous tissues or lymphatics, whose walls are first inflamed by the reception of septic matter from the cavity of the uterus. Abscess does not occur readily in purely muscular tissue. Metritis proper may, however, run on rapidly to the formation of abscess, as in the following case told by Scanzoni. A young woman had violent metritis after suppression of menstruation. The pains were very acute, resisting all treatment for eight days. The sensibility increased, rigors were repeated several times, and suddenly there was developed, above the horizontal portion of the pubes, a tumor the size of a hen's egg, somewhat resisting, and accurately defined. On the twenty-second day of the illness, symptoms of violent and extensive peritonitis set in, and the patient died on the thirty-first day. Dissec- tion proved that the cause of death was the rupture of an abscess, situ- ated in the right and upper part of the uterus, the pus from which had worked through the outer strata of the uterus and its peritoneal in- vestment. 440 METRITIS. It can hardly be doubted that this case was one of metritis proper passing into abscess. But a case related by Hervez de Ch^goin (Soc. de Chirurgie, 1868), in M'hich an abscess was found at the fundus of ' the uterus quite closed, the size of a uterus at the fifth month of preg- nancy, with enormous development of the fleshy fibre, was probably the result of suppuration in a fibro-cystic tumor. Amongst the consequences of chronic metritis, Scanzoni lays stress upon the frequent implication of the ovaries. Supplied by the same system of vessels, these readily partake in the like hypersemia, and in the increased action attending the uterine condition. He says ovarian cysts are a frequent complication. They arise out of chronic oophor- itis ; probably in this way an ovum may ripen, but owing to the thick- ened condition of the surrounding stroma the follicle cannot burst, and the fluid cannot escape. Succeeding menstrual periods with attendant hypersemia cause fresh exudation into the follicular cavity, and so this grows to a cyst. The other forms of cystoid of the ovary are also often found as complications of chronic metritis. Chronic catarrh of the Fallopian tubes often comes as an extension of the affection of the uterus ; and one of its consequences is adhesion to the ov^ary. And, either by adhesion or by simple closure of the tube at its abdominal end, the tube may become distended by accumu- lation, producing dropsy. The vagina, in the higher grades of the disease, is almost constantly in the state of chronic catarrh, with more or less swelling and relaxa- tion of its tissues. This is especially true of the upper part or fundus of the vagina. The bladder participates in the disordered circulation of the pelvis, being involved in chronic catarrh, and perhaps thickening of its coats. The rectum is also, in like manner, liable to chronic catarrh, at- tended with various dilatations of the hsemorrhoidal veins, especially when there is retroversion or retroflection of the uterus with enlarge- ment. In various ways the skin shows evidence of disordered nutrition. Hebra says the influence w^hich uterine disorder exerts over the origin of skin diseases, especially of the eczemata, is manifested in the fact that all the chronic skin affections in women undergo a marked deteri- oration, a fresh irritation, during menstruation. Many women, he says, feel a day or two before this process — commonly in the course of the vessels of the extremities — smarting, burning, and twitching, so that by these symptoms they can foretell with certainty the speedy appearance of menstruation. Hebra also calls attention to the frequency with which women suf- fering from uterine disorder lose their hair. Every one who sees much of these disorders is familiar with this complaint. In not a few cases it is associated with syphilitic complication. But I am satisfied that in a great number of cases there is no reason to invoke this explana- tion. It appears to be induced by the deteriorated nutrition which follows upon chronic uterine disease. It is often cured, the hair- growth being quite restored when the uterine disease is removed. The influence on pigmentation is often very striking. Independ- METRITIS. 441 ently of the pale, sallow, or dull earthen hue, the result of the circula- tion of impoverished blood, more or less tainted with unhealthy ele- ments, there are frequently seen on the face, namely, on the forehead, cheeks, or skin, brownish spots or patches of lentigo or chloasma uteri- num. This chloasma is a form of pityriasis versicolor. I have seen marked examples on the chest, which underwent striking increase in depth of color during menstruation. Although in all likelihood due to disordered nutrition of the skin, it is not determined whether the yellowish-brown color of the epidermic scales depends upon the pecu- liar fungus developed in this disease, as G. Simon believes, or upon the marked accumulation of fat — smegma — as AYedl suggests. Acne is not at all uncommon. I have known this disfiguring erup- tion disappear soon after cure of uterine disorder, aided by iodide of potassium, arsenic, and other appropriate remedies. Fugitive attacks of erythema, erysipelas, or furuncle, are more fre- quently observed during the ansemia of amenorrhoea, but are not un- common at the climacteric period. Nervous symptoms or complications. — The seat and intensity of the pain are very variable. There is most commonly a painful sense of weight, pressure, at times of forcing, in the hypogastrium and pelvis. This is more or less constant, but is aggravated by standing, walking, or other exertion. There is often, a sensation as of a large body tend- ing to force its way out of the vulva. On coughing, sneezing, or other forcible expiratory acts, the pain is increased, and these bring out new pains in the loins, sacrum, and groins. There is often distress at the anus, and down the thighs. At the menstrual epochs, the hyper- sesthesia is more generally diffused. The frequency with which pain is felt in those regions which are supplied by the lumbar plexus, is remarkable. It is deserving of attention in a diagnostic point of view, that the intense pain often complained of in chronic metritis in the inguinal regions is so explained, and is therefore not indicative of oophoritis. In two cases, says Scanzoni, in which an autopsy was made of women who had suffered intensely from pain in the ovarian region, so that he was all but convinced that they had organic disease of the ovaries, these organs were found perfectly sound. Bennet, as we have seen, has long insisted that this pain is pathognomonic of chronic inflammation of the cervix. I have on several occasions known intense ovarian pain produced at the moment of touching an abraded surface of the os uteri with caustic. The nerve most frequently affected appears to be the ilio-hypogastric. The pain often runs along the course of this nerve from the anterior border of the crest of the sacrum, downwards to the inguinal ring. When the pain extends to the labia pudendi, we have to conclude that the external pudic nerve has been seized. I have known this, or the external pudic nerve, to be the seat of persistent pain concentrated there, of the most distressing kind. It seems as if, after long irritation of the nerves involved, pain settles in a particular branch, and becomes difficult to dislodge, even after the disease which provoked the nervous trouble had ceased. This remark applies peculiarly to the lumbar, dorsal, and sacral aching pain, which often lasts weeks and months after 442 M E T E I T I S. the uterus has been restored to a comparatively healthy condition. In these cases, it seems highly probable that the long-continued irritation of the lower part of the spinal cord has induced a chronic alteration of nutrition. This lingering ill is often the source of disappointment and discouragement to patients who have really recovered from metritis. It is necessary to explain that effects do not immediately cease after the cause is removed ; that the return to healthy nervous function, to vigorous muscular power, is necessarily gradual. Muscles long dis- used have fallen away ; all the functions exhibit the weakness of structure of the organs which execute those functions. Healthy tis- sues can only be built up by regulated exercise and other hygienic measures. A not uncommon attendant symptom of chronic metritis is the " Coccygodynia" of Simpson. This is sometimes so distressing that the sufferer cannot sit in the ordinary way, but is obliged to rest upon one or other ischium ; and some women on this account constantly use an air-cushion. Pain is often felt on defecation. Since the metritis to which this pain is due, itself probably arose after labor, it is natural to conjecture that the sacro-coccygeal joint received injury during labor, and became the seat of chronic inflammation. In some in- stances this is really the case. But in most no evidence, beyond the pain, will be found of local mischief. It is a form of neuralgia. It is, however, desirable to determine the local condition by examination. For this, the forefinger of one hand is passed into the rectum, whilst the other hand feels along the sacrum or down the joint externally. In this way the joint is closely approached on either side, and the rela- tion of its constituent bones, the mobility of the coccyx, the condition of the joint can be accurately made out. The removal of this sacro- coccygeal neuralgia must be waited for in the same way as the subsi- dence of other nervous disorders, when the causing disease is cured. A nervous affection of a peculiarly distressing kind, is pruritus vagmce et vulvae. This is not an uncommon symptom of chronic me- tritis. It is due to the general hypergesthesia of the pelvic nerves, and, in some cases, to inflammation of the mucous membrane. The nervous filaments distributed in the papillee being involved, of course present extensive points of peripheral irritation. Where there is inflammation of the mucous membrane, there wnll commonly be more or less spas- modic contractility of the vulva, constituting vaginismus. But an equal degree of irritability is not uncommon where there is no local inflammation. This distressing complication is sometimes successfully treated by belladonna or morphia pessaries. But the only effectual remedy is the use of the " vaginal-rest." The wear and tear of the nervous system, and the degradation of the blood attending chronic metritis, hardly ever fail to bring about dis- turbance of distant parts. This is manifested in various sympathetic nervous disorders. One of the most frequent is facial neuralgia. The association of this disorder with uterine and ovarian trouble, is placed beyond doubt by the exacerbations which so often accompany the men- strual periods. Hysteria is another frequent attendant. Where the disease has lasted some years, being prolonged into the climacteric age, METRITIS, . 443 the nervous disorders characteristic of that epoch will be earlier and more strikingly produced. A symptom, says Peaslee,^ almost pathognomonic of uterine affec- tions, is the " uterine headache/' referred to the top of the head, usually extending over a circular or oval surface, and relieved by pressure. Sometimes a "crazy feeling," a sensation of cold or heat, or a numb- ness is complained of, or the surface is tender on pressure, or hot. The Symptoms and Diagnosis. — The disease is usually so protracted, coming under treatment, perhaps, long after its earlier stages have been passed through, that it is difficult to gather up a complete orderly history of the symptoms. The later symptoms will, in many respects, differ from the earlier ones. Still, the subjective symptoms, when cor- rected and complemented by the objective ones, are clear enough to mark what is going on. The most marked symptom is acute hypogastric pain, differing from the pains of retention by being persistent, and becoming more intense. It frequently comes on suddenly, with initial protracted rigor. Fever is constant in acute metritis, and not rare in the chronic form. Inflam- mation is apt to spread to the surrounding organs, and if the peritoneum become involved, as it frequently does, the pain may extend from the pelvis to the abdomen. The patient complains of a feeling of burning heat in the hypogastrium, vagina, and vulva. On examination, the vagina feels hot, tense, tumid ; pressing the cervix uteri produces acute pain, especially if so pressed as to move the uterus. Arterial pulsations may be felt in the utero-vaginal sinuses. The uterus is felt to be increased in bulk. If the sound be introduced — and this ought to be avoided if we find the foregoing signs present — the most acute pain is caused by the passage along the cervix, and some oozing of blood is very likely to ensue. The diagnosis, indeed, admits of being perfectly established without the sound. The state of the uterus — perhaps softened, easily bleeding, even easily penetrable by the point of the instrument — is a valid rea- son for not using it. The pain is intensified by movement, by the slightest jar or shock, and even by the action of the bowels or bladder. If acute metritis attack during menstruation, the menstrual flow is commonly sup- pressed. In the chronic form it may also be suppressed; but some- times an attack of menorrhagia or metrorrhagia supervenes. Dys- menorrhoea is almost inevitable. Suppression of menstruation is more characteristic of parenchymatous metritis. When the mucous mem- brane is principally affected, there is more often menorrhagia. Nausea and vomiting are hardly ever absent. Bennet looks upon nausea as a characteristic symptom of parenchymatous inflammation. The active engorgement of the vessels and tissues stretching the uterine fibre accounts for this symptom. The "facies uterina" is commonly well marked. Sterility is almost constant in metritis. In the acute stage pain would prevent inter- course, and in the slower chronic forms the altered tissues and secre- 1 American Medical Monthly, 1860. 444 METRITIS. tions are unfavorable to conception, and to the retention of the embryo in the rare event of conception taking place. In the more chronic forms of metritis, the simple vaginal touch may not in every case produce pain. If the surrounding structures be not involved, so as to im])ede the mobility of the uterus, and the body of the organ be the chief seat of the inflammation, it rises and retreats before the examining finger, so that the tender inflamed part escapes pressure. But when we combine external pressure by the hand above the pubes, pushing the fundus down, we evoke pain by bringing the inflamed part under compression. By this mode of examination we are sure to bring out with precision the signs of disease in the uterus; and by, in like manner, examining the remaining organs in the pelvis, we may exactly trace the disease to the uterus. The enlargement of the uterus which always attends metritis, chronic or acute, is easily determined by the abdomino-vaginal, or the recto- abdominal touch. The fundus of the uterus in acute puerperal me- tritis almost invariably rises above the symphysis pubis. In the non- puerperal acute, and in the chronic forms, it is usually not difficult to feel the fundus by pressing the fingers a little firmly behind the sym- physis, having previously emptied the bladder. If the inflammation arise out of, or be associated with, cancerous, fibroid, or other disease, the enlargement of the body of the uterus is usually greater, and the fundus rises proportionally so as to be easily reached. This enlargement of the uterus imparts some degree of tumefaction to the lower abdomen. And it is a point to attract attention, that the tumefaction or distension of the abdomen is almost always much greater than the mere increase in size of the uterus can account for. The sur- plus is, I believe, often due to the disturbance in the state of the intes- tines, which the neighboring inflamed organ produces. All parts in contact with an inflamed organ are constantly disordered. This is especially the case when movement is a necessary condition to the due performance of the organs implicated by proximity. The intestines are in this case ; and they appear to be compelled to a state of inaction or paralysis, in order to spare the sensitive inflamed uterus. Hence distension. This is made manifest by a degree of tympanitis. So long as the inflammation is limited to the uterus, not involving the peritoneum or the broad ligaments, the uterus remains mobile. If it be found at all fixed, we may conclude that the inflammation has extended to the surrounding structures. Although in a large propor- tion of the cases of chronic metritis the uterus retains its mobility, we must always be prepared for extension of inflammation to the neigh- boring parts. When this occurs, as it may do under the influence of cold, overexertion or violence, especially if encountered during a men- strual period, there will be exacerbation of pain, and this more widely spread ; and there will be some febrile excitement. Metritis may be mistaken for congestion, flexion, uterine tumor, or perimetric disease. I do not here stop to point out the special means of diagnosis, because these will be discussed when describing these several disorders. METRITIS. 445 In simple congestion, fever is usually absent. There is not the burn- ing heat in the vagina, nor the same degree of tenderness of the uterus. The duration of acute parenchymatous metritis, if not complicated with septic conditions, or perimetritis, is generally from three weeks to a month. The usual termination is in resolution. But in patients who have neglected care, rest, and appropriate treat- ment, and especially in those who are the subjects of strumous or other morbid diathesis, or who are simply of weak constitution, the inflam- mation merges into the chronic form, and is not unlikely to spread to neighboring structures. Perimetritis, or inflammation of the peritoneal investment of the uterus, will be more conveniently described in connection with pelvic cellulitis and pelvic peritonitis in a subsequent chapter. The Curability of Meti'itis, Acute and Chronic. — There can be no doubt in the mind of those who have had large opportunities of observ- ing puerperal diseases, that acute and even subacute metritis is often followed by substantial, if not complete, recovery. We cannot avoid this conclusion, if we accept as evidence of restoration the return to healthy functional activity. Who has not known women who have suffered metritis after labor or abortion, subsequently menstruate easily, become pregnant, go through labor, lactation, and resume the duties of life with comfort? It is scarcely possible that a history such as this should be frequent, if any decided uterine disease persisted. The case is somewhat different, however, with chronic metritis. Slow changes of tissue, continuing over months and years, are with difificulty counteracted. Still, appealing to the same evidence which proves the cure of acute metritis, we cannot absolutely deny the curability of chronic metritis. Pregnancy is assuredly, if I may trust my own ob- servation, not infrequent. It sometimes, no doubt, takes place whilst the uterus is still in an imperfectly restored condition. But the value of this test of return to functional work is strong. I think this fact should qualify the discouraging conclusion of Scanzoni that, perhaps, with the exception of some extraordinarily rare instances, it is not in the power of the physician so to cause the tissue-changes of chronic metritis to disappear, that the uterus is completely brought back to its normal condition. When once the process of hypertrophic induration with condensation of tissue has been accomplished, it is certainly con- trary to experience to find that, either by internal remedies or by local applications, we can reverse the process which has taken place, cause the new material to be absorbed, and restore the uterus to its pristine condition. We have the clearest evidence of the permanent character of the tissue-changes wrought by chronic metritis brought directly under our senses in the chronic hypertrophic elongation of the cervix. Growth with induration having taken place, it may be confidently said that nothing short of surgical agency will remove the disease. It may by analogy be contended that like changes in the body of the uterus will be equally permanent. Although this part is liable to similar tissue-changes, still this does not appear to be so frequent. Now if, as Scanzoni himself asserts, there is no such thing as chronic metritis absolutely limited to one part of the organ, of course when we have 446 METRITIS. hypertrophic induration of the cervix, about which there can be no doubt, before us, we must infer that the body of the uterus is similarly affected. Xow, it is a fact beyond dispute that pregnancy is not uncom- mon in cases of very advanced, even extreme, hypertrophic elongation of the cervix. I have notes of many such cases. We are driven, then, to conclude that the hypertrophy resulting from chronic metritis may either be so far cured that the uterus can resume its highest function, or that the persistence of the hypertrophic change is not an absolute bar to this resumption of function. Practically, whichever alternative we adopt, there is a cure. This brings us to another question of great practical interest. What is the influence of pregnancy in curing chronic metritis and its results? If we assume that all must be cured before gestation can go on, of course the question falls to the ground. But if, on the other hand, we assume that conception may take place and gestation proceed to term, in an organ which is the seat of chronic metritis and its results, what will be the effect upon the disease? Speaking from clinical observation and analogical reasoning, I feel confident that, under this condition, a cure may be effected, that is, that the new hypertrophied tissue may be re- moved, and the uterus brought back to its pristine state, or nearly so. Instances have come under my observation as well as under that of others, proving that fibroid tumors have been dispersed by absorption — I do not mean by sloughing or by casting off in mass, more common events — under the influence of pregnancy. These tumors, composed of tissue, not dissimilar from that of the morbid hypertrophic element, are caught in the involution-process, which reduces the normal hyj^er- trophic element, and like it, they vanish. Is it not in the highest de- gree probable that the new hypertrophic matter, uniformly distributed in the midst of the proper uterine tissue, may be equally caught in this absorption-process, and be thus removed? I believe I have seen dis- tinct diminution in bulk of the hypertrophied cervix follow upon labor. I think, then, we may conclude that the uterus hypertrophied under chronic metritis may be restored, at least, sufficiently for the resump- tion of its duty. If the morbid hypertrophic matter can be removed by gestation, why not by other means? I do not pretend that other means at our disposal are of equal efficacy wdth pregnancy. But if we can establish a reasonable presumption that the condition is curable by any means, surely we need not despair of finding other means that may accomplish the same end. Again, uterine fibroids occasionally undergo a process of degenera- tion or atrophy, the senile involution, after the climacteric. The proper uterine tissue itself undergoes this atrophic involution. Why should not the abnormal hypertrophic tissue undergo the like change? As a rule new formations are more ready to undergo atrophy by absorption or degeneration than healthy tissue ; and, as a matter of observation, I think I shall be supported when I affirm that hypertrophic indm-ation, the result of chronic metritis, does undergo atrophy under this condi- tion. It is in accordance with general opinion that active inflammatory process of the uterus and ovaries tends to spontaneous remission and METRITIS. 447 cure at tlie climacteric period. Ceasing to be stimulated by the periodi- cal liypersemia of ovulation, the local inflammation naturally subsides. But we must not hastily conclude that uterine disease will always un- dergo spontaneous cure or alleviation at this period. In many cases the disease continues, often attended with hemorrhage. The morbid action, once set going, is maintained by the hyperemia of obstructed venous circulation, and by the disposition to local hsemostasis so com- mon at this period of life. And there seems to be also a more or less persistent ovulation-efFort going on, in many cases, for years after the climactei'ic has, according to all presumption, arrived. Scanzoni urges many reasons why sterility is the doom of women suiFering from chronic metritis. 1. There is the accumulation of more or less unhealthy secretion. 2. Premising that the shedding of the mucous membrane itself is much more common than is generally thought, he says he has never known a case in which considerable fragments of mucous membrane having been regularly cast at each menstruation the woman has conceived. The membrane is cast just at the end of the period, the very moment when the impregnated ovum wants a decidua to attach itself to. 3. The ovaries are frequently im- plicated in chronic metritis. 4. There is pain or indifference attending the sexual act. Certainly sterility is a frequent consequence, but it is far from uni- versal. Scanzoni himself admits that pregnancy may occur, and he rightly says that its course is generally unfavorably affected by the morbid state of the uterus. Can the so-called benign tumefactions caused by chronic hyperemia and inflammation pass into cancerous degeneration? This is another question often anxiously put. The treatment of acute metritis will be governed by the opinion we may form as to whether the case is one of metritis simple, or of metritis complicated with septic infection. In the former case the treatment will be more purely antiphlogistic. Twelve to twenty leeches may be usefully applied above the pubes. Aran and most French physicians advise six or eight leeches to the cervix uteri. Fomentations give re- lief. A pasma consisting of one drachm of extract of belladonna mixed with half an ounce of mild blue ointment and two ounces of simple cerate, spread in a thin layer on a piece of lint, and applied to the hypo- gastric region, the whole covered over with a light packing of cotton- wool, will not only give ease, but be of material use in subduing the inflammation. Experience has proved the importance of completely securing the surface covering inflamed organs from contact with the air. It is by acting in this way that the cotton-w^ool packing undoubt- edly does good. It is desirable to unload the rectum of any fecal accumulation by an enema. But this done, it is not advisable to disturb the inflamed parts by purging until the acute stage is past. When the stage of resolution is advanced, purgatives are very useful. Piillna or Friederickshall waters are excellent forms. Tepid vaginal irrigations with water or decoction of poppyheads, or with a little laudanum, are useful. 448 METRITIS. Salines, especially the acetate of ammonia and nitrate of potash com- bined with sedatives, constitute the best internal remedies. It is needless to add that absolute rest is the essential condition of successful treatment in the more acute forms of the affection. Precau- tion is especially necessary when the menstrual epoch is approaching. When there is septic complication, leeching must be avoided. The mercurial belladonna ointment may, however, still be useful. Salines must be early combined with, or give place to bark, quinine, and gen- eral tonic treatment. The discharges should be carefully examined. If they be in any degree oifensive, tepid intra-uterine injections of weak solution of per- manganate of potash should be used. Septicaemia is kept up by the continuous or intermittent imbibition into the vascular system of fresh doses of septic matter. The system may frequently be able to throw off a moderate amount of the poisonous element, and the local inflam- mation as well as the general disturbance may soon subside if the re- newal of the irritating cause be prevented. The treatment of chronic metriiis is conducted essentially on the same principles as that of arrested involution. The first question to decide is as to the application of what is called antiphlogistic treatment. Upon the usefulness of local abstraction of blood, opinions are very much divided. The indication seems clear to relieve the local hypersemia which is so essentially concerned in the genesis and maintenance of the disease. And I am willing to admit that great ease is often felt by patients after leeching the cervix uteri. But it has appeared to .me that this benefit is chiefly experienced when the disease is in the early or subacute stage, that is, during Scanzoni's first stage of infiltration. When induration has set in, I believe not much good is to be expected from bleeding. And the indication to relieve the tension of the local circulation may often be greatly met by supporting the loaded organ at its proper level by a lever or other suitable pessary. This contri- vance will often not only facilitate the return of blood by the veins, but it also, by nursing the uterus, as it were, secures a degree of rest which is essential to cure. There is always some degree of prolapsus, if not of version or flexion, which involves more or less strangulation of the vessels at the point of their entry and exit. If this sinking or displacement be counteracted, one great cause of the maintenance of the disease is j3ro tanto mitigated. This mechanical support will be useful chiefly in the earlier stages, but it will be of service at times all through. One great recommendation of it, is that it renders " lying down" less necessary. I am sure that in many cases a woman will obtain more effectual ''rest" for the uterus, by a properly adapted pessary, whilst taking a moderate ampunt of exercise, than she will by rigorous "lying down" without it. If, therefore, leeches be employed, it will be wise to watch the effect well, and not to repeat them unless we are well assured that they do what is wanted of them by relieving gorged vessels. It is well to remember — I do not mention this as an objection to the proper use of leeches — that more or less troublesome events may attend their use. 1st, a leech may make its way into the cervical canal and TREATMENT. 449 bite there; the pain is generally excruciating. To avoid this it is M^ell to insert a small plug of lint in the os uteri, if this be patulous. 2d, the bleeding may be too profuse. To stop this, it ^vill usually be enough to wipe off the congealed blood so as to expose the bite, and to apply to it a small compress steeped in a styptic solution of perchloride or persulphate of iron. If the bleeding break out some time after the leeches have been withdrawn, and the patient has been left, the same course is still the best. Get at the wound, and apply the styptic to it direct. As a temporizing measure we may sometimes apply first one plug soaked in a strong solution of alum, carrying this up to the fundus of the vagina, and then a succession of other plugs of lint lightly lubri- cated with oil, so as to exert compression. 3d, sometimes the most agonizing pain follows the bleeding. This may be allayed by opium by the mouth, or by an opiate lotion, or by a narcotic pessary. Scanzoni, who is a strenuous advocate for leeching, signalizes another consequence. He describes a peculiar erythema or urticaria, which comes on a few minutes after the leeches have taken. A shudder or even a rigor is followed by swimming in the head, disorder of the senses, even delirium. Then the urticaria blebs come out. Leeches should not be applied when tliere is marked ansemia ; when the signs of acute hypersemia are not present ; when the disease is of long standing, and the induration process has made way. Warmth is of the greatest service in the treatment of chronic metritis. When there is an exacerbation of pain from fatigue or exposure, heat may be applied dry, by heated bags of salt or bran to the hypogas- trium. But in almost every stage, warmth, combined with moisture, renders eminent service. The whole bath at a temperature of 90° to 95° F. is perhaps the best method of applying it. It acts in a twofold man- ner. It exerts a not unimportant resolutive influence upon the gorged, loaded uterus. . Not that any marked power can be proved in promoting absorption when the organ has become hypertrophied and indurated. But in the earliest stages, there seems reason to believe that warm mois- ture may aid in relieving congestion. No one doubts the beneficial soothing action of hot fomentations on superficial phlegmasia. A similar action can be exerted on the uterus. Secondly, warm baths are useful in promoting a healthy secreting action of the skin ; and this is an essential condition of the relief of internal hypersemic processes. The hip-bath may often be conveniently substituted for the whole bath, although it is open to the objection that it compels an uncomfort- able position. To get the full benefit from warm baths, it is necessary to give the water free access to the vagina. This can be accomplished by the use of the bath-speculum. The most convenient form is a conical one, with a very wide inferior opening. The cone — the part introduced into the vagina — is perforated with holes the size of a sixpence. The patient can easily apply it. In many cases, the value of warm baths is enhanced by the addition of various medicinal substances. Amongst those I have found the most useful are Vichy salts, or the Woodhall Spa waters. Gallard, however, cautious against the prolonged use of Vichy or other alka- 29 450 METRITIS. line or mineral waters. He advises, in preference, more simply ther- mal springs, as Plombieres. The general treatment should be sustaining and tonic. Iodine, iron, strychnine, quinine, and arsenic, become entirely useful when active inflammatory conditions have been subdued. Of late years, so-called resolutive pessaries of iodine, made up into conical balls, with cocoanut butter or other ingredients, have been largely used. Most patients find it troublesome, if not difficult, to apply them properly ; often, whether from being badly made or other causes, they fail to melt down in situ as desired ; and, not seldom, they are a source of so much irritation that they have to be given up. I have, for some time past, found it better to introduce into the cervical canal, or into the cavity of the uterus, some weak iodine oint- ment by means of the instrument figured at p. 129, Fig. 44. The subject of intra-uterine medication will be more fully discussed when dealing with Endometritis. Since intra-uterine medication can only be carried out by the physi- cian, and as it is essential to apply iodine frequently, the method of Scanzoni can be employed at the same time. This consists in intro- ducing, by means of a small bath-speculum, a drachm of iodide of potassium in an ounce of glycerin to the fundus of the vagina, keep- ing it there all night. A better plan is to apply a pledget of cotton- wool soaked in the iodized glycerin by means of the speculum figured at p. 131. C. Mayer speaks highly of the value of pyroligneous acid in treat- ing the bleeding papillary affections of the os uteri and cervical canal. He says there is no more efficacious means. He applies it either alone or with equal parts of aqua creasoti, through the speculum. It is left in contact long enough to stop the bleeding, and until the abraded spot assumes a white appearance. It is then washed away by a syringe. Amongst the most effective measures for substituting a healthy for the morbid nutritive process going on, and of promoting absorption of morbid tissue, are the various forms of cautery, actual and potential. The actual cautery was extensively used by the late M. Jobert. It was in the clinique of St. Louis that I first became acquainted with its action and use. I think it would have become more firmly estab- lished as a resource in the treatment of the results of chronic metritis, were it not for the natural deterrent influence of fear lest so potent an agent may do harm, and the formidable preparations which the use of the hot iron involves. The following precautions are necessary when applying the incan- descent iron to the vaginal-portion : 1. To use a horn speculum, which is less heat-conducting than metal; or else, if using a metal speculum, to interpose a packing of lint outside the blades, so as to protect the vagina. 2. To be careful to have nothing in the field of the speculum but the vaginal-portion, so that no risk be run of cauterizing the vagina. 3. To apply the cautery to the outer edge of the os uteri, avoiding the cervical cavity. The galvano-caustic apparatus would always be used in preference to the heated iron, were it not so cumbersome and inconvenient in TREATMENT. 4^1 preparation. It admits more easily of precision ; the point which carries the heat can be adjusted when cold to the spot to be burned, and being thus deliberately and accurately applied, the heat is then turned on, and maintained as desired ; it is even possible to shift the cautery to diiFerent parts of the morbid surface, and by turning off the heat, as may be done at will by breaking the galvanic current, the in- strument can be removed without danger of burning more than is desired. It also possesses the great advantage of being worked with a much shorter handle than is necessary with the heated iron, so that both hand and eye can be brought nearer to the seat of operation, and work w^ith more exact command. The best substitute for the actual cautery is the potential cautery. Various caustics have been used. They all act substantially in the same way. By chemical action they kill a portion of tissue, which is thrown oflP as a slough or eschar, leaving a sore which has to heal by granulation. During this healing, some amount of absorptive action is set up in the proximate tissues ; and the healing taking place by cicatrix, further diminution of bulk is effected by the contraction. The substances most employed are, — the acid nitrate of mercury : this is very convenient and effective ; potassa cum calce fused in sticks : this is the most convenient and generally useful caustic with which I am acquainted; it was recommended to me by Dr. Henry Bennet. It differs from the acid caustics, such as nitric, chromic, and sulphuric acids, which, absorbing moisture rapidly, and coagulating albumen, produce only a superficial slough. Potash also has a great affinity for water ; but not possessing the property of coagulating albumen, it is carried more deeply into the substance of the part to which it is ap- plied. Herein consists the advantage it possesses. Upon this pene- tration it is that the absorptive action it sets up depends. The time selected for applying it should be within a few days after the termination of a menstrual period, so as to secure ten days or more for the granulating process to go on undisturbed by the menstrual flux. The mode of using it is to introduce the speculum so as to get the vaginal-portion well into the field ; to wipe off all adhering secretion ; then, holding a small piece of the potassa cum calce in a long speculum- forceps, to rub it across one or both lips of the os uteri several times. This produces a blackish bar. Care should be taken not to touch be- yond the hard substance of the cervix, avoiding the vagina. When a sufficient application has been made, a pledget of cotton-wool steeped in vinegar is immediately applied to the part. This, neutralizing any remains of the caustic, obviates extension of its action to the vagina. A bit of string attached to the wool, enables the patient to withdraw it, which may be done in a few hours. After such an application no further local treatment is necessary until after the lapse of ten days. The granulating surface may then be lightly touched with nitrate of silver. At one time a very favorite remedy, one employed, it is true, with- out precise diagnosis of metritis, was blistering by tartar-emetic oint- ment. By rubbing this substance over the groins or hypogastrium. 452 METRITIS. or inside the thighs, a revulsive action is produced, which is sometimes serviceable. It has been recommended to establish a seton in the vaginal-portion as a derivative and resolutive. I have not put this to the test ; but I can quite understand that it may act beneficially. The potassa cum calce, however, answers the same indication. Dr. Robert Johns recommended as a derivative the establishment of a blister on the cervix uteri by the application of blistering fluid. I very much prefer the application of potassa cum calce or the actual cautery. Far less irritation is caused ; and the small eschar falling leaves a healthy sore which must heal by granulation. This process usually sets up an absorptive action in the neighboring infiltrated tis- sues. And when the sore is healed, almost always something is gained in the diminished bulk and lessened hyperemia. The cautery, poten- tial or actual, should not be employed whilst there is any degree of active inflammation. It comes in most beneficially when vascularity is subdued, where there is a languid process of tissue-change going on. Laxatives become important in chronic metritis. The compound decoction of aloes, or lenitive electuary, are useful forms. But I have found the greatest benefit from the daily or occasional use of a pill containing two grains of watery extract of aloes, half a grain of extract of belladonna, half a grain of extract of nux vomica with Castile soap. Scanzoni speaks emphatically against the plan of enforcing the ^'repos absolu,'' that is, " lying-down," as one of the most serious errors that can be committed. I have seen so much evil from this course, and have seen so many M^omen who had been kept for months in the recumbent posture, not only without benefit, but with decided detri- ment, get well quickly when subjected to a more liberal treatment, that I heartily indorse Scanzoni's conclusion. Scanzoni says the Friedrickshall, Piillna, Kissingen, Ems, Carlsbad, and the other waters, act only on the diseased uterus through their virtue as purgatives. In all chronic uterine diseases the habitat becomes an important matter. Women, far more than men, especially when invalids, are " adscriptse glebse." If the soil be damp, or other hygienic conditions be unfavorable, women suffer seriously, and often in such a degree as to frustrate the best-directed medical treatment. Change of air, then, which means change of soil, is often essential to recovery. A dry ele- vated site is generally the most suitable. The restorative treatment comes into use when the local disease has subsided, at least, in part. Iron is usually badly borne whilst inflam- mation, no matter how slight, is going on. The way must also be prepared by salines, laxatives, bismuth, and other agents which regu- late and allay all irritation of the stomach. Ulcerative Processes^ Besides the uterine abscesses, the result of acute metritis, the cancer- ous and tuberculous ulcerations, and the puerperal suppurations, ulcers occur on the vaginal-portion. ENDOMETRITIS. 453 In the course of uterine and vaginal catarrh there arise excoriations or abrasions of a stellate or annular form around the os externum which commonly extend into the cervical canal. These at times pass into erosions and ulcerations marked by papillary granulations, of a fungoid aspect, or tlie surface is tuberous through the exuberant development of ovula Nabothi. The origin and persistence of this state is favored by hypertrophy, hypersemia, and varicosity of the vessels of the vaginal- portion. The so-called phagedenic ulcer, the corroding ulcer of Charles M. Clarke, of the os uteri, is very rare. Its existence otherwise than as a stage of cancroid or cancer is questioned. But I believe I have seen it as an indented hollowed ulcer on a hypertrophied, hard, callous vaginal-portion, eating away the cervix uteri, and seizing upon the neighboring structures, in a manner very similar to that of lupus exedens. The syphilitic ulcer possessing the proper characters of the primary chancre is not common ; but it may at times be observed exhibiting a closely similar aspect to that which is seen on the penis, and producing in like manner sores more or less sharply defined on the vaginal dupli- cature which lies in contact with the cervix uteri. On examining by the finger, the sharply-defined edge of the syphilitic sore may at first im- pose on the sense of touch for the os uteri, the pit or depression formed in the fundus of the vagina is so distinct. Endometritis : Uterine Catarrh. Inflammation may be more or less limited to the lining membrane, constituting endometritis. This may take its rise in childbirth ; and it may be general, or chiefly restricted to the original seat of the pla- centa. The placental seat remains rough, presenting papillary projec- tions ; perhaps one may be large enough to deserve the name of a polypus. In the case of endometritis proper, the uterine contraction after labor has been efficient, so as to prevent the entrance of septic matter into the venous channels and lymphatics, and thus to obviate metritis. Where the constitution is sound, free from morbid diathesis, endo- metritis, treated early, admits of easy cure. Rest alone may be suffi- cient. The regenerative power of the uterine mucous membrane is so active, that the degenerated tissue being cast off a new sound one is easily formed. But if there be a morbid diathesis, as strumous, tuber- cular or syphilitic, the cure may be indefinitely protracted. The mu- cous membrane of the uterus and its glands are not less prone to receive the stamp of these diatheses than is the mucous membrane of other organs. The strumous mucous membrane of the uterus is tumid, undergoing constant epithelial shedding, its glands are hypertrophied, and secrete an excess of mucus. This, in fact, is one of the most troublesome forms of uterine catarrh. Chronic endometritis leads to the exuberant production of ovula ^abothi in the cervix and on the vaginal-portion. Indeed, Lance- reaux has designated this as " cystic metritis." In some cases the cer- 454 ENDOMETRITIS. vix is virtually closed by a collection of cysts disposed in a loculated stroma, and containing gelatinous mucus, compressing each other. The vaginal-portion is hard, tuberous, from the distension caused by these projecting distended sacs. Often, one or more of these cysts make their way through the os externum, and, becoming more pe- dunculated than the rest, appear in the vagina as vesicular polypi. When these occur in women past the climacteric, the touch and appearance forcibly suggest the suspicion of commencing malignant disease. The shot-like hard projections around the os, the red, or bluish-red, angry-looking mucous membrane in which they are set, make up a condition hard to distinguish. Usually, however, the vagi- nal-portion does not become so large as in cancer, and it does not be- come fixed. It is best treated by decided applications of actual cau- tery, or of potassa cum calce. The ovula ISTabothi are partly closed dilated mucous sacs of the mucous membrane of the cervix, but much more frequently they ap- pear as small collections of nuclei at various depths in the submucous tissue of the cervix ; these capsules grow with transformation of the nuclei to cells, and project upon the surface, where they dehisce, or pro- lapse as polypi. They contain a gelatinous mucus, mixed with cells and nuclei, fat-globules, spindle-shaped and many-branched cells, and colloid granules. When there is free secretion of mucus, these polypous, mucous-mem- branous growths, vesicular polypi, and small sarcomata lead to contrac- tion or even closure of the os uteri, by means of a richly nucleated, fibrinous outgrowth of connective tissue. This leads to retention of the gradually increasing pus or mucus in the uterine cavity and cer- vical canal. The uterus may thus be distended to the size of a goose's egg, of a fist, or even to that of a man's head ; its walls become hard, sometimes thinned; its raucous membrane is transformed into a smooth or papillary connective tissue growth ; its contents are a colorless syno- vial-like, or yellowish, red-brown, or chocolate-colored glutinous fatty fluid, showing cholesterin or pus. This is the so-called hydrometra. When the canal of the cervix gets distended, in like manner, the os internum remaining narrow, the hour-glass form of uterus is produced, the uterus bicameratus. In some rare cases, perforation has occurred through an ulcerative process allowing the contents to escape into the peritoneum. This distension of the uterus almost necessarily leads to retrograde distension of the Fallopian tubes, which are even more likely than the uterus to undergo perforation. Within the period of generative capacity, chronic catarrh may lead to hypertrophy of the uterus. During decrepitude it leads to relaxa- tion and a pulpy state. An exudative or croupous endometritis is seen in rare cases as a sec- ondary appearance in the course of typhoid, cholera, exanthemata, and especially with a diphtheritic inflammation of the vagina. Bennet says internal metritis is a rare form of uterine inflammation ; that it has only been considered common because it has been confounded with inflammation of the cavity of the cervix, a disease which is very UTEEINE CATARRH. 455 common. On the other hand, it may perhaps not unfairly be said that internal metritis, being out of sight, may often escape recognition. Certain considerations, however, incline me to think that the reaction against Bennet's too exclusive limitation of inflammation to the cervix, has been carried too far: 1. In a large number of cases, treatment directed solely to the os and cervix uteri cures all the disease. 2. Not infrequentlv, before the cervical disease is healed, pregnancy, a function which pertains to the body of the uterus, and which therefore implies a healthy condition of that part, occurs. 3. The proportion of cases in which it is necessary to resort to intra-uterine medication, although certainly greater than Bennet would seem to acknowledge, is limited. 4. The cervix is far more subject to injury in parturition. Generally speaking, endometritis proper takes its" origin in imperfect involution after labor or abortion, in obstructed or interrupted men- struation, and in irritation from foreign bodies ; whilst inflammation of the cervical cavity far more frequently takes its rise in the traumatic process of labor, in excessive sexual intercourse, and in infection. Under common origin, or by extension, there may be, and frequently is, coexistent inflammation of the mucous membrane of both cervix and body. It is especially, however, subjects of strumous or lymphatic diathesis who are prone to this disease. It is remarkable what slight causes will in such subjects produce it. And it is in these that the disease is also most rebellious to treatment. Uterine and Vaginal Catarrh. — The uterine and vaginal mucous membrane is liable to similar morbid influences to those which attack other mucous membranes. For example, it is liable to inflammation from suppression of function, as from cold acting whilst the membrane is in physiological hyperemia. It is liable to be affected by morbid poisons, as variola, scarlatina, measles, which are carried to it in the blood. It is liable to be affected by poisons or irritants directly applied, as the poison of syphilis or gonorrhoea, or, as in labor, by the poison of scarlatina carried by the touch. Just as catarrh is produced in the air-tubes and intestinal canal by exposure to cold, damp, and irritating agents, so it is with the mucous membranes of the genital tract. The catarrh so produced is a subacute form of inflammation. The membrane becomes vivid red, there is a sense of local heat, and almost always there is a raucous discharge, more or less tenacious, and varying in color from cream-white to yellow and yellowish-green; sometimes it is sero-mucous. If the discharge is yellowish-green, very abundant, and coming from a highly injected surface, and the vagina and urethra be implicated, so that there is pain on micturition, the presumption is that the source of the inflammation is gonorrhoeal infection. But the greatest circumspection is necessary in giving an affirmative opinion. Gonorrhoeal infection is only one of numerous causes of colpitis. In very many cases it is impossible to assign the particular cause. There is often no distinctive mark. Colpitis is colpitis. It is often no more possible — apart from history — to declare that a particular colpitis arose from a specific cause, than it is to declare the actual cause of a case of 456 CATARRHAL, ENDOMETRITIS. bronchitis. The practitioner who is not on his guard, is constantly in danger of falh'ng into etiological errors that may entail the most painful social and domestic consequences to the patient and others, and involve himself in serious complications. I have known the existence of leu- corrhoeal discharges in girls give rise to the suspicion of their having been abused, when there was the strongest reason to believe that the true source was struma, and in one or two cases, scarlatina. Here, as in so many difficult positions in medical practice, we must be content to limit our utterances, verbal or written, to the strictest conclusions from exact observations. The history or extraneous considerations must be rigorously excluded. To admit in these delicate scientific questions the historical element in forming a diagnosis, is to make our opinion the reflection of the errors, the prejudices, the suspicions, the malice of others. Science has nothing to do with all this. The only safe course is to discard from our consideration everything but what we can subject to actual observation. The physician can diagnose colpitis when the disease is before him. He can only form a conjecture as to the cause, which cannot be before him. The most common form is the catarrhal endometritis. This may be acute or chronic. The acute catarrhal endometritis arises from the sudden action of cold, especially if acting at a menstrual period, from excessive sexual inter- course, from gonorrhoeal infection ; it occurs in acute fevers, especially the exanthemata. It is in cases of the latter kind that opportunities of studying the affection in the dead body occur. The mucous mem- brane of the body of the uterus presents red streaks or spots from injec- tion, or it is uniformly red, more or less swollen, softened, here and there bleeding, and covered with a red-streaked mucus, or creamy fluid with pus. The submucous layer is, in severer cases, hypersemic, soft- ened, pulpy. The mucous membrane of the cervix is at times greatly injected, the contents of the ovula Nabothi are turbid ; when burst, they yield a thinner fluid. The mucous membrane of the vaginal- portion is remarkably reddened, its papillae are swollen, near the os externum abraded. The parenchyma of the vaginal-portion is itself swollen. The acute endometritis often passes into the chronic. The vagina also is frequently involved. Chronic Catarrhal Endometritis. — This is frequently a continuation of the acute form, and especially of repeated acute endometritis in cachec- tic persons. It is also frequent as the result of morbid deposits or processes in the mucous membrane, as tuberculization, or from the irri- tation of tumors protruding into the uterine cavities. The mucous membrane of the body of the uterus appears uniformly or in patches reddened, swollen, spongy, decidua-like, or has a granu- lar papillary aspect ; it is covered vAt\\ a mucous-purulent moisture or pus. Very often, chronic catarrh consists essentially in blennorrhoea, that is, in a condition of profuse* secretion of a more or less hyaline or creamy opaque mucus, from a swollen, partly pale, partly injected, dark brown or grayish pigmented membrane. The mucous membrane of the cervix is very often, but not con- stantly reddened, swollen, especially on the summit of its folds. It is CHRONIC CATARRHAL ENDOMETRITIS. 457 eomraonly studded with Nabothean ovules, and covered with a clear or yellow-streaked turbid mucus. The vaginal-portion is often swollen, the mucous membrane red- dened, its papillae swollen and injected. This condition and the simul- taneous presence of small cysts, give it a villous granulating appear- ance. And not seldom there is actual excoriation or ulceratiou. Although we can only admit the word "ulceration" as describing the loss of epithelial investment in the case which forms the subject of the last chapter with some qualification, it seems impossible to discard the term "inflammation" as inapplicable. It may be described as en- gorgement, congestion ; but if this congestion, or whatever else it may be called, produce all the effects usually attending upon inflammation, the distinction becomes too subtle to be followed out. And when it is remembered that the increased action going on, takes place in a part exposed to frequent fluxions of blood, to functional work, to accident, it is hard to imagine how it can long escape passing the imperceptible boundary which rigorous theory, rather than actuality, places between it and inflammation. One fact may at any time be verified, which appears to lend support to the theory that inflammation is an essential factor in the case. It is the abundance of chlorides in the viscous secretion exuding from the cervix. The concentration of chlorides in inflamed tissues is an established fact. The moment nitrate of silver is allowed to touch the cervical surface bared of epithelium, a dense opaque white layer is produced, and any viscid secretion is instantly turned into a white clot characteristic of chloride of silver. It has often appeared to me that the indication thus obtained of the presence of an excess of chlorides is very marked, and that it may be explained in the way described. What is the seat of this inflammation ? I should say it is exactly that of the original traumatism sustained in labor, namely, the cervix uteri, more especially the lower part of the vaginal-portion. So far as it concerns the case under consideration, I agree with Henry Bennet. It is essentially inflammation of the neck of the womb, subacute, or chronic. I rest this conclusion more upon clin- ical observation than upon the anatomical grounds so much insisted upon by him. It is true that the structure of the body of the uterus differs from that of the cervix in that there is more connective tissue in the cervix, and also that the latter part is in more direct communi- cation with the source of vascular supply. But the great reason why the cervix is more frequently the seat of inflammation is, that it is more directly exposed to injmy. At the same time I am of opinion that chronic inflammation of the body, in a less intense degree per- haps, commonly attends inflammation of the cervix. Indeed, it is hardly possible for one part to escape being involved in a process which has seized upon the other. The tissue, muscular and mucous, is con- tinuous ; the vascular supply is nearl}' the same. And, as a fact, we observe by the touch and sound, that in these cases there is frequently some enlargement, and increased sensitiveness of the body of the uterus. Still, there is a striking feature in uterine pathology which lends 458 ENDOMETRITIS. weight to Dr. Bennet's views. The frequent sharp limitation of tuber- cular disease to the body of the uterus, and of cancerous disease to the cervix, seem to point to some decided distinction in the pathological proclivities of these regions. And their physiological destination is equally distinct. Both incontrovertible facts j)oint to a difference of structure which greatly favors the idea of a difference in liability to inflammation. Another fact forcibly insisted upon by Dr. Bennet is, that treatment applied to the cervix uteri is in the majority of cases sufficient to cure the patient. This appeal to the Hippocratic maxim, " Curationes morbum ostendunt," is difficult to resist. But is not un- answerable. Counter-irritants applied to one part of a diseased struc- ture may, by derivation, or by setting up healthy nutrition in contigu- ous parts, cure the whole diseased organ. And I am in a position to affirm from observation in many cases, that the cure is much more quickly attained if the treatment is extended to the body of the uterus. It appears to me that attention has been too strictly fixed upon the visible changes in the cervix and os uteri ; and that, thus engrossed, the mind has been closed against the less telling evidence of changes in the body of the uterus. The body of the uterus which formed the nidus of the embryo, which underwent the most wonderful process of development, is liable to interruption in a process which concerns the cervix in a very sec- ondary degree. Involution especially affects the body of the uterus. It has to repair the placental seat, and to restore the mucous lining. Disorders of involution, then, principally affect the body of the uterus. Traumatism principally affects the cervix. But in some degree both processes affect the whole uterus. Although the formative elements of a new mucous lining exist in the cavity of the uterus at the time of the separation of the placenta and decidua, it can hardly be said that a mucous membrane, compar- able in development to that of the cervix, exists. Whatever changes, then, of a pathological character occur in the body of the uterus after labor must have their chief seat in the walls of the body, if we except the placental seat. That inflammation may spread from the lining membrane to the substance of the uterine wall can scarcely be doubted; but this inflammation does not often extend deeply. The more usual origin of metritis is in the invasion of the vessels and lymphatics by foul matter; the coats of the vessels are so delicate that irritation easily spreads from them to the substance of the uterus in which they run. The veins of the uterus can scarcely be said to possess distinct coats ; at least it is difficult to isolate a venous channel from the wall in which it runs ; fibre-cells, identical with those of the uterine wall, are always seen in abundance in the walls of the veins. It is easy to con- ceive how a tissue, permeated by channels which carry irritating matter, may become inflamed in its substance. This may be actually seen in the acute septicemic metritis of childbed. Collections of pus are seen in the venous channels, and the surrounding muscular structure is softened. There is evidence enough to show, apart from analogical argument, that a similar process takes place in the non-pregnant uterus. But, especially in young women, in whom the affection is the result ENDOMETRITIS. 459 of menstrual suppression from cold, the inflammation may be strictly limited to the body of the uterus. The neck being less concerned in the menstrual hypersemia, and not subject to the same physical disturb- ance as in married women, more often escapes. In such cases, examination, limited to inspection through the spec- ulum, will fail to detect the intra-uterine disease. But in most cases the cervix becomes involved at no distant period. Endometritis is a frequent consequence of obstruction at the os in- ternum or OS externum. Hence, it is not uncommon in women who have never been pregnant, and even in virgins. The contracted os externum, by impeding the discharge of the menstrual fluid and ordi- nary uterine mucosities, leads to congestion, irritation, and inflammation of the lining membrane of the body as well as of the cervix. Reten- ' tion by valvular closure of the os internum from flexion leads to the same consequences. The cavity enlarges under the distending influ- ence of accumulation ; the retained discharges undergo decomposition, resulting in irritating matter. It is not uncommon for women subject to this aifection, to describe themselves as subject to " gathering and bursting of an abscess." That is, there is a stage of accumulation of muco-purulent matter, during which the pain of distension is felt, merging in spasm or colic, the pain of expulsion ; and then, expulsion effected, relief is felt. The quantity of the fluid thus collected varies, and it is difficult by direct observation to define it correctly. But there is little doubt that it amounts in some cases to an ounce or more. The condition and the symptoms resemble in many points those of dys- menorrhoea from retention. Indeed, dysmenorrhoea is often associated with it, as arising from similar mechanical causes. The discharge occasionally becomes exceedingly offensive, has acrid properties causing redness of the vaginal canal and vulva ; and is, in all probability, capable of exciting blennorrhagia in the male. Endometritis may occur at all ages, beginning from the outset of menstrual life clown to old affe. I have already said that endometritis may be limited to a particular area of the uterine cavity, and that this area is that which was origin- ally the seat of the placenta. In many cases the return of this area to the normal state is slow and imperfect ; and for weeks and months after labor it may present a rough surface, secreting a muco-purulent dis- charge, cut off by a sharp line of demarcation from the smooth, perhaps healthy, mucous membrane of the rest of the cavity. In the earlier periods, after labor, the uterine wall at this part is thicker, and remains more vascular than at other parts ; and this comparative thickness may persist for some considerable time. There is, in fact, imperfect invo- lution, especially of this part of the uterus, as the first step of a con- dition which merges into partial endometritis and metritis. Since the most common seat of the placenta is near the fundus, this variety of disease might be called "Fundal Endometritis." But this name has been used by Dr. Routh to describe a condition^ which does not necessarily depend upon pregnancy. He says, that part of the 1 On " Fundal Endometritis," Obstetrical Trans., vol. xii. 460 ENDOMETEITIS. mucous membrane which lies between the Fallopian tubes is especially prone to inflammation. If he is correct in his interpretation of the cases he relates, he establishes the conclusion that there is an endome- tritis limited to this particular area, which has been confounded with general endometritis. Quoting Dr. Beck, he shows that the fundus is supplied with nerves by a branch coming from the ovary, that is, from a different source from that which supplies the lower part of the body and the neck of the womb. The symptoms are exactly those described by Dr. Gooch as belonging to the " irritable uterus." " The abdomen is painful just over the pubes. Indeed, pressure here will often make the patient sick." If the sound be passed per anum or per vesicam, and the point be turned upon the fundus, pain will be produced. If passed into the uterus, there may be no pain until the point has passed the OS internum, and has struck the fundus. " If it be pressed at all forcibly against the fundus, absolute agony may result, which may pro- duce vomiting, an hysterical faint or fit, sometimes a regular epileptic fit." The disease. Dr. Routh says, is often the result of the use of in- tra-uterine passaries, of retained menstruation, or the retention of mucoid discharges. Recognizing, as my own observations compel me to do, the limited endometritis of the placental seat, to which I confess to have been led more by post-mortem inspections, at various periods after labor, than by clinical diagnosis, I am not prepared to accept without further evidence the description of Dr. Routh. I concur in the opinions expressed by Dr. Tilt and Dr. Fordyce Barker, at a discussion on the subject in the Obstetrical Society (Obstetr. Trans., vol. xiii), that the symptoms relied upon are not sufficiently distinctive. As Dr. Barker pointed out, undoubtedly the fundus is more sensitive than other parts of the uterus. When the sound touches it, pain is almost always felt; and this whether the organ be diseased or healthy. Dr. Routh describes one form of fundal endometritis as " convulsive," because he has found some cases to be attended with hysteria or other variety of convulsion. I am disposed to merge fundal endometritis in general endometritis. The inflammation may be chiefly limited to the cervical cavity. To specify this form, the objectionable term endoGervicitis, a barbarous com- pound of Greek and Latin, is in common use. It would be better to sacrifice conciseness, and to speak of " endometritis cervicalis." This is a very common affection ; and from its seat being partly within direct observation by touch and sight, it has engrossed an undue share of attention. The Course, Symptoms, and Diagnosis. — The diagnosis of endometritis rests upon the subjective symptoms, the history, and the objective signs. The patient complains of pain referred to the uterus, increased by exertion, attended often by dysuria ; the pelvic pain radiates to the back, and there is more or less constant lumbo-sacral heavy aching distress. Headache is also frequent, and various nervous symptoms of a depressing character arise as the disease becomes chronic. The history begins with pregnancy, with arrest of menstruation, with intra-uterine irritation or injury, as from wearing a pessary, with reten- tion of menstrual discharge, with flexion or version ; in short, the ENDOMETRITIS. 461 origin is in many cases the same as that of other forms of uterine in- flammation. The symptoms have probably at first been acute ; the uterine pain was intense, setting in with rigor, perhaps vomiting, and attended by fever. Passing into the chronic or subacute form, the pain has become less severe ; it has been intermittent, brought out into exacerbations by overexertion or by menstruation. The objective signs are made out by palpation, by the sound, and by the speculum. Palpation, vagino-abdominal or recto-abdominal, will generally establish increased Aveight and bulk of the uterus, and bring out pain or tenderness in the body of the uterus. The sound will commonly cause more pain than is usual on entering the healthy uterus ; it will often cause a little oozing of blood. Unless there be flexion, the sound passes easily, because the orifices are almost certain to be expanded. And when the point is in the cavity, the dilatation of this part is made manifest by the freedom with which the sound can be turned round. The uterus has lost its flattened condition, havino; become more pear-shaped. Diagnostic purj)ose being fulfilled, it is henceforth desirable to use the sound as little as possible. It is often a source of irritation. The speculum will in most cases show some amount of congestion of the vaginal-portion, perhaps abrasion or other lesion ; but tliis is an acci- dental not a necessary complication. Gosselin and Aran, describing the frequency of so-called ulcerations seen around the margin of the os uteri in chronic endometritis, affirm that they have little significance, and are generally the result of the maceration of the epithelium in the mucous secretions. As soon as the discharge lessens the ulceration heals rapidly. I must, however, re- mark that in most cases which follow labor, the loss of epithelium is due to the necrotic action I have described. Very acute pain, evoked by touching the fundus externally, is either an indication of extreme hypersesthesia in the subject, or of inflamma- tion of the substance of the uterus. When chronic or subacute catarrh arises primarily, that is, without acute beginning, leucorrhoea is often the first symptom which attracts attention. Then pain on excretion follows. Dysmenorrhoea becomes more pronounced. This last symptom is the more important in women who previously had not suffered from dysmenorrhoea. There are many women in whom dysmenorrhoea may be called secondary, that is, it is acquired as a consequence of metritis or non-involution after labor. Menorrhagia is a frequent attendant. The tumid, engorged, vascular mucous membrane easily allows blood to exude. The catamenia return in advance of the proper period, that is, every three weeks or fortnight, and last for a week or more, sometimes profusely. The blood-flow is commonly succeeded by a muco-puriform discharge ; and not seldom, slight causes will determine a flow of blood in the intermenstrual periods. A common remark is that the flow returns a day or two after having apparently ceased, so that the subject hardly knows when the period is fairly at an end. Sometimes clots of dark blood " like leeches " are voided. In one case of intense endometritis the woman 462 ENDOMETRITIS. passed every morning a cylindrical mass about three inches long, slimy and streaked with blood. Dysmenorrhoea more especially attends the catarrhal inflammation of the body of the uterus, probably because this condition is apt to involve some degree of inflammation of the uterine wall itself. The form in which dysmenorrhcBa appears is uterine, that is, pain is felt shortly before and at the time of the uterine flux ; it is referred to the uterus or middle of the pelvis, and radiates to the loins and sacrum. In the milder forms of catarrh, the discharge is chiefly mucus entan- gling epithelial cells ; it may be clear or opaque. The hypertrophied uterine glands at times pour out a profuse, even exhausting, secretion. In severer forms it is often tinged with blood. This, Bennet says, is as characteristic as is the rusty sputa of pneumonia. It is due to the intense congestion, the blood easily permeating the thin epithelial covering. The neighboring organs are commonly somewhat disturbed. In the acute forms, even dysenteric symptoms may be produced. In the chronic forms diarrhoea is not uncommon, alternating perhaps with constipation. Diarrhoea in the acute form, however, is not alone the consequence of proximate irritation ; it is more likely to be due to septicEemia. Both in the acute and chronic forms some bladder-distress is a frequent attendant. Dysuria and frequent micturition, and some- times cystitis, are observed. Disorder of nutrition and of the nervous system are sure to follow sooner or later upon chronic uterine catarrh. The abnormal derivation of vascular and nervous action leaves the digestive organs imperfectly supplied ; and the constant wear and tear of pain exhausts the nervous centres. Hence the appetite is impaired, capricious, difficult to stimu- late. Despondency, fretfulness, sometimes hysterical symptoms harass the patient. Nausea, vomiting, gastralgia, distension of the stomach follow. The urine becomes turbid, loaded with uric acid or phosphates, and sometimes with mucus. This is especially the case in women towards middle age, with a tendency to obesity and sluggish liver. In other cases, the discharges and the impaired nutrition entail ema- ciation. The face puts on a dull, languid, worn expression ; the fades uterina becomes formed. The features fall ; dark circles surround the eyes. Acute endometritis may end in spontaneous recovery. Perhaps rest and careful regimen for a few weeks may suffice for cure. But of the accomplishment of this we cannot be certain, until one or two menstrual periods have passed by without rekindling the symptoms. The signs of cure are : the cessation of febrile movement and of local pain ; the moderation of discharge, the closure of the os externum uteri, and the return of the mucous membrane of the cervix to its natural pink color. Chronic endometritis, on the other hand, is a most obstinate disorder. It shows little disposition to spontaneous cure. Some observers in- deed doubt whether it can even be cured by art. But this doubt I do not share. A well-directed local treatment will almost certainly be followed by success, unless there be diathetic or other morbid com- plications. ENDOMETRITIS. 463 Scanzoni throws almost equal doubt upon the curability of chronic endometritis, that he does upon chronic metritis. Chronic catarrh, he urges, is the almost never-failing companion of chronic parenchymatous metritis, and how shall it be healed whilst the disorders of the circula- tion in the walls of the organ persist ? How shall the hypersemia, swelling, and hypersecretion of the mucous membrane disappear whilst the causative disorders in the wall of the uterus persist ? I have already discussed the possibility of cure of parenchymatous metritis. If this possibility be admitted, then the possibility of curing endometritis follows as a corollary. I cannot help attributing this eminent physician's unfavorable opinion, in some measure, to his imperfect estimate of the etiological importance of constriction of the os externum uteri, and of flexion. Treatment which fails to take cognizance of these conditions must necessarily be imperfect, and wuU therefore often fail. The indication to begin by removing any complication, such as flexion, inflammation of the vaginal-portion or cervix, or atresia, is obvious. Indeed, the principal remedies, those to be applied to the interior of the uterus, cannot be brought into use until the cervical canal is made permeable for at least a No. 8 or No. 9 catheter. Inflammation or engorgement of the cervix must be subdued by the methods already described. And when this is done, it will sometimes be found that the signs of endometritis have disappeared. Whether it be by derivation or by other agency, curing inflammation of the cervix will sometimes cure inflammation of the body too. But, although this is an essential part of the treatment, it ought not to be trusted to alone. For, if it occasionally is sufficient to cure, yet the process being indirect is slow and tedious. It is remarkable and gratifving to observe, in some cases, how quickly a long-standing case of endometritis is cured by direct treatment. The Treatment. — In the acute stage, which is most likely complicated with metritis proper, the application of twenty leeches to the hypogas- trium, fomentations, sedatives, salines, will be necessary. In the chronic stage, the cure will depend greatly upon the judicious use of intra- uterine remedies. Just as in the case of chronic inflammation and hypertrophy of the fauces with its glands, topical applications offer the most effective means of bringing about a healthy condition of the altered tissues. The solid nitrate of silver, wdiich acts so well else- where, is of signal service in this case. The sulphate of zinc I have found almost equally beneficial ; and it has the advantage of being safer. But tincture of iodine, carbolic acid, chromic acid, chlorate of potash, perchloride and persulphate of iron, nitric acid, acetic acid, have all been extolled. These remedies are best applied either solid or in the form of ointment, or as liquid carried on swabs. The prac- tice of injecting liquids into the uterine cavity offers no marked advan- tages over the methods described, and the attendant objections are so serious that it is desirable to discuss the subject of intra-uterine medi- cation with special care. 464 ENDOMETRITIS. The various Modes of applying Remedies to the Internal Surface of the Uterus. The treatment of morbid conditions of the body of the uterus by intra-uterine injections is a subject that calls for earnest discussion on account of its utility and its dangers. If we treat morbid conditions of the eye, mouth, throat, larynx, bladder, rectum, and vagina by injections with such manifest advantage that we have come to look upon this method as in many cases indispensable, it seems reasonable to expect equal advantage from its action on the mucous membrane of the cavity of the uterus. Experience amply justifies this expectation. Topical applications to the diseased mucous membrane are in many cases essential to cure. But in the form of injected fluids they are not free from danger. Almost every author who has w^ritten upon the subject, refers to cases of accidents, ranging from severe pain to shock, collapse, metritis, perimetritis, and death. It is desirable to refer to some of these cases which best illustrate the conditions of danger. Henry Bennet relates a case which occurred under Jobert. A girl, aged twenty-four, had a large fibroid of the uterus. Jobert made an astringent injection into the cavity of the neck. Almost immediately there arose shiverings, agonizing pains in the abdomen, then fever, then death in a few days from metro-peritonitis. Bennet performed the autopsy. He found nothing besides the marks of peritonitis. In my work on '' Obstetric Operations" (2d ed., 1871), I have related a case which occurred in the London Hospital after I had left that institution. The history was supplied to me by Mr. Hermann, resident-accoucheur at the time, and the account of the autopsy by Dr. Sutton. A woman, aged forty-eight, had had six children and five abortions. For eighteen months she had suffered from menorrhagia. On admission there was decided retroflection of the uterus. An in- jection of perchloride of iron, in the proportion of one part of the satu- rated solution to six of water was used. About half a pint of this was injected through a double-channel catheter attached to a Higginson's syringe, the patient lying on her left side. The fluid appeared to flow out as fast as it entered. The catheter was kept half rotated, so as to hold the uterus in its proper axis during the injection. The os uteri had been well dilated. Immediately after the operation the patient complained of intense pain in the abdomen. In the evening the pain was worse, and she had vomited. The pulse and temperature rose, and she died in collapse fifty-eight hours after the injection. In the peritoneal cavity was found a quantity of blackish-green opaque puri- fbrm fluid. Much of the peritoneum covering the intestines around the uterus w^as of a black color. There was a quantity of pus in the pelvis. The left Fallopian tube was enlarged, and the vessels on its peritoneal surface highly injected. The outer half of the tube was much dilated, and filled with dirty, pus-like fluid. There was marked retroflexion of the uterus. Dr. Sutton's opinion was that the fatal peritonitis was caused by the iron solution escaping through the Fallo- pian tube into the peritoneal cavity. INTRA-UTEEINE MEDICATION. 465 Dr. v. Haselberg relates an instructive case.^ A jpueJla publica, having had an abortion six months before, came under treatment with anteflexion of the uterus to such an extent as to render the pas- sage of the sound difficult. She suffered from profuse menorrhagia, and it was determined to try injection of perchloride of iron. It was only after repeated trials that the syringe was made to pass beyond the seat of flexion into the cavity of the uterus. The patient suffered no pain at the time, but at night had a severe rigor. On the fifth night rigor was accompanied by severe vomiting, and abdominal pains immediately ensued. On the following night this was repeated, where- upon she fainted and died. The intestines were found united by recent exudation. The lower parts of the pelvis were filled with stinking pus ; the source of this was discovered in a cyst in the right ovary, which, through a small opening, gave issue to like matter. The right tube was permeable throughout its Mdiole length by a large sound. The mucous membrane of the uterus was stained, as if with ink, and the same appearance extended along the right tube. The black patches showed iron by chemical tests. One fact, at least, is clear from this case, — that perchloride of iron, like other fluids, may run along the Fallopian tubes. But it is not so obvious that the fatal result was due to this accident. No immediate symptoms followed the injection. The signs of intra-abdominal injury seem due to the perforation of the ovarian cyst under the pressure of vomiting. Hourmann, of Lourcine, relates the following : A girl, aged nine- teen, had profuse leucorrhoea. He injected a decoction of nut by a clysopompe into the uterus. At the first stroke she cried out and put her hand to the left iliac region. Severe shivering set in, and lasted several hours ; then febrile reaction followed. The pain spread to the abdomen, indicating metro-peritonitis. Hemorrhage appeared in two days, and she was relieved. It deserves notice that the intense pain called forth by applying various substances into the cavity of the uterus is most frequently of the nature of colic ; it does not generally indicate metritis. Metritis may, however, be caused if the substances used are caustic, as distinguished from styptic or astringent. This difference of course depends upon the degree of concentration of the agents employed. It is a point which has been strangely neglected by some practitioners, who having used caustic solutions of perchloride of iron to arrest hem- orrhage, have caused sloughing of the uterus, and have straightway condemned the agent, instead of their own want of discretion in the use of it. The danger of fluids running along the Fallopian tubes seems to depend upon undue patency of these canals. This undue patency in its turn is owing in many cases, at least, to obstruction at some lower part of the utero-vaginal canal. Thus in V. Haselberg's case, and in the one at the London Hospital, there were decided flexion of the uterus and dilatation of the tubes. It is not enough to know that patients occasionally die after injec- 1 Monatsschrift fiir Geburtskunde, 1869. 30 466 ENDOMETRITIS. tions are thrown into the uterine cavity — we want to know why they die. Knowing this, we may learn how to avoid the causes of danger, without abandoning the use of a mode of treatment which renders in a great number of cases incontestable service. Many experiments have been made on the dead body to ascertain the behavior of injections. Hennig, Klemm, Guyon, Fontaine [on 'puerperce), Alph. Gu6rin, Guichard, Scanzoni, and others have done this. The experiments generally show that there is extreme difficulty in making fluids run along the tubes, especially if the injecting syringe does not completely fill the os uteri internum. I will not relate or analyze these experiments, because they appear to me to be of little practical value. The conditions of the dead and of the living tissues are essentially different. For example, in the dead body there is no muscular contractility, no irritability under stimulus, no response of the nervous centres to peripheral injury. Yet these are conditions which come into play when injections are thrown into the living uterus. It may, indeed, seem at first sight that these experiments would at any rate illustrate the problem of the permeability of the Fallopian tubes. But, even here, their value is small. They may prove that great force is necessary to drive fluid along these canals ; and that, unless the cavity of the uterus be closed below, as at the cervix, fluids will rather regurgitate than run onwards. But it is certain that in some of the cases where fluid injected into the living uterus ran along the tubes, the accident could not be accounted for by the very small amount of injecting-force employed. Another power, therefore, must have been in action, and this could be no other than that exerted by the uterus itself contracting spasmodically upon the irritating fluid thrown into it. This force, the lower or cervical orifice of the uterus being closed, w^ould pump the fluid onwards into the tubes. Dr. J. Whitehead, in a valuable practical paper (Brit. Med. Journal, 1873), suggests that fluids may be carried onward into the peritoneum by capillary or ciliary action. He prefers the use of solid or unctu- ous substances. Again, it is not necessary for the production of alarming or even fatal accidents, that the fluid should run along the tubes. The fluid injected into the cavity of the uterus may cause metritis, and the inflam- mation may spread to the adnexa and to the peritoneum. Or severe pain, shock and collapse may be the immediate and simple result of the irritation produced on the uterine superficies by the contact and retention of the fluid. The agony attending some cases of dysraenor- rhcea is simply due to the irritation set up by retained blood causing uterine contractions or colics. The pain, the prostration, the other nervous phenomena attending dysmenorrhcea are sometimes as severe as those attending intra-uterine injections. In some unfortunate cases, as in one related by Tessier, the fluid injected has been, not simply of styptic and congulating power, but actually caustic. It ought to be needless to point out so fundamental an error. But it has been committed more than once ; and the fault ol the operator has been assigned to the method. It is not even necessary that fluids should be injected into the uterus INTRA-UTERINE MEDICATION. 467 at all. I have seen pain and collapse so severe as to cause the utmost anxiety for the result, follow an ordinary injection of weak sulphate of zinc into the vagina. This occurred in the case of a lady, whose maid was administering, as she had often done before, a zinc solution, by means of a Higginson's syringe. The cervix in this case was pat- ulous, but it is certain that the pipe of the syringe was not inserted into it. She recovered in some hours, no inflammation supervening. It will further be remembered that the mere touch of a sound or bougie against the fundus uteri will in some cases produce severe pain, and even prostration. Again, symptoms resembling in character and severity those caused by injected fluids, are occasionally observed when solid or unctuous substances are used, which cannot from their nature flow along the tubes, which must, in short, act in loco. Thus, Aran says he has known three cases of fatal peritonitis from actual cauterization of the os uteri, and one case of fatal ovaritis from the application of Vienna paste. I have known the most severe pain and prostration followed by hemorrhage and metritis, caused by the application of solid nitrate of silver to the interior of the uterus ; and I have seen fatal peritonitis follow the simple application of nitrate of silver to the cervix uteri. The severity of the accidents is not explained by the nature of the fluids injected. Alarming symptoms have followed the use of compar- atively weak solutions. It has been supposed in these and other cases that the untoward phenomena were due to the forcible propulsion of air along with the fluid. In some cases this hypothesis may be well founded. But I think its importance has been exaggerated. It is even doubtful whether a quantity of air at all calculated to produce serious distress can be driven into the vessels or tissues of the unimpregnated uterus ; and the small quantity that might possibly run along the Fal- lopian tubes into the peritoneal cavity could hardly do much harm. One all-important caution is to be religiously observed, namely, never to use any topical application to the uterus, or to perform any sur- gical operation upon the uterus, ivhen a menstrual period is impending. It is at this time when the menstrual flux is imminent, when the nervous system is at its acme of excitability, that even slight causes are sufficient to light up acute inflammation. At this time, it may be said, the uterus resents all interference. Dr. Cohnstein gives^ a careful historical survey of the practice and opinions of those who have related their experience upon this subject. The general conclusion arrived at is that injection of very powerful caustics is likely to cause inflammation of the uterus and peritoneum, or severe prostration and uterine colics ; and that these dangers are less urgent if care be taken first to dilate the cervix. Dr. Lente^ discusses this question, passing under review the various topical methods of treating disease of the cavity of the uterus. Iodine in solution he has known cause intense pain and alarming collapse, which, however, passed away, no further bad effect ensuing. 1 Beitra2:e zu Chronischen Metritis, 1868. "^ New York Journal of Medicine, 1870. 468 ENDOMETRITIS. The leading gynaecologists of New York have also discussed this question. Instances of serious accidents were adduced. The general opinion seemed adverse to the use of intra-uterine injections, whilst Dr. Thomas was especially emphatic in his condemnation. To avoid the dangers of intra-uterine injections, several j)i'ecepts have been enjoined. The great object aimed at is to avoid or lessen the risk of the fluid running along the tubes. This it is sought to attain — 1st. By securing free dilatation of the cervix uteri before injecting, so that the fluid may readily run back into the vagina. For this pur- pose the preliminary use of laminaria-tents is advised. 2d. By using only graduated quantities of fluids, and injecting very gently and slowly. 3d. By using a double canula, so as to secure a return-current. To effect this the more surely, the openings of the canulse at the uterine end are made at different levels. I have not much faith in the double canula. The end which should serve for the return-current is liable to be choked. The preliminary free dilatation of the cervix and the use of gentleness in propel- ling the fluid should never be omitted. But I do not believe that the observance of these precautions is an absolute guarantee against ac- cidents. It is probable that the mere forcible impact of any fluid striking upon the inner surface of the uterus, especially upon the fun- dus, may cause severe pain and prostration. Since nothing is gained by forcible injection, this consideration affords additional reason for in- jecting with all possible gentleness. Hence, it is well to use injecting- pipes having lateral openings of very fine calibre, so as to "pulverize" the liquid. I strongly advise not to use injections at all in cases of marked flexion of the uterus. Even if we dilate the cervix first by tents, and maintain the uterus erect during the injection, we cannot always be sure that the flexion will not be reproduced, so as to prevent the issue of the fluid ; and it must not be forgotten that it is especially in these cases that the uterine cavity is likely to be enlarged, and the Fallopian tubes dilated. The general conclusion at which I have arrived is to restrict the use of intra-uterine injections within the narrowest limits. I rarely em- ploy them now, except in cases of urgent danger from metrorrhagia. We may obtain almost all the advantages that injections are capable of giving by other means. For example, the same agents which are so useful in the form of solutions for injection, may be applied either by swabbing, or solid, or in the form of ointment. Thus, wliere the use of chromic or nitric acid, perchloride of iron, iodine, or bromine, is indicated, these agents can be applied soaked on a sponge or piece of cotton, or on a glass or hair-pencil, having previously well dilated the cervix. Nitrate of silver is far better applied in the solid form. Even then it is liable to cause severe colic. The risk of this may be lessened by reducing the t^austic by fusing it with equal parts of nitrate of potash. The ordinary way of using the solid nitrate of silver, that is, by holding a piece of the stick in a forceps or porte-crayon, is objection- able. The piece may fall out or break, and a fragment left behind in INTEA-T7TERIXE MEDICATION. 469 the cervix or body of the uterus may give rise to intense agony, and even metritis. To avoid this accident I have for many years used the contrivance figured on p. 129 (Fig. 42). This is far the best way of applying nitrate of silver to the os and cervix uteri, and it is the only safe way of applying it to the interior of the uterine cavity. The armed end of a probe may be passed into the uterus without the speculum, although the aid of this instrument is sometimes convenient. For example, unless the armed probe is pro- tected by a canula, the caustic will first touch the vulva and vagina in its passage, which is apt to have unpleasant effects, and the guiding finger of the operator will be stained. One of the most widely useful topical applications to the mucous membrane of the cervix and body of the uterus is sulphate of zinc. The value of this agent, when applied to the relaxed or morbid mucous membrane of the vagina in the form of injections, is familiarly known. How to apply it to the uterine mucous membrane is therefore a matter of great interest. A solid stick of two or three grains can be carried quite into the uterus without having touched the vagina by the way, by means of my canula (Fig. 43, p. 129), now generally sold by in- strument makers. It is a great advantage of this contrivance, that the use of the spec- ulum is Cjuite unnecessary after it has aided in establishing the diag- nosis which supplies the indication in treatment. When the instrument has gone the proper depth, the piston pushes out the stick, and the instrument is withdrawn, leaving the stick to dissolve. This it soon begins to do, and by its speedy effect in constringing the mucous mem- brane, it keeps itself ?n situ until it is completely dissolved. iXitrate of silver reduced by admixture with nitrate of potash may be used in the same way. So may persulphate of iron, but this should be considerably reduced. When used nearly pure, I have known it cause severe colic and bleeding. A most precious way of applying astringents, caustics, solvents, or alteratives, to the interior of the uterus, is in the form of ointment or pasma. In this way almost any substance may be applied. Where grease is objectionable as a vehicle, a pasma of suitable consistence may be made by glycerin or other substances. In this form we may use rem- edies which cannot easily be applied in any other way. For example, we can hardly use bromine, or iodine, or mercury, in a solid shape; and to use them in the liquid form is open to the objections already discussed. Almost anything can be made into an ointment or pasma; and we thus get a complete practical command over a large range of useful agents. To introduce ointment into the cavity of the uterus, the instrument figured at p. 129, Fig. 44, is both convenient and effective. It is used without aid of the speculum. It is charged by dipping the end into the ointment. This carries a sufficient quantity into the uterus, when, by pushing home the piston, the ointment is deposited there. If it be desired to apply a powerful licjuid caustic, as chromic acid or strong bromine, to the interior of the uterus, this can be done by the same instrument. A few shreds of asbestos may be packed in the 470 ENDOMETRITIS. space between eyelet-holes, and charged with the fluid. On ramming down the piston the fluid exudes. Vaginal lotions of tannin, sulphate of zinc, acetate of lead, or alum, render important aid. There is often some complication of chronic inflammation of the fundus of the vagina, with ulceration ; and it is useful to remedy this condition. This is the more important, since the patient can herself keep up this treatment. A mode of medication applicable to the vagina I have often found useful, is to wrap about twenty grains of alum in powder in a pledget of cotton-wool ; and to insert this in the vagina daily, or every other day. This contrivance acts in two ways ; first, there is the astringent, corrective action of the alum, gradually acting as the powder melts down; and, secondly, the cotton plug acts by keeping the irritable vaginal walls from contact and friction. It secures "rest." Sometimes, however, plugs act as foreign bodies, cause irritation, and are not tolerated. They should not be allowed to remain more than four hours. They can be applied by help of the plug speculum figured at page 131. In Dublin and America the fuming nitric acid is highly extolled. Dr. Lombe AtthilP advises first local bloodletting by scarification. Then he proceeds to the swabbing the interior of the uterine cavity with strong nitric acid. In order to secure its due application, he dilates the cervix uteri with a fagot of laminaria-tents ; then he intro- duces an intra-uterine speculum, which makes a channel, protecting the cervix, through which the charged swab can be carried direct to the fundus of the uterus. The uterus is drawn down and steadied by seizing the os uteri with a vulsellum. Dr. Kidd, Dr. Ringland, Dr. Evory Kennedy, Dr. J, A. Byrne, all speak highly of the efficacy and safety of this method. For my own part, I feel compelled to repeat that experience has amply proved that the dilatation by tents of the cervix uteri, howsoever necessary it may be in some cases, is almost invariably a painful, and sometimes a dangerous proceeding. The action of the nitric acid, itself, I do not doubt is useful, and as safe as most other agents. Constitutional treatment should not be neglected. In the acuter stages salines and sedatives, with a bland unstimulating diet, should be given. In the stages of debility, when nutrition has become im- paired, and when the nervous centres have suffered from long-continued impressions of pain, and the wear and tear of illness, neuralgia, in one or more of its numerous forms, is almost sure to be developed. Reme- dies presumedly directed ad hoc, are almost as sure to fail, unless, indeed, the exhausting disease, the endometritis, be cured. But still, the use of tonics and other remedies calculated to improve nutrition, to procure ease from pain, to regulate the secretions, should go on pari passu. Copaiva, which may be given in the form of capsules, appears to possess some virtue in restraining secretion from the mucous membrane of the uterus, although it is less to be depended upon than in the case of the lungs or bladder. Ergot and digitalis are also at times useful ; ' Dublin Medical Journal, Januarj', 1873. TREATMENT. 471 quinine, bark, and strychnine, I think, are even more so. These agents, then, must not be neglected as adjuvants. Purgatives become of essential importance. Saline aperients, aloes, an occasional mercurial alterative, generally combined with belladonna, give the best results. Aran speaks highly of aloetic enemata. Indeed, no indication is of more general apj)lication than that of keeping the rectum free from accumulation. Exercise should be regulated by the patient's strength, and her lia- bility to pain. A sense of weight, of oppression, of pain in the pelvis, extending down the legs, should be taken as a warning to rest. Hip- baths and the consequent friction bring some of the benefits of exercise. When the active symptoms have been subdued by local treatment, the stimulating salines, sulphur or iron waters will be useful in con- firming the cure. Hip-baths of plain cold water, combined with vaginal irrigation, often render great service. But in most cases warm baths are safer and more useful. There is a form of inflammation of the cervix, chiefly limited to the mucous membrane, unconnected with pregnancy, which may also be called traumatic. It is the result of undue or awkward sexual inter- course, associated or not with infection or local poisoning. Although most frequent in young married women, I have seen a similar condi- tion independent of sexual intercourse. In some of these the cause was obscure ; in others the disease ensued upon cold or violent exertion. The patient complains of pain more or less acute, in the centre of the pelvis, radiating to the hypogastrium and groins. She stoops in walk- ing, in order to relieve the pain. Any exertion quickly induces such pain and exhaustion that she is compelled to rest. There is often some degree of constitutional irritation and disturbance of the function of the stomach. Sometimes there is leucorrha?a; but often the reply to ques- tions upon this point is in the negative. On examination, it may be found that there is a copious accumulation of muco-puriform matter in the fundus of the vagina, where it lodges, being retained there as in a sac by the contraction of the vagina below. Such a collection may be voided unconsciously during defecation. The rugse are prominent, angry-red ; copious, epithelial secretion is found between the ruga, and viscid glairy secretion is seen oozing from the cervix uteri. The mem- brane covering the vaginal-portion of the cervix may be smooth, or may present spots of epithelial abrasion ; but it is in either case in- tensely red, injected, and somewhat swollen. This form of disease not uncommonly induces vaginismus. Dyspareuuia is often very marked. The treatment consists in " rest." Injections of lead are especially useful. In aggravated cases, especially those marked by vaginismus, the vaginal-rest, or a cotton- wool plug soaked in glycerin, renewed daily, will be of essential service, and will greatly shorten the period of treatment. One form of endometritis leads to exfoliation in mass of the mucous membrane. This constitutes the dysmenorrhcea membranacea, which has been described in Chapter XXII. In some cases of this kind I have known inflammation affect the mucous membrane of the cervix, as well as of the body. The epithelium of the os uteri, and presumably 472 ENDOMETRITIS. that of the cervical canal as M'ell, being thrown off, leaving a pseudo- ulcerated or denuded surface, although there had been no labor. If there be a tubercular diathesis the case is more troublesome still, probably incurable; for tubercularization is rarely limited to the uterus. The syphilitic taint is commonly acquired through the gestation of a diseased ovum, and often first becomes manifest after the birth of a child, at times showing marks of the disease, or, more frequently, after the premature birth of a dead child, or after an abortion. The syphilized mucous membrane is thickened — constantly tending to rapid superficial decay ; and its regeneration is imperfect. The taint remains, as in the skin, for an indefinite time. Such a mucous membrane is unfitted to develop a healthy decidua, and yet it is not a bar to impregnation. Hence conception after conception issues in abortion ; and every time the new mucous membrane is reformed with the same characters. More or less chronic engorgement or inflamma- tion of the body of the uterus commonly attends. Unlike the tuber- cular diathesis, the syphilitic commonly affects the cervix as well as the body of the uterus. There is always hypersemia, sometimes chronic inflammation ; and the menstrual disposition is towards excess in loss. The appearance of the vaginal-portion has struck me in many cases as being peculiar, so that I have thought I could recognize the syphilitic complication by the sight. But in practice we are not often obliged to trust exclu- sively to the local symptoms. It is rare that the history and the pres- ence of symptoms in various parts of the body do not reveal the nature of the case. Sore throat, fissured or ulcerated tongue, characteristic eruptions on the skin, falling of the hair, will generally be found. Leucorrhoea, the discharge being often more offensive than usual, is a constant symptom. The treatment must obviously be both constitutional and local. Iodide of potassium, occasionally iodide of mercury, bark, should be per- sisted in for several months. A cure cannot be effected in a few weeks. Baths of Yichy salts, or better still, the internal and external use of bromo-iodic waters, as those of the Woodhall Spa, Kreuznach, Carls- bad, or Wiesbaden, will render eminent service. The best local remedies are the iodide of lead, or iodide of mercury ointment applied inside the uterine cavity. The direct contact with the diseased mucous membrane I have found especially beneficial. Sometimes the part may be touched with solid nitrate of silver, or a small stick of sulphate of zinc may be inserted. All these remedies are best applied without the speculum, by means of the tubes figured on page 129. The applications should be made every fourth or fifth day between the menstrual epochs. The local treatment may be partly carried on by the patient herself. Sulphate of zinc injections daily will be of service, although they touch the vagina and vaginal-portion only. Should pregnancy occur, and it is to be deprecated until the mucous membrane shall have recovered its soundness, the local treatment must be stopped. But the constitutional remedies should be sedulously per- CYSTIC ENDOMETRITIS. 473 sistecl in. We may usefully combine with the iodide of potassium five or ten grain doses of chlorate of potash. In this way abortion is sometimes averted. The submucous uterine tissue becomes hypertrophied into connec- tive-tissue outgrowths (Sarcomata), which gradually form the so-called fibrous polypi, in whose interior are often contained separated portions of elongated uterine glands, or gland-tubes, of new formation, which degenerate into cysts [Cysto-sarcoma adenoides). Sometimes the uterine mucous membrane degenerates into a more or less hard, richly nucleated, fibrillous, callous, connective-tissue sub- stratum, in which the glands have shrunk away. Often it is studded with small cysts, containing mucus or colloid, the remains of the sepa- rated portions of the uterine glands. Cystic Endometritis. The development of cystic tumors at the cervical orifice out of ob- structed glands is not uncommon. It is less frequent in the cavity of the uterus, but still it is occasionally observed as a result of chronic endometritis. The utricular follicles may, as we have seen, be greatly hypertrophied. They may be seen as small rounded tumors, projecting as hemispheres, or sometimes pedunculated ; their walls are transpar- ent ; they feel like little resisting grains, slightly elastic. They range from the size of a pin's head to that of a small nut. They contain a transparent liquid. They are often associated with the so-called fun- gosities, granulations, or vegetations. Ch. Robin has shown that these bodies are formed of exactly the normal elements of the uterine mucous membrane. There is a disposition to fatty degeneration at their base. In some rare cases the elongation of the uterine glands takes place in both directions, that is, into the uterine cavity on the one hand, and into the uterine parenchyma on the other. These little cystic growths sometimes form a cluster, hanging round the upper end of the cervical canal, near the os internum ; or may be more or less isolated ; or they may occur in groups or singly, near the OS externum. When they form in the cervix the os externum is usu- ally patulous, and the finger passed into the cavity feels them as rough projections, or as soft pedunculated bodies rolling under the finger. Sometimes, as in a case figured by Lancereaux, these cervical cystic growths are associated with a similar formation in the body of the uterus. In this case the enlarged uterus contained a thick viscid fluid ; its mucous membrane M^as red, injected, had at its fundus a mammil- lated mass, grayish, formed of vascular connective tissue, in which were found multiple cavities filled with clear serosity. These changes of the mucous membrane probably include some of the most difficult pathological and therapeutical problems. The " fun- gosities," " carnosities," " excrescences," so often associated with some degree of enlargement of the body of the uterus, attended by hemor- rhage, and inducing cachexia, not seldom, by their obstinacy and other characters, simulate malignant disease. Sometimes, indeed, there is 474 CYSTIC ENDOMETRITIS. good reason to believe that the endometritis is dependent upon, and modified by, a tubercular or cancerous complication. But even apart from such complication, the changes of structure resulting from long- standing slow congestion or infiamraation are exceedingly troublesome. They may sometimes be distinguished from the malignant disease which attacks the lining membrane of the uterus after the menopause by this circumstance : if there have been a distinct interval after the meno- pause, marked by absence of blood-discharge, then the sudden appear- ance of hemorrhages is strongly presumptive of the rise of malignant disease. But where during the latter years there has been persistent menorrhagia, followed by hemorrhages more or less periodical, without any prolonged break to mark the cessation of ovarian life, although the insidious invasion of malignant disease may be possible, the pre- sumption is greater in favor of chronic inflammatory change in the mucous membrane. Forming sessile or pedunculated tumors, they resemble, and sometimes may be, early papillary epithelioma. Whether malignant or benign, a symptom which cannot be over- looked any more than the hemorrhage, is almost constant, that is, severe pain. This I have found, both when the growths were in the cervix and when they were in the proper cavity of the uterus. The bleeding is often profuse to the extent, by its quantity and fre- quent recurrence, of endangering life. When the seat of the disease is the cervix the blood is sometimes bright arterial ; when the seat is in the body of the uterus, and the blood is liable to temporary or partial retention, it may be darker, even black. This gradual rise of the affection towards the advent of the meno- pause, and its comparatively rare occurrence at an earlier age, supply evidence of its slow development out of chronic inflammation. They are not uncommonly associated with fibrous tumors or polypi in the body of the uterus, as may be seen in illustrations in the chapter on those affections. As already said, the body of the uterus is almost invariably enlarged ; its walls are thickened. This commonly induces some signs of pro- lapsus, but flexion is by no means a necessary concomitant. I think I have more frequently observed anteversion. The enlargement of the womb is the result of slow hyperplastic process. There is generally a degree of softness of structure. Increased vascularity or congestion, aggravated by ovarian stimulus, leads to menorrhagia, now and then amounting to alarming flooding. Dyspareunia commonly attends, and intercourse is sometimes the excitino; cause of hemorrhage. The uterus is found by touch to be increased in bulk and weight, and to be unusu- ally sensitive. The sound will often cause bleeding, and more pain than is usual. The speculum shows tumefaction and vascularity of the vaginal-portion ; a patulous state of the cervical canal, and blood or mucus issuing from the uterus. The systemic symptoms are the expression mainly of the losses of blood, and of the impairment of the functions of nutrition and inner- vation, consequent on ansemia and local irritation. This exhaustion and the attendant pain will commonly give the patient a peculiar, worn, haggard expression of countenance. CYSTIC ENDOMETRITIS. 475 The first indication in treatment is usually the urgent one to arrest bleeding. To carry this out the most effectual means are the topical application of perchloride or persulphate of iron in styptic strength, or rather concentrated chromic or nitric acid. These agents may be carried into the uterine cavity on a sponge or strip of linen, mounted on a whalebone probang, or on a glass pencil, through a speculum, if the canal of the cervix is open and straight enough; or better still, we may pursue the method already described, of Dr. Atthill. In the contrary case it may be necessary first of all to dilate the cervix by sponge or laminaria tents. Indeed, the rule laid down in the chapter on " Hemor- rhages " to " obtain and maintain free patency of the cervical canal " applies strictly to this case. So true is this, that in many cases the mere artificial dilatation will check the hemorrhage. Dr. Routh^ even affirms that the action of " the sponge-tent itself suffices to cause absorp- tion and diminution of volume of the uterus." When the hemorrhage has been checked, tonics, as strychnine, quinine, ergot, will be useful. The diet should be light ; stimulants should be sparingly given. The introduction into the cavity of the uterus of solid sulphate of zinc every fourth or fifth day, nitrate of silver and nitrate of potash fused in equal parts, chlorate of potash, iodide of potassium, and iodide of mercury, will in turn often be of eminent service. In obstinate cases where the above or other topical applications fail, the expediency of removing the diseased tissue must be considered. It was in such cases that Recamier practiced the operation of scraping off the excrescent fungosities by a curette. The proceeding seems a bold one, even rough ; but then the condition of the patient is serious. Undoubtedly patients have been rescued from imminent danger by it. I affirm this from my own experience in several cases. In this aflPec- tion, as in undoubted malignant disease, it is the surface, the papillary projections, which are the immediate source of the bleeding. When the superficial stratum is removed the bleeding is usually arrested, at least for a time. Fig. 97 represents Marion Sims's curette, which I have found a very convenient instrument. It has two sizes, one at either end of a stem about ten inches long. Fig. 98 represents R^camier's curette. The two forms may be con- veniently united in one instrument, so that either end may be used. The curette held in the right hand is passed into the body of the uterus, guided by a finger of the left hand applied to the os uteri, the fundus being supported by the hand of an assistant above the symphysis. The subacute edge of the curette is then drawn down over the entire inter- nal surface, so as to break down and detach any projecting masses. Sometimes small pisiform or pyriform bodies, like minute vascular or mucous polypi, are brought away. By injecting a light stream of water these bodies will be washed out, and may be collected in a cloth ^ " Cases of Menorrhagia treated by Injection, or the Removal of the Uterine Mucous Membrane by the Gouge." By C. H. F. Eouth, M.D., Obstetrical Trans., vol. ii. 476 CYSTIC ENDOMETEITIS. applied to the vulva, for examination. It is not generally necessary to apply anything to the surface after the curette has done its work. But there is better security against bleeding, and probably useful action upon the diseased surface, by mopping with nitric or carbolic acid. Marion Sinis's curette. When applying the nitric acid it is necessary to introduce the specu- lum — my modification of Neugebauer's 1 have found the most conveni- ent — and to draw down the os into a direct line, by seizing the anterior lip with Sims's hook. The os being thus held open, the probang Eecamier's curette. charged with the acid is easily introduced, without touching other parts. Absolute rest is essential. There is of course room for appre- hension, lest metritis follow. The operation should not be resorted to except when milder and safer proceedings have failed to relieve urgent symptoms. Occasions arise when timidity on the part of the surgeon will seal the patient's fate; and when his duty is calmly to balance the dangers of expectancy, and of resort to even a doubtful remedy. I therefore think that it ought not to be condemned. But it should be adopted only in a limited class of obstinate cases and with all due cir- cumspection. After this decisive course of action, we have reason to hope that a healthier mucous membrane will be produced. But the truth must be admitted, that the disease is apt to return. This, however, may not occur for several months; and during this time the patient may suffer little from hemorrhage or other trouble. During this period of inter- mission, or of apparent cure, much may be done to bring down the chronic congestion and tumefaction of the uterus. Strychnine, quinine, iodide of potassium, even iodide of mercury will be useful. And, in- ternally, the application of solid sulphate of zinc, or of iodide of mer- cury in ointment will prove serviceable. Anomalies of Consistency. — One of the most remarkable is the pulpi- ness of advanced age coming on after long-continued mucous secretions, which disposes to apoplexy. Another form of softening is that ensu- ing upon childbearing, where involution is arrested by marasmus. The mucous membrane may also become soft and pul])y in young per- sons from repeated hemorrhage. From constant infiltration it swells and disintegrates. SENILE UTERINE CATAREH. 477 Abnormal hardness of the uterus affects chiefly the vaginal-portion, in consequence of the predominance of connective tissue in hypertrophy. Senile Uterine Catarrh. — I have already adverted to this disease when discussing the subject of atresia. It deserves separate considera- tion, on account of its frequency and importance. It probably in most cases is continuous from chronic metritis acquired before the meno- pause. Notwithstanding the disposition to uterine senile involution or atrophy, a change wliich, in some cases, may terminate that vascular activity upon which inflammation and even secretion depend, a degree of morbid action is often perpetuated. The pelvic vessels often con- tinue engorged after the menopause from impeded hepatic circulation. The uterus in these cases will remain unduly congested, and the slow chronic inflammatory process is thus easily fed. This condition in some cases will account for the occasional apparent return of the menstrual discharge several months after the function had been supposed to have ceased. This is one form of senile uterine hemorrhage. In other cases there is not so much vascular fulness ; yet the mucous membrane continues to throw off a more or less abun- dant thin opaque mucous secretion. The walls of the uterus are usu- ally somewhat thicker than usual. Atrophy in fact has been arrested. The cavity is almost always enlarged. The sound readily turns round in it. The flaccid condition of the uterus disposes to flexion, most fre- quently to retroflexion ; although it is certain that in many cases the flexion existed before, and may have been the cause of the endome- tritis. When this occurs there will of course be more or less retention of mucosities in the uterus. And it is to this retention that some of the most marked symptoms are due. It brings about a sense of fulness, weight, and oppression, with pain in the pelvis. The constant wear and tear tells upon the nervous system, and often the most distressing nervous phenomena are produced. Mental despondency is the most marked characteristic. In a considerable number of cases I have found complete closure of the cervical canal, generally at either the os internum or os externum. The walls have grown together by a process compounded of inflamma- tion and atrophy. But the uterine cavity continuing to secrete, the fluids secreted accumulate; and thus again retention with its conse- quences ensue. Expulsive pains are felt, which generally subside, to be renewed at variable intervals. In some cases it is certain that the aged uterus, not receiving the stimulus of menstruation, and but feebly responding to other stimuli, accommodates itself to the distension. Atrophy progressing, the fluid part of the mucus may disappear, or be retained without causing further trouble. But in other cases, and those, if I may judge from my own observation, not a few, the distress does not subside. Advice is sought on account of the pelvic suffering, or metrorrhagia. Then we find the roof of the vagina contracting into a cone, at the apex of which is a small depression, recognized as the os uteri. There may be little or no projecting vaginal-portion. Behind this depression we may feel the retroflected body of the uterus ; or this part may be in natural position. On trying to pass the sound we find it soon meets with an obstruction. The os externum is occluded. 478 LESIONS OF CONTINUITY. Sometimes a little steady pressure with the point of the sound will penetrate the obstruction. But I have several times found it necessary to restore the cervical canal by incision or puncture. For this purpose a most convenient instrument is the sheathed male urethral stricture bistoury. The probe end of the sheath is filed off, so that when the end is applied to the seat of the os uteri the point of the knife is made to protrude and penetrate the cervix. This done, an ounce or more of muco-purulent fluid has escaped with manifest relief. To prevent re- lapse it is necessary to pass the sound every now and then ; and to correct the morbid state of the cavity a stick of two grains of sulphate of zinc should be introduced every four or five days. By this treat- ment a cure is commonly effected in a few weeks. The atrophic j^ro- cess goes on undisturbed. One form of this atresia is represented in Fig. 92, page 404. Fibroid tumors distorting the cervical canal may bring about atresia. In chronic internal metritis, especially in elderly women, Aran ad- vises the use of the hollow sound or catheter, as a means of diagnosis. The retained mucous fluids are thus drained off, and their quality and quantity may be estimated. The ordinary sound will not effect this object. We may use a male silver or elastic sound, but the curve must be very moderate. The ointment-carrier (see Fig. 44, page 129) also answers the purpose. Dr. Charles Hen nig sent to the Obstetrical Society^s Exhibition an aspirator-tube, designed to draw out fluids from the uterus. The following remarks apply generally to the treatment of chronic endometritis. The exhaustion wrought by disordered nutrition may, there is great reason to believe, in some instances end in the develop- ment of tubercular mischief in the lungs. This termination is not surprising, when we remember that a strumous or lymphatic diathe- sis is a powerful factor in producing and in giving the stamp of ob- stinacy to chronic metritis. In some cases marked by peculiar obstinacy there is, as I have already said, a tubercular condition of the uterine mucous membrane. For this I doubt if there is any cure. To pursue local treatment in such a case, beyond perhaps applying an occasional disinfectant, would be to inflict needless distress. It must also become a question how far, when lung mischief has become revealed, it is desirable to persist in treating the uterine catarrh. It should not, I think, always be given up. The principle of curing, as far as we can, every component part in a chain of morbid complications obtains here. But often it will be found the most judicious course to abandon local treatment, and to apply all our care to the general system, and the alleviation of the lung-distress. Lesions of Continuity of the Uterus. — Lacerations may occur in the non-pregnant uterus. I have carefully described the lacerations of the pregnant uterus in ray " Lectures on Obstetric Operations," second edition, 1871. Under excessive distension from collections of blood or mucus, laceration has occurred. The uterus has also ruptured from the presence of a polypus in its cavity. PERIMETRIC INFLAMMATION. 479 Connective-tissue new formation appears chiefly in the shape of fibrous tumor, of sarcoma, and j^apillary tumor. The fibrous tumor — desmoid es uteri — is the most frequent of all uterine growths. It chiefly affects the body of the uterus, and more especially the fundus, rarely the lower part; very seldom the cervix or vaginal- portion. It is not seldom seen in company with fibrous polypus, mucous and vesicular polypi, or with uterine cancer, or ovarian cystic disease. The tumors will be more especially described in a future chapter. CHAPTER XLI. PELVIC CELLULITIS (PAKAMETKITIS) : PELVIC PEKITONITIS (PEKIMETEITIS); PEKIMETRIC INFLAMMATION (PERIUTE- EIJSTE INFLAMMATION) ; 3IETE0-PEE1T0NITIS. The subject of inflammation of the pelvic tissues connected with the uterus and its appendages has been worked out, of late years, with great clinical skill; and, I may venture to add, with superfluous critical acumen. There is a natural tendency to embody or condense the new views we arrive at as to the essential pathological condition, by assigning to this condition a new name. If this name be tolerably precise and descriptive, it is often readily accepted as the last expression of science. Hence a name is apt to impose upon the learner the belief that he has caught the true clinical idea. And then, in accordance with another tendency, the mind, satisfied with the seeming fulness of the idea embodied in a new term, proceeds to eject every other term hitherto associated with the condition under discussion as false. Unable to entertain two ideas at the same time, hastily concluding that one or the other must be false, the one which is presented in the most attrac- tive or authoritative manner is accepted, to the absolute exclusion of the other. This reflection is remarkably illustrated in the history and varying nomenclature of inflammations of the pelvic structures. These inflam- mations of course remain, or continue to be reproduced, as they always have been. New names may represent new theories, but the clinical facts are unchanged. It is these which it is important to understand. It is to be feared that new names have tended, rather to obscure these 480 PERIMETmC INFLAMMATION. facts than to elucidate them. In attaching too much importance to names, that is, in allowing the mind to be dominated by the theories that names represent, we are apt to lose sight of the truth which lies in the rival names and theories. A true theory and a false theory are antagonistic. If we accept the one we must, logically, reject the other. But there is no antagonism between two true theories. These must be reconcilable, however widely observation and reasoning carried on in different lines may place them in opposition. I will now endeavor to state the case plainly, divested of all theory or school-doctrine. All the structures in the pelvis are liable to inflam- mation. It is conceivable, and true in fact, that any one of them may be alone the seat of inflammation. It is conceivable, and true, that two or more of them may be inflamed together. We have already endeavored to trace the history of inflammation of the ovaries. Fallopian tubes, and uterus. It remains to fill up the account by tracing the history of in- flammation of the other adjoining structures. What are these struc- tures ? We are not called upon in this place to consider inflammation of the rectum, bladder, or vagina, otherwise than incidentally. The structures with which we are now concerned are the cellular or con- nective tissue, the peritoneum, and the broad ligaments. No one disputes that each of these structures may be the principal focus of inflammation. For example, however we may cavil at the term " pelvic cellulitis," we cannot deny that the pelvic cellular tissue, that is, the connective tissue in relation with the uterus and broad ligaments, is liable to inflammation. Paris, Frarier, Courty,^ E, Simon, Alph. Gu^rin, each relates cases of distinct pelvic cellulitis. "Pelvic cellu- litis" expresses this fact, and nothing more. Again, however we may cavil at the term " pelvic peritonitis," we cannot deny that the peri- toneum which invests or covers in the organs in the pelvis is liable to inflammation. " Pelvic peritonitis," then, is a good term, as express- ing this fact. So again, at the bedside we are often called upon to speak of inflammation of the broad ligaments. When we so speak we do not pretend to define rigorously which of the constituents of the broad ligaments — connective tissue, vessels, muscular fibres, or perito- neum — is especially the seat of inflammation. Although undoubtedly inflammation may begin in the vessels, or in the connective tissue, or in the peritoneuui, w^e shall rarely find an instance in which inflamma- tion does not involve the proximate tissues more or less. We are therefore generally compelled to speak of inflammation of the broad ligaments in the aggregate. It is scarcely possible for the vessels and connective tissue inclosed in a thin lamina between the folds of the peritoneum to be inflamed, without involving the peritoneum. Now, the cellular tissue is chiefly situated on either side of the uterus, sur- rounding the vessels and nerves at the line of ingress and egress ; in front of the lower third of the uterus where its cervix is attached to the bladder ; behind the uterus and vagina, where a stratum connects these organs with the peritoneum and rectum ; and between the peritoneal folds of the broad ligaments. All this cellular tissue may be described 1 See Courtv's " Maladies de I'Uterus." &c. 1870. PERIMETRIC INFLAMMATIOjSr, 481 as continuous ; and therefore inflammation beginning at one part may spread to the rest. The part which seems most isolated from the rest is that mass of tissue which connects the cervix uteri with the base of the bladder. Accordingly this part is occasionally the seat of inflam- mation^ which may run its course without spreading beyond its own limits, and wdthout implicating the peritoneum, at least in any impor- tant degree. But the like limitation can hardly be predicated of any other part of the cellular tissue. The vessels whiclj so often carry the cause of inflammation, and the peritoneum, are in such intimate relation with the cellular tissue at the sides of the uterus, and with that in the broad ligaments, that the serous investing membrane can rarely escape. We thus come to the general conclusion, one amply borne out by clinical observation, that pelvic cellulitis, pure and simple, is a rare affection. Thus when we use the term "pelvic cellulitis," in the great majority of cases we use a term which only expresses a part of the morbid process. So far then the term is open to objection. Again, the peritoneum covering in the pelvic organs being continuous with the abdominal peritoneum is subject to inflammation spreading to it from the abdomen. With this secondary inflammation we are not now concerned. The pelvic peritoneum is far more frequently the primary seat of inflammation, which, beginning here, may spread to the abdominal portion of the serous membrane. Now, if we ask how it is that the pelvic peritoneum is so prone to inflammation, we shall find a plain answer in the clinical and pathological facts. There is not — I say this with some confidence, yet not without reserve — evidence to show that inflammation begins in the pelvic peritoneum ; inflamma- tion in this membrane is excited by a morbid condition of the structures which it invests. That is, where the uterus, tubes, ovaries, vessels, and cellular tissue are healthy, scarcely any cause, other than extension of inflammation from the abdominal peritoneum, can produce inflamma- tion of the pelvic peritoneum. The chief exceptions to this proposition are those cases where inflammation is kindled by some irritating matter poured into the peritoneal cavity, and which by gravitation or prox- imity to the seat of injury is chiefly concentrated in the dependent pouches of the pelvic peritoneum. And even in these cases where the peritonitis takes its rise in conditions independent of inflammation or disease of the pelvic organs, the cellular tissue, at least in some degree, soon becomes involved. We come then to the further conclusion, that pelvic peritonitis, pure and simple, is also a very rare affection. Disease rarely consents to the limits which medical nomenclature would assign to it. All terms, therefore, wdiich profess to be precise definitions are pretty sure to be fallacious. If then we conclude that the terms " pelvic cellulitis " and " pelvic peritonitis," which have been for some time in use, imperfectly, and therefore inaccurately, represent what we find at the bedside, the more recent terms, which are equally exclusive, must be equally fallacious. The more recent terras to which reference is made are those intro- duced by one of the greatest of living pathologists, one from whose 31 482 PERIMETRIC INFLAMMATION. authority no one can dissent without hesitating long. Virchow^ pro- poses to substitute the terms " Perimetritis " and " Parametritis." He bases the first term on the analogy with " Pericarditis." Just as the serous investment of the heart may be the special seat of inflammation, so may the serous investment of the uterus. Perimetritis, then, may be taken as the equivalent of pelvic peritonitis. It is difficult to see any sufficient grounds for preferring the new to the older term. The analogy with the heart is surely strained. The heart is completely, solely, and everywhere closely invested by its own exclusive serous membrane; the pericardium reflected upon itself forms a special bag, within which the heart alone is inclosed. The pericardium then en- joys absolute immunity from inflammation extending from the serous investment of other organs ; and comparative immunity from inflamma- tion extending from any other source than the heart itself. Pericarditis probably, like pleurisy, chiefly owes its origin to offending matters car- ried in the blood. Peritonitis undoubtedly often owes its origin to like conditions. But the pelvic peritoneum, whilst not free from lia- bility to inflame under general toxaemic influences, is exposed to in- flammation from other causes. These are, as we have seen, metritis, salpingitis, oophoritis, pelvic cellulitis, inflammation of the vessels carrying septic matter from the uterus, irritating matters poured into the peritoneal sacs of the pelvis, and extension of inflammation of the abdominal peritoneum. The serous investment of the body of the uterus forms a very small part of a membrane which has numerous other relations, and which is therefore exposed to numerous sources of disease. If the term " perimetritis " be limited to the few square inches of peritoneum which covers the body of the uterus, it only ex- presses a very small part of the clinical case. Inflammation so limited is extremely rare. If the term be made to embrace inflammation of the serous membrane of the tubes, ovaries^ and broad ligaments, then it is strained beyond its etymological meaning, and is wholly inade- quate for clinical purposes. The correlative terms, " perisalpingitis" and " perioophoritis," proposed to supplement " perimetritis," prove the inadequacy of this latter term. Themselves, they are hardly worthy of discussion. I submit, then, that there is no sufficient reason for adopting the term " Perimetritis." The term " Parametritis," intended to describe inflammation of the cellular tissue in the neighborhood of the uterus, is also open to objec- tion. It is less comprehensive than " pelvic cellulitis." It is not alone the tissue immediately surrounding the uterus which is exposed to inflammation. Indeed, inflammation of the cellular tissue is rarely so limited. Nor does it even always begin in this part. The inflam- mation in the broad ligament often begins from disease of the Fallopian tubes or ovaries, and may never re^ch the cellular tissue near the uterus. We are driven then alike by etymology and by clinical observation 1 Archiv. fiir Pathol. Anat. und Pliys. 1862. PERIMETRIC INFLAMMATION. 483 to reject both the terms " Perimetritis " and " Parametritis " as being inadequate, and not justified by scientific necessity. The truth being that tlie pelvic peritoneum and the pelvic cellular tissue being each liable to inflammation, we want the terms " pelvic peritonitis " and " pelvic cellulitis.'^ And it being also true that in a great, perhaps the greater, proportion of cases, both peritoneum and cellular tissue are inflamed together, we want a term which shall ex- press this common affection. The term " peri-uterine inflammation," adopted by Courty, answers to this want. It is indeed open to an objection, which not seldom meets us in medical nomenclature, namely, that it is a discordant compound of Greek and Latin. This may be avoided by substituting the term " perimetric inflammation." In adopting this term I mean to include inflammation involving the broad ligaments and their contents. This term carries us back somewhat to the term " Phlegmonous intra-pelvic abscesses," adopted by Marchal (de Calvi), to whom science is indebted for the most important of all modern contributions to this subject.^ His is the great merit to have shown that the chief seat of the puerperal and many other abscesses in women was in the pelvis. He thus exploded the erroneous ideas which connected these inflamma- tions with the iliac fossse. And since perimetric inflammation is so frequently consequent upon, and therefore complicates, inflammation of the uterns or its appendages, to express this compound condition we want the term " metro-periton- itis." The researches of Bernutz^ and of MM. Bernutz and Goupil,^ con- ducted in the most admirably philosophical spirit, have been pre-emi- nently useful in extending and in correcting our knowledge of the subject. These researches have demonstrated that what had hitherto commonly passed for pelvic cellulitis was often pelvi-peritonitis. The phlegmonous masses rising out of the pelvis, and extending into the iliac foss8e, so frequently met with after labor, are shown to be, strictly speaking, not pelvic cellulitis, but peritonitis. This much, with some qualification, may be granted. But it is to be feared that here again is an instance of one idea making good its way by driving out another from ground where both have a common right. In these post-puer- peral cases, with which we are the most familiar, because they most frequently come under clinical and post-mortem observation, there is almost always a complication of cellulitis and peritonitis ; and, it might also be added, of metritis as well. The peritonitic element will, it may be admitted, generally predominate. But the other elements coexist. It appears to me then that Bernutz, whilst rendering incontestable service in calling attention to the important part played by peritonitis in these cases, has rather undervalued the other factors of the disease. If I may trust my own clyiical observations, which I may fairly 1 " Des absc^s phlegmoneux intra-pelviens." 1844. 2 " Archives gen^rales de Medecine." 1857. ' " Clinique inedicale sur les maladies des femmes; Memoire de la pelvi-p^rito- nite et de ses diverses varietes." Paris, 1862. 484 PERIMETRIC INFLAMMATION. say are numerous, and my dissections, which I frankly acknowledge are not so numerous nor so exact as those of Bernutz, I should say that whilst the term "pelvic cellulitis" fails to express the whole nature of the case, still it ought not to be altogether suppressed in favor of " pelvic peritonitis." In post-puerperal perimetric inflammation, which must serve for a type or illustration of other orders of cases as well, there may be dis- tinguished three kinds : 1st. That kind which, as far as we can judge, is simply inflam- matory. 2dly. A kind in which septicaemia plays a conspicuous part. The inflammation is of a low type. There is a tendency to diffuse, or erysipelatoid inflammation and to general systemic empoisonment. 3dly. There is a kind of intermediate between the two preceding, in which there is a septic factor, but which is held in abeyance by the superior vigor of the blood. In these cases the septic matter is blocked out by the healthy blood coagulating in the efferent pelvic vessels, and intercepted by the lymphatic glands. In this way the system escapes, and the morbid influences are mainly concentrated in the pelvis. In the first, or purely inflammatory kind, the action is chiefly spent upon the peritoneum. These may properly be called cases of pelvic peritonitis. They are analogous to the cases of pericarditis and of pleurisy, which supervene on a sudden impression of cold, when the pericardium and pleurae have undergone unusual strain, the blood being also modified, under violent bodily exertion. The violent per- turbation of parturition induces a peculiarly susceptible condition of the uterine and pelvic peritoneum, and an alteration of the blood which is favorable to the development of inflammation, if an exciting cause, such as cold or emotion, be applied. These are the cases to which the description of Bernutz more strictly applies. In this order of cases the peritonitis, in many instances, does not break out until two or three weeks or more after labor. Thus, a young lady of delicate organization, suckled imperfectly for seven weeks ; whilst menstruating she went to town, undergoing great fatigue, and came home with intense abdominal and pelvic pain and fever. Pelvic peritonitis had been produced. This is not an uncommon history. But not even in all these essentially inflammatory cases is the in- flammation chiefly expended upon the peritoneum. There is a sub- order of cases which appear to be essentially of traumatic origin, in which the chief, or at least the primary, seat of the inflammation is in the perimetric cellular tissue. During the passage of the child's head through the cervix uteri there is commonly laceration of the margin of the OS, bruising of the mucous membrane, and of the whole sub- stance of the neck, attended by a dragging or gliding movement' of the structures in most immediate contact with the head upon the deeper parts. The cellular tissue around the cervix, where cellular tissue most abounds, is especially contused, stretched, vessels in it are torn, efl'usion of serum and ecchymosis take place in it. All this I have fre- PERIMETRIC INFLAMMATION. 485 quently verified by actual inspection. Everything is prepared for in- flammation. There is the local injury, the effusion. There is the altered blood charged with effete matters, hyperinotic, under the influ- ence of pregnancy and labor. An exciting cause alone is wanting. A chill is often sufficient. The chief seat of the inflammation in this case M'ill be the wounded cellular tissue. In this tissue it may run its course, ending in resolution or in abscess ; and affecting the peritoneum slightly, if at all. In the second order of cases, characterized by the predominance of a septic factor, the inflammation of the pelvic tissues is universal. The uterus itself, its bloodvessels and lymphatics, the cellular tissue around and in the broad ligaments, and the peritoneum are all involved in a low kind of inflammation. The inflamed pelvic peritoneum throwing out unhealthy lymph which rapidly breaks down into pus, sets up the like inflammation in every part of the abdominal peritoneum with which it comes into contact. The poisonous matter may be generated in the woman's system under the strain of labor, her blood becoming overcharged with noxious materials, resulting from tissue-changes. To this order of cases I have given the name of " autogenetic puer- peral fever." In another order of cases the poisonous matter is inocu- lated, it comes from without. The woman, whilst in a highly suscep- tible .state, takes in the poison of scarlatina or some other zymotic. The general infection of the blood here acts as the exciting cause of inflammation ; and the inflammation will naturally, in the first in- stance, break out in the pelvic tissues, rendered suscej)tible by trau- matic action. In these cases again the inflammation will not be limited to the peri- toneum. It will invade the uterus, cellular tissue, and peritoneum alike. It must, however, not be forgotten that patients seized with this, the heterogenetiG form of puerperal fever, not seldom die of the fever before any marked local inflammation declares itself. A feature distinguishing cases of this order from the first or simple inflammatory kind, is that the disease commonly breaks out much earlier, that is, within three or four days after labor. In the third, or mixed order of cases, in which there is a septic factor, controlled by a comparatively healthy state of the blood, the inflamma- tion begins in the uterine sinuses and lymphatics. Under the com- bined influence of traumatism, and of blood somewhat impaired by the tissue-changes of pregnancy and labor, and sometimes of decomposing debris of placenta, membranes, and blood-clots in the uterus, foul mat- ters form in the uterine cavity, get into the uterine sinuses and lym- phatics, and, not arrested there, either from want of contractile energy of the uterine fibre, or because, being as yet too abundant for the blood it meets in its course to segregate by coagulation, it invades the vessels in the broad ligaments, where further progress may be stayed by the formation of clots. This thrombotic process is generally attended by inflammation of the perivascular tissues, and of the broad ligaments, which is pretty sure to involve the peritoneum. If the lymphatics be concerned as well as the veins, then the phenomena of phlegmasia dolens are developed. 486 PEEIMETEIC INFLAMMATION. That the broad ligaments are chiefly involved in the majority of these cases, seems proved by the seat of the tumefaction being in the sides of the pelvis ; and by the uterus itself remaining in many cases apparently free from inflammation. That is, in this rather consider- able order there is not necessarily, perhaps not very often, inflamma- tion of the peritoneal investment of the body of the uterus ; that is, there is no perimetritis. It is perimetric inflammation. Trousseau may be cited as insisting upon the frequent complication of phlebitis with inflammation of the broad ligaments. He believes that phlebitis is the most frequent cause of this inflammation. A very similar description will apply to the perimetric inflamma- tions supervening on abortion. It applies often very closely to inflam- mation of the broad ligaments leading to phlegmasia dolens, beginning in cancer of the uterus. Hemorrhage at the time of labor or abortion powerfully predisposes to perimetric inflammation. The parts being so predisposed, compara- tively slight causes set up inflammation. Amongst the most frequent of these, is cold, usually so freely applied in the form of ice, cold water injections, cold douche to the abdomen, and other ways of swamping the patient. Exposure to chill and of getting about too soon are com- mon causes. It deserves to be remembered that pelvic peritonitis is not uncom- mon in the foetus ; and that, although it is, in this case, often de- pendent upon conditions which lead to death, the child may grow up, and in after-life the pelvic organs may remain bound by persisting ad- hesions. This condition, it is highly probable, renders the subject un- usually liable to new attacks of peritonitis when the organs are called into functional exercise. Perimetric inflammations occurring in the non-pregnant state, pre- sent features which it is interesting to compare with those which follow labor. They follow the same laws. When metritis is set up from the retention of decomposing matters in the body of the uterus, from trau- matism, as from injury by the sound or other instruments, or from an intra-uterine pessary, the primary inflammation being in the body of the uterus, the secondary inflammation will attack the uterine peri- toneum, at least chiefly. On the other hand, when the cervix is first attacked by inflammation, resulting from operations performed upon it, by the irritation of tents or other causes, the nearest tissue external to the cervix — that is, the cellular tissue in which the vessels run — will first catch the inflammatory process, and perimetric cellulitis will be the chief, perhaps the exclusive, secondary affection. Another illustration of this proposition may be found in the history of epithelioma of the cervix. This disease in its progress long respects the body of the uterus; as it extends, it involves the perimetric cellular tissue, and it is often late before the peritoneum is attacked. Perimetric inflammation, apart from pregnancy, is not uncoramou as the consequence of suppressed or disordered menstruation. During this function, we have in miniature the conditions of pregnancy and labor. The gorged organs, caught in a state of intense susce]itibility, are exceedingly prone to become softened. In these cases, dissections PERIMETEIC INFLAMMATION. 487 of Bernntz and Goupil prove incontestably that it is the peritoneum which is the chief seat of inflammation. They found the cellular tis- sue perfectly free. This is no subject for surprise. Abortion and arrested menstruation differ from labor in this particular : the cervix escapes all traumatic injury ; the seat of functional activity, and there- fore of susceptibility, is the body of the uterus, the tubes, and the ova- ries. Hence the body of the uterus, the tubes, and ovaries are prima- rily subject to inflammation, and inflammation of these organs is readily followed or attended by inflammation of their investing mem- brane. Beruutz and Goupil affirm, and, if I may be permitted to express my own opinion, prove, that pelvic peritonitis, acute or chronic, takes its origin, in a vast proportion of cases, in disease of the uterus, tubes, and ovaries ; that peritonitis is, therefore, secondary, symptomatic ©f other disease. They further maintain, and here also I concur in their con- clusion, that inflammation of the pelvic peritoneum proceeds more fre- quently from inflammation of the tubes and of the ovaries than from inflammation of the uterus. Although facts enough exist to prove that metritis, acute or chronic, may excite inflammation of the peritoneum, yet it is a remarkable clinical fact that, common as chronic metritis is, the uterus rarely be- comes fixed, as it would be were its peritoneum to become inflamed. Although pelvic peritonitis in a large proportion of cases is caused by disease of the uterus, tubes, or ovaries, or is secondary upon pelvic cellulitis, it is nevertheless true that there is a large class of cases in which this membrane is the seat of primary inflammation. For clini- cal purposes it is important fully to recognize this distinction. The history of the two orders of cases is often strikingly contrasted. The secondary form following upon diseases of the pelvic organs is of course preceded by the symptoms which belong to those diseases ; the perito- nitis is an epiphenomenon, declaring itself in the course of another disease ; its special characters often make their appearance gradually, even insidiously, being for a time masked by those of the original dis- ease. On the other hand, the primary peritonitis makes its appear- ance suddenly; it is ushered in by acute and severe symptoms, often by shock or collapse, and other signs of traumatism or local injury. Such is the history of peritonitis caused by the escape of offending matter from the Fallopian tube, either running from its fimbriated extremity, or from bursting or perforation of its walls ; from bursting or perfora- tion of an ovarian cyst or abscess ; from rupture of the uterus, or of an extra-uterine gestation-cyst ; from effusions of blood into the perito- neum ; from perforation of the intestine ; from rupture of a dermoid cyst. Even in some cases of this class the symptoms are not marked by suddenness of invasion or by great severity at first. For instance, when an ordinary ovarian cyst or a dermoid cyst undergoes perfora- tion, the amount of irritating matter escaping into the peritoneal cavity may be small, and the consequent peritonitis will be limited and subacute. Pelvic peritonitis may, like inflammation of the peritoneum of the 488 PELVIC INFLAMMATION. abdominal intestines, arise from 1, tubercular affections; 2, cancerous; 3, traumatic. Encysted serous peritonitis may appear to be, and sometimes is, as- sociated with antecedent pelvic disease. But it may be independent. I have related one characteristic example in the chapter on the "Diag- nosis of Ovarian Tumors/' at page 318. The connection of some unilateral pelvic or abdomino-pelvic abscesses with a pelvic origin is sometimes obscure. We make out clearly enough an abscess, and even define its limits ; but dissection only can reveal the cause of the peritonitis, the products of which envelop and shut out from observation the offending disease. This is illustrated in the case related at page 319, in which a small ovarian cyst was found im- bedded in a peritoneal abscess, or rather a congeries of communicating suppur£?ting cavities. Perimetric inflammation is rare after the menopause. This fact confirms the modern view that this inflammation takes its rise almost invariably from the inflamed uterus, tubes, or ovaries. This proposi- tion, although generally true, is however often affirmed too absolutely. Malignant disease, especially of the body of the uterus; chronic me- tritis, depending upon stenosis or flexion ; the various forms of hyper- trophy of the mucous membrane attended with hemorrhage, are very liable, especially on rough surgical treatment, to lead to perimetric in- flammation. It may also, as I have seen, result from local violence, such as too frequent subjection to sexual intercourse. Bernutz gives a valuable summary of the cases observed. Of 99 cases of pelvi-peritonitis — .„ , r 35 after delivery at term. 43 were puerperal. | 8 after abortion. 28 were blennorrhagic. 20 were menstrual. ( 3 after venereal excess. I 2 after syphilitic disease of cervix. „ ^ ,. 2 after use of the sound. 8 were traumatic. j ^ ^^^^^ ^j^^ ^^^^ ^f ^ ^^^^-^^^ ^^^^^^^ ^^_ \ ployed in a case of membranous ulce- [ ration of the cervix. Peritonitis meretricum. — When gonorrhoeal infection is the starting- point, the course is usually as follows : The poison, acting first at the point of contact, lights up inflammation of the vaginal and cervical raucous membrane. This spreads to the mucous membrane of the body of the uterus, thence along the Fallopian tubes. The ovaries are very commonly engaged. In the case of gonorrhoea, Dr. Matthews Duncan says, "he has never seen pelvic inflammation come on without the presence of ovaritis in addition, and as the ovaritis follows the endometritis, so the latter is itself a consequence of the original vagin- itis." In some of these cases, proof has been obtained that the perito- nitis was immediately caused by the escape of infected pus from the fimbriated ends of the tubes. But in many cases, probably, the peri- toneal coat of the tubes and ovaries becomes inflamed, consequent upon the inflammation of these orsrans. PELVIC INFLAMMATIOJSr. 489 Mr. Giles, in an interesting communication/ relates three cases in which peritonitis, the result of gonorrhoea, broke out after childbirth. It must not, however, be concluded that the peritonitis of prostitutes is always traceable to infection. In many instances there can be little doubt that it is due to the wilful suppression of menstruation by the local application of cold, and to other forms of exposure and violence. I have known firm masses, the result of pelvic peritonitis, following on incision of the cervix uteri for dysmenorrhoea and sterility, last for over three years. One such case I saw in consultation with Dr. Gus- tavus Murray. The illness dated from the operation performed three years before by Professor Simpson. She had got about too soon, caught cold, and inflammation followed. Since then she had suffered constant pelvic pain, increased on exertion ; there was oozing of san- guineous mucous discharge, and dyschezia. The cervix remained patulous, engorged ; the body of the uterus was deviated to the left ; a hard mass surrounded the cervix, fixing it immovably. Examining by rectum, when the finger reaches the level of the uterine neck, it is encountered by a narrowing of the rectal canal, barely admitting the finger ; all round was a hard mass, which fixed the rectum to the sacrum behind, and to the uterus in front. She was treated with pessaries con- taining mercury and iodine, and other measures ; but her recovery Dr. Murray attributed principally to the use of the Wood hall Spa water. When the opportunity occurs of examining the subject of pelvic cellulitis in the early stage, we may find a lax condition of the connec- tive tissue ; its meshes infiltrated with serum, lemon-colored, and limpid, or turbid and brownish, from being stained with blood or mixed with pus. When the affection is the result of labor, there is commonly ecchymosis from the rupture of small vessels. At a later stage, the watery part of the serous effusion has disap- peared ; there is a firm, more or less circumscribed tumefaction, which on section exhibits reddish points, and evidence of hyperplasia. In some cases, comparatively rare, pus is found in the phlegmonous swelling. But almost always when this is the case the peritoneum is involved, and the appearances are lost in those characteristic of peri- tonitis. The chief character of peritonitis, of course, is plastic effusion. But this is preceded by intense vascular injection of the membrane. It is bright with punctate stellate and arborescent injections, and it is often uniformly red. The membrane has lost its glistening smoothness; it looks villous or granular. This condition probably lasts only a few hours. Plastic lymph is quickly thrown out over the whole inflamed membrane, and glues opposing surfaces together. It is common to find the ovaries and tubes enveloped in a mass of yellowish lymph, more or less solid, and united to the peritoneal lining of the iliac fossse, the summit of the bladder, the anterior wall of the lower part of the abdomen, and the front of the rectum. The fundus of the uterus is the part that most frequently escapes. As in life this part can often be felt and made 1 British Med. Journal, 1871. 490 PELVIC INFLAMMATION. out distinct from the firm tumefactions on either side or behind it, so after death we often find it cropping out comparatively unaiFected from the fibrinous conglomerations of the sides and hollow of the pelvis. At a stage more advanced in progress, but often even earlier in point of time, evidence, more or less extensive, of suppuration will be found. Where there was a septic factor, the lymph may be found in flakes, dirty red or yellow, adhering loosely to a dull-red peritoneum ; easily breaking down, this lymph will be seen pultaceous, semifluid, puru- lent. In the half-circumscribed cavities formed between the imper- fectly adhering peritoneal surfaces, a dirty turbid serum collects; or, in some cases, the lymph seems to have no plastic property at all ; then on being opened streams of dirty serum and pus flow out from the general peritoneal cavity. In the stage of recent effusion, the parts can be separated by break- ing down the still soft agglutinations. The ovaries or tubes or uterus, in which the inflammation probably began, will then be seen red or dull on their peritoneal aspect, generally swollen beyond their normal bulk, and fuller of blood. At a later stage, but still not remote from the beginning, the effusions found will be increased in bulk and solidity. The organs, especially those of the pelvis, will be so buried in the con- solidated masses of effused matter, that only by tedious dissection can they be traced and isolated; often the ovaries will be glued to the pos- terior wall of the uterus. If a case in life correspond to the above description, recovery by resolution may still occur. The swelling seems to melt away, and the only post-mortem evidence of what has gone before are dull-white strings or bands tying the ovaries and tubes to the sides or posterior surface of the uterus, or to surrounding structures. Perimetric or Pelvic Abscess. — In many cases suppuration takes place. Various estimates, fairly open to all the objections that invalidate most statistical operations performed upon pathological histories, have been made to express the proportion of cases which end in suppuration. It is certainly large, probably much exceeding those which end in reso- lution. McClintock, out of seventy -seven cases of puerperal pelvic cellulitis, found thirty-seven end in suppuration, with discharge of pus; twenty-four burst or were opened externally ; six discharged through the vagina ; five through the anus ; and two burst into the bladder. The termination in suppuration is liable to be overlooked. Pus escap- ing into the rectum, or even into the vagina, may not be noticed, or, if observed, may not always be set down to the right source. These un- detected suppurations naturally go in a statistical table to swell the number of cures by resolution. The clinical physician will form a much more correct prognosis as to the advent or not of suppuration, by weighing the characters of the case before him. If there be septicaemia ; if the patient be of strumous or lymphatic diathesis ; if she be reduced by hemorrhage ; if, in short, the individual conditions be of a depressing kind, the probability of suppuration is vastly increased. Generally, but not always, in this event a fresh increment of the febrile symptoms is observed. Shivering or rigor occurs : the pulse is PELVIC INFLAMMATION. 491 subdued in power; sometimes vomiting is excited. These mark the first entry of septic matter into the circulation, and constitute the stage of shock. The characteristic is depression. Then come the signs of reaction. The pulse is accelerated, the temperature rises. _ If the amount of septic empoisonraent be great, signs of attempt at elimination appear. The poison, carried like almost all poisons to the intestines, irritates the mucous membrane and causes diarrhoea ; and perhaps vomiting is again excited. This is the stage of irritation or elimination. If only one moderate dose of the poison is imbibed, the signs of constitutional irritation quickly subside ; but if, as often happens, fresh doses con- tinue to be imbibed, the symptoms of shock, reaction, and elimination will recur in regular order. This dependence upon the repeated dosing with, or accumulation of poison, is remarkably proved by the cessation of these signs when the purulent collection bursts or is artificially opened. Suppuration goes on, in many cases for two or three or four weeks before the pus breaks through its investing sac. This event is achieved in one or more of three chief directions : 1, through the skin; 2, through a mucous membrane ; 3, into the serous sac of the peritoneum. In some cases imperfect and temporary relief only is obtained on the discharge of pus. The hard tumefaction in the pelvis subsides but slightly. Hectic or irritative fever continues. Pus continues to flow in more or less remittent or intermittent discharge; and sometimes successive purulent collections form, and burst at intervals, extending over weeks, months, and even years, until the patient sinks exhausted. In some cases of this class, happily the most frequent, the suppu- rative action at length ceases, the cavities contract, the solid deposits gradually become absorbed, and the recovery may be complete, even the adhesions disappearing. But patient and physician must be pre- pared for a tedious course of treatment. Where the septic element has been inconsiderable, and especially where the inflammation has been excited by disease of the tube or the ovary proceeding slowly, or only inflicting upon the peritoneum a suc- cession of slight injuries, repeated at long intervals, the pelvic organs may, as in more acute cases, be found imbedded in thick masses of hard brawny effusion, involving the rectum and the superincumbent small intestines and omentum. This condition may last, kept up or extended by occasional accessions of fresh inflammation, for many months, or even years. This is the case especially when the inflamma- tion is excited by a diseased ovary, cystic or dermoid. But sooner or later, under the irritation of the advancing disease, or of some acci- dental intercurrent cause, suppuration comes on. The pus forming in the substance of the effused mass, commonly beginning at the surface or in the substance of the diseased organ — by a process incident to the disease, one of the events of which is bursting or perforation — forms an abscess, or a congeries of purulent collections. Up to a certain time an abscess thus formed may be fairly encysted or isolated by effusions which shut it off" from the healthy portion of the peritoneal sac. The imprisoned pus may even undergo a transformation which ends in absorption. But in the majority of cases the sac of the abscess, extend- 492 PELVIC INFLAMMATION. ing its adhesions by eccentric action, effects a consolidation with some structure through which a communication can be made with the ex- terior. Thus a pelvic abscess will make its way to the external surface through the skin, or into the intestine, bladder, vagina, or rectum ; or unfortunately failing in these directions, it may perforate its own sac, and pour its contents into the peritoneal cavity. In this latter event we shall have the ordinary phenomena of "abdominal shock," often fatal speedily ; and if not so, then followed by peritonitis, from which the patient may or may not recover. If the pus work its way out by the skin, the place of election is most commonly the iliac region above Poupart's ligament. Before this happens there will have been a history of irritative fever, marked generally by rigors more or less distinct, by small pulse, ranging from 100 to 120, by temperature running up to 101° F., 102° F., or 103° F. ; by sweats ; occasionally by diarrhoea. The hard, somewhat ellip- tical mass, becomes softer, doughy ; near the skin, a patch at first red, then bluish, appears ; iluctuation becomes distinct ; and then, if the abscess be not opened, it bursts. Sometimes the abscess points nearer to the median line below the umbilicus. This is more likely to be the case if the cause of the peri- tonitis be a dermoid ovarian cyst. Where the inflammation takes its rise deep in the pelvis by the side of the vagina, it will sometimes find an exit by the outlet of the pelvis through the perineum. I have seen several examples of this in puerperal cases. In these the evacuation has been preceded by great distress from the intra-pelvic pressure on the bladder and nerves. It has also made its way by the sacro-sciatic notch, or by the side of the anus. I believe, however, the route most frequently selected is the vagina. An oj)ening is made through the roof, mostly behind or to one side of the cervix uteri. This issue, as well as that by the rectum, is some- times overlooked. The pus escaping perhaps gradually is not distin- guished from the other discharges. When the inflammation is retro- uterine, the pus will almost always make its way by the roof of the vagina or by the rectum, just as a retro-uterine hsematoccle will do. I have known one or two cases in which the abscess opened into the cervix uteri. In the majority of cases, discharge of pus, either by the skin or by a mucous canal, is followed by recovery. Pus continues to escape by the opening for some days, becoming thinner and more serous. In most instances the discharge ceases in about twenty-one or twenty-eight days ; in some even earlier. A notable diminution of the swelling, relief from pain, and subsidence of the irritative fever take place almost immediately. The rigors caused by the absorption of ichor into the blood cease when the matter finds a vent externally. But occasionally abscess after abscess points in different places, or sinuses keep open, and continue to drain off the secretions formed in the suppurating cavities. These cavities seem to be prevented from closing by the rigid walls composing them being fixed to the sides of the pelvis or to the intestines. An exhausting suppuration then goes on, lasting for months and even for years, until the sufferer sinks from PELVIC INFLAMMATION. 493 inanition, the wear and tear of pain, and the gradual impairment of vital functions. These cases of protracted suppuration are, I believe, mostly the result of inflammations set up by the perforation of ovarian cysts, or of an extra-uterine gestation cyst, or a dermoid cyst into the vagina or the rectum or some higher part of the intestine. But I have seen similar cases which followed upon labor and abor- tion, after surgical operations upon the uterus, and after wearing a fixed intra-uterine pessary. The protracted intermittent course of some of these suppurating cases is partly explained by the multilocular character of the abscesses or suppurating cavities. These burst successively. Perhaps the sup- puration in one compartment sets up suppurative action in the rest, and so on. How these multiple abscesses form is probably accounted for by the irregular shape and the movements of the organs which form the framework or scaffolding of the peritonitic efi'usions. The intes- tinal folds and convolutions form endless recesses and projections, and the plastic layers which invest them will almost necessarily follow, to a great extent, these recesses and projections ; whilst the incessant ver- micular movements and the alternations of distension and collapse of the coiled intestinal tube, acting whilst the effused matter is still soft, will leave irregular spaces, divided partially or completely by septa running in various directions. These hollow irregular spaces will in the first place be filled with serum, or sero-purulent fluid, which at a later time is replaced by pus. When the solvent process of suppura- tion has set in, the septa gradually break down ; the pus-containing spaces are fused together more or less completely. But the process is tedious, and it may be long before it is complete. This irregular multilocular arrangement will also account for the fact that perimetric abscesses sometimes open in several directions. Thus we may see an abscess first make an exit at the iliac region ; then, successively, it will burst in the rectum and vagina. When such abscesses with thick walls, not capable of collapsing under atmospheric pressure, burst or are opened, air is sometimes drawn in. Decomposition of retained pus and blood ensues, so that the discharge becomes extremely offensive. The sac, which hitherto emitted a dull sound on percussion, will now be resonant. To a cer- tain extent, often effectual, pressure by well-regulated com^^resses will supplement the failure of atmospheric pressure, in keeping the walls of the empty sac in contact. One possible termination, happily rare, of which I do not remember having seen an unequivocal example, is sloughing or gangrene. Gri- solle^ describes it as follows : " Gangrene is scarcely ever observed except in abscesses consecutive to mortification of the csecum or of its appendix, and to the escape of stercoraceous matters into the neighboring cellular tissue. I do not believe that gangrene has ever been observed in abscesses of spontaneous origin, which are developed in the sub- peritoneal cellular tissue. If, on the contrary, the inflammatory en- gorgement, although spontaneous, is subjacent to the fascia iliaca, this 1 Arch. G6n. de Medecine, iii serie, tome iv. 494 PELVIC INFLAMMATION. may produce there a true strangulation of the inflamed parts ; and it will be sufficiently common to see in those subaponeurotic abscesses the fibres of the iliac muscle blackish, softened, and exhaling a fetid odor. No symptom can produce a sure diagnosis of this unfortunate termination ; but, when issue is given to the effused matter, it exhales a fetid odor, and brings with it gas, faeces, and bits of cellular tissue, of muscles, and of mortified tendons- One can understand that death should be the consequence almost inevitably of such disorders." I, however, once tapped an encysted serous peritonitic effusion giv- ing issue to a small quantity of fecal matter, foul gas, and horribly stinking serum, which ended in recovery. Matthews Duncan mentions as one " peculiarity of pelvic, and prob- ably of perimetric abscess only, that some have no tendency to burst at all. He has repeatedly opened such abscesses, whose existence cer- tainly dated several years before his seeing them, and which showed no tendency to point in any direction." Such abscesses are occasion- ally found in the dead-house. One was recently observed in a woman who died shortly after admission into my ward. I had recognized in her a pelvic peritonitis six years before. The inflammation and sup- puration were found to have arisen around a dermoid cyst. The course that perimetric inflammations run, and the pathological appearances, will vary according to the parts involved ; the compli- cation with, or absence of, septicsemia ; the diathesis or constitutional state of the patient; the treatment and other accidental circumstances. In puerperal cases, I have satisfied myself that perimetric inflamma- tion, including cellulitis, is especially prone to arise in women of stru- mous diathesis. The same subjects are particularly prone to inflam- mation and abscess of the breast. I have little doubt, although I have not made out the fact with equal distinctness, that the same di- athesis also disposes powerfully to like inflammation in the non-preg- nant state. In women of this constitution lymph is rapidly and freely thrown out, forming large tumefactions. The effused matter, more readily than in sound constitutions, degenerates into pus. Dissections at different stages of perimetric inflammation appear to me to prove that it is not always, perhaps not even generally, the plastic or semi- coagulated lymph which, in the first place, is transformed into pus. There is commonly a considerable quantity of thin serous fluid which becomes inclosed by the plastic eifusion, forming a cyst single or many-celled around it. It is this serous fluid which forms, as it were, the focus of the phlegmon, which becomes turbid and purulent. Very soon no doubt the innermost layer of the plastic investment breaks down in part, and contributes to the purulent collection, helping to form the abscess. That this plastic investment does give way is proved by the abscess bursting or perforating. The effusion sometimes takes place with great rapidity, as in the following not rare case : A young lady, who had been delivered of her first child about two months, and had returned to her usual avocations, took a long walk, came home fiitigued to her husband, was next day seized with intense pain in the lower abdomen and vomiting ; consti- PELVIC INFLAMMATION. 495 pation and tympanites followed. On the fifth day, I found the uterus set fast in a mass of firm eifusion ; the bowel also was so compressed that there was nearly complete obstruction for nine days. Under rest, opium, and enemata she got well. In a number of cases, very difficult to estimate, the inflammation terminates in resolution. The effused consolidated masses of plastic matter gradually disappear. As this process goes on, the uterus recovers its mobility, if not entirely, to a great extent. The finger begins to travel around the vaginal-portion. The subjective symptoms become moderated. This process usually takes several weeks, even months, for its com- pletion. In a considerable proportion of cases I have seen the Avhole process completed in eight, ten, or twelve weeks. But the last stage often lingers longer still. In not a few cases, when the bulk of the effusion has melted away, there remain cellular adhesions which may restrain the movements of the uterus, and bind it down in various directions. Thus, adhesions between uterus and bladder will produce anteversion; adhesions in the retro-uterine pouch will produce retroversion ; and we may find lateral inclination from ovario-uterine and alar adhesions. These adhesions undoubtedly often practically disappear — that is, under the constant strain of the pelvic organs in their functional move- ments, the adhesions incessantly stretched undergo atrophy complete or partial, so that they no longer impede the uterus. In the case of retro-uterine adhesions, I have often accelerated their atrophy by the use of a lever-pessary, which, lifting up the fundus uteri, puts these bands on the stretch. One very efficient cause of the disappearance of these uterine adhesions is pregnancy. The uterus enlarging, drags and attenuates them, so that they undergo atrophy. On the other hand, they sometimes last an indefinite time, bindiiig the uterus down in various abnormal positions, impeding this organ in its natural move- ments, and thus leading, as Madame Boivin insisted, to abortion. The ovaries, which possess much more limited natural movement, and are, moreover, smaller and less rigid bodies, are not so capable of exerting a strain upon adhesions, and are consequently more frequently doomed to perpetual bondage. Aran examined fifty-three women who died in his wards with ref- erence to this point. He found adhesions in twenty-nine. The adhe- sions were twice as common in women who had had children as in women who had not. These, of course, are selected cases dying in a special gynsecological ward, and cannot represent the general propor- tion of adhesions. I have had the opportunity of watching the course of one case of ad- hesions with requisite precision. A young woman was admitted into my ward with retro-uterine hsematocele. The blood-mass made its way through the roof of the vagina, and on several occasions we saw blood oozing through the opening. I passed a probe three inches into it. When the opening closed the tumor gradually disappeared, and it was found that the body of the uterus was pulled back, and held in that position by adhesions. Six months later the uterus had nearly recovered under the gradual lifting action of a Hodge pessary. 496 PELVIC INFLAMMATION. When the uterine adhesions are persistent and short, binding the uterus down tightly, they may be the source of severe pain. They may keep up congestion or chronic metritis. And so long as adhe- sions remain there is a liability to renewed attacks of peritonitis. This disposition to relapses, or the "rechublements" of French authors, is always to be borne in mind in the antecedent stages whilst the inflam- matory effusions are still thick and hard. The sym;ptoms of perimetric inflammation are generally compound. In order of time, signs of disease of the uterus, tubes, or ovaries com- monly take precedence. Then follow those of perimetric inflamma- tion. And these are for the most part severe enough to overwhelm and obscure those of the original disease. This addition of perimetric inflammatory signs is usually more or less sudden. It is marked by acute intra-pelvic pain ; more or less shock, according to the cause ; ac- celeration of pulse to 120 or 130 ; heat of skin, the temperature rising to 103° F., 104° F., or even 105° F. There is a sense of fulness and pressure, sometimes of bearing-down. The bladder and rectum are often disturbed in their functions. Tym- panites, the result of a kind of paralysis of the intestines whose peri- staltic movements seem to be instinctively restrained in order to avoid pain, is a common symptom. This induces constipation, which is fur- ther caused by the narrowing by compression of the rectum, and by the inability to exert effectually the expulsive movement necessary to defecation. Some amount of dysentery is not uncommon. Colic pains, tormina, flatulence, are often exceedingly distressing. The bladder symptoms are often distressing, but are not constant. There is dysuria, frequent call to pass water, an unsatisfied sense of the bladder having been emptied. This distress is partly due to the interference with the contractile action of the bladder, and with the abdomino-pectoral act of expulsion, and partly to the irritating quality of the urine. This is often loaded with lithates and mucus. If an. abscess be about to burst into the bladder, the dysuria increases, and not uncommonly there is retention of urine. When the bursting has been effected, of course pus will be voided with the urine. Reten- tion may also precede the bursting of an abscess into the rectum or vagina. The ovario-uterine function is variously affected. Sometimes there is metrorrhagia. This is especially the case when there is concomitant metritis or subinvolution of the uterus with abrasion of the mucous membrane of the cervix. But, not uncommonly, even in post-partum cases, in which subinvolution is a tolerably certain attendant condition, menstruation is scanty or suspended. The secretion of milk is generally suspended either quickly or gradu- ally. In spite of the mother's anxiety to keep it up, it falls off*; it is rather exceptional for it to last out the course of the disease; and still more rarely is injudicious to make the attempt. When the seat of the inflammation is in one side of the pelvis the thigh is commonly kept slightly flexed to relieve the pain which extension by stretching the inflamed structures produces. This causes the patient to limp on the affected side when walking. This lameness PELVIC INFLAMMATION. 497 is SO characteristic that I have often diagnosed lateral pelvic inflamma- tion to my class on seeing a woman enter the consulting-room with the ausemic aspect following parturition, and this painful limp. In some cases the patient finds she cannot get the heel to the ground. In not a few cases one or both legs swell soon after labor, constituting the earliest sign to attract attention. Sciatica on the side of the eifusion is a symptom I have several times observed. In one the pain along the sacral plexus of the left side was very severe, and underwent exacerbations marked by recurrent sup- purations, over a period of twelve years. The sciatica disappeared when the disease was cured. When suppuration is proceeding, the sense of intra-pelvic tension and of pain is increased. In some puerperal cases I have observed pelvic inflammation to be complicated w^ith metritis. This indicates, I believe, a strumous or leucophlegmatic diathesis. The Diagnosis. — The objective signs are made out by abdominal, vaginal and rectal touch. Palpation over the lower i:)art of the abdomen, especially if the hand be pressed into the pelvic cavity, gives rise to acute pain. There is often some degree of tympanites ; and almost always tension of the abdominal muscles, excited by the dread, even more than by the act, of examination. In the early stage no very marked tumefaction or irregularity may be felt in the pelvic brim; but very soom a firm mass, more or less rounded or cylindrical, is made out in one or other, or in both sides of the pelvic brim ; and as the dis- ease continues, this tumefaction extends out of the pelvis, spreading laterally and forwards into the iliac fossae, bulging out above Poupart's ligament, and sometimes rising as high as the level of the umbilicus. This swelling is hard, brawny, tolerably uniform, cylindrical. At an early stage the skin can be moved over it, but later, especially if the process be tending to suppuration, the abdominal wall becomes one with the tumefaction underneath. The shape and limits of the tumor rising out of the pelvis can usu- ally be defined by the hand pressing in the abdominal wall above, and getting even a little way behind the tumor. By percussion the evidence thus obtained may be checked and extended. An area of dulness will correspond with the tumefaction behind the abdominal wall, whilst resonance will disclose the position of the intestines. The vaginal touch gives the most decisive evidence. The examining finger entering the vagina is first conscious of increased heat and puffi- ness of the walls. The os uteri is reached much more readily than in the ordinary state, because an almost invariable efifect of the perimetric inflammation is to bring the uterus down to a lower level. The situa- tion of the OS uteri is usually near the centre of the pelvis. This is the case when the chief seat of inflammation is in the broad ligaments or in the sides of the pelvis. If one side be chiefly affected, the cervix may be pushed over towards the opposite side. But if the case be one of retro-uterine cellulitis and peritonitis, the uterus is pushed bodily forwards, coming sometimes so close to the symphysis pubis as to com- press the neck of the bladder, and cause retention of urine. 32 498 PELVIC INFLAMMATION. In post-puerperal cases the os uteri is generally more or less patulous. Surrounded as it is by inflammatory effusion, contraction and involu- tion are impeded. Feeling round the margin of the os uteri, we com- monly fail to define accurately the usually projecting vaginal-portion. Instead of the hemispherical or conical smooth mass, merging at the fundus of the vagina into soft yielding tissue, we find hard brawny bumi^s occupying the summit of the vagina, encircling the os down to, or even below its level, preventing our feeling any portion of the cervix. If the inflammation be general, that is what is felt. But if the inflam- mation be unilateral or anterior or posterior only, the inflammatory swelling projects in the* corresponding part only, leaving the remaining part of the circumference of the cervix accessible to the finger ; and the uterus will be fixed on the side of the swelling. This is represented in Fig. 99, from a case under my care. Representing the collar of hard inflammatory eflfusion encircling the cervix uteri. When the inflammation is limited to the peritoneum of the body of the uterus and the utero-vesical reflection — and I have seen several such cases, strictly " perimetritis " — the adhesions contracting in the chronic stage pull the fundus down in nutation ; the os uteri is thrown up and backwards in the contrary direction, so that it is actually higher than normal. And since the packing of cellular tissue between the cervix uteri and the base of the bladder may not be affected, the finger is free to travel all round the vaginal-portion in front as well as else- where. But by pressing a little firmly in the anterior vaginal roof we are sure to come upon a firm resisting plane or prominence, which is caused by the inter-utero-vesical consolidation. Fixing or immobilization of the uterus may generally be accepted as a sign of peritonitis with adhesive effusions. In the case of localized cellulitis, especially in the utero-vesical connection, the uterus may move along with the phlegmonous mass and the bladder. In the case of retro-uterine peritonitis, the tumefaction, or rather tumor formed by the effused lymph and serum, may attain considerable magnitude, pushing the uterus forward, rising above the fundus of this organ, and PELVIC INFLAMMATION. 499 coming within reach of the fingers applied above the symphysis pubis. In not a few cases, even, the peritoneal investment of the opposed in- testines and omentum being caught, a large firm tumor may be formed, reaching to the umbilicus and even higher. This is especially the case when the peritonitis is caused by a retro-uterine hsematocele. When the inflammation is unilateral, I have often been struck with the sensation of a firm, almost knife-like, or rather " hog-back" ridge, running from the edge of the os uteri across to the side of the pelvis. In these cases, in the adhesive stage, the fundus uteri is pulled towards the affected side. The sound, although not generally necessary, often lends precision to the investigation. For instance, when adhesive inflammation pre- vents the finger in vagina, or hand above pnbes from tracing the form and position of the body of the uterus, this being concealed in a mass of firm effusion, we cannot easily tell whether a hard rounded mass projecting the posterior roof of the vagina be the retroflected uterus or a retro-uterine mass of inflammatory deposit. The sound at once puts us right by defining exactly the course of the uterus. The sound in uterus thus serves as a central axis from which we may estimate the relations, bulk, and nature of all the surrounding structures. It also enables us to test more closely the degree of mobility the uterus enjoys. The sound being in the uterus, on depressing the fundus or the inflam- matory mass above the pubes, any movement imparted is clearly seen and felt by the descent or obliquity communicated to the handle of the instrument. Mobility en bloc is preserved in a modified degree until the adhesions extend to the walls of the pelvis. When, suppuration having taken place and the abscess is pointing in the roof of the vagina, we may feel a part which before had been hard, brawny, become soft, permitting the tip of the finger to sink in, and immediately to bulge again as pressure is taken off. There is, in fact, fluctuation. It may not be possible to get a wave propagated to the touching finger by percussion at another part of the sac, but it is quite possible to get what is strictly fluctuation by one finger. When a liquid is displaced by pressure, and flows back on the removal of the pressure, there is fluctuation, and this wave may be felt by delicate contact preserved upon the containing sac. The pointing spot, soft and prominent, is surrounded by a hard mass. When the abscess points within the rectum, we may commonly make out the same conditions by rectal touch. Rectal toueh furnishes valuable assistance. It checks and extends the information obtained by abdomen and vagina. The finger, cours- ing along the anterior wall of the rectum, can reach considerably above the level of the os uteri. If the case be one of inter-utero-vesical cel- lulitis, the finger can explore the posterior wall of the uterus, determine its condition, and ascertain if it be bent or straight, free or not from tumor. In the case of lateral cellulitis and peritonitis, the finger can commonly feel above the lower margin of the inflammatory swelling projecting into the vagina, and even trace it as a curved ridge across to the sides of the pelvis. Combined wdth abdominal palpation, the size, 500 PELVIC INFLAMMATION. position and relations of the uterus with the surrounding inflammatory swellings can often be defined. The finger having reached the level of the os uteri, comes upon the hard peri-uterine tumefaction ; it is commonly compelled by the back- ward projection of this tumefaction to be directed backwards into the hollow of the sacrum, following the globe which carries the anterior wall of the rectum against the posterior wall. In this M'ay we some- times find the rectum remarkably compressed, and its calibre contracted. Tracing the inflammatory swelling to the sides of the pelvis, we find the pelvic structures, those of the broad ligament especially, fixed to the pelvic wall, perhaps on either side of the rectum, by adhesive eflii- sion forming a collar through which the rectum passes. Three varieties of peritonitis in many points resemble pelvic peri- tonitis, and, indeed, frequently are associated with it. One is perityph- litis ; the second, a localized adhesive peritonitis, occupying one iliac fossa; the third, peritonitis of the lower part of the abdomen connected with cancerous affection of the pelvic organs and lumbar glands. In the case of perityphlitis, the tumor is always on the right side ; it is higher, generally, than inflammations springing from the pelvis ; it rarely passes beyond the median line, and does not extend into the pelvic cavity ; and the greatest bulk or diameter of the tumor is above the pelvis, whereas in pelvic peritonitis, the supra-pubic portion of the tumor can be traced downwards into the pelvic brim, and by combin- ing vaginal touch is felt to be a part of inflammatory masses in the pelvis. The localized peritonitis of the hypogastrium is also distin- guished by its not penetrating the pelvic cavity. And in both these cases the mobility of the uterus is commonly preserved. The cancerous inflammation in many cases takes its rise in malignant disease of the ovaries ; and especially when the lumbar glands are in- volved. In this case the disease is not so often localized or encysted. Dropsy of the peritoneum, ascites, not seldom attends. The signs of the cancerous cachexia will rarely be absent. But at certain stages of either disease vaginal examination may lead into error. Before the ulcerative stage of cancer has commenced, and therefore before the malignant cachexia has become marked, the uterine neck may be found set fast in the roof of the vagina by surrounding deposit, hard in some cases to distinguish from the deposit of simple inflammation. There are features of differentiation. In malignant disease of the vaginal- portion, in the first place, the history will generally be different ; the disease has come on insidiously ; its early stages have probably escaped observation; whilst in perimetric inflammation the starting-point is usually labor, abortion, a chill, accident, surgical operation, or other well-defined antecedent. In malignant disease, the jierimetric eff'usion is usually pretty uniform, that is, it extends all round the vaginal-por- tion, catching the bladder and rectum; whilst in inflammation the deposit is often unilateral or anterior or posterior, causing deviation of the OS uteri from its central position, and permitting the finger to touch a part of the circumference of the cervix, and ascertain that it is smooth. When these points are made out, the diagnosis of perimetric effusion is sufficiently decisive. But occasionally cancer is first noticed shortly PELVIC INFLAMMATION. 501 after a labor; and not seldom inflammatory deposits encircle the vaginal-portion all round. In these ambiguous conditions, we must fall back on individual tactus eruditus ; and now and then we must suspend our judgment, waiting for the more characteristic changes which time will certainly bring. That there is a difference in the feel of a cancerous os uteri and its entourage and that of inflammatory effu- sion, is certain. The first is more nodular, perhaps harder, " stony ;" the disease, in short, may be traced to the cervix uteri itself, as its centre of departure, whilst this part is only engorged, abraded perhaps in the second case. But it is difiicult to describe the tactile sensations produced by degrees of solidity and shape. Practice alone can teach the finger to recognize them. A difference worth remembering is, that cancer makes a hard cervix, whilst pelvic cellulitis or peritonitis makes hard masses round about the cervix. The chief objective characters of perimetric inflammation are described with great accuracy and point by Doherty, in a memoir/ which consti- tuted an important chapter in the history of the subject. "On intro- ducing the finger into the vagina we find the hardness, so remarkable in the iliac fossa, has extended to theroof of the vagina, which is tender to the touch, and as firm and inelastic as a deal board — a condition which must immediately arrest our attention. Not the slightest im- pression can be made on it by our pressure, while we may observe that the uterus is bound down to the affected side, either throughout its whole extent, by which it suffers a lateral displacement, or only par- tially, so that the fundus is drawn in one direction, while the os tincse is turned in the opposite." An observation of Aran is important. He says small perimetric inflammatory swellings may have their seat in the subperitoneal cel- lular tissue; but the voluminous swellings are the result of perimetric peritonitis. The subject of diagnosis may be appropriately concluded with the caution not to pursue it at the bedside with too much zeal. By insti- tuting repeated and minute explorations it is very easy to do a great deal of harm to the patient — more than enough to counteract any good which the knowledge thus derived may enable us to apply. Nothing in the treatment is so necessary as '' rest " of the affected parts ; and examinations mean disturbance. The treatment, like that of metritis, must vary according to the types of the disease and its complications. If the result be puerperal metritis associated with septicsemia, the treatment of the perimetric inflammation is simply subsidiary to that of the puerperal fever. In the more purely inflammatory cases, whether post-puerperal or not, leeches, to the number of twelve or twenty, to the groins and hypogastriura, will gen-, erally be useful in the early stage. Fomentations or moist warmth applied by a large thick linseed-meal poultice or spongio-piline are of material service. In many cases to which I have been called in con- ^ " On Chronic Inflammation of the Uterine Appendages occurring after Partu- rition," 1843. 502 PELVIC INFLAMMATIOK. sultation not only had leeches already been applied, but calomel and opium had been steadily given. It was manifest to me that this treat- ment had often done good. This favorable opinion has been confirmed by the observation of cases so treated by myself from the beginning. A pill of one or two grains of calomel with half a grain of opium may be given every four hours for twenty-four hours ; and then every six or eight hours for a day or two longer. If there is any disposition to diarrhoea the calomel may be reduced, and the opium increased. Or, in some cases, I have been better pleased with pills or powders consist- ing of three grains of gray powder and five grains of Dover's powder. An obstacle to this and other treatment, however, often exists in obstinate nausea, hiccup, or vomiting. To subdue this symptom is the first necessity. Bismuth, hydrocyanic acid, creasote, ice, soda- water in various combinations, will be useful. To allay fever, the acetate of ammonia and nitrate of potash with a sedative answer best. In the more chronic stages, where there is no obvious process of suppuration or pointing, blisters applied to the groins and hypogastrium are often of great service. In the same stage iodide of potassium be- comes extremely serviceable, and may be combined with bark in decoc- tion or tincture. The question as to opening abscesses does not seem to demand much discussion. Not seldom Nature solves it for herself. The abscess bursts into the rectum or roof of the vagina without obvious warning ; and generally recovery progresses from that event. It seems to me that these are the easiest routes ; that evacuation by them takes place earlier, and often with less disturbance. This may be partly because the walls of these organs are thinner and more easily perforated than the abdominal wall. At any rate the pointing and perforation of the abdominal wall is often slow and painful. The progress of an abscess towards the skin generally makes itself visible by the growing promi- nence and puffiness of the tumor, its reddening, its fliuctuation, and finally by the skin becoming blue and palpably thin. It is possible to err by opening an abscess too soon and too late. If an inflammatory tumefaction be opened before fluctuation is made out we may fail to find pus ; the incision must be carried deeply through tender vascular structures, and cause serious bleeding; and the suppuration-process will not be stopped. On the other hand, if we wait until the abscess is on the verge of bursting we shall have prolonged unnecessarily the patient's suffering; the blue skin may slough in spite of puncture, and will only heal with an ugly scar ; and there is the risk of the abscess effecting an opening internally into the peritoneum or in some other direction as well. The proper time for opening an abscess pointing to the skin appears to me to be as soon as fluctuation is clearly ascertained. Incision may be made with a bistoury, or a Syme's knife ; and if a depending position cannot be obtained a drainage-tube will be useful. The wound should not be allowed to close at once, as pus will continue to flow for two or three days at least. To keep it open a strip of lint, soaked in carbolic oil, may be inserted into the wound. I think it is important to keep the cavity of the sac as small as possible, by adjust- ing compresses in such a manner as to bring the walls together. PELYIC HEMATOCELE. 503 If we find fluctuation in the roof of the vagina or in the rectum the same rule should be followed. The puncture may be made by a long sharp-pointed hernia knife, or by a long trocar — for the rectum the long curved trocar used for tapping the male urethra is very conveni- ent. Where there is any doubt as to the presence of pus the fine aspi- rator-trocar is the proper instrument to use. It is sometimes an ad- vantage to insert a drainage-tube in the case of opening an abscess by the vagina. An excellent and convenient drainage-tube will be found in the Avinged male catheter. It is easily inserted, by passing the stilet into the eyelet near the end. Thus supported it is carried into the sac, where the end is retained by the wings. Whether the opening be effected spontaneously or artificially, by the rectum or the vagina, it is desirable to apply moderate pressure to the upper part of the tumor by pads and bandage to the abdomen. When an abscess has been opened, and sometimes earlier, quinine generally becomes useful. The diet should be nutritious and support- ing. Rest will still be necessary. At a later period, when suppuration has ceased, quinine may still be useful ; but iron now comes into service. The bowels must be kept gently acting. Bed may be changed in the daytime for the sofa; and gradually, but watchfull}^, gentle exercise may be indulged in. If taken too soon, or exceeding moderation, it is always probable, so long as any marked intumescence or diminished mobility of the uterus re- main, that a return of inflammation may occur. In the advanced, or confirmed chronic cases, warm baths will render great service. The iron-waters are not always safe. I believe many experienced physicians have arrived at this conclusion. The best re- sults I have seen have been derived from the Woodhall Spa. CHAPTER XLII. PERIMETRIC HEMATOCELE; RETRO-UTERINE HEMATOCELE; PELVIC HEMATOCELE; BLOOD-EFEUSIONS IN THE NEIGH- BORHOOD OF THE UTERUS. The study of perimetric hoBmatocele most conveniently follows im- mediately upon that of perimetric inflammation. Clinically, the two conditions have close relations. Indeed, blood-effusions into the peri- toneum almost necessarily entail pelvic peritonitis. And at the bed- side the practical difiiculty often is to distinguish hsematocele from in- 504 PELVIC HJEMATOCELE. flammatory effusions. It is certain that until within the last twenty years, or less, almost every case of perimetric hsematocele was con- founded with inflammatory effusions. It can hardly be said that hfematocele had been recognized as a distinct affection. And even now many men are slow to admit the evidence upon which its existence is established, and are consequently unable to appreciate the frequency or the conditions of its occurrence. In 1850 only the disease was so little known that Malgaigne is re- ported to have attempted the enucleation of a supposed fibroid tumor of the uterus, which proved to be a collection of blood; and the operation was followed by a fatal issue. And Scanzoni says, in his work on "Chronic Metritis," published in 1863: "We regret not to be in a position from personal experience to speak of this disease, for in our certainly extensive and protracted observation we have not been able to diagnose peri-uterine hsematocele in a single case." So long ago, however, as 1831, Recamier described in the " Lancette Francaise," under the name of " Turaeur sanguine du bassin," a very clear case. A woman, aged twenty-eight, after an abortion, had a large tumor formed in the pelvis, behind the uterus, which bulged the vagina forwards. R^camier, believing it to be an abscess, opened it, but instead of pus, dark, half-coagulated blood escaped. The patient recovered. Velpeau, in his " Medecine Op^ratoire," 1839, published additional cases. He was evidently acquainted with the characteristic features of these pelvic blood-swellings. In 1850 and 1851 Nelaton, in lectures in the "Gazette des Hopi- taux," laid the foundations of the present more accurate knowledge of the subject. It was he who proposed the name " retro-uterine haema- tocele." From this date cases and memoirs, still chiefly emanating from the French school, rapidly multiplied ; proving that it was only necessary to look for examples of this hitherto unknown affection with intelligence, in order to find them. Vigues, Fenerly, Aran, Prost, Bernutz, Puech, Nonat, Laborderie, Laugier, Yoisin, Gallard, Richet, Goupil, and Trousseau, have all contributed important materials. In England Tilt and West were the first to describe the affection. McClintock has given the best original account in the English lan- guage.^ He had published a case in the " Dublin Hospital Gazette " in 1860. In 1861 Dr. Madge communicated to the Obstetrical Society a veiy complete report of a case, illustrated l)y figures, representing the conditions found on dissection, and commented by a valuable re- view of the subject. Dr. Tuckwell, in 1863, published an important memoir, entitled " On Effusions of Blood in the Neighborhood of the Uterus." This contains an excellent historical sketch, a tabular view of ninety-eight cases collected from various sources, and histories of some original cases not before published. In Germany contributions have been accumulating since 1859. C. R. Braun, Alfred Hegar, Sjixinger, Seyfert, Olshausen, and others have added materially to the casuistical history of the subject. 1 "Diseases of Women," 1863. PELVIC HJEMATOCELE. 505 Bernutz claims to have been the first to demonstrate by post-mortem examination the position and relation that these tumors hold to the uterus. He was the first to maintain that many cases directly de- pended upon retention of menstrual blood. The Seat of the Blood-tumor. — The term " perimetric hfematocele " is used to define the state of tumor formed by effusion of blood in the neighborhood of the uterus. It is more comprehensiye than " retro- uterine hsematocele," which strictly means a blood-tumor behind the uterus. This latter term is correct as far as it goes. It would be al- together correct if it expressed the whole truth ; that is, if blood-effu- sions were not liable to occur elsewhere than behind the uterus. But blood-effusions do occur in other relations to the uterus. To admit these into a general definition we want the term perimetric or peri- uterine hsematocele ; or perhaps the term " pelvic hBematocele," pro- posed by Dr. McClintock, being more comprehensive, is better still. If we start from the arbitrary definition which some have proposed, namely, to restrict the term hsematocele to blood-effusions into the peritoneal cavity, it would almost necessarily follow that the adjective, retro-uterine, is the proper and only one to employ. For, if blood be poured out into the peritoneal cavity in the neighborhood of the pelvis, it must gravitate to the retro-uterine pouch, which is the lowest part of the general cavity. The ante-uterine or utero-vesical pouch is so shallow, and is so liable to disturbance or obliteration, by the filling and rising of the bladder, that lodgment of fluid blood in this position is rarely possible. If a little blood were to find its way into this pouch it would probably soon be dislodged, and made to run over the fundus of the uterus and the upper edge of the broad ligaments into the pouch behind. Moreover, the most frequent sources of effused blood are the ovary and the extremity of the Fallopian tubes, and these parts being in the posterior wing of the broad ligament, blood from them naturally falls direct into the posterior pouch. Intra-peri- toneal effusions then are almost always retro-uterine. But is this all we have to consider ? Are there no other blood-effu- sions ? Adhering to the cardinal principle of this work, that of making scientific pathology subsidiary to clinical book, I have determined to bring together all the blood-effusions Avhich may take place in the neighborhood of the uterus ; and then to proceed to analyze or differ- entiate them as best we can by the aid of the history and symptoms of individual cases and of general experience and pathological knowledge. It is only in this way that we can usefully investigate any given case. We may not know, in the first instance, what the source of the bleeding may be, or the particular nature of the lesion which led to it. That is a problem to be solved by clinical investigation. In a memoir on this subject' I distributed in groups all the cases I had met with which were characterized by the escape of blood in considerable quantity into the pelvic peritoneum. Some of these groups included cases which those who look at the subject from a rigorous systematic point of view refuse to recognize as legitimate examples of retro-uterine hsematocele. 1 St. Thomas's Hospital Reports. 506 PELVIC HEMATOCELE. But the objection, I submit, is critical, not practical. It seems unrea- sonable to contend that a case of rupture of the uterus, or of an extra- uterine gestation-sac, one of the almost certain effects of which is effu- sion of blood into the peritoneum, is not a case of retro-uterine hsema- tocele. It is quite arbitrary to restrict the term to effusions of blood the result of one particular cause ; for example, rupture of ovarian ves- sels. In no case is the outpoured blood the disease. It is only a con- sequence of some lesion or injury. In some cases the more immedi- ately serious symptoms are due to the shock of the injury ; in others, to the loss of blood and the attendant shock. This difference is an accident, of clinical importance, it is true, but still not such a difference as to dictate absolute separation of the cases possessing so important a common feature as hemorrhage. In all the cases the hemorrhage, sooner or later, is a serious element. In all hemorrhage plays an important part. First, by the shock caused by the sudden impression of the outpoured blood upon the peritoneum; secondly, by the loss of blood ; thirdly, by the consequent peritonitis. The patient may be destroyed by the shock alone, or by the shock combined with the loss of blood, before there is time for inflammation to arise. This is to say, that in those most formidable cases, as of rupture of the uterus, or of an extra-uterine gestation-sac, life may be extinguished before a hsematocele, properly speaking, is formed. But this is no more than is true of those usually less fulminating cases, in which the blood proceeds from burst ovarian vessels. In these cases sometimes the shock and bleeding kill before a tumor can be formed by the segregation of the blood by inflammatory effusions. In all there are common features which bind them together as members of one clinical family. Putting aside then for the present all pathogenic theories, we shall find that the cases of perimetric hemorrhage may be arranged as follows : f T M *. J fl- Rupture of uterus. T M *. J fl- Rupture of uterus. I. Non-encysted I ^ \, of tubal-cyst. (cataclysmic). I 3_ , of ovary. Intra-peritoneal ^ „ of subovarian vessels, (retro-uterine). I II. Encysted (peri- / 1. Menstrual. I tonitic). 1 2. Abortion, -p . , / I. In the broad ligaments. iliXtra-pentoneai. ^ jj-_ -j-^ cellular tissue between cervix uteri and bladder. III. In cellular tissue between uterus and rectum. I do not pretend that this is a rigorously exact classification. Hem- orrhage from rupture of an extra-uterine gestation-sac may become encysted ; hemorrhage from menstrual deviation may be cataclysmic. But if we regard the arrangement simply as a framework for descrip- tion, it will be found useful in aiding to obtain a clear knowledge of the subject. When blood is rapidly poured out in large quantities into the peri- toneal cavity the shock and loss of blood alone, as we have seen, may kill. No opportunity is given for the establishment of the conserva- PELVIC HEMATOCELE. 507 tive process of inflammation, which, by segregating the blood in one mass in one compartment of the peritoneum, limits both the quantity of blood effused and the area of irritation, and hence the extent of shock. In such a case the hemorrhage is said to be " non-encysted." Looking at the terrible suddenness and severity of the blow struck at the vital powers, I have called these cases " cataclysmic." The most common causes of the effusion in these non-encysted or cataclysmic cases are rupture of the uterus, gravid or not gravid, rupture of a tubal gestation-cyst, rupture of a diseased ovary, or of a varix of the pampiniform plexus. But in some cases where the hemorrhage is due to one of these causes the blood does become encysted. The course they run resem- bles closely that run by the cases of the second order, in which the source of the blood is the gorged vessels of the ovary, or the Fallopian tubes during menstruation or abortion. And even in some of these latter cases the blood is poured out so rapidly that it does not become encysted. These too may be cataclysmic. Instances of encysted hsematocele resulting from ruptured extra- uterine gestation-sacs are reported by Voisin, Aran, and myself, and many others. Nor can the extra-peritoneal cases be on sound clinical or patholog- ical grounds separated from the intra-peritoneal cases. If we base our classification or definition on origin, we shall find that some of the same causes which lead to blood-effusions into the peritoneum may lead to blood-effusions outside the peritoneum into the perimetric cellular tissue. And more than this, we shall find cases in which the blood being first effused into the cellular tissue has burst its way through the peritoneum into the peritoneal cavity ; thus breaking down the arbi- trary barrier which theory had placed between the two orders of cases. We see then from this statement that the perimetric blood-effusions are brought into close pathological and clinical relationship with the so-called " thrombus," or blood-effusion in the peri-uterine cellular tissue. It is this relationship which justifies the term " Pelvic Hsema- tocele," proposed by Dr. McClintock. It is true some authors of de- served repute would exclude all but intra-peritoneal effusions. The objection to ranking extra-peritoneal effusions along with intra-peri- toneal effusions has been insisted upon by Voisin and Bernutz. The latter author, justly celebrated for the precision of his researches, con- tends that the extra-peritoneal effusions are thrombi, and only result from labor. But the objection of Aran is more pointed, as being based on a clinical distinction. This excellent author affirms that there are no subperitoneal perimetric blood-tumors at all important in size, so as to come into consideration. They cannot become large because they are limited within the cellulo-fibrous layer covered in by the perito- neum. To this it may be answered that intra-peritoneal retro-uterine effusions are not always very large ; and that small tumors of this de- scription may be equalled in size by some extra-peritoneal ones. And Huguier, ISTonat, Robert, Becquerel, Verneuil, Frost, all maintain that hsematocele may be extra-peritoneal. In some extra-peritoneal cases, Nonat says, the tumor is nearer the anus. Frost relates two well- 508 PELVIC HEMATOCELE. authenticated cases, in one of which the blood was effused between the layers of the broad ligament, and in the other it occupied the connec- tive tissue behind the uterus. Tuckwell cites Becquerel as relating a case in which more than two pounds of blood were found outside the peritoneum, the blood having dissected its way between the different organs, and displaced them all. A specimen, presently to be described, in Bartholomew's Museum, seems a clear example of large extra-peri- toneal heematocele. If we look to the source of some intra-peritoneal effusions, we can- not fail to see that the effusion into the peritoneum is accidental, that the blood would be quite as likely to make for itself a sac in the cellu- lar tissue of the broad ligaments. For example, a varix, or the di- lated pampiniform plexus may be supposed to give way without ruptur- ing the peritoneum, the blood finding a lodgment by separating the peritoneal investments of the broad ligament. Olshausen (Arch, fur Gynakol., 1870) relates a case of subperito- neal ante-uterine catamenial hsematocele following on acute dysmeuor- rhoea. Fever, absorption, and recovery ensued. The anterior lip of the OS uteri was short, whilst the anterior vaginal roof was driven backwards by a tumor of half-soft consistence. I have seen two cases which I believed were examples of ante- uterine hsematocele, probably extra-peritoneal, since they corresponded in relations to the thrombus which forms in front of the uterine neck during labor. Both cases came under my observation in the chronic stage ; in both there was a firm tumor, the size of a small orange, in front of the uterus, throwing the fundus uteri backwards. The diag- nosis was confirmed by the gradual complete disappearance of the tumor, without any signs of ruj)ture or suppuration. These cases meet the objection of Aran that extra-peritoneal blood-tumors cannot be large enough to enter into clinical consideration. Professor G. Braun relates (Wien. Med. Wochenschr, 1872) a case — he thinks the only one — in which ante-uterine intra-peritoneal hsematocele was diagnosed during life. A married woman, aged thirty-five, had a smooth elastic swelling in front of the uterus. Dieulafoy's trocar gave issue to a pint of dark-red blood. Collapse and death followed. A sac, the size of a foetal head, was found in the left side of the pelvis, in front of the uterus. There was also peritonitis. TuclvAvell found in the synopsis of cases made by him that the blood was found to be intra-peritoneal in thirty-eight out of forty-one post- mortem examinations ; that in twenty-six of the thirty-eight it was diffused, and in twelve circumscribed, and limited to the retro-uterine cul-de-sac. We are then drawn to the conclusion that there are cases of both kinds ; but that the intra-peritoneal blood-effusions are by far the most common, apart at any rate from pregnancy and labor. Perimetric hemorrhage may occur in the pregnant state and in the non-pregnant state ; and in either case the effusion may be intra-peri- toneal or extra-peritoneal. It does not fall within the scope of this work to describe the accidents of the pregnant state. But some of the conditions of uterine pregnancy, and more especially those of abnormal PELVIC HEMATOCELE. 509 pregnancy, are so connected with the history and diagnosis of perimetric hsematocele that no complete idea can be formed of the subject, if we exchide the blood-effusions of pregnancy from the discussion. An all- sufficient reason for taking these into account is that in many instances we cannot know at the time of the accident what the source of the hem- orrhage is, or whether the subject is pregnant or not. The 'pathology of intra-peritoneal hsematocele is well illustrated in the following cases. Olshausen relates^ the case of a woman, aged twenty-five, who was delivered in March, 1863, of her first child. Menstruation returned regularly until the middle of September. In the middle of October it returned too early, and with repeated pain in the belly, and vomiting. Thenceforward metrorrhagia lasted for seven weeks. She walked into the physician's room. There was frequent desire to micturate. In the median line of the abdomen was a ball- shaped, somewhat painful tumor, the size of a gravid uterus at three months. The os uteri was driven against the symphysis pubis ; behind it was a ball-shaped, slightly painful elastic swelling, filling the hollow of the sacrum. The tumor became less in bulk, and harder. She died in June, 1864, of typhus. At the autopsy adhesions were found in Douglas's space, especially behind the broad ligaments. A membrane extended from the point of insertion of the left broad ligament to the cervix uteri backwards to the rectum, dividing off a small portion of the retro-uterine pouch ; in this a small coagulura remained, containing fluid in its centre. It lay quite free. The space showed a remarkable pigmentation abruptly terminating above, yellow and black in the tis- sue of the peritoneum. Both ovaries adhered to the uterus. The anatomical illustrations in the London museums are few. Amongst the most striking is one in St. Thomas's, a representation of which is given in Fig. 101, p. 515. There is a very interesting specimen in Guy's Museum (Fig. 100). It is not described in the catalogue. It shows the remains of a blood- cyst, h, h, behind the uterus in Douglas's pouch. The peritoneal sur- face is roughened by inflammatory deposits tinged with blood -debris. There is a specimen in Bartholomew's Museum of sj^ecial interest (No. 31.36) thus described : " Uterus and appendages. Between the layers of the right broad liga- ment is a globular cyst, about as big as a walnut, whose walls in the recent state were seen to be formed by the separated layers of the liga- ment, and whose cavity was filled with quite recent blood-coagula. On the anterior aspect of the cyst were two small, recently formed irregular openings. " From a patient, aged twenty-five, who, while in the hospital for treatment of warts on the vulva, was suddenly attacked with symptoms of internal hemorrhage, and died in twelve hours. Post mortem : The cavity of the peritoneum contained five pints of recently shed blood, loosely coagulated ; and dark fluid blood oozed slowly from the open- ings in the cyst above described. The interior of the uterus, along with all the other parts of the body, was very pale. Careful examina- 1 Archiv fiir Gynakologie, 1870. 510 PELVIC HEMATOCELE. tion failed to discover the source of the hemorrhage. No evidence of extra-uterine pregnancy, no ruptured vessel was discovered. It is uncertain whether the patient was menstruating at the time of the attack." Fig. 100. tv-^ (From Guy's Museum, half-size.) Remains of a retro-uterine hoematocele. o. The right ovary laid open, h, h. The roughened peritoneum of Douglas's pouch, which formed the anterior wall of the sac of the hsematocele. The nature of the cyst in the broad ligament is not clear. Was it a simple cyst, such as is not uufrequently seen in this situation ? If so, how can we account for its becoming filled with blood ? Is it a true extra-peritoneal hsematocele, resulting from rupture of a vessel in the broad ligament, the sac subsequently bursting, and giving rise to a cata- clysmic intra-peritoneal eifusion ? This seems to be the more probable conjecture. At any rate, the specimen gives anatomical demonstration of the possible existence of extra-peritoneal hsematocele. The following case from Olshausen affords distinct evidence of the genesis and nature of the affection. Atresia of the vagina after typhus ; hsematometra and hsematocele ; death by peritonitis ; regurgitatiou of blood through the tubes. When the subject came under treatment fluctuation was felt by rectum. Puncture made by rectum let out a little thick blood. Two days later at stool a larger quantity was voided. Peritonitis and death quickly followed. On dissection diffuse perito- nitis, with copious purulent exudation, was found. Blood-remains were seen in Douglas's pouch. The uterus was much enlarged ; its cavity empty. Both tubes were much dilated, darkly pigmented in- side, chiefly towards the uterine ends. Both ostia uterina allowed a sound to pass easily. The left ovary contained several small cavities filled with blood ; it adhered to the uterus. Dr. Jilno-el told Dr. Ferber that in about 3000 minute dissections PELVIC HEMATOCELE. 511 of women he had never found hsematocele or remains. On the other hand, obvious remains of pelvi-peritonitis, and of slight pigmentation of Douglas's pouch were very frequent. In pueUis publicis pelvi-peri- tonitis of old or recent date was always found, but never hfematocele. Since pigmentation is probably the residuum of blood, the presump- tion is that small hsematoceles are not unfrequent. It is certain that adhesions often disappear so as to leave scarcely a trace behind. Heurtaux describes the following confe?ife of a hcematocele : 1. Drop- lets like oil of a brown-yellow color ; 2. Spherical cells, entire or re- duced to fragments, abounding in adipose nucleoli ; 3. Amorphous fragments of hsematoidin ; 4. Quad rilated crystals, resembling ammo- nio-magnesian phosphates ; 5. Some blood-globules, well colored ; 6. An extraordinary quantity of blackish corpuscles, of various forms, resulting from the alteration of the coloring matter of blood. Dr. Madge describes the contents in his case as consisting of blood-corpus- cles, some perfect, others undergoing various degrees of change ; also pus-globules and little black and yellow masses, some of them assum- ing a crystalline form ; the chief part, however, was made up of unde- finable debris of blood, fibrin, and pus. The Sources of the Blood-effusions. — The seat of the blood-efPusion being not constant, it almost necessarily follows that the source is not constant. I propose to enumerate the various sources to which the hemorrhage has been traced. This review will throw considerable light upon the subject. In the first place, we may state generally that blood may be poured out from the ovaries, the Fallopian tubes, the uterus, and from the broad ligaments ; in the second place, it may pro- ceed from an extra-uterine gestation-sac, ovarian, tubal, or abdominal ; in the third place, it may proceed from lesion of some abdominal struc- ture, as aneurism of the aorta, or of the mesenteric arteries. Group I. — In ordinary uterine pregnancy the uterus may rupture at any time. H. Cooper^ relates a case of rupture of the gravid womb in the third month. At subsequent periods rupture becomes progressively more frequent. In almost all, if not in all, cases of rupture during pregnancy, the rent is through the body of the uterus ; and therefore the blood escapes into the peritoneal cavity, the ovum or embryo being either retained in the uterus or expelled into the peritoneum. In the first case, there is strictly intra-peritoneal hemorrhage. In the second, there is intra-peritoneal hemorrhage, complicated with the presence of the embryo and ovum. In either case the blood may or may not coagu- late, and become encysted. The more likely event is that it will not become encysted, but that the patient will die of the shock. The blood rarely coagulates more than partially ; remaining liquid, it is diifused over the intestines, only a portion being able to settle in the pelvic cavity ; the conservative peritonitis which under more favor- able circumstances secludes the blood in the pelvic region by plastic effusions cannot take place. It does not, in technical language, become " encysted." It therefore does not form a tumor : it is not a "hsemato- cele." It is the most severe form of intra-peritoneal hemorrhage, re- ' British Medical Journal, 1850. 512 PELVIC HEMATOCELE. sembling the bursting of an aneurism. It is a cataclysm of blood, not a slow or gradual effusion. In this respect, but differing in some of its symptoms, cases of rupture of the gravid uterus resemble those in the next group, in which the cyst of an extra-uterine gestation bursts. Group II. — In abnormal or ectopic pregnancy, rupture of the fruit- sac is a still more frequent issue; and this at so early a period that the existence of pregnancy may be unsuspected or doubtful. This subject has been treated of in some detail in a special chapter. It is only necessary here to call to mind, 1st, that the bursting of an abnormal fruit-sac is often preceded by metrorrhagia, resembling in this respect the more typical cases of intra-peritoneal hemorrhage, in which the blood flows from the ovary or Fallopian tube ; 2dly, that the severity of the injury, the quantity of the blood effused, and the rapidity with which it is poured out, induce such a degree of shock that the blood rarely becomes coagulated and encysted, so that the case, like that of rupture of the gravid uterus, is " cataclysmic." Still in some cases there is reason to believe that the blood may coagulate, become sur- rounded by plastic effusions, and constitute a true hsematocele. The following case, in which the diagnosis was verified by post- mortem examination, shows the possibility of a true hsematocele forming as the result of rupture of a tubal gestation-cyst : Fallopian Gestation — Pelvic Hcematocele — Death — Autopsy. On the 28th November, 1867, I went to Sheerness to meet Mr. Swales and Mr. Jaap, of Sheerness, and Dr. Jardine, of Chatham, in the case of Mrs. J . About a month ago, being presumed to be two months pregnant, she was taken with abdominal pain and flooding, but got better. On the 26th November, being out at dinner, she was seized with acute abdominal pain, prostration, and was with difficulty got home. The following day she was much worse: vomiting, hiccup, tympanitis ; urine not retained ; had calomel and mercurial inunction. 2Sth. — Pulse 150; constant vomiting and hiccup; great depression. The case had at first been taken for retroversion of the uterus, as the OS was near the pubes, and low down, and a swelling was felt behind the OS, simulating the body of the uterus. I passed a catheter into the bladder ; there was no obstruction. Per rectum : the cavity of the sacrum tolerably free, but there is a firm swelling in the roof; this swelling was also felt by the vagina ; the os was open, admitting the tip of the finger; it was pointing downwards. The sound curved enters nearly an inch beyond the normal length in a forward direction, over the symphysis : the swelling behind is, therefore, not the uterus. The uterus is fixed rather low in the pelvis, and driven forwards by the mass behind. Diaarnosis : retro -uterine hsematocele. Treatment : opiate enemata. The sickness and pain abated somewhat, but otherwise there was no amendment. The patient died under the shock and loss of blood on the 30th. Mr. Jaap wrote to inform me that a " post mortem was per- formed on the 2d December by Mr. Swales, assisted by the staff- PELVIC HEMATOCELE. 513 surgeon of the dockyard and Mr. Keddell. It must be a melancholy source of gratification to you to know that your diagnosis was verified in every iota." Mr. Swales, some time after, communicated the follow- ing — an accidental injury he had sustained prevented him from mak- ing the minute examination he wished : " The body was completely blanched ; I was shown what was called an adhesion between the left Fallopian tube and the intestines which had been cut away ; it certainly was not an adhesion, the product of peritonitis, about the thickness of the thumb ; it was more like half-organized fibrin ; the Fallopian tube had been ruptured, in my opinion, at the point to which this so-called adhesion had been attached ; the uterus was very pale, enlarged ; all the other organs healthy ; an immense amount of coagulated blood was packed in among, and almost covering the uterus and other pelvic con- tents, besides which there was a large quantity of serum. No ovum was found. I formed the opinion that it was a case of arrested ovum in the Fallopian tube which had escaped into the peritoneum ; but that she died more from the internal hemorrhage than from inflam- mation." Here, as in many cases of rupture of an extra-uterine foetal cyst, there were two distinct attacks of pain and shock, the first one slighter, and giving hopes of recovery ; the second crushing and fatal. Another case is quoted further on from Matthews Duncan. Group III. Rupture of Diseased Ovaries. — This appears to be a very frequent source of the severer forms of intra-peritoneal hemorrhage. Cystic ovaries of all sizes may rupture. In some cases the fluid effused in chief proportion is that proper to the cysts, the amount of blood being inconsiderable. In other cases, the large vessels in the walls of the cysts may be torn, so that hemorrhage may be great. In yet other cases, there may escape both blood in considerable quantity, and viscid or puriform matter from the cysts. In the latter cases, the blood effused being mixed witli a peculiarly irritating fluid, peritonitis is sure to ensue if the patient survives the first shock of the injury. This peri- tonitis naturally tends to segregate the effused matters ; but the segre- gation is rarely so complete as in cases where blood alone is effused. The peritonitis often takes the lead as the more urgent disease, and is commonly the immediate cause of death. Rokitansky describes as one source of the blood in lisematocele the bursting of cysts of the ovary formed of distended follicles into which blood has been extra vasated. In those cases where the blood-effusion predominates, the symptoms and consequences resemble those of rupture of tubal gestation-cysts. There is at first preponderance of shock over ansemia ; and the encyst- ment of the blood is rarely complete. But in a case which came under my care in St. Thomas's Hospital, and which I have related in detail in the memoir above referred to, complete encystment did take place. It thus connects the series very distinctly with the classical retro-uterine lisematocele. As the case is made complete by a post-mortem examination, and is illustrated by the preparation preserved in our museum, and by a dia- gram, I think it desirable to reproduce it. 33 514 PELVIC HEMATOCELE. Retro-uterine Hcematocele from Rupture of a Diseased Ovary — Punc- ture — Death — Autopsy. Reported by Mr. Seaton, Resident Accoucheur. M. A. C, aged thirty-six, married, having eight children, was ad- niitted into St. Thomas's Hospital, June 13, 1870, under Dr. Barnes. She had been attending as an out -patient, and as she had had some difficulty in passing her water, he deemed it advisable to take her in. The difficulty in micturition was found to have lasted for about three weeks, and it had now become so great as to necessitate the em- ployment of the catheter. On examination per vaginam this retention was found to be due to a tumor occupying a median position in the posterior wall of the vagina, in feel resembling the retroverted gravid uterus. The os was high behind the symphysis; the sound passed up- wards and forwards, over the symphysis, showing that the uterus was compressed bodily forwards, and was distinct from the tumor. The history she gave was that six months ago she was taken sud- denly with pain in the stomach whilst engaged in washing, and that this happened at a menstrual period. June 23cL — Has had some white discharge during the last two or three days. Her general appearance is much the same as on admission. Her complexion is straw-colored, the eyes are sunken and surrounded by a dark vein. Pulse feeble and quick (between 90 and 100). Appetite impaired. Tongue pretty clean. Is very thin. Skin dry. June 2Sth. — As the hectic condition persisted, indicating that the blood-poisoning was progressive. Dr. Barnes punctured the tumor, which was now distinctly fluctuating. A fine trocar and canula was thrust into the most depending part of the tumor. However, on with- drawing the trocar nothing came. Dr. Barnes, thinking that he had not put it in far enough, punctured again, and this time there flowed away about two ounces or more of dark treacly fluid, like retained menses. The canula was left in for about an hour, pressure on the belly being made at the same time by a bandage, but very little fluid beyond the above-mentioned quantity came away. After the opera- tion, on examining by the rectum, the tumor was found to have be- come flattened instead of forming a bulging prominence as before. 2dth. — Passed a good night. No sickness. Some tumefaction in the vagina yet, perhaps more than soon after the puncture. Pulse be- low 100. Vagina feels hot. In afternoon pulse went up to 120, and temperature to 103°. 30^/i._Temperature 104.8°. Pulse 130. Mucous discharge by bowel. Scalding micturition. Tongue moist. A good deal of ten- derness over the belly. Poultice ordered. July 1st. — Pulse 125. Temperature 104°. Great pain in belly. Vomiting. Bowels not open. 2d. — Pulse 135, very feeble. Temperature 103.6°. Troublesome vomiting. Enema returned without stool. Has passed water. Abdo- men tense. A point of emphysema was felt in tumor above the sym- PELVIC HEMATOCELE. 515 physis, from which Dr. Barnes diagnosed that air had got into the cyst. The outline of the fundus of the uterus was clearly distin- guished from the summit of the tumor by palpation. Appearance more prostrate. Tongue coated with brown fur. 3d. — Vomiting still, though not so much. Tongue still coated with brown fur. Complains of great pain in her belly, which is a good deal swollen, without giving fluctuation. Slimy discharge. Pulse, morn- ing 130; evening, 135. Temperature, morning, 102.2°; evening, 101°. ^th. — Signs of sinking. Dark mark round eyes increased. Pulse very feeble; scarce countable. Vomiting continues. Belly rather larger. Bowels not thoroughly open yet. Still same slimy discharge. Temperature, 101.4°. bth. — Vomiting worse than ever, allowing very little sleep. Com- plained of much pain to the end. She sank at four A.M. The autopsy was made on the following day, and confirmed the diagnosis. The fundus uteri was pushed forwards above the sym- physis ; behind it was a tumor, semi-fluctuating, which was opened by slight manipulation, and then showed masses of partly coagulated, partly fluid blood, and some bubbles of air. This blood was contained in a cyst, bounded above by the intestines, in front by the posterior wall of the uterus, behind by the anterior wall of the rectum, and below by the floor of the pelvis and the depressed posterior wall St. Thomas's Hospital Museum. (Dr. Barnes.) Representing a retro-uterine lisematooele from a diseased ovary. u. The uterus pushed forwards, a. The hsematocele filling the cavity of the sacrum, bounded above by plastic effusions and the small intestines. of the vagina. The cyst walls were formed by peritonitic plastic matter. The relations and extent of the tumor will be seen by the dia- 516 PELVIC HEMATOCELE. gram (Fig. 101), which, with the assistance of Mr. Stewart, the curator of the museum, and of Mr. Denison, librarian, I have constructed from the preparation and my notes of the examinations made during life. No trace of the right ovary could be discovered, unless a smooth ser- ous-looking cyst, projecting from and opening widely into the main cyst, were the remains of it. At this point was firmly adherent a clot of blood. It seemed to be the source of the hemorrhage; and it was concluded that the case was one of diseased ovary which had burst, dis- charging blood into the retro-uterine pouch, probably gradually at dif- ferent intervals. The course of the trocar was traced by small punc- tured wounds ; it penetrated the lower posterior wall of the vagina, then a small duplicature of the rectum before entering the cyst. In another case which came under my care, a post-mortem examination showed that the source of the blood was a cancerous ovary. The blood was encysted. Group IV. Effusions of Blood into the Peritoneum attending Abortion. — During abortion, if there should be any obstruction to the free escape of the blood from the os uteri, it seems not improbable that, under the extreme tension of vessels from increased turgescence, escape may take place by the Fallopian tubes into the peritoneal cavity. These cases naturally follow in order upon Group II. The symptoms are generally less severe ; but they are more severe than those attending ordinary cases of impeded menstrual function. The following case was very carefully observed ; and there is no doubt on my mind that it is a good illustration of retro-uterine hsema- tocele following on abortion : Abortion — Pelvic Hcematocele — Recovery . On the 19th October, 1867, I met Mr. Burton of Blackheath in the case of a lady aged forty-two. She had her last child three years ago ; labor natural ; and Mr. Burton ascertained that the uterus contracted well, all being normal. Since then Mrs. C. has menstruated regularly, not in excess ; no metrorrhagia until July and August last, when two periods had been missed. Six weeks ago, when away from home, she had a profuse loss which was taken to be an abortion. Since then she has suffered hypogastric pain, not so severe as to confine her to bed ; at times there has been difficult micturition and constipation. She has had an attack of jaundice, now passing off; no marked fever or hectic. A firm rounded tumor rises to the umbilicus, defined by touch and percussion ; it is continuous with a firm swelling passing into the left ilium. The os uteri is soft, a transverse slit comj^ressed close behind or rather above the symphysis pubis ; beliind the cervix is a large rounded firm but not hard swelling filling the brim of the pelvis, and partly projecting into the cavity, depressing the roof of the vagina; this is also felt per rectum-, it is more developed in the right ilium. The sound gently curved passes three and a half inches to the fundus of the uterine tumor, by directing the point well forwards round the symphysis towards the umbilicus. The uterus, therefore, is in front, enlarged, and is insulated from the larger mass behind it ; the uterine PELVIC HEMATOCELE. 517 neck is pushed forwards and upwards against the pubes by the swell- ing, and the body of the uterus is carried upwards so that it is lifted quite out of the pelvis. Hence the apparent large size of the uterus, which seems to be as great as the uterus at four months' gestation. Diagnosis : retro-uterine hsematocele ; hemorrliage beginning with abortion. Prognosis favorable. Treatment : rest. December dth. — Examined again ; uterus still enlarged, in same position, but not rising so high ; the whole mass, uterine and retro- uterine, movable. The extra- uterine mass gradually disappeared, the uterus recovered its normal size, position, and mobility. The condition of things is indicated in Figs. 102 and 103, con- structed at the time the case was under observation. Fig. 102. Retro-uterine hsematocele. (Dr. Barnes.) u, the enlarged uterus lifted up and pushed forwards by h, the retro-uterine haematocele. The following is another case in which a discharge of blood per rectum confirmed the diagnosis : Abortion — Retro-uterine Hcematooele — Recovery. On the 6th October, 1868, I met Mr. Garman, of Bow, in the case of Mrs. C B., aged thirty-four, m^io had had one child fourteen years before. Has had several abortions. At the time of my seeing her she seemed to have recently aborted ; the uterus was three to three and a half inches long; cervix patulous; some hemorrhage; the sound penetrated in normal direction. 518 PELVIC H.EMATOCELE. November 1st. — We met again. Within the last week there has been rapid increase of abdomen ; sense of weight and forcing forward of womb upon the pubes ; pulse 90 ; no marked abdominal pain, but there is a solid mass the shape of the uterus rising to the umbilicus ; dulness on percussion is uninterrupted from umbilicus to pubes. Per vaginam : fundus vaginas depressed, the posterior wall bulging forward from pressure of a semi-elastic mass behind and above ; the cervix and OS uteri are pressed down and forwards close to the pubes ; the os is flattened to a narrow chink. The sound — an elastic bougie — passes three inches forwards and upwards towards the umbilicus. Per rectum : a semi-elastic rounded mass is felt filling the hollow of the sacrum. Sectional yiew of the parts. (Dr. Barnes.) The h^ematocele fills the space between the uterus and the rectum, and descends into the pelvic cavity, h. The hsematocele. u. Uterus, b. Bladder, v. Vagina, e. Rectum. Diagnosis : pelvic hsematocele following abortion. Treatment : rest, opiates. In February, 1869, I received a letter from Mr. Garman from which the following is an extract : " Soon after your last consultation with me Mrs. B. passed a large quantity of blood per rectum, which very much relieved her. The womb has gradually assumed its proper position. The catamenia appeared for the first time ten days ago, and lasted the usual time, five days, a healthy and natural discharge. She is now convalescent." Group V. Menstrual Disturbance or Diffi.culty, leading to Effusions of Blood into the Peritoneum. — This group includes by far the largest proportion of cases. At the same time the danger is usually less, and the symptoms are not so severe. It may be stated as a general rule, that whenever there is any impediment to the free discharge of the PELVIC HEMATOCELE. 519 menstrual blood by the natural route, if the quantity of blood exuded in the uterine cavity be excessive, or suddenly increased by accident, by emotion or other causes, escape may take place by the Fallopian tubes into the peritoneum. We thus get sub-groups containing — 1. Cases of probable very early Fallopian gestation and escape of ovum into the peritoneum. 2. Cases in which there existed a mechanical impediment to the natural escape of the menstrual blood. 3. Cases in which there was disturbance or interruption of the menstrual flow from — a. Cold and overexertion. h. From emotion. 0. From excessive sexual intercourse. 4. Cases in which the hemorrhagic character of the blood was in- creased by disease. Nelaton and Laugier insisted that a great cause of hseraatocele con- sisted in the physiological work of ovulation, blood being poured out from the ovary at the seat of rupture. They enforce this theory by observations which show that in many cases the first appearance of the hsematocele coincides with a menstrual epoch ; that it is especially at the return of the menstrual epochs that the gradual augmentations of the hgematoceles take place ; that the pain of menstruation and hsema- tocele has the common character of pain in the side of the pelvis, where ovulation takes place ; and that the rut in animals may cause an ovarian congestion, followed by rupture of this organ, that is to say, accidents similar to those of retro-uterine hsematocele. Gallard^ gives another explanation of catamenial hsematocele. He contends that Laugier has exaggerated the importance of ovarian con- gestion in putting it forward as the principal cause. It is true, indeed, that it always acts, but by itself it is incapable of producing a hsema- tocele. Gallard, not denying the efficacy of other causes, insists that the principal cause of spontaneous hsematocele is the dehiscence of an impregnated ovule. According to this view these hgematoceles should be regarded as true extra-uterine gestations. This theory would, to a certain extent, explain the frequency with which hsernatoceles are caused by coitus. Trousseau even thought that in these mild cases of men- strual hsematocele there was no peritonitis ; such is their benignity. They are almost indolent. But Bernutz describes a case in which the hsematocele became encysted in thirty-six hours. Dolbeau, again, says retro-uterine hsematocele is a grave complaint, but is rarely fatal. A case related by Sireday which occurred under the observation of Aran proves that the blood may coagulate in the pelvic region without setting up peritonitis at all. This woman pre- sented symptoms of intra-abdominal hemorrhage, but no trace of retro- uterine tumor could be detected by internal examination during life. Again, experience of ovariotomists shows that blood may be effiised into the peritoneal cavity without exciting inflammation. 1 "Menioire sur les hematoceles peri-uterines spontanees." 1858. 520 PELVIC HEMATOCELE. In that order of cases in which the blood -mass undergoes disinte- gration, the symptoms of irritative fever supervene. The temperature and pulse rise ; rigors, vomiting, sweats appear ; and, unless a vent be found for the imprisoned matter which is poisoning the system, the patient will be in great danger of sinking. There is commonly a com- plication with unhealthy peritonitis. The abdomen becomes more tense, tympanitic, and painful. Dissections demonstrate that adhesions binding the uterus to the rectum and neighboring parts may last for a considerable time, and that these remains are marked by pigmentation from hsematoidin. In one case — it is recorded in this chapter — the fundus uteri was tied down in retroversion for some months. The blood may flow back from the uterus and tubes, and escape by the abdominal opening of the tubes under various conditions. The chief of these are obstruction of the tubo-uterine canal, and sudden excessive effusions of blood into the tubes and uterus, so that the whole is unable to flow onwards by the vagina and vulva. The most indubitable cases of obstruction of the tubo-uterine canal are those of atresia, congenital or acquired, of the vagina or cervix uteri. They have been sufficiently discussed under the head of " Atresia." They have been accurately described by Bernutz. The blood escapes into the peritoneum either by regurgitation by the abdominal end of the tube, or by the bursting or perforation of the tube. Ruj^sch, Hal- ler, and Brodie, all believed that blood, menstrual or lochia 1, could flow back from the uterus into the peritoneum. Trousseau held the same opinion. Basing upon his aphorism that "all physiological blood comes from mucous membranes," he contends that the blood in metrorrhagia and abortion is simply blood in excess from the same source. Copious exudation of blood from the mucous membrane of the uterus and tubes, appearing as metrorrhagia, is, indeed, one of the most constant facts in the history of the affection. Where this out- pouring of blood is in excess of what can be readily discharged by the vagina, it is easy to understand that some may be driven back by the tubes. The mechanism by which this is effected, is probably the same as that by which I have explained the propulsion of fluids injected into the uterus along; the tubes. The uterus being suddenlv irritated by the invasion of a quantity of blood beyond its capacity to tolerate, contracts spasmodically, and the fluid blood is propelled towards all the three openings from its cavity. This is borne out by the history of cases. The origin of hsematocele is often marked by the initial fact of a strong emotion, or physical shock, producing a sudden afflux of blood to the pelvic organs, followed by intense uterine pain, and then by pain of wider diffusion. Bernutz's theory of reflux is essen- tially similar to the above. The case quoted at p. 510 from Olshausen is a good illustration. But obstruction and retention of menstrual fluid need not be com- plete in order to lead to retrograde escape by the Fallopian tubes. In the chapter on " Dysmenorrhoea " I have drawn a comparison between cases of complete and of incomplete retention, showing that the differ- ence between them is one of decree rather than of kind. Similar conse- PELVIC HEMATOCELE. 521 quences may be expected to attend upon similar physical conditions. Accordingly we find that the narrow os externum uteri, which is so frequent a cause of dysmenorrhoea by retention, may lead to pelvic hsematocele. Trousseau has further expressed his opinion that obstruction from retroflexion of the uterus may lead to hsematocele. The following case seems to me to be one of retrograde flow from stenosis of the uterus : In August, 1871, I saw, with Mr. Cass, a young lady who had had no child, but who was said to have had an abortion. She had been losing blood for a month. When under exposure and fatigue from travelling, and there was reason to conclude also from undue sexual excitement, she was seized with pain in the pelvis which rapidly in- creased. This was followed by retention of urine. When we met this had lasted three or four days. The pulse was 100; there was pain on pressure above the symphysis, and in both groins. There was an area of dulness on percussion, and of firm tumefaction rising to the level of the umbilicus, and extending into either iliac fossa. The uterus was pushed close behind the symphysis, the sound passed forwards, demon- strating that the fundus projected about two inches above the symphysis pubis. The os was small, the cervix conical, presenting the characters usually associated with dysmenorrhoea and sterility. Behind the uterus, occupying the brim of the pelvis, and extending into the hollow of the sacrum, was a smooth elastic swelling. This was also felt by rectum. She had been leeched, and there was a blister on the abdomen. There had been vomiting ; constipation. Diagnosis: retro-uterine hsemato- cele, and consecutive pelvic peritonitis. We agreed upon sedatives and rest, and to puncture the tumor if the pulse rose. On the next day she was sensibly worse ; there was more pain in the abdomen, and more diffused pain came on rather suddenly. The bladder now seemed re- lieved from pressure, for the urine was passed spontaneously, and the tense fluctuating mass behind the cervix uteri was lessened. The uterus, in fact, was found less tightly jammed against the symphysis. The pulse was 130 ; respiration, 36 ; temperature, 102° F. The symp- toms indicated a fresh shock ; and as the tension of the tumor was less, we did not use the trocar as contemplated. Under opium, the pulse, respiration, and temperature went down next day, and she was alto- gether easier. At this time I was absent from town, and Mr. Cass subsequently gave me the following report : " The tumor and symp- toms subsided greatly, when, on the 20th, menstruation impending, fresh swelling and great pain set in, and Mr. Spencer Wells saw her. He punctured by the vagina ; a pint and a half of fluid blood flowed ; the canula was kept in. For three days the discharge went on. When the canula was removed there was great pain. The swelling and pain again subsided, and after a long illness she recovered." The following case illustrates the formation of hsematocele from obstructed menstruation : On the 2d September, 1863, I met the late Dr. Stevens, of Bedford Square, on the case of a girl, aged fourteen and a half years, who had never menstruated. She was of tubercular family. She was appar- 522 PELVIC HEMATOCELE. ently in good health three weeks before, not having complained of ovarian or menstrual symptoms. Fourteen days ago, being then at Margate, peritonitis appeared, and she was sent home. Effusion pro- ceeded rapidly. I felt a firm, rounded tumor rising above the pubes. The catheter was passed, and the bladder emptied, but the tumor re- mained. It increased in size. When I saw her again it was as large as the uterus at three months' gestation ; but the pain and distension from effusion were so great as to forbid minute exploration. Per vagi- nam, hymen permitted finger to pass; vagina of fair size; a somewhat firm mass was felt at brim of pelvis ; the os uteri could not be clearly made out ; the cervix seemed distorted and compressed by the tumor. The whole was slightly movable in connection with the tumor above the symphysis. Fluctuation everywhere in the abdomen, and dulness in front; pulse, 120 to 140; continuous expression of pain; prostra- tion ; tongue dry. Dr. Stevens, having regard to family history, thought there was tubercular peritonitis. The symptoms seemed to me too rapid for this. The abdominal shock and inflammation indi- cate some sudden injury. Is it effusion of blood into the peritoneum from the ovaries, or sudden distension of uterus by menstrual fluid, with retention, ending in escape of blood by Fallopian tubes, haemato- cele and peritonitis following ? She died next day. No autopsy could be obtained. Under the hypersemic turgescence attending the onset of the first ovulation and the attendant menstrual flux, there is a rapid transuda- tion of blood from the mucous membrane of the uterus. This organ, comparatively immature and unused to the duty it is called upon to perform, does not readily expand to accommodate the blood poured into its cavity, and which is retained by an imperfect development of the cervix from being discharged by the natural outlet. There is con- sequently reflux along the Fallopian tubes, hsematocele, and periton- itis. There can scarcely be a doubt that this is the explanation of some, at least, of those apparently obscure attacks of peritonitis which sometimes seize young girls at their entrance upon the ovarian epoch. The following case of menstrual hsematocele was observed to the end under such favorable circumstances as to furnish a good clinical illus- tration. L. H., aged thirty-five, was admitted into my ward with retention of urine on the 1st of October, 1871. She has had four chil- dren and one abortion. The catamenia have been irregular for eighteen months. There is now metrorrhagia. The uterus is driven forwards behind and above the symphysis by a mass behind which fills the pelvis. The os uteri is wide, gaping; the sound goes three inches above the pubes. The mass is fixed in the brim of the pelvis, project- ing somewhat above the plane of the inlet. Her history is, that five weeks ago, having been menstruating three days, she was seized one afternoon with intense pain in the lower part of the abdomen. She kept her bed ten days, then became an out-patient until her admission. Early on the morning of the 7th a considerable flooding occurred. The pulse was weak, 74, temperature 99.5° F. After this the bladder was relieved naturally. On examination I passed a sound three inches through a hole I felt in the upper part of the vagina, behind the uterus; PELVIC HEMATOCELE. 523 the point moved freely round. It was in the cavity of the haematic cyst. By specukim we saw the hole, and blood oozing from it. From this time she continued to improve; the tumor lessened rapidly in bulk ; so that on the 24th there was very slight discharge, the opening had nearly closed, and the uterus had retreated to its normal position. She was again made an out-patient ; and we had several opportunities of seeing the scar left by the healing of the opening by w^iich the blood-tumor had discharged its contents. The uterus continued bound down in retroflexion for some months. The adhesions were gradually overcome by wearing a Hodge pessary. Several curious examples have been recorded of hsematocele result- ing from dilatation of a tube where there was a double uterus. M. Deces relates a case of double uterus and vagina, in which the left vagina was imperforate ; there was accumulation of menstrual blood, consecutive dilatation of the left uterus and tube, and death from rup- ture of the tube. Group VL In which the Hemorrhagio Disposition is increased by Disease. — The influence of variola, as of other zymotic diseases, in dis- posing to hemorrhage, is well known. "Where there is a normal hemor- rhagic molimen, as from the uterus and tubes during menstruation, if a zymotic disease supervene, the normal flow is apt to become hemor- rhagic. Barlow published a case of pelvic hsematocele supervening on purpura (Edinburgh Monthly Journal, 1841); Scanzoni one of hemor- rhage arising during measles. Helie and Laboulbene describe cases, the first of variola, the second of scarlatina, in which large clots were found in the uterus, and the Fallopian tubes were distended by blood coming from the uterus ; but there was no blood in the peritoneum. These two cases are cited by Bernutz to show that the blood forms in the uterus, and may flow back into the peritoneum. The hemorrhagic tendency induced by small-pox is illustrated in a case related by Bouil- laud. A patient in La Charite, suffering from modified small-pox, was seized with alarming hemorrhage, when the catamenia returned three days after the eruption. I have seen a case in a young lady suf- fering from modified small-pox. The fever was severe. She was men- struating when seized. Next day she was attacked suddenly with the most acute pelvic and abdominal pain. Peritonitis and tumefaction followed, and she was for some days in a critical state. I have little doubt that in this case the cause of the peritonitis was blood-effusion into the peritoneum. The case is of interest in this respect. Had the symptoms which attended the effusion in this case come on in the course of typhoid fever they would almost certainly have been taken to indi- cate perforation of the intestine. Is it not possible that such an error has been made? Bernutz relates a case of hsematocele from acute jaundice in a preg- nant woman. When we reflect upon the extreme hemorrhagic ten- dency which marks this dire disease, we cannot be surprised that hemorrhage should take this form. In the menstrual cases it is clear that fresh effusions into the perito- neum take place at successive menstrual epochs, producing temporary exacerbations of the local symptoms. In these cases it is probable that 524 PELVIC HEMATOCELE. the subsequent effusions do not always take place into the cyst formed around the primary hsematocele, but outside it, so as to cause fresh peritonitis. Hence those several collections of blood, divided more or less by fibrinous septa, which are sometimes found where there has been the opportunity of making a post-mortem examination. In the case related as attended with Mr. Cass the menstrual exacerbations were clearly observed. (See p. 521.) A remarkable example of menstrual hsematocele is that which results from effusion of blood from the stump of an ovarian cystic tumor. Spencer Wells states that his personal experience of pelvic hsematocele has been chiefly as a sequel of ovariotomy. He believed the less severe forms, where only small quantities of blood are effused, and afterwards ab- sorbed, are very common. When the tied or cauterized pedicle, being treated on the intra-peritoneal plan, is in the pelvis, a good deal of trouble is sometimes observed at each menstrual period for some months, with all the signs of hsematocele. When the pedicle has been treated by clamp on the extra-peritoneal method, the stump is occasionally seen to menstruate, so that we thus have demonstration of the source of the blood. Dr. Playfair relates (Lancet, 1865) a very interesting case, in which a pelvic abscess appeared to be the cause of hsematocele. Following on pelvic cellulitis there was a large discharge of pus by vagina. Three days later there was a sudden escape of a great quantity of dark-colored blood, the coagulum of which filled one-third of an ordinary-sized chamber vessel. She eventually recovered. He conjectures that blood- vessels opened into the sac of the abscess. There are observations to show that the blood may flow from a varix of the broad ligament. The vessels belonging to the ovary may become varicose, and under pressure of unusual distension they may burst. Richet and Ollivier d' Angers adduce evidence in point. Bernutz points out that in cases of hsematocele from varix the accident comes on, not at a menstrual epoch, but after fatigue, which causes distension of the varix. It is certain that varix of the pampiniform plexus, and of the plexuses about the vagina and vulva, may result from pregnancy and complicate varices of the veins of the legs ; and there are several examples known of a varix of a leg in a pregnant woman bursting, the accident proving rapidly fatal. I have myself known such a case. Richet especially describes hasmatocele as taking its source in rupture of varices of the ovarian or subovarian veins. In these cases the loss of blood has been so rapid and profuse that no time has been allowed for it to become encysted. These, then, will swell the cataclysmic order of cases ; and by their clinical history link hsematoceles of ovarian origin with those proceeding from rupture of extra-uterine gestation- sacs. We may then conclude that hasmatocele from varix is possible ; but observation shows that it is rare. Dr. Tuckwell records a case related to him by Seyfert in which the blood came from the rupture of a tubal vein. A maid-servant, aiged eighteen, while carrying a large vessel of water on her back, upset it and received the whole of its contents over her back and shoulders. She fell down suddenly and died rapidly. The occurrence took place PELVIC HEMATOCELE. 525 at the time of the catamenia. The autopsy disclosed an immense mass of blood in the sac of the peritoneum. One of the veins of the left tube was found to be ruptured, and a small opening in the layer of perito- neum that covered the tube had allowed the blood to escape into the abdominal cavity. One source of blood-tumor has been put forward on great authority as common. Virchow affirms that the hlood exudes from the delicate neiv-formed vessels of inflamed peritoneum; that is, in fact, that there has been antecedent peritonitis. Tardieu relates two cases in which he concluded that fatal hemorrhage came from the peritoneal surface. Bernutz, however, does not admit that these cases prove the existence of a hemorrhagic pelvic peritonitis. Schroder goes so far as to affirm that a tumor caused by a collection of blood, which can be felt in the vagina, can only arise where a cavity is preformed for it; that is, when Douglas's sac is first closed above by a partial adhesive peritonitis. I cannot help agreeing with Ferber, who objects that this preformed cavity is a pure hypothesis. But one cannot dispute a proposition made by a pathologist so rich in experience and sagacity as Virchow without misgiving. If, however, I might venture to interpret my own observations, I should be compelled to conclude that the peritonitic source must be extremely rare ; and that the general opinion, which declares the peritonitis to be secondary, not primary, is correct. Dr. L. Atkin reports a case (Edinb. Med. Journal, 1870) in which a hsematocele seemed to be caused by the use of a laminaria tent. The influence of coitus has been specially treated by French authors. Thus Voisin says that in ten cases the commencement was traced to a menstrual period — i. e., that in seven of these, coitus had taken place, either during menstruation or shortly after, and pain began during the sexual act. Aran relates a marked case of the kind. In one instance observed by myself, I have little doubt this cause was an essential factor. In the other three cases of Voisin, cold, fatigue, or violence, daring menstruation, seem to have determined the attack. Group VII. — I have seen cases in which there was reason to believe that hemorrhage was caused by injury to the abdomen. In these cases of direct violence it is not easy to determine the source of the blood effused unless a post-mortem examination be made. Should the patient be pregnant at the time, the commotion will be likely to determine hemorrhage from the uterus or ovaries. Of course, the nature and extent of pelvic and abdominal lesions inflicted by violence are infin- itely various. When a student at St. George's Hospital, I saw a case under Dr. Wilson of rapid death that ensued from the bursting of an aneurism of the superior mesenteric artery. The blood poured out was in great quantity ; it was diffused all over the intestines. There was no attempt at cystic segregation. The Symptoms and Diagnosis. — The great variety of causes and sources of blood-elfusions into the peritoneum which we have passed in review, renders it manifest that we cannot lay down any concise general sum- mary of symptoms. Perusal of the cases, and comparison of the features characteristic of the several groups into which I have arranged them, will convey the best idea of the significance of the symptoms. The 526 PELVIC HEMATOCELE. cases I have pointed out may be broadly divided into two great classes : 1. Those in which an overwhelming shock attends a sudden and pro- fuse loss of blood. This is the cataclysmic class. These cases generally coincide with the non-encysted class, the great majority of which end fatally. 2. Those in which the shock is less pronounced, in which the eflPusion is less profuse and less rapid, in which general and local signs of inflammation supervene. These form the encysted class, a large proportion of which end in recovery. The history of the first, or cataclysmic class, is almost wholly com- prised in that of rupture of the uterus, of extra-uterine gestation, and of ovarian disease. I will not dwell upon it here. The history of the second, or encysted class, presents features admitting of being defined with great precision. It must not, however, be lost sight of that effti- sion resulting from menstrual reflux, although usually falling within this second class, may be cataclysmic. In the encysted cases, the history may commonly be told in three chapters. 1st. There is shock and pain referred to the pelvis and lower abdomen, and ansemia. 2d. There are signs of reaction, of fever, and pain indicating peritonitis, and usually attended by evidence of me- chanical obstruction, as of the bladder. 3d. There are the signs attend- ing the disposal of the blood-mass and the inflammatory deposits. 1. A woman within the reproductive period of life, during a men- strual period, usually profuse, after being exposed to cold, fatigue, or sexual excess, is seized suddenly with pain in the pelvis. This is at- tended by shock, inducing more or less collapse, according to the sud- denness and profuseness of the loss, and the susceptibility of the patient. The surface becomes cold, the face pale, the pulse falls ; perhaps there is syncope : there is usually vomiting. If the loss be extensive, the signs of hemorrhage, of ansemia, are added. 2. In the second stage, the signs of reaction appear. The pulse rises, the skin becomes warmer. There is felt a sense of warmth or burning, with distension of the lower abdomen. The pain persists. Frequently retention of urine occurs, and constipation follows. Men- orrhagia commonly goes on. The rectum shows signs of irritation, a dysenteric condition is observed, marked by tenesmus and muco-san- guineous discharge. But this is not constant. Examination of the abdomen usually reveals more or less enlarge- ment and tenderness. The enlargement is in the form of a rounded swelling rising out of the pelvis towards the umbilicus, and stretching towards either ilium. In several cases the tumor has risen quite as high as the umbilicus. Examination by the vagina reveals conditions closely resembling those characteristic of retroversion of the gravid womb at the third or fourth month. The finger cannot proceed to- wards the hollow of the sacrum because a rounded tumor occupying that space pushes the posterior wall of the vagina forwards, altering the direction of this canal ; following this, the finger is directed upwards and forwards, behind and above the symphysis pubis ; and usually closely compressed against the symphysis just behind it, or a little be- low its level, the os uteri is felt. In cases where the cervix is soft, and the OS large, this may be flattened out into a narrow transverse chink. PELVIC HEMATOCELE. 527 The finger may be able to penetrate by pressure in front of the vaginal- portion, and also on either side ; but the tumefaction is almost continu- ous with the posterior margin of the os uteri, seeming to form one with the uterus, and thus closely simulating the physical signs of retrover- sion. In the early stage, the tumor feels soft and fluctuating, but it soon becomes more tense, less resilient, and may eventually become quite solid. The solidity depends partly upon coagulation of the blood- mass, but more especially upon the formation of plastic effusions, the product of the peritonitis excited to segregate it. Before removing the finger from the vagina, examination should be completed by catheter and sound. The use of the catheter may be in- dicated by retention of urine. When the bladder is emptied, the way is cleared for further precise observation. The finger resting upon the OS uteri or in front of it, is opposed by the fingers of the other hand applied to the abdomen, just above the symjjhysis. Between them the body of the uterus may usually be traced, since the fundus is driven forward so as to project above the pubic symphysis. But this is made quite clear by the use of the sound. Passing this instrument into the uterus, it is found to penetrate upwards and forwards for the normal length of two and a half inches, or usually more, the point being carried directly over the symphysis. And now abdominal palpation is repeated with more advantage. The uterus supported on the sound, is felt by its fundus ; pressure by the fingers upon this portion imparts a move- ment which is plainly felt by the hand which holds the sound. Thus no doubt remains as to the position of the uterus. We know for cer- tain that the softer, semi-fluctuating, or even, it may be, solid mass be- hind the cervix, is not the body of the uterus. Its rapid appearance under symptoms of shock, the quickly succeeding signs of local pressure and distress, tell us with great certainty that it is not a fibroid tumor, or an ovary, or an inflammatory effusion ; and the knowledge derived from pathological studies tells us that only blood-eifusion can produce a tumor in this situation, ushered in by the circumstances, and attended by the local conditions described. Examination by the rectum carries the diagnosis to still further precision. The finger is immediately met by the rounded, more or less yielding swelling ; by this, the finger is directed backwards along the sacral hollow ; and it is rare that it suc- ceeds in getting above the tumor, or even beyond its equator ; the sen- sation imparted by the tumor differs from that of the retroverted uterus by being less solid. In the slighter cases of menstrual heematocele, when the amount of blood poured out is moderate, Douglas's pouch may be well filled, it will displace the uterus forwards and downwards ; but there may be no tumefaction felt above the pelvic brim. But in some cases, the swelling, if not early, still in the progress of the case, rises to various points above the level of the symphysis, even as high as the umbilicus. In these cases, it may be possible, with or without the help of the sound in utero, to make out the round hard fundus of the uterus distinct from the larger tumefaction of the encysted hsemato- cele. This is illustrated in Fig. 101. The enlargement of the tumor is not so often effected by continuous gradation, as by sudden starts. At every menstrual epoch, there may 528 PELVIC HEMATOCELE. be a fresh increment, due to renewed hemorrhage. This event is marked by reproduction of the symptoms described in the first series, by exacerbation of distress. 3. As the case proceeds, the general and local signs undergo some modification. Pain usually persists, although it may be moderated. In cases tending to spontaneous cure, irritative fever subsides; the pulse may fall to 100, or less; the temperature to 100° Fahrenheit, or less. Usually some degree of tenesmus continues. More or less me- trorrhagia is common. As the tumor lessens in bulk, under the ab- sorption of its fluid elements, the uterus retreats a little towards the middle of the pelvis, relieving the bladder. Still the uterus is im- movable; and behind it there is still the tumor. Dolbeau (Medical Times and Gazette, 1873) thus accurately describes the course of the affection : " The different phases through which the encysted sanguineous tumor passes are revealed by signs, which must be searched for with the greatest attention. The induration and progressive diminution indi- cate that recovery is taking place. On the other hand, when seven or eight days after the accident you can certify that the tumor has become soft and fluctuating, you may be quite sure that the tumor is retro- grading, and will empty itself externally. When, in addition to the softness which persists, fever adds itself to this symptom at the end of the day, with a real elevation of temperature, shivering, night sweats, and a great dislike to all kinds of food, you can be sure that the hsema- tocele is going to suppurate ; and this is a most important point to know beforehand, often indicating surgical intervention to obviate sep- ticaemia. " Generally the tumor diminishes in size as it becomes harder, and as it approaches recovery. But in some cases, after improving for three or four days, a relapse takes place ; the tumor, which seemed to be getting gradually less, suddenly increases in size, and at the same time grave general phenomena are observed. After this interruption, the symptoms rapidly ameliorate. . . . Now, in most cases, the menses influence this retrocession in a curious manner. Women suf- fering from this complaint are quite regular, the menstruation being scarcely deranged. In all cases, from the moment the catamenial flux commences, a most sensible diminution takes place in the size of the tumor." The tumor may disappear by absorption, by perforation through the roof of the vagina, by perforation into the rectum. These issues are the normal methods of spontaneous cure. But the blood-mass may undergo a process of suppurative or decomposing liquefaction, setting up septicsemia and irritative fever. Hsematoceles undergoing tliis or other change, distended by fresh effusions, under violence or without, may burst their cyst, and throw out the contents into the general cavity of the peritoneum. This issue is rare, but cases liave been recorded. It is of course attended by fresh signs of abdominal injury and shock, and is likely to be quickly fatal. Dr. West records a case. Tuck well relates the following on the authority of Seyfert : A woman, in whom retro-uterine hsematocele had been diagnosed, was frightened by a PELVIC HEMATOCELE, 529 patient in the next bed being seized with convulsions. She sprang out of bed, and at the same moment felt a violent pain in the abdomen, which was followed by rigor and collapse. Three days after this she died. The general cavity of the peritoneum was found filled with bloody fluid, the blood having escaped from a sac situated behind the uterus, which sac had burst. The sac was formed by adhesions be- tween the rectum on the one hand, and the uterus, right tube and ovary on the other. It contained a quantity of blood, part fluid, part in clots, in a state of decomposition. The right ovary, of the size of a hen's egg, and filled with clotted blood, was easily recognized, and was found to have burst and discharged its contents into the cavity of* the cyst. Dr. Matthews Duncan relates a case (Edinburgh Medical Journal, 1864) of extra-uterine gestation, in which signs of rupture occurred at two and a half months of gestation, followed by formation of hsema- tocele. A month later, signs of fresh rupture appeared, and death followed in thirty-six hours. Autopsy revealed a tumor the size of a very large orange, between the sacrum and uterus, which contained a foetus of less than two months' development, and clotted blood. A rupture of considerable extent had taken place in the anterior wall of the cyst. Dr. Breslau, of Munich, relates (Mon. fur. Geburtsk., 1857) a case diagnosed as rupture of a haematocele, followed by recovery. The ' hsematocele, which had been made out before, quite disappeared after signs of rupture. The specimen described from Bartholomew's Museum also may be referred to as illustrating the termination by internal rupture of the blood-tumor. In some cases, the intra-peritoneal perforation seems to be dealt with like the original eifusion, by a fresh conservative peritonitis, which surrounds the new effusion of blood. Accordingly, in some cases. Dr. Madge's is an example, the blood-sac seems divided into two by a septum. Two cases have been recorded, one being that of Dr. Madge, and another by Bernutz, in which phlegmasia dolens of one leg was devel- oped in the course of the affection. The proportion of cases which disappear by absorption is hard to estimate. It can scarcely be doubted that in some cases assumed to have terminated in this way, an opening was really effected into the vagina or rectum, very small, perhaps, but large enough to permit of slow evacuation of the haematic cyst. The process may be so gradual, that the moderate rectal or vaginal blood-discharge is not suspected to come from the cyst. In other cases the discharge by rectum or vagina is manifest enough. At a variable time, ranging from two weeks to two mouths, or moi'e, blood escapes in one solid mass, or in small coagula mixed with fluid portions over several days. In one case re- ported in this chapter, we had several opportunities of seeing blood ooze from an opening in the posterior vaginal roof; we saw this open- ing gradually become smaller, the tumor melting away simultaneously, and at last only a scar was left. 34 530 PELVIC HEMATOCELE. Dr. Willoughby Wade conjectured that in some cases the blood- tumor liquefying discharged itself by the Fallopian tubes and uterus. But distinct evidence of this is wanting. As we have seen, a sanguineous discharge from the uterus and vagina is common ; but it may be the expression of the general congestion or turgidity of the uterus. It is not evident that it comes from the cyst in the way Dr. Wade suggests. In some cases the symptoms are essentially the same, but the general and local distress is less intense. The pain is slight, the fever moder- ate, the effusion is seldom large enough to be felt above the pubes. A few days, or at most a few weeks, suffice for recovery, the tumor disap- pearing almost as quickly as it came. All the best observers recognize this order of cases, and hold them to be not infrequent. Of the truth of this I am firmly convinced. There seems no valid reason to doubt that small as well as large quan- tities of blood may be effused into Douglas's pouch ; and there is ample evidence to prove that small quantities of blood may give rise to only slight irritation. If, as Tuck well says, the objection be urged that as they do not terminate fatally, and are not large enough to ne- cessitate puncture, the presence of blood as the cause of the tumor is merely conjectural, it may be answered that their close resemblance to the more pronounced cases, the nature of which is unmistakable ; the position of the tumor ; and the rapidity with which it is absorbed, are sufficient to justify the diagnosis. Those who reject all evidence ex- cept that furnished by dissection, or by puncturing the tumor, shut themselves out from the possibility of instruction by clinical observa- tion and reasoning. In the milder order of cases, and in those which end by discharging through the rectum or vagina, the sac itself formed by peritonitic effu- sions has to be absorbed. This is effected more or less rapidly and completely. The diagnosis flows from the appreciation of the symptoms described. It may be affirmed with confidence that nothing else but a hsemato- cele will produce them in their aggregate or cumulative character. The conditions most likely to lead to error are : 1. Retroversion of the Gravid Womb. — This is the error I have known most frequently made. The distinction is made out by the physical exploration described above ; by the history of pregnancy when there is retroversion ; and by the absence of the fundus uteri from the pelvic brim or from the abdomen above the symphysis. 2. Fibroid Tumor. — The presence of the body of the uterus in its normal place, or at any rate its being made out separately from the tumor under investigation, distinguishes fibroid from htematocele. The history of the two cases is essentially different. The fibroid is of slow growth ; the hsematocele rapid and sudden. 3. A small ovarian cyst locked in the hollow of the sacrum behind the uterus. By the unaided physical exploration, it is sometimes diffi- cult to bring out decisive differential signs. A small ovarian tumor is fluctuating, elastic, occupies exactly the position of hsematocele, dis- places the uterus forwards in a similar manner, causes retention of urine, and carries the vaginal canal forwards, compressing it. But PELVIC HEMATOCELE. 531 there is a difference in the feel of the tumor manifest to the practiced touch ; the history is different ; the symptoms have usually come on gradually. The sudden shock of hsematocele, the attendant peritonitis are wanting. 4. Perimetrie Inflammation. — The invasion of this affection is some- times very similar to that of hsematocele; indeed it may be concluded that in some cases of presumed perimetric inflammation there is hsema- tocele as well. The characters of perimetric inflammation have been described in the preceding chapter. It is enough here to repeat that the seat and nature of the tumefactions felt in the vagina and rectum differ from those of hsematocele. They are rarely so purely retro- uterine; they are commonly lateral, often unilateral; they fix the uterine neck lower in the pelvis, and generally near the centre, or de- viate it to one side; they are more knobby, irregular in shape; they are hard, brawny. But in one case N^laton found the walls of a hsem- atocele hard, like cartilage ; and Madge describes the same condition. Retention of urine is more exceptional, and in the issue not blood, but pus is voided. 5. Abscess in the Neighborhood of the Utei'us. — This may be distin- guished by the following differential signs : Abscess is rarely so dis- tinctly retro-uterine as hsematocele. In all the cases I have seen which gave rise to doubt there was some degree of laterality. It is not so frequently connected with menstrual accidents ; there is no coincident metrorrhagia. It does not attain suddenly its greatest intensity. The tumor is not formed from the commencement. The skin does not sud- denly become anaemic. The mass, hard at first, becomes later soft and fluctuating, the contrary being usually the case in hsematocele. The constitutional symptoms follow an inverse order from those of hsema- tocele. But I have known pelvic abscess cause retention of urine. The diagnosis may in some doubtful cases be assisted by the explo- ratory needle, or Dieulafoy's aspirator-trocar. But this should not be lightly used. The finest puncture may set up inflammation ; and if the blood have coagulated, the negative result might betray the inex- perienced explorer into the error that the tumor was not a hsematocele. Should pus escape, the diagnosis of abscess is tolerably certain. I am tempted to add Dolbeau's picture of the diagnosis : " The diagnosis," says Dolbeau, " is sometimes very easy, at others very difficult. Great importance must be attached to the more or less advanced stage of the malady. If the case is seen at the commence- ment, you must bear in mind that hsematocele is not the only uterine malady whose onset is sudden. The lypothymic symptoms, the pain and distension of abdomen, occur in both pelvic peritonitis and in intense ovarian congestions. Ovarian congestion and hsematocele are never accomj)anied by fever. Pelvic peritonitis, on the contrary, is a malady essentially febrile. "Position of Tumor. — In hsematocele it gives rise to a projection just above the pubes, and sometimes almost reaches the umbilicus. The tumor in pelvic peritonitis never extends beyond the level of the symphysis, or if it does, it extends slowly ; whereas, in hsematocele, 532 PELVIC HEMATOCELE. the tumor suddenly attains its maximum, and afterwards diminishes rather than increases. " The excessive pallor of the face, so important a symptom in hsema- tocele, is never seen in pelvic peritonitis. " The direction of the cervix forwards belongs exclusively to hcema- tocele." The treatment now admits of being indicated with some authority. Disposing, first, of the cataclysmic cases, it may be stated that the treatment merges in that of rupture of the uterus, of rupture of an extra-uterine gestation-sac, and of other great abdominal lesions. We must seek to rally from collapse by rest, by opium, and the sparing use of stimulants. In the milder class of cases of true encysted hematocele, as in all the other cases, rest is the first and most imperative prescription. If we suspect that hemorrhage is proceeding, we may apply cold to the abdomen. When signs of peritonitis are coming on, salines and opiates are of eminent service. As topical applications, leeches to the abdomen are often of use; then hot cataplasms or fomentations. Whenever there is retention of urine, the indication to use tlie catheter is obvious. It should be done at stated intervals — say every eight hours. If there is tenesmus or dysentery an opiate suppository should he administered. Purgatives, as breaking the law of rest, should be sedulously avoided. The bowels will probably act by and by, as in other cases of obstruc- tion, under the use of opium ; and an enema may be given after a few days, when the fecal accumulation is marked. The great contention has been as to the expediency of puncturing the tumor. Experience has gradually led to definite rules upon this point. So long as the local distress is not urgent, so long as the tumor remains hard, so long as there is no sign of septicaemia or irritative fever, so long is it wise to follow the expectant method, observing strict rest, and abstaining from all local interference. But when the tumor softens, when it enlarges immoderately, when the pulse and tempera- ture rising indicate septicsemia, then it is time to consider the resort to juncture. This step being resolved upon, we have to weigh the method of performing the operation. The most convenient spot to select is the most bulging part behind the cervix uteri in the roof of the vagina. We may use a medium-sized trocar or a bistoury. The instrument should be plunged in the direction of the axis of the pelvic brim, par- allel with the posterior wall of the uterus. This line can be accurately defined by first passing the sound into the uterus. We thus get a land- mark. If the instrument be directed obliquely backwards, it is apt to perforate the rectum first, and to enter the hEeraatocele obliquely, affording only an imperfect escape. It is well to leave the canula in situ to serve as a drain. If the blood be in great part coagulated, we may scoop out what can be easily reached with tlie handle of a spoon ; but generally it is wiser not to meddle too much. In cases where decomposition arises, the sac should be w'ashed out twice a day with Condy's fluid, or weak carbolic acid. Out of fifty-three cases of recovery tabulated by Tuckwell, thirty were treated without any operation. The remaining twenty were PROLAPSUS OF THE UTERUS. 533 punctured. But it is at least doubtful whether in some of these latter the puncture was not superfluous, whether, indeed, it were not a source of danger. One source of such danger is the admission of air into the sac, and the consequent decomposition of its contents. Aran records a case of this kind in which puncture was made by an exploratory trocar, a fis- tulous opening remained, and death ensued from putrid infection. Here, as in all other pelvic and abdominal inflammations, it should be a standing rule to avoid repeated examinations. Manipulation must disturb parts which above all things require repose ; it can hardly fail to irritate and aggravate inflammation ; it may burst the blood-cyst, and lead to a fatal renewal of hemorrhage and peritonitis. CHAPTER XLIII. DISPLACEMENTS OF THE UTERUS; DEFINITION; VARIETIES OF; PROLAPSUS DESCRIBED; HYPERTROPHY OF THE VAGINAL-PORTION. The uterus may be said to be displaced whenever it is removed from its usual position by some more or less persisting cause. Of course allowance must be made for the normal mobility of the organ. Move- ment within certain limits, if followed by return to the normal statical position, is not regarded as displacement. The displacements of the uterus are as follows : Upwards or elevation. Downwards or prolapsus. To either side or lateral deviation. Forwards. Backwards. In all the above displacements the uterus may preserve its normal form and size ; its axis may remain unchanged ; its shape may be un- affected. In connection with displacement in reference to the axis of the pelvis, the uterus may be altered in its inclination : that is, its fun- dus may be inclined forwards, constituting anteversion ; backwards, constituting retroversion ; to either side, constituting right or left lateri- version. These displacements are estimated chiefly by the deviation of the body of the uterus from its central position, the cervix remain- 534 PROLAPSUS OF THE UTERUS. ing more or less fixed by its axis of suspension to the base of the bladder. Displacements may be associated with change of form. Thus, the uterus may be bent, its axis undergoing deviation. It may be bent forward, constituting anteflexion ; backwards, constituting retroflexion ; to either side, constituting right or left lateriflexion. The uterus also may undergo torsion or twisting on its axis. Prolapsus or Descent of the Uterus. It will be convenient to begin with the description of prolapsus. This is, if not the most common of all the displacements, at any rate that which most frequently comes under treatment. In the great majority of instances the history is a continuous one, beginning with labor, and marked successively by uterine engorgement, subinvolution, inflammation, prolapsus, retroversion, and hypertrophy. The most rational and profitable course then must be to follow the historical order ; to study first the immediate consequences of labor, and then to trace out the subsequent events to their full accomplish- ment. The first chapter of this history has been already traced. The leading fact then in the history of prolapsus of the uterus is imperfect involution after labor. If this great fact be kept steadily in mind, and the lessons in practice which it dictates be carried out, many cases of prolapsus will be prevented altogether, and many more will be arrested in their early and most curable stages. Prolapsus uteri of course strictly means a falling of the womb. In- stead of swinging at its proper level, it descends lower into the pelvis, and may even make its way through the vulva. Hence there are different degrees of descent. The minor degrees in which the womb only drops in the vagina are usually distinguished as prolapsus ; whilst the extreme degrees in which the womb passes forth through the vulva bear the name of procidentia. Etymologically viewed, these terms have an arbitrary significance assigned to them ; but it is convenient to retain them in the sense which custom has associated with them. Prolapsus and procidentia may be more accurately defined as follows. If we regard the cavity of the uterus as a continuation of the walls of the vagina, the whole forming one tube, there will be, at the commence- ment of prolapsus, three duplicatures : 1. A central portion, the uterus itself, dropping down into the roof of the vagina, is invao-inated. 2. Then there are the two folds or reflections of the vagina, one of which, representing the part in which the uterus is inserted, is carried down inverted by the uterus ; the other is the part of the vagina which retains its normal position, and receives the inverted portion contain- ing the uterus. So long as this stage of depression, of partial inver- sion of the vagina by the squatting of the uterus continues, there is prolapsus. 3. Procidentia exists when the body of the uterus, continuing its invagination, has passed quite through the vulva. When this has taken place, there are only two duplicatures, viz., the uterus which has PROLAPSUS OF THE UTERUS. 535 passed into the now nearly completely inverted vagina: As Cruveilhier, however, observed, some vestige of the second duplicature formed by the vagina is constantly met with in the furrow, of greater or less depth, situated behind the procident mass ; for though the inversion of the Diagram illustrating successive stages of prolapsus of uterus, and the attendant degrees of retroversion. A B. Axis of brim of pelvis, c, D. Axis of outlet. B, E. Curve of Carus, or curvilinear axis of pelvis. 1, 2, 3, 4. Stages of prolapsus. The uterus tethered to the symphysis, revolves round it in descent. anterior wall of the vagina may be complete, that of the posterior wall is scarcely ever so. Hence the tumor caused by prolapsus uteri, is- alwavs lono-er in the vertical direction in front than it is behind. The theory of prolapsus and procidentia uteri may be summed up as follows : Invagination or intussusception of the uterus is prolapsus ; complete inversion of the vagina or hernia uteri is procidentia. In complete prolapsus the inverted vagina contains the uterus. This is hypertrophied; its cavity is mostly enlarged, filled with mucus. Besides the uterus, the vaginal sac commonly contains in front a por- tion of the bladder-base ; behind, the anterior and lower part of the rectum. Looking into the pelvis from above we see between the blad- der and the rectum into a funnel-shaped cavity, in the depth of which 536 PROLAPSUS OF THE UTERUS. lies the fundus of the uterus, dragging down after it the tubes and ovaries. Such, then, is the typical form of prolapsus and of procidentia. The uterus, by its attachment in front to the base of the bladder, is tethered to the pubic bone by its lower third. The consequence is, that as the uterus descends towards the outlet, it must revolve round the pubic bone as a centre. The fundus then gradually rolls back, so that retroversion keeps pace with prolapsus, and when prolapsus has merged into procidentia, the fundus will be directed backwards towards Fig. 105. O V Complete procidentia uteri. (Half-size, from St. George's Museum.) p. Symphysis pubis, b. Bladder, v. Urethra drawn almost vertically downwards to open into B', a sacculated diverticulum of bladder outside the vulva, and in front of the procident uterus, o u. Os uteri. D. Douglas's pouch extended outside the vulva. O. The ovary dragged down. a. The anus. the anus, whilst the os externum will be turned a little forwards. The exact position of the uterus at any point of this downward course may be accurately determined by the fingers and sound. The lower the uterus the more the point of the sound must be turned backwards to pass along its canal, and the more easily Avill the fingers in the rectum get above the fundus. When the procidentia is complete the whole PROLAPSUS OF THE UTERUS. 537 uterus may be grasped between fingers and thumb, and its contour and size exactly made out, through its sac of inverted vagina. The alteration in the course of the urethra sometimes makes it diffi- cult to introduce a catheter. The catheter passes backwards and down- wards into the substance of the tumor to a greater or less extent, ac- cording to the degree of procidentia. A good idea of this, as well as of the appearance of the tumor of procidentia, may be formed from Fig. 106. O U Prolapsus uteri, front view. Uterus, bladder, and pelvic bones removed en masse. (Half-size, from specimen in St. George's Museum.) p. Symphysis pubis. P, b. Fundus of enlarged bladder, b. Bladder opened, bougie passed into it from u, urethra. The bladder is drawn outside by the uterus behind it. o u. Os uteri. Fig. 105, which I have drawn from a specimen in St. George's Mu- seum. B represents the bladder, b' the pouch, or diverticulum, and u b' the deviated urethra. There is an excellent figure in Boivin and Dug^s, showing a front view of a procident uterus and bladder; the bladder is laid open in the front of the tumor, and a bougie marks the downward course of the urethra. Instead of copying this I have preferred to introduce the drawing from a specimen in St. George's Museum, which shows the same points equally well. Fig. 106. The analogy between procidentia uteri and hernia has always at- tracted attention. The inverted vagina is the hernial sac ; the uterus 538 HYPEETEOPHIC ELONGATION. is the displaced intestine. Not uncommonly the sac contains a mass of small intestines besides. Owing to the peritoneum descending below the uterus and behind the upper fourth of the vagina before it is reflected up- wards over the rectum, a deep pouch is formed, which undergoes great extension as the uterus and vagina are carried downwards. This pouch may receive an enormous mass of small intestine, so that the external swelling may be as big as a man's head. The intestine may be plainly felt by its gurgling. The anterior cul-de-sac of the peritoneum formed by the reflection from the bladder on to the anterior wall of the body of the uterus is too shallow to admit the small intestines into it. The descent and inversion of the anterior wall of the vagina neces- sarily drags the base of the bladder and urethra with it, causing saccu- lation of the bladder and deviation of the urethra from its natural course. The degree of displacement, however, will depend somewdiat upon whether the prolapsus have taken place gradually or quickly. If it have taken place quickly, the organs are carried down bodily to- gether; but if the prolapsus be of slow production, the connective tis- sue uniting the vagina and bladder may yield and stretch a little, so that the urethra may not be so much distorted. But in the majority of cases the base of the bladder is so drawm down below the level of the meatus, that its contents cannot be perfectly voided. The constant straining to accomplish this causes distension and the gradual forma- tion of a vesical pouch, which is partly outside the vulva. In this pouch there is a continual tendency to stagnation of urine. This leads to the deposit of lithates and phosphates, and the concretion of calculi in the diverticulum. But Cruveilhier met with a case in which the whole cavity of the undisplaced portion of the bladder was filled by a calculus. Golding Bird pointed out how it led to formation of phos- phates and annnoniacal urine. Dr. G. Boper related to me a case of prolapsus uteri et vesicae, in M-hich the bladder contained several calculi which could be rattled about by the hand. A similar case of complete procidentia with eversion of the vagina, and calculi in the pouch of the bladder was under my care at the London Hospital. Dr. West says there is also great liability to kidney degeneration as a retrograde con- sequence. According to Cruveilhier, the deviation of the meatus uri- narius is less the effect of the disjjlacement of the bladder than of the anterior wall of the vagina. The bladder generally is greatly enlarged. Although, according to my own observations, prolapsus and proci- dentia are distinct from hypertrophic elongation of the uterus, these conditions are so frequently associated in the same patient, and are otherwise so intimately related, that it is most convenient to describe hypertrophy in this place. Hypertrophy of the Vaginal-poiiion. The greater number of cases of considerable hypertrophic elongation of the cervix uteri occur in women who have had children, and after the age of forty-five or fifty, although we see its incipient stages at an earlier age. The hypertrophic elongation observed in women, married HYPERTROPHIC ELONGATION. 539 or single, who have never had children, is of a different form, and the cases are not very numerous. We may fitly describe this form first. 1 . The Hypertrophic Elongation of the Cervix Uteri of Women ivho have never borne Children. — This form may be observed in comparatively young women. If, in the majority of cases, it first comes under obser- vation in married women, this is commonly because before marriage the malformation, for such I believe it to be, lies quiescent. When the enlarged structure comes to be exposed to the contingencies of married life, which include possibly a considerable amount of direct violence, and certainly greater liability to congestion, distress arises. It entails all the inconveniences of a foreign body. It may be com- pared to a polypus in the vagina. It is usually conical in shape, the base starting from the fundus vaginae, and tapering somewhat towards its lower end, at the point of which is seen the os uteri. This is usu- ally a round opening, that will barely admit the uterine sound. The length of this hypertrophied vaginal-portion varies from an inch to two inches, or even more. The os uteri may come nearly down to the vulva, so that the vaginal canal may be nearly filled with the protu- berance. It not uncommonly happens as an aggravation of trouble that the vagina itself is short. Thus the male organ comes into vio- lent contact with it, or after a time it distends the posterior wall of the vagina, and a pouch is formed in the roof behind the cervix uteri. That the excessive leno-th is due to the elongation of the vas-inal- portion is proved by the sound and by the touch, which show that the body of the uterus occupies its normal position in the pelvis, and is of normal length. Under the irritation to which it is constantly subjected it first becomes the seat of congestion, then of inflammation, perhaps of abrasion or ulceration. Friction against the vagina sets up inflammation in this canal, erosions of its mucous membrance occur ; copious muco-purulent leucorrhoea and dysmenorrhoea and dyspareunia are sure to follow. The following case observed at the London Hos- pital is typical: W., aged twenty-six, married, never pregnant; is harassed by menorrhagia and profuse leucorrhoea : has complained of prolapsus and procidentia for two years. From girlhood always had discharge and bearing-clown. The vaginal-portion is smooth, round ; the OS externum projects beyond the labia majora; there is no eversion. The elongated vaginal-portion produces all the distress of a foreign body in the vagina; like a polypus it keeps up vaginal irritation, and induces expulsive efforts which increase the procidentia and hyper- trophy. Relief ensued on amputation. The only effectual treatment for these cases where the projection of the elongated vaginal-portion is at all considerable is, I believe, ampu- tation. And the best way of amputating is by the galvanic cautery wire. A superfluous structure has to be removed, and amputation is not only the most complete method of accomplishing this, but also the quickest and least distressing. The operation is performed in the following manner. (See Fig. 107.) The patient is placed either in the semi-prone position or in the lith- otomy position, and brought under the influence of chloroform. A retractor is inserted into each side of the vulva, whilst a Sims's specu- 540 HYPERTROPHIC ELONGATION. liim pulls back the perineum, and exposes the vaginal-portion. This is then seized by a strong vulsellum, and drawn outwards, aided by pressure by an assistant's hand above the pubes. The battery being ready, the wire-loop is then adjusted round the vaginal-portion about half an inch below the line of reflection of the vagina. When the heat is turned on, the wire is gradually screwed up until it has severed the structure included. The severed surface presents a clean smooth aspect, showing Fig. 107. Representing one form of hypertrophy of the vaginal-portion, and the application of the wire for amputation by galvanic cautery. concentric rings, the marks of the varying intensity of the cautery as it made its way. There is rarely much bleeding, and no special means are usually required to arrest it. Any protracted oozing from the sur- face of the stump or a pumping artery is soon stopped by touching with the porcelain-cone made incandescent by the galvanic current. Further security against bleeding is obtained by allowing full time for the heated wire to make its way through the part, and thus to secure a rather prolonged contact with the surface. A pledget of cotton-wool, HYPERTROPHY OF THE CERVIX UTERI. 541 soaked in carbolic acid oil, is the only dressing required. The section goes through the expanded portion of the spindle-shaped cavity of the cervix. This is not very liable to close during cicatrization, but to obviate this risk it is desirable to insert an intra-uterine pessary, to be Appearance of the vaginal-portion after complete cicatrization from amputation by the galvanic cautery. (Ad. nat.) worn for a month. The after-treatment consists in rest for a fortnight during the process of repair by granulation and cicatrization. The state of the new os uteri must be watched for some time afterwards, to be sure there is no undue contraction. The result in my experience has been satisfactory. The inflamma- tory symptoms have subsided, the dysmenorrhoea and dyspareunia have been materially mitigated. 2. Other Forms of Hypertrophy occur after Childbirth. — They may be said to grow out of the state of congestive hypersemia and subacute inflammation of the cervix, which takes its departure from labor. The course to be pursued to prevent this result, consisting in the cure of the primary stage, has been already described. If this course be not adopted the development of hypertrophy in some form, and to a greater or less degree, is pretty sure to follow. This secondary or acquired hypertrophy is slowly progressive ; it may take many months or even years to attain its full extent. Daring all this time a degree of endome- tritis and inflammation of the vaginal-portion, with vaginal irritation, is kept up. Dysmenorrhoea frequently attends ; more or less dyspareu- nia is common ; there are attacks of metrorrhagia ; and muco-purulent leucorrhoea is hardly ever absent. The increased bulk of the uterus and the relaxation of the vagina and other pelvic structures give rise to prolapsus, perhaps to retroversion. As in all cases where there is inflammation of the cervix the os externum remains patulous. Often there is a degree of eversion or of rolling-out of the lining membrane of the cervical canal'; the lower margin of the palmse plicatse protrudes through the os, and comes into sight in the field of the speculum. (See Fig. 109.) The rough granular appearance thus exhibited, espe- cially when the epithelium investment is shed, as it often is, is due to the prominence of the ridges of the arbor vitse, and to the projection 542 HYPERTROPHY OF THE CERVIX UTERI. of the bared villi upon them, which in the natural state are levelled down somewhat by their epithelium covering. A somewhat similar appearance is produced when the hypertrophied lips are turned outwards in consequence of an exuberant growth of the ovula Nabothi, and acquire from the burst vesicles a red, angry, pitted, and furrowed aspect. What to the eye appears to be procidentia uteri, and was long be- lieved to be procidentia, is, in the majority of cases, a hypertrophic elongation of the cervix, which extends downwards until the os exter- num and the inverted vagina protrude beyond the vulva. It was no- ticed by Morgagni, the forefather of so many modern discoverers. In a case he particularly described, he attributed the elongation to pro- lapsus and hypertrophy of the vagina. Levret, in 1773, also described it in a memoir entitled " Sur un allongement considerable qui survient quelquefois au col de la matrice." Fir. 109. Eversion of the mucous membrane of the cervix uteri. Cloquet correctly represents the condition in a plate,^ and Cruveil- hier has invariably observed it. This elongation chiefly occurs in the point of junction between the body and neck, and is accompanied by a striking contraction or narrowing of the part. In the second part of his work on pathological anatomy — the most magnificent contribution to the science we yet possess — Cruveilhier gives another plate, and ad- ditional observations, explanatory of the changes in the relation of parts, occasioned by the inversion of the vagina, or prolapsus of the uterus. It appears from his researches, that sometimes the elongation, and sometimes the depression of the uterus, aids in the greater degree. He met with cases in which the lengthening of the uterus was so considerable, that when the part was viewed within the pelvis it seemed as if it occupied its right situation. The coexistence of an inversion or doubling of the vagina, without any displacement of the womb, which has only undergone elongation, seemed to him to prove, that in certain cases at least, the displacement of the uterus has its beginning in the foregoing change of the vagina. The vagina becomes inverted ^ Pathologie Chirurgicale, 1831. HYPERTROPHY OF THE CERVIX UTERI. 543 on itself, like the finger of a glove, by a mechanism precisely like that which takes place in intestinal invaginations. This process has been explained above. This is illustrated in Fig. 110, from a specimen in the London Hos- pital, in which f represents the fundus uteri in situ, whilst the mass outside the vulva appears to be the procident uterus. Fig. no. '/rh.rrr Prolapsus of uterus, with hypertrophic elongation and complete eversion of vagina. m.ur. Meatus urinarius. f. Fundus uteri, u.v. Uterus covered by inverted vagina, o.u. Os uteri. (London Hosijital, nat size.) Another point observed by Cruveilhier is the greater or less deform- ity of the OS tincse. One of its lips, usually the posterior one, is very prominent, whilst the other is effaced. This is illustrated in Fig, 111, taken by me from a case under my care. In some instances the os is reduced to a very diminutive aperture. This is mostly the case in aged women, in whom atrophy probably preceded the prolapsus. 544 HYPEETEOPHY OF THE CEEVIX UTEET. Virchow, in 1847/ described this occurrence as a peculiar form of prolapse, under tlie name of prolapsus uteri loithout descent of the fundus. The connection between prolapsus and hy])ertrophic elongation of the cervical portion of the uterus demoiistrated by the illustrious men Fl6. 111. Hypertrophy with procidentia of the vaginal-portion. Greater enlargement of the posterior lip. Development of " hypertrophic polypi." (Ad. nat. R. B.) whose names I have quoted, has been since (1859) described with great minuteness by Huguier. He was, however, far too absolute in his statement that prolapsus scarcely ever exists. He distinguishes four varieties. The first affects the body of the uterus only, and may cause prolapsus ; the second invades the os tincse only, or the sub vaginal- portion ; the third invades nearly the whole of the neck, but especially the supra vaginal-portion. When the first and third coexist, they make the fourth variety. To this I may add that hypertrophy of the body is very apt to cause retroversion, or retroflexion, or anteversion. Stolz, of Strasbourg, in a memoir published' a few months after Huguier's account was read to the Academy of Medicine, described it with a completeness of detail which leaves but little to be added. The mode in which hypertrophic elongation of the cervix uteri oc- 1 Verhandlungen der Gesellschaft fiir Geburtskunde in Berlin, vol. ii, 1847. 2 Journal hebdomadaire, Juiii, 1859. HYPERTROPHY OF THE V AGI N A L -PO RT ION. 545 curs is in many cases, I believe, as follows : The first factor is arrested involution of the uterus. This entails endometritis, which in its turn leads to active hypersemia and interstitial fibrin-eifusions. Then a process of gradual continuous eversion and growth of the cervix takes place thus : the external tissues of the cervical portion are fixed to the bladder and the fundus vaginae, and, being comparatively free from liability to congestion and inflammation, maintain their original con- dition as to length and relative position. The mucous membrane, on the other hand, which lines the cavity of the cervix, is extremely vas- cular, is the primary seat of injury during labor, and of congestion and inflammation; it becomes swollen, with gorged vessels and serum and fibrin poured out into its submucous layers ; hence there is in- creased villous growth, which can only find room by bulging out through the os tincse. The peculiar traumatic condition of the vaginal-portion of the cervix caused by labor, combined with its subsequent special exposure to disturbance, is the reason why the cervix is more commonly arrested in its return to the "normal condition than the body of the uterus. It has not only to undergo involution, but it has to repair damage. A chronic subacute inflammatory process sets in, which entails a perverted or exaggerated nutrition of the part. The watery part of the serum Early stage of hypertrophic elongation of the cervix uteri ; eversion of the lips exaggerated by their being parted by the bivalve speculum. (Ad. nat. R. B.) effused into it at the time of the original injury is absorbed ; probably the solid constituents remain ; fresh material, the result of the hypersemic state compounded of congestion and inflammation, is added. Hyperplasia results, and is maintained by the irritation of an abraded surface, which, if the term ulceration be objected to, is at any rate distinguished by being bared of epithelium, by angry projecting villi easily bleeding. This growth or extension of the cervix takes place from within out- wards, and involves a process of eversion. That is, the hyperplasia is most active at the inner and lower part of the cervix. Growth being in excess at this part, eversion and elongation downwards necessarily follow. Then the increased bulk and weight of the organ favor descent, 35 546 HYPERTEOPHY OF THE V AGIIST AL-PORTION. which is imperfectly opposed by the attendant relaxed state of the vagina, and the other supports of the uterus. The presence of the lower part of the cervix near the vulva then excites reflex action, and ■minima "«seiiv Form of advanced hypertrophic elongation of the cervix uteri. The two lips being extruded outside the vulva, diverge. Half-size. (R. B.) the consequent straining efforts increase the protrusion and the conges- tion. In this prolapse the two opposing forces of downward pressure upon the fundus uteri, aided by the increased weight of the cervix, and of pulling up upon the cervix by the fundus of the vagina and the attachments to the bladder, tend still further to promote eversion and downward groAvth. In some cases the two lips elongate separately, so that when a bi- valve speculum is introduced, and the blades are expanded, the two lips are made to diverge, exposing the cervical cavity between them. I have endeavored to represent this condition, which I believe is fre- quent, in Figs. 112, 113. The os gapes like an alligator's mouth. In the earlier stages, whilst the os is still in the vagina, the lips are flattened together by the walls of the vagina closing upon them. When opened by the speculum, endometritis is always seen. When the part has grown outside the vulva, the two lips freed from outward compres- HYPERTROPHY OF THE V AG IN AL -P ORTION. 547 sion diverge and expose the interior of the cervix, just as the bivalve speculum caused the lips to diverge whilst the part was still intra- vaginal. This eversion is also favored by the compression exerted by the vulva above the os. In a memoir on "Hypertrophic Polypi,"^ I directed attention to a circumstance which marks the extreme activity of the growth of the lower segment of the vaginal-portion. This is the frequent association of small polypi at the os viteri with this hypertrophy. They are iden- FiG. 114. Hypertrophic elongation of both supra and infra vaginal-portions of the cervix uteri, with atrophy from pressure and dragging of the cervix, and tumefaction from strangulation at the os internum. (King's College Museum, No. 9902. Nat. size.) tical in structure with the hvpertrophied cervix from which they spring. (See Fig. 111.) The hypertrophic polypus of the cervix uteri then, is simply an accidental outgrowth from the hypertrophic cervix. It differs in this ' 1 St. Thomas's Hospital Keports, 1872. 548 HYPERTROPHY OF THE VAGINAL-PORTION". respect from the fibroid or myoma of the body of the uterus. The latter begins from what may be called an aberrant nucleus in the mus- cular wall, and by its own growth causes hypertrophy of the uterus. But I have also noticed them occasionally in association with fibroid of the body of the uterus. These polypi sometimes form at a comparatively early period in the history of hypertrophy of the cervix. Bat they are more frequent in the advanced stages, and especially when the elongated cervix has pro- truded beyond the vulva. I may here call attention to a noteworthy fact in the history of hypertrophic elongation of the cervix uteri. When this condition has reached its extreme limit, the cervix and uterus almost invariably measure exactly 5 in., — that is, just double the normal length. This I have demonstrated so frequently to my classes by the sound that I have come to regard it as a law. I have only known two or three cases in which this dimension was much exceeded. There are other conditions which appear to cause hypertrophic elon- gation of the uterus. These I have observed under various conditions where the uterus was exposed to displacement and pressure, and to stretching. In some cases the first factor in the process was pregnancy. For example, in extra-uterine gestation, the uterus, feeling the stimu- lus, enlarges ; and the enlargement is maintained perhaps for some months by the advancing development of the embryo ; then if the uterus becomes displaced, as by being pushed forwards or to one side, adhe- sions forming between it and the foetal sac, elongation is pretty sure to occur. A similar effect is produced sometimes when involution of the uterus is prevented by pressure upon it from the masses of plastic matter resulting from perimetritis. Fibroid tumors not uncommonly cause hypertrophic elongation by a combined process of interstitial growth, stretching, and pressure. Ascitic fluid distending Douglas's pouch, and thus causing a kind of vaginal rectocele, may induce pro- lapsus. Another form of hypertrophic elongation is seen in Fig. 115. In this case the elongation chiefly affects the supra vaginal-portion of the cervix. Looking at the part below the reflection of the vagina, there is little appearance of hypertrophy. The long, thinned, cylin- drical appearance of the cervix above the reflexion of the vagina suggests the conjecture that the body of the uterus has been dragged upwards, whilst the cervix has been grasped by the surrounding structures. In some cases the elongation of the vaginal-portion is not uniform ; it affects the two lips of the os unequally. The anterior lip may be almost exclusively affected. This is thought to be explained by its being directly within the influence of the traction made on it by the prolapsed bladder. This produces the singular appearance termed by Ricord the " col tapiroide." The inner surface of the lengthened lip has a channelled appearance, the continuation of the cervical canal. The drawing (Fig. 116), accurately taken from a unique and valu- able preparation in St. Thomas's Museum, illustrates many of the most interesting features in the history of hypertrophic elongation. An HYPERTROPHY OF THE VAGINAL-PORTION. 549 especial value of this preparation consists in the relative position of the parts being perfectly preserved. The changes undergone by the uterus are remarkable. The body of the uterus is decidedly elongated ; it Great hypertrophic elongation of the supra vaginal-portion of the cervix uteri. (Bartholomcw'a Museum, No. 32.30. Nat. size.) F.T. Fallopian tubes also diseased, v. Vagina containing spherical infra vaginal-portion of cervix uteri. c.V. Cervi.K uteri elongated. looks as if it had undergone stretching by pulling downwards. Its walls are a little thickened ; its cavity is enlarged, especially in length. The demarcation between the canal of the cervix and that of the body is scarcely distinguishable. This may be due partly to senility. The cervix has undergone enormous elongation ; and the part between the sacculation of the bladder and the rectum is remarkably thinned ; it 550 HYPEETROPHY OF THE V AGIIST AL-PORTI ON. looks as if it had been drawn out, so that its length had been acquired by pulling, as when we stretch an elastic tube. What is the cause of this elongation and thinning of the cervix? In the first place, it must be observed that these two conditions do not always coincide. If we examine a case of comparatively recent forma- tion, before the subject has entered the climacteric, we shall not find the substance of the cervix thinned. It is a thick, firm cylinder throughout its length. On the other hand, if we examine a case of long standing in an old woman, we do find this thinning. The con- clusion seems to be legitimate that the thinning is consecutive. It is Fig. 116. Hypertrophic elongation of the uterus. (From a specimen iu St. Tliomas's Museum. One-third size.) a process of atrophy, partly senile, partly the result of continual stretching which bears upon the weakest point of the canal, and partly from constant pressure between the distended sac of the bladder and the loaded rectum. I believe the thinning is also caused by the con- striction to which the elongated cervix is subjected where it is embraced by the vulva. HYPERTROPHIC ELONGATION OF THE UTERUS. 551 The entire length of the uterus in this specimen is about seven inches. The fundus and body are somewhat lower in the pelvis than natural ; the body has undergone apparently very little elongation, the chief excess of longitudinal growth being spent upon the cervix. The two lips of the os uteri are much hypertrophied and somewhat everted. They form a mass covered by the everted vagina outside the vulva. That this is the result of downward growth, not of simple prolapsus or stretching, is seen in the condition of the bladder and of the ante- uterine and retro-uterine peritoneal pouches. The base of the bladder is carried down along with the down-growing anterior wall of the cer- vix uteri, forming a sacculated pouch below the level of the urethra, and therefore below the symphysis pubis. The urethra is also dis- torted into a curve, of which the convexity looks upwards, the blad- der-end of it being carried downwards along with the base, so that a catheter to pass would have to be directed, first a little upwards, then backwards and downwards. The body of the bladder is enormously enlarged ; that is, its capacity is greatly increased, but its walls are not materially thickened. The change seems to be simply distension, probably the consequence, not of actual obstruction to the passage of urine, but to a habit of long voluntary retention acquired through the desire to avoid the irritation caused by the dribbling of urine over the protruding mucous membrane of the everted vagina. The fundus rose as high as the umbilicus, and considerably higher than the fundus of the uterus. The peritoneum, descending behind the abdominal wall, is reflected upwards over the bladder at a point about two inches above the symphysis pubis. It descends behind the bladder quite down to a point on a level with the sacculated pouch of the bladder ; that is, below the level of the lower margin of the symphysis pubis. Rising over the fundus uteri, the membrane descends behind, forming a Doug- las's pouch quite below the vulva. The only part not much disturbed is the rectum. Of course there is no apparent vagina, since the down-grow- ing OS and cervix uteri have carried the vagina before them, completely everting it and turning it into an investment of the protruded parts. The specimen and the drawing exhibit very clearly the danger of amputating the hypertrophied cervix. It would not be possible to remove more than a portion of the os without opening the retro-uterine peritoneal pouch. It also explains the difficulty commonly encountered in keeping the protruded parts inside the pelvis by pessaries. The drawing exhibits the relations of the bladder, uterus, and rectum, ex- actly as they were found ; that is, in apposition with each other. There were no folds of intestine descending between them in the anterior or posterior peritoneal pouches. The Etiology of Prolapsus, Procidentia, and Hypertrophic Elongation of the Uterus. It is desirable to start with an enumeration of the different circum- stances under which these conditions have been observed. I have seen prolapsus uteri in virgins caused, 1, by attacks of epi- lepsy ; 2, by violent coughing ; 3, by the dragging of a polypus ; 4, 552 PROLAPSUS OF THE UTERUS. by succussion, as from a fall upon the nates, and from railway collisions. In the first, second, and fourth cases the prolapsus may be called acute. It is produced by sudden violence, tending to drive the uterus and other pelvic contents out through the vulva. It is liable to be attended by acute inflammation, and is commonly marked by excessive local pain. 5, by the pressure of an ovarian or other tumor upon the uterus ; 6, by habitual overexertion during menstruation, when the local con- ditions resemble those of parturition. Dr. Roberton and Dr. Whitehead, of Manchester, were consulted respecting a girl, aged fifteen, who had just received a sudden fright. The entire uterus was beyond the vulva and external to an intact hymen. It was replaced, and no future inconvenience resulted. Dr. McClintock, in his valuable clinical work on " Diseases of Women," says he has certainly seen three cases where the displacement resulted solely from the violent efforts required in defecation to overcome an organic stricture of the rectum. But it is during the exercise of the childbearing function that pro- lapsus is most common. To the accidental causes which produce it in virgins, are now added causes springing from sexual relations attended or not by pregnancy. The dominant feature of these causes is increase of bulk arising from physiological or morbid congestion, from inflam- mation, from imperfect involution after labor; this is primarily or secondarily attended by relaxation of the structures which support the uterus, including the ligaments, and above all the vagina and the con- nective tissue of the pelvis. The vagina alone, if in a state of healthy contractility, will maintain the uterus in situ ; but when its contractility is impaired by overdistension, and by inflammation, the uterus squats down, or sinks in it, producing a minor degree of vaginal depression or inversion. The close attachment of the anterior wall of the cervix uteri to the base of the bladder, making the point of union the most fixed point or centre of movement of the uterus, renders it impossible for the cervix to fall without dragging the base of the bladder down with it. In discussing the etiology of prolapsus great importance is usually laid upon the study of the mechanism by which the uterus is suspended in its place. The attachments of the uterus have been described in the anatomical summary. We have seen that it is slung or suspended in the folds of the broad ligaments to the sides of the pelvis, and steadied to a certain extent by the round ligaments in front, and the utero-sacral ligaments behind ; that it is in a manner balanced upon the vagina, which, in its healthy state, forms an elastic muscular column of con- siderable strength ; that it is attached by its anterior wall to the base of the bladder ; and that it is further supported by what may be called the padding of the pelvis, constituted by the connective tissue between the peritoneal folds, the vessels, nerves, and other organs. No doubt the proper preservation of the position of the uterus is due to the in- tegrity of all these structures. The power of the vagina as a support to the uterus, and as an agent in restoring it to its place, is capable of demonstration. When the speculum is introduced, the widening of the vagina produced by it, shortens the canal and brings the uterus down; as the speculum is being withdrawn, the vagina is seen to contract PROLAPSUS OF THE UTERUS. 553 strongly behind it, and the consequent restoration of the organ to the normal columnar state carries the uterus up again. And we may at any time by strong astringents restore the vagina to its original con- dition. AVest further insists that the curved direction of the vagina, and the angle at which the uterus is inserted into it, afford a further obstacle to prolapsus ; whilst at either extremity the vagina is strengthened by its connection through the medium of the pelvic fascia with the blad- der and rectum above, and by the sphincter which surrounds it below, as well as by the other muscles of the pelvic floor and by the perineal fascia between the two layers of which those muscles lie. The value of experiments on the dead body designed to show how the uterus maintained its position, notwithstanding that the vagina was cut away, as by Hohl and others, or after division of the ligaments, seems to me to be exaggerated. It is clearly, indeed, proved that the uterus cannot be dragged out of the vulva, unless considerable force, amounting, says Le Gendre, to from thirty to one hundred pounds, be used. But it is also certain that the broad ligaments must at the same time undergo great stretching or be severed. The conditions of the living body are widely different. In the dead body there is no turges- cence from vascular fulness, elasticity of tissue, muscular contractility, constant movements from respiration, and the varying states of the bladder and rectum ; indeed, all the conditions as we meet them in practice, are wanting. Deductions drawn from experiments upon the dead body can only be applied with great caution and reserve. For solution of the main questions we must rely upon clinical observations. In the great majority of cases prolapsus is accomplished by small forces acting continuously or with brief intermissions over long periods of time. The fact that prolapsus does not occur in healthy structures, except under the influence of direct force, points to the necessary conclusion that the sustaining tissues of the uterus lose their power of resisting a down-bearing force through changes wrought in them by disease. With the knowledge of these two factors: force, acting upon tissues weak- ened by disease, the explanation of the mechanism of prolapsus is not far to seek. Tlie downward force is always acting. It is exerted at every expiratory effort, and is exaggerated by coughing, or by strain- ing at stool ; by every exertion, in short, which fixes the chest. If the resistance be diminished, the pelvic organs will be carried down, the ligaments will undergo gradual stretching, and the vagina, wanting tone and contractility, squats down under the pressure, the uterus sink- ing into it. Then the force of gravity is added, and is always at work when the body is in the upright posture. The vagina, then, is a passive, not an active, factor in the production of prolapsus. It yields and permits prolapsus, because its contractility and power of resistance are weakened. It does not cause prolapsus, although when prolapsus has begun, it may aid the subsequent steps of the descent. This discussion is not without practical interest, be- cause the knowledge of the mechanism by which prolapsus is brought about must govern the principle of treatment. In studying the con- 554 PROLAPSUS OF THE UTEEUS. ditions of treatment, the first thing that strikes us is, that we cannot act directly upon the broad and other ligaments. We cannot, in nau- tical phrase, brace up or tauten these. We must act from below. Hence we are reduced to two principal sets of mechanical expedients. The first set comprises the mechanical supports, as pessaries, which help to lift up the uterus and anterior wall of the vagina. The second set comprises the various methods of strengthening the vagina so as to restore its power of supporting the uterus. The efficacy of the vagina, especially of the muscular posterior wall which includes the perineum, in sustaining the uterus will be clear to any one who will remember the opposition it offers to the descent of the child's head in labor. Nor can any one who has felt the thick firm inclined plane in which muscle so largely enters, formed by the peri- neam and the posterior vaginal wall, doubt its power to support the anterior wall of the vagina and the uterus. We may, in fact, feel the uterus resting upon it. Thus, when this inferior support is lost, as when the perineum is lacerated, the tendency to prolapsus is greatly increased ; and we find the use of an external perineal pad, which acts as a substitute for the perineum, of signal service in supporting the uterus. We see that in virgins, force alone exerted upon healthy structures is enough to cause prolapsus. This force obviously comes from above. It is produced by the pressure of the intestines upon the uterus, bladder, and broad ligaments propagated from the diaphragm and abdominal walls. Now, this force which acts alone in a certain number of cases, enters as an important factor into every case. It acts, of course, with especial advantage after labor, when the bulk and weight of the uterus are in- creased, and when all the tissues are relaxed. After labor at term, and after abortion, the mobility of the uterus is enormously increased. Any one who has frequently been called upon to remove a retained placenta in abortion, will have satisfied himself upon this point. The uterus is, in the first place, at a lower level than usual ; and in the next, the most moderate traction will draw it down to the vulva with a facility unknown at other times. This implies that the broad and other ligaments are elongated and more yielding, and that the vagina is relaxed. For the above reasons I am of opinion that, in the majority of cases, prolapsus of the uterus is a primary affection. But there are facts which favor the view more prevalent in Germany, which is, that pro- lapsus is secondary upon prolapsus of the vagina. For example, if we examine a woman who is subject to procidentia when the mass is within the vulva, and tell her to bear down, we see the anterior wall of the vagina appear first ; that is, there is apparent vaginal cystocele pre- ceding the appearance of the uterus. It is inferred that the vagina drags down the uterus. The vaginal cystocele is also, it is said, the first condition. I suspect there is a fallacy in some of these observa- tions. If by the hand in the vagina we watch the course of events during an expulsive effort, we feel the uterus borne bodily down under the force of the superincumbent pressure. Of course the uterus and PEOLAPSUS OF THE UTERUS. 555 bladder, being intimately adherent, must descend together. The vagina can only be forced downwards through pressure exerted upon the uterus, or bladder, or both. It is possible, of course, that frequent pressure exerted by the distended bladder may push down the anterior wall of the vagina, which in its turn will drag down the uterus. But that such a process is not frequent, seems to be proved by the fact that one almost constant factor in prolapsus uteri is enlargement and increased weight of the uterus, which must necessarily destroy the balance between the forces that suspend the uterus and those that tend to drive it down. This correlation being destroyed, the uterus cannot but fall, and it is unnecessary to invoke an independent or superfluous force, such as the downward dragging of the vagina. I have frequently made the observation with such care that I am sure of the fact, namely, that the earlier stages of hypertrophic elonga- tion of the cervix are accomplished whilst there is no perceptible descent of the bladder, no bladder distress, and no prolapsus of the anterior vaginal wall. I have even seen cases of marked hypertrophy of the lips without j^erceptible prolapse. I have also seen the converse, that is, decided vaginal cystocele, the anterior vaginal wall rolling out under straining, without any hypertrophic elongation of the cervix. There is not, therefore, any necessary connection between the two conditions, since each may exist without the other. I go further, and afiii'm that hypertrophy of the vaginal-portion may take place independently of prolapsus of the uterus. Symptoms, Effects, and Course of Prolapsus. When prolapsus is produced suddenly, the symptoms attending are generally complicated with the effects of the accident which caused the displacement. Thus, when produced by a fall or concussion, there may be other injury besides the prolapsus, and there is always more or less shock. Then, the sudden succussion occasions violent stretching of the uterine supports. As these are all connected with the peritoneum, inflammation of this membrane is very likely to follow; there will be severe pain over the whole abdomen, especially acute in the pelvis, tenesmus, or bearing-down, perhaps uterine hemorrhage, and severe febrile symptoms ; and bladder and bowel distress. Sometimes the parts quickly resume their normal position, especially if rest in the horizontal posture be duly observed. But this will not always be the case. The uterus may have been driven through the pelvis with such force as to break through the hymen ; and the uterine ligaments, once stretched, do not quickly recover their pristine condi- tion. Moreover, the general health may be so affected by the shock and local injury, that the recovery of tone of the muscles and other tissues will be retarded by impaired nutrition. When prolapsus takes place slowly, the symptoms are less acute. As prolapsus is surely attended by antecedent or consequent engorge- ment, or other morbid state of tissue, the symptoms of course are a complication of effects depending upon the tissue-changes, and of me- chanical effects due to the displacement.. The first class of symptoms 556 PROLAPSUS OF THE UTERUS. will be described in their appropriate place. The mechanical condi- tions are traced to dragging and to pressure. The uterus having lost the support of the vagina, and of what may be called the padding of the pelvis, drags upon the utero-sacral and broad ligaments, which are stretched and elongated. In the upright posture, especially, and under bodily exertion, the prolapsus is necessarily increased ; the sense of dragging and bearing-down is then aggravated. At stool and during micturition, some additional difficulty being felt from the pressure of the uterus, greater straining is exerted to empty the bladder and rectum. The uterus itself being larger and pressing upon the lower part of the vagina and near the anus, excites reflex irritation, the response to which is seen in increased bearing-down or expulsive efforts. The uterus, in fact, acts now as a foreign body. Its presence in a situation not accustomed to receive it, is resented, and the effort at ejection increases the displacement, and constitutes a main difficulty in treat- ment. The dysury and dyschezia} increase in proportion as the patient continues in an upright posture, and as the uterus descends nearer to the vulva. Besides these reflex effects upon the motor nerves, the patient feels pain from the congested state of the uterus, from its pres- sure upon surrounding organs, from dragging upon the peritoneum. These pains are intra-pelvic, sacral, dorsal, and lumbar, partly from indirect pressure upon the pelvic nerves and sacral plexus, partly from irritation of the ganglionic nerves, and partly from the spinal exhaus- tion, resulting from continual irritation. The congestion often leads to menorrhagia, or even to hemorrhages in the intermenstrual periods ; and leucorrhcea is hardly ever absent. When the uterus in its descent comes to press upon the vulva, the muscles, the elastic tissue, and mucous membrane, and skin which surround and constitute the walls of this opening, undergo distension. Under continual pressure the opening enlarges, the perineum especially is thinned out, it dilates, is partially everted, and rounded. The con- tractility of the vulva is greatly impaired ; the floor of the pelvis no longer gives adequate support to the structures above it. Prolapsus then easily passes into procidentia. The inverted vagina becomes vir- tually a hernial sac, which receives the uterus and often a n)ass of small intestines. Although the peritoneum is drawn down so low that Douglas's pouch is outside the vulva, the stretching of the ligaments having been very gradual and slow, a degree of accommodation and tolerance has been acquired, so that the pain of dragging may be even less than during the early stages of prolapsus. The uterus being now outside the range of the sphincters, the reflex expulsive efforts and pains may also be less troublesome. The subjective symptoms change in character. The local symptoms are different. Under great exer- tions in the upright posture, the dragging upon the peritoneum may be very severe. The swelling protruding between the thighs is at first of an oblong, nearly cylindrical form, and terminates below in a narrow extremity, in which a transverse opening, the os tincse, may be discerned. At a 1 Difficult defecation, from (5"? and xel,olypus. The uterus was restored to its position. The symptoms of recent inversion are chiefly those of shock, indicat- ing sudden severe injury. They vary with the degree and progress of the inversion. Thus, the first degree, or simple depression, may be un- attended by pain, and indicated solely by hemorrhage and a corre- sponding depression of the vital powers. The hemorrhage comes from the relaxed introcedent part. The depression at the fundus may be felt through the abdominal walls as a cup-like hollow. As the descent proceeds, and becomes introversion, urgent symptoms arise, according to the degree of compression exercised by the uninverted portion upon the inverted portion. A sense of fulness, weight, as of something to be expelled, is felt. Expulsive eiforts, both uterine and abdominal, sometimes very violent, follow. Hemorrhage is not con- stant. It seems that when the inverted portion is firmly compressed, the hemorrhage is arrested, and that bleeding is a mark of inertia. When the inversion is complete, the uterus is felt in the vagina, or may even be seen outside the vulva. Then pain and collapse are aggra- vated. Clammy sweats, cold extremities, vomiting, alarming distress, restlessness, extinction of the pulse occur. During the expulsion the woman has often exclaimed that her intestines were passing from her. A tumor appears in the vagina, or externally, generally covered by 622 INVERSION OF THE UTERUS. the placenta. The cord is traced up to the insertion, and the placenta, of convex form, is spread over the tumor. The shock, either with or without hemorrhage, is sometimes so great as to quiclvly extinguish life. Cases are known where the shock at- tending simple depression has been fatal. Where the case is not fatal, and the uterus is not reduced, the symptoms of chronic inversion suc- ceed. First, the tumor by its bulk causes distress of the bladder and rectum. Then it is probably forced externally. Chronic inflamma- tion, thickening and induration of the parts ensue; the surface may be- come dry from exposure, or ulcerated and bleeding from chafing. It may be difficult or impossible to reduce it within the vagina. If the tumor remain within the vagina, it may still be a source of chronic irritation to the vagina, and may itself be the seat of chronic inflamma- tion. Congestion, abrasion of surface, ulcerations, give rise to pro- fuse muco-purulent leucorrhoea, frequently to hemorrhage. Irritative fever, emaciation, pain, discharges, break down the constitution, and after some mouths, or even years, the patient may sink from exhaus- tion. As Windsor remarked, an epoch of special danger is that of weaning and the resumption of menstruation. The discharges of blood then become more frequent and profuse. When the climacteric age has been reached, the uterus undergoing natural atrophy, severe symp- toms may subside, toleration ensuing. In the recent state retention of urine is not uncommon, owing to the distortion aud compression of the neck of the bladder and urethra. The retention has been relieved when the uterus was restored. Cases have been known of the inverted uterus sloughing off: Saxtorph (in Actis Soc. Med. Hav.) ; Deborieir (Hichter's Chir. Bibl.) ; Radford (Dublin Journ. of Med., 1835). In other cases the strangula- tion caused by the cervix has ended fatally before there was time for sloughing (Velpeau). More marvellous still, cases have occurred in which the recently inverted uterus has been torn away by the attendant, the patient recovering (Dr. J. C. Cooke). J. L. Casper says (Hand- book of Forensic Medicine, New Sydenham Soc. Translation, vol iii) laceration of the pelvic ligaments may attend spontaneous inversion of the uterus. E. Clemensen relates' a case of complete inversion, in which the uterus separated by gangrene. A woman at fifty had borne two chil- dren, the last thirteen years ago. Some eight years ago she observed that the uterus prolapsed (it was probably inverted). A profuse hemor- rhage took place. The uterus was then found completely inverted between the thighs, the size of two fists. In several spots lacerations were observed extending into the muscular tissue. Some days later the uterus seemed diminished in size; irritative fever set in; gangrene showed itself in the left side of the uterus. The uterus contracted more and more. At last only the orifice remained as a scar. The woman recovered. Clemensen attributes the origin of the inversion to the altered texture of the organ, resulting from fatty regression after labor. In recent inversion death has ensued from strangulation of intestine 1 Hospital Tidende, 1865. CONSEQUENCES. 623 in the uterus. Gerard de Beauvais relates a case (Acad. Medecine, 1843). But such a termination can hardly occur when the inversion has become chronic. It is a remarkable circumstance that notwithstanding the extreme difficulty experienced in reducing an inverted uterus, it very rarely happens that the constriction of the os is sufficient to close the inverted cavity, or that adhesion exists. Commonly the finger is readily admitted, and even through the abdominal wall a passage into the cavity may be felt. Sometimes, the uterus being irreducible, death ensues from hemor- rhage, as in a case described in St. Bartholomew's Catalogue (specimen No. 32.56), and reported by Dr. West (Pathological Proceedings, vol. iii). " Uterus entirely inverted, with the exception of the os, which, however, does not cause any constriction, the finger passing easily between it and the uterine wall. The openings of Fallopian tubes not discovered. The peritoneum at the jDoint of inversion is thickened and uneven, the insertions of the uterine appendages are drawn into the cul-de-sac of inverted uterus. This inversion was irreducible, and the displacement of the uterus caused death in consequence of frequently recurring hemorrhage twenty-nine months after its occurrence." A remarkable termination is illustrated in the following case, of which the specimen is preserved in the London Hospital (No. Ea 57) : " Uterus perforated at its fundus by disease. Its mucous membrane appears to have been everywhere destroyed, and at its fundus is an aperture the size of a shilling." Dr. Ramsbotham thus refers to it: " Ulceration having commenced in the whole lining membrane of the uterus has almost destroyed the uterine texture, and has formed an opening into the peritoneal cavity. The uterus is turned inside out. Epithelial carcinoma of the internal uterine membrane. I have seen only one other such case." Crosse says, " There is not a shadow of evidence of total inversion in the strict sense replacing itself spontaneously." A few cases, as those related by Boyer (Maladies Chirurgicales) and Baudelocque (Daillez, These) are examples of reduction following external force in the form of a blow or succussion. Dr. Meigs, nevertheless, relates several cases. Of such cases Dr. West remarks that " it is easier to conceive that an experienced man should commit an error of diagnosis, than to under- stand how any effi3rts of nature could cure a chronic inversion of the womb." The error may be one of the two following — either the tumor was a polypus, which has disappeared by being spontaneously cast off, or it was a true inverted uterus, which has been separated by sloughing, and cast off in like manner. In some instances the subject of inversion has evinced more or less perfect toleration of her infirmity. This was the result in a case reported by Guyon (Journ. de Chir. et de Med. Prat., 1861), in which inversion had existed twenty years without alteration of health ; in one by Dr. Comstock (Boston Med. and Surg. Journ., vol. viii), the patient fol- lowed her occupation as a dairymaid ; in one by Dewees (Midwifery),. she was enjoying good health ten years after the accident ; in one by Ramsbotham, the patient regained flesh, her health became good ; in one by Lisfranc (Clin. Chir., 1843), he examined the body of an old 624 I]S'VEIlSION OF THE UTERUS. woman at the Salpetriere, the uterus was completely inverted, it had not been suspected daring life; in one by Dr. C. H. Lee (American Journ, of Med. Sc, 1860), inversion remained undetected for twenty- five years, ablation was given up, the patient was so well ; in other cases referred to by Gregory Forbes,^ in one reported by Dr. Woodman (Obstet. Trans., vol. ix), brought to the London Hospital whilst I was obstetric physician there, and in Dr. Mackenzie's case (see Fig. 135), toleration was established. When reduction has been effected, the uterus may recover its func- tion, and pregnancy ensue. There is also a probability, not indeed high, but suggesting caution, that inversion will again take place dur- ino- labor. For a long time after replacement the cavity of the uterus probably remains shorter than normal. The thickened walls take time to resume their natural condition. I state this from the observation of a ease reduced by myself. This depends no doubt in some instances upon the reduction being imperfect, the fundus remaining in the state of depression, or squatting. The prognosis must always be serious. Weber truly calls inversion "malum ingeiis periculique plenum." Crosse, who has shown the great- est industry in the collection of cases, says that above one-third of all the cases, under whatever circumstances, or in vvhatever degree they occur, prove fatal either very soon, or within one month. He analyzed 109 fatal cases. Seventy-two proved fatal within a few hours, most of them within half an hour ; eight cases proved fatal in from one to seven days; and six in from one to four weeks. If the patient survive a mouth, the case is chronic, and the immediate danger is small. But the danger recommences at eight or nine months, when the menstrual function is resumed. Many of these will die within two years. If the inversion take place suddenly and completely, the uterus remaining flaccid, the danger is extreme ; if it take place slowly, that is, under spontaneous uterine action, the danger is less. As to the prospect of reduction, a much more favorable expectation than was lately held is justified by the improved methods of treatment; and reduction will diminish the mortality. Denman thought that if two hours had elapsed, reduction could not be effected. But more recent experience has abundantly proved that both in the recent and chronic cases reduction can in the great majority of instances be accom- plished. If the patient survive the first dangers of shock and hemor- rhage the prospect of recovery under surgical treatment is good. The diagnosis is especially important; it is not always easy; and the most deplorable consequences have followed from error. M. A. Petit had a patient in the hospital at Lyons. Six surgeons decided that it was polypus, and a ligature was applied. A shriek caused sus- picion of inversion ; the ligature was removed ; but the woman died at the end of five days. On examination inversion was found. Dr.William Hunter tied what he thought was a polypus in a young woman who said she had never been pregnant. She died ; the uterus was found inverted. 1 Medico-Chirurgical Transactions, vol. xxxv. DIAGNOSIS. 625 Dubois (Dictionnaire de Med., 1846) says he knew of two cases of inversion mistaken for polypus by two of the most skilful surgeons in Paris. In one case a ligature was put on; the patient died in thirty- six hours. In the presence of the recent accident the most frequent mistakes have been to suppose the mass is a second placenta, or the head of a second foetus. The forceps has been applied to the inverted uterus to drag it away. The diagnosis is especially difficult when inversion is complicated with polypus. The polypus may be detected, but not the inversion, and a ligature applied to the polypus may include a portion of the uterus. Gooch relates (" Diseases of Women ") the following case : Dr. Denman passed a ligature round a polypus of the fundus ; as soon as he tightened it, he produced pain and vomiting. As soon as the liga- ture was slackened, these symptoms ceased ; but whenever he attempted to tighten it, the pain and vomiting returned; the ligature was left on, but loose ; the patient died about six weeks afterwards, and on opening the body it was discovered that the uterus was inverted, and that the ligature had included the inverted portion. The following case occurred to Dr. Gooch at Bartholomew's in 1828: The patient had been delivered by forceps six months before. When standing, a large tumor protruded externally, but could easily be re- placed. The OS uteri could not be felt. The ligature was applied round what was supposed to be the stalk of the tumor : it occasioned little pain when first applied, but towards evening pain became so severe as to resemble labor. She died on the fifteenth day after the operation. The uterus was of natural size and structure. The tumor grew from the orifice of the uterus all round, so as to be continuous with the cer- vix, and to make it impossible to say where the neck of the uterus ended or the stalk of the tumor began. The ligature had included the projecting neck of the uterus. The posterior part had occasioned ulcera- tion into the cavity of the peritoneum. There was no inflammation of the peritoneum. The diagnosis has to be made under the two different circumstances of recent occurrence and chronicity. In the first case, the history fur- nishes useful indications. The sudden sense of injury and shock, fol- lowing labor, suggests immediate exploration. Negative and positive signs occur in pointing to a conclusion. In the first place the uterus is not felt, as it ought to be, a firm, round ball behind the pubes. On pressing the hand firmly into the pelvic cavity from above downwards, behind the symphysis, a vacuum is felt. Keeping the hand in this situation, the fingers of the other hand are passed into the vagina, and there a mass rounded, soft, or firm is felt. The relations and position of this mass are clearly defined between the two hands. If the placenta is attached, the uterus is obscured by it. But bared, the diagnosis will be cleared up, if the finger is carried all round the mass up to its inser- tion. On pressing the mass upwards as in attempt to replace it, the fingers exploring through the abdominal wall will sink into a pit formed by the disappearance of the uterus through its os. Then the finger in the vagina exploring the root or insertion of the tumor comes to a cir- 40 626 INVERSION OF THE UTERUS. cular farrow at the fundus of the vagina, and a prominent ring, which is the OS uteri. If the inversion be not complete, the finger, or more easily the uterine sound, will pass a little way between the ring formed by the os and the pedicle of the tumor. If the inversion is complete, only the furrow will be felt. If the inversion has been followed by prolapse of the mass beyond the vulva the exploration is easier, as the tumor may then be felt continuous by its origin with the inverted vagina. It may also be seen. Its aspect is that of a florid tumor with a very vascular velvety surface, easily bleeding on the slightest touch, or if the presenting part be that to which the placenta had grown, it is uneven, of a dark hue, with placental shreds or coagula attached to it. The tumor is painful to the touch. Any attempt to drag upon it causes a sensation described by the patient as if her inside were being pulled out. Pain is also felt down the legs. Vomiting is likely to occur. In size the tumor may equal a child's head, or it may be no larger than a fist. A crucial test is the alternation of the mass from contraction to dilatation. This vital act inducing characteristic changes of size and consistence pertains to the uterus alone. The diagnosis from polypus is not always easy. A polypus may complicate pregnancy. Pregnancy usually causes an intra-uterine polypus to grow at an accelerated ratio. After the birth of the child, the polypus will be extruded, perhaps dragging the fundus uteri a little with it, thus simulating, if not producing, a minor degree of in- version. To distinguish this from inversion it must be remembered that polypus thus appearing after labor is actually even more rare than inversion. The probability, therefore, of inversion ought to operate with at least equal force upon the mind of the surgeon. The chief points of distinction are: that a polypus is not sensitive; it does not change its form or size ; it does not contract or relax. Its expulsion does not produce severe shock. In form and size polypus may resemble in- version, but it differs in relation to other parts. It is quite possible that the placenta may have been partially attached to the surface of the poly- pus; it will then exhibit placental shreds and clots like the uterus. The finger and sound must be relied upon to make the case manifest. The hand outside will discover the uterus in situ behind the pubes. The finger in the vagina Avill travel round the polypus, between it and the ring of the OS uteri which embraces it. If the attachment of the tumor is to the cervix, the pedicle will be felt on one side of the circumference, whilst in the other parts the finger or sound will pass several inches beyond into the cavity of the uterus. If the attachment is at the fundus, then the sound will pass all round. A case lately occurred in London in which the recently inverted uterus was mistaken for a polypus. Extreme exhaustion from hemor- rhage ensued, for which transfusion was successfully employed by Dr. Aveling, who also detecting the true cause of the hemorrhage, restored the uterus on the third day. The difficulty of distinguishing inversion in the chronic state from polypus is greater. Velpeau having in error tied an inverted uterus, said, " I know too well that there are cases in which doubt is the only rational opinion." Soon after the accident the uterus diminishes greatly DIAGNOSIS. 627 in bulk, becomes harder, perhaps less sensitive, and, in these features, more nearly resembles polypus. But setting the history — always a fallacious diagnostic element — apart, the means of discrimination are satisfactory. The speciilum may reveal the oozing of the menstrual fluid. In other respects its use is doubtful. The sound (Simpson, Edin. Med. Jour., 1843) is of more value. "If it passes two inches and a half or more beyond the edge of the cervix, the disease is not inversion of the fundus; if it cannot pass at any point around the stem of the tumor to a greater extent than about one inch, the uterine cavity may be considered as shortened by inversion." The inverted uterus is flattened anteriorly and posteriorly ; its largest point is lowest; it diminishes very gradually, presenting a comparatively large neck at its highest part, where it is encircled by the inverted cer- vix, if the inversion is not complete, and by a thickened ring or ridge if complete. The size of the inverted uterus is scarcely larger, and is often smaller, than in the natural state. Herbiniaux placed so much stress upon this as to affirm " that if the tumor be so large as to distend the vagina and prevent your getting at the os uteri, it may be boldly pronounced polypus, and not a partial inversion, which is always of small size, and tills the vagina." The form of the tumor has been thought to offer distinctive characters. S. Cooper described the inverted uterus as forming a mass wider or as wide above at its origin as at its most dependent part, whereas in poly- pus the neck is narrower. This is often true, but not constantly so; and it would not be safe to rely upon a variable sign. J. G. Forbes describes a case of complete inversion of eighteen months' standing, in which the tumor close to the os was four inches and a quarter in cir- cumference; this was the widest part. This seems to be more espe- cially the character of incomplete inversion. In many cases of complete inversion the upper part is narrowed so as not to be distinguished in this respect from many polypi. This was the condition in two cases observed by myself. A sign insisted upon by Crosse is the feeling the stretched round ligaments within the tumor (inverted uterus), and pain being produced in the groins on lowering the tumor a little so as to render the tension greater. To this I would add that by drawing the tumor well down by a vulsellum or a noose (see Fig. 137, p. 636), the insertion of the root in the vaginal roof being put on the stretch, the continuity of the two parts is made manifest. Malgaigne advises the following method : Introduce a male catheter into the bladder, direct its end downwards and backwards, so that, carrying the coats of the bladder before it, it may enter the peritoneal cul-de-sac formed by the inversion, and be felt by the finger in the vagina through the coats of the inverted organ. Another method is this : The catheter in the bladder, direct the end backwards so as to bring it to project in the rectum, where a finger will feel it with only the coats of the rectum and bladder intervening; but if the firm resist- ing uterus be there, the end of the catheter will not be felt. Digital examination by the rectum will also enable the surgeon to explore the tumor in the vagina more fully. Often the end of the finger will get 628 INVERSION OF THE UTERUS. above the tumor, thus completely exploring it. If the uterus be iu its place, it may thus be felt between the finger in the rectum and the finger of the other hand pressed down behind the pubes. If the uterus be inverted, then the vacuity above the tumor felt in the vagina will indicate that this tumor is the uterus. This mode of exploration should never be omitted. Dubois takes occasion to say that the mis- takes he refers to, in which death occurred from ligaturing an inverted uterus, would not have been made if exploration by catheter in bladder and finger in rectum had been resorted to. Where doubt exists there is still another mode of exploration which gives absolute evidence. Under chloroform the hand may be passed into the rectum, so that the fingers may feel above the tumor and completely command its whole contour. The operation is not very difficult, and if carefully performed no injury will result. An intra-uterine polypus sessile on a broad basis may simulate par- tial inversion. The diagnosis will be established by the hand outside feeling the unimpaired rotundity of the uterine fundus in the first case ; and the cup-shaped depression on its sphere in the second case. The sensitivenesss of the inverted uterus furnishes indications. Thus Gueniot (Arch. Gen. de Medecine, 1868) recommends acupuncture of the tumor to test this property. But it must be confessed — at least, I make this admission on my own behalf — that the sensitiveness of the inverted uterus has been more distinctly revealed by applying a liga- ture or wire around its neck with a view to removal for a polypus. Regarding this fact, and the associated fact, that a polypus is not sensi- tive, I have insisted upon the rule that patients should never be sub- mitted to anaesthesia for the removal of a polypus. Pain may give the last warning, and save the patient at the last moment. The diagnosis from prolapse of the uterus and vagina ought not to be doubtful. The presence of the os uteri at the lowest point of the tumor, admitting the sound for a distance of two and a half inches or more, at once decides the existence of prolapsus. The difficulty of diagnosis has been felt even in the presence of the parts put up in spirit. Thus Crosse, by further dissection, proved that a specimen, which for years had passed for one of inversion in the Glas- gow museum, was in reality one of polypus growing from and perfectly occluding the os uteri. He pleads with pardonable urgency that the mode of putting up these specimens is bad ; and that the tumor ought to be slit open by a longitudinal cut so as to expose the cavity and its contents. I possess a wax-model taken from a patient who came under my care in the London Hospital. There was a procident mass outside the vulva which was for some time taken to be a fibroid tumor attached to the fundus of the inverted uterus. It was only after prolonged examina- tion that a small opening, seated in the angle of junction of the tumor, was discovered by means of the sound to be the os uteri. The tumor had grown by a broad basis to the cervix, and had caused not inversion but ])rolapsus. The model is figured in the Obstetrical Trans., vol. iii. What has been said will indicate some of the principles of treatment. Attempts to reduce should be made as early as possible ; but success TREATMENT. 629 should never be despaired of. In the recent accident we may or may not liave the attaclied placenta complicatino; the case. Should we first detach the placenta ? If we do, we lose a little time. If we do not, there is the greater bulk to pass back through the os uteri. I believe it is the better practice to get rid of the complication first. To effect it, look for the margin of the placenta, insinuate one or two fingers between it and the globe of the uterus ; supporting this organ by the other hand, continue to peel off the placenta by sweeping the fingers along. When it is wholly detached, proceed to reduction. The mode of manipulation must vary according to circumstances. If the uterus is large, flabby, and the cervix dilated, it may be quickly replaced by depressing the fundus with the fingers gathered into a cone, and carry- ing the hand onwards through the os. Lazzati recommends to apply the closed fist to the fundus. This is better than the fingers which, as he truly says, might perforate the uterine wall. In executing this, two things must on no account be omitted : one is to support the uterus by the other hand pressing firmly down upon it from above the symphysis pubis externally, lest we lacerate the vagina; the other is to observe the course of the pelvic axes, and the form of the pelvic brim. Pres- sure will first be made a little backwards towards the hollow of the sacrum ; then the direction must be forwards to the brim, and at the same time to one side so as to avoid the sacral promontory, as in attempts to reduce a retroverted gravid uterus, failure has often ensued from not understanding this latter point. It was first, I believe, pointed out by Dr. Skinner, of Liverpool, I can testify to the value- of the rule from personal experience. By attention to it mainly, I was enabled to reduce a uterus in fifteen minutes which had been in- verted for ten days, defying repeated efforts of other practitioners. The patient made a good recovery. When reduction has been com- pleted, the hand following the receding fundus will occupy the cavity of the uterus, and the organ will be grasped between the hand inside and the hand supporting outside. The opportunity should be taken to induce contraction, by pressure externally, and by excitation internally. But I would not withdraw the hand from the cavity, lest re-inversion take place, until I had taken the following further security. Pass up along the palm of the hand a uterine tube connected with a Higginson's injecting-syringe ; throw up by means of this six or eight ounces of a mixture composed of equal parts of the strong solution of perchloride of iron (Brit. Pharm., 1867) and water, so as to bathe the whole inner surface of the uterus. The effects of this are to instantly constringe the mouths of the vessels, to stop bleeding, to excite uterine contraction, and to corrugate the tissues. When this state is induced there is safety. Or the stypic may be applied by swabbing by means of a pledget of cotton or sponge carried on a probang. If uterine action be present, especially if the cervix and os are con- stringing the inverted part, the difficulty is greater, and it is no longer judicious to commence by pushing in the fundus. As Dr. McClintock (" Diseases of Women," 1863) has well shown, to do this is to double the inflexion of the uterine walls, and thus to double the thickness of the mass that has to pass through the os. He advocates the method 630 iNVERSioisr of the uterus. practiced by Montgomery, which consists in regarding the inversion as a hernia, and in replacing that part first which came down last. The tumor must be grasped in its circumference near the constricting os ; firmly compressing it towards the centre ; and at the same time push- ing it upwards, forwards, and to one side. The pressure must be steadily kept up, as it is sustained pressure that wears out the resist- ance of the OS. After a time the os is felt to relax, the part nearest is pushed through, and then generally suddenly the body and fundus spring through. Two things facilitate this operation : chloroform and a semi-prone position of the patient. In recent inversion reduction has been effected by the aid of cold irrigation. Dr. Ch. Martin, of Orleans, relates (Gaz. des Hop., 1853) a case in which success attended this method on the thirteenth day. Probably continuous cold irrigation may be found useful in cases of even longer duration. If the opportunity of reducing within a fcM^ hours or days be lost, the difficulty increases through advancing involution of the uterus and contraction of the os. Still the same manipulation may be attempted. We must act steadfastly in the faith that pressure sufficiently long kept up upon the os uteri Mall cause it to yield. It is really a question of time — too long a time indeed for the hand of the surgeon to work — but not for other mechanical appliances. Dr. Tyler Smith is entitled to the credit of proving this point by success (Med.-Chir. Trans., 1858). In a case of inversion of twelve years' standing he effected reduction by maintaining pressure upon the tumor and thus upon the os by an air-pessary during several days. Pridgin Teale (Med. Times and Gaz., 1859) reduced an inversion of six months by the air-pessary in three days. Dr. C. West (Med. Times and Gaz., 1859) by similar means reduced an inversion of a year's standing. Dr. Bockenthal (Monats- schr. f. Geburtsk., 1860) succeeded in six days in reducing an inver- sion which had lasted six years. Mr. James Hakes (Liverpool Med. and Surg. Reports, 1868) by same means reduced a chronic inversion in fourteen days. Dr. Schroeder, of Bonn (Berlin Klin. Wochnschr., 1868) thus reduced an inversion of two years. And latterly (1869), Mr. Lawson Tait, on my suggestion, effected reduction in the same manner. The last woman died ; but her case Avas already desperate. Borggreve, indeed, had applied the same principle. He used a stem eight inches long with an egg-shaped knob which he fitted to the in- verted fundus, and held it in gentle pressure by a T-bandage. In three days the uterus was returned. Dr. Marion Sims relates an in- teresting instance of the influence of constant pressure. A stem-pes- sary with an external support, after pressing for some days upon the inverted fundus, w^s found to be taken up into the inside of the re- inverted uterus, the os having yielded and allowed both to pass in together. Courty ("Maladies de I'Uterus," 1866) relates a case in which in- version had existed ten months, inducing repeated hemorrhage and extreme debility. He reduced it in the following manner. The uterus was dragged outside the vulva by Museux's vulsellum ; then, the index and middle finger of the right hand were passed into the rectum, and TREATMENT. 631 hooked forward over the neck of the uterus; then the uterus was seized with the left hand, and passed back into the vagina; still holding the neck hooked down, the fundus of the uterus was turned so as to look forwards to the pubes, the neck turned to the sacrum. The fingers in the rectum separating, rest firmly in the angular sinuses formed by the utero-sacral ligaments ; then the thumb and index of the left hand pressing on the pedicle of the tumor gradually increase the depth of the utero-cervical groove. The two hands acting thus in concert, the uterus was reduced without violence in a few minutes. He had failed with the air-pessary; the patient could not bear it. He cites Barrier (Bull, de I'Acad,, 1862) as having reduced a case of fif- teen months' standing, who found a point d'appui by pushing the neck of the uterus against the sacrum. Dr. Emmet (Amer. Journ, of Med, Sci., 1866) succeeded in the following manner: He passed his hand within the vagina, and whilst the fundus uteri rested in the palm, the five fingers were made to encircle the portion within the cervix, as near as possible to the seat of inversion ; whilst the portion Avas thus firmly grasped, it was pushed upwards, and the fingers were immediately afterwards expanded to their utmost. This manipulation, with the aid of the other hand over the abdomen, was persevered in until the fundus had passed within the os uteri. The advance gained was in proportion to the amount of dilatation accomplished by the spreading of the fin- gers, thus increasing the transverse diameter of the uterus, and shorten- ing its long diameter. When the reduction had so far advanced that the fingers could not be passed fully up to the seat of the inversion, steady pressure was applied to the fundus by the tips joined together, whilst an increased effort was made by the hand outside to roll out the parts by sliding the abdominal parietes over the edge of the funnel. It has happened in several cases that only partial reduction could be effected ; that is, the body would return through the cervix in a doubled form, the fundus still being depressed, and presenting just above the cervix. In such cases, continuous steady support by a cup-shaped pessary or the end of a stethoscope, may in time complete the restora- tion. This difficulty has been met in an ingenious way by Dr. Emmet, He effected the closure of the os externum by silver sutures, so that the fundus imprisoned in the cavity of the neck tends to dilate the con- striction near the os internum. At a subsequent period the stitches are removed, and the taxis is practiced again. Dr. Emil Noeggerath, of New York, has described a method of taxis which deserves attention. "It consists in compressing the uterine body opposite to each horn, so as to indent one of these, and thus offer to the cervical canal a wedge, which passes up, and is followed rapidly by the other horn, and the whole body," Thomas reports that he has practiced this manoeuvre on two occasions with success. From time to time a method which may be described as the forcible taxis has been employed. Of late years a proposition has been made, supported by several distinguished American physicians, to admit this method to a recognized place in the treatment of chronic inversion. The fact that death after rupture of the uterus or vagina has several times been the consequence of forcible taxis should alone be sufficient to dis- 632 INVERSION OF THE UTEEUS. credit the method. No number of successes ought to outweigh failure so deplorable. Forcible reposition has been attempted either by the hand alone or by aid of a repoussoir, that is, some kind of blunt instru- ment of wood or ivory. Depaul (Gaz. des Hop., 1851) used a repoussoir in a case eleven days after labor. The patient died in a few days from rupture of the uterus. Laceration has also occurred in several cases in America. It is true that success restores the woman to her former integrity, but the penalty of failure to return the uterus is not infrequently death. The part will not sustain more than a certain amount of violence without laceration ; much force is necessary, and it is impossible to restrict with nicety the force employed within safe limits. Sustained solid or elastic pressure is free from the objections that surround the preceding methods. Success means restoration to integrity, and failure does not mean death or injury. It simply leaves the patient in statu quo, and in a condi- tion to be treated with every prospect of success by the adjuvant method of cervical incisions. This method of forcible taxis has been confounded, especially by some American authors, with that of gradual reduction by sustained elastic pressure. The principles of the two procedures are totally opposite. One tries to overcome resistance by sheer force rapidly applied, the other by wearing out resistance by gentle pressure long sustained. The first is replete with danger, the second almost absolutely safe. A method of effecting reduction remarkable for its boldness has been put in practice by Professor Thomas. This consists in making an incision through the abdominal wall so as to get at the constricted os uteri from above, and then applying a dilating force. The idea was enunciated by the late Sir James Simpson at the discussion of my paper before the Medico-Chirurgical Society in 1869. A case in which it was carried out by Thomas is thus described : An assistant introduced his hand into the vagina, and " lifted the uterus so that I could detect the cervical ring against the abdominal wall. I then slowly cut down upon the median line, as for an exploratory incision in ovariotomy, and leaving the wound exposed to the air until all oozing had ceased, cut into the peritoneum. I then inserted my finger into the uterine sac, and found no adhesion whatever to exist. Replacing the assistant's hand by my left hand, I now inserted the steel dilator and dilated the stricture. (The dilator is constructed on the principle of a glove- stretcher, R. B.) The dilatation was exceedingly easy and rapid, but I found that as I withdrew the dilator, the tissue of the organ would at once contract. After dilating the stricture fully, I partially returned the uterus. . . . Drawing it down to the vulva, I rapidly pushed it up, and was gratified at finding that it was nearly replaced. Drawing it down again, this time outside of the body, to my dismay I discovered that the artery cut one week before was spouting freely. ... I rapidly returned the organ, and was delighted to find one horn rise into place. But the additional force employed was a little more than the vagina could bear, and one finger passed through between the uterus and the bladder. One horn was still inverted. Passing the dilator into this, I stretched it open, and instantly the uterus resumed its normal posi- TREATMENT. 633 tion. The artery bled freely that day into the vagina and into the peritoneum through the vaginal rent. But the patient ultimately re- covered." Dr. Thomas operated in the same way in another case. " She did perfectly well for forty-eight hours, but at the expiration of that time peritonitis developed itself, and proceeded to a fatal issue." Reflection upon these cases will hardly, I think, justify the recom- mendation of Dr. Thomas. In the first case, even after dilatation of the cervical ring, so much force was necessary in taxis as to rend the vagina; whilst in the second, fatal peritonitis was the result. A method which requires gastrotomy for its execution, involves conditions of dan- ger so great that even amputation seems preferable. Amputation may be likened to catting the Gordian knot. It is an apt illustration of John Hunter's aphorism. It is a confession of ira- potency to solve the problem of reduction. It is the last resource; one to which I am firmly convinced we need hardly ever, if ever, be driven. Notwithstanding the histories of a considerable number of cases of re- covery after the operation, it cannot be said to take rank as a scientific proceeding. Recovery cannot be guaranteed. The conditions of safety depending upon nature may be absent, and the surgical means at present known are imperfect. When the uterus is cut across at the neck, of course a hole is made opening from the fundus of the vagina into the peritoneal cavity. The danger of fatal peritonitis is great. The shock of the operation also is serious. Hem- orrhage is likely to ensue, and some blood will escape into the abdo- men. There are various methods of performing the operation. The uterus has been seized by a vulsellum, drawn down, and the cervix cut through with a knife. Then it was thought that the ligature ap- plied to strangle and to slough through, as in the case of a polypus, would be less dangerous. Treated in this way the result has been varied. In several instances where a whipcord ligature has been ap- plied by Levret's or Gooch's double canula, agony so intense has been produced, as to render it necessary to remove the ligature, and the pa- tient has died notwithstanding. The cause of the excruciating pain is, I believe, the compression of the included Fallopian tubes. I have observed the same pain in cases when the tubes have been tied-in the pedicle of an ovarian tumor. And it has been observed in several cases that the surface and substance of the uterus proper was nearly insensible, pain being developed only on tightening the ligature. In some cases the patient has died with the ligature attached. There is a preparation illustrating this in the museum of Bartholomew's Hospital, death en- suing from peritonitis eight days after tying. On the other hand, it seems not unreasonable to hope that a ligature gradually tightened may set up adhesive inflammation in the neighboring peritoneum, and thus shut off the abdomen from communication with the vagina when the uterus falls away. Certain it is that this hope is not always re- alized. Thus Dr. McClintock (opits cited.) relates a case in which a liga- ture was applied during eighteen days, occasionally relaxing it on ac- count of the severity of the pain, before the uterus was separated. No peritoneal adhesion had taken place; the woman, however, made a good recovery. In eighteen cases where the time that elapsed before 634 INVERSION OF THE UTERUS. the uterus fell is stated, the ligature took from nine to twenty-eight days to sever the parts. The average time was seventeen days. It has been remarked that the ligature has arrested the hemorrhage. Dr. Ramsbotham lias related a case in which the ligature had to be removed at the end of twenty-four hours, owing to symptoms of vio- lent peritonitis ; but the profuse sanguineous and mucous discharges ceased. Mr. J. G. Forbes (Med.-Chir. Trans., vol. xxxv) suggests that the simple application of a ligature around the neck of the tumor to de- stroy its vitality appears to possess more advantages than the other modes of operating. Dr. INIcClintock relates two cases in which strangulation was first effected by a ligature for four days, and then the uterus was removed below the ligature by the chain -^craseur. The patients recovered. This combined method seems likely to unite most conditions of suc- cess. Dr. Marion Sims relates (op. cit.) a case in which, after vain at- tempts at reduction, and being compelled by the consequent pain and prostration to abandon the ligature, he resorted to the chain-ecraseur. When the parts were all divided except the right broad ligament, "all at once the most fearful hemorrhage he ever encountered took place." It was happily stopped by passing the finger into the abdominal open- ing and compressing the source of the hemorrhage. The blood which had escaped into the peritoneal cavity was sponged out, and the divided edges of the cervix were united by five or six silver sutures. The pa- tient recovered. Mr. Baker, of Birmingham, relates (Brit. Med. Jour., 1868) a case of recovery after amputation by the chain-ecraseur. The bleeding vessels were sealed by actual cautery. Dr. Hall Davis relates (Obstetrical Transactions, 1873) a case in which he amputated the uterus ten months after labor. He used the single wire ecraseur. He em- ployed it without first dragging upon the neck of the uterus, expecting thus to lessen the risk of the sudden springing up into the peritoneal cavity of the severed cervical portion of the uterus. No hemorrhage occurred. The patient recovered. Pain was subdued after the opera- tion by subcutaneous injection of morphia every six hours during the first twelve days-, it being found that any suspension of its use was fol- lowed by severe uterine and ovarian pains. The pulse was vei;^ small immediately after the operation, and the temperature fell to 97° F. It appeared that in this case there were peritoneal adhesions, a condition which, no doubt, supplied a safeguard against peritonitis, and which, as it would have rendered reduction impossible, justified the recourse to amputation. Professor Barba (II Morgagni, 1872) amputated an inverted uterus of three months' standing by Chassaignac's ecraseur. There was no great bleeding; but syncope set in immediately, and lasted seven hours. This was followed by peritonitis, which subsided in fourteen days. The patient recovered. Dr. Valette (Lyon Medical, 1871) relates a case of successful amputation by means of a clamp, each blade of which was grooved to carry chloride of zinc paste. The neck of the tumor being seized in this caustic clamp, the uterus was cut off in front of it, and the stump TREATMENT. 635 cauterized with chloride of zinc. The actual cautery would give greater security against hemorrhage. The preceding histories will show some of the dangers attending amputation, and how they may best be encountered. In those rare cases where adhesions or extreme exhaustion forbid the attempt to reduce, the best method of amputation appears to be by the wire-ecraseur. The induction of ansethesia is of course indispensable. Were I compelled to resort to this ultima ratio, I should, before amputation, transfix the neck of the tumor by a needle carrying a wire suture, so as to command the divided edges of the opening, and facilitate the application of the cau- tery to the bleeding surface. The use of the galvanic cautery wnre to effect the amputation seems to possess advantages over the other forms of ecraseur. In cases wdiere neither reduction nor ablation can be attempted, hemorrhage and other discharges may be restrained by lotions of tan- nin, alum, perchloride or persulphate of iron, or of carbolic acid; and probably some advantage may be derived by compressing the uterus by wearing an air-pessary in the vagina. In my memoir in the Medico-Chirurgical Transactions, 1869, 1 gave a summary account of the results which had attended the various modes of operating in the cases which I had then been able to collect. Further research, and the records of subsequent histories, some of which are referred to in the two preceding pages, involve some modification of the conclusions then arrived at. But the practical lessons flowing from this summary are still valid. " Six different modes of dealing with ehronio inversion have been tried with the following results in the cases I have been able to examine. " I. By ligature alone. Of these twenty -six were successful, ten unsuccessful. Of the unsuccessful eight died, and two recovered without extirpation. " II. By ligature and excision : nine were successful, three unsuc- cessful. These three all died. " III. By excision simple : three were successful, two died. " IV. By sustained solid pressure there have been several successful cases. "V. By sustained elastic pressure in eight cases the uterus w^as restored ; in seven of them recovery was perfect, one died, being already beyond hope. In three or four cases reported, the pressure was given up. " VI. By forcible taxis : six successful cases are reported ; four failed, all of them dying." In appreciating the relative merits of these different operations it must be remembered that the highest success attained by ligature or excision is achieved at the cost of mutilation; the woman is unsexed; and failure commonly means death. The following passage is quoted from my memoir above referred to: " Another proceeding stands before amputation. For twenty years I have taught in my lectures that the unyielding cervix may be divided by incisions carried into its substance from above downwards at different 636 INVERSION OF THE UTERUS. points of its circumference. Pressure then applied will cause it to yield more easily. Huguier, Professor Simpson, and Dr. Marion Sims have suggested the same plan. " I am not aware that it had ever been carried into execution before 1868, when I treated a case in this manner with complete success. The inversion was complete ; it had lasted six months ; the patient was so prostrate from continuous discharges that the prospect of her holding out many weeks was small. I first tried to rein vert by keeping up continuous elastic pressure during five days, with occasional attempts by taxis as recommended by Tyler Smith. This failing, I drew down the tumor to the vulva by passing a sling-noose of tape round it, thus putting the neck on the stretch (see Fig. 137); T then made three Dr. Barnes's operation. Showing inverted uterus drawn down by tape-noose. ab c. Line of incisions in the cervix. incisions in the neck about a third of an inch deep, one on each side and one behind in a longitudinal direction, that is, across the fibres of the cervical sphincter. Then, compressing the uterus with my left hand, and supporting the os uteri by the fingers of the right hand through the abdominal wall, I found the cervix yield, and the body went through into its place. The cervix yielded by laceration extend- ing from the incisions ; and I very much feared at the time that serious if not fatal mischief had been done. No material incon- venience, however, followed ; and examination three weeks afterwards showed the cervix and uterus to be in their proper places. Notwith- standing the successful issue, I believe that the method should only be resorted to after a full trial of Tyler Smith's plan, and then with great caution. I should recommend that only two incisions be made, one on TREATMENT. 637 each side of the os, and these of moderate depth. The rein version should be trusted to sustained elastic pressure." This suggestion I have since had the good fortune to carry out with complete success. I have narrated the history in a memoir in the first number of the Obstetrical Journal (1873).^ The first woman has had two children since the operation. The operation, then, has been twice successful. Coming in, as it does, as supplementary to the plan of sus- tained elastic pressure, extending the application of this plan, its value is incontestable. The evidence of experience, as well as of physiological reasoning, is now so strong that we can rarely be justified in resorting to the ultimate remedy, one full of danger, of amputating the inverted uterus. Professor Thomas reports a case in which he incised the cervix as follows (" Diseases of Women," 1872). In June, 1869, attempts by taxis having failed, "I pushed the uterus as far as it would go; thus fixing by my finger the point of constriction, I drew it down, and cut down through the neck, the incision first involving the mucous mem- brane, and extending down toward the subjacent peritoneum, as recom- mended by Aran. No sooner was the knife withdrawn than a free jet of blood was projected from an artery which appeared nearly equal in size to the radial. This jet was not per saltum, but steady, as it is often seen to be from small arteries located in dense fibrous tissue. For half an hour we strove to ligate this. Upwards of a dozen ligatures were one after another applied, but the vessel had retracted into the brittle tis- sue of the uterus and could not be tied. The flow was at last checked by passing a suture through both of the wounds and bringing them forcibly together." This is the case which was completed by Thomas's plan as described at page 632. The application of sustained elastic pressure requires care and watch- ing. The distress, even pain, occasioned by the ccmtinuous distension is severe; and in several cases it has been felt necessary to abandon the method. To obviate this difficulty, the pressure may be occasionally relaxed ; and we may have recourse to chloral or the subcutaneous in- jection of morphia. The proceeding undoubtedly requires steady per- severance and some skill in adjusting and regulating the pressure. But these conditions given, success will rarely be wanting. The best Time for attempting Heduction. — Sometimes, as when the symptoms are very urgent, we have no choice. But where the oppor- tunity is given, it would, I think, be better to work between the men- strual epochs, observing the general rule to avoid operations during menstruation. Malgaigne, however, preferred a menstrual period, on the ground that at this time the tissues are softer and more yielding. In my second case I used the elastic pessary (Fig. 138). It consists of a fixed stem made to fit the pelvic curve, and surmounted with a cup-shaped disk of hollow rubber which receives the inverted uterus. At the end of the stem, which is outside the vulva, are attached strong rubber bands which are brought up before and behind to be attached to an abdominal belt. By means of these bands the difficulty of main- 1 " On a New Method of Reducins; Chronic Inversion of the Uterus." 638 INVERSION OF THE UTERUS. taining steady pressure, which occurs when inflated bags are used, is entirely obviated. By tightening or relaxing these bands it is easy not only to regulate the pressure to a nicety, but also to give it the exact direction we want. For example, by bracing up the posterior bands we throw the force forwards, and may spend it directly upon the Dr. Barnes's elastic pessary for reduction of chronic inversion of the uterus. neck of the tumor. Thus pulling upon the ring of reflection, there is kept up a constant eccentric pull tending to open the constriction. The pressure upon the body of the uterus at the same time tends to press out the blood and serum from its tissues, diminishing its bulk and arresting hemorrhage. Counter-pressure should be exerted by pads to the abdomen supported by a firm binder. Once a day, or every other day, the instrument may be removed, and, under chloroform, an attempt at reduction by taxis may be made. For this purpose one hand should be passed into the vagina, whilst the other hand applied above the pubes exerts counter-pressure upon the funnel-like ring of the inverted organ. The fingers grasping the neck of the tumor, alternately compressing and pushing at the circumference, we persevere either until we feel the ring expanding and a part of the mass going through it, or until fatigue or the condition of the patient warn us to desist. In the latter case we readjust the elastic pessary. In the former case the reduction is commonly effected at last suddenly; we feel the fundus go into its place with a jerk. The restored cavity of the uterus should then be swabbed with a solution of iron, and the patient left to rest. TUMORS OF THE UTERUS. 639 When well adapted and steadily pursued attempts to reduce have failed, and the patient's life is threatened, then only shall we be justified in resorting to the anceps remedium of amputating the offending organ. When attempts at reduction have failed, the operators have in some cases been too ready to conclude that the cause of failure lay in adhe- sions. But it is remarkable how seldom this conjecture has been borne out by facts. The truth is that adhesions are extremely rare. It has even been difficult to produce them by proceedings directed ad hoe in order to obviate some of the dangers of amputation. The possibility then of adhesions opposing reduction may be practically disregarded if gradual elastic* pressure be employed. CHAPTER XL VII. TUMORS OF THE UTERUS; MALIGNANT AND NON-MALIGNANT; FIBROID OR MYOMA; DESCRIPTION OF FIBROIDS, THEIR NATURAL HISTORY, RISE, PROGRESS, AND TERMINATIONS; VARIETIES OF FIBROID TUMORS; THE DIFFUSE TUMOR; THE FIBRO-CYSTIC ; THE RECURRENT FIBROID; THE ERECTILE TUMOR OF CARSWELL; THE DEVELOPMENT AND DECAY OF FIBROIDS; EFFECTS OF FIBROIDS UPON THE UTERUS AND SURROUNDING ORGANS AND SYSTEM GENERALLY"; THE SYMPTOMS AND DIAGNOSIS; THE TREATMENT. Alike for pathological and clinical study, new growths or tumors in the uterus may be divided into malignant and non-malignant. Although there are forms of transitional character which it may be difficult to refer with absolute certainty to one or the other class, it is still convenient to observe this distinction as far as we can. Thus I propose to devote one chapter to non-malignant tumors, and another to the malignant diseases generally associated under the common name of " cancer." Non-malignant tumors are classified first, according to their histo- logical characters ; secondly, according to their seat or other clinical characters. It may be stated as a proposition generally true that non- malignant tumors affect the body of the uterus, and malignant growths affect the cervix. But in accepting this statement we must be careful in practice not to forget that there are many exceptions. In most cases the seat of the tumor, malignant or non-malignant, exerts a material influence upon the clinical history, and often influences treatment. 640 FIBROID TUMOR OF THE UTERUS. Fibroid Tumors. — There is perhaps no organic change in the uterus more common than the development of tumors of this character. The statement of Bayle that 20 per cent, of all women dying after the age of thirty-five have fibroid tumors in the uterus is always quoted in > reference to this point ; and Klob, a more recent writer, says, " Un- doubtedly 40 per cent, of the uteri of women who die after the fiftieth year contain fibroid tumors." Although unable to oppose these state- ments with numerical deductions, I venture to doubt whether the fre- quency of this affection is so great as these figures would indicate. Admitting their approximate accuracy, two conclusions are sufficiently justified. First, in a large proj)ortion of cases fibroid tumors in the uterus occasion no marked distress, and entail little danger to health or life ; secondly, they occur with increasing frequency with the advance of age until the climacteric is reached. 1 do not know that it has ever been clearly made out that fibroid tumors originate after the climacteric. Undoubtedly they may grow after this epocli, and that very rapidly, but the time of their formation is mainly, if not absolutely limited to the period of sexual activity. Cruveilhier called attention to the remarkable affinity of the uterus for these fibroid bodies. It must also be borne in mind that similar tumors form wherever there is muscle resembling that of the uterine wall. Thus they are found in the broad ligament, and in the vagina. Although far more frequent in the body of the uterus, where the mus- cular element preponderates, they occasionally arise in the cervix. Indeed, there is a form of fibroid degeneration which seems especially to affect the cervix, producing thickening of some portion of its wall, generally the anterior. This form, however, is not identical with the common fibroid ; it is not distinctly capsulated. But tumors in all respects resembling the true fibroids do occur in the cervix. Thus Professor Faye in an elaborate memoir (Christiania, 1866) on inflam- matory hypertrophic and fibrous tumors of the cervix uteri, relates in detail a case of unusually large fibrous tumor growing from the anterior lip of the vaginal-portion. I have seen several such cases assuming a polypoid condition. I have also removed several from the vagina quite separate from the uterus. Dr. Honing (Berlin. Klin. Wochenschr., 1869) relates the case of a woman aged forty-one, who suffered from dysuria and bowel-obstruction. A tumor the size of the fist projected from the genitals; it sprang from the left side of the urethra. A still larger tumor was contained in the vagina. The mass was a "soft fibroid." The various names given to these growths attest the varying ideas that have been current as to their nature. Baillie called them " hard tubercles ;" Hooper, " subcartilaginous ;" then they were called "fibrous ;" to this name succeeded the one in common use, " fibroid," or "fibroma;" and some insist that "myoma" and "fibro-myoma" are more correct designations ; M'hilst Broca, regarding the similitude of their structure with that of the uterus, proposes the name " hysteroma." Cruveilhier observed that there were " hard polypi, which consisted in hypertrophy of the tissue of the uterus — such is the one figured pi. vi, liv. xi*" of his work — and others consisting of fibrous bodies developed NATURE. 641 under the uterine mucous membrane." The celebrated French pathol- ogist thus describes the structure of the polypus referred to : " The figure represents an antero-posterior section of the polypus and of the fundus of the uterus. The tissue of the polypus is seen to be continu- ous, without any line of demarcation, with the proper tissue of the uterus ; it is a prolongation of this proper tissue, and not a fibrous body developed in the thickness of the uterus, capable of being sepa- rated by enucleation. The identity between the tissue of the uterus and the tissue of the polypus is such that the closest examination does not reveal the slightest difference." Cruveilhier does not appear to have suspected that the ordinary fibroid tumor, distinctly defined from the ]3roper uterine tissue, and capable of enucleation, might also consist of muscular fibre, in every respect resembling the muscular fibre of the uterus. VogeP was one of the first to demonstrate the essential identity of structure of the " fibrous " tumor with that of the muscular wail of the uterus in which it takes its origin. One case (Fig. 8 in Yogel's work) exhibits the " mature fibres of a fibrous tumor of the uterus found in the body of a woman who died of puerperal fever. In the fundus uteri two tumors of the size of almonds were found externally projecting under the peritoneum. They consisted of jDarallel fibres, forming a thick, very dense, milk-white tissue. The fibres became pale, and gradually dissolved in acetic acid ; most of them were long, spindle-shaped cells, which were not affected by acetic acid. The normal substance of the uterus consisted of like fibres, resembling in every respect those of the two tumors." Vogel gave several other illustrations of the muscular nature of uterine fibres, and further established their histological affinity by showing the muscular character of fibrous tumors found in other parts of the body. I have cited the above passage because the observation it refers to was made upon a puerperal uterus. In 1844 (Guy's Hos- pital Reports) Dr. Oldham described the constitution of a polypoid mass which was driven down by the uterus after labor. "The prevail- ing tissue was a clear unstriped fibre, which, when examined with a portion of the muscular fibre of the uterus, differed only in the latter being more full of cells and blood-corpuscles, which rendered its defi- nition as fibre less distinct than the former." In February, 1851, I had an opportunity, in conjunction with Dr. Hassall, of verifying this identity of structure between fibrous tumors and the uterus in the non-pregnant state. (Lancet, vol. i, 1851.) The specimen was exhibited to the London Medical Society. This entirely confirmed the observations already cited. Lebert, in 1852, describes these tumors as consisting of — 1. Cellular tissue and fibro-plastic ele- ments ; 2. Muscular fibre-cells like those of the uterus ; these come out clearly with acetic acid. On the 19th April, 1853, Dr. Bristowe re- ported to the Pathological Society the result of his examination of two fibrous tumors. Robin says "the muscular fibre-cells are larger than those of the empty uterus, but smaller than in the gravid womb ; that Erlaiiterungstafeln zur puLliol. Histologic," 1843. 41 642 FIBEOID TUMOR OF THE UTERUS. they constitute from one-quarter to one-half of the morbid mass ; that there is also a large ])roportion of finely granular amor])hous matter, very tenacious, half solid, binding the fibres of tlie cellular tissue, and also the fibre-cells together." The granular amorphous element tends to' increase in proportion to the rapidity of the growth of the tumor. I am indebted to Mr. Henry Arnott for the following illustration of the structure of the uterine fibroid or myoma : Fig. 139. k 2 2 structure of fibroid of uterus. Showing structure of waving hands of the long spindle-cells, with rod-shaped nuclei of plain muscu- lar tissue ; the nuclei stained with carmine. At one point a lew cells divided transversely. (Ad. nat., by H. Arnott.) The similarity of constitution, then, of "fibrous" tumors with tliat of the muscular wall of the uterus in which they originate is now amply determined. But I think this similarity is somewhat over- strained. We do, indeed, find the same histological elements ; but certainly they are combined in different proportions, so as to produce marked differences in some of the physical characters. For example, the "fibroid" tumor is commonly pearly white, more striated, under the knife it gives a different sensation; compared with the uterine wall in which it is imbedded, its density and feel are different ; its interior is less vascular; it behaves, in short, in many respects as a foreign body. It is true that in the pregnant uterus it follows to some extent the same laws of development and of involution as the muscular wall; but even in this circumstance, remarkable differences arc occasionally observed, especially in the course of involution. The fibroid tumor being less one with the uterine wall, being less vascular, does not always follow jyari passu the retrogression of the proper muscular tissue. It some- times remains larger. And sometimes, having less vitality, less power of resistance to injury, it pas.ses into a state of low inflammation, or necrosis, which leads to it§ death, entailing either total disappearance POSITION AND SHAPE. 643 by absorption, or the spread of inflammation to the proper structures of the uterus, and pyaemia. This is especially liable to happen when such a tumor being situated in the lower zone of the uterus is exposed to unusual contusion by the passage of the head during labor. The process of extrusion is further facilitated by the slightness of the at- tachments by which these tumors are connected with the uterine wall. I believe, however, that the chief factor in extrusion is not in all cases active uterine contraction. It is sometimes the result of the dif- ferent ratio of growth of the tumor and of the uterus. A dense, solid substance, isolated from the uterine wall in which it is imbedded, and continuing to grow, whilst the uterus itself partakes but slightly in the process of enlargement, will in time form a projection upon the one or the other surface of the organ. And further growth will cause it to bulge more and more ; thus growing out of the uterus, rather than being expelled from it. Looking at the histological characters of fibroid tumors we may im- agine them to arise from accidentally aberrant growths of points of the original muscular structure of the uterus, that get surrounded by con- nective tissue or the regularly disposed muscular fibres, and thus be- come isolated in masses instead of being disposed in strata in the gen- eral structure. The position of fibroid tumors varies infinitely. Beginning in the substance of the muscular wall, they are all at first interstitial. As they increase in size they tend to bulge out either on the outer or inner surface of the uterus. In the first case they are called subperitoneal ; in the second, submucous. They are far more common in the body of the uterus than in the neck. This may be accounted for by the lesser proportion of muscular fibres in the neck. In shape fibroids vary greatly. All are at first probably rounded, and whilst single and of moderate size they generally remain so. The irregular nodulated tumors are mostly conglomerates of many nuclei growing together at different rates. When the tumors are separate, they may by mutual compression assume various shapes. The rate of growth is hard to determine. It is not uniform. It is governed greatly by the ovarian stimulus. Probably the intramural or subperitoneal tumors grow more slowly than the submucous. Many are comparatively small and inert for many years. That their usual rate of growth is slow may be interred from their structure, which is but scantily supplied with bloodvessels ; from the fact that fibroid tumors of considerable size are rare in young women ; and in many it is a matter of observation. I have several women under observation in whom the existence of fibroids in the uterus was established many years ago. It is almost exclusively in women approaching or after the climacteric that very large tumors are seen. Fibroid tumors are single or multiple, and some tumors apparently single are really compound, that is, conglomerates of single tumors. The characteristic of a single tumor is that it consists of one bundle or mass ; in the case of multiple tumors there are two or more masses situated apart from each other in distinct parts of the uterus ; whilst conglom- 644 FIBROID TUMOR OF THE UTERUS. erate tumors consist of several masses packed together in close approxi- mation. There is scarcely a limit to their number. In size they vary from a pin's head to that of a man's head, or even bigger. Examples of the single and multiple tumors are seen in Figs. 141, 144. Fig. 140. Conglomerate of fibroid tumors of uterus. (Two-thirds nat. size, St. Thomas's Hospital.) Fig. 140, taken from a specimen in St. Thomas's Museum, is a beautiful illustration of the conglomerate form. Each constituent mass appears surrounded in a separate matrix, whilst all are encapsuled in uterine tissue. Law of Gh'owth of Iluscular Tumors and Polypi. — The mode of growth of these tumors, by the development of unstriped muscular fibre from nuclei, is sufficiently shown by the description and figures of Professor Vogel. But, whilst their histological formation seems to be similar to that of the true uterine tissue, they appear to enjoy a certain amount of independent developmental force. This is proved by their greater compai^ative rapidity of growth, and by the fact that they sometimes attain a very large size in the unimpregnated uterus — that is, during a time when the uterus itself scarcely enlarges at all, or only so much as may be attributed to the morbid stimulus imparted by the presence of the tumor. At the same time it is worthy of remark that fibrous tumors are very rarely found before the age of puberty ; if they are, they remain passive until the period of activity of the generative system. After the childbearing period, and the cessation of menstruation, fibrous tumors previously existing exhibit a marked tendency to recede. It is, I believe a very rare occurrence to observe that any fresh tumors become developed after this epoch. The period of active growth of fibroid tumors and polypi is the period of func- tional activity of the generative organs. The periods of greatest GROWTH. 645 activity of growth of these tumors are the periods when the generative organs exhibit the greatest activity. The periodical stimulus the uterus undergoes at the epochs of menstruation is shared by the tumors lodged within its walls. The rapid enlargement of the uterus during preg- nancy is often attended by a commensurate growth of the tumors. Subperitoneal fibroid tumor of uterus. (Half-size, London Hospital.) The tumor is only attached by a thin pedicle to the fundus uteri. But, although it may be laid down as a general rule, that fibroid tumors do not continue to grow after the termination of the normal period of menstruation, it must be admitted that exceptions occur. I have even observed that the constitutional ferment which frequently attends this critical period of life seems to determine in the temporary exacerbation of any form of uterine disease existing at the time. The organic force which had hitherto been exerted in healthy physiological work, is now diverted into a morbid channel. In this way these tumors not infrequently acquire an enormous size, equalling or even exceeding that of the gravid uterus at terra. Both the subperitoneal and the submucous tumors seem to be con- stantly pressing towards expulsion. The first step in this eifort is seen in bulging or projeetion on the surface ; the second is seen in peduncu- lation, when they are called polypi ; the third is actual detachment from the uterus. The process of extrusion, a very important point in the clinical history of these growths, deserves attention. It may be likened generally to labor. The tumor is a parasitic growth which, drawing its means of nutrition from the uterine wall, and stimulating the struc- ture in which it grows to increased development, may be said to pro- duce in the uterus a state analogous to pregnancy. The uterus enlarges, its muscular element increases, and consequently its contractile property is called into play. The uterus thus developed tries to get rid of its parasite. Contractions of its muscular coat act upon the tumor and drive it towards the nearest surface, that is, the tumor is made to pro- 646 riBEOID TUMOR OF THE UTERUS. ject at that part where the investhig wall is thinnest. One of the con- ditions favoring this process is the difference in solidity between the tumor and the uterine wall. The texture of the tumor is usually more dense and compact, and is consequently less capable of contraction. It cannot follow or partake in the uniform contraction of the organ ; Fig. 142. Fibroid tumor of the uterus. (Two-thirds uat. size, St. Thomas's Hospital.) Showing encapsulation in the proper uterine tissue, and attendant formation of cystic polypi in the cervix. The tumor starts from its capsule on section being made. as an unyielding body, preserving to a great extent its original dimen- sions, it must be driven towards one or other surface of the uterus as this diminishes in size. This liability to extrusion is the more especial characteristic of the dense fibroid encapsuled tumors. Those tumors whose texture more nearly resembles that of tlie uterine wall, which are continuous with this wall, show less of this tendency towards extrusion. The expulsive action of the uterus is strikingly manifested in those cases in which the organ inverts itself in the eifort to cast out a tumor. Cases of this kind are described in the chapter on "Inversion." They extend the similitude to labor. In St. George's Museum is a specimen (xiv, 21) showing a fibroid in course of spontaneous elimination. The tumor is nearly detached as though a ligature had been applied. The attempt of the uterus to rid itself of its guest by contraction suggests a course of treatment which is sometimes followed bv success. Acting as if the object were to expel a foetus, ergot, strychnine, quinine, MODE OF EXPULSION. 647 galvanism have been employed to stimulate the expulsive power of the uterus. Sometimes, aided in this way or not, the tumor is actually detached, and cast out from the body. Many cases of this method of spontaneous cure are known. There appear to be two ways in which it is carried out: 1. The thin layer of proper uterine tissue which forms the shell of the tumor may become inflamed and give way ; the tumor itself softening, may be broken up in such a manner that the fragments, not perfectly separated from each other, but preserving a slight connection, may be driven down into the uterine cavity ; or the Fig. 143. Uterus with two large fibroid tumors. (Half-size, St. George's, xiv. 10.) One projects into the uterus, filling its cavity ; it adheres to the inner surface of the uterus. The other tumor is at the back towards the peritoneal surface, not seen in this view. tumor may come away entire, being, as it were, enucleated by the uterine action. This is especially likely to occur after labor. 2. The other way is by gradual pedunculation as explained. When the stalk is much thinned, the tumor breaks away by a slight force like an etiolated leaf or ripe fruit. The extrusion of fibroid tumors following labor is often attended by great danger. The tissue of the tumor, either through having suffered violence from compression or not, is very apt to be affected by a low necrotic form of inflammation which may give rise to metritis and pyaemia. And even when a tumor is expelled independently of labor, the process is not always carried out harmlessly. Thus, Cruveilhier relates a case of a young woman who had suffered during four months from uterine hemorrhage, followed by a discharge horribly fetid. At the end of this time she expelled some small masses, recognized to be fibrous tumors. The patient, whose health was undermined by hectic fever, and who presented all the marks of cancerous cachexia, recovered, contrary to all expectation, after the. expulsion. In St. George's Museum is a specimen (xiv, 20) " taken from the 648 FIBROID TUMOR OF THE UTERUS. body of a lady who, on first consulting Mr. Stone, ])resented a tumor projecting from the uterus, and much resembling a polypus in the process of coming down. Severe pain came on, and the tumor began to project more, but never presented any neck. She sank exhausted by the discharge." Sometimes the process simulates abortion so closely as to be mistaken for this event. This happened in the case of the wife of a medical friend. After profuse hemorrhages and expulsive pains, a substance of the size and shape of a small egg was passed. Both she and her husband believed she had aborted. But on making a section of the mass, I found it was a fibroid tumor. It is needless to say that such a series of events occurring in a single woman would almost infallibly give rise to imputation against her chastity. The history enforces the rule to submit every substance passed from the uterus to careful examination. The subperitoneal tumors may also become pedunculated, being the exact counterparts of uterine poly}>i. In proportion as the peduncle elongates, becoming more remote from uterine influence, they become less and less dangerous. I have known them to acquire a peduncle so long that the tumor could be grasped in the hand through the abdomi- nal wall, and be moved freely about, only restrained by its mooring to the body of the uterus. When in this condition, the subject may go through pregnancy and labor quite unaffected. And, like the uterine polypus, the subperitoneal tumor may be actually cast oflp. It then sinks down into the lower part of the abdomen, where it may cause peritonitis or mechanical distress ; or, its presence may give rise to no inconvenience. This tendency tp casting-off by the peritoneal sui^face is well illus- trated in Figs. 141, 144. Professor Turner (Edin. Med. Journ., 1861), who has discussed this subject with illustrative examples, says : " Should a subperitoneal tumor be attacked by inflammation of its peritoneal investment, and contract adhesions to surrounding parts, it is thus placed in a position favorable to become separated from the uterus. This would be especially liable to occur if it became connected to a viscus, such as the bladder or rectum, which is constantly under- going changes both in size and position. The alternate dilatations and contractions of these viscera would necessarily exercise a considerable traction upon the tumor, which w^ould tend to produce elongation of the pedicle; and ultimately, should the case be sufficiently long in ope- ration, complete detachment from the uterus. Even if the tumor were to attach itself to a fixed part, as the ]->ubes, or other portion of the pelvic wall, and the woman subsequently become pregnant, the grow- ing uterus, gradually rising into the abdomen, might exercise such an amount of traction upon the pedicle as to attenuate it even to complete separation. The entanglement of the tumor between the coils of small intestine which so frequently hang down into the pelvic cavity, even although no distinct attachments took place between them, would, during the peristaltic movements of the gut, exercise a certain degree of dragging upon it, esjDecially if at the same time its pedicle became CASTING-OUT. 649 twisted. In those cases in which the tumors attain great size, or great density, through calcareous degeneration, even without becoming con- nected to adjacent parts, their own weight might probably assist in producing attenuation of the pedicle ; but in estimating this as a cause Fibrous tumors of the uterus. (Half-size, St. George's, xiv, 9.) Some are in the walls of the uterus ; others between the peritoneal coat and outer surface ; one im- mediately beneath the mucous membrane projecting into the cavity of the uterus. productive of separation, we must always bear in mind the constant and reciprocal pressure exercised upon each other by the walls and con- tents of the abdominal cavity." The frequent occurrence of tumors, which, in many ])athological and clinical points are very distinct from the ordinary fibroids, has not been sufficiently recognized. Yet, nothing is more important than this recognition. They cannot always be treated like fibroids ; and what is more important, they cannot always be distinguished before operating. These tumors are not so often multiple as the hard fibroid ; they almost invariably affect the body of the uterus ; they attain a large size ; they are softer, looser, more like muscle, have often interspaces filled with serum ; they are more disposed to become " fibro-cystic." They are not so often encapsuled. They are much less disposed to calcareous degeneration. They are more liable to become oedematous. They are more vascular, and, therefore, more prone, under surgical interference or other violence, to become inflamed, to undergo necrosis, to give ori- 650 FIBRO-CYSTIC TUMOR. gin to septicaemia and peritonitis. They are less prone to become polypoid, or to be eliminated. They frequently give rise to profuse metrorrhagia. Fig. 145, from a specimen in St. Thomas's Museum, seems to be an example of this kind. It represents a " uterus with a large tumor developed in its anterior wall. The cavity of the uterus is much enlarged, being almost equal to the long diameter of the tumor, nearly seven inches. The posterior wall is | in. thick. The subject, set. 45, had long been subject to profuse uterine hemorrhage." Red, fleshy, loose-textured, they contrast remarkably with the white dense, "subcartilaginous" appearance of the common hard "fibroid." The distinction was recognized by Cruveilhier (see p. 641) and is in- sisted upon by Rigby. The form of uterine tumor which, next to the common fibroid, has attracted the most attention is, the Jibro-cystic. This is the form which Fig. 145. Fibroid or muscular tumor of uterus, causing great enlargement of the uterus and uterine cavity. (Three-eightlis nat. size, St. Tliomas'.s, 0. G-, 29.) has so often been mistaken for ovarian tumor, even inducing the sur- geon to jjerform gastrotomy. (See page 312.) They seem to be gen- erally more fleshy, of looser texture than the common fibroid, more continuous with the ])roper uterine tissue, more vascular, and often grow to a very large size. Cysts sometimes form in the substance of EECURRENT FIBROID. 651 fibroids through a localized inflammatory process, so that pus or serum collecting forms a cavity ; or an effusion of blood into the substance may in like manner form a cavity. But in some examples, there are many spaces or cysts of various sizes, whose origin cannot be accounted for in these ways. " The formation of cysts," says Paget, " is not rare in fibrous tumors, especially in such as are more than usually loose- textured. It may be due to a local softening and liquefaction of part of the tumor, with eifusion of fluid in the affected part, or to an accu- mulation of fluid in the interspaces of the intersecting bands; and these are the probable modes of formation of the roughly bounded cavities that may be found in uterine tumors. But in other cases, and especi- ally in those in which the cysts are of a smaller size, and have smooth and polished internal surfaces, it is more probable that their produc- tion depends on a process of cyst-formation corresponding with that traced in the cystic disease of the breast and other organs." There is a form of tumor, distinguished by the name of "i-ecurrent fibroid," which affects the uterus. It presents, especially in this char- acter of recurrence, affinities with malignant disease. Probably some of the cases reported were of the nature of " sarcoma." The following history illustrates some of the features of this growth: Mr. Hutchinson presented to the Path. Soc. (Trans., vol. viii) a uterus, the seat of recurrent fibroid. A single woman, aged thirty- nine, had repeated floodings. The uterus M-as enlarged, os and cervix normal. The uterus enlarged rapidly ; later a lobulated polypoid mass occupied the vagina connected with an intra-uterine growth. The discharge was very offensive; the patient's aspect resembled that of malignant disease. A portion of the mass was removed by the hand. The patient's state was very critical for a fortnight afterwards, masses of slough coming away. Then she recovered, and the uterus scarcely exceeded its normal size. But after some months of apparent good health flooding recurred, and the uterus was again found very large. Another attempt at enucleation was made by the hand. Again she recovered, the uterus returning to its ordinary size. Two or three months later, the floodings returned, and a large growth was found in the uterus. It was removed by ligature, but she died in a fortnigiit. Every organ in the body was found healthy except the uterus and vagina. The uterus on section was found to contain a white soft groM'th attached by a very broad basis to the whole of the fundus and posterior surface. The mucous lining of the cervix was healthy. The tumor grew far too rapidly for a fibrous tumor, was too soft, and too lobulated. Fibrous tumors, too, do not reproduce themselves. There were no other deposits in any organ of the body, although the disease had existed three years. Its history is like that of recurrent fibroids elsewhere. Bristowe, who reported on the tumor, confirms the opinion of Hutchinson. It did not present the characters of any of the forms of cancer usually met with; it was certainly not fibrous; there was no cancer-juice. The tumors were composed of the char- acteristic oat-shaped cells freely mingled with others of a flattened fibroid form, each containing a single nucleus, having within it several clearly defined nucleoli. 652 ERECTILE TUMOR. Mr. Callender describes (Pathol. Trans., vol. ix) a case of recurrent fibroid tumor of the uterus, with growths of a similar character in the pericardium, the lungs, and in the body of the sixth cervical vertebra. Partly by rej^eated operations, partly by sloughing of portions of the growth, considerable fragments were from time to time removed. The fragments removed presented the ordinary characters of recurrent fibroid tumor. Profuse hemorrhages occurred, portions of the tumor Erectile tumor of the uterus (malignant ?). (Half-size. Carswell.) being discharged. This was her history for several years. The uterus at last increased greatly in size, being felt above the umbilicus, and a lobulated soft growth occupied the vagina, and was continuous with that which filled the interior of the womb. She died exhausted. The impression was that the operations did not retard the growth, the re- productive power was so great. The uterus contained a tumor con- tinuous wath one in the iliac fossa. Passing up from the pelvis, the lumbar glands were found infiltrated with the fibroid material. Carswell figures ("Pathol. Anatomy") an erectile tumor of the uterus. Fig. 146 "represents an erectile tumor of the uterus which gives rise to frequent and extensive hemorrhage, a. Vagina; h. Cavity of uterus greatly enlarged ; c. A fibrous tumor lodged in the substance of the uterus, and projecting inwards, covered by the mucous membrane d; e. The erectile tumor rising above the surface of the uterus, covered by a smooth, glossy membrane, and traversed by a multitude of ves- sels, from which the hemorrhage proceeded." In the same work Carswell figures a specimen of atrophy of the uterus and ovaries from ossification of the arteries. Projecting in the FIBROID TUMORS. 653 cavity of the uterus is "a tumor composed of dilated veins and cellulo- fibrous tissue." The Development and Decay of Fibroid Tumors. 1. During the Period of Groicth. — A fibroid tumor being like in con- stitution to the uterine muscular wall, growing in it and depending upon it for its existence and nutrition, may be expected to follow closely the conditions of its parent organ. Accordingly, it grows during preg- nancy, and undergoes retrogression or involution when pregnancy is over ; and sometimes involution being thus started passes into atrophy, and the tumor disappears altogether, as in cases narrated by Dr. Sedg- wdck,^ Scanzoni, and others. Thus pregnancy may, in very exceptional cases, it is true, cure fibroid tumors. This process of complete absorp- tion or atrophy has been questioned. It has been objected that the tumor was simply cast off unobserved. But since the uterus itself may vanish through atrophy, so, a fortiori, may a fibroid tumor. They may soften and become fluctuating, oedematous. Cavities or cysts may form in them containing pus, blood, or serum. When these cysts are large, and the tumor rises into the abdomen, the tumor is called fibro-cystic, and may simulate ovarian disease. I incline, how- ever, to think that it is not so often the pure fibroid which is liable to this state, but the more fleshy tumor, wdiose texture is looser and more continuous with the proper structure of the uterus. The fibroid may undergo inflammation, suppuration, and gangrene. It has been supposed that fibroid polypi are liable to become con- verted into scirrhus or cancer. It can hardly be admitted that the abnormal muscular growth of which they are composed is more liable to such a change than is the normal muscular structure of the womb. A muscular fibre cannot be changed into cancer. It may, however, give place to it. It is quite possible that the cancer element may be developed in the substance of a uterine tumor, as it may be in the proper substance of the uterus ; and that the activity of the new growth may cause the atrophy of the old, and the gradual substitution, not conversion, of a cancerous tumor for a benignant polypus. Or the normal structure of the uterus or vagina being first the seat of cancer, the disease may spread and invade the fibrous tumor. Of this I have seen examples. In one case I removed a large fibroid or muscular tumor which showed no trace of malignant disease. The patient got apparently well ; but two years later it was found that malignant disease had been developed in the uterus. Tli€ following history by Drs. Benporath and Liebman illustrates this question : A woman, aged forty-eight, had suffered from metrorrhagia, had had in early life several abortions, and in the latter years had never con- ceived. A tumor became manifest in the abdomen. After death a careful examination was made. There was a fibroid near the right Fallopian tube; another almost encircling the uterine cavity lower 1 St. Thomas's Hospital Reports. 654 FIBROID TUMOES. down ; carcinoma of the upper part of the vagina. It resulted that the lower segment of the uterus was invaded by the progress of the vaginal cancer, and with it the fibroid tumors contained in its walls. The lower parts of the tumor were most affected; tiie upper parts, those most remote from the original seat of the cancer, were free. The case may be summed up as follows : Uterine fibroids possess no immunity from cancerous degeneration; but they are scarcely more prone to it than the proper uterine tissue. 2. During the Period of Retrogression. — When the normal ovarian stimulus to uterine growth ceases at the climacteric, there is a tendency in fibroid tumors to undergo the like retrogression or senile involution or atrophy which seizes upon the uterus. They sometimes diminish in bulk. They generally tend to become inert, oifending only by their bulk and mechanical interference with surrouudinw; organs. But not seldom, uterine fibroid growing prolongs the period of uterine growth. Hence hemorrhages continue recurring with more or less periodicity until the age of fifty, or even beyond. Lancereaux (Atlas d'Anat. Pathol., 1871) says the fatty transforma- tion of fibroids is the most common. In muscular tumors and polypi of long standing, the vessels often become very scanty, or disappear. Their entire structure sometimes undergoes an earthy or bony degeneration. In this condition, the hemor- rhages which had attended the earlier stages of their growth often cease. They seem to be removed by this change from the sphere of organic activity, and excite little or no irritation in the organs with which they are connected. I examined the body of a lady who had died suddenly from heart- disease, at the age of about sixty. Thirty years previously she had suffered from repeated uterine hemorrhages, when she was thought by her physicians in Holland to be laboring under scirrhus uteri. I found one of the ovaries converted into bone ; the other partly into cartilage and partly bone. In the place of the uterus was an immense firm, fibrous tumor, partly converted into an osseous substance. This tumor had undoubtedly been the cause of the floodings she had expe- rienced in early life. This stony or bony conversion is not very uncommon. It especially affects the hard fibroid tumors. There are some excellent examples in the Museum of St. Thomas's Hospital, and in most of the other hospital museums of London. Fig. 147 is from a specimen in St. Thomas's. Baillie describes " a bony mass in the cavity of the uterus," and sus- pects it is the result of the conversion of a hard tubercle (fibroid). The process of calcification may be manifested in two forms : one is peripheral incrustation, by which the tumor acquires a shell of cal- careous matter ; the other is, calcareous infiltration, the substance of the tumor being pervaded with the earthy material. This is found to be phosphate of lime and carbonate of lime. In Bartholomew's Museum is a specimen (No. 32.50) which affords clinical illustration of one feature in the history of calcification, " It is a large lobed fibrous tumor, spontaneously expelled from the uterus. The texture is softened and soaked with fluid, as if through partial de- EFFECTS. 655 composition. On its surface are numerous thin plates of bone-like substance, which seem to have been nearly separate while it decom- posed. The plates are simply calcification of the librous tissue. Pa- tient, aged forty -six, had observed the tumor for twenty years ; during that time had borne many children. For many weeks prior to dis- FlCr. 147. /; Ossified or cretificd fibroid tumor of uterus. (Half-size, St. Thomas's, G. G. 40'.) charge of tumor, which was expelled with pains like those of labor, flakes of bones passed away. Her recovery was comjilete." (Cata- logue.) This source of bone mu.st be borne in mind. By examination, the masses discharged may be distinguished from the foetal bones of extra- uterine gestations. Effects of Fibroids upon the Uterus, surrounding Organs, and the System generally. — Let us first examine the connection of fibroid tumors with the uterus. The hard fibroids commonly have no continuity of tissue with the uterine substance. They are surrounded by a layer of loose connective tissue, and then by developed muscular tissue of the uterus disposed in a stratified manner. The tumor is therefore encaj)- suled. It is upon this disposition that the process of enucleation, spontaneous or surgical, depends. In some cases, however, it is pre- sumed as the consequence of inflammation, the tumor contracts adhe- 656 FIBROID TUMORS. sions with the uterine wall. This may occur whilst the tumor is still intramural, attachments forming with the muscular wall in which it is imbedded. But when the tumor has become polypoid, and projects into the uterine cavity, adhesions become more frequent. Thus a tu- mor may be more or less completely adherent to the mucous membrane of the uterus or vagina. There is a fine example of vaginal adhesion in St. George's Museum (xiv, 43). The uterine adhesion is not un- common ; it may usually be broken down by the finger. An important point in the constitution of fibroid tumors of the uterus is their vascularity. Cruveilheir observed that " it is in these bodies that the vascular system of fibrous bodies in general can best be studied. A considerable vascular network envelops them ; this is entirely venous ; it communicates largely with the veins of the uterus, which have acquired a calibre proportioned to that of the volume of the fibrous bodies, and to the development of the uterus. On the other hand this venous network receives all the veins which arise in the substance of these bodies. No uterine artery has appeared to me to penetrate the fibrous bodies, whose circulation is reduced to its most sim- ple expression ; no lymphatic vessel has been demonstrated ; no uterine nerve has been traced into them. Hence the absolute insensibility of these bodies." When a tumor is submucous or polypoid, its mucous investment ex- hibits evidence of greater vascularity than is proper to the healthy membrane. When a ligature is put on such a tumor, the vessels being strangled become gorged, dark-red, and easily bleed. When seized by vulselkira, ecchymosis is produced from the rupture of small vessels ; but this appearance is chiefly seen in the capsule of the tumor ; deeper in the substance the tissue even under section shows little sign of bloodvessels being divided. There is, however, an injected specimen in St. George's Museum (xiv, 65) whicli shows the injection throughout the substance. It appears to be a true fibroid. In Bartholomew's is a specimen (32.12) showing "several tumors in the uterine wall. The vessels of the uterus have been injected, and the injection has entered the tumors." Examination of this specimen will, however, show that this is true chiefly of one large tumor near the inner surface of the uterus, and of looser texture ; and that this tumor is less vascular than the uterine wall itself, whilst two smaller tumors, subperitoneal, are scarcely injected at all. In another specimen in the same museum (32.6), " a section of a uterus, with a firm fibrous tumor imbedded in the middle of its anterior wall, the vessels are minutely injected ; but none of the injection appears in the morbid growth." This re- mains white, in remarkable contrast with the vascular uterus. This comparative absence of vessels, and the consequent low vitality, accounts for the impunity with which these tumors can be cut or lacer- ated during surgical operations. The venous character of the blood- vessels on their surface explains the free hemorrhages occurring whilst they retain their relations, and the speedy cessation of the bleeding when the tumors are removed. Connected with the vascularity is the source of the hemorrha,ge which is so common a consequence of fibroid tumors and polypi. It has EFFECTS. 657 been contended that the blood flows principally, if not exclusively, from the surface of the polypus. Lisfrauc especially strenuously ad- vocated this view. It has been urged in support, that the hemorrhage is observed to be immediately arrested upon the removal of the tumor, and even in many cases upon the application of a ligature. It has been pointed out that the pedicles of large polypi frequently carry bloodvessels of considerable size, that the investing membrane is highly vascular, and that it has been seen to pour out blood upon being injured. On the other hand it has been urged that the real source of the blood is the mucous surface of the uterus. Whilst the particular facts urged in support of the view that the surface of the polypus pours out the blood, admit of a complete solution by the theory that it is poured out by the uterus, there are also special reasons which support this latter opinion. It is observed that profuse hemor- rhage attends very small polypi as well as those of large size ; and it is difficult to imagine how the extensive and rapid losses of blood which often occur can escape from the surface of a tumor in many in- stances not larger than a small nut. Again, the hemorrhage mostly assumes the form of profuse menstruation; and it will not be con- tended that the ordinary menstrual flow comes from any other source than the uterus. Metrorrhagia may arise from any cause which sets up a preternatural action. The presence of a polypus is a cause of in- creased afflux of blood. It is difficult then to avoid the conclusion that the excess of the ordinary menstrual discharge occurring when a polypus is present flows like the normal proportion from the womb. When the tumor or polypus is very, large, almost the entire mucous membrane of the uterus may be protruded before it ; that is, there is no mucous membrane but that investing the tumor. Why the hemor- rhage ceases when the tumor is removed, is exactly why it ceases after the expulsion of the ovum in abortion. The developmental attraction of blood is at an end. It has been observed that in some cases the menstrual flow is actually lessened. Fibroids almost invariably cause enlargement, more or less deformity, and displacement of the uterus. They may produce every variety of flexion, and even inversion. By attracting an undue supply of blood, they often induce congestion ; sometimes chronic endometritis ; these conditions give rise to hypertrophy of the uterus generally, and to glandular irritation and outgrowths in the cervix. The disposition to neoplasraata or outgrowths where fibroid tumors exist, is very great. Thus we frequently find not only multiple tumors in the body of the uterus, but tumors of various kinds in the cervix as well. And it is not uncommon to find complications in the form of cystic disease of the ovaries, and dilatation with obstruction of the Fallopian tubes. In St. Bartholomew's Museum is a specimen (No. 32.52)of a uterus, in the side wail of which is imbedded a large fibrous tumor. The tumor has bent the uterus laterally, and so encroached upon its cavity, that the cervical portion was shut off from that within its body. The 42 658 FIBROID TUMORS. cavity of the uterus is greatly dilated ; its walls are thinned ; its mucous membrane was intensely vascular, and it was filled with pus. Another specimen in the same museum (No. 32.13) shows retrograde dilatation of the uterus above the seat of constriction. It exhibits the obliteration of that portion of its cavity which is within the cervix. The rest of its cavity is dilated. The extremities of the Fallopian tubes are adherent to the ovaries. But in a considerable proportion of cases the cervical portion remains free from other than mechanical distortion. A small fibroid in the anterior wall may cause anteflexion, one in the posterior wall retro- flexion. A larger tumor in the anterior wall may, however, push the fundus over backwards, producing retroflexion, and vice versa. If growing in the sides of the uterus, or indeed elsewhere, if they develop unequally they destroy the symmetry of the organ, may distort it in any conceivable manner, so that there is nothing in nature more fan- tastic than the shapes which a uterus invaded by fibroid tumors may assume. The cervix itself, although generally free from tumor, may be twisted and distorted in the most extraordinary manner. It is often flattened out on the deformed body of the uterus ; the course of its canal is made tortuous, and its calibre compressed or obliterated. The os uteri may be small or large. Sometimes it is very difficult or impos- sible to pass a sound along it, so devious and narrow is the canal. The uterus impeded in its functions gives rise to the following symptoms : dysmenorrhoea, dyspareunia, and sterility. These are especially apt to occur when the body of the uterus is bent upon the cervix at a right or even an acute angle, constricting the os internum. In the event of pregnancy occurring, abortion is a very probable issue. Such cases are apt to lead to profuse flooding. The uterine wall is unable to contract uniformly. The course to adopt is — 1, to remove the ovum completely by preliminary dilatation of the cervix, if neces- sary ; 2, by swabbing the interior of the uterus with persulphate of iron. Fibroids may cause dragging and atrophy. Thus Bristowe and Hutchinson (Path. Trans., vol. viii) report on a case of absence of the cavity of the uterus and extreme atrophy. Two tumors existed, and had become pedunculated, and it is evident that between them the uterus had been pulled out and attenuated. It is probable too that in this case, as in others, the tumors were at first surrounded by the substance of the uterus, and that as they became detached, they carried with them as a capsule a considerable portion of the uterine tissue, which has since wholly disappeared, and between these two processes, co-operating in the same direction, there can be no difficulty in understanding how the body of the womb should have been reduced to the remarkable condi- tion in which it was found. Fibroids may even cause axial twisting of the uterus, as in a case related by Dr. E. Kiister.^ "An unmarried woman, aged thirty-four, who had suffered from dysmenorrhoea, died of diarrhoea. The body of the uterus was as large as a man's head and presented several projections on its surface. Through the enlargement of the body of the uterus, the neck was enormously drawn out and 1 Beitrage zur Geburtskunde uiid Gynakologie, 1870. EFFECTS. 659 twisted. It had undergone two and a half turns, so that the right ovary was turned to the left and forwards, and the anterior surface of the uterus was turned backwards. The cervical canal was almost closed; its walls were very thin, its length was ten centimetres. The cavity of the uterus was filled with blood." A submucous tumor even if not quite polypoid, may by pressure upon the opposite uterine Avail cause ulceration, perforation, and even rupture. Larcher relates the following case (Arch. Gen. de Med., 1867) : "A woman was admitted into the Hotel-Dieu with pain in the abdomen. After four days profuse bleeding set in. She refused examination. Two days later meteorism and peritonitis appeared, and she died. Sec- tion revealed diffuse peritonitis and adhesion of all the organs of the small pelvis. A polypus was found in the uterus, seated in the anterior wall near the isthmus. The posterior surface of the cervix was ulcer- ated, and at one point torn through, communicating with the cavity of the abdomen." I have recorded a case (Obstetrical Transactions) in which a small tumor in the anterior wall of the uterus led to perforation into the bladder, owing to the pressure caused by the passage of the head in labor. The effects upon the surrounding organs are those oi pressure and con- sequent interference with their functions. If the uterus enlarged by tumors be retained in the pelvic cavity, and grow to the extent of com- pressing the surrounding parts against the unyielding walls of the pel- vis, the results will be similar to those caused by retroversion of the gravid womb or a retro-uterine heematocele. But they come on more gradually. The uterus in its growth causes eccentric pressure. The bladder, at first irritated, is frequently excited to void itself, then, per- haps, retention of urine follows. The rectum may exhibit signs of tenesmus, and constipation is very common. Pain and reflex irritation set up expulsive efforts in the uterus and abdominal muscles. Complete obstruction may even be caused, and simulate most of the conditions of strangulated hernia. Dr. Peter Eade, of Norwich, com- menting (Lancet, 1872) upon three cases of the kind, suggests that such cases might be relieved by Amussat's operation, and asks whether ex- ploratory gastrotomy, with a view to the removal of the tumor, be worthy of serious consideration in the case of intestinal obstruction? If the obstruction be connected with movable subperitoneal tumors, as in one of Dr. Eade's cases, this proceeding would offer considerable hope of benefit. But where, as is most frequently the case, the ob- structing tumors form part of the uterus, little good can be expected from gastrotomy, unless the uterus itself be removed. But regarding intestinal obstruction or strangulation from an enlarged surgical point of view, it may fairly be stated as a general proposition, that if no external hernia be found as the presumed seat of obstruction, search should be made for it by gastrotomy. Cases of internal strangulated hernia have been reported which justify this operation; and we may find constriction by fibrinous adhesions, which may be divided, or twisting of the bowel, which may be released, or, as is not uncommon in children, invagination. 660 FIBROID TUMORS. Pressure upon the sacral plexus may cause excruciating pain in the form of sciatica. This I have seen several times. Dr. G. H. Kidd relates an interesting example (Dublin Med. Journ., 1872). The pain was relieved by wearing an air-pessary to lift up the tumor. The tumor ultimately completely disappeared. Dr. Kidd calls attention to the important clinical fact that these pressure eifects are more or less intermittent. He explains this by remarking that the pressure is often increased at the menstrual epochs. He noticed in one case that sciatica was always increased at these times. He further observes that great increase of pressure arises from flatulent distension of the bowels. He has known pressure from above so caused to drive a tumor more firmly into the pelvis. Large tumors growing in the abdominal cavity may produce mechani- cal effects similar to those resulting from large ovarian tumors. They may, although this seems rare, cause peritonitis and ascites, and ad- hesions resulting may lead to strangulation of the intestines. They may be the cause of laceration of the intestines by dragging, as under the influence of sudden shock or fall. And by mere bulk, they may so impede the action of the heart and lungs, as to bring about gradual asphyxia and exhaustion. Retrograde disorder of the alimentary canal ensues from the rectal obstruction. Flatulence, various dyspeptic phenomena, blood-contami- nation from absorption of the products of decomposition of retained fecal matter — a condition for which I have proposed the term "coprse- mia" — ensues. A time arrives when, if the tumor is not dislodged from the pelvis, the pressure becomes so great that the distress arising from pain and impeded function becomes intolerable; and the obstruction to the local circulation may be so complete, that gangrene of the vagina is caused. The bladder becomes congested, inflamed, the ureters and kidneys dis- tended, and death may ensue from urinsemia. We may sum up the dangers ensuing upon the presence of fibroid tumors in the uterus as follows, premising that in a large, but unknown proportion of cases, no ill consequence occurs : 1. Hemorrhage. This may be fatal. The hemorrhage is mostly recurrent, and, as in other cases of repeated hemorrhage, the system accommodates itself more or less to the losses, acquiring the power of rapidly regenerating blood. More often the hemorrhages prove injurious by degrading nutrition generally, by inducing 2, Exhaustion, under which the patient is liable to sink gradually or more quickly under the immediate effect of some secondary disease, to which the exhausted system is especially prone. 3. A not unfrequent cause of death is Peritonitis. McClintock says, "from his own experience, the most fruitful source of danger is peri- toneal, or pelvic inflammation." The fotal attack may be induced by the giving way of the serous membrane over a fibrous tumor, which has undergone the process of softening ; or there may be escape of foul matter from the tumor into the peritoneum. Another mode in which not only peritonitis may occur, but 4, Metritis and lyycemia, is from partial decomposition of the tumor. 5. Pressure impeding the func- SYMPTOMS AND DIAGNOSIS. 661 tions of the bladder, kidneys, intestines, stomach, lungs, or heart, or causing mechanical lesions of these organs. Symptoms and Diagnosis. — The symptoms are the expression of those features the history of which has been already discussed. They may be briefly summed up as follows: 1. Those which take their rise in the uterus itself. 2. Those which are the result of interference of the affected uterus on neighboring organs. 3. The remote or constitutional symptoms. 4. The physical or objective signs. The signs of the first three kinds are many of them common to other affections of the uterus or of neighboring structures. They can hardly obtain the importance of being diagnostic. Thus, pain and hemorrhage referred to the ute- rus, attend many other conditions. The pain is generally of spasmodic character ; it is more common when the tumor projects into the uterine cavity, or towards its external surface ; it is in these cases the evidence of contraction tending to cast out the tumor from its walls. It is not constant. Scanzoni observes that the spasmodic pain is greater in the case of intramural tumors than of polypi. Tiie hemorrhage varies greatly. Cruveilhier had noticed that it was less common when the tumor was subperitoneal. It is most common when it is submucous, and is rarely absent when it is polypoid. It usually observes some degree of periodicity, that is, it takes the form of menorrhagia. But, in not a few cases, hemorrhage breaks out in the intermenstrual intervals ; and in some of long standing, it becomes constant or nearly so, alternating at times with a sanious serous oozing likened to the green waters which follow labor. Irritation or obstruction of the bowel or bladder, dorsal and sacral pain, dysmenorrhoea and dyspareunia, with or without hemorrhage, are common to retro-uterine hsematocele, and retroversion of the uterus. The remote signs, those referred to the nervous system, and those resulting from blood-impairment and disordered nutrition, are equally observed in various other pelvic disorders. AVe are then compelled to resort to physical exploration in order to trace these symptoms to their actual cause. As we have already seen in Chapter VI, pain and hemorrhage must be regarded as " conditions indicating the necessity for examination." When examination is made by touch we become conscious that the uterus is altered in size, shape, position, and consistence. We then, by applying the various means at our disposal, try to assign these altera- tions to their true cause. Of the cases which most frequently lead to error some are external to the uterus ; they deceive by concealing the uterus from observation. The moment we can detect the uterus and can determine its outline, we are at once in a position to exclude tumors in its substance. Such are retro-uterine hsematocele, perimet- ric inflammatory effusions, ovarian tumors, accumulations in the rectum. In some cases the source of error lies in conditions of the uterus it- self. Such are retroflexion, anteflexion, and other deviations from the natural shape ; enlargement from hyperplasia, of the uterus ; preg- nancy ; malignant disease of the uterus. The diagnosis of fibroid tumors flows in great measure from the con- 662 FIBROID TUMORS. sideration of their natural history, and of the effects they produce upon neighboring organs. It is, however, especially necessary to call atten- tion to the signs brought out by physical exploration. The uterus is almost necessarily increased in bulk. This may be determined by vag- inal touch. Poising the uterus on the tip of the finger we feel the in- creased weight. By combining abdominal palpation, we determine ac- curately the extent of the enlargement, measuring the organ between the two hands. We may often distinguish enlargement due to fibroid tumor from the enlargement due to hypertrophy or subinvolution, by observina; the form of the uterus. In the latter cases the enlarg^ement is uniform, the organ remains smooth on the outside, whilst tumors distort the contour, causing irregular bumps or protuberances; and these protuberances are often harder than the proper uterine structure. Whilst the tumors are small, the mobility is not much affected. But when they become large, the mobility may be much impaired or com- pletely lost. This is especially the case when the enlarged uterus is locked in the pelvis. This immobilization is distinguished from that produced by cancer by the os and cervix uteri being felt free from disease, by the absence of the other characteristic signs of cancer, and by the presence of the irregular nodosities on the fundus or body of the uterus, felt above the pubes. It is distinguished from the immo- bilization due to perimetric inflammation by the history of this latter affection ; by the seat of the inflammatory deposits outside the uterus as ascertained especially by rectal touch. Fibroid tumor of the posterior wall of the uterus producing retro- flexion, or bulging of the posterior wall, is very likely to be mistaken for retro-uterine hsematocele, or for simple retroflexion of the uterus. In all these cases a firm rounded mass is felt behind the cervix uteri apparently continuous with it. Combined rectal and abdominal pal- pation will help in the differentiation. But the sound gives the clearest evidence. If the sound penetrate in the normal axis of the uterus, the hand pressed in behind the symphysis will feel the body of the uterus impaled on the sound, and will make it clear that the mass felt behind the cervix is something else. Retroflexion is also determined by the sound being directed backwards; and simple retroflexion is made evident by our being able to lift up the fundus of the uterus, thus re- moving the apparent tumor. This can rarely be done if the apparent tumor be really a fibroid. If, when the sound is in the uterus, the contour of the body be explored by the finger or hand in the rectum, the presence of tumors may be made out with considerable probability by the irregular knobbed projections they produce. Anteversion of the uterus may be distinguished by similar tests. When tumors are of large size, especially if fluctuation can be made out in any part, the risk of confounding them with ovarian tumors is great. This point has been discussed when studying the diagnosis of ovarian tumors. One of the most characteristic marks of distinction is brought out by the sound. By the use of tins instrument and by the finder, we mav generally in the case of ovarian tumors determine that the uterus is of normal size, and move it about separately from the tumor : and vice versd, moving the tumor about by the hand applied DIAGNOSIS. 663 to it ou the abdomen, we find that no movement is imparted to the uterus. But great caution is necessary in trusting to these mana?uvres. If the sound penetrate much beyond the normal length, the probability that the elongation of the uterine cavity is due to fibroid tumors is very great. The best sound to use in these cases is the whalebone probe, Fig. 36, p. 124. This will follow the sinuosities of the uterine cavities Mdthout danger of injuring the uterine wall. The diagnosis of retro-uterine hematocele, perimetric inflammation, and ovarian tumors has been carefully discussed in the chapter treating of these subjects. The chief means of distinction consist of careful pal- pation, aided by the sound, so as to define the size and position of the uterus, and to isolate it from the extra-uterine tumefaction. In uterine fibroid the uterus, unless jammed in the pelvis, generally retains some degree of mobility ; and when immovable from locking in the pelvis, the cervix is generally distorted, and the history is distinctive. In perimetric deposit there is a history of inflammation dating back to labor, abortion, or other tolerably defined event ; whereas in fibroid the history is less defined, more often associated with menorrhagia, and of longer standing. I have known a fibrous tumor in the bladder simulating fibroid in the anterior wall of the uterus or anteflexion. The sound in utero and the catheter made the case clear. McClintock jjoints out that, to distinguish an ovarian tumor from uterine tumor, the ulnar edge of the hand should be pressed down above the pubes. If the tumor be ovarian, the edge of the hand can be passed down deeply between the tumor and the pubes. But where the tumor is uterine the hand is resisted, and cannot be sunk to any- thing like the same extent. Palpation and the sound can also almost always be relied upon to distinguish flexions of the uterus. The removal of the tumor by re- storing the uterus to its normal position by the sound is distinctive of flexions. The condition most likely to be overlooked is that where flexion is complicated with a tumor. In this there is generally more or less marked irregularity in the shape of the body of the uterus. Bumps or projections may be felt on its peritoneal surface or projecting into its cavity ; and the size will often be greater than is usual in flexion or simple hyperplasia. If, in addition, the cervix be twisted, flattened, or otherwise distorted, the probability of the existence of fibroid tumors is greatly enhanced. The hardness of the common fibroid is peculiar : it is usually greater than that of anything with which it is liable to be confounded, excepting perimetric inflammation ; and this may be dis- criminated by history. It is distinguished from cancer by the seat, which in cancer is most frequently in the cervix. The diagnosis from pregnancy is a most important point to make out. Women, the subjects of tumor, may think themselves, or be thought by others to be pregnant. In pregnancy, the enlargement of the uterus is uniform, thus being in contrast with the often irregular contour and hardness of the uterine fibroid. The speculum is not of much value in giving characteristic signs of fibroid ; but it is of great value in giving presumptive evidence of pregnancy ; and thus in lead- 664 FIBEOID TUMOES, ing us to prosecute diagnosis in this direction. A violet coloration of the vagina and os uteri should at once impel to follow out all the other modes of investigating this question. The detection of the violet color- ation by rousing suspicion of pregnancy will save us from resorting to the sound. For this reason I think it is a good general rule in prac- tice to pursue examination in the following order : 1, by vaginal touch ; 2, by speculum ; 3, by sound. In many cases we shall stop at the first method, or at the second. In doubtful cases, examination by rectum should never be omitted. By this route the finger can generally distinguish perimetric effusions by feeling their attachment to the walls of the pelvis, and by defining more accurately the outline of the uterus. By the sound we can often make out the exact position of a tumor. Thus it may penetrate beyond the normal uterine length behind or in front of the tumor, which may then be felt between the finger or hand by vagina, abdomen, or rectum, and the sound in the uterine cavity. We thus learn in what part of the uterine wall the tumor is situated. It is chiefly when we have to deal with tumors of considerable size, too big to be retained in the pelvis, that we have to make the diag- nosis from ovarian tumor and pregnancy. The difficulty is often in- creased by the fact that these large tumors cause so uniform an enlarge- ment of the uterus, that the shape closely resembles that of the preg- nant uterus. Having excluded pregnancy, which we ought always to be able to do, by carefully collating all the historical data and the physical signs, positive and negative, and especially by the aid of time, which seldom fails to resolve doubts upon this point, we may resort to the sound. By help of this we may generally exclude ovarian tumors. If the sound have to pursue a devious course through the cervix, or if it run to a distance much beyond the normal length along the direction of the tumor, we shall rarely be wrong in concluding that the case is uterine tumor. Or, if the mass is solid, the probability that it is uterine is very great. It must, however, be remembered that in some cases of great enlargement of the uterus by fibroids, the sound will not travel beyond two or three inches. There is one character occasionally present in fibroid tumors espe- cially to be borne in mind when the question lies between these tumors and pregnancy. In a considerable, proportion of cases a sound resem- bling the placental sound is heard. " Sometimes," says McClintock, " it is short and abrupt, a mere whiff accompanying each arterial pul- sation. At other times it is jirolonged and musical, and not to be dis- tinguished by the most acute and practiced ear from the bruit placen- taire" We should not, then, declare that the case is one of pregnancy on the single evidence of this sign. Nor is it likely, if pregnancy exist, that we shall be reduced to this necessity. Almost invariably some other confirmatory sign will be present. The cases of real diffi- culty are those where both pregnancy and tumor exist together. The chief character in this complication is the want of uniformity in the shape of the uterus. In some cases of doubtful diagnosis we may arrive at distinct evi- dence by dilating the cervix uteri, so as to facilitate exj)loratiou of the TEEATMENT. 665 internal surface of the uterus. Then by sound, or even by the finger, we may feel a tumor forming a projection into the cavity, or we may by finger in the cavity and combined abdominal palpation, take accurate note of the condition of the intervening uterine wall. This mode of ex- ploration is especially indicated when the subject is suffering from hemor- rhages. It thus becomes a means of treatment as well as of diagnosis. Acupuncture, or the aspirator-trocar may be usefully employed. Dr. Gueniot has discussed this subject (Arch. Gen. de Med., 1868). He observes that it gives indication as to sensibility, resistance, hardness of tissue, and the greater vascular development. In a woman, aged fifty- six, a second tumor was discovered immediately after the removal of a uterine tumor, the place of which it assumed. The closest examina- tion left it doubtful whether this was a second fibrous polypus or a partial inversion. The sound penetrated a short distance all round the tumor. Puncture caused no pain. It was concluded to be a fibrous tumor, and was accordingly removed with a good result. Diagnosis may be difficult when the uterus, enlarged by fibroid tumor, is complicated with ascites. In this case a sensation of hallotte- ment is felt, differing from the intra-uterine ballottement of pregnancy in this, that it is more distinctly felt above the pubes through the abdomi- nal wall. Malignant tumors of the lumbar glands, peritoneum, and surface of the intestines may also simulate uterine tumors. In these cases we may derive diagnostic indications from the history and general symp- toms. It is rare for fibroids of the uterus to be attended by such marked constitutional symptoms as are commonly observed in malig- nant disease. Uterine tumors, like ovarian tumors, may be distinguished from tumors arising in the abdominal cavity by tracing them from the pelvis upwards. Tumors of abdominal origin may usually be traced from above downwards, leaving a line or space of demarcation at their lower margin, which marks them off from the pelvis. In determining the course of treatment, especially the direction of operative measures, it is important to form an opinion as to the part of the uterus an intra-uterine tumor grows from. This may often be done by observing a character pointed out by Dr. Kidd. He says the uterus bulges out most in the wall opposite to that to which the tumor is attached. So that feeling a decided prominence, say of the anterior wall, we may predicate with certainty that the attachment of the tumor is at the opposite part of the uterus. The Treatment of Tumors, especially Fibroids of the Uterus. — In dis- cussing this question, it is evidently desirable to keep in mind the properties and natural history of these tumors. The natural termina- tions furnish the most-useful indications. Knowing these terminations we may often assist in bringing them about. These terminations we have seen are : 1. Absorption or atrophy. 2. Calcareous degeneration. 3. Gangrene or other form of decomposition. 4. Spontaneous expul- sion or enucleation. 1. Can we aid or bring about the process of atrophy f This question involves the inquiry into the action of internal remedies and local sol- 66Q TUMORS OF THE UTERUS. vent applications. We have seen that tumors have occasionally van- ished under the influence of pregnancy and labor. In some of these instances the process of elimination was in all probability inflammation and breaking-down of the tumor; in others, detachment and expul- sion ; but in others, there seems no reason to doubt that it was true absorption, analogous to that process by which the excess of proper uterine tissue is removed after labor. Then, again, there is the slower atrophy of advancing age. Can we set up or accelerate similar atro- phic processes ? Before entering upon this question it is desirable to discuss a very important practical question which not infrequently cojr.es before the physician. What is the risk of marriage to a woman known to be the subject of uterine tumors ? I have discussed this question in my work on " Obstetric Operations," and can only give the general conclusions in this place. All authors agree in the opinion that pregnancy brings serious danger ;, and all agree in discouraging those who are the subjects of uterine tumors from marriage. This is certainly the wiser course. Apart from the dangers attending preg- nancy, the increased afflux of blood and consequent developmental force excited under the conditions of the married state give material imj)etus to the growth of these tumors. Metrorrhagia will probably be increased. And, although fibroid tumors act in many cases as an obstacle to impregnation, still pregnancy often occurs notwithstanding. If pregnancy and labor are occasionally observed to be followed by the atrophy or expulsion of the tumors ; and if, as is even more fre- quent, no accident occur to interrupt the smooth course of pregnancy, labor or childbed, the tumors remaining unafiected, the accidents in other cases are so serious that we shall rarely be justified in sanction- ing disregard of the established rule. In cases where we can clearly determine that the tumors are seated in the substance and projecting on the peritoneal surface of the fundus of the uterus, we may predicate that the risk is small. But where tumors are found in the lower seg- ment, and especially if projecting into the cavity of the uterus, the danger is so great that we are bound to prohibit marriage with all the authority we possess. Tumors in this situation are doubly dangerous; first, they are exposed to braising and tearing during the passage of the child ; secondly, they may descend before the child into the pelvic cavity, and obstruct labor. Medicines have been given with the four following designs : 1. To promote absorption or calcification. 2. To restrain growth. 3. To restrain bleeding. 4. To promote extrusion. Medicines designed to promote absorption and to restrain groicth may fitly be considered together ; and some agents which are chiefly given for their supposed efficacy in restraining hemorrhage probably act also by promoting extrusion. Simpson, Rigby, and others were very posi- tive as to the absorption of fibroids. Simpson says they are sometimes seen in fatty metamorphosis. Spencer Wells observes that no one could expect a true fibrous tumor to disappear spontaneously; but mus- cular tumors rapidly grow and rapidly disappear. He expresses him- self as astonished to find that doubts are entertained as to the fact of their disappearance. The cellular spaces between the fibres of these TREATMENT. 667 tumors may become filled with serum ; and that portion of the tumor thus due to oedema may undoubtedly disappear. In such cases Wells thinks the use of bichloride of mercury is often followed by remark- able diminution. Simpson praised the bromide of potassium. Where there is much irregular bleeding, Wells agrees with McClintock in regarding chloride of calcium as of great value. This remedy had been introduced by Rigby in 1846. He says he "found that, if com- menced in 5?s. doses of the solution twice a day, the patient could gradually increase it until she had reached 5j without inconvenience. After continuing at this dose for a month, she left it off for a few weeks, and again resumed it as before ; a decided change was observ- able in several cases." McClintock relates a case in which complete cure was effected by this remedy combined with perchloride of iron. Wells, however, has found that, if persisted in for a length of time, the chloride of calcium is apt to bring about calcareous degeneration of the arteries generally ; and this is so real a danger that the remedy must be used with great caution. Its action in arresting the growth of fibroids probably depends upon this property. The tumor perhaps has a greater affinity for the chloride of calcium than have other struc- tures ; and if the calcareous deposit could be limited to it, the remedy would be without a drawback. Rigby further possessed great faith in the Kreuznach water. Adopt- ing the suggestion of Dr. O. Prieger, he tried this water in a very con- centrated form, and believed he increased its efficacy by adding from two to five grains of bromide of potassium. "In many cases," Rigby says, "the results have been very successful; in some, where this arti- ficial mineral water formed the sole treatment; in others, where it was combined with the local application of leeches and mercurial ointment." The remedies applied in the hope of restraining growth are the same as those designed to promote absorption. It may be reasonably ex- pected that greater success would be attained in accomplishing this lesser result. Observations upon this point are, however, even more fallacious. If we can demonstrate a sensible diminution in the bulk of a tumor, and even follow the diminution on to complete disappear- ance, the only doubt as to the reality of absorption rests on the possi- bility of an original error of diagnosis. The supposed tumor might have been retro-uterine ha3matocele, an enlarged body of the uterus from hyperplasia, or some other condition. That some cases of cure by absorption reported before the characters of retro-uterine hsematocele were known were falsely interpreted is highly probable. But the reality of fibroid tumors having been absorbed is too well established to admit of doubt. It does not, however, follow that this absorption was due to the remedies employed. In some cases of absorption no treatment deserving consideration was adopted. And in the rest in which internal remedies were used, doubt as to their share in the result is not unjustifiable. My own experience lends little or no support to the proposition that internal remedies exert any influence in promoting absorption of the hard fibroid tumor. I suspect that the favorable opinions as to their efficacy, which some authors have expressed, spring from the observation of the larger, looser-textured tumors, and that the 668 TUMORS OF THE UTERUS. diminntion was due to the absorption of fluid infiltration, the solid con- stituent remaining untouched. West and S(!anzoui doubt whether the Kreuznach waters have cured a single case. Sustained elastic pressure, as by means of an abdominal belt, may be useful in promoting the absorption of infiltrated fluid. It is doubtful whether it exerts much influence in diminishing the solid constituents. It may, however, be useful in supporting the mass, and in preventing injurious dragging. The ergot of rye has also been used with this indication. It has been supposed that nutrition might be arrested by the constricting action of the ergot upon the vessels feeding the tumor ; and by the compression exerted upon the tumor by the contraction of the muscular wall. Hildebrandt (Berlin Klin.Wochenschr, 1872) treated nine cases by the subcutaneous injection of ergotin. "In four," he says, "the diminution of the tumor was free from doubt ; in the others trouble- some symptoms subsided." But more frequently ergot has been used with the object of promot- ing the expulsion of the tumor. The fallacies which weaken any conclusion as to the influence of remedies in arresting the growth of fibroid tumors are: 1. That these tumors are often of extremely slow growth, so that any change in size within even a considerable time would be difficult to appreciate, and still more to prove. 2. That many of these tumors, when they have reached a certain size, exhibit no tendency to increase, but remain sta- tionary, although no treatment is employed. 3. That in a large num- ber of instances there is a natural tendency towards inertness or even retrogression after the climacteric; and that since these tumors fre- quently do not come under treatment until this period is approaching, such treatment may be merely coincident with the natural process of cure, not conducive to it. And, lastly, the most persistent use of reme- dies in many cases has not been followed by any sensible alteration in the hands of many competent observers. The effects of mechanical pressure may sometimes be obviated by lift- ing the tumor out of the pelvis. The uterus with its parasitic growths may be movable en masse. Sometimes the hand in the vagina or rec- tum may liberate the pelvis. But more often, a method used with success by Dr. G. H. Kidd is better. The patient is placed in knee- elbow position, and one of my dilating-bags is placed in vagina or rec- tum, which, made to expand below the tumor, gradually raises it. This proceeding would also be effectual by relieving the bowel from obstruction, in removing the flatulent distension which sometimes drives the tumor down into the pelvis. Or, where flatulence is extreme, and the tumor cannot be moved or extirpated, relief may be given by punc- ture by a fine trocar into the intestine, as was done by Dr. Kidd. In a case he relates a great escape of gas took place. A candle brought near the gas took fire, burning with a blue flame. Next day the bowels acted freely. Treatment designed to restrain hemorrhage may fitly be considered in connection with that designed to promote absorption or to check TREATMENT. 669 growth of fibroid tumors. Treatment for this purpose consists of in- ternal remedies, of local applications, and of surgical operations. The principal internal remedies have been already described. To chloride of calcium and ergot may be added strychnine, quinine, digitalis, tur- pentine, Indian hemp, the lead and opium pill, alum and gallic acid — all agents of unquestionable efficacy as haemostatics. They now and then act satisfactorily, but much more often they fail. Small doses of mercury have in some cases been attended with success. Local styptics, on the other hand, may almost always be relied upon to stop hemorrhage for the time. Of these the best are, perchloride or persulphate of iron, chromic acid and nitric acid, or iodine. Their efficacy depends upon their being applied directly to the bleeding sur- face, that is, to the mucous membrane of the uterus, as well as to that immediately covering the tumor. To accomplish this, it is necessary in the first place to obtain free dilatation of the cervix uteri. This preliminary dilatation can be effected by means of laminaria or sponge- tents left in for several hours, or by incisions of the cervix. If the canal is tortuous, incisions will be necessary, at least in the first in- stance; and sometimes it will be desirable to resort to both incisions and tents. It is a remarkable fact that dilatation of the cervical canal alone is in many cases followed by arrest of hemorrhage. Baker Brown, N^laton, and McClintock have established this fact as to the effect of incisions in the cervix. I have in so many instances practiced this operation with advantage that I entertain no doubt of its value. It does not appear to be necessary that the tumors themselves should be cut into. Simple dilatation by laminaria-tents is often efficacious. The incisions should not be deep ; they should especially not be carried deeply into the neck at the level of the os internum. Incisions made in this way have appeared to me to exercise a beneficial effect in modi- fying the nutrition of fibroid tumors; a free os uteri externum will often, as we have seen, when studying the history of dysmenorrhoea and menorrhagia, relieve these symptoms. I have acquired the con- viction that these incisions have even arrested the growth and promoted the absorption of uterine fibroids. But supposing that dilatation, whether by knife or tents, is not fol- lowed by arrest of bleeding, the road being open, v/e now apply the styptic. This is best done by means of a swab. A probe mounted on a wooden handle, or the instrument made to carry nitrate of silver (see Fig. 42, p. 129) answers perfectly. Around the end a little cotton-wool is twisted ; this is steeped in the styptic fluid, and carried quite into the cavity of the uterus and pressed steadily against the inner surface. It is desirable to have three or four of these probes mounted with cotton- wool, using one or two of them first to wipe out the blood from the interior of the uterus before introducing the styp- tic. To facilitate this introduction, and to obviate the inconvenience of losing much of the action of the styptic in its passage along the cervix, we may resort to one of two expedients. Using a jSTeugebaiier's or a Cusco's speculum, both of which bring the os uteri down within easy sight and reach, seize the margin of the os with a Sims's hook or a 670 TUMORS OF THE UTERUS. vulsellum, so as to steady and hold oj)en the cervix for the passage of the styptic ; or insert a cervical tube, such as those designed by Dr. Lombe Atthill and myself. This serves as a protecting channel along which the styptic can be passed direct into the uterus. The perchloride or persulphate of iron should be used very strong, nearly concentrated. The chromic acid crystals should be simply moistened with a little water. This is a very powerful styptic. The nitric acid should be used fuming. The acid mostly acts as a superfi- cial styptic or caustic. But Dr. Gogarty relates a successful case (Medical Press, 1871) in which the "lining membrane was denuded, and it came away a perfect cast of the uterine face of the tumor." Dr. Savage extols strong tincture of iodine. If we find swabbing inefficacious or not to be carried out, then the best thing to do is to in- ject a solution of persulphate or perchloride of iron. Of course it is eminently desirable that the cervix should be dilated; but we are supposing this not feasible, and that the hemorrhage is so serious as to threaten life. In such a case a vulcanite tube may be passed into the uterus, and two or three ounces of a solution of perchloride of iron or of the persulphate may be injected by means of an india-rubber ball which can be adapted to the tube. This will rarely fail. I have saved several lives by this treatment. Dr. Kidd, I am bound to state, says that, "in his experience the injection of perchloride of iron is the least useful and the most dangerous treatment. The last case in which he ti'ied it proved fatal. The woman got a low form of metritis and died." I have not myself seen any ill effect from it. In my " Obstetric Ope- rations" I have cited in detail the history of a case ending fatally from injection of perchloride of iron into a uterus dilated by retroflexion. But surely we ought not to be deterred by this risk from the imme- diate and urgent duty of saving a woman from bleeding to death. Should bleeding have brought the patient to extremity, there is still a resource in transfusion. Dr. Gentilhomme relates an interesting case (Gazette Hebdomadaire, 1868) in which life was saved by this ope- ration. The preceding means should be steadily jjersevered in, combating symptoms as best we can, striving to support the patient against them until the climacteric period, when we may reasonably hope that the tumors will pass into degeneration or atrophy, or at any rate become inert. It is only when the patient's condition is so serious that we cannot afford to temporize, and these means can no longer be trusted to, that we shall be justified in resorting to the more decided but more hazardous surgical proceedings which we have now to discuss. We have lastly to consider the means of getting rid of the tuinors altogether. This embraces the discussion of the various proceedings available for promoting their expulsion ; for causing their destruction and elimination by setting up inflammation or necrosis ; for ablation by enucleation, avulsion, ligature, knife, scissors, ecraseur, cautery; and for removing the uterus itself along with the tumors by gas- trotomy. The idea of enucleation seems to have been first clearly discussed by TEEATMENT. 671 Velpeau. It was practiced by Araussat, and has beeu rather exten- sively tried of late years. The means for bringing about enucleation and expulsion may be conveniently described together. The larger tumors, whose texture is continuous with the uterine Avail, are not proper subjects of these pro- ceedings. It is from not bearing in mind this fact, which has been so distinctly insisted upon by Rigby and McClintock, that failure and disaster have so often followed surgical proceedings. And since the difficulty of diagnosis between these and the encapsuled tumors is great, the subject is involved in doubt at the very threshold. These pro- cesses, then, are chiefly, if not exclusively applicable to the hard fibroid bodies which are encapsuled. Expulsion may l)e accomplished with- out enucleation. This occurs in those cases where the tumor is thrust out of the wall of the uterus, becoming a polypus. A polypus after hanging for a time by a pedicle, may be thrown off altogether, a thin capsule of uterine tissue carried before it still investing it. Or expul- sion may be effected by spontaneous enucleation. The investing cap- sule may ulcerate, and uterine contraction going on, the tumor loosened may be thrown out. These processes of expulsion may be aided by the use of so-called oxy- tocic remedies. Treating the tumor-bearing uterus as we would the childbearing organ, we give certain remedies that possess the property of provoking or strengthening the uterus to contract. The chief of these are ergot, quinine, strychnine, g-alvanism. The action of these agents upon the uterine muscle, even in the non-pregnant state, is undoubted. But they cannot be expected to act so efficiently as in pregnancy M'hen the mhscular fibre is highly developed, and when the nervous centres are in a peculiar state of tension ready to respond to comparatively slight excitation. The remedies must therefore be given over a con- siderable space of time. And generally they cannot be trusted to alone. It is conuiionly necessary to dilate the cervix freely by inci- sions and tents; and if we find the tumor or tumors projecting into the uterine cavity, to seize them with a vulsellum, to draw them down, to try enucleation by scratching through the capsule at the margin of uterine attachment, or even by aid of scissors making nicks into its substance. Under this manipulation of combined traction and inci- sions, the tumor will sometimes come away. But this result will rarely be accomplished at the first trial. Several sittings may be necessary. Where the tumors seized with the vulsellum cau be surrounded at the base with a wire, it is best to remove what we can by the ecraseur. In some cases if the loop of wire can be made to bite beyond the equator or greatest diameter of the tumor, when the screw is turned on, the loop naturally closing in on the farther or uterine side may actu- ally effect enucleation. The wire used for this purpose should be firm, like a piano-cord, of steel, so that the loop can be passed into the uterus compressed in an elongated form, and will open out again when released from pressure into an oval or circular shape that will run over the tumor. Carried in an Ecraseur the end of this instrument is pushed on to the base of 672 TUMORS OF THE UTERUS. the tumor, whilst a finger applied to the wire-loop guides this down over the tumor until it has got beyond the greatest diameter; and then the loop is drawn in by the screw and made to divide the tumor at its base. The tumor may then be taken out by the vulsellum or the fingers. When the wire-loop cannot be slipped over the tumor by the finger, it is convenient to use a little crutch on a long stem, which seizing the wire can be made to push it up towards the fundus of the uterus. Under the "Treatment of Polypus" is a figure illustrating the ap- plication of the wire ^craseur. Enucleation failing, the tumor will be divided by the wire flush with the inner surface of the uterus. Then one of three things may happen: 1. The tumor may heal, cicatrize at the incised surface; but the hemorrhage will in all likelihood cease, and relief be gained for a time. 2. Slow inflammation or necrosis is set up in the attached portion of the tumor, and its capsular attachments losing their vitality, the tumor is cast out. During this process, there is sometimes con- tinuance of pain due to the spasmodic action of the uterus, offensive serous discharge, and possibly some degree of irritative fever. All this trouble ceases when the residuum of the tumor is expelled. 3. In- flammation may extend from the tumor to the uterus itself, and pysemia added to metritis may try the constitution to the utmost. But this third event is exceptional. These tumors bear a great deal of rough handling without entailing any serious consequences. In some cases enucleation of even large tumors may be effected by the hand alone or aided by the knife or scissors. After free dilatation of the cervix has been secured, a hernia-knife guided by a finger in utero makes a long incision into the projecting part of the tumor dividing the capsule. Then the finger insinuated between the solid tumor and its investment may shell it out. In other cases more diflicult, we may succeed in removing a large tumor, one even too large to be drawn unaltered through the pelvis, by the process called spiral elongation. Seizing the most accessible part of the tumor by a vulsellum, and by its means dragging the tumor as near the vulva as possible, aided by supra-pubic pressure by an assistant, a series of incisions are made in the tumor in a spiral or oblique direc- tion. Under the combined effect of dragging and these incisions the tumor is drawn out, it elongates, so that fresh incisions can be carried successively into higher parts of it, until we reach the last part, when all comes away. I have practiced this operation successfully. SoQietimes the removal of a tumor can only be effected piecemeal. Wedge-shaped pieces are cut, or torn away, or the ^craseur takes away portions successively. In this manner, removing gradually the ob- structing parts of the tumor, we work towards the base. Bleeding seldom complicates these proceedings in a dangerous degree. When it is at all copious it may be arrested by swabbing the surface with nitric or chromic acid. It has been sought to bring about the destruction of a fibroid tumor and its enucleation by the action of caustics. Simpson thus made an opening in the capsule of a tumor at the most depending point ; ergot TEEATMENT. 673 then exciting uterine contraction, the tumor was gradually driven down through the opening and it was eventually taken away by the hand. The patient died on the sixth day of pyaemia. Dr. Atlee, in a " Report on the Surgical Treatment of certain Fi- brous Tumors of the Uterus heretofore considered beyond the resources of art," published in 1854, described a method for bringing about de- struction by disintegration of the tumor as a part of the process of enucleation. ''A section made through their thin investing membrane will sometimes be followed by the death of the whole mass. This may be owing to the admission of air causing it to degenerate. Indeed it M'^ould appear that the action of the oxygen of the air, like a portion of yeast in a fermentable mass, may originate in any part of a fibrous tumor an action of eremacausis which may extend throughout the whole." It is needless to discnss the theory here expressed as to the process by which the vitality of the tumors is destroyed. The impor- tant point is to examine the results. The history of the cases reported in this memoir did not afford much encouragement to follow the prac- tice. Allied to Dr. Atlee's plan is that of Baker Brown, which consists in gouging or excavating a piece of the tumor. The efFect is in most cases to cause necrosis. It is easy to set up this process. It is not easy to limit it ; and death has resulted from the extension of inflam- mation to the uterus, and pysemia. If decomposition of a tumor have begun, and constitutional symp- toms of irritation from absorption appear, a decided attempt at least should be made to bring away the tumor. The patient being under chloroform, the hand in utero may effect detachment unaided, or scissors may be used to divide any bands or connections. Dr. Grimsdale and Mr. Bickersteth, of Liverpool, thus undoubtedly saved a life immi- nently threatened. The woman afterwards became pregnant. (Liver- pool Med.-Chir. Journ., 1857.) Pean and Urdy^ trace the history of gastrotomy for the removal of uterine tumors through three distinct periods. The first, which comes down to 1843, comprises those cases in which surgeons having opened the abdomen with a view to ovariotomy, finding the tumors to be uter- ine, shrank before the consequences of amputation of the uterus, and closed the wound. In the second period, that of trials and groping, which coiiics down to 1863, during which ovariotomy had made great strides, several surgeolis, Atlee, Heath, Charles Clay, Parkinson, find- ing uterine tumors where they expected ovarian, yet did not hesitate to remove the uterus. In the third period, beginning with April, 1863, Koeberle, in the presence of a doubtful case, prepared for either ovari- otomy or hysterotomy. Storer, Pean, and others deliberately resorted to gastrotomy for the purpose of removing the uterus affected by tu- mors. Between September, 1869, and February, 1872, Pean had performed the operation five times for fibrous tumors of the uterus, and four times 1 " Hysterotomie : Etude sur les tumeurs qui peuvent n^cessiter cette operation." Paris, 1873. 43 674 TUMORS OF THE UTERUS. for fibro-cystic tumors, with the result of two deaths out of the nine cases. One death is ascribed to retro-uterine hsematocele on the elev- enth day ; the other to shock, fifty-seven hours after the operation. He gives a table^ intended to be complete, of forty-four cases performed down to 1872, including those of Koeberle, of which fourteen re- covered, and thirty died. To this list, however, I might object that I have myself seen one fatal case, which is not recorded in it, and could easily add others from various sources. Before performing the operation the same general preparations which are practiced before performing ovariotomy are indicated. The time to be selected should be within a week after a menstrual period. The instruments required are the same as for ovariotomy. But there should be provided in addition several powerful serre-noeuds, such as those of Dr. Cintrat, and wires of different sizes. Since much cannot be gained by lessening the bulk of the tumor, the abdominal incision must generally be longer than is necessary for ovariotomy. When the tumor comes into view, the extent to which its volume can be lessened must be considered. If there are cysts, these must be punctured. If it is solid, and too big to come through the wound, the process of cutting up, " morcellement " of the tumor must be resorted to. This is effected by piercing the middle part of the tumor, or if that cannot be done, the most accessible part, by several metallic wires, and tightening them by serre-noeuds. These serre-noeuds resemble small wire ecraseurs. The circulation through the part above the ligatures being thus stopped, this part may be freely cut away, and the surgeon may proceed to deal with the rest. Pean insists that the success of the operation depends upon securing the peritoneum from the entry of fluids into it. Hence if a cyst is to be opened it is first drawn outside the abdomen. In separating adhe- sions like care is extended, to obviate bleeding into the peritoneum. Small bleeding vessels are tied with silk, and the ends cut short. The actual cautery by aid of the cautery-clamp should be used to sever parietal or omental adhesions. When the tumor has been drawn out of the abdomen the question of how best to amputate it will be decided by the conditions of its connec- tions. If attached by a small pedicle, it may be clamped like an ovarian tumor, or ligatured by traversing the pedicle by two wires or pieces of whip-cord to be drawn tight by serre-noeuds. If the pedicle be large, and have a very broad attachment to the uterus, it becomes a question whether the immediately involved part of the uterus or a greater part of the organ shall be removed. Pean advises in this case to remove the uterus at the neck. Besides having lost two cases in which he confined himself to removing only a part, whilst he saved those in which he practiced amputation at the neck, he gives the following good reasons for adopting the latter course : In the cases which compel re- sort to gastrotomy, the uterus is always hypertrophiecl, perhaps other- wise diseased; a much larger surface must be divided and exposed in removing a ])art of the body of the uterus than by amputating at the neck, laying open large sinuses, which fiivor pyremia; and the supra- vaginal amputation is really easier. EXTIRPATION OF THE UTERUS. 675 In another class of cases the relations of the tumor are such that there is no choice but to remove the whole uterus. By catheter in the bladder the relation of this organ to the neck of the uterus is made out; this part is traversed by two straight, rigid needles, perpendicularly to each other, preserving as long a pedicle as convenient. This done, a strong curved needle notched at the end is passed through the pedicle or uterine neck immediately above the most superficial of the two straight needles traversing the pedicle. The notch catches a metallic thread which, being brought through by its loop, forms a double ligature. These are then tightened by the serre-noeud. If the part be very vas- cular another ligature jnay be passed beneath the two straight needles. The uterus may then be removed. There is no valid reason against removing the ovaries along with the uterus. The end of the stump is brouo;ht outside the abdomen, the four ends of the straio-ht transfixins; needles and the ligatures rest upon the abdominal wound, and the wound is closed as after ovariotomy. The after-treatment resembles that for ovariotomy. Pean at the close of this very practical clinical memoir presents the two following conclusions: 1. Fibrous or fibro-cystic tumors of the uterus having reached a certain degree of development may cause serious ac- cidents capable of entailing, sooner or later, certain death. In these circumstances the surgeon is not only right in performing gastrotomy, but it is his duty to do it. 2. If the connections of the tumor with the uterus are ever so little intimate, it is better to amputate the body of the uterus without attempting to preserve the ovaries, than to seek to enucleate the tumor. The justification for attempting enucleation, avulsion, or other mode of removing large fibroid tumors will rest upon — 1. Uncontrollable hemorrhages endangering life ; 2. Signs of sloughing or decomposition of the tumor, with present or threatening peritonitis or pyaemia; 3. Dangerous pressure upon the bladder and rectum. The same conditions threatening life, and removal by the processes above enumerated being precluded, may justify the last resource, that of gastrotomy. The case is analogous to dystocia. If we cannot effect delivery through the pelvis, we resort to gastrotomy. And this must be the rule of action in dealing with uterine fibroids, assuming always that extirpation is necessary. The time has not yet come for forming a confident opinion upon the practice of gastrotomy for the removal of uterine fibroids either alone or with the uterus. At present there is little ground for enthusiastic advocacy of the practice. The case may best be summed up by stating that the question is adhuc sub judice. We must for awhile be content with the divided opinions expressed in the Academy of Medicine on the occasion of a report presented by Demarquay on Memoirs by Koe- berle, who advocates the proceeding, and by Boinet, who condemns it. Boinet showed that the operation had for the most part been performed accidentally in cases mistaken for enlarged ovary ; that it could not be defended on the same grounds as ovariotomy ; that it should always be rejected when the tumor was not pedunculated, and especially when 676 POLYPUS OF THE UTERUS. it involves the entire or partial removal of the uterus. Demarquay agreed with Boinet. • On the other hand, Richet cautioned the Academy against pro- nouncing any summary condemnation of an operation which at present is dreaded as ovariotomy once was. In conclusion it may be stated that the question will be decided, like ovariotomy, by experience ; but to acquire that experience justifi- ably, extreme caution, judgment, and conscientiousness, as well as sur- gical skill, are required. CHAPTEE XLVIII. POLYPUS UTEEI. DEFINITION; FOEMS OF: FIBROID OR MYOMA; GLANDULAR OR MUCOUS; HYPERTROPHIC; VASCULAR; PLACENTAL ; FIBRIN- OUS; HISTORY OF FIBROID; FIBRO-CYSTIC VARIETY; SYMP- TOMS; TERMINATIONS; INTRA-UTERINE AND EXTRA-UTERINE POLYPI; DIAGNOSIS; TREATMENT; SLOW STRANGULATION, DANGERS OF; TORSION, CRUSHING, AND EXCISION BY SCIS- SORS; REMOVAL BY POLYPTOME, ECRASEUR, GALVANIC WIRE- CAUTERY. Under the name of polypus are included all tumors, stalked or ses- sile, which hang from the inner wall of the uterus or vagina. It is, however, convenient to exclude cancerous growths and the cauliflower excrescence. The history of the polypus of the uterus naturally follows upon that of tumor. In the greater number of cases of clinical interest, a poly- pus is nothing more than a tumor in one of its ulterior stages. We have seen that the fibroid tumor is liable to be extruded from the wall of the uterus into the cavity. In this process of extrusion, a stage arrives when the tumor becomes first sessile, then pedunculated. When the main bulk of a tumor projects into the uterine cavity, its seat of attachment being narrower than its equator, the tumor has be- come a polypus. This definition, especially true of fibroid polypus, is generally true of the other forms. Polypi, like ordinary tumors, differ in their histological structure, and in their situation and other clinical characters. The source of a polypus will commonly be an indication of its anatomical character. POLYPUS OF THE UTERUS. 677 This is the consequence of the law that like tissues produce like out- growths. For example, the muscular wall of the body of the uterus produces the fibroid or myomatous tumor or polypus. The cavity of the cervix and the os uteri produce mucous, glandular, or cystic polypi. The varieties of polypi are then, 1. The fibroid or myoma; 2. The glandular or mucous ; 3. The hypertrophic polypus of the cervix ; 4. The vascular ; 5. The placental ; 6. The fibrinous. The form which most frequently comes under clinical notice is the fibroid or myoma. The structure and history of this form are described in the preceding chapter on tumors of the uterus. It is only necessary here to trace those clinical features which are peculiar to the polypoid character. It mostly springs from some part of the wall of the body of the uterus, generally from the fundus. Projecting into the cavity of the uterus and preserving organic connection Avith this organ, it acts in two ways — 1st, it irritates as a foreign body ; 2d, it stimulates uterine growth like an ovum. It is a parasitic body. It is upon these two conditions that most of the accidents attending polypus depend. The uterus struggles to cast out the unwelcome guest. Hence spasmodic pains, which are exponent of the uterine contractions. Hemorrhage and leucorrhoeal discharges occur as the exponent of the increased vascularity and development of the uterus. Just as we have fibro-cystic tumors of the uterus, so we may have fibro-cystic polypi. The softer myomatous tumor which is more con- tinuous with the proper muscular wall of the uterus may also become polypoid. Fig. 148 is a good illustration of a fibroid intra-uterine polypus. Fig. 149 is a good illustration of a stalked polypus. Sometimes instead of forming a pedicle, the tumor is cast out entire. In the process of extrusion a pedicle is formed which is sometimes capable of elongation, permitting the tumor to descend lower and lower. The thin layer of proper uterine tissue which forms the shell stretches out, and through the stalk, the vascular connection with the uterus is maintained ; at the same time the connection is further aided by the investing mucous membrane. At other times the connection is more intimate ; the fibroid structure of the tumor is extended into the sub- stance of the uterus, forming a dense, short, thick, unyielding stalk. Under uterine action, since the tumors will not separate, and the stalk will not lengthen, the uterus itself is dragged down, producing partial or complete procidentia of tumor, and vagina, and uterus. Such a case simulating inversion of the uterus is figured in Obstetr. Trans., vol. iii, by the writer. It was only after considerable trouble that the os uteri "was found, when a sound being passed up into the uterus, this organ was distinguished from the tumor. Occasionally, polypus produces actual inversion of the uterus. Ex- amples of this accident are referred to in the Chapter on ^' Inversion." In some instances the stalk is so drawn out whilst the attachment is at the fundus uteri, the tumor is quite outside the vulva, occluding the entrance. The symptoms differ in the cases of polypus still retained within the cavity of the womb, and of polypus which has escaped through the os 678 POLYPUS OF THE UTERUS. uteri into the vagina. In the latter case we have the advantage of digital examination to aid the subjective symptoms. When the tumor Fig. 148. Fibroid polyijiis filling the cavity of the uterus. (Ad nat., Coll. of Surgeons, No. 2666.) In this case the wall of the uterus is much thinner where the tumor is attached. Fig. 149. Fibroid polypus which has been extruded from the cavity of the uterus, the triangular shape of which it retains. (Half-size, College of Surgeons.) It is attached by a long stalk, the root of which is traced into the wall of the uterus. is locked up in the uterine cavity, we may have to depend upon the subjective symptoms alone. The general symptoms are these : 1. Hem- POLYPUS OF THE UTERUS. 679 orrhage, generally at first in the form of menorrhagia, afterwards liable to recur at any time. This is very common, but not constant. 2. Leu- corrhoea of a mucous, purulent, or serous character ; at times tinged with blood, and very offensive, owing to the discharges being retained in the vagina and decomposing there. 3. Bearing-down, or expulsive Fig. 150. Fibroid polypus moulded to shape of uteriue cavity. (Ad uat., College of Surgeons, No. 2679.) pains. 4. Abrasion, ulceration, bleeding of the margin of the os uteri, or of the vagina from friction of the polypus. Similar conditions have been noticed inside the uterus, when the polypus has been intra-uterine. All this irritation commonly disappears when the tumor is removed. 5. Even more serious injury may be caused, as in the following case. Larcher describes a case' of spontaneous rupture of the uterus with 1 Arch. G^n de Med., Nov. 1867. 680 POLYPUS OF THE UTEEUS. intra-uterine polypus. A woman was adniitted into the Hotel- Dieu, with pain in the abdomen. After four days profuse bleeding set in. She refused examination. Two days later meteorism and peritonitis appeared, and she died. Section revealed diffuse peritonitis and adhe- sion of all the organs of the small pelvis. A polypus was found in the uterus, seated in the anterior wall near the isthmus. The opposite side of the uterus was ulcerated, and at one spot torn through, communi- cating with the cavity of the abdomen. 6. They may cause metritis, and septicsemia. 7. Perhaps some distress in micturition or irritability of the bladder; and in some cases, Avhen the tumor has been very large, so as to compress the bladder and rectum against the walls of the pelvis, symptoms like those of retroversion of the gravid womb have been developed, as retention of urine, urin?emia, and intense pelvic pain. Gangrene and sloughing of the vagina have even been known. 8. When hemorrhage and leucorrhoea have continued some time, the phenomena of anaemia, blood degradation, impairment of digestion, and disordered nutrition follow. The aspect may become sallow; the patient emaciated ; and the discharges offensive. These, together with pain, constitute a series of symptoms that have often given rise to the conclusion that the disease M^as cancer. In the case of intra-uterine polypus, all the foregoing symptoms may be present ; but in addition there will commonly be enlargement of the body of the uterus, and ex- pulsive pains of a spasmodic character, constituting uterine colic. Another not uncommon symptom is vomiting. This appears to be due to distension of the uterine fibre. It especially characterizes the intra-uterine polypus. What has been said of the vascularity of fibroid tumors and of the source of the hemorrhage, applies to the fibroid polypus. This is rarely very vascular in its substance. But the investing mucous membrane is commonly very vascular. A network, chiefly of veins, is formed in it, from which blood easily oozes iu profusion at the menstrual periods, and under injury to the surface. Occasionally, however, vessels of considerable size have been seen penetrating the substance of fibroid polypi. The growth of fibroid polypi, like that of fibroids still imbedded in the uterine wall, is stim- ulated by the ovarian or menstrual nisus, and still more actively by pregnancy, obeying the same impulse as that which governs the cognate muscular tissue. In like manner they are disposed to undergo a similar retrogression or decline when pregnancy has passed, and even atrophy or calcareous degeneration when the period of menstrual life has ended. Hence the bony or stony polypi of Gerdy.^ But this post-climacteric retrogression is not constant. The tumors may even continue to grow. As to the consequences of polypi much variety is observed. Vel- peau (Journ. de Med. et de Chir. Prat., 1859) says they are sometimes harmless, and that the consequences are not in relation with their vol- ume. Some disappear spontaneously. They may be found loose, or may drop off unperceived. But commonly repeated hemorrhages in- 1 " Des Polypes, et de leur Traitoment." Paris, 1833. TERMINATIONS. 681 duce such a degree of ansemia, that even death follows if the tumor be Dot removed. And this danger is greatly increased if pregnancy super- vene. (See fatal cases, in Gooch, p. 145.) Dr. Cockle relates (Med. Times and Gaz., 1863) a case of a large, pedunculated, fibrous polypus attached near the fundus uteri, distending the uterus and vagina, and giving rise to frequent bleedings and offensive discharges. The patient died after symptoms of peritonitis from perforation. The ovarian extremity of the right Fallopian tube was found distended by the dis- charge, some of which had escaped into the abdominal cavity. Many patients have died exhausted by bleeding caused by an intra-uterine polypus not suspected during life. The following case^ is an instruc- tive example : Dr. Ramskill was called to see a young woman who was suffering from uterine hemorrhage. The patient was twenty-six years of age ; she began to menstruate at the age of fourteen, and this function was performed very regularly until her marriage, eight months ago. From that time she had suffered almost perpetual hemorrhage. A month ago, the flooding was so profuse that it was thought she had miscarried. Since then there have been slight occasional intermissions, but her health was deeply impaired. When Dr. Ramskill was called the hem- orrhage had returned. He observed strong bearing-down, expulsive efforts. The patient died the same night in convulsions, evidently from loss of blood. The body was examined by Dr. Ramskill on the following day. The organs were all healthy. There was no abdominal inflammation. The os uteri was healthy, but flaccid; it was filled with a fresh clot. There was also blood in the cavity of the uterus. The larger portion of the uterus, with a body adhering to the inner Avail, was forwarded to me by Dr. Ramskill. I subjected the parts to a careful examination. The walls of the uterus were dense, pale, somewhat thicker than natual, and the Avhole size of the organ somewhat larger tlian the normal unimpregnated Avomb. There was no tumor or other abnormal condition of the muscular Avail, but attached to the inner sur- face near the fundus, and altogether inclosed Avithin the cavity of the uterus, Avas a tumor of the size of a small Avalnut. The tumor did not reach to the uterine neck. The mucous membrane of the cavity was stretched over it. It Avas connected by a broad basis to the uterus, but would have admitted of isolation by ligature. The apex, or most pro- jecting part, had undergone partial disintegration ; it AA'^as a little broken up, softened, and had evidently quite recently been the source of hemor- rhage. Examined by the aid of the microscope, the substance Avas found to consist of nucleated fibres, the nuclei being large and distinct. Por- tions, especially those taken from near the apex, exhibited abundance of oily globules and numerous blood-globules. The structure of the tumor differed from that of the uterine wall in this respect only, that the fibres in the latter were longer, narrower, and more densely inter- woven, and the nuclei less distinct. There was no evidence of fatty degeneration in the fibres of the uterine Avail. There was no doubt greater developmental activity in the tumor than in the uterus. 1 On " Uterine Polypus." By Robert Barnes, M.D. Lancet, 1854, 682 POLYPUS OF THE UTERUS. The practical deductions from this case are of the highest interest and importance : 1. The condition of the uterine muscular walls leads me to conclude that the conjecture that the patient had aborted a month before her death was erroneous. 2. The comparative indolence of the tumor, and the absence of any remarkable amount of hemorrhage up to the period of marriage, and the constant floodings following immediately upon that event and con- tinuing until the death of the patient eight months afterwards, forcibly illustrate the influence of ovarian and uterine stimulation in develop- ing the growth of uterine polypi. 3. The case is peculiarly one of that class to which I have pointed as strongly indicating the necessity of exploration beyond the os uteri. When pregnancy supervenes, the presence of the polypus is a source of serious danger. The tumor partakes of the general development and increased vascularity of the uterine wall. In this state injury inflicted upon it is more severe in its consequences ; inflammation and necrosis, for example, are more liable to follow. To anticipate the spread of morbid processes from the tumor to the uterus, it is best to remove the tumor by the wire ecraseur as soon as its presence is discovered after the labor. The history of this complication is pursued more fully in my " Obstetric Operations." Our business here is more especially Avith the non-pregnant uterus. It is, however, desirable to call to mind that polypus is likely to be a cause of abortion. Generally, however, polypi prevent pregnancy. A curious case occurred to the writer, of a uterus removed in the dissecting-room, in which a polypus the size of a filbert grew at the orifice of each Fal- lopian tube, both being completely closed. In another case the tumor had been driven outside the vulva, quite closing the entrance to the vag-^ina. And in the common case of the polypus filling the vagina, sterility almost necessarily follows. A point of great importance in the constitution of fibroid polypi is noticed by E,. Ferguson (Introduction to New Sydenham Soc, ed, of Gooch), which is, "that injury to this structure is rapidly followed by a form of decay like that which is seen in vegetable matter. Never- theless," he continues, " inflammation ending in suppuration has been known to take place in the very heart of these growths. Their centres are also the occasional seats of softening, of effusion of blood, and of cysts." The glandular or mucous polypus generally grows from the os uteri, varying in size from a filbert to a walnut. It is smooth and vascular, and contains, in some instances, a curdy matter, or yellowish viscid fluid, Herbiniaux described this form. It is not uncommon. Paget thus describes it : The mucous or Nabothian cysts probably originate in cystic degeneration of the glands of the mucous membrane about the cervix uteri. Protruding either alone or with polypoid outgrowths of the mucous membrane, they are observed successively enlarging, then bursting and discharging their mucous contents, and then replaced by others following the same morbid course. Or instead of clusters of such cysts, one alone of larger size and simpler structure may be found. GLANDULAR POLYPUS. 683 There is a remarkable example in the Middlesex Museum of a cyst which appears to have been produced in this way. They generally grow from a broad basis, rarely becoming stalked. An illustration of one form of mucous polypus is seen in Fig, 151. The patient was subject to profuse hemorrhages and leucorrhoea. They often attend chronic metritis, especially of the cervical portion. They induce great hypersemia, and give rise to profuse bleedings. Being small, soft, and easily retreating within the os uteri, they readily escape detection by touch. The speculum is necessary to reveal them. They project as stalked little tumors on the red, abraded margin of the os uteri, but are occasionally seen higher up the cervical canal. They range in size from a quarter of an inch to half an inch long, and some- times they exceed this. On pressure, as in trying to seize them with a forceps, they easily break up. They are the result of a morbid con- dition of the cervix. They contain a viscid fluid, and therefore may be identified with their glandular origin. But some are really papil- lary outgrowths. These latter are especially vascular. Fig. 151. Mucous or glandular cervical polypus, causing abrasion or ulceration in its neighoorhood. (Ad nat., R. B.) The so-called "channelled" polypus of Oldham appears to be a variety of the glandular polypus, although the fibro-cystic tumor may put on the appearance of channels. Fig. 152, for which I am indebted to Mr. Arnott, shows the histo- logical characters of these outgrowths. It exhibits the proliferating connective tissue, with imbedded, winding gland-ducts, lined with co- lumnar epithelium. These mucous polypi appear sometimes in the form of cystic tumor of the cervix uteri. Such a case is described in Path. Trans., vol. ix, by Spencer Wells. It showed epithelial debris with oil-globules and compound granular-cells, found in the larger cells ; glandular epithe- lium lined the younger cysts. I have seen several such cases ; one is described in my Memoir on " Uterine Polypus." Another is described by Mr. Gray (Path. Trans., vol. iv) : " It was connected with the lining membrane of the cervix. Its size and form were not unlike that of a dried plum, and it was con- nected with the lining membrane by an exceedingly narrow pedicle. 684 POLYPUS OF THE UTERUS. It was covered with a thick, viscid secretion. It consisted of a con- geries of cysts of a size varying from a fine point to a horse-bean ; their walls were formed of dense fibrous tissue, and their cavities con- tained a thick viscid fluid, similar to that found on the outer surface. The neck of the tumor was composed of mucous and fibrous tissues, a continuation of those of the neck of the uterus. The mucous mem- brane, where it was contained on the surface of the neck of the tumor, presented a continuation of the same transverse and longitudinal folds found on the mucous lining of the cervix." Fig. 152. Section of a " channelled " glandular polypus, slightly diagrammatic. (H. Arnott.) The liypertrophiG polypus of the cervix uteri. Although most polypi may in some respects be regarded as hypertrophies of ordinary struc- tures, there is one form to which the name seems to me to be more especially applicable. In a memoir^ on the hypertrophic polypus, I have described as frequent the outgrowth of dense fibrous polypi on the edge of the os uteri in cases of prolapsus. So frequent is this co- incidence that one is natui'ally led to conjecture either that a common cause produces both, or that one entails the other. It can hardly be that polypus is the cause of hypertrophy of the cervix, for in the majority of cases of hypertrophy there is no polypus. The truth ap- pears to be that that excessive growth Avhich results in hypertrophy, sometimes — in my experience, often — produces jjolypus as well. These polypi are generally small, sometimes not larger than a pea, St. Thomas's Hospital Eeports, 1872. HYPERTROPHIC POLYPUS. 685 sometimes they are as large as a cherry; they may be round, but are occasionally elongated, cylindrical, but more or less irregular in form. (See Fig. Ill, p. 544.) They easily escape detection by the finger; hence it often occurs that their existence is first revealed by the specu- lum. They generally begin to form just inside the ring of the os uteri, and growing first inwards, the hypertrophied os uteri conceals them and protects them from the touch. When they have existed some little time, have increased in size, and have frequently caused hemorrhage, they sometimes descend below the edge of the os uteri, and may then be felt like a soft pea by the finger. But before this stage they can often be seen through the speculum, especially through a good bivalve which makes the os gape widely when applied. They are commonly single, but it is not infrequent to find two or three; and some show a disposition to subdivision or rather to lobulation. They entail the common consequence of other polypi, namely, hemorrhage. It is this symptom which mainly leads to examination and their detection. Gen- erally their removal is followed by diminution or cessation of the hem- orrhage; but here the benefit of the operation ceases. The distress which properly belongs to hypertrophy continues. For this further treatment is necessary. The pathological history of those "hypertrophic polypi" may, I think, be told as follows: The first condition of their existence is hyper- trophy of the cervix uteri. This hypertrophy we know frequently pur- sues a very uniform course affecting the whole structure of the cervix alike; but sometimes one lip, and sometimes even a part of one lip, is more especially affected. Thus we sometimes see the anterior or the posterior lip shooting out an inch or more beyond the other. At other times the os uteri being lobulated or fissured, as is seen after labor, one lobe or portion of a lip may take on an exaggerated growth, and project beyond the level of the rest of the os. In such a case, if studied by the light of observation of more advanced or completed polypoid for- mation, we may see the origin of the hypertrophic polypus. A small lobe more or less marked out on the os by a fissure or depression on either side continues to grow under the same stimulus that determines the general hypertrophy of the cervix. It grows a little more quickly; then, its base being compressed by the firm structure of the os on either side of it, is squeezed and elongated until it assumes the characteristic polypoid shape. All this, I think, I have been able to trace in the suc- cessive stages in different cases. The structure of these hypertrophic polypi of the cervix uteri entirely accords with this theory of their formation. It is identical with that of the hypertrophied cervix from which the polypi spring. The mucous membrane with which they are covered presents exactly the same ele- ments as the mucous membrane of the corresponding part of the cervix or OS uteri. If they are attached within the cervix, we find columnar and ciliated epithelium-cells. If they are attached to the outer edge of the os, then we find chiefly large squamous epithelium-cells. The in- terior in both cases is composed of bands of smooth fibres like those of the unimpregnated uterus. In November last I removed by galvano-cautery a hypertrophied 686 POLYPUS OF THE UTERUS. lip of an OS uteri, and received from Dr. John Harley the following report of its constitution : " It contained one or two little cysts, natural follicles enlarged, full of glairy mucus consisting of normal mucus- corpuscles. The mass was composed of the usual uterine structures, that is, interlacing bands of smoother fibres." These facts I had often observed myself, but was glad to find them verified by my colleague. Whilst still attached to the cervix uteri, they are usually vivid red, having a very vascular appearance. This is owing to the mucous membrane investing them being full of blood, deeply congested, like the cervix itself. When the tumor is removed the surface often becomes quite pale. The vascular polypus takes its rise from a dilatation or varicosity of the vessels running under the mucous membrane. All these three forms are found in the cervix or os uteri. Among conditions simula- ting polypus may be mentioned a mushroom-like hypertrophy of the OS uteri. It is referred to by Dance, Berard, Cruveilhier, Mayer, Meissner, Malgaigne, and Montgomery. Malignant growths of the os also often resemble polypus by their form. In addition to the above recognized forms, Rokitansky, Kiwisch, Scanzoni, and C. Braun have described other varieties. C. Braun (1851) describes the jjlacental jioly pus. This results from the remains of the placenta consisting of hypertrophied decidua, which, projecting into the uterine cavity, forms a polypoid mass. Braun relates five cases in which violent hemorrhage broke out some time after delivery. Polypi of the kind described were found. In four cases they were ex- tracted with the finger ; in one the polypus separated spontaneously. The fongosites intra-uterines of Nonat, according to Stadtfeld of Copen- hagen (Dubl. Q. Journ. of Med., 1863) are placental remains. Such a case was sent to the writer by Dr. Woodman. Arthur Farre (Todd's Cyclop, of Anat.) says he has satisfied himself of the correctness of Heschl's opinion, which agrees with the above, upon the formation of the placental polypus. Malgaigne describes " multiform polypi " containing hair. Kiwisch describes ^.6rmoMS polypi. This author says when menstrua- tion has been retarded six weeks, fibrinous polypi may arise from long persistent hemorrhage, a kind of apoplexy of the uterus, a large coagu- lum forming the upper part consisting mostly of fibrin and adhering by a stalk to the uterine wall, whilst the lower part consists of red soft coagulum having a coat of firm fibrin. These polypi always occasion profuse metrorrhagia. Scanzoni, however, does not admit this view. He contends that these are cases of abortion. An ovum after fixing itself in the mucous membrane of the uterus, and after being quite clothed Avith a decidua reflexa, is soon driven down by uterine contrac- tion into the cervical canal, its attachments lengthening into a stalk by the stretching and growth of their tissues. The embryo escapes, whilst a portion of the membranes or stalk remains, and by accretions of fibrin- coagula forms the basis of fibrinous polypus. McClintock gives an excellent illustration of a dense coagulum simulating a fibrinous polypus. I have little doubt as to the o;eneral correctness of Scanzoni's criticism. DIAGNOSIS. , 687 There is a preparation in St. George's Museum, described by Dr. Ogle (Pathol. Trans., vol. xi) as a "large mass within the uterus, supposed to be a fibrous tumor, but which proved to be formed by retained placenta and foetal membranes. A woman died after an operation for femoral hernia. On removing the uterus a quantity of dark semi- coagulated blood, along with some shreddy tough material, M^as found protruding from its orifice. A firm substance was found filling the cavity of the uterus. Excepting at its upper part, where it was as it were continuous with the muscidar structure of the uterus, its whole extent was free. It consisted of placenta. No foetal growth was discovered. But it was evident that the growth had been retained a long time." The diagnosis of a polypus which has emerged from the cavity of the uterus is usually not difficult. The sources of fallacy are chiefly pro- lapsus of the uterus, and inversion. Confusion is only possible when the tumor resembles in size that of the uterus in one or other of these states. A tumor not bigger than a walnut can hardly be mistaken for the uterus. A tumor bigger than an orange is not likely to be the uterus. But tumors ranging between these sizes may give rise to error. The great landmark is the os uteri. In prolapsus this can always be found at the lowest part of the tumor. By passing the sound through the OS we shall rarely fail to take exact measure of the uterus. Again, the sensation conveyed to the touch by feeling the body of the uterus through its coat of inverted vagina, which can be made^o glide over the solid mass within, is very different from a solid polypus felt directly without any intervening coat. The uterus moreover is sensitive to compression, whilst a polypus is not. Complete inversion is distinguished by — 1, the absence of an os uteri at the lowest part; 2, by the neck of the tumor being continuous with the roof of the vagina which is directly reflected off from it ; 3, by determining the absence of the body of the uterus from its normal po- sition by the combined rectal and abdominal touch, and the other diag- nostic manoeuvres described and illustrated in the chapter on " Inver- sion." Partial inversion, namely, where the fundus of the uterus only comes through the os uteri, is more likely to lead to error. In this case, as in polypus, there is a rounded tumor encircled by a ring, per- mitting a sound or the finger to pass up betM'een. See Figs. 134, 135, pp. 616, 617. The following tests will commonly distinguish the partial inversion. The sound will not run more than an inch, perhaps less, beyond the margin of the encircling ring, whereas in the case of polypus it will generally run at one part or another at least two and a half inches. And the manoeuvres which define complete inversion are almost equally conclusive in the case of partial inversion. For ex- ample, the cup- or funnel-like depression of the fundus uteri may be felt through the abdominal wall. Polypi which have been detected at one time by touch and even by sight, may escape observation at another. It is possible that the polypi may have become detached and expelled. But more often this intermittent appearance is due to the greater relaxation of the cervix, 688 . POLYPUS OF THE UTERUS. and some contractile action of the uterus attending hemorrhage or menstruation. Under these conditions the tumor projects through the open OS ; and retreats when these conditions subside. Commonly polypi are detected, and their size and attachment best made out by the touch. But I have now and then discovered glandular polypi by the speculum which had escaped detection by the finger. A good bivalve speculum which fairly parts the lips of the os uteri will often enable the sight to explore further than the touch. An intra-uterine polypus may escape detection unless the cervix uteri be sufficiently dilated to admit the finger. But if the rule I have ven- tured to lay down, namely, that in all cases of obstinate uterine hem- orrhage, the cavity of the uterus should be explored by dilating the cervix, be observed, we shall a,lways be able to determine the presence or absence of a polypus. And whether the hemorrhage be due to a fibroid polypus, to malignant disease, endometritis or other cause, not only is accurate diagnosis arrived at, but the way is opened for the most efficient treatment. It has been noticed that the hemorrhage is generally more profuse when the polypus is intra-uterine. It is curious to notice how deceptive is the sensation communicated to the touch by some fibroid polypi. Even under palpation after re- moval they may give the impression of fluctuation, as if they were cystic and contained fluid, whereas on section they are found quite homogeneous. A very important practical rule is, in a case of presumed polypus, to trace up the tumor to its attachment before operating. This can generally be accomplished by finger or sound. If the finger can find room to pass along the tumor to its insertion, then by combined ab- dominal palpation we may get the body of the uterus above the tumor between the two hands. The information so obtained is unequivocal. Where the finger cannot reach, the sound will answer nearly as well. We feel the fundus of the uterus supported on the sound through the abdominal wall, whilst a finger in the vagina distinguishes the tumor. Were these methods of diagnosis rigorously carried out, error would be almost impossible. But polypus is so common, and inversion so rare, that the mind is taken possession of by the more common event. The rarer event not being contemplated, we readily accept as conclusive in favor of polypus evidence which is really insufficient. One form of the placental polypus may easily be mistaken for an ordinary polypus. Thus I have been called to cases where the patient was said to be bleeding from polypus, and I have found a mass more or less firm partly projecting from the os uteri, and attached to the inner surface of the body of the uterus. By dilating the cervix by laminaria-tents, these masses were sometimes removed by the finger, and sometimes by the wire-§craseur. On examining the structure of the masses removed, they have been found to be the placenta of abortion. The Treatment — A polypus, being a tumor in process of spontaneous expulsion, seems to invite surgical assistance. We are simply called upon to complete a cure where Nature points the way. The treatment is generally successful. It constitutes one of the most satisfactory ap- TKEATMENT. 689 plications of surgical skill. The principal methods resolve themselves into — 1, removal by strangulation ; 2, by torsion ; 3, by various meth- ods of excision. Palliative or temporizing measures are rarely indicated. If hemor- rhages, leucorrhoea, forcing down, or other urgent local or general dis- tress exist, the indication to remove the tumor is generally imperative. Even if a polypus give rise to no trouble, it is the wiser course to re- move it, since it may at any unexpected time be the occasion of mis- chief. 1. It is convenient in the first place to dispose of strangulation. Experience of its dangers, and the perfection to which the proceedings for effecting immediate removal of polypi have been brought, have fairly exploded this method. The ligature was for a long time applied so as to effect strangulation and slow detachment by sloughing. Levret contrived an instrument consisting of two silver canulse curved, and so united by a joint that they are shaped like a pair of forceps. A ligature is passed through the tubes, the noose is applied round the root of the polypus, and the ends are then drawn tight, and tightened daily until the tumor drops. Another instrument is described by Nissen (De Polypis Uteri. See Richter's Chir. Bibl., b. ix, s. 613). It consists of two silver tubes curved carrying a ligature. The tubes are brought together by a third double canula, and then the ends of the ligature are tightened. Gooch's well-known instrument is a modification of Nissen's, the tubes being made straight. Until recent years this method of slow strangulation was generally pursued in cases where the polypus was large and the pedicle thick. The strangulation by arresting the circulation through the pedicle gradually caused the tumor to fall off by sloughing or mortification. This process would take from two to ten days or more to be completed. During this time, the tumor sloughing, would give rise to offensive discharges ; inflammation has extended from the pedicle to the sub- stance of the uterus, peritonitis and death ensuing. The metritis and perimetritis might be induced, as stated, from simple extension from the injury caused to the neck of tlidb hiive been destroyed by ulceration, of cancerous nature. The adjacent part of the \agina is superficially ulcerated. (Two-third size, St. Bartholomew's Mu- seum.) with cohering edges. In some cases a section carried throuo;h the mu- cous membrane of the cervix close to the ulceration showed hyperplasia Fir. 151. Cancer eating away the lower half of the uterus and perforating into the bladder. (Half-size, St. Thomas's Museum, G G 55.) 710 CANCER OF THE UTERUS. of the epithelial elements upon and between the papillae, with infiltra- tion of the same elements amongst the deeper structures ; other sections from a more diseased portion of the same uterus, exhibiting only the confused heaps of epithelial cells, with much broken-down, oily or granular debris. The caulifloiver excrescence of Dr. John and Sir Charles Clarke is the best known form of the epithelial cancer of the uterus. It appears from Gooch's criticism to be the same disease as was described by Levret and Herbiniaux, under the name of "turaeur vivace." It also affects by preference the cervix. Epitheliomata take their habitual origin in the epithelial layer of the upper part of the vagina and os uteri. Here the epithelial buds become developed, and form a tumor, which projects into the vagina. Opinions differ as to its malignancy. Rokitansky believes it to be cancerous, calling it the villous cancer. He describes it as a conferv^a-like growth, consisting of corpuscles the size of linseed grains, pale red, transparent, tolerably firm, hanging from the os uteri into the vagina, bleeding profusely on the slightest touch, and devel- oped out of an encephaloid. It often fills the vagina, and causes pro- fuse watery secretion. During life it becomes turgescent, like the uterine surface of the placenta; but dead, it shrivels up, and then only resembles a flocculent mass. Virchow, on the other hand, says it is not cancerous, ranking it under the papillary tumors, of which there are three forms, — the simple, the cancroid, and the cancerous. The cauliflower excrescence, accord- ing to him, begins as a simple papillary tumor, and runs into cancroid, but not into cancerous papillary tumor. It is formed only of papillary or villous growths, which consist of thick layers of peripheral flat and cylindrical epithelial cells, and a fine inner cylinder of extremely small cellular tissue with large vessels, running in loops. This tumor is also called papillary hypertrophy of the cervix uteri. Mayer regarded it as an originally local affection. Hannover separates it from cancer, under the name of epithelioma. Lebert and Schutz call it epithelial cancroid. Virchow points out that the forms which yield dry, juiceless masses are relatively benignant; -whilst those which produce succulent tissues have always more or less a malignant character. Cancroid remains for a long time local. Fig. 162 shows epithelioma in an early stage. It consisted of epithe- lial cells and " epidermic globes ;" some of the cells had multiple nuclei. The subject was thirty-eight years old, pluripara. After suffering for several months from white and red discharges, pains in the hypogas- trium and loins, she was admitted to the Hotel Dieu with severe flood- ing; a second flooding carried her off'. The pelvic and lumbar glands were unaffected. Fig. 163 seems to be an example of epithelioma affecting the body of the uterus. The divergence of opinions as to the cancerous nature of this growth is difficult to reconcile. But if it be admitted — and clinical observation dictates the admission — that the cauliflower excrescence frequently springs from a base of medullary cancer, or at some stage is associated with cancer, there is strong ground for taking the more unfavorable EPITHELIAL OR CANCROID. 711 view. Certainly, in some cases the cauliflower form becomes lost in the ordinary characters of medullary cancer ; appearing to be simply a Paveinent-epithelioma of uterus. (Half-size, early stage. After Lancereaux.) The uterus laid open, e, mamillary vegetation filling the vaginal cul-de-sac and almost covering the OS uteri ; u, softening and ulceration of the vaginal mucous membrane. phase in the development, of the latter. Moreover, with cauliflower excrescence of the uterus, malignant disease of undoubted form is occa- sionally found in other parts of the body. At the same time it is emi- nently important in a therapeutical aspect, to bear in mind the appar- ently lesser degree of malignancy of the cauliflower excrescence, and its greater concentration in, or limitation to, the vaginal-portion of the cervix, up to a certain period of its growth, than is at all common with regard to the medullary cancer. Ablation of the growth by amputation of the vaginal-portion is fairly successful, if performed during the stage of localization. It is not easy to get an opportunity of examining the disease in its initiative stages. The symptoms produced are not such as to lead the patient to seek advice. Dr. West says, when he has first seen it, the cervix has been already somewhat increased in size, the os uteri not open, but its lips flattened and expanded, so that their edge, which felt a little ragged, projected a line or two beyond the circumference of the cervix, while their surface was rough and granular. This irregularity was seen to be produced by the aggregation of numerous small, some- what flattened, papillae of a reddish color, semi-transparent, and often bleeding very easily. Generally these small papillae increase in size, and form a distinct outgrowth from the whole circumference of the os uteri of the size of an Q^g, an apple, or even larger. These growths are split up by deep fissures into lobules of various size, all of which seem to be connected together at their base. The dimensions of these growths are not in general the same throughout, but they spring from the surface of the os uteri by a short, thick pedicle, which is the elon- 712 CANCER OF THE UTERUS. ' gated and hypertrophied cervix, and then expand below into the pecu- liar cauliflower shape. At the base the substance is much firmer. Though the vagina does not by any means escape from participation Malignant disease of the uterus, whicli has become brolteu down, the result of ulceration (sometimos called cauliflower excrescence). (Ad nat., St. George's Museum, xiv, 84.) The patient labored under a discharge from the vagina. A fungus excrescence is seen growing from the fundus. She had scirrhus of the breast, and fungus hrematodes of the liver. in the disease, and a granular or papillary structure may be felt some- times extending over its roof, and for some distance along one or other wall, yet this is by no means constant. The tendency to involve adja- cent parts is far less than in ordinary cancer. Usually the outgrowth, in the course of time, disappears in part, under the processes of alter- nate partial death and reproduction which characterize the medullary SAECOMA. 713 cancer. The irregular, sharp-cut edge of the os, whence it grew, is at first felt granular and mucous within, but afterwards grows thicker and nodulated, assuming by degrees all the characters of a part which has from the first been the seat of medullary cancer. Cauliflower growth of the cervix uteri (sarcoma). (By H. Arnott.) From a specimen furnished by the author, removed by galvano-caustic operation. 3. Spindle-cell sarcoma is a structure made up of densely-packed cells having a spindle shape, being usually arrayed in a tolerably reg- ular manner, and containing generally single, rarely two, compara- tively large oval nuclei. In neither of the cases of uterine sarcoma was anything like encapsulation observed, either in the uterus or in the nodules in the lungs or glands. The sarcoma in to the last. I diagnosed, however, from the general cachexia and increasing weakness without an explainable cause. There were no secondary deposits in other organs ; the liver was, however, in PROGNOSIS AND DURATION. 725 a state of amyloid degeneration." Pain is due partly to the stretching of the muscular fibre, partly to the contractile efforts aroused by the parasitic growth, partly by the pressure of the enlarged uterus upon surrounding structures, partly to the invasion of surrounding structures by the disease, and partly by the nerves themselves being affected by it. In some cases reflex irritation produces pain in distant parts, and vomiting is not infrequent, especially in the advanced stages. After lasting some time, the cervical canal will commonly undergo some dilatation. But the surest test of intra-uterine cancer is to bring away small fragments of the superficial projections from the cavity, and subject them to microscopical examination. In describing endometritis, we have seen that there are cases in which small pisiform excrescences exist, whose nature, or rather whose history, is for a time a source of doubt. In endometritis or metritis not complicated with cancer, the walls of the uterus are less rigid. To facilitate this preliminary dilatation of the cervix, it may be effected by tents. Then Sims's curette (see Fig. 97, p. 476) may be in- troduced and a shred easily scraped off. This dilatation will also per- mit of digital exploration. The patient under chloroform, the hand may, if necessary, be passed into the vagina, the finger will then easily survey the interior of the uterus, and recognize the pulpy projections of malignant disease. There is the less objection to this proceeding, because dilatation effected for diagnosis is useful for treatment. As a guide to treatment as well as to prognosis, it is important to distinguish the hind of malignant disease. Thus outbreaks of can- cerous disease are comparatively frequently met with in neighboring glands or in remote viscera. This furnishes a strong argument against hasty operative interference with a view to extirpating the disease. These secondary foci being greatly more common with true cancer and sarcoma than with epithelioma, the microscopic examination of the morbid structure becomes of great importance in determining on a line of treatment. " The scrofulous ulcerations are almost always accompanied by con- siderable engorgement of the cervix uteri." On the other hand, under the microscope, the softened matter is found not to consist of the elements of tubercle, but of epithelial cells similar to those of the uterine mucous membrane, while the indurated callous structure which forms the base of the ulcer is formed of a mixture of fibro-plastic and epidermoid materials. Robin says this kind of ulcer is to the uterus what lupus or cancroid ulcers are to the face. Lebert, Hannover, and Dr. Charles West support the testimony of Robin. The 'prognosis may in general terms be said to be settled when the diagnosis is determined. It is henceforth limited to the questions, How long will the patient survive ? In what manner and to what degree will she suffer? Of course, if we adopt the more hopeful doctrine that at the initial stage the disease is a local one, the prognosis will be favorable in cases where the diagnosis is formed whilst the disease appears to be isolated in the vaginal -portion in such a manner as to admit of complete amputation or destruction. But it is precisely in 726 CANCEE OF THE UTERUS. these cases that diagnosis is liable to be fallacious ; and erroneous diagnosis will vitiate the prognosis. What is the dwalion of cancer of the uterus ? As the early stages so often escape detection, it is not easy to determine the total duration. It is probable that the stage before ulceration, of limitation to the cervix, may last for some months, even two or three years. When ulceration has begun, the downhill course is often rapid. Prognosis will be affected by treatment. For example, if the dis- ease be allowed to run its course uninterrupted, the fatal termination will in many cases come at an earlier date than in those cases where judicious surgical treatment has been adopted. It is very difficult to set out this comparative statement in figures. But a comparison of cases seems to justify certain deductions. Thus we take two cases of cauliflower excrescences, apparently chiefly limited to the vaginal-por- tion, and amputate as far as we can the diseased mass in the one case, and avoid surgical treatment in the other. We may pretty confidently predict that in the second case hemorrhage, watery discharges, and general infection will destroy the patient in a few months. We may with equal confidence predict that, if the diseased mass be fairly removed, the destructive processes will be arrested for a time, and that the patient's life will be prolonged. I have known a patient recover so far that she and her friends believed recovery to be complete ; she became pregnant three months after operation, and was delivered by artificial induction of labor at the end of eight months' gestation. At this time there was return of the disease, but her general health was good. At the time of the operation she was so reduced by hemor- rhages, and the disease M^as so progressive, that it seemed highly probable that she would sink within three months. So in some cases of superficial malignant disease, whether of the cervix uteri or of the interior of the body of the uterus, the removal or alteration of the diseased surface by actual cautery, by nitric, chromic or acetic acid, or by scraping, has stopped bleeding and decom- position, and thus cut off a source of blood-infection. Patients so treated have improved considerably, and it cannot be doubted have had their lives prolonged, and made for a time more endurable. In not a few cases of epithelioma in which no decided local treat- ment has been employed, life has been prolonged several years after the disease has been recognized ; and we have no means of estimating how long it had existed before recognition. In cases of this kind the disease is not uniformly progressive. It seems to proceed by stages with intervals of halt. For a time, seldom indeed very protracted, the disease may even appear to be so completely arrested that the patient is tempted to accept tlie reprieve as a promise of cure. If one of these delusive halts coincide with a new treatment, especially if backed up by the bold assurances of a " cancer-curer," she eagerly interprets all things according to her wishes, and builds up upon this transitory foundation the most confident hope of recovery. Tliese alternations of progress and arrest suggest another reflection which it is very important to bear in mind when we are called upon to pronounce a prognosis. If we express an adverse opinion without TREATMENT. 727 such qualification as the uncertain march of the disease demands, if, straightway on forming a diagnosis of cancer, we declare the nature of the disease and venture to foretell a brief duration of life, especially if we assign a specified limit, we commit a twofold error. One error inflicts needless misery on the patient, the other falls back with not undeserved retaliation upon ourselves. To utter the word " cancer," and to say that the sufferer has only a short time to live, is literally to pronounce sentence of death unmitigated by the hope of reprieve. Such a sentence, whenever it comes, even after long and advancing disease, even after sufferings to escape from which death may have been often silently invoked, falls like a crushing blow, adding to phys- ical torture the agony of despair. Cancer differs in this respect from phthisis in its effect upon the mind. The buoyant hope that to the last so often sustains the subject of phthisis, that flatters him with the belief that the doctors are mis- taken in his case, that there is nothing serious in it, has little or no place in cancer. It may be confidently said that, whereas many persons struck with incurable phthisis, refuse to believe in this reality, few or no persons struck with cancer long indulge in such a dream. INIany who have no sign of cancer are ready to believe that they are suffering from the disease ; few or none who are really suffering from it fail to recognize their condition. And this they will do, although the physician may never have uttered the word. The error that rebounds upon the physician who is too hasty to con- demn is this : Not long after he has passed sentence the patient unex- pectedly improves, or thinks she does; one of those delusive halts is reached, and "another opinion," possibly less skilled and less honest than his own, encourages the welcome belief. For the. time he is dis- credited; to the patient's own injury probably he is discarded. And when at length the inexorable disease resumes its fatal course, he will hardly be forgiven. And as an additional caution against an absolute and uncompromising condemnation, humility should dictate the possi- bility of error in diagnosis. The proper course in framing an opinion, one dictated by truthful- ness, the first law, by the modesty which is conscious of fallibility, and tempered by mercy, is to explain that the case is only to a certain extent amenable to treatment, that, whilst some improvement may be expected, it is likely to be temporary only, and that the usual course of the disease when once established is to shorten life. The patient will almost invariably draw the true significance from such expressions. She will believe that she has cancer. But she will be grateful for having been spared the cruel word. The treatment may most conveniently be discussed under the leading heads of curative and palliative. The first question which always chal- lenges attention is that of curability. In the great majority of cases when first seen, unhappily, this is quickly answered in the negative. The disease has gone too far, or it has assumed a form which precludes the idea of removing it. But in a certain number of cases, the disease is sufficiently isolated in the vaginal-portion to justify the attempt; and in some cases of epithelioma of the cavity of the uterus, where the dis- 728 CANCER OF THE UTERUS. ease is ascertained to be superficial, an attempt to remove or destroy the diseased surface may also be made. The epithelioma or cauliflower excrescence of the vaginal-portion offers the best prospect of cure by amputation. The best test of the fitness for amputation, I think, is the freedom in mobility of the uterus. Amputation was at one time a mode of dealing with cancer of the uterus much in vogue. But it would be useless to invoke the experiences of the past generation of surgeons as to the efficacy of their practice, because error of diagnosis vitiates it to an unknown extent. It is, however, well to cite the ex- cellent summary Samuel Cooper gives of this subject down to his time. "Modern experience proves," he says, ''that when cancer, or rather scirrhus, is confined to the neck of the uterus, it wdll sometimes admit of being successfully removed by excision. The cervix uteri, in the healthy state, projects from three to six lines into the vagina; but M. Lisfranc has known it make no projection at all. The vagina around it is thin, and in contact, on one side, with the bladder, and, on the other, with the rectum ; while upwards it is continuous with the proper substance of the uterus. The vagina may be detached from the cervix uteri to the extent of more than half an inch, without any risk of open- ing the cul-de-sac of the peritoneum, which separates it from the blad- der; but since the latter viscus adheres very intimately to its anterior surface, it might then be reached by the instrument. Behind, the peritoneum not only covers the corresponding surface of the uterus, but also descends over the vagina, to form what M. Velpeau terms the rectogenital excavation ; so that, on this side, the knife, if carried only a few lines would open the peritoneum. M. Velpeau considers it erroneous then to say that there is a space of eight lines in front, and ten behind, between the upper edge of the cervix uteri and the serous membrane of the abdomen. The distance is stated by M. Malgaigne to vary, according to the greater or lesser projection of the cervix. M. Malgaigne also states, that the vagina may always be detached from the cervix to the extent of more than half an inch in front, without hazard of wounding the peritoneum; but, behind, the vagina ascends further, and there is less space between it and the peritoneum. It may be added, that no very large arteries, or veins, are distributed to the neck of the womb. (See Velpeau, 'Nouv. Elem. de Med. Oper.,' t. iii, p. 620; Malgaigne, 'Man. de Med. Oper.,' p. 747, ed. 2.) " According to Baudelocque, the excision of the cervix uteri was fii'st suggested in 1780, by Lauvariot. M. Tarral even ascribes it to Tulpius ; but the tumors which the latter took away were, according to M, Vel- peau, evidently polypi. Lazzari, who puts in a claim for Monteggia, is also believed to have made a similar mistake ; nor has M. Velpeau been able to satisfy himself that the operation was ever performed by Andre-de-la-Craix and Lapeyronie, as M. Tarral represents. Troisberg recommended it, however, in 1787; and as a critical writer observes, sometimes the cervix uteri was removed accidentally with the knife by ignorant persons, who mistook it for a polypus. (See Edin. Med. and Surg. Journ., No. 103, p. 377.) Professor Osiander, of Gottingen, first executed the operation in 1801, on a widow, whose vagina was filled by a very vascular fetid fungus, as large as a child's head, grow- TREATMENT. 729 ing from the orifice of the womb. By means of Smellie's forceps, the fungus was drawn down ; but it broke oft', and a tremendous hemorrhage ensued. The operator, without loss of time, introduced several crooked needles, armed with strong ligatures, through the bottom of the vagina, and body of the uterus, until they emerged at the os tincse. These ligatures served to draw down the uterus, and retain it near the mouth of the vagina. Qsiander then introduced a bistoury above the scirrhous portion, and divided the uterus exactly in the horizontal direction : for an instant the bleeding was profuse, but it was quickly stopped by means of a sponge, saturated with styptics. In about a month the woman recovered. Osiander afterwards performed eight similar opera- tions upon difterent patients, all of whom are reported to have experi- enced a cure. The observations of Osiander were no sooner promulgated in France, than M. Dupuytren adopted the new operation, and made numerous trials of it. M. Recamier followed Dupuytren ; so that, by 1815, the excision of the cervix uteri had become in France a common operation. However, it remained for M. Lisfranc to extend the prac- tice, and to convince the most incredulous of the little danger resulting from it. (M. Yelpeau, ' Nouv. El6m. de Med. Op6r.,' t. iii, p. 615.) Dupuytren also performed the operation eight times ; but, instead of employing the ligatures and knife, as Osiander did, he drew down the uterus with hook forceps, and divided it above the scirrhous part with curved knives and scissors. One of the patients, on whom Dupuytren operated, had a return of the disease, and submitted to a second opera- tion with no better result ; but was afterwards efiPectually cured by the application of caustic, with the aid of the speculum invented by M. Rec- amier. " Even with regard to the excision of the cervix uteri, it is perfectly manifest to me that many of the cases in which it was performed were not truly cancerous. Doubts may be entertained, I think, whether the enormous tumor removed in the very first instance of such opera- tion by Osiander, was really a cancerous aftection. Several of the cases operated upon in Paris were decidedly not of this character. On this point I fully agree with Dr. Brown, an eye-witness, who remarks : ' While I admit the facility with which such a measure may be accom- plished, I must be permitted to doubt its necessity in some of the cases related. The second and third were, in my opinion, such aifections as would have yielded to common local and constitutional measures, and would, I have no doubt, have been so treated by British surgeons, and perhaps by a few of our French brethren.' M. Velpeau would not absolutely renounce the operation. 'It is better,' says he, 'to try it than abandon the woman to a certain death, whenever the disease leaves a hope that the whole of it may be removed.' (See ' Nouv. Elem. de. Med. Oper.,' t. iii, p. 616.) "In 1828 M. Lisfranc had performed this operation on thirty -six individuals, as is stated, for Ganoer uteri, the recognition of which last declaration as a positive fact, I beg to observe, is a matter of great im- portance in determining the merits of the operation. Of the thirty-six patients thus operated upon, 'thirty were then well, three dead, and three in progress of recovery. One female, operated on some years 730 CANCER OF THE UTERUS. before, had since become pregnant, and recently given birth to twins. Lately, at the Hdtel Dieu, the entire uterus has been removed by M. Recamier ; and it has been performed at La Charite, by M. Roux. The patient died in twenty-four hours after the operation.' (See ' Practical Formulary of the Parisian Hospitals,' by F. S. Katier, p. 17.) Lan- genbeck's extirpation of the entire uterus, by cutting through nearly the whole of the linea alba, I do not deem it necessary to detail, as it is a proceeding which I would never recommend to be imitated. The poor woman experienced the same fate as the patient of M. Recamier." In Guy's Museum is a preparation (No. 2259^*^) of the vagina, blad- der, rectum, and part of the colon of a woman, from whom Dr. Blundell a year before death had removed the whole uterus for cancer ; disease invaded rectum, vagina, &c., which proved fatal, but complete union had taken place between the pelvic organs. Dr. Wiltshire has recorded (Brit. Med. Journ., 1873), a case in which the entire uterus was accidentally brought away or sloughed off after an operation, which consisted in scraping the diseased surface. Some cicatrization of the vaginal roof took place, but the disease returned. The question of total extirpation of the uterus is one that scarcely admits of discussion. The circumstances under which it can be seriously contemplated must be very rare. West gives a table of recorded cases of total extir]>ation of the uterus on account of cancerous disease. In three only did the patient survive the operation, and that only for a month; in twenty-two death was the consequence. The Selection of Cases for Amputation of the Vaginal-portion. There is one class of cases in \vhich there should be no hesitation in operating. Just as the surgeon recognizes the propriety of amputating the. breast when the tumor is clearly circumscribed, movable, and no evidence of glandular or constitutional infection can be traced, so should he when similar conditions are found in connection with cancer of the uterus. If, then, we find the uterus freely movable, a distinct neck above the diseased portion, so that we can work beyond the disease in sound tissue, and especially if the disease is ascertained by microscope to be epitheliomatous or cancroid, it is our duty to amputate. This should be done whether profuse bleedings occur or not. The plain course is to anticipate the evils which will certainly come if we leave things alone. In such cases complete cure is not hopeless ; and a long respite from the usual effects of the disease may be confidently looked for. In another class of cases the indication, although not so urgent, is still clear. I refer to those cases in which a certain degree of mobility of the uterus remains, but in which the base of the disease has caught the roof of the vagina, so that no distinct neck or demarcation between healthy and diseased tissue can be made out. If a cauliflower-growth be found under such conditions, and be the source of hemorrhagic and other discharges, the ablation of so much of the diseased mass as can well be surrounded by a wire should be attempted. For a time, at TREATMENT. 731 least, the disease will be stayed. And there is little drawback in the shape of danger from the operation to deter from its performance. Where the vaginal-portion is attacked by medullary cancer, whilst in the stage of localization, especially in the mushroom form, the uterus being still movable, amputation should be performed. The fixing of the uterus being due in almost every case to the exten- sion of the disease to the roof of the vagina, the base of the bladder, and the broad ligaments, is evidence that it has passed the boundary where it can be reached by topical remedies. This fixing is also, I think, in many cases evidence that the disease has invaded the lym- phatic vessels and glands, a still further discouragement from resort to severe surgical treatment. When the operation is determined upon, we have to consider the best mode of performing it. If we use the knife or scissors, especial care must be taken to avoid opening the roof of the vagina behind, and per- forating the retro-uterine peritoneal pouch. To obviate this accident, which might be fatal, the vaginal-portion of the uterus must be care- fully isolated from the vagina. Dr. Emmet (Amer. Journ. of Obstet- rics, 1869) recommends before amputating to examine M^hilst the patient is placed on her knees and elbows. This, by favoring gravitation, enables us to note the exact length of the neck more accurately, since, in the ordinary posture, the neck is always apparently longer from pro- lapse of the uterus. But since it is almost indispensable to the use of the knife or scissors that the whole uterus be brought low down near the vulva, there must always be danger of drawing down the roof of the vagina and the retro- uterine peritoneal pouch with it. And in pursuance of the object to divide the cervix as high as possible in order to get into sound tissue, the danger of opening this pouch is serious. It constitutes an important objection to this mode of operating. The objection applies also to the chain-6craseur, which is very apt to drag in the peritoneal pouch. It applies in a minor degree to the single-wire ^craseur. But the galvano- caustic wire is almost wholly free from this objection. The knife and scissors, and the single wire also, entail serious danger from hemorrhage. To arrest this it may be possible to transfix the stump with a curved needle carrying a silver wire. But the best way is to use the actual cautery. Copper or iron cauteries should always be ready when this operation is undertaken. The Operation of Amputating the Vaginal-'portion of the Uterus affected with Malignant Disease. — By far the best plan is to use the galvano- caustic wire. The patient is placed under chloroform in lithotomy position. (See p. 539.) Sims's speculum is introduced to keep well back the perineum and posterior wall of the vagina. An assistant on either side holds open the lateral and anterior walls of the vagina by small retractors. The diseased mass thus well exposed is seized as far back as possible with a vulsellum, taking care not to tear through the fragile structure. The mass thus brought forward near the vulva partly by gentle traction, but more by the firm pressure of an assistant's hand upon the fundus uteri applied above the symphysis pubis, is then encircled by the cold platinum-wire loop passed over the vulsellum. 732 CANCER OF THE UTERUS. The loop is then accurately adjusted by the finger close to the base of the mass, and therefore close to the roof of the vagina. The slack of the wire is then drawn in, so that the loop, tightly embracing the root of the mass, buries itself in a groove all round. The heat now being turned on burns at once into the part to be removed, leaving the vagina quite secure. The loop is gradually screwed up as the burning pro- ceeds. There should be no hurry in this proceeding. The wire being fine is rapidly cooled by the tissues; it must have time to renew its heat, so that the substance is burnt through, not cut by overtightening the loop. This slow process gives more effectual security against hemor- rhage, and the more thorough burning of the surface also destroys more effectually the remains of the disease in the stump. When the wire has burnt its way through, the diseased mass is removed by the vulsellum, and the stump is carefully examined. A series of concentric rings mark the alternate incandescent and cooler states of the wire in its progress. The bleeding is generally arterial ; one or more fine spirts may be seen. These I have always succeeded in stanching by the actual cautery applied by the galvanic porcelain button. Light swab- bing with small bits of sponge soaked in iced water will facilitate the search for bleeding points. And it is well to syringe out the vagina by playing a stream of iced water against the stump. All bleeding stopped, the vagina should be firmly, not tightly, packed with strips of lint soaked in carbolic oil. The after-dangers are : hemorrhage and retention of urine. The first may be arrested for a time by further plugging. If this fail, all plugs should be removed, and the stump swabbed with perchloride or persulphate of iron. If this fail, the patient must be placed in lithotomy position, the part exposed by Sims's speculum, and the bleed- ing points or surface seared with the actual cautery. The carbolic oil dressing may be removed next day, and a single strip of lint soaked in the same fluid may be renewed daily for a week. After this, washing out with Condy's fluid, or weak chloride of soda, will be useful. The surface will granulate and may cicatrize in two or three weeks. The os uteri should be watched, the sound being oc- casionally passed to obviate cicatricial closure. It would be better to abstain henceforth from sexual intercouse. I have known pregnancy to occur after the operation. The stump, or granulating surface, may be sprinkled every three or four days with powdered sulphate of zinc ; or if any sprouting of ma- lignant excrescence show itself, it may be kept down by nitric acid or chromic acid. As already stated, amputation is sometimes advisable even when there is no reasonable hope that the operation will be curative. It is quite justified in some cases where the disease has extended beyond the vaginal-portion, on the principle, sanctioned by experience, that much good is effected by removing the most active portion of the disease. Amputation of the diseased jiart is not the only method which has been proposed and practiced with the view of curing cancer. As in the case of cancer of the breast various caustics have been employed : as the chloride of zinc, Vienna paste, and others. Their use with the TREATMENT. 733 i view of destroying the diseased mass, is now, I believe, generally abandoned. But quite recently attempts to effect a radical cure by acting upon the cancerous growth have been made on a somewhat dif- ferent principle. Bromine in solution has been recommended by Dr. Wynn Williams and Dr. Routli to be applied on pledgets of lint to the diseased surface. In some cases it has appeared to check the disease by destroying the vitality of the cancer-cell. I have used it extensively, and have acquired the impression that disease is checked by it. And there is no doubt that it is most effective as a deodorant. Dr. Broadbent (1866) recommended acetic acid on the following reason- ing; : *' Cancer owes its malia-nancv to its characteristic structure To alter its cells is to put an end to their power of dividing and mul- tiplying, and consequently to arrest the growth of the tumor. In acetic acid we have an agent which on the microscopic slide rapidly effects important changes in cells of every kind, dissolving the cell- wall and affecting the nucleus. Not coagulating albumen, it may dif- fuse itself through a tumor, and, reaching every part equally, it may probably produce similar results when the cells are in situ." He injects equal parts of acetic acid and water. I do not know how far this pro- posal has borne the test of clinical experience. But it seems that a hope of controlling this hitherto intractable disease may be found in its further pursuit. In one case in which I repeated the application several times, phlegmasia dolens supervened. The patient died. Dr. Skene (Amer. Journ. of Obstet., 1869) inserted arrows of chloride of zinc into a presumed cancei"ous affection of the cervix uteri ; recovery resulted. The following passage is quoted from Cooper's " Surgical Diction- ary : " " M. Bayle advocated the application of caustic ; and his advice was founded upon the fact shown by pathological anatomy, that, in the early stage of malignant ulceration of this part, the texture of the uterus is healthy at the distance of two or three lines from the ulcer- ated surface. The patient having been placed in the right position, and the speculum introduced, the cancer is to be cleansed with dossils of charpie. If the surface is irregular, or the seat of fungus granula- tions, they are to be removed with curved scissors, or a sharp-edged kind of scoop (Dupuytren). In this manner, indeed, such growths may be removed, not only from the cervix, but from the interior of the uterus. After the ulcer has been cleaned, a roll of charpie is placed below the speculum, in order to protect the vagina from the action of the caustic. Then the caustic is applied, either the arsenical paste (Bayle), or the pure potash, scraped to a point, and fixed in a ])orte- crayon ; or the acid nitrate of mercury, with which lint is wetted and conveyed with forceps to the ulcer. The application is continued for one minute ; then copious injections of tepid Avater are employed for the removal of the uncombined particles of caustic ; the charpie and specidum are withdrawn, and the patient put into a warm bath. In about four or six days, the application is to be repeated, and, if no ill consequences follow, it is to be continued at short intervals, but more and more lightly each time, in proportion as the cure advances. (Lis- franc ; also Malgaigne, Man. de Med. Oper., p. 745, ed. 2.") 734 CANCER OF THE UTEEUS. . More lately chromic acid, nitric acid, and strong bromine have been used, more with the object of improving the superficial condition of the diseased surface, and of retarding the march of the disease, than with the hope of cure. The strong disposition to thrombosis in the pelvic veins in cancer must be considered in dealing with cases of this disease. The process may be started by the remedies employed, and thus the fatal issue may be precipitated. The actual cautery, and sulphuric acid, chromic acid, perchloride of iron, may easily cause coagulation of the blood in the vessels near the surface where they are applied, and the thrombi so formed may spread backwards. The rule for this application may, I think, be laid down as follows : If our hope is to cure or materially arrest the disease, the cauterizing agent must be applied boldly to the disease so as to cause a slough of some depth. Now this cannot be done safely if the disease is not limited to the cervix or the lower part of the uterus. If the uterus still retain its mobility we have a reasona- ble assurance that the disease has not invaded the connective tissue and vessels in the broad ligaments around the cervix. Under these condi- tions the caustics may be freely applied. But if the disease have ex- tended high up in the cervix it will not be judicious to ap[)ly the cauteries named so freely as in the first order of cases. There is, however, another indication for the use of powerful cauteries, namely, to arrest profuse hemorrhage and to alter the character of the discharges. This may commonly be most effectually done by a superficial applica- tion of strong chromic acid, nitric acid, or perchloride of iron, or the actual cautery. The bleeding is instantly controlled ; and a thin slough is formed, which, when thrown off, leaves a comparatively healthy granulating surface, from which for a time the discharge is not offen- sive. Considerable constitutional improvement often attends the local change. Mr. Campbell de Morgan says,^ in reference to the caustic treatment of cancer, there is an evil attending slow cauterization, namely, that while the caustic is doing its work increased action is going on in its neighborhood, with augmented growth of that part of the cancer which the cancer has not yet reached. If the whole diseased structure be not included in one operation, the chances are that the undestroyed tissue will grow with greater rapidity, and quickly affect distant parts. Still in many cases the method by gradual cauterization is safe and effective. He however urges it as an absolute rule that if caustics are employed with a curative intention, they must be used fully and decisively. Latterly Dr. Routh has advocated the topical use of pepsin. Two successful cases had been published by Drs. Tansini and Pagello (Gazetta Med. Lomb., 1869). Dr. Routh employs this agent in the following way : He first destroys the surface of the morbid growth by the actual cautery, by scraping, by bromine or other agents. A raw surface thus obtained, or even whilst the slough still remains, he applies the gastric juice on a piece of lint by help of a speculum. This is covered 1 " The Oric;in of Cancer considered with Ileference to the Treatment of the Disease." 1872. TEEATMENT. 735 by a piece of oil-silk, and supported by a plug. This should be done twice a day, oftener if practicable. The digestive property of the pep- sin acts powerfully uj)on the morbid structure. He reports eases in which decided benefit, even cure resulted. Of course the objection has been raised that the cases were not cancer. But the proper course it appears to me is to pursue the treatment in cases whose nature is not doubtful. I have seen one case with Dr. Bantock treated in this way. I was satisfied that the solvent and antiseptic action of the remedy upon the diseased surface M'as great and beneficial. All objections of a theoretical kind must ultimately fall before the evidence of clinical experience. But we should remember that pepsin does not act upon the structure of the living stomach ; that it only acts vigorously on dead tissue. At one of the first meetings of the Pathological Society I exhibited the stomach of a woman, a great part of which had been dissolved after death by its own gastric juice. John Hunter's observa- tions on this subject are well known. In its application to cancerous growths as advised by Dr. Routh, a slough is first formed. This will be easily dealt with by the pepsin. But further observations are desirable to try how far the pepsin can be made to act upon the deeper parts of the living morbid substance. I do not refer to the use of arsenic in this connection, on account of the danger there is of poisoning the system when applied in quantity sufficient to do any local good to an ulcerating absorbing surface. In the case of sarcoma beginning in the body of the uterus, if we have the opportunity of recognizing the disease in its early stage whilst limited to the lining membrane, caustics may be applied decisively, the cervix uteri having been previously dilated to allow this to be done. But this form of malignant disease also tends to advance into the cervix, attacking the region where the vessels enter. When it has reached tliis point, and especially if any marked amount of fixing of the uterus exist, cauteries should no longer be applied with that degree of severity which is indicated when their curative agency is looked for. The mode of proceeding in dealing with intra-uterine cancer is, 1st, to dilate the cervix with one or more laminaria-tents ; 2dly, having ascer- tained the form which the disease assumes, we proceed, if there are projecting masses more or less polypoid, to shave them off by the wire- ecraseur, and to cauterize the surface afterwards with the actual cautery or nitric acid, or if there are small excrescences to scrape them off' with Sims's or Becamier's curette, applying nitric acid afterwards. The actual cautery may be applied by an iron or copper olive-cautery through the cervix, held well open by tenacula. But this is difficult to accomplish without burning the cervical canal in transit. The porce- lain olive of the galvanic apparatus is decidedly superior. It can be introduced whilst cold to the very spot we want to cauterize ; and the heat being turned on and off" at will, its action can be defined with absolute precision. To apply nitric acid, we insert a tube like Atthill's into the cervix to serve as a sheath or canula, through which a rod carrying cotton- wool steeped in the acid is passed. I have devised a funnel-shajoed tube (Fig. 166, p. 737), mounted on a stem for this purpose, which I 736 CANCER OF THE UTERUS. find more convenient than Atthill's. I use aSims's duck-bill speculum in the ordinary way ; then the cervical tube is passed into its place, and the stem and handle keep back the anterior wall of the vagina, aifording ready access to the uterus. The instrument has also the advantage of being easily withdrawn. The nitric acid swab should be pressed firmly down upon the inner surface of the uterus, so as to insure decided action upon the morbid surface. The action is quite superficial. There is no reason to apprehend danger from its use. The palliative treatment of cancer consists in controlling pain, hemor- rhage, and oiFensive discharges ; in mitigating the distress produced by the extension of the disease to neighboring organs, especially the bladder and rectum ; and in meeting as best we may the constitutional deterioration. Pain becomes especially exhaustive in the latter stages. We must have recourse to opium in its varied forms, in pill, draught, suppository, vaginal pessary, subcutaneous injection ; to conium, belladonna, Indian hemp, chloral, and the other known narcotics and sedatives. The local application of sedatives has been extensively tried by Simpson. He played streams of carbonic acid, and of chloroform vapor upon the diseased parts. In some cases benefit resulted, but the difficulty is great in sustaining the action of these remedies. The effect is but tem- porary. The application of cold by ice or freezing mixtures was at one time urged by Dr. James Arnott, in the belief that it was even curative by killing the diseased tissue. I have tried the application of cold by means of the ether-spray in several cases. It produced such suffering that I have abandoned it. The necessity of restraining hemorrhage when profuse becomes urgent. Patients, however, often affirm that they have felt material relief after an attack. No doubt local congestion is relieved by it, and the habit of free bleeding is commonly attended by a habit or capacity for mak- ing blood with rapidity. But we never know that bleeding will not exceed the recuperative capacity of the system, and in the long run repeated losses break down the constitutional powers. Bleeding, there- fore, must, as a rule, be stopped. Two principles call for attention. The first is to produce such a change in the condition of the diseased part as will lessen its morbid activity and the determination of blood to it. The means of accomplishing "this are included in the curative treatment : removal of the diseased mass wholly or in part, by cautery, by knife or scraper, and the securing a new surface. The second principle is that of simple hsemostasis. This is carried out by the direct application of styptics. Amongst these the best are chromic acid, nitric acid, perchloride and persulphate of iron. To apply these effectually, the speculum must be used. Great care is necessary in passing this instrument, as the fragility of the morbid tissues is so great that it is often difficult to introduce it without causing fresh bleeding. If chromic acid be used, the crystals just moistened with water is the best form. A small pledget of lint or cotton-wool steeped in this is then pressed gently on the bleeding surface. It turns the part bright yellow, chars it, and generally stops the bleeding effec- tually. The superfluous acid can be washed out by a Higginson's TREATMENT. 737 syringe. Nitric acid fuming should be used in a similar manner. The iron-styptics should also be used very strong. But since an attack of hemorrhage may come on at any unforeseen time, and under circumstances which preclude skilled assistance, the patient or her attendants must be armed with appliances and instruc- tions to meet the emergency. As a temporary expedient, a lump of ice may be passed into the vagina. But a more cer- tain way is first lightly to syringe out the vagina with cold water, then to introduce by means of my plug- speculum (see p. 131) a pledget of cotton-wool soaked in the strong solution of perchloride of iron. As a rule, the plug should not be left in more than an hour. Its retention is often accused by patients of causing heat, distress, and of provoking return of bleeding. The control of the offensive watery disharge in- cludes the use of deodorants or disinfectants. Clean- liness is the first thing to secure. Syringing with Condy's solution is of service. But since the frequent use of instruments is attended with more than incon- venience, injection of more efficient disinfectants should be resorted to. The agent which has given me the most satisfaction on the whole is acetate of lead. The action of this is heemostatic, deodorant, and sedative. It has often struck me that it has a beneficial effect upon the diseased surface. It may be used in the pro- portion of one drachm to a pint of water. An excellent disinfectant is a weak solution of bromine made of five fluid ounces of the British Pharmacopoeia solution diluted with fifteen ounces of water. One objection to its use, inseparable however from its virtues, is that it has a pungent odor. A weak solution of carbolic acid is often useful. I have found creasote singularly efficacious, and in a ward where a cancerous patient is so often a source of annoyance to other patients, the nurses have assured me that the odor of creasote so used was not only not complained of, but was even liked. Chlorozone is an excellent disinfectant. Alum is one of the best deodorants. Its property of coagulating albuminous matter makes it extremely useful in these cases. Chloride of zinc has also its advantages; but the lead and alum, being powerful astringents, are generally to be preferred. I have tried the much-vaunted chloralum \vithout discov- ering that it is superior to the agents described above. Dr. Burow, of Konigsberg, speaks highly of the effect of the chlorate of potash upon ulcerating carcinoma. The surface is sprinkled once a day with the salt. The steady use of styptics and disinfectants is often attended by good effect in lessening constitutional infection 47 Intra-uterine specu- lum. (Half-size.) By remov- 738 CANCER OF THE UTEBUS. ing the foul excretions as soon as formed, and by altering the excreting surface, absorption of noxious material is prevented. In this way the agents we have been describing exert an important secondary effect. The Gonstitutional treatment or management of cancer patients is a matter of great importance. We may with advantage begin by elimi- nating the Isedentia. Foremost amongst these is excess of alcohol. Stimulants carried beyond the most moderate extent are decidedly injurious. By exciting the circulation, they increase the determination of blood to the diseased organ, and promote hemorrhage, if not also the advance of the disease. The diet of patients suffering from cancer is a matter of great moment. Mr. De Morgan called attention to a fact, the truth of which cannot be doubted, namely, that the disease occurs for the most part in persons strong and well-nourished, and remarkable for general good health. This shows that the disease does not arise from want of tone or defect of nutrition. Hence it would appear very doubtful whether it is wise to recommend the patient, as is often done, " to keep up well," to take plenty of nourishment, to use stinuilants, with the view of counteracting this supposed poisoned state of system. If an undue amount of nourishment is taken, a fair share of it will go to the increase of the disease, and stimulants which are taken to the extent of quickening the circulation will at the same time increase that of the tumor and accelerate its growth. The restriction to a light milk and farinaceous diet has been recommended from early times. A distin- guished physician told Mr. De Morgan that his wife had cancer of the uterus ; he kept her for a long time on the sparest vegetable diet, just enough to sustain life ; the disease disappeared. Years afterwards the cancer reappeared and destroyed her, circumstances having prevented her from observing the same regime as before. Rest is commonly necessary. But if it be found that moderate exercise, as in driving, does not increase pain or hemorrliage, it is desi- rable to take it. Physiological rest is the most important. The wise physician will exercise great reserve in enforcing sexual abstinence in the great majority of cases of uterine disease. But in the case of cancer, his injunction should be decided. The direct and remote evils produced by intercourse are so great that regard for the patient's safety leaves no doubt as to the necessity of abstinence. Attacks of hemor- rhage, even fatal, have been traced to imjjrudence in this respect. That the activity of the disease is promoted by it there can be no doubt. And in the not improbable event of pregnancy, the risk encountered is vital. The internal use of remedies is greatly limited to the fulfilment of special accidental indications. The bowels commonly demand atten- tion. Constipation is a troublesome complication. It must be met by suitable aperients, and by enemata. Bromine and iodine internally were greatly relied upon by Boinet. Iron seems indicated by the degraded state of the blood. But it is not often well borne. Salines I have found of great service. Bismuth, strychnine, hydi'ocyanic acid will occasionally be required to allay irritability of stomach. I have seen in many cases remarkable benefit from cod-liver oil. DISEASES OF THE VAGINA. 739 CHAPTER LI. THE DISEASES OF THE VAGINA. COLPITIS: SIMPLE, INFECTIOUS, ACUTE, CHRONIC; DISPLACE- MENTS ; WOUNDS ; DILATATION; ATROPHY; SLOUGHING; CIC- ATRICES; VESICO-VAGINAL AND RECTO-VAGINAL FISTULA: RUPTURED PERINEUM; NEW FORMATIONS: FIBROUS TU- MORS; SARCOMATA; CYSTIC TUMORS; HEMATOMA; CAL- CULI; CANCER. Some of the abnormal conditions of the vagina have been described in preceding chapters (see Atresia, Leucorrhoea, &c.). It will here be necessary to describe those which have received insufficient attention. Vaginitis or Colpitis. Acute vaginitis sometimes follows labor, the result apparently of contusion of structures in a state of exalted vascularity. In these cases exfoliation or desquamation of the epithelial layer is very active, so that the bared surface presents a raw, velv^ety, red, angry appearance. Even during pregnancy the intense vascularity of the vagina disposes to free shedding of epithelium, which often collects about the summit of the vagina in the form of a creamy pasma, or in shreds or pellicles. Acute vaginitis may also occur from exposure to cold during a men- strual period, from injury, from the introduction of foreign substances, from the use of irritating powders or injections. In children it may be caused by ascarides, by neglect of cleanliness, by improper manipu- lation. At page 77 I have referred to the association of vaginitis with the eruptive fevers. Scarlatina, especially, affects the genito-urinary mucous tract, and thus I have known intense vaginitis produced. The first case of the kind I saw was that of a young woman in Chomel's wards at the Hotel Dieu, in 1840. In these cases there is prolific gen- eration and casting off of epithelium, attended and followed by a severe form of leucorrhoea. Leucorrhoea in children is not very uncommon, and when observed is sometimes the source of most distressing suspicions. It is therefore eminently necessary to call attention to the fact that children are liable to non-virulent discharges, depending upon accidental causes. The symptoms of vaginitis and vulvitis in children are : in the acute stage, the patient complains at the onset of itching or burning at the vulva. This is increased during micturition. A whitish opaque moisture is formed over the surface of the labia, and these are often redder than in the normal state. The patient has often a difficulty in walking, the 740 DISEASES OF THE VAGINA. friction increasing the irritation of the inflamed surfaces. In the chronic state, the discharge is a serous or lactescent moisture ; there is little pain in the vulva, but sometimes a dull pain above the pubes, spreading to the groins and inner part of the thighs. This form of vulvo-vaginitis has been noticed at the time of denti- tion, from indigestion, from exposure to heat and fatigue — as from dancing, — froui constitutional diathesis, especially the strumous, resem- bling in this respect the tumid chronic inflammation of the conjunctiva and nares. The treatment consists in putting the child in a warm bath every two or three days, applying demulcent lotions, as poppyhead, mallow, or linseed decoctions, or weak acetate of lead, and in regulating the secretions ; in the use of iron, iodine, and cod-liver oil. The most common cause of acute or subacute colpitis is gonoi^rhoeal infection. In this case the mucous membrane, especially at the fundus of the vagina, is intensely red. There is copious muco-purulent secre- tion of a yellowish or greenish tint, sometimes tinged with blood. This is found chiefly at the fundus of the vagina, surrounding and bathing the vaginal-portion of the uterus, which is involved in the like condition. An experienced practitioner will generally recognize the specific character of this inflammation ; but it is easy to fall into error in diag- nosis. The moral and social complications are at times so intricate, and the reasons for dissimulation on the part of the patients are so strong and various, that even in the presence of the most convincing clinical proof, it will rarely be wise to commit ourselves to a plain expression of opinion. The subjects themselves may, moreover, be perfectly in- nocent and unconscious of the nature of the affection. And we must not always expect to be dealt with candidly. What we say will per- haps be misinterpreted or misrepresented. A circumspect reticence therefore becomes a virtue and a duty in the physician. Gonorrhoeal colpitis is very apt to invade the cervical canal, and thence to pass into the chronic stage, a condition analogous to gleet in the male. It is also apt to spread along the urethra. This is more frequent, says Guerin, than is commonly thought. Occasionally the orifice of the urethra is inflamed, swollen, dotted with red points or pimples, cor- responding to the openings of the lacunse, and in such cases recogni- tion of urethritis is easy ; but when the disease is internal, and when no mucus or pus appears externally, detection becomes more difficult. When any doubt exists, the patient should be prevented from em]3tying the bladder for several hours ; the finger should then be introduced into the vagina, and drawn along the anterior wall, so as to press out any purulent matter collected within the urethra. Dr. Giles, Dr. Noeggerath, and Dr. Angus Macdonald, have written interesting clinical memoirs on latent gonorrhoea, w'lih. special reference to the puerperal state. They have shown that at this time there is a peculiar danger of peritonitis if gonorrhoea existed. Chronic catarrhal inflammation commonly occurs after rejieated acute inflammations, as from menstrual suppression, gonorrhoeal infection, TEEATMENT. 741 childbed, in chlorotic or scrofulous persons, from uterine catarrh, the irritation of uterine polypi, or hypertrophied vaginal-portion, disloca- tions of the uterus, the formation of morbid growths, and ulcerative processes. It is also frequent, and often at first acute in character, in newly-married women, from excess or awkwardness in intercourse. Vaginal catarrh is of importance from its liability to spread to the uterus, and thence to the tubes; and it disposes to intussusception and prolapsus of the vagina. Inflammation of the submucous fibrous coat of the vagina is not common apart from traumatic causes. Iviwisch has called attention to the occurrence of abscesses in this tissue during pregnancy. But there is a chronic form, not very uncommon, the result in most of the cases which I have seen of imperfect or irritating intercourse. It is marked by thickening of the walls of the vagina, the formation of abscesses, and a degree, sometimes considerable, of atresia of the canal. Diphtheritic inflammation most frequently occurs in childbed, and especially in lying-in hospitals ; but I have seen an example in home practice. There is a form of vaginitis in which the mucous membrane is covered by pellicles, or flakes, white, very brittle, to which the name diphtheritis is sometimes given. At best this should be called pseudo- diphtheritis. It is not usually attended by febrile symptoms. The vaginitis is not very acute, it is strictly limited to the nmcous mem- brane,, and the pellicle consists almost entirely of agglomerated epithe- lium scales. The formation of the pellicle seems simply due to the preponderance of these scales over the mucous plasma. If the mucous plasma were more abundant, the discharge would be called leucorrhoea. The Symptoms and Diagnosis of Colpitis. In the acute stage there is pain, often severe, characterized as " burn- ing," in the part^ Dyspareunia is almost necessarily present. Some febrile excitement attends. Unlike metritis, it is very rarely complica- ted with peritonitis. Hence the local and constitutional symptoms are less severe. Dysuria may also attend the gonorrhoeal form. In this form also there is leucorrhoea of the character described. But absolute diagnosis can only be made out by aid of the speculum, when we can take note of the vivid red mucous membrane, and see the discharge in situ. In the chronic and non-specific forms, pain is not so much com- plained of. I must refer to the chapter on " Leucorrhoea " for further information on this subject. When the disease has involved the cervi- cal canal, vaginal injections are inefficient. Topical applications inside the cervix are essential. One form of pain, " Vaginismus," has been described in the chapter on " Dyspareunia." The treatment of colpitis consists greatly in observing rest and cleanli- ness. To aid in securing rest, an essential condition often is to keep the inflamed walls of the vagina apart. This is accomplished by wearing Sims's or my vaginal-rest for hours during the day ; by using a plug of cotton- wool steeped in tannin and glycerin, changing it two or three 742 DISEASES OF THE VAGINA. times a day, or by simple rest in the recumbent posture. Douches of tepid water or poppy-head decoction are often of signal service. In the more acute stages injections of lead in proportion of one drachm to a pint of water are best borne; later, sulphate of zinc, chloride of zinc, alum, tannin are more serviceable. The gonorrhoeal inflammations may be treated exactly on the same principles as the similar affection in the male. The quickest method of cure is undoubtedly to touch the dis- eased surface lightly every other day with solid nitrate of silver, or to swab it with, a strong solution. This, of course, requires skilled aid and the speculum. Displacements of the Vagina. — Displacements of the vagina can hardly arise without the preliminary condition of relaxation, or of displacement of the uterus. Whether prolapsus of the uterus be the cause or the effect of prolapsus of the vagina is a question already dis- cussed. No doubt, prolapsus of the vagina is commonly associated with prolapsus of the uterus, but I believe prolapse of the vagina may exist independently. There is a preparation in St. George's Museum (No. xiv, 106) which seems to show that vaginal rectocele may exist without prolapse of the uterus. Hernias consist in an inversion of the anterior wall of the vagina with the bladder, — cystooele vaginalis ; or in inversion of the posterior wall from the lower end of the rectum, — rectocele vaginalis; or in a hernia vaginalis posterior, — enter ocele vaginalis. This last form consists in dilatation of Douglas's pouch to a hernial sac, so that the peritoneum is carried deeply down behind the wall of the vagina to the perineum. The intestinal folds contained in it drag upon the vagina, then tilt it from behind, pressing from above downwards more and more of its circumference, according to the degree to which the uterus follows the traction and descends. The prolapsus of the vagina thus produced gradually proceeds to a complete inversion, which contains in its cavity the prolapsed uterus, which in consequence of this traction undergoes very frequently a considerable or even monstrous elongation of its cervix. Commonly the rectum is also protruded to a prolapsus by the hernia. In rare cases, in consequence of the mass of intestinal convo- lutions accumulating in the hernial sac between the uterus and the inverted vagina, laceration of the posterior wall of the vagina has occurred with a fatal issue. The treatment of vaginal prolapse and hernia in most cases merges in that which is indicated for prolapsus of the uterus. In some lew cases a Hodge or stem-pessary may be useful. Astringent injections are almost always serviceable. But when the prolapse is great so that folds of vagina protrude through the vulva, becoming liable to chafing , and inflammation, surgical treatment is necessary to remove the redun- dant portion. A piece of the mucous membrane of size and form indi- cated by the conditions of the case must be dissected off, and the edges brought together, so as to contract the canal. It will commonly be necessary to combine this proceeding with the perineal operation. The vagina is liable to wounds from the introduction of foreign bodies, from accidents, and from surgical operations. The most frequent cause of the lesions that come before the surgeon WOUNDS. 743 is severe labor. The vagina is liable to undergo laceration, contusions, leading to partial necrosis, or sloughs. Hence result cicatrices, M'hich may lead to occlusion of the vagina, or fistulous opening into the bladder or rectum. Yesico-vagmal fistula may be produced by the mere pressure of the head, long continued, jamming tlie bladder against the pubes. In precipitate labor, or in protracted labor in primiparse where the vulva is rigid, the perineum is apt to undergo laceration, backwards to the anus. The anterior commissure also, as I pointed out many years ago (see Tyler-Smith's "Obstetric Medicine,") is liable to rupture, wdience severe hemorrhage may arise. There is a singular preparation in the Museum of St. George's Hospital (Series xiv, 108). It is a case of laceration of the vagina from coition. There is a rent passing along the upper two inches of the vagina, dividing the mucous membrane and the adjoining fibres of the muscular coat. The rent deepens as it ascends, and on a level with the OS uteri has broken through into the peritoneal cavity. The hole in the peritoneum is not quite large enough to admit the little finger. The subject was an old woman. The most trivial tvounds of the vagina are sometimes followed by profuse bleeding. This is especially the case during pregnancy. But at any time the slightest nick, puncture, or incision may give rise to profuse bleeding if the patient assume the erect posture and be exposed to any exertion. A surgeon snipped off' a very small warty excrescence from the vagina just inside the vulva. The woman nearly bled to death. Plugging and the application of styptics failed to arrest it. I passed a curved needle armed with a suture so as to get quite under the little wound. Tlie suture drawn tight effectually controlled the bleeding. This is the surest plan to adopt. A short sewing needle held in a forceps might on emergency answer. But in some cases, steady pressure with a pad of lint steeped in per(rhloride of iron or other styptic may be enough, absolute rest in recumbent posture being understood. Professor E. Martin describes a condition of the vagina which is observed under particular circumstances. It consists in a temporary dilatation of the fundus, not the result of stretching or distension, but which is caused by a pathological action of the neighboring ligaments ; that is, the pubo-vesico-uterine, and the sacro-uterine, the muscular bundles of which contract. The examining finger finds the roof of the vagina so wide that it seems as if its walls were applied close to the sides of the pelvis. This condition is found when there is hemorrhage with uterine colic, and in secondary puerperal hemorrhage (and especially in abortion, R. B.). In such cases the os uteri is open, and the roof of the vagina seems higher than usual. Under the use of means to arrest the bleeding this dilatation disappears completely in twenty-four hours. Dr. V. Haselberg, speaking on the subject, says the dilatation takes place under the effort of the uterus to empty itself. (Monats. fur Geb., 1869.) There is a form of atrophic contraction of the vagina which takes 744 DISEASES OF THE VAGINA. place in advancing age. • The walls lose elasticity, the canal becomes smaller, sometimes funnel-shaped or conical, the apex being at the roof, where the remains of the atrophied cervix uteri may be felt. Some cases of this kind are not easy to distinguish from the strictures which ensue occasionally upon cancer. This atrophic contraction is most common in women who have abandoned the habit of sexual intercourse. It explains the rupture in the specimen in St. George's Museum, de- scribed at page 743. The vagina may be the seat of various uleerative processes. Excoriations occur from catarrhal suppuration or the chafing of fibroid polypus, of pessaries, &c. Syphilitic sores may occur in any portion of the vaginal canal, but the most frequent locality is the fold or duplicature at the fundus, into which the vaginal portion of the cervix uteri is inserted. This is com- monly attended by colpitis. To the touch an excavated syphilitic sore may at first impose upon the surgeon for the os uteri. The tuberculous and cancerous ulcerations generally begin on the vaginal-portion, and spread to the roof of the vagina. The latter especially are unhappily frequent, and often lead to destruction of the walls between bladder and rectum, establishing cloaca. The vagina is also sometimes ulcerated from without, through the burrowing of subperitoneal abscesses which make their way into the vagina. Sloughing of the vagina also occurs as the result of the bruising and pressure encountered during protracted labor, from diphtheritis, from necrosis in severe fevers, from peri-vaginal hjematoceles and abscesses, from necrosis resulting from the pressure of fibroid tumors so large as to become impacted, or from the impaction of a retroverted gravid uterus. The healing of vaginal sloughs by granulation frequently results in the formation of cicatrices. Those cicatrices which lead to atresia or stenosis of the canal have been described, in their pathological and therapeutical bearing, under " Dysmenorrhoea from retention." But cicatrices, in the form of bands or falciform projections into the vagina, not extensive enough to close the canal, are not uncommon. They produce distress of a different kind. The cicatrix I have most frequently met with is a crescentic or falciform band, beginning at the os uteri by one horn and the vaginal wall by the other, at a distance of an inch or more. This, contracting, may half shut off the os uteri from the canal of the vagina below, forming a pouch or sac above. It also not uncommonly pulls the cervix uteri to one side, or forwards or back- wards, producing deviation of- the uterus. It thus becomes a cause of dysmenorrhoea, sometimes of monorrhagia, and of dyspareunia. I have seen these cicatrices follow labor, instrumental and not in- strumental, also cauterization of the os uteri by potassa cum calce, and even by nitrate of silver incautiously applied. They have also followed 'the use of too concentrated chromic acid and perchloride of iron. The symptoms caused by these cicatrices are so severe that treat- ment to relieve them assumes importance. This treatment consists in dividing the cicatrices so as to allow the vaginal wall to resume its FISTULA. 745 natural form. When the cicatrix extends up the vaginal-portion this part should be set free, by dividing the horn which seizes and binds it to the vaginal wall. The first step is to dissect off the adventitious membrane from the vaginal-portion, so as to restore this part to its normal condition; and then several nicks should be made at different points of the crescentic edge, as deeply as is felt to be safe, taking great care of course not to go through the vaginal wall. This operation is best done without the speculum. The cicatrix is made tense by the fore- finger of the left hand, and then the edge of a Simpson's metrotome is turned upon it. When thus nicked these cicatrices have a tendency to disappear. But it is likely that the incisions will have to be repeated from time to time before they are overcome. Sometimes the bleeding attending this operation is very profuse; and it is, I think, always prudent to plug the vagina firmly with j)ledgets of lint soaked in olive oil and carbolic acid. The operation should in every case, however slight it may seem to be, be performed on the patient in bed. Absolute rest in the recumbent posture should be, rigidly enforced for four or five days afterwards. If these precautions are adopted there will prob- abl}^ be no bleeding of importance; if neglected, profuse, even fatal hemorrhage may result. Under no consideration should the operation be performed in the out-patient's room of a hospital, or in the physi- cian's consulting-room. A day or two after the operation it is desirable to apply a Hodge pessary, so shaped that it will keep the roof of the vagina on the stretch, so as to obviate the disposition to contract, which the scar fre- quently manifests. I have seen extensive cicatrices gradually disap- pear under the continual stretching of a Hodge pessary. In one case, that of a lady who had suffered extensive sloughing after labor, the vagina was very contracted. But in a year the canal was so nearly restored to its natural state that she subsequently bore a child at term without artificial aid. Fig. 167 represents a not uncommon form of utero-vaginal cicatricial band. Raised on the finger it is made tense for division. There are four kinds of fistulce of the genital organs, — 1. Between the bladder or urethra and vagina; the most common. 2. Between bladder and uterus; rare. 3. Between rectum and vagina; not very rare. 4. Between rectum and uterus ; very rare. To these might be added uterine fistulae, communicating with an abscess in the pelvis; and fistulse opening into the vagina from perimetric abscesses or retro- uterine hsematocele. The most common seat of the vesico-vagina[ fistula is near or half an inch below the anterior edge of the os uteri'. This is the part which is most liable to compression between the child's head and the os pubis during; labor. It is not so often the result of laceration as of mortifica- tion from protracted pressure. I have no doubt that in many cases the mortification has been due to the pressure of an edge of the short straight forceps, the instrument having been applied according to the old and erroneous law, one blade behind the pubes. In these cases the urine may either be retained for a few days after labor, or it may flow by the urethra with more or less pain. But at the end of a week or so the pa- 746 DISEASES OF THE VAGHSTA. tient becomes conscious that her water runs awaj by the vagina more or less continuously; in fact, that she cannot hold it; that she is, as the expression goes, "always wet." Excoriation of the external genitals is a frequent consequence. Sometimes, in the recumbent posture, the vulvar sphincter being unimpaired, the vagina forms a pouch, which Fig. 167. Cicatricial band binding os uteri to roof of vagina. will retain a considerable quantity of urine, acting the part of a sub- sidiary bladder. But on rising or exertion this accumulation is dis- charged, and the dribbling goes on. The incontinence begins from the falling of the slough. This leaves a hole in the septum between bladder and vagina, the edges of which gradually cicatrize. In this process the hole contracts, often so much that there may be great difficulty in finding it. But a hole that will barely admit a fine probe is big enough to drain off the urine as fast as it is secreted. The hole may be big enough to admit the tip of the finger. The greater part of the urethra may be destroyed. In some cases the lower seg- ment of the uterus is lost, as well as the base of the bladder. The an- terior lip of the OS uteri is not unconuiionly lost. In one case lately under my care no cervix could be found. There was nothing in the roof of the vagina to be found but a fistulous opening admitting the tip of the finger. This was cured in two operations; and tlie patient menstruated through the bladder. The diagnosis is established by sight and by touch. Whenever incontinence of urine has come on after labor, examination by finger and sound, and by speculum is indicated. The patient lying on her left side, the catheter or sound is passed into the bladder, and the fore- finger in the vagina carried to the os uteri, and then brought down along the course of the urethra, feeling for the sound through the fistula, if one exists. Generally the puckered cicatrix of the fistula is felt, and guides to the opening. Through this opening is felt project- ^ FISTULA. 747 ing a velvety nipple-like mass, the mucous membrane of the bladder. Through this the point of the sound is sometimes carried from the bladder. This evidence, complete in itself, may be extended by the use of Sims's speculum. The perineum being lifted away the aperture may usually be seen ; the mucous membrane of the bladder bulging like a cherry or a raspberry, and urine oozing or dribbling through it. The point of the sound may be seen in the fundus of the vagina. In the case of recto-vaginal fistula, the opening may have become so contracted that escape of faces into the vagina is only occasional, that is, when the stools happen to be liquid. It may require some pains to detect the opening. It usually lies rather low down, at the point where the floor of the ])erineum begins to incline forward from the hollow of the sacrum. It may be made evident by finger and sound. Operations for Vesioo-vaginal and Recto-vaginal Fistulce. — Experi- ence is now so ample that a decided conclusion can be arrived at as to the best method of proceeding. The complicated methods in which shot, splints, lead-plates, and other mechanical contrivances, constituted such an essential part, are now either discarded, or ought to be so. All have given way to a very simple proceeding. The instruments really useful are very few, 1. A Sims's speculum. 2. A good forceps to hold the edge of the fistula whilst paring ; some surgeons use a hook. I have contrived a forceps which answers admirably for this purpose. It has the gi'eat advantage of seizing accurately a long strip of mem- brane without tearing through. 3. Right and left-handed fistula- knives set at an angle of 45°, and a straight one. 4. Small stout needles, straight for about an inch from the edge, and then gently curved at the point. 5, A forceps with leaded bite and a sliding catch to hold the needles at any required angle, 6. Fine silver or iron wire, Chinese silk or catgut. The tubular needles through which wire is propelled by a cog-wheel, are really clumsy contrivances. They are very apt to disappoint at the critical moment, and are not so easy to manipulate accurately as the simple needles described. If wire be preferred, the ingenious tubular wire clamps of Dr. Aveling for closing the wound answer best. The two ends of each suture are passed through a tube, this is then run down to the wound by the fingers, bringing the edges accurately together, and the tube is then secured by a perforated shot. The advantages of this contrivance are : accurate closure of the wound by avoiding twisting ; and great facility in removing the sutures, it being simply necessary to cut the tube across, when an end of suture is always found, and easily withdrawn by forceps. I have used this several times with success. But the simple silk suture answers equally well. It was long thought that the recent success attained was due to the use of silver or iron sutures. Gosset led the way by curing a case with silver-gilt wire in 1834. Sims and others adopted metal wire. But the expe- rience of Charles Brooke has been strangely overlooked in the history of this operation. This surgeon thirty years ago cured fistulse by silk sutures secured by his beads. He was also, as I can testify from per- sonal observation, eminently successful in curing perineal lacerations 748 VESICO-VAGINAL FISTULA. by silk and bead sutures. The simplicity and success now attained may be attributed mainly to the introduction of ansesthesia, which enables the operator to proceed with deliberation and accuracy, and to the use of Sims's duck-bill speculum, which gives such complete access to the part. An objection to Sims's speculum, however, is the necessity for its being held by an assistant, and its liability to slip at a critical moment. This is greatly lessened by using Weiss's speculum, which can be fixed to the patient by a fenestrated blade applied outside to the back. Before operating it is necessary to be assured that the parts are in a healthy condition. Any morbid condition of the cervix uteri should be healed. Any constitutional taint should be removed. The time selected should be a week after a menstrual period, and not, as a rule, until three months after recovery from labor. No operation should be done during gestation. The bowels should be relieved by castor oil and enema. The position of the patient may be the semi-prone or the lithotomy position. If the latter be preferred, the hands are fastened to the ankles by Prichard's wristbands and anklets. Assistants on either side support the legs, and by retractors or fingers help to keep the vulva open ; another holds back the perineum by a Sims's speculum. The operator seizes the margin of the fistula by a suitable toothed for- ceps or hook, and pares off a circular strip of the mucous membrane of the vagina, including the cicatricial tissue of the edge, but carefully avoiding the mucous membrane of the bladder. The edges should be bevelled o&, making the pared surface oblique, so that whilst the vaginal mucous membrane is cut away for about half an inch all round the fistulous opening, the opening in the bladder itself is not enlarged. The bleeding is not often great. A little time may be given to stop it by syringing with ice-cold water and pressure with sponges. The sutures are then to be passed, the needle entering and coming out a good half-inch beyond the fresh pared edge. They should take in the entire thickness of the pared edge, but avoid the mucous membrane of the bladder. They should be about four or five to the inch. They should not be drawn tight until all are passed. When tied it is useful to test the accuracy of the closure by trying the interspaces of the sutures by a fine bent probe. If this passes in, another suture may be useful at the part. Superficial sutures between the deep ones are commonly useful. A winged catheter should then be inserted in the bladder. Such is the simple operation which is the outcome of all the inge- nious and complicated proceedings initiated by Charles Brooke, and carried out bv Brown, Sims, Bozeman, and numerous other surgeons. The after-treatment consists mainly in rest. The catheter should be taken out and cleansed daily, care being taken that the reintroduc- tion is done gently. The sutures may be removed on the sixth or seventh day. When the cervix uteri is involved in the loss of substance it becomes a question whether the opening can be closed without also closing the OS uteri. Sometimes it is necessary to pare tlie posterior surface of the OS uteri, making this one side of the wound which is to be united to LACERATION OF THE PERINEUM. 749 the neck of the bladder. In many cases the anterior lip of the os uteri may be pared and made to form one side of the wound. This, united with the neck of the bladder, leaves the os uteri open behind it. When the fistula is vesico-uterine, it may be impossible to ^et at the fistula itself. In such a case Jobert closed the os uteri. The urine was then retained. J. E,. Lane, having operated in this manner, found that the uterus enlarged afterwards. This was at first thought to be due to retention of menstrual fluid, and a puncture was made through the place of union. This resulted in an abortion of four months' gesta- tion. It is conjectured that the semen got access along the track of one of the sutures. The patient was cured by repeating the operation. In those still more severe cases in which the urethra, neck, and floor of the bladder have been destroyed, various attempts more or less suc- cessful have been made. Jobert proposed to make an opening into the rectum, and then to close the vulva completely. Baker Brown pro- posed to make a new urethra by passing a small trocar through the tissues under the pubic arch, keeping a catheter in until a permanent canal is formed, and then making a new floor for the bladder by draw- ing the uterus down and uniting the sides of the vagina together. Dr. Kidd describes a case in which a large opening existed from the vagina into the bladder, through which the fundus of the bladder protruded. There not being sufficient tissue for Brown's operation, he resolved to close the vagina entirely, leaving a small opening anteriorly for the urethra. This he did by paring off' the mucous membrane from the inner surfaces of the labia and posterior wall of the vagina, dissecting as high up as he could in this part, to avoid making a pouch, and having removed the nymphse anteriorly he placed a No. 10 catheter close up under the pubic arch, and thus brought the pared surfaces into contact by four deep-quilled sutures, as in the operation for ruptured perineum. A spring pad, like a truss invented by Trelat, of Paris, was fitted on to the orifice of the urethra, and the woman was able to retain the urine perfectly. In some cases of incontinence of urine the urethral pad referred to is extremely useful. Dr. Thomas Chambers showed me a case in which great relief was gained by a similar contrivance. It acts as a substitute for the natural sphincter. The transverse obliteration of the vagina described by Simon may be the last resource. At one time small fistulse were treated by the actual cautery, in the hope that the resulting slough would be followed by cicatricial con- traction and closure. This method cannot be depended upon. The more certain and scientific procedure by suture ought to be adopted at once. Vesico- vaginal fistulse once fairly healed are not very liable to re- lapse. But Dr. Bourdon (Arch, Gen. de Med,, 1872) reports four cases of relapse from Yerneuil's cUnique, all in women who became pregnant. Lacerations of the -perineum may be of various degrees. It is prac- tically enough to consider two. These are distinguished by the reten- tion of the integrity of the sphincter ani in the one case, and by its being torn through in the other. 750 LACERATION OF THE PERINEUM. The loss of the perineal floor is attended by other inconveniences besides the increased liability to prolapsus. Indeed, prolapsus uteri does not always follow on laceration of the perineum. I have known sterility persist until the perineum was restored. Probably the loss of the retentive capacity of the vagina was the cause. The subject feels " open." She is conscious of being unsound. When laceration of the perineum is detected at the time of its occur- rence, it is best to stitch it up at once. Three or four sutures of wire or carbolized silk are applied by means of a needle set in a handle, or even by long needles held by forceps. This is now a recognized prac- tice approved by experience. Immediate union usually takes place. Union is also sometimes effected by keeping the parts in contact by means of " serrefines." Indeed, even without sutures, more or less perfect restoration will not unfrequeutly be effected. Granulations extend from the fork of the fissure forwards, filling up the space. This process is much promoted by keeping a strip of lint soaked in solution of chloride of soda in the wound. If the opportunity of applying sutures within twelve hours of the occurrence of the injury be lost, it is better to wait for perfect cicatrization, and the recovery of the pa- tient from the puerperal state. About three months after labor is generally early enough. The operation for restoring the split perineum is well described by Mr. James Lane (Cooper's Surgical Diet., 1872). The operation, when the sphincter ani is not injured, is as follows : A portion of skin and mucous membrane is dissected off on each side of the lower half of the vulva, so as to form a raw surface, which should be about an inch and a half in length on each side, the right and left portions being continu- ous with each other below across the median line. It should be an inch or more in depth antero-posteriorly at the loM'er part next the anus, but may diminish to about half an inch in depth towards its upper part. It is better first to mark the outline of the raw surface by inci- sions with the scalpel, and then to dissect off the mucous membrane, the thinnest possible layer of which should be removed. Care should be taken that the denuded surface is not situated too far outwards upon the buttock, or too far inwards towards the vagina, but just where the opposite sides would naturally and readily come in contact. The deep sutures which are to hold the quills are next to be inserted. For this purpose the most convenient instrument is a strong needle set in a handle, with an eye near the point, and bent at a right angle at about three and a half inches from the point, the part from the angle to the point being slightly curved. This should be entered through the skin on the left side of the patient, about an inch external to the cut sur- face, and be brought out close to the posterior edge of that surface, taking hold of as much tissue as possible, and should be then thrust onwards through the opposite side at a corresponding depth. The eye near the point may then be threaded with a strong wire suture, and the needle is withdrawn, carrying the suture with it. Mr. Lane uses four deep sutures of silver wire, and fastens them to perforated ivory bars, which represent the quills. Each ivory l)ar is perforated with four holes, about half an inch apart. One of these should be ready OPERATION. 751 threaded with two pieces of wire, each piece being looped througli the two adjacent holes, and when these four sutures have been passed, they are threaded through the holes in the second ivory bar, and, being drawn tight, the whole is firmly secured by twisting the ends together, first of the two lower, and then of the two upper wires. By having the wires looped on the one side, no fastening is required on that side, while on the other side two adjacent wires are fastened simultaneously, thus saving time, and securing a more uniform pressure on the part. The quill suture serves to hold the deep part of the cut surfaces in contact, but the cutaneous edges must also be held together by four or five superficial sutures of finer wire or catgut. The bowels should be restrained by opium for seven or eight days. A winged catheter should be kept in the bladder, or the urine should be drawn off every eight hours. The deep sutures should be cut and removed, together with the ivory clamps, at the end of forty-eight hours. Some oedematous swelling generally takes place, but soon subsides when the pressure of the quill suture is removed. If left longer than this, irritation and suppuration are apt to be set up, and no compensating ad- vantage is obtained. The superficial sutures need not be removed till the sixth or seventh day. The bowels may now be opened by a brisk ajjerient, followed by an enema. In the cases where the perineum has been torn through into the anus, somewhat greater care is necessary to secure accurate contact, and especially to prevent any aperture being left between the rectum and newly made perineum. The latter untoward result may be best avoided by splitting the recto-vaginal septum for a short distance in the horizontal direction, at the point where it forms a sort of eperon at the centre of the torn part. Then, by turning up the vaginal portion of the split septum, and causing the two lowest of the deep sutures to take a hold of it on its new surface as they are passed through, it will eflPectually cover the spot where otherwise recto-vaginal communication might probably be left, while it will at the same time increase the thickness of the lower part of the new perineum. In this class of cases division of the sphincter is beneficial, as the action of the muscle otherwise tends to separate the surfaces, and especially to open the torn angle of the wonab. But an incision on one side only is sufficient. In the still more severe cases in which the recto-vaginal septum is torn for a greater or less extent upwards, the operation above described will be insufficient, as a recto-vaginal communication would be almost certain to remain. It is therefore necessary first to unite the recto- vaginal septum, and afterwards to restore the perineum. To unite the recto-vaginal septum the edges must be pared on each side, and a sufficient number of wire sutures inserted. These may be secured by simply twisting their ends, no quill suture being required. When union is complete and firm, which will usually be at the end of about three weeks, the second operation for the restoration of the perineum above described may be undertaken. To secure fine adaptation of the rectal and vaginal mucous and of the cutaneous structures, the operation as described by M. Hulke is 752 DISEASES OF THE VAGINA. effective : Two triangular flaps of vaginal mucous membrane are first dissected up ; then the cleft in the rectum is sewn with three fine silk sutures, the ends of which are left in the bowel. Several sutures of the same material are then adapted to the vaginal mucous membrane that had been previously dissected up. Next, the raw surfaces made by thus raising the flaps of mucous membrane are brought together with quilled sutures passed deeply, making a long and thick perineum ; and lastly, the tegumentary edges of this are joined with fine silk sutures. The new formations in the vagina are not numerous or frequent. They consist almost exclusively in fibrous tumors, cystic tumors, sar- comata, or the papillary excrescence, and cancer. Fibrous tumors and sarcomata are developed in the fibrous or mus- cular coat of the vagina, and often but not invariably are associated with similar formations in the uterus. The fibroid tumors project into the vagina, and sometimes assume a considerable bulk. Tumors also form in the connective tissue, between the rectum and vagina, and are developed equally towards either canal, or bulge out more into one or the other. The sarcomata proceed mostly from the uterus, and from the cervix. Mr. Curling (Pathol. Trans., vol. i) describes a firm solid tumor growing from the upper part of the vagina, to which it was attached by a broad peduncle, which commenced just behind the meatus of the urethra. The tumor consisted of a mass of dense fibrous tissue partly arranged in large lobules, and developed in the submucous areolar tissue of the vagina. It had been forming for many years, and lately had projected outside the vulva. Free bleeding occurred from one or two large vessels at the posterior part of the peduncle. Papillary outgrowths are not so common in the vagina as on the cervix uteri, but they sometimes assume a cauliflower-shape, with a more or less defined stalk. At the entrance of the vagina they take the form of condylomata. Cystic tumors are occasionally found in the walls of the vagina. Their most common seat in my experience is the anterior wall, along the course of the urethra. They are certainly of rare occurrence. Thus Scanzoni says (1856) that lie had only met with one case, and West's experience furnishes only two. Several clear examples have come under my observation. McClintock gives the histories of two cases. The origin and nature of these cysts are not clearly determined. In some cases possibly they resemble fibro-cystic tumors of the uterus, the cystic element being specially developed. In others, according to Huguier, they originate in obstructed nuicous follicles. Scanzoni says, in autopsies, one meets with cysts, the size of a pea or of a cherry ; but accurate information always proves that these neoplasms were not de- veloped in the walls of the organ, but in the peri-vaginal cellular tissue. Rokitansky also says the primitive seat of these cysts is out- side the vagina, with which they have only a secondary relation. This, I think, I have verified in some cases. Strictly vaginal cysts must be distinguished from vulvar cysts, which are not uncommon. There are two specimens of cysts removed from the vagina in Guy's Museum, CANCER. 753 Nos. 2281^° and 2281*^ I have removed two by wire-ecraseur. In one case it appeared to me that the origin of the cyst was a blood- tumor or hsematoma. I have seen several hsematomas of the walls of the vagina not always traceable to labor. The absorption of the blood would leave a cyst which would subsequently be filled with serum or muco-purulent fluid. The treatment consists in removing the tumors altogether, if this can be done without involving too extensive a wound. Otherwise they may be laid freely open by bistoury, and the cavity plugged with tincture of iodine on lint. They sometimes burst and continue to pour forth an offensive dis- charge. There was recently under my care in St. Thomas's a case of a cyst which burst into the urethra. It gave rise to extreme dysuria. It caused a considerable fluctuating swelling in the vagina. It was cured by free cauterization with nitrate of silver of the cavity of the cyst through the urethra. Dr. Gibb described (Path., Trans, vol. v) a specimen in which small calculi (phebolites) were taken from between the coats of the vagina in a colored woman. Primary cancer of the vagina is exceedingly rare. McClintock says no well-marked and undoubted instance has fallen under his notice. In all cases of vaginal cancer, the disease he found had spread from the uterus or the vulva. Dr. West believes that the rarity of primitive vaginal cancer has been exaggerated. I cannot absolutely contest McClintock's statement, but I have now and then met with a peculiar contraction of the vagina in old women, attended with ulceration and offensive discharges, which I believed to be of cancerous nature, and in which I concluded that the uterus was not involved. In one case which came under my care at the London Hospital, that of a woman aged seventy, there had been for ten months a sanguineous discharge of "dirty white" color, pain down inside thighs and lower belly, chiefly at stool. She was obliged to lie down ; she felt as if sitting on a sharp instrument. About one inch up the vagina, an annular constriction is felt just admitting the finger; through this is a pouch, at the back of which is the enlarged and hardened os and cervix uteri. The sensation is much as if the finger passed through a fistula into the rectum. But passing one finger into the rectum and one into the vagina, the septum is felt perfect, and her " stools pass the right way." Blood flowed on examination. Atresia of the canal is not uncommon when the vagina is the seat of cancer. Rare as is vaginal cancer, there may occasionally be seen here and there scattered over the vaginal surface independent roundish, or flat medullary watery projections, discoid or honeycomb elevations of the cauliflower excres- cence. The vagina affords, like the peritoneum, clear opportunities of ob- serving how cancer can propagate itself by contact. Thus it is not un- common to find a patch of cancerous growth on the opposing surface of the primary seat of the disease. Dr. Cay ley describes (Path. Trans., xvii), a case of epithelioma propagated by contact from the posterior to the anterior wall of the vagina. 48 754 DISEASES OF THE VULVA. The diagnosis, presuming that a digital examination is made, is easy. The rough, hardened, contracted walls of the vagina communi- cate a sensation different from that of the healthy, or of any other dis- eased state of the vagina. The examination, howsoever gently made, is moreover pretty sure to cause a little bleeding ; and the offensive discharge supplies further evidence. The course and terminations of vaginal cancer resemble those of uterine cancer. Indeed, in almost every case vaginal cancer is but an ulterior stage of uterine cancer. The disease extending deeper invades the rectum and bladder, leading probably to perforation. Death occurs through exhaustion, blood-infection, and degradation, mechanical im- pediment to the functions of the bladder, kidneys, and intestines. In treatment unhappily little can be done. There is no room for attempt at ablation. We can but seek to arrest progress by powerful caustics, and failing this, fall back on palliative measures. Dr. West in one case found great benefit from the free use of acid nitrate of mercury. Three or four applications produced complete cicatrization of all but just that part of the disease which affected the roof of the vagina. There the application was extremely difficult, and there the disease spread. The palliative treatment differs in no respect from that described as applicable to cancer of the uterus. CHAPTER LII. THE DISEASES OF THE VULVA. INFLAMMATION: GENERAL OR PARTIAL; OF THE VULVO-VAGI- NAL GLANDS ; ABSCESSES ; ULCERATIONS; SLOUGHS; HEM- ATOMA; VARICOSITY; PRURITUS; HYPERTROPHY OF LABIA AND CLITORIS; " ENDERMOPTOSIS ;" NEUROMATA; CYSTS; SYPHILITIC WARTY EXCRESCENCES; LUPUS; CANCER; ME- LANOSIS; VASCULAR EXCRESCENCE OF THE MEATUS URINA- RIUS; FISSURE OF THE VULVA. COCCYGODYNIA. Some of the diseases of the vulva are marked by exquisite pain. The free distribution of sentient nerves, the riclmess and complexity of the vascular apparatus, and the multiplicity of the delicate organs accumulated in this region account for this feature. Another condition to be noted is the active reflex association with the nervous centres, cerebral and spinal. This is remarkably manifested when we induce INFLAMMATION, 755 anaesthesia to facilitate examination or operations. The vnlva seems ahnost the last part in which the reflex irritability is suspended. The reactions upon the general nervous system are often complicated and distressing, and are not seldom overlooked. In addition to these con- ditions, which always exist, there is often found a morbid neurotic element inherited or acquired, or a blood dyscrasia or diathesis, as gout. Inflammation of the vulva. — vulvitis — may be partial, that is, limited to a part of the structures of the vulva, as to one vulvo-vaginal gland and one labium; or it may be general, that is, involving all the struc- tures of the vulva on both sides. It may be limited to the vulva^ which is not uncommon, or it may be complicated with colpitis. The vulva is liable to various forms of inflammation : Erythema, phlegmonous inflammation of the labia, acute or chronic, furuncle, ery- sipelas, herpes, eczema, prurigo, and the follicular inflammation of Huguier. QEdema is a frequent complication of these affections. They often leave a degree of thickening, hypertrophy, or sclerosis of the tissue of the nymphse, clitoris, or vulva. Inflammation of Bartholini's glands is frequently caused by unclean sexual intercourse, especially of a gonorrhoeal character, I have seen a chronic inflammation, which had lasted ten months, disappear quickly under no other treatment than iodide of potassium. I had suspected syphilitic disease. It may be the result also of want of cleanliness, and the irritation produced by the retention and partial drying of leu- corrhoeal discharges. Inflammation having attacked the substance of the gland, causes extreme pain from the distension of the gland within its capsule and the surrounding connective tissue. The inflammation may be limited to the gland and its duct, or may spread to the loose connective tissue around. In either case abscess may form. When the gland is the chief seat of the inflammation, a swelling forms of an ovoid shape, distending one labium major, and causing it to protrude so as to overlap and conceal the labium on the other side. The surface of the tumor is usually vivid red, shining from tension, and bathed with a serous mucus. The size varies from that of a pigeon's egg to that of a hen's egg. Bulging over towards the opposite side, it narrows the entrance of the vulva so that the introduction of the finger causes exquisite pain. It is generally possible to detect the orifice of the duct of the gland on the inner surface of the labium. Pus accumulating in the gland may from time to time force its way out of the duct, then collect again. But most often this mode of evacuation is imperfect, and great distension is the result. Even when the abscess has burst, an obsti^ nate secretion of pus may go on for an indefinite time. The subjective sym])toms are intense pain and a sense of throbbing in the part. When the inflammation spreads to, or has its chief seat in the cellular tissue of the labium, the symptoms and appearances are similar. Per- haps the pain is less ; but pain is a relative term, often more expressive of individual susceptibility than of the intensity of the disease, so that no conclusion can be drawn from this. Where the cellular tissue is aflected, the swelling extends much beyond the limits of the gland. It 756 DISEASES OF THE VULVA. may terminate in resolution, but suppuration is, I think, the more common event. In this case fluctuation soon becomes evident. Abscess of the gland itself will not often burst. After a time the inflammation may even subside, and the cyst formed may be tolerated. I have known many examples of this condition. It is nevertheless desirable to lay them open when detected, as they may at any time be the occasion of renewed trouble. In the treatment of inflammation of the labia majora and Bartho- lini's gland, the first thing to enjoin is rest. Indeed, this injunction is not very likely to be disregarded, the pain on movement, especially in the upright posture, is too agonizing for that. If suppuration has not begun, leeches, poultices, and lead lotion give most relief, and dispose to resolution. When the formation of pus is made out, a tolerably free incision should be made. As the part is very vascular free bleeding may follow ; but this gives such obvious relief that it ought not to be imme- diately stopped. If it goes beyond desirable bounds it can be readily stopped by compresses alone, or by a tent soaked in perchloride of iron. A poultice should be applied after the incision. An abscess of the cel- lular tissue thus treated will commonly heal without further trouble. But if it is the result of inflammation of the gland itself, something more may be necessary. The contents of the inflamed Bartholini's gland are not always simple pus ; a glairy tenacious mucus often is mixed with pus. The distension may have produced a cystic dilata- tion of the gland, the inner surface of which will secrete even after it is laid open, unless its character be changed by the free application of some strong escharotic or irritant. I have never found any trouble Avith these cysts, if their cavity be stuffed with a strip of lint soaked in tincture of iodine. They quickly shrivel up ; the remaining cavity gets filled by granulations. If abscesses of the vulva are allowed to burst, or have been insuffi- ciently laid open, fistulous tracts are apt to form, which keep up great irritation and discharge, and even inflammation and induration of the tissues around. The treatment of these sinuses consists in giving them a free external opening, and in injecting a solution of iodine into their track. Ulcerative loss of substance occurs in the form of excoriations, superficial ulcers, and small follicular and larger abscesses. The vulva is also liable to lupus and syphilitic sores. Sloughs of the vulva are especially apt to follow severe labor. They may occur after typhoid, scarlatina, diphtheria, and may be primary, as in the noma of young children. Sloughs following labor may result in various degrees of cicatricial atresia. Hemorrhages of the Vulva. Hsematoma, or thrombus of the labia majora, is produced under the obstruction caused to the return of blood by the advancing head during labor, and also by the bruising and laceration occasioned by the passage of the head. It may also proceed from submucous rupture of varicose veins. It sometimes attains the size of a fist, or even of a HEMORRHAGES. 757 child's head, and consists sometimes more in a diffused extravasation of blood in the connective tissue of the labia, sometimes rather in a collection of blood poured out into a sac formed by rending away of the mucous membrane from the underlying tissues. If the mucous membrane be torn through, free external bleeding may ensue. The extravasation may spread up\vai"ds, dissecting the mucous membrane up, and burrowing behind it far into the pelvis. Suppuration at times takes place in the sac, and gives rise to repeated bleedings. I have seen a marked case of hsematoraa of the clitoris and urethra. The pudenda are subject to a varicose dilatation of the vessels, a con- dition which may prove serious. During pregnancy the vaginal and pudendal plexuses become still more highly developed ; the augmented afflux of blood, and the occasionally increased obstacle to its return from the pelvis, may lead to considerable dilatation of these plexuses. The inside of the vulva and lower part of vagina at times assume a distinctly convoluted appearance, owing to the prominence of the vessels ; these bulge forth turgid, elastic, deep red, or purple. In this condition should a breach of surface take place at any point, profuse, even fatal bleeding may easily occur. A blow may rupture the vessels by bruising them against the pubic bones. Simpson says, " In the Scotch law courts during the last five-and-twenty years a con- siderable number of trials have taken place in consequence of women bleeding to death after sustaining some injury of the pudenda. In most of these cases all that was alleged as the cause of death was that the woman had received a kick on the part at the time she was pregnant, and that a slight laceration had been produced, from which the fatal hemorrhage took place." Some years ago a butcher was tried at Bris- tol for killing a married woman. Rupture of the pudendal vessels had taken place during coitus. But rupture of the gorged vessels may occur spontaneously, that is, without any direct violence to the part. Varicose veins of the legs during pregnancy may present a similar state of turgidity, entailing a like danger. I have known a woman bleed to death from a slight injury inflicted on a bunch of such veins. The varicose condition, of which the foundation was laid in preg- nancy, persists more or less when the pregnancy is ended. The affected vessels become less turgid, but may undergo changes disposing to dan- ger in another way. Thrombosis taking place in them, necrosis of the walls of the vessels may ensue, and thus becoming perforated, may be the source of hemorrhage or ulcers ; inflammation of a low, some- times erysipelatous type is common. When hemorrhage takes place from varicose vessels of the vulva or vagina, the one effectual remedy is pressure. This must be flrmly ap- plied. The best way is by plugging the vagina above and down to the level of the bleeding points. The horizontal posture and moderate diet of course will be enforced. Simple compresses dipped in cold water will answer the purpose. But occasionally it may be found de- sirable to soak them in a solution of perchloride of iron. Although pregnancy is the usual antecedent of varicose veins, I have known very severe cases which could not be traced to this condition. Pruritus is one of the most distressing of the affections of the vulva. 758 DISEASES OF THE VULVA. It is associated with, or dependent upon, a variety of conditions, so that it may generally be regarded as symptomatic. Before determin- ing upon a course of treatment, it is a clear indication to investigate thoroughly the state of the pelvic organs, and even to study the gen- eral condition of the system. In some cases the irritation depends upon diabetes. In some there is a gouty diathesis or lithiasis, the blood carrying irritating elements to every organ and tissue of the body ; pain is especially evoked in certain elected parts, the vulva being one of these. In some there is congestion or inflammation of the cervix uteri, and the attendant discharges appear to be the imme- diate cause of the valvar pruritus; but, in some instances, there is pruritus, intra-vaginal, as well as pudendal, without any discharge. Then, in a considerable number of cases, there is obvious pudendal disease, as herpes, eczema, erythema, scabies, pediculi. In some apparently inflammatory cases, it is difficult to say whether inflammation or neurosis predominates. In many of the most painful of these disorders there is no very obvious inflammation, and in others, where inflammation is obvious enough, the pain, although generally troublesome, is more endurable. Some of them have been described under the head of climacteric diseases. It is at this period that the most troublesome cases occur. This, indeed, is especially the epoch of irregular disorderly nervous affections. But other forms may occur in young women, married or single. One form especially arises during pregnancy, a time when the nervous system is in a state of peculiar erethism, and when the seat of the pruritus is peculiarly vascular and hyper^sthetic. I have seen a very troublesome form in single young w^omen following a sedentary occupation as governesses. The sitting may have an injurious local eflect, but probably emotional and 'other centric nervous conditions may be influential. And this may, I think, be stated as a general proposition : there must be exaggerated centric irritability as well as an eccentric irritation to produce the marked forms of pruritus. Indeed, it is not uncommon to find in obstinate cases that a general irritation or hypersesthesia of the whole skin be- comes gradually developed. It is remarkable that most of these painful affections of the vulva are aggravated at the menstrual epochs. This is due, no doubt, to the exalted centric irritability attending ovulation, as well as to the increased local vascular fluxion. A similar exacerbation is observed in neuralgia of the face and other parts. Indeed, there are cases of intense vulvar pruritus where no local lesion can be detected, which might with pro- priety be called vulvar neuralgia. A considerable proportion of cases are due to inflammation of the structures about the vulva. These are already described. A not un- common form in climacteric women tending to obesity is eczema. In cases of this kind the disease is not limited to the vulva but extends to the dependent fold of the abdomen, to the folds of the groins, to the upper parts of the thighs; in fact, to all tliose skin-surfaces which overlap each other and chafe. The skin loses its natural epidermal character, becomes moist, red, angry-looking, approaching to the appear- ance of inflamed mucous membrane. Sometimes aphthous or diphther- TEEATMENT. 759 itic patches form. The labia majora are often much swolFen, even hypertrophied. Minute vesicles or pustules give place to scabs. Some- times little abscesses form and burst. I have seen pruritus from eczema brought on by gonorrhoea, and the use of irritating lotions. In one such case, that of a young woman, a pustular eczema spread all over the mous Veneris, the labia, and inner side of the thighs. Nitrate of silver had been used freely without benefit. She was cured by healing the attendant metritis and vaginitis, and by the local application of zinc ointment. Pruritus is not uncommon in connection with cancer of the uterus or vagina. My observation confirms the statement of McClintock that, in many cases, pruritus of the vulva is one of the earliest symptoms of cancer of the womb. In some cases the pruritus is due to the breeding of pediculi. These are effectually treated by mild mercurial ointments. In hospital, the nurses ask for stavesacre for this purpose. It answers well. But there are other cases in which the affection is in no way associated with parasites, Mdiich are remarkably benefited by stavesacre. The prurigo senilis, for example, is successfully treated by Mr. Balmanno Squire's formula, consisting of oil of the seeds 1, lard 7. In this disease I have also seen great advantage from the application of a pasma formed of flowers of sulphur and water. A not uncommon form of vulvitis is the vulvar folliculitis of Huguier. This affects the labia majora, the external aspect of the labia minora, the genito-crural folds, and is limited to the sebaceous glands and hair- bulbs of these parts. These parts appear slightly swollen, rosy, and are the seat of small elevations due to inflammation of the sebaceous glands and hair-bulbs. These are very numerous, are at first small, then enlarge, and resemble pustules, and soon suppurate. Bursting, they discharge an irritating, offensive, purulent matter. This vulvitis is frequently complicated with erythema, ecthyma, sometimes with oedema, erysipelas, or abscess. It is principally observed during preg- nancy, when this secretory apparatus is very active. In a variety called ^' vulvite folUeuleuse," by Robert, the mucous mem- brane of the vestibule and that covering the interior of the crypts only are affected. The mucous crypts present at their orifices a vivid red areola; their cavities inclose a droplet of pus, which can be squeezed out. This vestibular vulvitis, Robert says, is always more or less allied to urethral blennorrhagia. Treatment. — The inflammatory forms or complications of pruritus are best treated by soothing applications. Oxide of zinc, oxide of bis- muth. Fuller's earth, in ointment or lotion, or mixed with glycerin, are especially useful. I have seen the most satisfactory result from the linimentum calcis applied on strips of lint. The local treatment must first of all be directed to prevent the affected surfaces from lying in contact, and from chafing. The dependent ab- domen must be well supported by an abdominal belt. The labia must be guarded from the groins and thighs by interposing shreds of lint soaked in glycerin and bismuth, in lead-lotion, in the lime-liniment, in glycerin of borax, in a solution of cyanide of potassium in glyc- 760 DISEASES OF THE VULVA. erin ; or sometimes alkaline solutions of potash or soda are very effec- tive j weak solutions of creasote or carbolic acid are useful in some cases. When small pustules form, painting the surface over with a solution of nitrate of silver, a drachm to the ounce, is often very use- ful; it sometimes allays pain in a remarkable manner. Constitutional treatment is often of the greatest importanee. It is necessary, in the first place, to remove, if we can, any complicating, local, or general disease. In women who have reached the climacteric, in whom there is probably a gouty or lithic acid diathesis, strict atten- tion must be paid to the correction of this state. Alteratives, mercu- rial salines, alkalies, aloes, colchicum, podophyllin, taraxacum, are often indicated. The peculiar nervous condition of the climacteric age must be studied. Bromide of potassium in large doses is of essential service. Digitalis and aconite are useful. Sometimes we are com- pelled to resort to more decided narcotics, as opium or chloral. When clear urine and well-acting bowels indicate that the blood is comparatively freed from lithic acid and other impurities, tonics as bark or quinine are often useful. Gueneau de Mussy insists that a gouty or other diathesis is often present. He advises the use of small doses of arsenic. Such patients should avoid stimulants, especially beer; and moderate exercise in the open air should be enjoined. When the inflammatory condition is subdued, we may try in succes- sion a variety of local measures. Gueneau de Mussy recommends the following means : Emollient baths containing poppy, or laurocerasus, belladonna, aconite, or pulverized water with belladonna; a weak solu- tion of bichloride of mercury, alkaline washes, glycerin with calomel, tannin or benzoin. Intra- vaginal washes of decoctions of rice and poppy-heads are useful. In the chronic form, strong sulphur baths, some hyposulphite baths, as those of Aix, pomades with mercury and belladonna, carbolic acid lotions, come into use. But we must be pre- pared to find some cases for a long time rebellious to all treatment. The pruritus of pregnancy is associated with the exalted centric nervous irritability developed by pregnancy, and with the increased local afflux of blood. Leucorrhoea generally attends, and the vascular fulness exceeds the usual degree. Saline purgatives, as Piillna or Friedrickshall water; alkaline baths, as Vichy, which can be prepared at home, or even bathing with plain cold or tepid water, constitute the best palliatives. Salines and colchicum may be indicated. Bromide of potassium may be useful. Amongst the acquired abnormities is hypertrophy, which sometimes assumes a monstrous appearance. It occurs as elephantiasis, and con- sists in increase of volume of the cutis and subcutaneous connective tissue. It affects the entire vulva, or only a part, as the nymphse, or the labia raajora, or the clitoris. The mass thus formed may attain the M'cight of several pounds. The surface of the enlarged part is smooth, or rough from irregular growth of epidermis, generally warty, uneven, lobulated. In these cases the tumor reproduces all the marked characters of tlio papillary growth, and resembles the condyloma. In its substance it consists of dense fibrous connective tissue. Often the hypertrophy spreads upwards over the mons Veneris, and backwards CYSTS. 761 over the perineum. Frequently the mass, under traction of its own weight, becomes pedunculated, and its removal is then easy. I haye known the labia minora enlarged so as to form flaps hanging down below the labia majora to be a source of trouble, especially during the menstrual periods, when they swell from congestion, and by chafing against each other produce irritation and leucorrhoea. Atrophy of the labia occasionally follows chronic syphilitic affections of the vulva, attended by progressive cicatricial formations. The clitoris is subject to abnormal enlargement. This, says Roki- tansky, is more often congenital than acquired. This is one of the condi- tions which, especially when conjoined with excessive development of the nyraphse, as is often the case, simulates hermaphroditism. The glans may be very large, and the prepuce so developed as to resemble a penis, whilst the enlarged nympha^ assume the appearance of a scrotum. There is a good example of this malformation taken from an infant in St. Thomas's Museum. As the subject of hermaphroditism has little clinical interest, I must refer those who seek information on it to Rokitansky's work.^ Little tumors are sometimes found in the labia, which Huguier has described under the name " Endermojjtosis." These are due to hyper- trophv of the sebaceous glands. They are not painful ; they give vent on squeezing to sebaceous matter. The radical cure is to cut them out w^th scissors. Neuromata of the vulva have been described by Simpson as sensitive points and structures external to the orifice of the urethra, and as analogous to the caruncles of this part. True small nodular. neuromata may be found under the mucous membrane here as well as in other parts of the body. They are the occasion of much suffering, and to obviate this the removal of the offending nodules is necessary. Vascular outgrowths occur as teleangiectasis in the labia majora, and as the vascular excrescence of the meatus urinarius. Cysts are formed sometimes in the labia majora, and may attain a large size. They contain a serous, synovia-like colloid, or a brown sanguineous fluid. Fatty cysts containing hair and teeth have been observed. Other cysts result from a degeneration of the vulvo-vaginal glands. Cystic dilatations are also formed in Bartholini's glands by the occlusion of the duct, which may be the result of inflammation. In this case it is probable that the proper glandular structure undergoes more or less extensive atrophy or degeneration. The cyst forming a tumor which enlarges, the labium containing it becomes the centre of inflammation, swelling, and pain in this and the surrounding parts. The treatment consists in freely incising the cyst, and dressing the cavity with lint soaked in tincture of iodine. Blood effusions or thrombi may be the source of cysts in the vaginal wall. The original thrombus may have been overlooked. A woman aged sixty came to me at the London Hospital for metrorrhagia. There was a sanguineous effusion in the left labium forming a considerable tumor. 1 "Lehrbuch der Pathologischen Anatomie," 3d ed., 1861. 762 DISEASES OF THE VULVA. Cystic swellings of the labia majora have come under my notice accidentally when examining on indication of other disease. It is therefore certain that after a time the inflammation and distress which are usually so acute at first may subside, and tolerance ensue. The patients have become unconscious of trouble ; but the mere enlargement, causing more or less occlusion of the vulva, must occasion some annoy- ance. In these cases puncture has let out a dirty turbid pus. The tumors or outgrowths of the vulva are so w^ell described by McClintock that I am induced to follow his account. He classifies them as — 1. AYarty and hypertrophic ; 2. Fibrous and fatty; 3. Cystic; 4. Vascular; 5. Cancroid and carcinomatous. The labia may be also enlarged from effusions of blood or serum, from the presence of an abscess or of a hernia, or from elephantiasis. Warty {syphilitic) excrescences may grow from any part of the vulva, but they most commonly appear around the orifice of the urethra or of the vagina ; in this latter case they look like elongations of the corpora myrtiformia. They are usually found in clusters, but sometimes occur singly. Often three or four grow by a common root. Their color is nearly w"hite, and their structure tolerably firm. They are ])robably always of syphilitic origin. They seldom cause much pain, but they cause more or less local irritation and mucous discharge. At least two varieties of w^arts are met with on the vulva. One of these, says McClintock, is the true warty excrescence, the verruca or thymion of Celsus. It is very similar to the warts which appear on the hands, except that it frequently has a pedunculated shape, the stalk or neck having a smaller diameter tlian the body of the growth. When of large size they are apt to be fissured at the top, and to bleed if scratched or otherwise hurt. They have the color of the surrounding skin, and do not yield any discharge. The greater labia and adjacent common integument are the parts from which these warts generally spring. Warts of the other kind or variety grow from the vestibulum, meatus urinarius, carunculse myrtiformes, or some of the parts ordinarily concealed within the vulvar sinus. Their structure is firm, but they are remarkably pale in color and semi-transparent, so as to bear much resemblance to the white muscular tissue of fish. Considerable hypertrophy of the nymphse, clitoris, or more rarely of the labia majora, is not unfrequently associated with these warty ex- crescences, a circumstance which McClintock suggests strengthens the probability of their being due to some venereal taint. But these enlargements frequently occur when there are no warts, and they may unquestionably occur where there is no syphilitic taint. The syphilitic hypertrophy is generally marked by a rugous warty surface ; and other evidence of syphilis, either historical, or still impressed upon other parts of the body, as the skin or throat, will rarely be wanting. Sur- geons are familiar with the mucous or gummous tubercle or condy- lomata of the anus in syphilitic patients. Xot unfrequently the anus is affected at the same time as the vulva, and then the syphilitic nature of the vulvar growth is at once recognized. The vulvar gummous tubercle greatly resembles that of the anus. See Fig. 168, p. 763. In Bartholomew's Museum is a specimen, No. 32.80, of a large fibro- SYPHILITIC HYPERTEOPHY, 763 cellular tumor, which was attached by a broad pedicle to the left labium of a woman aged thirty-five. It had existed for ten years. Three years previous to its removal she had syphilis, since which time it rapidly enlarged. These growths should be treated in the same manner as the gum- mous tubercle of the anus. In the early stage the warts may some- times be dispersed by astringent and caustic applications ; keeping the parts very dry, and dusting them frequently with prepared chalk, or some other absorbing powder, will occasionally remove them. The syphilitic growths are often effectually treated by frequent powdering with calomel. A very effective application is painting with strong acetic acid. This has seemed to me even better than nitric acid. Sypliilitic hypertrophy of left nympha. (From MoClintock.) But when the growths have attained a considerable size, extirpation by knife, scissors, ecraseur, or galvanic cautery is by far the best plan. When cut off on a level with the surrounding raucous membrane they are not likely to be reproduced ; but if a portion of the base or stem be allowed to remain, this is very apt to throw out fresh shoots or pro- cesses. I have removed a very large mass of syphilitic tubercle of the labia at an advanced stage of pregnancy, on the ground that during labor laceration might occur. It is, I believe, under all circumstances, best to remove them. Should hemorrhage occur after ablation, it may be restrained by pi^essure with or without perchloride of iron, by the actual cautery, or still better by acupressure. Needles transfixing the bleeding surface and twisted sutures will effectually stop the bleeding. Although I believe the syphilitic excrescence can generally be dis- tinguished from other forms, we meet in practice with growths which present considerable resemblance to them where there is no room to admit the complication with a venereal taint. Dr. West is undoubt- edly right in his statement that some of these belong to the same class as lupus, "and are quite independent of venereal taint, and of these 764 DISEASES OF THE VULVA. some pass by gradations, difiicult to seize, into the same class with epithelial cancer." To these forms the names herpes exedens, lupus, rodent ulcer, tertiary syphilis, esthiomenus (Alibert) have been applied. Huguier adopts the last. Fig. 169, from McClintock, represents the characters of lupus. Fig. 169. Hypertrophic lupus of the vulva. (From McClintock.) Cancer, frequent in the uterus, rare in the vagina, again becomes frequent in the vulva. The medullary cancer occurs very rarely as a primary disease of the labia. It is most commonly a propagation of the disease from the vagina in association with cancer of other organs, and especially w'ith medul- lary warts in the skin and consecutive cancer of the inguinal glands. More frequent is the epidermal cancer (cancroid), which appears as a proliferating widely spreading degeneration of the labia or clitoris. This latter organ is especially prone to cancer, and like the same dis- ease in the penis, it may for a considerable time be limited to the organ. Owing to its almost external position, and the distress which the disease and attendant enlargement produce, it is generally detected early. These circumstances make ablation especially hopeful. It is not wise to be deterred from operating even when there is evidence of enlargement of the inguinal glands. A respite of comparative ease may at any rate be counted upon. The operation should be thorough. The patient is placed in the lithotomy position. The diseased part is firmly seized by a curved Museux's forceps, and drawn out so EXCRESCENCE OF MEATUS URINARIUS. 765 as to put' its attachments upon the stretch. With strong scissors the mass is cut away close to the pubic bones. Free hemorrhage is likely to follow. This may be restrained by the actual cautery, or by very firm pressure by compresses. A mode of proceeding preferable when the diseased mass can be fairly commanded by the wire-loop, is the galvanic cautery. Beginning in the clitoris, cancer spreads to the contiguous structures, and soon invades the labia minora et majora. When this is the case, the prospect of relief by operation is much diminished. Still ablation by knife, ecraseur, or galvanic cautery may in some cases be attempted. Where ablation has to be abandoned, we must fall back upon caus- tics or palliative treatment. All the measures adopted in the case of cancer of the uterus find application here. In St. Bartholomew's Museum is a specimen (No. 32.61) of melano- sis of the labia and vagina. The parts were removed by operation, on account of a large mass of melanotic disease which, arising at the front part of the vagina, encroached equally upon either labium. In the same museum is another specimen (No. 32.42) of a labium on the surface of which is an oval, elevated, warty growth of moder- ately firm texture, and with a finely-granulated surface, very similar to the chimney-sweeper's cancer of the scrotum. The vascular excrescence, or tumor of the meatus urinarius. This is in many cases an outgrowth from the mucous membrane of the urethra, most commonly found at the meatus. At this orifice it often protrudes, bulging out as a small tumor, sometimes, but rarely, as large as a cherry. When it so bulges, of course it is easily seen, and so it has come to be described as a disease of this particular spot. But a simi- lar condition not seldom extends a little distance up the urethra. The word " vascular " gives a good idea of its appearance. It may be roughly described as an outgrowth of vessels loosely held together in a mass by a little connective tissue, and covered by a thickened mucous membrane. The surface is irregular, a little lobulated, deep red, or blue-red. It is soft, difficult to seize with tenaculum or forceps, it so readily breaks down. The morbid mass and appearance are generally bounded by the margin of the urethral orifice, that is, the growth seems to be peculiar to the urethral mucous membrane ; it stops abruptly at the mucous membrane of the vulva. M. Quekett examined one of these vascular growths, and found it to be composed of epithelial cells, and a number of capillaries coming up close to the surftice. This explains the occasional tendency to bleeding. Wedl, in his Pathological Histology, describes and figures the appearance presented by the urethral caruncle. He regards these bodies as " dendritic, papillary, new formations of connective tissue." The one he examined was of a somewhat elongated figure, of a bluish- red color, and spongy texture, and exhibited, when cut into, cavities containing colloid matter. The most interesting point was the dis- tribution of the bloodvessels, which could be very distinctly traced in transverse sections, moistened with a solution of sugar or common salt. Their ramification precisely resembled that seen in the vasa vor- ticosa. Several vessels of considerable size, entering one of the lob- 766 DISEASES OF THE VULVA. nles, divided into a multitude of smaller ones, which, though not of capillary dimensions, made numerous undulating curves, extending up to the periphery of the lobule, where they terminated in mostly short and abrupt loops. The walls of these vessels were everywhere simple, like those of capillaries. There were extravasations of blood at several points, of old and recent occurrence. The late Dr. John Reid exam- ined for Sir J. Simpson a very sensitive and painful caruncle, and came to the conclusion that there was a very rich distribution of nervous filaments in it. It seems, in many cases, to be analogous to hemor- rhoids in the anus. It is most frequent, according to my observation, in women who have reached the climacteric, or passed it, and who have been married. But it is found occasionally in girls and young women, single or mar- ried. There is a tendency to venous hsemostasis in the pelvic organs, especially in the mucous membrane of women advancing in years, which appears to me to predispose to these irregular vascular protu- berances. The excrescence may be "gummous." At least I have seen cases connected with secondary syphilis. And Scanzoni believes they result from chronic urethritis. In many instances there is a previous history of gonorrhoea. The principal symptom of the disease is acute, agonizing pain on micturition, compelling the sufferers to postpone the inevitable torture by submitting as long as they can to retention in the bladder. Hence there is a retrograde risk of inflammation of the mucous membrane of the bladder, and distension. Not uncommonly a little blood is passed with, or after the urine; and bleeding may occur at other times, as from rubbing to ease the pain, friction in walking, and sexual inter- course. Dyspareunia is almost a necessary consequence. Often there is a muco-purulent discharge from the urethra and from the vagina, which may be an accidental complication. Pains in distant parts seem to take their rise from this local disease as reflex or sympathetic phe- nomena. It may give rise to the suspicion of stone in the bladder. The con- stant pain exhausts the nervous force, inducing prostration and disor- der of the functions of other organs. The real source of the mischief is often long overlooked by those who neglect the prime clinical maxim of making a direct examination of the part which is the central seat of pain. The diagnosis is made out by taking the indication furnished by subjective sensations as the guide to objective exploration. The pa- tient lying on her side, the upper labium is drawn up so as to expose the structures of the vestibulum, when the angry-looking orifice of the urethra will be seen. By passing a catheter gently we gain informa- tion as to the state of the urethra beyond the meatus. And it is often useful to dilate the urethra with a Weiss's dilator, or the excellent in- strument contrived by Dr. Emmet for dilating the cervix uteri. The treatment consists in destroying the offending growth. This may be done more or less successfully by various methods. Where there is much irritation, and the patient declines to submit to operation, some relief may be had from lead lotion, or poppy-head fomentations. COCCYGODYNIA. 767 Simpson speaks highly of an ointment consisting of two drachms of hydrocyanic acid to an ounce of lard. A bit of this the size of a pea is applied to the part three or four times a day. Aconite and chloro- form ointments are also useful. But things of this kind can only be sanctioned as temporary and trivial palliatives. If the tumor present a distinct polypoid form, it may be removed by a ligature, by snaring it, and cutting through its base by a fine wire ^craseur, or by snipping off with scissors. Excision is better than the ligature. The tumor must first be seized with a small hook or forceps, and lightly drawn out, so as to enable the scissors to get well at the base. Some bleeding usually follows, but compression with a bit of lint steeped in solution of perchloride of iron will soon stop it. Still these troublesome growths are very apt to recur. There seems an active germinating or proliferous property in the mucous membrane from which they rise, so that the smallest particle left retains the property of reproducing the disease. Mere excision, says Richet (Gaz. des Hop., 1872), will not remove the contraction and hypertrophy of the urethra, which often give rise to the most painful symptoms. To effect this he advises for- cible dilatation of the urethra. I have applied nitrate of silver repeatedly, always with good effect for a short time, although causing great pain at the moment of appli- cation. I have also used potassa cum calce, nitric acid, and other caustics, all with more or less advantage. But the best plan, I believe, is to touch them with the actual cautery, either the hot iron or copper, or the galvano-caustic wire or button. Cold-water dressing should be applied after the operation, and astringent lotions when the sloughs have fallen. The orifice of the vagina is subject to fissures. These are found as linear irritable ulcers, or clefts in the mucous membrane. The most frequent seat is the posterior commissure, but I have seen them at the anterior commissure. They are sequelae of slight lacerations expe- rienced during labor ; they have been produced by coitus, and have resulted from an altered condition of mucous membrane, the result of inflamraaticm, especially of a syphilitic character. As fissure of the anus is a source of pain during the performance of the functions of this part, so is fissure of the vagina or vulva. It may be chafed and irritated by walking, by discharges, by a drop of urine; but the most distressing symptom is dyspareunia. The painful spot may be detected by digital examination, and by retracting the labia it may be brought into sight. The treatment is the same as for anal fissure. The edges may be torn open by the fingers, or it may be divided by the knife. But the incision should not be deep, lest severe hemorrhage ensue. It is enough to make a shallow incision through the base of the ulcer. Coocygodyma. This disease has become familiar to gynaecologists through the writ- ings of Sir James Simpson ("Diseases of Women," 1872, vol. ii, edited by A. R. Simpson). But Dr. J. C. Nott, of New York, in an 768 COCCYGODYNIA. interesting memoir on the subject, refers to two cases published by himself in the New Orleans Medical Journal fifteen years before Simpson's first communication. The name is derived from coccyx and cdbvrj, pain. The leading symptom is pain in the region of the coccyx felt by the patient when- ever she sits down and rises, and sometimes when she remains in a sit- ting posture. Most of the patients affected with it are obliged to sit on one hip, or with only one side resting on the edge of a chair, or with the weight partially supported by a hand on the chair. Some patients dread sitting down. There are other movements of the coccyx liable to be attended by pain. Thus, patients have pain with every step they take, whilst in others walking causes no uneasiness. Others feel the pain most when the bowels are being evacuated, or under any circumstances in which the sphincter or levator ani, or the ischio-coccy- geal muscles are called into action. The pain is not in every case very acute, nor at all times equally severe. The distinguishing feature of the disease in every case is that the pain is felt at the low^est part of the spine, or rather in the seat of the coccyx, and where pressure always aggravates it. Pressure and movement of the coccyx too, with the finger in various directions, produce pain, and the kind of move- ment which is then attended with suflFering differs in different cases. Simpson believes the pain is due to inflammation of the coccygeal joint, or other morbid change, wdien any action of the muscles in con- nection with it, by moving the joint, produces pain. We might naturally look for the origin of this disease in some injury of the part; and in a considerable proportion of cases injury can be traced. But it is remarkable that the disease occurs in the unmarried, and where no history of injury can be made out. I, myself, have known several aggravated cases follow labor. In these I cannot doubt that the joint received injury during the passage of the child's head. In some cases we know the sacro-coccygeal joint is anchylosed, the tip of the coccyx projecting so much forwards as to form an angle with the lower part of the sacrum. The anchylosis is likely to give way during labor. And where there is no anchylosis, as the head emerges, the coccyx may be felt to be stretched very much backwards, and under the strain some of the fibres of the anterior ligaments wdiich bind this bone to the sacrum may be torn, and in the joint thus ex- posed and injured inflammation is very apt to be set up. Simpson saw abscess follow. The coccyx again is liable to fracture or dislocation from direct violence, as from a fall on the seat. Patients have complained that '^a bone growls in," and so it is found. It is also liable to malforma- tions, to deficient development, to tumors, and even double monstrosity by inclusion. But in a certain proportion of cases no local lesion can be made out, and we are driven to conclude that the disease is a neurosis, a form of neuralgia, the expression, perhaps, of some remote morbid condition. But latterly some new light seems to be cast upon these more anoma- lous cases. In Virchow's Archiv, 1860 (Die Steissdriise des Menschen), Luschka gives an account of a small gland situated just at the anterior COCCYGODYNIA. 769 end of the coccyx ; it is in immediate relation with the hindermost part of the levator ani, and is connected with filaments from the ganglion impar of the sympathetic nerve, and with small branches of the middle sacral artery, between the levator ani and the posterior end of the ex- ternal sphincter. The gland is rich in nerves, which form a network perforating its stroma. This, the " glandula coccygea," Luschka says, is probably the seat of the hygroma cystica periuealea. And when we consider its highly vascular and nervous elements, and its position, we can hardly doubt that it may in some cases be the seat of coccygodynia. Some cases called coccygodynia I have found to be due to fissure of the anus, and to the conditions which induce the spasmodic action of the vulvar and perineal muscles, and known as " vaginismus." I have also traced it to retroflexion of the uterus. The diagnosis is made out by local examination. The forefinger introduced into the rectum is applied to the inner aspect of the sacro- coccygeal joint, wdiilst a finger of the other hand is applied to the outer aspect. The bones and the joint thus embraced between the two fingers are completely explored, and the seat of pain and the condition of the parts are easily determined. The treatment, according to Simpson, is surgical. But I have met with cases which, after long and intense suffering, got well spontane- ously, or when uterine disease and general disorder were removed. At the same time, I am satisfied that surgical treatment is occasionally essential to relief. One may exhaust sedatives, neurotics, and tonics, and still the pain persists. When there is evident inflammation, leeches will be serviceable, followed by counter-irritation. Temporary ease may be obtained by the local subcutaneous injection of morphia. The surgical treatment is to completely separate from the coccyx the mus- cular and tendinous fibres that are in connection with it. This is done by a tenotomy-knife passed under the skin at a short distance from the tip of the coccyx, and made to shave along the posterior aspect of the bone, and then to divide the muscular and tendinous attachments, first on one side, then and lastly all round the tip of it. It is not in every case necessary to make the division so free. In some instances the division of the fibres of the gluteus maximus of one or the other side, or detachment from the coccyx of the sphincter and levator ani may be enough. No bleeding attends the operation, which possesses also the other advantages of subcutaneous sections. Simpson admits that this operation occasionally fails, and that he consequently suggested the removal of the coccyx. Dr. J. C Nott prefers extirpation of the bone. Simpson's subcu- taneous incision around the coccyx would divide the nervous branches which supply Luschka's gland, and in this way its success in some cases may be explained. 49 i INDEX OF AUTHORITIES. Adams, W., hook for peritoneum, 340 Addison, rupture of ovar. turn., 299 Aetius, sterility from contracted os ut., 205 Aitkin, L., danger of sponge-tent, 208; has- matocele, 625 Alibert, on diagnosis, 66; " esthiomenus," 763 ; menstr. and skin disease, 250 Allbutt, C , premature raenstr., 154 Altstiidter, conium to stop lactation, 417 Amussat, artificial route to distended ut., 178, 189; fibroid of ut., 671 Anderson, A., tubo-ovar. cyst, 284; keeping open ovar. cyst, 334 Aran, axis of ut., 38; abnormalities of men- str., 172 ; aloetic enemata, 471 ; catheter for diagnosis in chronic metritis, 478 ; diag- nosis of morbid from healthy follicles, 264 ; peritonitis in chronic oophoritis, 267 ; sup- puration of ov. and tubes from menstr. dis- turbance, 353 ; endometritis, 46 1 ; death from cauterization of os ut., 467 ; pelv. hsemat., 604, 508, 526 ; perimetric inflam., 5UI ; acute metritis, 447 ; ulcer, in chronic endometritis, 46 1 Aristotle, on catamenia, 146 Arnott, Henrj', histology of cystic turn, of ov., 282; of polypus ut., 683; cancer ut., 705; epithelioma, 708; sarcoma, 713; fungosi- tifs,716 Arnott, James, cold in cane, 736 Ashwell, diagn. of cane, ut., 721 Atlee, W. L., ovar. turn, not admitting of detachment of cyst, 345 ; ovariotomy during gest., 348 Atthill, L., nitric acid in ut. surgery, 470, 475, 736 ; fibroid of ut, 670 Aveling, atresia vag., 186 ; double metro- tome, 210; hernial gest., 394; inversion of ut. 626 ; polyptome, 691 ; vesico-vag. fist, 747 Babington, urine in dis. kidneys, 315 Bacchetti, electricity in tubal gest., 371 Baedeker, leuoin in ov. turn., 288 Baillie, absence of fimbriae of tubes, 110 ; dermoid cysts of ov., 2 90 ; dropsy of F. t, 356; fibrous turn, of ov., 274; fibroid turn. of F. t., 351; scrofulous ov., 269; fibroid turn, of ut. , 654 Bainbridge, subcutan. incision into ov. tum.. 336 Baker, amput. of inverted ut., 634 Bantock, pepsin in cane., 735 Barba, amput. of inverted ut., 634 Barker, Fordyce, quinine an oxytocic, 170; endometritis, 460 Barlow, pelvic hasmat. and purpura, 523 Basedow, drawing off liquor amnii through vag., 372 Basset, blood from nipples, 156 Bassius, periodicity of leucorrhoea, 74 Battye, Mr. R. F., ovarian turn., sudden death from asphyxia, 295 Baudeloeque, A. C, duct of Gaertner, 29 ; excision of cerv. ut., 728 Bayle, caustics in ennc. ut , 733 Beau, Le, early menstr.. 154 Beclard, rupture of ut., 182 Beck, Snow, nerves of ut., 55; arrested invo- lution of ut., 410 Beequerel, pelvic haemat , 507 ; cane, ut., 723 Begin, procuring adhesion between ovar. cyst and abdom. walls, 335 Bell, John, practicability of ovariotomy, 336 Benporath, fibroid of ut. , and decay of, 653 ; cane, ut., 716 Bennet, H., axis of ut, 38 ; isthmus ut., 206 : neuralgic dysmen., 194; ovar. pain sign of inflam. of ut., 99; soft bougies, 123; death from injecting ut. , 464 ; endometritis, 455 ; metritis. 441, 443 ; ovar. pain, 413 ; potassa cum calce, 451 ; cancer ut., 721 Berard. vascular polypus of ut. , 686 Bernutz, dysmenor. from obstruction of F.t., 224; membranous dysmenor., 226; pelvic haemat, 504, 607, 619. 520, 523, 529; perimetric inflam., 483, et seg. Bernutz and Goupil, tubercle of ov., 269 Beronius, puncture of distended half of bifid ut., 178 Berry, removal of ovarian cyst through rup- tured vag. . 304 Bickersteth, fibroid of ut, 673 Billroth, fluxion, 424 Bird, Golding, electricity in amen., 169 ; cil- culus in prolaps. ut. , 638 Bischoff, changes in ov. at puberty, 27 ; im- pregnation in ov., 375; menstr., 28, and periodicity of, 147; sterility, 109 Blachet, extra-uterine £;est., 787 Blainville, De, on duct of Gaertner, 29 Blundell, treatment of ovar. turn., 335 ; ex- tirpation of ut. in cane, 730 Bockenthal, inversion of ut. , 630 Bohmer. hydrorrhoea gravidarum, 84 Boinet. dropsy of F. t., 356 ; iodine in amenor., 168 ; tapping, iodine inject, into ovar. cysts. 332; tubo-ovar. cysts, 285; gastrotomy for fibroid of ut , 675 772 IISTDEX OF AUTHORITIES. Boivin and Duges, oophoritis, 259 ; ovarian hernia, e. u. gest.. 254 ; tuboovarian cysts, 284; prolapsus ut., 537; tubercle of ut. , 696 Borggreve, inversion of ut. , 630 Bouillaud, heemat. from variola, 523 Boulard, axis of ut., 39; nerves of ut., 55. 56; calibre of isthmus, 206 Bozeman, vesico-vag. fist., 748 Braun, G., incision of cerv., 214; arsenic in membranous dysmen. , 233; hasmat., 508; placental polypus, 686 . Breisky, bifid ut., 178 ; normal ut., 33 Breslau. polypi in F. t. , 367; physicians of, on epidemicity of leucor., 74 ; pelv. hsemat., 529 Brierre de Boismont, menstr. in hot climates, 150, 151 Bright, urine in dis. kidneys, 315; death from collapse in of ovar. turn., 295 ; malig- nant or scrofulous disease of ov., 274 ; tho- racic and abdominal p.ithology, 311 Briquet, pain in ilium, 220 Bristowe, elongation of cerv. ut., 313; per- forations of ovar. cysts, 301 ; tubercul. of ov. 269, 270 ; ulcer, of intestine opening into ov. cyst. 302; effects of fibroids of ut., 658 Broadbent, acetic acid in cane, 733 Broca, labia mnjora, 62 ; diagn. of cane. ut. , 722 Brodie, B.. peritonitis from blood escaping through F. t., 182, 520 ; operating during Brighfs dis.. 337 Brooke. Ch., vesico-vaginal fist, and lacera- tion of perineum, 747, 748 Brown, Baker, excision of part of ovarian cyst, 335; prolaps. ut., oper. for, 573; fibroid of ut., 669, 673 ; vesico-vag. fist., 749 Browne, Chrighton, influence of mind on ut. and ov., 236, 247 Bruce, A., sarcoma, 714 Burd, ovariotomy in pregn., 348 Burdach, menstr. in hot countries, 150 Burow, chlorate potash in cane, 737 Byrne, J. A., nitric acid in uterine surgery, 470 Callender, recurrent fibroid of ut., 652 Campbell, puberty in Siam, 152; extra-ute- rine gest., 365 Canestrini, extra-uterine gest., 391 Carswell, erectile tum. of ut. 652 ; atrophy of, 652; tubercle of, 697 Cnseaux, length of vaginal-portion, 41 Caspar, J. L., inversion of ut , 622 Cayley, sarcomii, 714 Chadwick, post, colporrhaphy, 574 Chairou, compression of left bv.. 221 Chalice, brain matter in ovarian cysts, 290 Chambers, T., cautery clamp, 343 ; pruritus vulvae, 251 ; adhesion between ovar. cj'st and abdom. wall, 335 Chambon, tubo ovarian cysts, 284 Champonniere, Lucas, lymphatic ganglion of ut., 54 Charcot, pressure on ov. region, 220 Chaussier, mucous membrane of ut., 50 Chegoin, uterine abscess, 440 Chomel, colpitis, 739 ; examination of pa- tients, 66 Churchill, dysmenor. membran., 226 Cintrat, fibroid of ut., 674 Clapton, effects of disease on menstr., 243 Clarke, C. M., corroding ulcer of ut., 453 Clarke, C. M., and John, cauliflower excres- cence, 710 Clarke, John, rodent ut. , 710; vicarious haemor., 156 Claudius, on Douglasian sac, 41 Clay Charles, cautery-clamp, 343 ; fibroid of ut., 673 Clemensen, inversion of ut., 622 Cloquet, hypertr. of cerv. ut., 542 Cockburn, quinine causes abort.. 170 Cockle, death from fibroid ut., 681 Cohnstein, intra-ut. medication, 467 Coindet, iodine in amenor., 168 Comstock, Dr., inversion of ut., 623 Cnnolly. on insanity, 235 Cook, foBtal bones in cancer ut., 717 Cooke, T. C, inverted ut., torn away, 622 Cooper, H. , rupture of ut., 511 Cooper, Sir A., early menstr. 153 Cooper, S. . cancer of ut.. 702, 719; diagn. by ut. sound, 122; inversion ut., 627; procid. gravid ut., 560 Coste, cause of e. u. gest., 369; corpora lutea, 24: development of ut. muc. membr., 227; impregnation in ov., 375; periodicity of menstr. and appearances in ov., 147 ; source of menstr. blood, 150 Courty, absence of ut. cavity, 110 ; cancer of ov , 271 ; chronic fluxion, 425 ; eczema of cerv., 437; hydro-therapeutics and tar- water in leucor., 81 ; membranes passed though hymen existed, 229 ; pelv. cellu- litis, 480 ; revulsion in fluxion, 427 ; vag- inismus, 104, 106 Cowper, vulvar gland, 64 Crosse, inversion of ut. , 615, 618, 623 Cruveilhier, calculus in prolaps ut. , 538; cane, of prolaps. ut., 560; cane, ut., 702; fibrous turn, of ov., 274; fibroid tum. of ut., 640, 656, 661 ; hydrorrhoea gravid- arum, 84 ; hypertr. of cerv. ut., 542 ; in- terstitial gest., 390; nerves and vessels of ut., 53, 55 ; OS tincEe, 42 ; round ligament, 35; prolaps. ut., 535; vascular polypus ut., 686 Curling, sterility in man, 115, 254; fibroid of vag., 752 Czihak, extra-uterine gest.. 391 D'Andrade, vicarious bleeding, 156 Dance, vascular pol. ut. , 686 Davis. R. A., menstr. and mental diseases, 246 Davis. D. D., inversion of ut.. 621 Davis, H., amput. of inverted ut., 634 De Morgan, cane, ut., 734 ; diet in eanc, 738 . . ■ . Deees, retention of menstr. fluid in bifid ut., rupture, 178 ; double vag., 523 Delacroix, excis. of cane. cerv. ut., 728 Delamotte, hydrorrhoea gravid., 84 Deleurye, hydrorrhcea gravidarum, 84 Delpech, gastrotouiy in e. u. gest., 386 Demarquay, gastrotomy for fibroid of ut., 675 Deneux, hernia of ov., 254; induces adhesion between ov. cysts and abdominal walls, 335 INDEX OF AUTHORITIES. 773 Denman, inversion of ut., 624 Deville, on F. t., 30 Dezeimeris, extra-uterine gest., 378 Dictionnaire des Sc. Med., epidemicity of leucor., 74 Dieffenbach, prolaps. ut., oper. for, 572 Dieulafoy, aspirator-trocar, 608 Disse, ov. cyst in fern, hernia, 322 ; recovery after rupture of ov. cyst, 298 Doherty, perimetric inflain. , 501 Dolbeau, retro-uterine hasmat., 519, 528, 531 Donne, menstr. blood, 149 ; Triciiomonas vaginalis, 72 ; leucor., 76 ; vaginal mucus. 73 Douglas, folds, sac of, 36, 37 Down, L., menstr. in idiots, 171, 246 Drejer, extra-uterine gest., 391 Dubois, hydrorrhoea gravid., 84; inversion of ut. , 625 ; puncturing by rect. for occlusion of ut. , 191 ; peritonitis, 191 Ducbenne, electricity in tubal gest., 372, 382; in amenorrboea, 169 Duncan, M., bursting of ov. cysts, 298 ; diag- nosis of suppuration in ov., 266 ; dilatation of F. t. , 363 ; fecundity, fertility, sterility, 109 ; ov. cysts on external surface of ut. in cancer, 319 ; resisting power of ut. , 150, 181 ; patency of F. t., 353 ; ut. sound passing along F. t., 142; pelvic inflam., 488, 613; pelvic ha3mat. , 529; prolaps. ut., 557 Duparque, gastrotomy in e. u. gest., 381 ; diagn. of cane. ut. , 721 Dupuytren, amput. of hypertrophied cerv. ut., 110; amput. of polypi, 691 ; excision of cane. cerv. ut., 729 Duverney, ov. gest., 375 ; vulvar gland, 64 Dyce, abdominal gest., &c., 377 Eade, effects of fibroid turn, of ut., 659 Edwards, St. John, axial rotation of ovarian turn., 296 Emmet, prolaps. ut., operation for, 573 ; in- version of ut., 620, 631 ; excision of cerv. in cane, ut., 731 Faille, B. de la, interstitial gest., 389 Farr, W., fruitfulness of marriage, 109 Farre, A.; peculiar dis. of ov., 266 ; bursting of hymen, 182; P. tube, 32; ov. gest., 375 ; casts of vag., 230 ; fungosities of ut., 686 Faye, abscess of ov. in pregnancy, 265 ; fibroid turn, of ut., 640 Fenerly, pelvic hssmat., 504 Ferber, pelvic hasmat., 525 Ferguson, R., irritable ut., 193 ; polypus ut., 682 ; dysmenor., 196, 226 Fletcher, stretching of vag., 189 Foek, mortality from tapping ov. cysts, 330 Follin, axis of ut., 38 ; duct of Gaertner, 29 ; parovarium, 28 Fontaine, experim. on injecting ut. , 466 Forbes, J. G., inversion of ut., 627, 634 Fox, Wilson, formation of cysts in ovary, 281 ; loculated fibroid of ov., 276 ; ext.-ut. cyst, 361; colloid turn, of ov., 284; sarco- ma, 714 FrankenhaUser, nerves of ut., 56 Frairier, pelvic cellulitis, 480 Fricke, prolaps, ut., oper. for, 571 Friedreich, brain matter in ov. cysts, 290 : morphia injections in tubal cysts, 372 Fritze, e. u. gest., 391 Galen, hysteria and lateriversion of ut., 223 Gallard, pelv. htemnt., 504, 519 ; expulsion of cancerous ut., 718 Galton.F., " Hereditary Genius," 108, 109 Gardien, duct of Gaertner, 29 ; gastrotomy in e. u. gestation, 382, 385 Gardner, A. K., on pessaries, 565 Gariel, air pessary, 666 Gendrin, causes of periodicity of menstr., 147 ; changes in ov. at puberty, 27 Gentilhorame, fibroid of ut., 670 Gerdy, gastrotomy in e. u. gest., 386 ; poly- pus ut., 680 Gervis, spontaneous cure of ovarian turn,, 297 Gibbes, dermoid cyst complicatipg pregnancy, 292 Gibson, procid. ut., 570 ; in oper. for prolaps. ut., 676 Giles, pelv. inflam., 489 ; latent gonorrhoea, 740 Girdwood, cause of periodicity of menstr., 146 ; changes in ov. at puberty, 27 Goddard, tapping ovarian cyst in pregnancy, 349 Godson, C, instrument for introducing 1am- inaria tents, 207 Gogarty, fibroid of ut., 670 Gooch, irritable ut., 193; neuralgic dys- menor., 196; polypus ut., 689; cauliflower excrescence, 710; torpid ut., 237; inver- sion of ut., 626 Good, Miison, pseudoeyesis, 235 Goodeve, puberty in the East, 152 Gosselin, endometritis, 461 Goupil, metrorrhagia in e. u. gest., 364 ; ova- rian gest., 375 ; pain in tubal gest , 364 ; perimetric inflam,, 483, 487 ; pelvic hsemat. , 504 Giaef, hydrorrhoea gravidarum, 84 Graves, leucor and vaginitis, 77 Gray, brain matter in ovarian cysts, 290 ; poly pus ut. , 683 Greenhalgh, arrest of tubal gest. by puncture, 372 ; double metrotome, 209 ; mod. of Hodge's pessary, 668 Grimsdale, fibroid of ut., 673 Grisolle, gangrene after abscess, 493 Gueniotj fibroid of ut. and diagn., 666; in- version ut. , 628 Gueneau de Mussy, pruritus vulva3 and gouty diath., 251, 760 Guerin, subcutan. incision into ovarian cyst, 335 ; pelvic cellulitis, 480 ; injection of ut.. 466 ; colpitis, 740 Gull, ovarian cyst containing air and fluid, 300 GUntz., e. u. gest., 391 Gusserow, sarcoma, 713 Guyon, obliterated os ext., 44 ; ruga? of cerv. ut., 43 ; size of ut., 44; experim. on inject- ing ut., 466 ; inversion of ut. , 623 Habit, sloughing of cancerous ut., 718 Hall, M., prolaps. ut., oper. for, 571 •74 INDEX OF AUTHORITIES. Haller, cicatrices on ov and corpora lutea, 27 ; source of menstr. blood, 150 ; pelv. hasmat. , 520 Halley, foetus retained in ut., 388 Hamilton, prolaps. ut., oper. for, 571 Hannover, epithelioma, 710 ; cane, ut., 715 Hare, elongation of ut., 578 Harley, G. , air expelled from ut., 82 Harley, John, polypu.s ut., 686 Harris, infantile men.=tr., 153 Harvey, uterine sound, 122 Haselberg, V., death from injecting ut., 465 ; dilat. of fundus vag., 743 Hassall [see Index of Figure.^!) Haussinan, dysmenorrhoeal membr., 227 Haydon, tubal gest., 380 Heath, colloid cancer of ov., 273 ; fibroid of ut., 673 Hebra, ut. dis. and skin dis., 440 Hecker, ov. gest., 376; interstitial gest., 389 Heckford, cancer in child, 703 Hegar. hydrorrhoea gravidarum, 84 ; pelv. hsemat., 504 Helie, muscular fibres of ut., 49 ; pelv. hsemat., 523 Heming, jjrolaps. ut., oper. for, 572 Hennig, tubal and ut. mucous membr. during gest., 371 ; exper. on injecting ut., 466 ; aspirator tube, 478 Henle, F. t., 31; follicles of vag., 60, 439; Graafian follicles, 22 Herbiniaux, "tumeur vivace," 710 Hericourt, De, air pessary for anteversion of nt., 587 Heschl, fungosities of ut., 686 Hermann, death from inject, ut., 464 Heurtaux, contents of pelv. hsemat., 511 Hev?er, atresia of vag., Ac, 186 Hewitt, G., anteversion pessary, 587 Heyfelder, e. u. gest., 391 Hicks, B., puncturing by rect. for occlusion of ut., 191; e. u. gest., 382; tubal gest., 380 Hildebrandt, fibroid of ut., 668 Hirschfield, nerves of ut., 55 His, lymphatics of ov., 26 ; medullary struc- ture of, 22 Hodgkin, complex ov. cysts, 281 Hoening, sound passing through F. t., 142 ; fibroid tum. of ut., 640 Hoffman, amenor., 169 Hohl, anteversion of ut,, 581 Hooper, dropsy of F. t, , 356 Huchard, menstr. metritis, 229 Huguier, amputation of hypertrophied cerv. ut., 110; arteries of ut., 54; bursting of ov. cysts, 298 ; cysts on ext. surface of ut. , 319; ut. sound, 122, 123 ; violaceous color. of vag. in pregnancy, 364 ; vulvo- vaginal gland, 64 ; ulc. of ut., 438; pelv. haemat., 607; hypertr. of cerv. ut., 544; prolaps. ut., oper. for, 573 ; inversio ut. , 636 ; cyst. tum. of vag., 752; vulvitis, 755; " ender- moptosis, " 761 Hulke, oper. for lacerated perineum, 751 ; sarcoma, 714 Hunter, John, imperfection of testes, 115; inversion of ut., 619 Hunter, Wm., suggests ovariotomy, 336 ; in- version of ut., 624 Hutchinson, adhesion of ov. cyst, 344 ; ova- riotomy clamp, 341 ; ov. turn., two classes, 324; amaurosis in lact., 413; gastrotomy in e. u. gest., 384; recurrent fibroid of ut., 651 ; effects of, 658 ; tubercle of ut., 696 Ingleby, e. u. gestation, 391 Ireland, prolaps. ut., oper. for, 571 Jarjavay, "corpus spongiosum" of ov., 25 Jobert, nerves of ut., 55 ; endoscope, 122 ; actual cautery in metritis, 450 ; vesico-vag. fist., 749 Joerg, e. u. gestation, 391 Johns, Robert, blistering cerv. ut. , 452 Jones, Sydney, ovariotomy forceps, 341 Jones, Wharton, transmigration of ovum, 367 Jungel, on hsemat., 510 Keith, on ovariotomy, 338 ; sulphuric ether in, 339, 347 Keller, gastrotomy in e. u. gest., 382 Kennedy, B., placental souffle in e. u. gest., 364 ; nitric acid in ut. medicat., 470 Kidd, axial rotation in ov. tum., 296; nitric acid in ut. medicat, 470 ; pressure of fib- roid on sacral plexus, 660: fibroid of ut., 655, 668, 670 Kiwisch, abdominal gest., 376, 381 ; absence of decidua in tub. gest., 371 ; div. ov. tum. into two classes, 324 ; drawing off liq. am- nii through vag., 372; F. t. bursting from carcinoma, 350; inflam. of follicles of ov. , 261; trocar for tapping ov. cysts, 328; mortality from tapping, 330 ; ov. gest., 376 ; parenchymatous ovaritis, 262 ; peritonitis, 182 ; rupture of tubal sac, 362 ; tubercu- losis in ov , 268; tum. (enchondromatous) of ov., 276; tubo-ovarian cysts. 284; ut. sound, 123; gastrotomy in e. u. gest., 381, 385 ; polypus ut., 686 ; fibrinous polypi, 686 Klemm, on injecting ut. , 466 Klob, application of one tube to opposite ov. , 368; obliterated os ext., 177; intra-ut. transmigration, 369 ; vag. forming sac in obstruction at vulva, 183 ; fibroid of ut., 640 Kobelt, bulb of vag., 60 ; parovarium, 28 Koeberle, diagn. of fibro-cystic tum. of uterus, 313 ; mortality in ovariot., 346 ; e. u. gest., 379 to 386; gastrotomy for fibroid of ut. , 674, 675 Kohlrausch, dermoid ov. cysts, 290 Kolliker, Fallopian tube, 32 ; vaginal glands, 439 Kussraaul, absence of ut. , 177 ; application of tube to opposite ov., 368; gest. in one horn of ut., 391 Kiister, Dr., effects of fibroid tum. of ut., 658 Laaser, bifid vag., 110 Laborderie, pelv. heemat., 504 Laboulbene, pelv. hasmat., from scarlatina, 523 Lair, uterine sound, 123 Lancereaux, cystic endometritis, 473 ; fibroid of ut., 654; forms of malignant dis. of ut., 715 Lane, J. R., vesico-uterine fist., 749; lacerat. of perineum, 750 INDEX OF AUTHOEITIES. 775 Langenbeck, cane, and amput. of prolaps. ut., 560 ; inversion of ut. , 620 Lapeyronie, excision of eerv. in cane. ut. , 728 Larcher, rupt. of ut., from fibroid turn., 390 ; effects of fibroid of ut., 659 ; polypus ut., 679 Laugier, pelv. hsemat., 504, 519 Lauvariot, excision of cerv. ut. in eanc, 728 Laycock, excessive pigment, 162 Lazzari, excision of cerv. in cane, ut., 728 Lazzati, inversion of ut., 618, 629 Leak, epidemicity of leucor., 74 Lebert, dermoid cysts of ov., 290; fibroid of ut, 641; cane, of, 702, 710 Ledran, incision of ov. cyst, 334 Lee, C. H., fibro-cystic turn, of ut., 313; in- version of, 624 Lee, Robt. , nerves of ut. , 55 ; cause of menstr. , 146 ; strangulation of polypi, 689 Leger, muciparous follicles of vestibule, 64 Legrand, injection of iodine into ov. cysts, 333 Leith, puberty in Bombay, 152 Lente, intra-ut. medic, 467 Leroy, occlusion of bifid ut. , 178 Lesouef, e. u. gest., 365, 372, 374 ; rupture of tubal sac, 374 ; bsemor. in., 364 , electricity in, 372 Letheby, changes in ov. at puberty, 27 ; micr. char, of menstr. blood, 151 ; retained men- strual fluid, 182 Leuret, mania with menstr., 246 Levrat, gastrotomy in e. u. gest., 382, 385 ; hypert. of cerv. ut., 542 ; anteversion of ut., 580 ; instrument for polypus ut., 689 ; " tumeur vivace," 710 Liebman, fibroid of ut. , 653 ; cane., 716 Liebreich, R., retinal hsemor. from suppressed menses, 155 Lisfranc, revulsion, 426 ; inversio ut., 623 ; fibroid, 667 ; amput. of polypus, 691 ; cane, ut., 721, 729 Little, Dr., and Little, L. S., saline injections in cholera, 97 Lize, retained menstrual fluid, 182, 418 Lobstein, nerves of ut., 55 Locock, excision of polypi, 691 Longet, nerves of ut. , 56 Louis, cessation of menses and tuberculosis, 243 Lowenhardt, diagn. of ovaritis, 263; inject- ing iodine into ov. cysts, 333 Lud, nerves of ut., 55 Liiders, pessary found in rectum, 566 Lunier, cretinism postpones puberty, 171 Luschka, transmigr. of ov., 368 ; ov. cysts, 281 ; glandula coccygea, 768 Macdonald, A., latent gonorrhoea, 740 Macintosh, dilatation of os, 206 ; sterility and contracted os ut., 205 Macleod, vaginal glands, 465 Madge, pelv. hsemat., 504, 511 Magrath, fibroids of ut. and e. u. gest., 367 Malgaigne, hair in polyp, ut. , 686; induces adhesion between ov. oyst and abdom. wall, 335; use of utero-sacral lig., 36; pelv. hsemat., 504; inversio ut,, 627 ; vascular polyp, ut., 686; "Champignons cance- reux,'' 728 Malpighi, muscular fibres of ut.^ 49 Mandl, menstr. blood, 149 ; vag. glands, 439 ; chlorate of pot. in membr. dysmenor., 233 Marcha], perimetric inflam., 483 Marotte, epilepsy with menstr., 246 Martin, C. A., muciparous follicles of vesti- bule, 64 Martin, Ch., inverted ut., reduced by cold irrigation, 630 Martin, Prof. E., arrest of tubal gest. by punct. through vag., 372 ; perforation of ut. by sound, 142 ; anteflexion of, 583 ; retroflexion, 602 ; inversion, 620 ; dilata- tion of fundus vag., 743 Mason, vicarious menstr., 155 Maurer, e. u. transmigration, 368 May, rupture of ovarian tum., 299 Mayer, A., on Zwanck's pessary, 567 Mayer, C, vascular pol. ut. , 686; cane, ut., 710; sarcoma, 713; foil, excor. of cerv., 436; pyrolign. acid, 450; bipartite ut. , 395 ; amput. of cerv., 574 Maygrier, use of round ligament, 35 McClintock, pelv. abscess, 490 ; hsemat., 504- 507 ; diagn., &g., of fibroid of ut., 663, 664, 667, 669 ; cysts on ext. surface of ut., 320 ; air in ut., 82 ; on pessaries, 563 ; inversion ut., 620, 633 ; peritonitis from fibroid tum. of ut., 660 ; fibrin-polypus. 686 ; death from polypus ut., 689 ; cysts of vag., 752 ; cane, of, 753 ; tum. of vulva, 762 ; syphil. hypertr. of nymphse, 763 ; lupus of vulva, 764 McDiarmid, influence of cold on menstr., 152 McDowell, first ovariotomy, 336 Meadows, cystiform dilat. of both F t., 355 ; opening periton. in amput. of cerv. ut., 576 . Meissner, vascular pol. ut., 686 Moir, retroflexion of ut., 614 Monro, muscular fibres of ut., 49 Montgomery, membranous dysmenor., 226 ; vascular pol. ut., 686 ; diagn. of eanc. ut., 721 Moore, dermoid cyst of ovary, 292 Morgagni, epidemicity of leucor., 74; tubo- ov. cysts, 284; ut. mucous membr., 50; hypertr. eerv. ut., 542 Mtiller, vibratile current accounting for ex- tra-uterine gestation, 368 Miiller, H., retained menstrual fluid, 182; cysto-sarcoma of ovary, 283 Murchison, cyst of ovary opening into reet., 300 Murray, G., pelv. peritonitis, 489; galvanic pessary, 4 1 6 Murray, John, closure of vagina, 182 Naegele, hydrorrhoea gravidarum, 84 ; os ut. sealed by false membr., 177 Negrier, ovaries act alternately, 223 ; epilepsy under ov. irritation, 246 ; periodicity of menstr., 146 ; changes in ov. at puberty, 27 ; dysmenor., 218 ; early cessation of menstr., 153 ; gest, on insanity, 247 ; iliac pain, 220 ; ov. function, 152; ov. temperament, 219; gest. and ovulation, 158; softening of brain and menstr. , 245; " ovarie" for "hysterie, " 222 ; vesieulite, 261 Nelaton. ovulation cause of haemat., 519 ; retro-uterine haemat., 504, 531 ; fibroid of ut., 669 Newman, spontan. cure of cane, ut., 718- 776 IXDEX OF AUTHORITIES. Nissen, instrument for polypus, 689 Noeggerath, taxis in inversion of ut., 631 ; latent gonorrhoea, 740 Nonat, pelv., hsemat., 504, 607; intra-uterine fungosities, fi86 Nott, coccygodynia, 7fi8 Nunn, elongation of ut., 578 Obre, case of menor., 92 Ogle, fibrous turn, of ut., 687 Oldham, no deciduain tube in tubal gest., 371 ; fluid in F. t. , 357 ; membranous dysmenor., 226 ; puncture by rect. in occlusion of ut., 191; enlargement of urethra in, 178; ster- ility from contracted os ut., 205 ; transmi- gration of ovum, 367 ; channelled polypus ut., 683 Ollenroth, tapping and keeping open ovarian cyst, 334 Olshausen, anteut. hsemat., 508 ; peritoneal hfemat., 509, 510 Osiander, excision of cancerous cerv. ut., 728 Pagello, pepsin in cane, 734 Paget, dermoid cysts, 292 ; ov. cysts, 277 ; fibroid turn, of ut , 651 ; scirrhous ut. , 714 Fallen, retention of menstrual fluid, 183 Paris, pelv. cellulitis, 480 Parker, fatal obstruction of rect. by enlarged ovary, 297 Parkinson, fibroid of ut , 673 Payne, gangrene in prolaps. ut., 558 Pean, ablation of ut., 673, 674 Peaslee, distension of F. t. with ov. cyst, 356 ; ov. turn, diagn., 305 ; treatment of, 325 ; ut. headache, 443 ; pessary for retroflexion of ut., 614 Perkins, absence of ut., 177 Petit, M. A., inversion of ut., 624 Pfetfinger, e. u. gest., 391 Piorry, iliac pain due to ov., 220 Playfair, pelv., abscess cause of haemat., 177; anteversion pessary, 587 Poppel, no decidua serot. formed in F. t., 371 ; interstitial gest., 388 Pott, P., removal of ovaries, 147 Pouchet, changes in ov. at puberty, 27 ; phases of menstr., 148 Powell, ciciitricial closure of vag., 184 Power, periodicity of menstr. , 146 Prieger, fibroid of ut.. 667 Priestley, intermenstrual dysmenor., 218: sound for dilating cervix, 207 ; perforation in cane, ut., 721 Prost, pelv. haemat., 504 Puech, atresia of vulva, 176, 182 ; pelv. hsemat., 504 Puzos, hydrorrhoea gravidarum, 84 Quekett, vascular growth of meatus ur., 764 Raciborski, ovulation and menstr., 147; changes in ov. at puberty, 27 ; periodicity of menstr.. 147; mucous membr. of dysme- nor. and decidua of pregnancy, 229 ; milk in menstr., 159 Radford, galvanism as an oxytocic, 171 Rainey, arteries of ut., 54; round ligament of ut. and uses, 34, 11 1 Ramsbotham, dermoid cyst in Douglas's space, 291 ; fibro-muscular tum. of ut. and ov., 274 ; punct. of imperforate hymen, 190 ; e. u. gest, 388, 391; inversio ut., 623; ligature of inverted ut. , 634 Ramskill, fatal hsemor. from polypus ut., 681 Rasch, Ad., vaginal movements, 82 Raulin, epidemicity of leucor., 74 Recamier, adhesion by caustics between ov. cyst and abdom. wall, 335 ; curette, 475 ; perimetric haemat., 504; fungosities in en- dometritis, 475 ; excision of cancerous cerv. ut., 729 Reid, John, vascular growth of meatus ur., 765 Richard, P. t., 30, 32, 110; ov. cysts dis- charging through F. t., 302 ; tubo-ov. cysts, 284 Richardson, spray apparatus, 105 Richet, axis of ut., 38; broad ligament, 34; nerves of, 55 ; size of, 44 ; utero-sacral lig., 36 ; pelv. haemat., 504, 524 ; fibroid of ut. , 676 ; vascular growth of meatus ur., 766 Rieord, oophoritis, 261 Rigby, neuralgic dysmenor. and rheumatic diathesis, 194 ; oophoritis and membranous dysmenor, 232 ; revulsives, 427 ; fibroid of ut., 666, 667 ; prolaps. of ov., 253; ov. dropsy from oophoritis, 280 Ringland, nitric acid in ut. medic, 470 Ritchie, fibro-cystic tum. of ov. 276 ; ova in simple ov. cysts, 277 ; ovulation without menstr. disch., 148 Roederer, condition of ov. in menstr., 147; hydiorrhoea gravidarum, 84 Robert, pelv. haemat., 507; intractable ulc. of ut., 714 Roberton, early menstr. and pregnancy, 154 ; prolaps. ut , 552 Robin, F. t., 32; leptothrix buccalis, 72; fibroid tum. of ut., 641 ; intractable ulc. of ut., 715 Rokitansky, absence of ov., 252 ; anomalies in corpus luteum, 255 ; atrophy and twist- ing of F. t. by ov. turn., 296 ; bifid ut. and ulcer, of septum from retained menstr. fluid, 178; brain matter in ov. cysts, 290 ; cancer of ov., 270 ; cause of separation of ov. from ut., 254; condition of mucous membr. of ut., 229 ; constriction of intes- tines by rotation of dermoid ov. tum., 297 ; degenerations of corpus luteum, 255; dupli- cation of corpus luteum, 255 ; oophoritis, 259 ; ova in simple ov. cysts, 277 ; remains of Wolffian duet, 350 ; F. t. represented by a rounded stump attached to horn of ut., 350 ; senile atrophy, producing obliteration of OS, 178; transmigration of ov., 368; tuberculosis of F. i;., 350; of ov., 268; en- larged uterine glands, 428, 431 ; abnormal gest., 388, 391 ; atresia, 401 ; pelv. hjemat., 613 ; lateral position of ut., 577 ; anteflex. of ut., 583, 590; retroversion of ut., 596; retroflex. of, 602; inversion of. 618; poly pus ut , 686; tubercle of, 697 ; villous can- cer, 710; scirrhus, 714; hypertr. of clit- oris, 761 ; hermaphroditism, 761 Romberg, iliac pain due to ov., 220 Roper, G., rupture of F. t., in tubal gest., 370 ; calculus in prolaps. ut., 538 INDEX OF AUTHORITIES. 777 Roseniniiller, abnormal gest., 392 Rouget, corpus spongiosum of ut., 54 ; medul- lary struct, of ov., 22 ; ov. bulb, 26 ; broad ligament, 34; v;ig., muscular walls of, 60 llouth, dilatation of urethra, 178; endome- tritis, 460 ; scarificator, 433 ; sponge-tent in heemor., 475; bromine in cane, ut., 733; pepsin in, 734 Roux, excision of cane. eerv. ut., 730 Rupin, twin pregn. outside ut., 373 Ruysch, hydror. gravidarum, 84 ; binding down of fimbriee, and so sterility, 110; pelv. hsemat. , 520; cancer of prolapsed ut., 560 Sacchi, induces adhesion between ov. cyst and abdominal walls, 335 Saint Morrissey, De, ov. gest., 375 ^ Savage, fibroid of ut , 670 Saxinger, pelv. hsemat., 504 Scanzoni, vaginal tapping, 328 ; amput. of hypertr. cerv., 110; aloetie enema, 169; bursting of distended hymen, 182 ; dis. ov.. 110; classif. of ov. tum., 324; dropsy of Graafian ves. from oophoritis, 280 ; fibrous tum. of ov. , 274; leueor. and vaginitis, 77; effect of dysmenor. on ut., 195; effect of menstr. on ov. turn., 303 ; incision of cerv., 212 ; effect of ovulation on hyperemia of genitals, 160; origin of salpingitis, 353; post-m. appearances of oophoritis, 260, 266 ; gest. not arresting ovulation, 158 ; iodic in- jections in ov. cysts, 333; sterility, 113; vaginismus, 106; abnormal gest., 391 ; en- dometritis, 463 ; diagn. of gest., 381 ; in- jecting ut., 466; intra-ut. med., 450; me- tritis, 435; pelv. hajmat., 504 ; haemat. from measles, 523; revulsion, 427 ; varicose ule. of eerv., 438; fibroid of ut., 653, 661, 668 ; placental polypus, 686 Scherer, contents of ov. cysts, 287 Schoenbein, aloetie enemata, 169 Schroeder, perforation of ut. by sound, 142 ; pelv. heemat., 525; invers. of ut . 630 Schultze, e. u. transmigr., 369 ; oophoritis, 263; position of ov. in oophoritis, 263 Schutz, epithelial cancroid, 710 Sehutzenberger, iliac pain due to ov,, 220 Sedgwick, decay of fibroid of ut., 653 Seller, hernia of ov., 254 Seaton, retro-ut. hasmat., 514 Seyfert, pelv. hsemat., 504 Siebold, amputation of polypi, 691 Simon, G., bifid ut., atresia of left vag., 179 ; closure of vag., distended ut., 182 ; post, culporrhaphy, 574 Simon, John, on inflammation, 430 Simpson, Alex , anteversion pessary, 587 ; in- version of ut., 636 ; fibroid of, 667 Simpson, Sir J., chloroform in phantom turn., 238; coceygodj'iiia, lOli, 4+2, 767; diagn. of ov. dropsy, ;^57 ; dry cupping ut. in ame- nor. , 170 ; fertility of peerage, 109 ; fibroid turn, of F. t. , 351; incision of cerv., 211 ; dysmenor. from obstruction at os int., 206 ; sterility from, 205 ; involution of ut., 409 ; inject, of chloroform into vag., 197 ; polyp- tome, 691 ; easts in membr. dysmenor., 226 ; adhesive vaginitis, 188, 190; tapping, 336; neuralgia, 167: galvanic pessary, 167; ut. sound, 123 ; retroflex. of ut. , 612 ; inversion of, 627 Sims, Marion, curette, 475 ; flexion of ut. by fibroid turn., 215 ; danger of dilating cerv. by sponge tents, 208 ; incision of cerv., 214; ovariotomy in gest., 348; speculum, 432; vaginismus, 103 ; ut. hook, 476 ; prolaps. ut., oper. for, 673 ; opening periton. in amput. of cerv. ut., 576; inversio ut., 630; liga- ture of inverted ut., 634 ; fibroid of ut., 669 ; vesieo-vag. fist., 748 Sireday, pelv. hsemat., 519 Skene, chloride of zinc in cane, ut., 733 Skinner, incision of cerv., 214; inversion, 629 Skoldberg, cautery clamp, 343 Smith, early menstr. and pregnancy, 154 Smith, P., retroversion of ut., 596 Smith, Tyler, endoscope, 122 ; Fallopian cathe- terization, 359 ; genesial cycle, 158 ; super- foetation in F. t., 380 ; transmigration, 369 ; leueor., 76, 78; inversion of ut., 630 Soltau, W. F., rupt. of ov. cyst into periton., 298 Southam, mortality from tapping ov. cysts, 331 Spiegelberg, tubal gest. going on t ) term, 362, 374 ; echinococcus of kidney and ov. cysts, 315; suppuration and perforation of ov. cysts, 301 Statfeld, fungosities of ut., 686 Stolz, hypertr. of eerv. ut., 544 Storer, gastrotomy for ut. fibroid, 673 Sutton, hypertr. of vag. walls, 183 ; injecting the ut., 464 Tait, L., perfor. of ut. by sound, 142 ; axial rot. of ov. turn., 296 : gastrotomy for e. u. gest., 383; inversion of ut., 630 Tansini, pepsin in cane., 734 Tardieu, crim. intercourse, 78 ; hemor. from periton., 525 Tarral, excision of cane. cerv. ut., 728 Tavignot, tapping ov. cysts by rect., 328 Teallier, diagn. of inflam. and cane. ut. , 721 Tessier, disch. of mucous membr. of vag. from perehl. of iron, 230, 466 Thomas, stillicidium mens, from contracted vag., 188; ut. sound, 123; intra-ut. medic., 468 ; anteversion pessary, 587 ; reduction of inverted ut., 632 ; incision of eerv. for inversion of ut. , 637 ; malignant dis. of ov. , 273 Thorman, abdominal gest., rupture of cyst, 377 Thudichum, leucin in ov. cyst. 288 Tiedemann, nerves of ut., 56 ; abnormal gest., 391 Tilt, unconsciousness from pressure in ov. region, 221 ; vaginismus, 106 ; endometritis, 460 ; pelv. hismat., 504 Tracy, prolaps. ut. , oper. for, 575 Trelat, urethral pad, 749 Trousseau, blood from mucous membr., 154 ; induces adhesion between ov. cyst and ab- dom. walls, 335 ; iodine and saffron in araenor., 168 ; pelv. haimat., 504, 619 ; peri- met, inflam., 486; turpentine in membran- ous dysmenor, 233 Tuckwell, occlusion of vulva, 183; intra- perit. hemor., 508 ; perimetric hemor., 604 ; rupture of tubal vein, 524 Tulpius, excision of eanc. cerv. ut , 728 778 INDEX OF AUTHOEITIES. Turner, Prof., separat. and transplant, of ov., 296 ; malform. of gen. organs, 393 ; fibroid of ut., 648 TJcelli, ov. gest. .375 Uhde, ov. gest., 376 Ulrioh, foetus retained in ut., 388 ; rupture of ov. cyst into bladder, 300 Urdy, on ablation of ut., 673 Uterhart, occlusion of vag. by cicatrix and dilated urethra, 178 Valleix, uterine sound, 123 j retroflexion of ut., 612 Valletta, amput. of inverted ut., 634 Veit, diagn. of oophoritis, 264 Velpeau, e. u. gest., 370, 375; gastrotomy, 381, 385; use of round ligament, 35, 111 ; inversio ut., 626 ; fibroid, 671 ; polypus, 681 ; on amputation for cancerous cervix ut., 728 Verneuil, axis of ut., 38 ; pelv. hsemat., 507 ; relapse of vesieo-vag. fist., 749 Vigues, pelv. heemat., 504 Virchow, absence of decidua from F. t. in tubal gest., 371 ; brain matter and muse. fibre in ov. cysts, 291 ; menstrual decidua, 227 ; detachment of muc. membr. of ut. during menstr. , 149 ; mucous membr., 87 ; struct, of ov. in chronic oophoritis, 266 ; perimetritis and parametritis, 482 ; pelv. hsemat., 525; hypertr. of cerv. ut., 544; prolaps. ut., 557; anteflexion of ut., 583 ; cane, ut., 710; sarcoma, 713; abnormal gest., 392 Vogel, fibroid turn, of ut., 641 Voisin, pelv. hsemat., 504, 507, 525 Wade, W., pelv. hsemat., 530 Wagner, hsematoma of F. t., 355 Waldeyer, erection of ov., 22 Walter, nerves of ut. , 56 Walter, P. U., ovarian gest., 375 Ward, 0., rupture of ovarian turn., 304 Webb, ova in simple ovarian cyst, 277 Wedl, uterine dis. , from malnutrition, 441; urethral caruncle, 764 Weit, sarcoma, 713 Wells, Spencer, passim in Chapter on Diseases of Ovary ; pelv. hsemat., 524 ; fibroid of ut., 666 West, conception without menstr., 153 ; neu- ralgic and congestive dysmenor. , 194; pru- ritus vulvffi and diabetes, 251 ; metritis hemorrhagica, 434; pelv. hsemat., 504; kidney in prolaps. ut. , 538; pessaries. 563; on oper. for prolaps. ut., 566 ; inversion ut. , 623, 6.?0 ; fibroid, 668 ; cane, ut , 706 ; can- cer, 711; syphil. of vulva, 763 Whitehead, Dr., vaginal mucus, 73, 149 ; con- ception without menstr., 163; suppression of menstr., 171; endometritis, 250; intra- ut. medic, 466; prolaps. ut., 552 Whitehead, Walter, atrophy of ut., 402, 418 ; on oper. for prolaps. ut., 576 Wilks, formation of cysts in ovary, 28 1 ; kinds of ovarian turn., 276 Williams, Wynn, bromine in cane, 733 Willigk, A., ovarian gestation, 375 Willis, on arresting convulsions, 221 Willoughby. tubercle of ut., 697 Wilson, J. Gr., early menstruation and preg- nancy, 1 54 Wiltshire, sloughing of ut. in cane, 730 Wiltshire and Watson, ovariotomy when cyst had ruptured, 348 Wood, ovarian cyst containing fat, 291 ; pro- lapse and hernia, 563 Woodman, inversion of ut., 624; fungosities of ut., 686 Woodson, inversion of ut., 619 INDEX OF SUBJECTS. Abdomen, dilatation of superficial vessels of, 295 enlargement and subsidence of, 150 enlargement of, 175, 183, 204, 223, 236, 237, 292, 296, 321 examination of, by palpation, &o., 139, 305, 307, 314 scar-like cracks on. 306 Abdominal belts, and use of, 238 distension, 75, 345, 346 sbock and collapse, 266, 362, 376, 492, 508 Abortion, 68, 79, 92, 95, 112. 203, 204, 225, 261, 304, 316, 348, 349, 365, 472 hemorrhage from, 355, 364 retrograde hemorrhage from, 93 ; and pelvic hsematocele, 516 Abscess, 310, 317 encysted peritoneal, 319 of breast, 416 perimetric, 319, 490, 531 pelvic, 83, 490, 493, 502 Acetic acid in cancer, 733 Acne, 244 Acupuncture in diagnosis, 665 Ague, 172 Air, expelled from vagina and uterus, 82 sucking of, into ovarian cyst, 329 Alcoholic stimulants, 224," 240 Amenorrhoea, 67, 163 apparent, 176 causes of, 165. 171 flocal, 165), 172 course, duration, consequence, and diag- nosis of, 173 from retention, 175 local exploration of, 68 presumptive, 68 primitive, 163 prophylaxy of, 173 secondary, or accidental, 163, 171 treatment of, 174 Amputation of hypertrophied cervix uteri, 111, 573 of cancerous vaginal-portion, 731 of inverted uterus, 631 Anteversiou and anteflexion of uterus " Uterus '') Aneemia, 69, 75, 165, 168, 300, 362 Anaesthesia, 197 Anasarca, 306, 337 Aorta, imperfectly developed, 165 pressure upon, 294 Aphasia. 239 Apoplexy, 235, 240, 241 Arbor vitse, 43, 50 Ascarides, 77 {vide " Leucorrhoea ") Ascites, 273, 303, 310, 318, 320, 323 with ovarian cystic disease, 319 Asphyxia, 295, 296 Aspirator-trocar, 314, 319, 371, 372, 665 Asthma, 244 Atelectasis of new-born infants, 295 Atresia, 175 {vide " Uterus," " Vagina," and "Vulva"') congenital or acquired, 176 of OS externum, 77, 184, 189 Auscultation, 309 Autogenetic puerperal fever, 485 Ballottement, 306 Barren, definition of, 108 Bartholini's gland, 64 inflammation of, 106, 557, 755 Bichloride of methylene, 339 Binder, use of, 85, 331 Bladder, distension of, 267, 310, 324 {vide also " Urine, Retention of") dragged down in prolapsus uteri, 537 emptying of, 357 fistulous opening of, 70, 745 irritability of, 100, 175 pressure upon, 69, 351 uterus and tumor pressing upon, 296 Blennorrhcea, 103, 263, 345, 353 Blood {vide '' Ovarian Tumors and Effusions," " Hemorrhage ") alteration in state of, 243 in cancer, 718 collection of, in Fallopian tube, 352, 355 effused into peritoneum, 299, 329, 347 ovarian cyst, 229 effusion of, 356, 377 behind uterus, 67, 138 hyperfibrination of, 347 watery state of, 164, 165 Bone in dermoid cyst of ovary, 290 Bowels, constipation of, 75, 76, 100, 169, 235, 253, 357 irritability of, 176 spasm of, 235 Brain, degenerative, inflammatory, and con- gestive disease of, 244 Breasts, atrophy of, 153 changes of, in pregnancy. 305 enlargement of, 237 influenced by ovarian tumor, 304 pain and duration of, 150, 236 turgidity of, 160, 204 tumor of, 244, 245 Bright's disease, 303, 306, 337 780 INDEX OF SUBJECTS. Broad ligament (vide n\so "Uterus") cysts of. 277. 320, 323, 327, 332, 350, 359, 360 (tapping of, 361) disease of, 261 encysted abscess of, 364 hemorrhage into, 374 inflammatioa of, 360 obstruction of bloodvessels and varix, 524; lymphatics, 360 Bromine, 117 in cancer, 733 Bronchitis, chronic, 244 Bronchocele. 243 Bruit-de-diable, 165, 168 Bulb of vagina, 60, 63 (vide also "Vagina") Cachexia, 273 Calculus vesicae in prolapsus uteri, 538 Canal of Nuck, 35. 62 Cancer (fjV« also "Uterus," "Ovary," "Va- gina," and "Vulva"), 91, 92, 100, 101, 103, 136, 320, 338 hemorrhage from, 89, 722 odor, 722 of breast, 160, 270 of vulva, 251, 764 of ovary, 270 (vide "Ovary") of uterus, 177, 219, 238, 239, 251, 270, 272, 312, 701 " cancer-mushroom, " 722 Canula, 334 Carbolic acid, 117, 294, 343, 344 Carunculse rayrtiformes, 59 inflammatioa of, 104, 105 Catamenia (vide "Menstruation") Catheter, 116, 324,326, 33 i, 333, 334, 338, 343 Cauterizing iron, 344 Cautery, 339, 346 galvanic, 540, 541 clamp. 339, 343 Caesarian section, 383 Cervix uteri (vide " Uterus") abrasion and hypertrophy of, 92 amputation of. 177, 540 conical, 205 cystic tumor of, 473 dil.atation of, by incision, 209 engorgement of, 92 impevfeciion of, 176 iniiammution of, 92, 138, 203 means and usefulness of dilating, 96 plugging of, 211, 214 spa.«modic contraction of, 184 turgidity of. 233 ulceration of (and os), 112, 158, 159, 436 "Change of life," 234 Chest-walls, fixing of, 295 Childbirth, influence of, on nervous system, 246 Chloasma, uterine, 441 Chloro-ansemi.i, or chlorosis, 163, 165, 281 distinction from leukfemia, 165 Chloroform and inhaler, 117 inhalation of, 224, 327, 339 Cholesterin crystals, 287, 2S9 Chorea, 243 Chorion. 369 hydatidiform degeneration of, 85 villi of. 375 villi of, in membrane, from uterus, 231 Chorion, villi, simulation of, by ducts of utric- ular glands, 231 Chorionic sac attached to ovary, 376 Chromic acid, 117 Clamp, 339, 341, 342 Climacteric [vide also "Menopause"), 106 early, 153 in man, 234 Clitoris, anatomy of, 60, 63 disease of, 63, 761 Clots, retained, 92 Coccygeal gland, 768 Coccygodynia. 106, 442, 766 Colic, 77, 375 Colica scortorum, 356, 366 Colitis, 103 Collapse, 266, 295, 329, 333, 345, 347, 362, 375 (vide "Abdominal," also "Shock") Colpitis, 103 (vide "Vaginitis'') Oolporrhaphy. 674 Conception, 148 Concussion or shock, 244 Condy's fluid, 294, 344 Convulsions, 221, 223, 239, 240, 245, 265, 374 Copraeuiia, 604, 719 Corpora lutea, 367, 368, 369 absence of, from follicle, 264 cystic degeneration of, 255 degenerations of, to a fibrous tumor, 257 to carcinoma. 256 dendritic protrusion of, 255 description of, 24, 25 duplications of, 255 evolution of, 25 false, 25 origin of, 25, 28 Corpus spongiosum of uterus, 54 Counter-irritation, 258 Cystocele, vaginal, 742 Cysts (vide "Ovary," " Broad Ligament, " "Vagina," "Vulva") between amnion and chorion, 84 layers of chorion, 84 extra ovarian, 310, 360 of chorion, 85 Cystitis, 293, 297 Decidua, 113, 227 tubal gestations, 370, 371 extravasations into, 113 hypertrophy of, 84 Delirium, 195, 197, 204, 239 Dementia, 197, 244 Deodorants and disinfectants, 737 Developments, imperfect and disproportion- ate, 106 Diabetes, 244, 251, 758 Diagnosis, 67 of disea.S significance of, 86 containing epithelium-cells, 70 fleshy, 69 indications of, 69 leucorrhoeal {vide " Leucorrhoea"), 68, 69, 72 membranous, 69, 225 mucous, 69, 70 purulent, 69, 87 sanguineous, 68, 69, 70, 88 Discus proligerus, 23 Displacements (vide "Uterus," &c.) Dodging time of life, 234 Dorsal decubitus, 83, 144 Douglas's sac or pouch, exudation in, 265 fluid in, 345 Drainage-tube, 339 Dropsy, 319 Dyschezia. 100, 182, 253. 262 Dysentery, 103, 244, 329 Dysmenorrhoea, 77, 79. 113, 163, 175, 184, 212, 244, 257, 262, 266, 280 sign of ovarian dropsy, 218 causes of, 68, 192, 199 congestive, 193, 198 treatment of, 199, 206, 210 definition and kinds of, 193 difference between membrane of, and de- cidua of pregnancy, 229 endometritic, 461 from tubal obstruction, 193, 224 from mechanical anomalies of uterus, 193 from obstructed excretion and causes, 201, 224, 262, 352 seat of stricture, 206 symptoms of, 204 from ovarian disorder, 193, 217, 219 inflammatory, 225 membranace"a, 200, 225, 227, 228 more common in married life, 231 symptoms, 231 treatment of, 232 neuralgic or sympathetic, 193, 196 uterine, 219 Dysootocia, 217, 266 Dyspareunia, 68, 107, 110, 203, 232, 253, 257 causes of, 68 acquired, 102 congenital. 102, 104 cure of, 103, 105 significance of, 102 Dyspepsia, 75 Dysuria, 106, 293, 316, 357 Eclampsia, 240 Ectopic gestation (vide "Extra Uterine Ges- tation") menstruation, 154 Ecraseur, chain and wire, 339 Eczema of vulva, 250, 758 Effusions of blood (vide " Blood,") 92 Electricity, in tubal gestation, 371 Embolism, 347, 720 Embryo, destruction of, 227, 374 Emmenagogue?, 170 Emotion, exaggerated, 104, 236, 237, 245, 260, 263 influence of, 166 Emotion, influence of, on menstruation, 171, 172 Emphysema, 244 Endocervicitis, 229. 460 Endometritis, chronic, 205, 245, 250, 453 (vide also " Uterus") cystic, 473. 474, 478 Endoscope, 116, 122 Enuresis, 297 Epilepsy, 197, 235, 240, 243, 246 Epistaxis, vicarious, &c., 154, 235, 238 Ergot and ergotin, 170, 667 Erysipelas, 250 Erythema nodosum, 155, 164 Ether, 339 Examination by bladder, 138 by speculum. 136 of patients, 67 of secretions, discharges or substances expelled, 136 rectum, 312, 313 vagina, 238 Excretion, 70, 163, 176 mechanical obstruction of, 198 Exploratory incision, 314, 324 Extra-uterine gestation (vide " Gestation") Eye, instrument of observation, 116 retinal hemorrhage, from suppressed menses, 155 vicarious ecchymosis of, 155 Facies ovariana, 307 Fallopian tubes, 19, 29, 110 abnormalities of, 213 absence of, 110, 252, 350 carcinoma of, 350 ■ catarrh of, and causes, 353, 354 catheterization of, 359 closure of uterine and fimbrial ends, 356, 359 congestion of, 150, 174 cysts of, 350, 355, 360, 365 dangers of distension, perforation, &e., 353 354 359 dilatation of, 181, 183, 191, 352, 354, 356 diseases of, 260 treatment, 358 dragging on, 253 dropsy of, 322, 327, 353, 356, 364 contents of tube in dropsy, 105 dropsy associated with general dropsy, 356 dependent on other causes, 357 symptoms, diagnosis and treatment of, 357, 359 elongation and causes of. 352 fimbriae of, 30 supernumerary, 350 gestation in, 59 hypertrophy of, 352 impervious, 224, 367, 369 inflammatory adhesions of, 366 inflammation and suppuration of, and causes, 353, 354, 355 laceration of, and cause, 181, 190 ligament of, 30 ligature of, 373 obliteration of vessels leading to atrophy of uterus, 361 obstruction of, by polypi, 367 occlusion of, 93, 110 782 INDEX OF SUBJECTS. Fallopian tubes, phlebolithes and phlebitis of vessels, 361 puncture of tubal sac, 373 retention in, 355 rupture of, 182, 353, 354, 362, 370, 373 374 signs of distension, 353 tubercle in, 269, 351 tumor of. 350, 351, 361 Fffices, accumulations of; 263, 310, 322 in csecum, 263 stoppage of, 365 Fecal abscess, communicating with ovarian cyst, 301 Fecundity, 112 Fibrinogen, 287 Fistula (vide "Vagina'') Flatulence, 75 Flooding {vide "Menorrhagia'' and " Metror rhagia") Fluctuation, double, 307 fallacy of 308 in fibro-cystic tumor of uterus, 314 in ovarian tumor, 307, 313 Fluxion, 423, 425 Foetus, movements of, 237 retardation of growth, 373 retention of, 380 Follicles of vulva, 64 Follicular inflammation of cervix uteri, 436 Forceps, 339 artery, torsion, and bull-dog, 339 Wells's long screw forceps, 342 Fossa navicularis, 62 Fourchette, 62, 105 fissure at, 1 04 Fungosities, intra-uterine, 475, 686, 716 Gallstones, 242 Galvanic cautery, 294, 541, 731 Ganglionic system, irritation of, 347 Gangrene from cancer, 704 in prolapsus, 557 Gastrotomy, 374, 375, 673 Genital canal, occlusion of, 70, 163 stenosis and atresia of 180 Germinal vesicle and spot, 24 Gestation, 107, 112, 234 abdominal, 370, 376 cervical, 369, 370 ectopic, 370 extra uterine, 92. 93, 254, 286, 293, 363, 365, 366 influence of, on uterus, 370 symptoms, dangers, &c., of, 363, 364, 365 treatment of. 371 in Douglas's pouch, 365 in one horn of uterus, 390 interstitial, or intramural, 362, 375, 387 ovarian, 375, 376 tubal. 322, .327, 353, 357, 362, 365, 366, 376, 377 danger and termination of, 363, 364 diagnosis of, 372 physical signs of, 365 treatment of, 371 tubo-ovarian, 362, 369, 375, 376 Gonorrhrjea, 71, 72, 78, 354, 356, 488, 740, 759 "latent," 740 Gout, 244, 250 Graafian vesicles, 22, 24 bursting of, into adherent tubes, 285 changes in at menstrual epoch, 27, 147 contents of, 287 dehiscence of, 148, 149 destruction of, 109 disease or bursting of, 262, 264 dropsy of, 280 enlargement of, 287 existence of, in foetus, 27 fibrous degeneration of, 256 inflammation of follicles, 261 inflammation of, 266 morbidly dilated, 277, 279 Green-sickness [vide " Chlorosis") Gynaecologist's bag and contents, 115 Hfematocele, 83, 138,174, 243, 310, 315, 316, 374 cataclysmic, 506 catamenial, 519, 523 dingnosis and treatment of, 530 pelvic, perimetric, retro-uterine, 503, 528 ante-uterine, 508 rupture of, 529 Hsematemesis, hereditary, 155 menstrual, 154 Hajmatometra, 191 Hsematuria, 92 Haemoptysis, 155 Hsemorrhoids, 104, 155, 235 Hsemostatics, application of, 95 Hemorrhages, 76, 89, 239, 329, 349, 363, 364, 365 abdominal, 93 active and passive, 89, 96 after-treatment of, 97 associated with other symptoms, 90 causes of, with structural alteration, 92 without structural alteration, 91 climacteric and senile, 91 death from, 347, 373 from blood disease, 91, 243 cancer, 722 congested cervical canal, 159 decidua vera. 158 emotion and shock, 94 excess of coitus, 91 heart, liver, or lung disease, 91 ovarian or mammary excitement, 91 polypus, 680 suppressed action of skin, 91 suppression elsewhere, 91 fibroids, 660 varicose ulcer (vicarious), 155 in endometritis, 474, 523, 524 pelvic, 506 during lactation and gestation, 91 of placenta prsevia and Fallopian gesta- tion contrasted, 370 poured out internally, 93, 346, 370 significance of, 88 treatment of, 93 Hemorrhagic diathesis, 155 Hand, in diagnosis, 116 exploration by, 136 Headache, 158, 164, 168, 174, 176, 204, 217, 223, 235, 239, 346 Heart, disease of, with amenorrhoea, ^3 INDEX OF SUBJECTS. 783 Heart, deposit of fibrinous eoagula in disease of and menstruation, 244 disease of and cancer of ovary, 272 disease of and ovarian tumor and ascites, 310, 317 fiitty and feeble, 91 feeble and irritable, 164 hypertrophy of, dilated, 240 imperfectly developed, 165 pressure upon, 295, 720 Hectic fever, 85, 175, 182, 293, 303, 334 Heterogenetic puerperal fever, 486 Hiccup, 347 Higginson'S vaginal syringe, 118, 131 Hip-bath, value of warm, 169 Hodge's pessary, 103, 117, 187, 188, 189, 268, 567, 598 Hull's utero-abdominal support, 570 Hydrometra, 180, 295 Hydrops tubse, 352 Hysterical mania, 247, 248 pains, 166 temperament, 257 Hydrorrhoea, catarrhal, 84 gravidarum, 83 puerperal form and causes, 84 Hydrometra, 454 Hydronephrosis, 704, 719 Hymen, 59, 64 atresia of, 176 description and structure of, 59 remains of, 105 unyielding and imperforate, 181, 189, 190 HypersRmia, 92, 251, 427 HyperEBsthesia, 69, 102, 103, 104, 194, 198, 219, 220, 245 Hyperlactation, 75 Hypochondriac stitch, 101 Hypochondriasis, 236 Hysteralgia, 99 Hysteria, 98, 104, 162, 195, 210, 211, 218, 220, 244, 249. 257 causes of, 222 depending on ovarian disturbance, 221 uterine irritation, 100 Idiocy and menstruation, 244 Ileus, death from, by ovarian tumor, 297 Illumination for examination, 143 Impregnation, 110, 112, 267 ovarian, 376 Incision of cervix, 293 followed by peritonitis, 489 mode of operation, and structures di- vided, 215 necessary instruments for, 215 results and appreciation of, 211 Indian hemp, oxytocic, 170 Inflammation, general theory of, 420 and vide individual organs by name Injections, uterine, 95, 464 Insanity, 246, 247 Instruments, diagnostic, 116 for special purposes, 67 importance of, in diseases of women, 67 therapeutical, 116 use of, 136 Intertrigo, 250 Intra-uterine, caustic holder and carrier, 117, 128 Intra-uterine, injecting apparatus, 117, 130 injections, 260, 263. 464 medication, 464. 468 transmigration of ovum, 369 Involution {vide "Uterus'") 407 Iodide of mercury ointment, 117 Iodine, 117, 373 in urine, perspiration, and breath after injecting cyst, 333 paint, 268 tincture of, injected, 322, 323, 325 Iron, mode of action, 167, 170 Irritative fever, 319, 329 {vide "Hectic") Kidneys, cystic disease of, 315 diseases of, 265, 273, 310, 318 in cancer, 719 in prolapsus uteri, 539, 557 echinococcus of, 315 enlargement of, 310, 315 floating, 315 hyperasmia of, 303 imperfect action of, 238 obliteration of, by tumor, 297 pressure upon, 242 secreting power increased after tapping, 332 Kreatin and kreatinin, in ovarian cysts, 289 Kreuznach, waters of, 113, 472 Kiichenmeister's metrotome scissors, 125 Labia majora, 62 adhesion of, 176 excessive development of, 110 sebaceous follicles of, 64 varicosity of vessels, 92 minora, 62 {vide "Nymphae") adhesion of, 176 Labor, 316 constitutional effect of, 407 effect of, on uterus, 418 induction of, premature, 349 Lactation. 107, 234, 412, 413 Leeches, use of, 92, 169, 224, 225, 233, 241, 246, 253, 258, 268, 346, 432 Leptothrix buccalis, 72 Leueocythsemia. 91 Leucorrhoea, 203, 230, 235, 247, 253, 267 causes and significance of, 73, 74, 75, 78, 164 diagnosis of, 79 menstrual, 74 occult, 79 of children, 77, 78, 739 physiological, 74 results or effects, 78 strumous and syphilitic, 80 uterine, vaginal, and vulvar, 74, 76, 77, ■ 78 Leukaemia, 165 Leucin in ovarian cyst, 289 Levator ani, 58 Lever pessary ii;ide " Hodge's") Ligatures, 341, 342, 344, 345 Liquor amnii, 84 drawing off in tubal gestation, 372, 373 Lithiasis, 242 Lithopsedion, 380 Liver, acute yellow atrophy of, 243, 523 atrophy of, 91 784 INDEX OF SUBJECTS. Liver, cancer of, 270 diseases of, 173, 244, 310. 318 enlargement of, 310, 315 extravasations of blood in, 265 hydatid of, 316 imperfect action of, 238, 241, 242 Lumbar colic, 246 Lumbar and pelvic glands, tubercular and other diseases of, 323, 324 Lung disease, 91, 173, 174, 310 condition of, 337 pressure upon, 295 tubercle of, 269 Lupus of vulva, 764 Lymphatic vessels and glands, 26, 703, 704, 720 Malarious affections, 243 Malformation, 68 Malignant disease {vide " Cancer ") of caput coli, 273 Malignant jaundice, 243 Mania, 195, 203, 244, 246 Measles, 243, 523 Meatus urinarius. 63 disease of, 92 vascular excrescence of, 104, 261, 765 Melancholy, 244, 246 Membranes, rupture of, 84 Menopause, 234 disorders and treatment of, 240 Menorrhagia. 89. 92, 111, 149, 163, 164, 200, 203, 204, 219, 228, 238, 247, 253, 267, 30-4, 354 common in hot climates, 150 local causes of, 68, 108, 112 Menstruation, absence of, 110 abrupt suppression, 172 age, when beginning, and how influenced, 161 characters of discharge, 148, 149, 257 retained blood, 182 climacteric irregularity, 234 compared with that of mammals, 27 critical, 243 dependent on quality of blood, 166 described, 27, 90, 160, 161 difficult, leading to effusion of blood, 518, 521 during lactation, 159 early cessation, causes of, 153 easy condition for, 206 exaggerations of, 91 first sign and first period, 148 hemorrhagic tendency hereditary, 91 imperfect, 164, 217. 218 increased by difficult ovulation, 219 indications of, 149, 150 influenced by surrounding organs, 68 influence of ovulation and menstruation in evoking morbid influences, 242 irregularity of, 89, 149 local conditions and impediments of, 160, 161 not coinciding with ovulation, 222 not index of state of ovary. 248 obstruction of, producing morbid influ- ence on breasts, 244 occult. 67, 163, 176 signs of, 176 partial retention of, 199 Menstruation, peculiarity of blood, 149 period of disappearance, 162 periodicity, dependence on, 146, 151 quantity of blood discharged, 150 relation of, to ovarian disease, 242 retention of, 175, 184, 199, 352 safety-valve and depurating channel, 238 similarity between advent and climac- teric cessation, 150 source of, 160 suppressed, 225, 236, 237, 260, 365 results of, 67 suspended, and causes, 158, 165, 171, 242, 264, 266, 316, 353, 364 vicarious or ectopic, 154 white, 153 Menstrual fluid, characters of, 149 changes produced by retention in uterus, 200 Mensuration (of abdomen), 307 Mental aberration, 245 distress. 257 Metalbumen, 287 Metritis {vide also ''Inflammation of Ute- rus"), 142, 226, 262, 264, 366 course of, 439 chronic. 229, 267, 434 curability, 445 cystic, 453 menstrual, 65, 229 Metrorrhagia, 89. 96, 205, 224, 245, 313, 461 definition of, 89 Metrotome, 117, 125 description of, 209, 215 objections to double-bladed, 209, 210 scissors, 117, 126, 215 Milk, alteration in, by menstruation and emotion, 159 suspension of, 496 Mole, fleshy, vesicular, 375 Mons veneris, 61 Morsus diaboli, 376 Mucous membrane of uterus differs from other mucous membranes, 60 Mucus, 72, 352 albuminoid, coagulated by injection, re- sembling membrane, 230 Mucin, 289 Muciparous follicles, 64 Myoma {vide "Uterus, polypus of") Myxorna, 715 Nabothian glands enlarged, 276, 453 Natural labor, 110 Nelaton's forceps, 340 Nerves of uterus, in pregnancy, 65 Nervous derangement, 69, 222, 223, 224, 235, 236 excitement. 343 irritability, 104, 248, 256, 349 Neuralgia, 69, 243, 245, 249 due to uterine disease, 99 treatment of, 166 Nonnengeriiusch, 165 Nurse and nur.'sing, 338 Nymphs9, 62, 762 Obesity, 237 Occipital headache, 101 INDEX OF SUBJECTS. 785 (Edema, general, 164 of legs, 295, 303, 321, 337 Ointments, 353 Omentum (and intestines), 344 enlargement of, 310, 316 Oophoralgia, 221, 256, 258 Oophoritis, 26, 99, 171. 218, 222, 225, 257, 258, 259, 260, 261, 285, 488 appearances of ovary affected, 260 causes of, 260 chronic, 266 course of, 261 diagnosis and symptoms, 262 treatment of, 268 Ootocia, 217, 222 Oozing excrescence of labia, 86 Opium, use of, 374 Os tinese or externum, 40, 41, 143, 144, 145 atresia of, 110, 176, 189, 250 character of, 137 congenital narrowing and results of, 183, 184, 195, 261 difficulty of making out, 180 dilatation of, 79 fungous granulation and ulceration of, 92, 177 incision of, 199, 250 intense red ring round, 250 narrowing of, 77, 79, 95, 96, 110, 199, 200, 201, 202, 205, 213 obstruction of, 204 opening into rectum or urethra, 1 78 patency of, and relative position, 304 sealing of, by false membrane, 177 variations of, 41, 46, 139 Ostium uterinum, 31 Ova, diseased, 110, 213 in abdominal cavity, 376 ripening and extrusion of, 255 Ovarian temperament, 219 Ovaries, abnormal conditions of, 252 abscess, termination and treatment of, 265, 266, 268, 350 absence of, 20, 109, 147, 166, 252, 377 action of, attracting blood, 260 activity of, during pregnancy, 158 adhesions of, to side of pelvis, bladder, rectum, &o., 254, 266, 310, 490 adhesions to uterus, 264, 259, 267, 310 adhesions of, with Fallopian tube, 114, 254 anomalies of relation, 254 atrophy of, 28, 110, 203, 205, 249, 252, 255 cause of, 214 atrophy, gangrene, and strangulation of, 295 attachment of foetus to, 375 congestion of, 93, 103, 151, 160, 203, 258 characters and significance of, 223, 255, 257 cystic disease of [vide " Ovarian Tu- mors ") defective development of, 114, 147, 166 deranged function of, 65 description of, 20, 25 development of, 26 disease of parenchyma. 70.108, 110, 114, 167, 173, 212, 213, 221, 262 displacement of, and causes, 252 dropsy of {vide " Ovarian Tumors") enlargement of, 376 Ovaries, excessive growth of follicles, 254 involution and senility of, 112 excitation of, 260 exfoliation of epithelium, 229 extirpation of (vide "Ovariotomy''), 147 extravasation of blood into, 260 fibroid degeneration of, with disappear- ance of follicles, 267 fibrous disease of, 271 hernia of, 252 diagnosis, 254 hyperemia and hypersesthesia of, 262 increased bulk, 218, 252, 254, 257, 260, 261, 285 inflammation of, 26, 99, 103, 171, 203, 252, 263, 267 inflammation of follicles of, 261 inflammatory adhesions of, 252 involution of, 219 irritation of, 99, 1U8, 113, 162, 203, 257 (vide "Oophoralgia"), ligaments of, 20, 22 lymphatics of, 26 malignant diseases of, termination and treatment, 266 morbid conditions of, 194 movement with uterus, 252, 253 neuralgia of (vide " Oophoralgia ") perforations and rupture of, 266, 513 prolapsus of, and symptoms, 253 proof of acting alternately, 223 pseudo-membranous adhesions of, 254 results of pressure when tender, 220, 221 scrofulous disease of, 351 stimulation of, 166 structure of, 20-24 swelling and tenderness of, 262 tubercle in, 350 tumors of — adhesions of, 310, 320 alteration in walls of uterus by, 306, 307 benign and malignant, 309, 310, 321, 322, 324 cancer of, 270 medullary and gelatinous, 270, 283 hard, 271 melanosis, 272 colloid, 272, 273, 283 cancerous with cavities, 324 cystic (various kinds), 266, 270, 277, 278, 316, 324, 357 cystic and malignant, 167, 252 adhesions of, with bladder, rectum, and diaphragm, 300, 302, 303 appearance of, 340, 344 atrophy and shrivelling of, 296 axial twisting of, 295, 296, 325, 349 bleeding from, without rupture, 300 into cyst, 295, 300 cases for selection of interference, 326 communicating with ileum, 299 complicated with pregnancy, 348 conception during presence of, 304 contents of, 287 cutaneous, proliferous, or dermoid cysts, 290 bursting of, into bladder and rectum, 293, 300 50 786 INDEX OF SUBJECTS. Ovaries, tumors of, inflammation and ulcera- tion of, &c., 283, 293 symptoms and treatment, 293, 294 cysts discharging througli Fal- lopian tube, 302 friable and rotten, 344 multilocular, 276 means of extracting, 344 simple, 254, 272, 356, 358, 359 simulating tubal gestation, 371 small, 365 dendritic, cauliflower growths of, 301 developed from wandering ova, 286 diagnosis of, in early life, 321 distended with blood, 280 excision of part of cyst, 335 extirpation of {vide "Ovariotomy") hemorrhage into, 321, 322 incision of, 334 keeping open, and mode of, 326, 327, 328, 340 mode of cure after tapping, 327, 328 multiple, and how formed, 280 natural course and termination of, 294 perforation and causes of, 301, 325 presumption of being free from ad- hesion, 320 proliferous or compound, with col- loid contents, 281, 283, 324 histology of, 282 proliferous, &c., with large sarcoma- tous formations, 283 rate of growth, 303 rotation of, 296 rupture of, 41, 93, 347, 349, 513 containing foetus, 375 simple or barren, 277, 283 spontaneous rupture of, diuresis, and recovery, 297, 298, 225 suppuration of, 301 tapping, 310, 312, 320, 323, 326, 330, 332. 337 by abdomen, and dangers, 329 by vagina, 326, 372 cases where most useful, 326, 327 objection to, 328 together with injection of iodic or other irritating fluids, 325, 327, 332 tubo-ovarian cysts, 256, 284 how formed, 280 treatment of, medicinal, 325 complicated, with pregnancy, uter- ine fibroid, and ascites, 309, 312 diagnosis of, 305 pregnancy coexisting, 312 enchondromatous, 276, 324 fibrous or fibro-muscular, 274 fibro-cystic, 276 in Douglas's pouch, 308 mistaken for pregnancy, 305 solid. 273, 312, 324 Ovariotomy, 310, 323, 329, 336, 339 after-treatment, 343 causes of death, 345 dangers of, 338 instruments required, 339 precautions before operating, 337, 339 Ovaritis {vide "Oophoritis") Oviduct {vide "Fallopian tube") Ovula Nabothi, 53, 453 Ovulation, 107, 114, 234, 248, 260, 266 diflScult, 109, 217, 218 influence of, on system, 158 not occurring, 109 precocity of, 152, 153 significance of, 148 Ovum, arrest of, 110 bursting of, in tubal gestation, 370 description of, 23. 24 impregnated, escaping into abdominal cavity, 374 locality of impregnation of, 369 perishing of, 267 Oxytocics {vide " Emmenagogues ") Pain, 333, 345. 365 abdominal, 85, 232 bearing down, 69, 232 meaning of, 100, 181 colicky, 71 ^ crural, 69, 98 iliac, 69, 203, 220 in cancer, 722, 724 inguinal, 98 lumbo-dorsal, 69, 98, 203, 219 lumbo-sacral, 98, 100, 219 ovarian 195, 196, 205, 257, 262, 267, 285 pelvic, 69. 85, 98, 204, 219, 232 rectal, 253 shooting, 101, 346 significance of, 98, 195, 196, 201, 248, 257, 266, 364, 371, 375 stabbing, 101 sudden, intense, 362 test of, depending on local diseases, 101 throbbing, 101 uterine, 100 Palpitation, 164 Pampiniform plexuses, 54 Pancreas, enlargement of, 310, 315 Paralbumen, 287 Paramenia, 163 Paraplegia, 244 Parasites of vagina, 72 Peculiarity of ovarian veins, 54 Pedicle {vide "Ovariotomy"), 341 Pelvic abscess, 83, 490 aponeurosis, 58 cellulitis, 87, 103, 211, 214, 310, 315, 316, 357 disordered organs, 69 distress, 316 hsematoeele, 243, 503 encysted, 374 Pelvic peritoneum, encysted abscess of, 363, 364 inflammation, 487, 488 adhesion in, 494, 495 cancerous, 500 peritonitis, 112, 171, 184, 201, 203, 207, 208, 211, 264, 310, 315 projection, 221 symptomatic of oophoria, 222 Pepsin in cancer, 734 Perchloride of iron, 117, 211, 214, 216, 230, 339, 347 Percussion, 309, 315 Perimetritic deposits, 200 Perimetritis, 181, 201, 225, 298 INDEX OF SUBJECTS. 787 Perimetric inflammation, 479 apart from pregnancy, 486 causes of, 486 diagnosis of, 497 in the foetus, 486 objective characters, 501 parametritis, 482 perimetritis, 482 pelvic cellulitis, 480, 489 rectal touch in, 499 Perineum, 62, 105 fissures of, 104 laceration of, 111, 749 operations for, 760 rupture of, 82 Peritonea] dropsy (encysted), 310, 317, 318 Peritoneum, 340, 347 closure of, by sutures, 343 division of, 340 exposed, 338 Peritonitis, 74, 85, 103, 175, 181, 182, 190, 195, 205, 208, 214, 254, 257, 260, 26], 262, 266, 267, 285, 286, 300, 302, 316, 319, 329, 333, 346, 489, 526 meretricum, 488 pelvic, 346, 347. 352, 353, 355, 356, 357, 362, 363, 372. 373. 377, 484 circumscribed, 67, 266 encysted, 346 general, 346 ovarian, 262 treatment of, 346 Peri-uterine effusions, 138 Pessaries, 92 air or Gariel's, 117 choice and mode of applying, 565 cup-and-stem, 669 description of, 564 for reducing inverted uterus, 638 Hodge's ivide "Hodge"), 667 intra-uterine, 117 medicinal, 117, 197, 253, 259 Simpson's intra-uterine, galvanic, 117, 201 stem, 118 Thomas's, 117 use of, 564 vaginal, 105, 224, 448 vulcanite, intra-uterine, 117 Wright's, 612 Zwanck's, 666 Phlegmasia dolens, 321, 486 and hEematocele, 529 from cancer, 720 Phthisis, 91, 173, 242, 243, 302, 303, 334, 337, 351 uteri, 697 Physo-hydrometra, 85 Physo-hsematometra, 182 Pigment in menstruation, 162 in ovarian cysts, 289 Piles {vide "Haemorrhoids") Placenta, 50, 369 detachment of, 92 hydatidiform, 92 prsevia, 369 retention of, 84 Plethora, 240 Pneumonia, 244, 260 Polyptome, Simpson's, 691 Aveling's, 691 Polypus, 76, 81, 85, 86, 91, 94, 110, 126, 183, 239 (vide •' Uterus, polypus of") Potassa cum calee, 117 Poupart's ligament, 352 Pregnancy, 159, 311, 348, 349, 366 false, or spurious, 235 objective signs of, 305 simulation of, 176, 178, 183, 236 {vidi: " Gestation ") Prolapsus {uide. "Uterus") Prostration, 69, 249, 258 Pruritus of vulva, 193, 768 Pseudo-ovarian cyst, 277 Pseudocyesis, 235, 237. 314 Pubico-vesical plexuses, 63 Pudic veins, 64 Puerperal, fever, 485 autogenetic, 486 heterogenetic, 485 mania, 246 pelvic peritonitis, 181, 226, 262, 479 peritonitis, 26 Purpura, 244 Purulent discharges, indications and causes of. 87 Pus, 77, 287, 345, 362 escape of, due to pelvic peritonitis and suppurating ovarian cyst, 316 Pysemic fever, 175, 185, 214, 244 Pyoid bodies of Lebert, 289 Quinine, an oxytocic, 170 Recto-abdominal pouch, 252, 304 distension of, 313 by cysts, 322 Recto-vaginal septum, 58 fistula {vide "Rectum") Rectocele vaginal, 742 Rectum, encroached upon, 297, 327 fissure, 104 fistula of, 70, 104, 747 position and relations of, 327 pressure upon, 69, 352 Renal dropsy, 367 Rest, 343 Rete mirabile of ovary, 25, 54 Retention of urine, 85 cause of, 67, 176, 183, 184, 211, 220, 321, 365, 496, 626, 532 Retro-uterine hsematocele {vide " Hsemato- cele ") Retroflexion and retroversion of uterus, 495 {vide " Uterus ") Revulsives, 610 Rheumatism, 244, 250 Richardson's styptic colloid, 117 Rutting of mammifera, 147 Salines, value of, 168, 327 Salpingitis (vide "Fallopian Tube, inflamma- tion of") Sarcoma (vide "Cancer") Scarifications in uterine diseases, 117, 432 Scarlatina, 78, 91, 172, 177, 243 Schwalbach, v^aters of, 113 Scrofula, 243 Scurvy, 91 788 IJSTDEX OF SUBJECTS. Sebaceous and sudoriparous glands of vulva and labia majora, 64, 73, 76, 77 Secretion, 70, 144, 163, 176, 241, 248 difficult, 218, 219 mucus, 75, 180 periodical, 248 Secretory apparatus of genitals, 64 Sedatives, 197, 224, 233, 241, 327 Semen and spermatozoa, 70, 79, 111 arrest of, 110, 213 Senility, disorders of, 349 Septicaemia, 85, 175, 181, 190, 206, 208, 319, 347, 484 Sexual act, 106, 107 awkward, 106, 108, 111 danger of, 106, 261 feeling, want of, 173 indulgence, excessive, 260, 521, 525 influence of, on maturation of ova, 148 organs, imperfectly developed, 166 tolerance of, 111 Shock, 374 [vide "Collapse") Sims's speculum, 83 dilator, 188, 189 tenaculum hook, 117, 125, 215 vaginal rest, 117 Silver wire v. silk, 117, 342, 747 Skeleton diagrams, 135 Skin affections and uterine diseases, 250 Small-pox, 77, 91, 177, 243, 523 Smell, sense of, 135 Sound (uterine), 116, 136, 139, 199, 203, 206, 211, 215, 216, 321, 326, 374, 499 caution respecting, 139, 142, 211 flexible whalebone, 116, 124 mode of using, 140, 143 perforation of uterus by, 142 use and description of, 122, 146, 357 use of interdicted, 364 Speculum, 79, 94, 103, 116, 117, 135, 136, 215 Barnes's, 131 bath, 449 Bennet's, Dr. Henry, 119 Cusco's, 120 Fergusson's, 119, 143, 188 forceps, 116, 125, 144 glass, 106 Neugebauer's, 121, 215 mode of introducing, 145 modification of (Barnes's), 121 Sims's, 83, 120 mode of introducing, 144 tubular, 118, 122 mode of introducing, 143 valvular, 118, 119, 122, 143, 145 advantages of, 118, 119 Weiss's self-retaining, 122 Spermatozoa in peritoneum, 376 Spinal cord, disease of, 243 Spinal irritation, 98 Spiritus Mindereri, 168 Spleen, enlargement of, 310, 315 Sterility, 73, 102, 203, 212, 231, 233, 253, 267, 359 absolute and incurable, congenital and acquired, relative and temporary, 109, 112 definition of, 108 in man, 115 of prostitutes, 366 significance and causes of, 107 treatment of. 111 Stethoscope, 116. 118, 305 Stimulants, use of, 374 Stillieidium mensium, 188 Strychnia, action of, 170, 373 Styptics, 346 Suppositories opiate, 224, 253, 343 Suppuration, 329 Supra-renal capsules, disease of, 172 Sutures, 343, 344, 747 Symptoms and subjective signs of uterine dis- ease, 66, 68, 69, 102, 115, 133, 193, 223, 237, 263 and objective signs of uterine disease, 66, 69, 115, 132, 193, 223 Syncope, 104, 240, 246, 247, 333, 375 Synovitis, chronic, 245 Syphilis, 92, 744, 762 secondary affections, 244 taint of, 232 Syphilization, 373 Syringe, for washing out vagina, 117 T bandage, 328 Taetus eruditus. 135 Taxis, 254 "forcible," 631 Temperature, rise of, 257, 303, 319 Tenotomy knife, 105 Tents, dangers of, 208 efiect of, on cervix, 208 laminaria, 116, 207, 250 mode of introducing, 207 sponge, 116, 207 Tetanus, 347 Thermometer, 118 Thrombosis of veins, 303, 347, 720, 734 Tonics, 233, 241 Touch, abdomino-vaginal, 136, 322 bi-manual, 268 education of, 135 mediate (sound in utero), 312 modes of application and importance of, 135 recto-abdominal, 136, 263, 268 recto-vaginal, 13& sense of, 135 simple abdominal palpation and percus- sion, 136 simple rectal, 136, 138, 268, 309 vaginal, 136, 268, 309, 312 urethro-rectal, 136 uterine (exploration by sound), 136 utero-abdominal, 136 Town life, 75 Trichomonas vaginalis, 72 Trocar and canula, 327, 332, 339, 345 Tubal catarrh {vide " Fallopian Tube ") retention {vide " Fallopian Tube ") Tube for carrying solid substances into uterus, 117, 128 Tubercle of abdominal glands, 351 of lungs, 351 (vide "Uterus," "Ovaries," MX admiration of a work which is so universally and deservedly appreciated. The most admirable svork of its kind in the English language. — rlasgow Medical Journal, January, 1866. A work to which there is no equal in the English language. — Edinburgh Medical Journal. Few works of the ciass exhibit a grander monument jf patient research and of scientific lore. The extent of the sale of this lexicon is sutficient to testify to its risefuiness, and to the great service conferred by Dr. Robley Dunglison on the profession, and indeed on others, by its issue. — London Lancet, May 13, 1865. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. — London Medical Oazette. TJOBLYN [RICHARD D.), M.D. A DICTIONARY OF THE TEKMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages ; extra cloth, i^l 50 ; leather, $2 00. It is the best book of definitions we have, and ought always to be upontne amdent's tabl«.— SoMfiern Med. and Surg. Journal. Henry C. Lea's Publications — (Manuals'). J^EILL {JOHN), M.D., may make it his constant pocket companion. — West- ern Lancet. In the rapid course of lectures, where work for the students is heavy, and review necessary for an exa- mination, a compend is not only valuable, but it is almost a sine qtta non. The one before us is, in most of the divisions, themost unexceptionable of all books of the kind that we know of. Of course it is uselesis for us to recommend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver — that class is the graduates in medicine of more than ten and ^MITH {FRANCIS G.), M.D., Prof, of the Institutes of Medicine in the Univ. of Penna. AN" ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OP MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12m(i. volume, of about one thousand pages, with 374 wood cuts, extra cloth, $4; strongly bound in leather, with raised bands, $4 75. The Compend of Drs. Neilland Smith is incompara- \ clous factstreasured up in this little volume. Acom- bly the most valuable work of its class ever publi-shed | plete portable library so condensed that the student In this country. Attempts have been made in various quarters to squeeze Anatomy, Physiology, Surgery, the Practice of Medicine, Obstetrics, Maieria Medica, snd Chemistry into a single manual; but the opera- tion has signally failed in the hands of all up to the advent of "Neill and Smith's" volume, which is quite a, miracle of success. The outlines of the whole are admirably drawn and illustrated, and the authors are eminently entitled to the grateful consideration of the student of every class. — N. 0. Med. and Surg. J'oxirnal. There are but few students or practitioners of me- dicine unacquainted with the former editions of this | years' standing, who have not studied medicine unas.suming though highly instructive work. The i since. They will perhaps find out from it that the whole science of medicine appears to have been sifted, | science is not exactly now what it was when they as the gold-bearing sands of El Dorado, and the pre- > left it off. — The Stethoscope. I TTARTSHORNE {HENRY), M. D., Professor of Hygiene in the University of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12mo. volume of more than 1000 closely printed pages, with over 300 illustrations on wood. (P?-fparing.) The favor with which this work has been received has stimulated the author in its revision to render it in every way fitted to meet the wants of the student, or of the practitioner desirous to refresh his acquaintance with the various departments of medical science. The various sections have been brought up to a level with the existing knowledge of the day, while preserving the condenta tion of form by which so vast an accumulation of facts have been brought within so narrow a compass. This work is a remarkably complete one in its way, and comes nearer to our idea of what a Conspectus should be than any we have yet seen. Prof. Harts- horne, with a commendable forethought, intrusted the preparation of many of the chapters on special subjects to experts, reserving only anatomy, physio- logy, and practice of medicine to himself. As a result we have every department worked up to the latest dale and in a refreshingly concise and lucid manner. There are an immense amount of illustrations scat- tered throughout the work, and although they have often been seen before in the various works upon gen- eral and special subjects, yet they will be none the less valuable to the beginner. Every medical student who desires a reliable refresher to his memory when the pressure of lectures and other college work crowds to prevent him from having an opportunity to drink deeper in the larger works, will find this one of tha greatest utility. It is thoroughly trustworthy from beginning to end ; and as we have before intimated, a remarkably truthful outliue sketch of the present state of medical science. We could hardly expect it should be otherwise, however, under the charge of such a thorough medical scholar as the author haa already proved himself to be. — 2^. York Med. Record, March 15, 1869. J VDLOW{J.l£:), M.D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12mo. volume of 816 large pages, extra cloth, $3 25; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the oflBce examination of students, and for those preparing for graduation. /TANNER {THOMAS HA WKES), M. D., ^c. A 'manual of clinical MEDICINE AND PHYSICAL DIAG- NOSIS. Third American from the Second London Edition. Revised and Enlarged by Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, &o. In one neat volume small ]2mo., of about 376 pages, extra cloth. $160. {Just Issued.) *** By reference to the " Prospectus of Journal" on page 3, it will be seen that this work is offered as a premium for procuring new subscribers to the "American Journal of the MsDiCAii Sciences." Taken as a whole, it is the most compact vade me- cum for the use of the advanced student and junior practitioner with which we are acquainted. — Boston Med. and Surg. Journal, Sept. 22, 1870. It contains so much that is valuable, presented in so attractive a form, that it can hardly be spared even in the presence of more full and complete works. The additions made to the volume by Mr. Fox very materially enhance its value, and almost make it a new work. Its convenient size make.s it a valuable companion to the country practitioner, and if con- stantly carried by him, would often render him good service, and relieve many a doubt and perplexity. — Leavenworth Med. Herald, July, 1870. The objections commonly, and justly, urged against the general run of "compends," "conspectuses," and other aids to indolence, are not applicable to this little volume, which contains in concise phrase just those practical details tbat are of most use in daily diag- nosis, but which the young practitioner finds it difll- cult to carry always in his memory without some quickly accessible means of reference. Altogether, the book is one which we can heartily commend to those who have not opportunity for extensive read- ing, or who, having read much, still wish an occa- sional practical reminder. — N. T. Med. Gazette, Nov. 10, 1870. Henry C. Lea's Publications — {Anatomy). fiRAY [HENRY), F.R.S., ^^ Lecturer on Anatomy at St. George's EosjMal, London. ANATOiMY, DESCRIPTIYE AND SURGICAL. The Drawings by H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged and improved London edition. In one magnificent imperial octavo volume, of nearly 900 pages, with 465 large and elaborate engravings on wood. Price in extra cloth, $6 00 ; leather, raised bands, $7 00. {J^lst Issued.) The author has endeavored in this work to cover a more extended range of subjects than is cus- tomary in the ordinary text-books, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en gravings form a special feature in the work, many of them being the size of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room; while combining, as it does, & complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their ofiices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Notwithstanding the enlargement of this edition, it has been kept at its former very moderate price, rendering it one of the cheapest works now before the profession. From time to time, as successive editions have ap- peared, we have had much pleatiure in expressiny the general judgment of the wnnderful excellence of The illustrations are heautifully executed, and ren- der this work an indispensahle adjunct to the library of the surgeon. This remark applies with great force to those surgeons practising at a distance from our lavge cities, as the opportunity of refreshing their mpmory hy actual dissection is not always attain- able.— Canada Med Journal, Aug. 1870. The work is too well known and appreciated by the profession to need any comment. No medical man can afford to be without it, if its only merit were to Serve as a reminder of that which so soon becomes forgotten, when not called into frequent use, viz., the relations and names of the complex organism of the human body. The present edition is much improved. — California Med. Gazette, July, 1S70. Gray's Anatomy has been so long the standard of perfection with every student of anatomy, that we need do no more than call attentioo to the improve- ment in the present edition. — Detroit Review of Med. and Pharm., Aug. 1870. Gray's Anatomy. — Cincinnati Lancet, July, 1870. Altogether, it is unquestiouably the most compleit and serviceable text-book in anatomy that has ever been presented to the student, and forms a striking contrast to the dry and perplexing volumes on the same subject through which their predecessors strug- gled in days gone by. — N. Y. Med. Record, June 15, 1870. To commend Gray's Anatomy to the medical pro- fession is almost as much a work of supererogation as it would be to give a favorable notice of the Bible in the religious press. To say that it is the most complete and conveniently arranged text book of its kind, is to repeat what each generation of students has learned as a tradition of thf elders, and verified by personal experience. — N. Y. Med. Gazette, Dec. 17, 1870. (^MITE [HENR Y H.), M.D., and TIORNER ( WILLIAM E.), M.D., Prof, of Surgery in the Univ. of Penna. , &c. Late Prof, of Anatomy in the Univ. of Penna. , Ac AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $4 60. The plan of this Atlas, which renders it so pecn- I the kind that has yet appeared ; and we must add, llarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "got up," tistical execution, have been already pointed out. We j is so creditable to the country as to be flattering to must congratulate the student upon the completion our national pride. — American MedicalJournal. of this Atlas, as it is the most convenient work of I ^HARPEY ( WILLIAM), M.D., and Q UAIN [JONES Sf RICHARD). HITMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. The very low price of this standard work, and its completeness in all departments of the 'subject, should command for it a place in the library of all anatomical students. nrODGES [RICHARD M.), M.D., Late Demonstrator of Anatomy in the Medical Department of Harvard University. PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In one neat royal 12mo. volume, half-bound, $2 00. The object of this work is to present to the anatomical student a clear and concise description of that which he is expected to observe in an ordinary couise of dissections. The author has endeavored to omit unnecessary details, and to present the subjejt in the form which many years' experience has shown him to be the most convenient and intelligible to the student. In the revision of the present edition, he has sedulously labored to render the volume more worthy of •■he favor with which it has heretofore been received. HORNER'S SPECIAL ANATOMY AND HISTOLOGY. I In 2 vols, flvo , of over 1000 pages, with more tha- Hif^hlh edition, extansively revised and modified. I 300 wood-cuts; extra clolh. *H 00. Henry C. Lea's Publications — (Anatomy). T^ILSON ( ERASM US), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. H. GoBRECHT, M. D., Professor of Geueraland Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, ol over 600 large pages; exira cloth, $4 00; lea- ther, $5 00. The publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition, ilesides a very thorough revision by the author, it has been most carefully examined by the editor, and the eiforts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- tomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. IIEA TH ( CHRISTOPHER), F. R. G. S., ■^-* Teacher of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. W. Kbjbn, M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Extra cloth, $3 50 ; leather, $4 00. {Lately PubUsked.) Dr. Keen, the American editor of this work, in his prei'ace, siiys : "In presenting this American editiun of 'Heath's Practical Anatomy,' I feel that I have been instrumental in supplying a want long felt for a real dissector's manual," and this assertion of its editor we deem is fully justified, after an examina- bion of its contents, for it is really an excellent work. Indeed, we do not hesitate to say, the best of its class with which we are acciuainted ; resembling Wilson in terse and clear description, excelling most of the 80-called practical anatomical dissectors iu the scope of the subject and practical selected matter. . . . In reading this work, one is forcibly impressed with the great pains the author takes to impress the sub- ject upon the mind of the student. He is full of rare and pleasing little devices to aid memory in main- taining its hold upon the slippery slopes of anatomy. —Ht. Louis Med. and Surg. Journal, Mar. 10, 1871. It appears to us certain that, as a guide in dissec- ion, and as a work containing facts ot anatomy in arief and easily understood form, this manual is jomplete. This work contains, also, very perfect .llustrations of parts which cau thus be mure easily inderstood and studied; in this respect it compares 'avurably with works of much greater pretension. Such manuals of anatomy are always favorite worka with medical students. We would earnestly recom- meud this one to their atteation; it has excellences which make it valuable as a guide in dissecting, as well as in studying anatomy. — Bugalo Medical and Surgical Journal, Jan. 1871. 'DELL AMY [E.), F.R.G.S. THE STUDENT'S GUIDE TO SURGICAL ANATOxMY: A Text- Book for Students preparing for their Pass Examination. With engravings on wood. In ono handsome royal l^mo. volume. Cloth, $2 25. {Just Ready.) ■We welcome Mr. Bellamy s work, as a contribu- tion to the study of regional anatomy, of equal value to the student and the surgeon. It is wriiten in a clear and concise style, and its practical suggestions add largely to the interest attacliiug to its leclmical details — Chicago Med. hxamintr , Maich 1, 1S7-1. We cordially congratulate Mr. Bellamy upon hav- ing produced it. — Mtd. Times and Gaz. We cannot too highly recommend it. — Student's Journal. Mr. Bellamy has spared no pains to produce a real- ly reliable student's guide to surgical anatomy — one which all candidates for surgical degree^ may c ;U- suli with advHUtage, and which posseses much ori ginal matter — Med. Press and Circular. MACLISE {JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one volume, very large imperial quarto; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size of life; together with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. Price $14 00. {ions have hitherto, we think, been given. While he operator is shown every vessel and nerve where j.n operation is contemplated, the exact anatomist is refreshed oy those cieai ana Ulstinct dissections, which every one must appreciate who has a particle of enthusiasm. The English medical press has quite exhausted the words of praise, in recommending this admirable treatise. — Boston Med. and Surg. Journ, We know of no work on surgical anatomy which can compete with it. — Lancet. The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publi- cation of its kind we have seen, and is worthy of a place in the libiary of any medical man, while the student could scarcely make a better investment than this. — The Western Journal of Medicine and Surgery. No snch lithographic illustrations of surgical re H AR TSHORNE [HENR Y) . M. D., Professor of Hygiene, etc , in the Univ. ofPenna. HANDBOOK OF ANATOMY AND PHYSIOLOGY. tion, revised. In one royal I2rao. volume, with numerous illustrations. Second Edi- {Prepari >ig .) Henry C. Lea's Publications — (Physiology). MARSHALL {JOHN), F. R. S., JXL Professor of Surgery in University College, London, &c. OUTLINES OF PHYSIOLOGY, HUMAN^ AND COMPARATIVE. With Additions by Fkancis Gurnet Smith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large and handsome octavo volume, of 1026 pages, extra cloth, $6 50 ; leather, raised bands, $7 60. In fact, in every respect, Mr. Marshall has present- ed us with a most complete, relinhle, and scientific work, and we feel that it is worthy our warmest commendation. — St. Louis Med. Heporter, Jan. 1S69. We doubt if there is in the English language any compend of physiology more useful to the student thitn this work. — St. LovAs 3Ied. and Surg. Journal, Jan. 1S69. It quite fulfils, in our opinion, the author's de'^ign of making it truly «f??4effliro'/ian nits character — which Is. perhaps, the highest commendation that can be asked. — Am. Journ. Med. Sciences, Jan. 1&69. We may now congratulate him on having com- pleted the latest as well as the best summary of mod- ern physiolugical science, both tiuman and coiupara tive, with which we are acquainted. To speak oJ this work in the terms ordinarily used on such occa- sions would not be agreeable to ourselves, and would fail to do justice lo its author. To write such a book requires a varied and wide range of knowledge, con siderable power of analysis, correct judgment, skill in ariangi-ment. and conscientious spirit. — Londori Lancet, Feb. 22, 1S6S. There are few, if any, more accomplished anatomists and physiologists than the distinguished professor of surgery at University College ; and ht has long en joyed the highest reputation as a teachei of physiol- ogy, possessing remarkable powers of cleai exposition and graphic illustration. We have rareli the plea- sure of beiug able to recommend a text-bool so unre- servedly as this. — British Med. Journal, Jar 25,1868. rtARPENTER [WILLIAM B.), M.D., F.R.S., V/ Examiner in Phy.nology and Comparative Anatomy in the University of London. PRINCIPLES OF HITMAN PHYSIOLOGY; with their chief appli- cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearly three hundred illustrations Edited, with additions, by Fkancis Gurnet Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo volume, of about 90U large pages, handsomely printed ; extra cloth, $5 50; leather, raised bands, $6 50. With Dr. Smith, we confidently believe "that the present will more ihan sustain the enviable reputa- tion already attained by former editions, of being one of the fullest and most complete treatises on the ?ti bject in the English language." We know of none from the pages of which a satisfactory knowledge of the pliysislogy of the human organi^.in can be as well obtained, none better adapted for the use of such as take up t he study of physiology in its reference to the institales and practice of medicine. — Am. Jour. Med. Sciences. We doubt not it is destined to retain a strong hold on public favor, and remain the favorite text-book in our colleges. — Virginia Medical Journal. The above is the title of what is emphatically tht great work on physiology ; and we are conscious that it would be a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any influence, that it is our authority. — Atlanta Med. Journal. jDT THE SAME AUTHOR. PRINCIPLES OF COMPARATIYE PHYSIOLOGY. New Ameri- can, from the Fourth and Revised London Edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations Pp.752. Extra cloth, $5 00. As a complete and condensed treatise on its extended and important subject, this work becomes a necessity to students of natural science, while the very low price at which it is offered places it within the reach of all. 17'IRKES [WILLIAM SENHOUSE), M.D. A MANUAL OF PHYSIOLOGY. Edited by TV. Morrant Baker, M.D., F.R.C.S. A new American from the eighth and improved London edition. With about two hundred and fitly illu.strations. In one large and handsome royal 12mo. vol- ume. Cloth, $3 26; leather, %'^ 75. [Nov.- Ready .) Kirkes' Physiology hns long been known as a concise and exceedingly convenient text-book, presenting within a narrow compass all that is important for the student. The rapidity with which successive editions have followed each other in England has enabled the editor to keep it thoroughly on a level with the changes and new discoveries made in the science, and the eighth edition, of which the present is a reprint, has appeared so recently that it may be regarded as the latest accessible exposition of the subject. On the whole, there is very little in the book which either tlie student or practitioner will notfind of practical value and consistent with our present knowledge of this rapidly cUaugiBg tcience ; and we hT THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- vania. With illustrations on wood. In one veryhardsome octavo volume of 336 pages, extra cioth. $2 25. 10 Henry C. Lea's Publications — (Chemistry). ATTFIELD {JOHN), Ph.D., Professor of Practical Chemistry to the Pharmaceutical Society of Oreaf Britain, *c. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; includi-ng the Cbemiptry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. Fifth Edition, revi.^ed by the author. In one handsome royal 12mo. volume ; cloth, $2 75 ; leather, $-3 25. (Just Issued.) "We commend tte work 'heartily as one of the best text-liooks extant for the medical student. — Detroit Sev. of Med. and Pharm., Feb. 1872. The be.«t work of the kind in the English ' iV. T. Psychological Journal, Jan. 1S72. The work is constrncted with direct reference to the wants of medical and pharmaceutical stndent-s; and, althongb an Englisb work, the points of differ- ence between the British and United States Pharma- copceias are indicated, making it as useful here as in England. Altogether, the hook is one we can heart- ily recommend to practitioners as well as students. —N. r. Med. Journal, Dec. 1871. It differs from other text-books in the following particulars: first, in the exclusion of matter relating to compounds which, at present, are only of interest to the scientific chemist ; secondly, in coniainin? the chemistry of every substance recognized officially or in general, as a remedial agent. It will he found a most valnable book for pupils, a.'sistants. and others engaged in medicine and pharmacy, and we heartily commend it to our readers. — Canada Lancet, Oct. 1871. When the original English edition of this work was published, we had occasion to express our high ap- preciation of its worth, and also to review, in con- siderable detail, the main features of the hook. As the arrangement of subjects, and the main part of the text of the present edition are similar to the for- mer publication, it will be needless for us to go over the ground a second time; we may. however, call at- tention to a marked advantage possessed by the Ame- rican work — we allude to the introduction of the chemistry of the preparations of the United States Pharmacopceia. as well as that relating to the British authority. — Canadian Pharrnnceutieal Journal, Nov. 1871. Chemistry has borne the name of being a hard sub- ject to master by the student of medicine, and chiefly because so much of it consists of compounds only of interest to the scientific chemist ; in this work such portions are modified or altogether left out, and in the arrangement of the subject matter of the work, practical utility is sought after, and we think fully attained We commend it for its clearness and order to both teacher and pupil. — Oregon Med. and Surg. Reporter, Oct. 1871. JDLOXAM (C. L.), J-^ Professor of Chemistry in King's College, London. CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- don Edition. In one very hand.=ome octavo volume, of 700 pages, with about 300 illustra- tions. Cloth, $4 50; leather, $5 50. (Now Ready.) It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- sive for tho.se studying the science as a branch of general education, and one which a student may use with advantage in pursuing his chemical studies atone of the colleges or medical school.*. The special attention devoted to Metallurgy and some other branches of Applied Chemistry rendei-s the work especially useful to those who are being educated for employment in manufacture. It would be difficult for a practical chemist and tparher to find any material fault with this most ad- mirable treatise. The author has given us almost a cyclopedia within the limits of a convenient volume, and has done so without penning the useless para- graphs too commonly making up a great part of the bulk of many cumbrous wurks. The progressive sci- entistis not disappointed when helonks for the record of new and valnable processes and discoveries, while the cautious conservative does not find its pages mo- nopolized by uncertain theories and speculations. A peculiar point of excellence is the crystallized form of expression in which great truths are expressed in very short paragraphs One is surprised at the brief space allotted to an important topic, and yet, afrer reading it, he feels that little, if any more, should have been said. Altogether, it is seldom you see a text-book so nearly faultless.— C'iweiwraa^i Lancet, iVov. 1873. Prjfessor Bloxam has given ns a most excellent and u.seful practical trettise. His 666 pages are crowded with facts and experiments, nearly all well chosen, and manv Quite new^, even to scientific men. . . . It is astonishinghow much iaformationhe often conveys in a few paragraphs. We might quote fifty instances of this. — Chtruical News. DLTNG {WILLIAM), Lecturer on Chemistry at St. Bartholomew's So.fpitaJ, iVc. A COURSE OF PRACTICAL CHEMISTRY, arranged for the Use of Medical Students. With Illustrations. From the Fourth and Revised London Edition. In on© neat royal 12mo. volume, extra cloth. $2. (Lately Issued.) /CALLOWAY (ROBERT), F.C.S., ty Prof, of Applied Ohernistry in the Royal College of Science for Ireland, &c. A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- don Edition. In one neat royal 12mo. volume, with illustrations ; extra cloth, $2 50. (Just Issued.) The success which has carried this work through repeated editions in England, and its adoption as a text-book in several of the leading in.stitutions in this country, show that the author has suc- ceeded in the endeavor to produce a sound pructical manual and book of reference for the che- mical student. Prof Galloway's books are deservedly io bigh i We regard this volnnie as a valnable addition to esteem, and this American reprint of the fifth edition the chemical text-books, and as panictilarly calcn- (1863) of his Manual of Qualitative Analysis, will be | lated to instruct the student in aralylioal re.searches acceptable to many American students to whom the of the inorganic compKunds, the iinportani vegetable English edition is not accessible. — A-m. Jour, of Set- j acids, and of cnmpounds and Viirious recrelions and «74ce and Arts, Sept. 1872. i ►-xcrelions of animal origin. — Am. Jotxrn. o/ PlionA., I Sept. 1872. Henry C. Lea's Publications — (Chemistry). 11 /^HANDLER {CHARLES F.), and nUANDLER [WILLIAM H.), \y Prof . of Chemistry in the N. ¥. Coll. 0/ ^ Pmf nf O'lemistry in the Lehigh Pharrnory University. THE AMERICAN CHEMIST: A Monthly Journal of Theoretical, Analytical, and Technical Chemistry. Each number averaging forty large double col- umned pages of reading matter. Price $5 per annum in advance. Single numbers, 50 cts. D:;^ Specimen numbers to parties proposing to subscribe will be sent to any address on receipt of 25 cents. *^* Subscriptions can begin with any number. The r.apid growth of the Science of Chemistry and its infinite applications to other sciences and art.« render a journal specially devoted to the subject a necessity to those whose pursuits require familiarity with the details of the science. It has been the aim of the conductors of "The American Chemist" to supply this want in its broadest sense, and the reputation which the periodical has already attained is a sufficient evidence of the zeal and ability with which they have discharged their tnsk. Assisted by an nble body of coUabor.ators, their aim is to present, within a moderate compass, an abstract of the progress of the science in all its departments, scientific and technical. Import- ant original communications and selected papers are given in full, and the standing of the " Chem- ist" is such as to secure the eontributinns of le wlin^^ in - in all portions of the country. Besides this, over one hundred journals and transactions of learned societies in America, Great Britain, France, Belgium, Italy, Russia, and Germany are carefully scrutinized, and whatever they offer of interest is condensed and presented to the reader. lu this work, which forms a special feature of the "Chemist," the editors have the assistance of M. Alsberg, Ph.D., Prof. G. F. Barker, T. M. Blossom, E.M., H. C. Bolton, Ph.D., Prof. T. Egleston, E.M , H. Endemana, Ph.D., Prof. C. A. Goessmann, Ph.D.,S. A. Goldschmidt, A.M., E.M., E. J. Hallock. Prof. C. A. Joy, Ph.D., J. P. Kimball, Ph.D., 0. G. Mason, H. Newton, E.M., Prof. Frederick Prime, Jr., Prof. Paul Schweitzer, Ph.D , Waldron Shapleigh, Romyn Hitchcock, and BIwyn Waller, E.M. From the thoroughness and completeness with which this department is conducted, it is believed that no periodical in either hemisphere more faithfully reflects the progress of the scieace, or presents a larger or more carefully garnered store of information to its readers. pOWNES [GEORGE), Ph. D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. A new American, from the tenth and revised London edition. Edited by Robert Bridges, M. D. In one large royal I2mo. volume, of about 850 pp , extra cloth, .■J2 75 ; leather, .-53 25. {Lately Issued.) This -work, is so well known that it .seem.s almost )ther work that has greaier claims oa the physiciao, saperfluous for us to speak about It. It has been a pharmaceutist, or student, than this. We cheerfully fovorite text-book with medical students for years, recommend it as the best text-book on elementary and its popularity has in no respect diminished. • chemistry, and bespeak for it the careful attentioa Whenever we have been consulted by medical stu- of students of pharmacy. — Chicago Pharmacist, A.ag, dents, as ha.s frequently occurred, what treatise on , 1869. ehemistry they t-hunld procure, we have always re- „ . ,.,. , . , , . , ,.,_:, eomraendid Fownes', for we regarded it as the best. , ^e'e is a new edition which has been long watche^d TJiere is no work that combines so manv excellen- ^-^^ ^^ eager teachers of chemistry. In Us new garb ces. It is of convenient size, not prolix, of plain and under the editorship of Mr. Watt.s, it has resumed perspicnous diction, contains all the most recent V'i'.^'^ "^l^^S -^^ ,^l^ "^Z^^ r ''"''f f^i" ^^^^-^'"'^^■- diseovenes, and is of moderate ptice. -CineinnatiJ'^^^'^'^ Medical Gazette, Jan. 1, 1869 Med. Repertory, Aug. 1869. | ^ ^-^n continue, as heretofore, to hold the Irst rank Large additions have been made, esppcially in the is a text-book for students of medicine. — Chicago department of organic chemistry, and we know of no Med. Examiner, Aug. 1869. TU'OIILER AND FITTIG. ^^ OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- ditions from the Eighth German Edition. By Iea Rejesen, M.D., Ph.D., Professor of Chemistry and Physics in Williams College, Mass. In one handsome volume, royal I2mo. of 650 pp. extra cloth, $.3. {Just Issued.) As the numerous editions of the original attest, this work is the leading text-book .and standard authority throughout Germany on its important and intricate subject — a position won for it by the clearness and conciseness which are its distinguishing characteristics. The translation has been executed with the approbation of Profs. Wdhler and Fittig, and numerous additions and alterations have been introduced, so as to reader it in every respect on a level with the most axivanced condition of the science. no WMAN [JOHN E.) , M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Sixth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. $2 25. _gF THE SAME AUTHOR. (Noio Rea-y ) INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- otis illugtrations. In one neat vol., royal 12mo., extra cloth. S2 25. KBTAPP'S TECHNOLOGY; or Chemistry Applied to I very handsome octavo volumes, with. 600 wood tbfi ,4.rts, and to Manufactures. With American I engravings, extra cloth, $6 00. addiii >n6, by Prof. Waltee E. Johsson. la two I 12 Henry C. Lea's Publications — (Mat. Med. and Therapeutics). pARRlSH {EDWARD), Late Professor of Materia Mediea in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wiegand. In ore handsome octavo volume of 977 pages, with 280 illusti-ations ; cloth, $5 60; leather, $6 50. ilSow Ready.) The delay in ihe appearance of the new U. S. Pharmacopoeia, and the siidden death of the au- thor, have postponed the preparation of this new edition beyond the period expected. The notes and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegnnd, who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- ence which have been introduced during ;be last ten years. It is therefore hoped that the new edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard text-book and work of reference for all engaged in the preparation and dispensing of medicines. We have examined this large volume with a good not wish it to be understood as very extravagant deal of care, and find that the anthor has completely I praise. In truth, it is not so much the best as the exhausted the subject upon which he treats ; a more only book. — The London Chemical News. complete work, we think, it would be impossible to find. To the student of pharmacy the work is indis- pensable ; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to pur- chase it, we feel sure the practical information he will obtain will more than compensate him for the outlay. — Canada Med. Journal, Nov. 1864. The medical student and the practising physician will find the volume of inestimable worth for study and reference. — San Francisco Med. Press, July, 1864. When we say that this, book is in some respects the best which has been published on the subject in the English language for a great many years, we do An attempt to furnish anything like an analysis ol Parrish's very valuable and elaborate Treatise on Practical Pharmacy would require more space thar, OBERTS ( WILLIAM), M. D.. •^^ Lecturer on Medicine in the Manchester School of Medicine. &c. A PRACTICAL TREATISE OX TJRIXARY AND REXAL DIS- EASES, including Urinary Deposits. Illustrated by numerous cases and engrayingrs. Sec- ond American, from the Second Revised and Enlarged London Edition. Tn one large and handsome octavo volume of 616 pages, with a colored pla.te ; extra cloth, $4 50. {Just Issued.) The author has subjected this work to a very thorough revision, and has sought to embody in it the results of the latest experience and investigations. Although every effort has been made to keep it within the limits of its former size, it has been enlarged by a hundred pages, many new wood-cuts have been introduced, and also a colored plate representing the appearance of the different varieties of urine, while the price has been retained at the former very moderate rate. diseases we have examined It is peculiarly adapted The plan, it will thus be seen, is very complete, ani the manner in which it has been carried out is in the highest degree satisfactory. The characters of the different deposits are very well described, and to the wants of the majority of American practition- ers from its clearness and simple announcement of the facts in relation to diagnosis and treatment of urinary the microscopic appearances they present are illus- j disorders, and contains in condensed form the investi- trated by numerous well executed engravings It ! gations of Bence .Jones, Bird, Beale, Hassall. Prout, only remains to us to strongly recommend to our j and a host of other well-known writers upon this sub- readers Dr. Roberts's work, as coniaining an admira- | ject. The characters of urine, physiological and pa- ble n'xume of the present state of knowledge of uri- | thological, asindicated to the naked eye as well as by nary diseases, and as a safe and reliable guide to the microscopical and chemical inrestigations, are con- clinical observer. — Edin. Med. Jnur. cisely represented both by description and by well The most complete and practical treatise upon renal I executed engravings.— Cincmnaii Juur^i. of Med. DASH AM (W.E.), M.D., -*-' Senior Physician to the Westmin-iter Hospital, &c. RENAL DISEASES: a Clinical Guidetotheir Diagnosis and Treatment. With illustrations. In one neat royal 12mo. volume of 304 pages. $2 00. The chapters on diagnosis and treatment are very [ details of larger books here acquire a new interest good, and the student and young practitioner will 1 from the author's arrangement. This part of the find them full of valuable practical bints. The third I book is full of good work. — Brit, and For. Medieo- part, on the urine, is excellent, and we cordially recommend its perusal. The author has arranged his matter in a somewhat ncivel, and, we think, use- ful form. Here everything can be easily found, and, what is more important, easily read, for all the dry Ihirurgical Bevieu), July, 1870. The easy descriptions and compact modes of state- ment render the book pleasing and convenient. — Ani.. Journ. Med. Sciences, July, 1870. J ONES [G. HANDFIELD), M. D., Physician to St. Mary's Uo.spital, &c. CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. Second American Edition. In one handsome octavo volume of 348 pages, extra cloth, $3 25. Taken as a whole, the work before us furnishes a I titioner will derive from it many a suggestive hint to short but reliable account of the pathology and treat- lid him in the diagnosis of "nervous cases," and in ment of a class of very common but certainly highly I ietermining the true indications for their ameliora- obscnre disorders. The advanced student will find it I tion or cure. — Amer. Journ. Med. Sci., Jan. 1867. a rich mine of valuable facts, while the medical prac- | T INCOLN [D. F.). M.D., -*-' Ph'/.ncian to the Department of Nervous Diseases, Boston Dispensnry. ELECTRO THERAPEUTICS ; 4 Concise Manual of Medical Electri- city. In one very neat royal 12mo. volume, with Illustrations. The chief aim cf the present volume has been the analysis of the principles which ought to govern our use of Electricity. The portions describing the practical applications which have been made of it in various disorders, may be found incomplete, but it is hoped that enough has been said to satisfy the needs of the general practitioner. — Preface. STCrDVC3S/I.A.I?,-5^" or' OOXsTTBlSrTS. Chapter I. Physical Laws — 11. Modes of Generating Electricity. — III. Physiology — TV. Ditignosis. — V. Methods of Applying Electricity. — VI. Medical and Surgical Practice. — VII. Cautions. — VIII. Apparatus. ^LADE [D. D.), M.D. DIPHTHERIA; its Nature and Treatment, with an account of the His- tory of its Prevalence in various Countries. Second and revised edition. In one neat royal 12mo. yolame, extra cloth. $1 25. TTdDSON {A.), M. D., M. R. L A., ■^-*- Physician to the Meath Hospital. LECTURES ON THE STUDY OF FEVER. In one vol. 8vo., extra Cloth, $2 50. r TONS {ROBERT D.), K.C.C. A TREATISE ON FEVER. In one octavo volume of 3G2 pages; cloth. $2 25. Henry C. Lea's Publications — (Venereal Diseases, etc.). 19 f>UMSTEAD {FREEMAN J.), M.D., •'-^ Professor of Venereal Diseases at the Vol. of Phys and Sicrg., New York, &e. THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Third edition, rev'ised and enlarged, with illustrations. In one large and handsome octavo volume of over 700 pages, extra cloth, $5 00 ; leather, $6 00. (Just Issued.) In preparing this standard work again for the press, the author has subjected it to a very thorough revision. Many portions have been rewritten, and much new matter added, in order to bring it completely on a level with the most advanced condition of syphilograpby, but by careful compression of the text of previous editions, the work has been increased by only sixty-four pages. The labor thus bestowed upon it. it is hoped, will insure for it a continuance of its position as a complete and trustworthy guide for the practitioner. It i.s the most compleiebook with which we are ac- ; much special coramendationasif its predecessors had quainted in the language. The .latest views of the best authorities are put forward, and tlie information is well arranged — a great point for the student, and 8till more for the practitioner. The subjects of vis- ceral syphilis, syphilitic affections of the eyes, and the treatment of syphilis by repeated inoculations, are very fully discussed. — London Lancet, Jan. 7, \^1\. Dr. Burastead's work is alieady so universally knuwn as the best treatise in the English language not been published. As a thoroughly practical book on a class of diseases which form a large share of nearly every physician's practice, the volume before us is by far the best of which we have knowledge. — N. Y. Medical Gazette. Jan. 28, 1871. It is rare in the history of medicine to find any one book which conlains all that a practitiouer needs to know; while the possessor of "Bumstead on Vene- i-eal" has no occasion to look outside of its covers for venereal diseases, that it may seem almost -uperflu- anything practical connected with the diagnosis, his- ous to say more of it than that a new edition has been ' toiy, or treatment of these affections. — N. Y Medical issued. But the author's industry has renilered this | Journal. March, 1871. new edition virtually a new work, and so merits as ■ pULLERIER (A.), and ~ ^-^ Surgeon to the Hdpital du Midi nUMSTEAD (FREEMAN J.), Professor of Venereal Disea.ses in the dollege of Physicians and Sicrgeons. N. Y. AN ATLAS OF VENEREAL DISEASES. Translated and Edited by Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life; strongly bound in extra cloth, $17 00 ; also, in five parts, stout wrappers for mailing, at $3 per part. {Lately Published.) Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, thus placing it within the reach of all who are interested in this department of prac- tice. Gentlemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. We wish for once that our province was not restrict- tvhich for its kind is more necasswr?/ for them to have. ed to methods of treatment, that we might say some^ thing of the exquisite colored plates in this volume — London Practitioner, May, lS(i9. As a whole, it teaches all that can be taught by means of plates and print. — London Lancet, March 13, 186fi. Superior to anything of the kind ever before issued on this continent. — Canada Me'l. Joiirnal, March, '69. The practitioner who desires to understand this branch of medicine thoroughly should obtain this, the most complete and best work ever published. — Dominion Med. Jotirnal, May, 1869. This is a work of master hands on both sides. M. Cullerler is scarcely second to, we think we may truly say is a peer of the illustrious and venerable Ricord, while in this country we do not hesitate to say that Dr. Bumstead, as an authority, i.« without a rival Assuring our readers that these illustrations tell the whole history of venereal disease, from its inception to its end, we do not know a single medical work, —California Med. Gazette, March, 1869. The most splendidly illustrated work in the lan- guage, and in our opinion far more useful than the French original. — Am. Journ. Med. Sciences, Jan. '69. The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in saying that its illu.-trations surpass those of previous numbers. — Boston Med. and Surg. Journal, Jan. 14, 1869. Other writers besides M. Cullerier have given us a good account of the diseases of which he treats, but no one has furnished us with such a complete series of illustrations of the venereal diseases. There is, however, an additional interest and value possessed by the volume before us ; for it is an American reprint and translation of M. CuUerier's work, with inci- dental remarks by one of the most eminent American syphilographers, Mr. Bumstead. — Brit, and For. Medico-Ohir. Review, July, 1869. IF LL [BERKELEY), . Siirgeon to the Lock Ho.spital, London. ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. one handsome octavo volume ; extra cloth, $3 25. {Lately Published.) In Bringing, as it does, the entire literature of the dis- ease down to the present day, and giving with great ability the results of modern research, it is in every respect a most desirable work, and one which should find a place in the library of every surgeon. — Gali- fornia Med. Gazette, June, 1869. Considering the scope of the book and the careful attention to the manifold aspects and details of its to whom we would most earnestly recommfind its study ; while it is no less useful to the practitioner. — St. Louis Med. and Surg. Joxirnal, May, 1869. The most convenient and ready book of reference we have met with.— iV^. Y. Med. Record, May 1,1869. Most admirably arranged for both student and prac- titioner, no other work on the subject equals it ; it is subject, it is wonderfully concise All these qualities j more simple, more easily studied. -^.Bw^atoJlfed. and render it an especially valuable book to the beginner, i Surg. Journal, March, 1869. MB. 7EISSh [H. A COMPLETE TREATISE OX VENEREAL DISEASES. Trans- lated from the Second Enlarged German Edition, by Frederic R. Sturgis, M.D In one octavo volume, with illustrations. {Preparing.) 20 Heney C. Lea's Publications — {Diseases of the Skin). TJ/^ILSON ( ERASM US), F. R. S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixtli and enlarged English edition. In one large octavo volume of over 800 pages, $5. A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 60. Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. No one treating skin diseases should be witliout a copy of this standard work. — Oanrida Lnnce.t. We can safely recommend it to the profession as the hest work on the suliject now in existence in the English language. — Medical Times and Gazette Mr. Wilson's volume is an excellent digest of the actual amount of knowledge of cutaneous diseases : it includes almost every fact or opinion of importance connected with the anatomy and pathology of thf skin. — Brififih and Foreign Medical Review. , Such a work as the one before us is a most capital ^Y THE SAME AUTHOR. and acceptable help. Mr. Wilson has long been held as high authority in this department of medicine, and his book on diseases of the skin has long been re- garded as one of the best text-books extant on the subject. The present edition is carefully prepared, and brought up in its revision to the pves-ent time In chis edition we have also included the beautiful series of plates illustrative of the text, and in the last edi- tion published separately. There are twenty of these plates, nearly all of them colored to nature, and ex- hibiting with great fidelity the various groups of diseases. — Ginainnati Lancet. THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Die- EASES OP THE SKIN. In One very handsome royal 12mo. volume. $3 50. {Lately Issued.) fJ'ELIGAN {J. MOORE), M.D., M.R.I. A. A PRACTICAL TREATISE ON DISEASES OF Fifth American, from the second and enlarged Dublin edition by T. In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. THE SKIN. W. Belcher, M.D. Fully equal to all the requirements of students and young practitioners. — Dublin Med. Press. Of the remainder of the work we have nothing be- yond unqualified commendation to offer It is so far the most complete one of its size that has appeared, and for the student there can be none which can com- pare with it in practical value. All the late disco- veries in Dermatology have been duly noticed, and >r THE SAME AUTHOR. — '.heir value justly estimated ; in a word, the work is fully up to the times, and is thoroughly stocked with most valuable information. — New York Med. Record, Jan. 1.5, 1867. The most convenient manual of diseases of the skin that can be procurec by the student. — Qhicago Med. Journal, Dec. 1866. B' ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, Ac, presenting about one hundred varieties of Extra cloth, $5 50. inclined to consider it a very superior work, com- bining accurate verbal description with sound views of the pathology and treatment of eruptive diseases. — Glasgow Med. Joxhrnal. A compend which will-very much aid the practi- tioner in this difficult branch of diagnosis Taken with the beautiful plates of the Atlas, which are re- markable for their accuracy and beauty of coloring, it constitutes a very valuable addition to the library of a practical man. — Buffalo Med. Journal. disease. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless, Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of di.-5eases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the "Practical Treatise," and we are TJILLIER {THOMAS), M.D., Phy.sician to the Skin De])artment of University College Ho.spital, &c. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations. Extra cloth, $2 25. We can conscientiously recommend it to the stu- dent ; the style is clear and pleasant to read, the matter is good, and the descriptions of disease, with the modes of treatment recommeuded, are frequently illustrated with well-recorded cases. — Londo7i Med. Times and Gazette, April 1, 1865. It is a concise, plain, practical treatise on the vari- ous diseases of the skin ; just such a work, indeed, as was much needed, both by medical students and practitioners. — Ghieago Medical Examiner, May, 1865. A NDERSON {McCALL), M.D., -^-*- Physician to the Dispensary for Skin Diseases, Glasgow, Ac. ON THE TREATISIENT OF DISEASES OF THE SKIN. With an Analysis of Eleven Thousand Consecutive Cases. In one vol. 8vo. $1. (Jiist Hea'ly,) GUERSANT'S SURGICAf. DISEASES OF INFANTS AND CHILDREN. Translated by R. J. Du.ngli- SON, M.D. 1 vol. Svo. Cloth, $2 .")0. DEWEES ON THE PHYSICAL AND MRnxrAL TREATMENT' at? OHrj.nv w)v Eleventh editloa. I vol. "^vo. of 548 pages. $2 80. Henry C. Lea's Publications— (Diseases of Children). 21 ^MITH{J. LEWIS), M. D., ^ Professor of Morbid Anatomy in the Bellemie Hospital Med. College, N. T. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Second Edition, revised nnd greatly enlarged. In one handsome octavo volume of 742 pages, extra cloth, $5; leather, $6. (Jiist Issued.) From the Preface to the Second Edition. In presenting to the profession the second edition of his work, the author gratefully acknow- ledges the favorable reception accorded to the first. He has endeavored to merit a continuance of this approbation by rendering the volume much more complete than before. Nearly twenty additional diseases have been treated of, among which may be named Diseases Incidental to Biith, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, and Typhoid Fevers, Chorea, and the various forms of Paralysis. Many new formulse, which experience has shown to be useful, have been introduced, portions of the text of a less practical nature have been con- densed, and other portions, especially those relating to pathological histology, have been rewritten to correspond with recent discoveries. Every effort has been made, however, to avoid an undue enlargement of the volume, but, notwithstanding this, and an increase in the size of the page, the number of pages has been enlarged by more than one hundred. 227 West 49th Street, New York, April, 1872. The work will be found to contain nearly one-third more matter than the previous edition, and it is confidently presented as in every respect worthy to be received as the standard American text-book on the subject Emineatly practical as well as judicious in its teachings. — Cincinnati Lancet and Obs., July, 1S72. A standard work that leaves little to he desired. — Indiana Journal of Medicine, July, 1872. We know of no hook on this suhject that we can more cordially recommend to the medical stiideut and the practitioner. — Cincinnati Clinic, June29, '72. We regard it as superior to any other single woi'k on the diseases of iuf;iiicy and childhood. — Detroit Bev. of Med. and Pharnuicy, Aug. 1&72. We confess to increased enthusiasm in recommend- ing this second edition. — St Louis Med. and Surg. Journal, Aug. 1S72. ftONDIE [D. FRANCIS), 31. D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $5 25; leather, $6 25. {Lately Issjied.) The present edition, which is the sixth, is fully up 1 teachers. As a whole, however, the work is the best to the times in the discussion of all those points in the | American one that we have, and in its special adapta- pathology and treatment of infantile diseases which I tion to American practitioners it certainly has no havebeenbroughtforwardhytheGermauand French | equal. — New York Med. Record, March 2, 1S68. T^EST [CHARLES), M.D., ' ' Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fifth American from the sixth revised and enlarged English edition. In one large and handsome octavo volume of 678 pages. Cloth, $4 60 ; leather, $6 50. {Just Ready.) The continued demand for this work on both sides of the Atlantic, and its translation into Ger- man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- sively felt by the profession. There is probably no man living who can speak with the authority derived from a more extended experience than Dr. West, and his work now presents the results of nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nearly 40,000 cases which have passed under his care. In the preparntion of the present edition he has omitted much that appeared of minor importance, in order to find room for the introduction of additional matter, and the volume, while thoroughly revised, is therefore not increased materially in size. Of all the English writers on the diseases of chil- I living authorities in the difficult department of medi- dren, there is no one so entirely satisfactory to us as | cal science in which he is most widely known. — Dr. West. For years we have held his opinion as I Boston Med. and Surg. Journal. judicial, and have regarded him as one of the highest | or THE SAME AUTHOR. {Lately Issued.) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., extra cloth, $1 00. ^MITH [E USTA CE), M. D., Physician to the Northwe.st London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, extra cloth, $2 50. {Lately Issued.) scribed as a practical handbook of the common dis- eases of children, so numerous are the affections con- sidered either collaterally or directly We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insight into the physiological and other peculiarities of chil- dren that Dr. Smith's book does. — Brit. Med. Journ., April 8, 1871. This is in every way an admirable book. The modest title which the author has chosen for it scarce- ly conveys an adequate idea of the many subjects upoQ which it ti'eats. Wasting is so constant an at- tendant upon the maladies of childhood, that a trea- tise upon the wasting diseases of children must neces sarily embrace the consideration of many affections of which it is a symptom ; and this is excellently well done by Dr. Smith. The book might fairly be de- Henry C. Lea's Publications — (Diseases of Women). rpHE OBSTETRICAL JOURNAL. THE OBSTETRICAL JOURXAL of Great Britain and Ireland; Including Midwifery, nnd the Diseases of Women and Infants. With an American Supplement, edited by William F. Jenks. M.D. A monthly of about 80 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 cents each. Commencing with April, 187.S, the Obstetrical Journal consists of Original Papers by Brit- ish and Foreign Contributors : Tninsaetions of the Obstetrical Societies in England and abroad ; Reports of Hospital Practice: Reviews and Bibliographical Notices; Articles and Notes, Edito- rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Rliever in the fveqnency of ioHammations of the aterns, to take strong ground against many of tha highest authorities in this branch of medicine, and the arguments which he offers in support of his posi- tion are, to say the least, well put. Numerous wood- cuts adorn this portion of the work, and add incalcu- lably to the proper appreciation of the variously shaped instruments referred to by our author. As a contribution to the study of women's diseases, it is of great valtre, and is abundantly able to stand on its From Prof. W. H. Btford, of the R-n^h Medical College, Chicago. The book bears the impress of a master hand, and must, as its predecessor, prove acceptable to the pro- fession. In diseases of women Dr. Hodge has estab- lished a school of treatment that has become -world- ivide in fame. Professor Hodge's work Is truly an original one from beginniog to end, consequently no one can pe ruse itspagei^without learning something new. The book, which is by no means a large one, is divided into _^ two grand secti.-jns, so to speak : first, that treating of 1 q.^^^ merits.' — N. Y. Medical Record, Sept. 15, 1868. the nervous sympathies of the uterus, and, secondly. 'W'EST (CHARLES), M.D. LECTURES ON THE DISEASES OF WOMEN. Third American, from the Third London edition. In one neat octavo volume of about 550 pages, extra cloth, $3 75 ; leather, $4 76. seeking-truth, and one that will convince the student that he has committed himself to a candid, safe, and As a writer. Dr. West staaUs, in our opinion, se- cond only to Watson, the "Macaulay of Jledicine;' he possesses that happy faculty of clothing instrnc tion in easy garments ; combining pleasure with profit, he leads his pupils, in spite of the ancient pro verb, along a royal road to learning. His work is one which will not satisfy the extreme on either side, but it is one that will please the great majoi'ity who art valuable guide. —i^''. A. Med.-Chiru.rg Review. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language, and that it stamps Dr. West as the facile princeps of British obstetric authors. — Edinburgh Med. Journal. B ARNES (ROBERT), 31. D., F.R.G.P., OhRfetrie Physician tn St. Thorna.'i's Hospital, &c. A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- CAL DISEASES OF WOMEN. In oT,e handonme onta.vn -trolnme of about 800 pages, with lfi9 illustrations. Cloth. $5 00, leather, $6 00. (Just Rmdy.^ The very complete scope of this volume and the manner in which it has been filled out, may be seen by the subjoined Sumaiary of Contents. Intboduction. Chapter I. Ovnries ; Corpus Luteum. II. Fallopian Tubes. III. Shape of Uterine Cavity. IV. Structure of Uterus. V. The Vagina. VI. Examinations and Diagnosis. VII. Significance nf Lencorrhoea. VTII. Discharges of Air. IX. Watery Discharges. X. Puru- lent Discharges. XI. Hemorrhagic Di.=oharges. XII Significance of Pain. XIII. Significance of Dyspareunia. XIV. Significance of Sterility. XV. Instrumental Diagnosis and Treatment. XVI. Diagnosis by the Touch, the Sound, the Speculum. XVII. Menstruation and its Disor- ders. XVIII. Amenorrhcea. XIX. Amennrrboea (continued). XX. Dysmenorrhoea. XXI. Ovarian Dysmenorrhoea. j > paper is superior to what is usually afforded by our American cousins, quite equal to the best of English books. The engravings and lithographs are most emergency of obstetric complication with confidence — Chicago Med. Journal, Aug. 1S64. More time than we have had at our disposal since we received the great work of Dr. Hodge is necessary to do it justice. It is undoubtedly by^ar the most original, complete, and carefully composed treatise on the principles and practice of Obstetrics which has ever been issued from the American press. — Pacific We have read Dr. Hodge's book with great plea- sure, and have much satisfaction in expressing our commendation of it as a whole. It is certainly highly beautifully executed. The work recommends itselfna^tructive, and in the main, we believe, correct. The for its originality, and is in every way a most valu- able addition to those on the subject of obsteti'ics Canada Med. Journal, Oct. 1864. great attention which the author has devoted to the mechanism of parturition, taken along. with the con- clusions at which he has arrived, point, we think, It is very large, profusely and elegantly illustrated, conclusively to the fact that, in Britain at least, the and is fitted to take its place near the works of great doctrines of Naegele have been too blindly received, obstetricians. Of the American works on the subject i — Glasgow Med. Journal, Oct. 1864. It is decidedly the best. — Edinb. Med. Jour., Dec. '64 I #** Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. JIANNER [THOMAS H.), M.D. ON THE SIGNS AND DISEAvSES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates and illustrations on wood. In one handsome octavo volume of about 600 pages, extra cloth, $4 25. The very thorough revision the work has undergone has added greatly to its practical value, and increased materially its efliciency as a guide to the student and to the young practitioner. — Am. Journ. Med. Sei., April, 1868. With the immense variety of subjects treated of and the ground which they are made to cover, the im- possibility of giving an extended review of this truly remarkable work must be apparent. We have not a single fault to find with it, and most heartily com- mend it to the careful study of every physician who would not only always be sure of his diagnosis of pregnancy, but always ready to treat all the nume- rous ailments that are, unfortunately for the civilized tvomen of to-day, so commonly associated with the function. — N. Y. Med. Record, March 16 1868. We recommend obstetrical students, young and old, to hav( this volume in their collections. It con tains not onl 3 a fair statement of the .signs, symptoms, and diseases of pregnancy, but comprises in addition much interesting relative matter that is not to be found in anj other work that we can name. — Edin- burgh Med Journal, Jan. ISbS. 8 WAFNE [JOSEPH GRIFFITHS), M. D., Physician-Accoucheur to the British General Hospital, &c. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised London Edition, with Additions by E. R. Hutchins, M. D. With Illustrations. In one neat 12mo. volume. Extra cloth, $1 25. (Now Ready.) * . * See p. 3 of this Catalogue for the terms on which this work is offered as a premium to subscribers to the "American Journal op the Medical Sciences." it IS really a capital little compendium of the sub- answers the purpose. It is not only valuable for Ject, and we recommend young practitioners to buy it ' young beginners, but no one who is not a proficient and carry it with them when called to attend cases of I in the art of obstetrics should be without it, because labor. They can while away the otherwise tedious hours of waiting, and thoroughly fix in their memo- ries the most important practical suggestions it cen- tal us. The American editor has materially added by his no'tes and the concluding chapters to the com- pleteness and general value of the book. — Chicago Med. Journal, Feb. 1870. The manual before us containsin exceedingly small compass — small enough to carry in the pockei, — about all I here is of obstetrics, condensed into a nutshell of Aphorisms. The illustrations are well selected, and serve as excellent reminders of the conduct of labor — regular and difficult. — Cincinnati Lancet, April, '70. ""h':: Ib a moBtadmirablelittle work, and completely it condenses all that is necessary to know for ordi- nary midwifery practice. We commend the book most favorably. — St. Louis Med. and Surg. Journal, Sept. 10, 1870. A studied perusal ,of this little book has satisfied us of its eminently practical value. The object of the work, the author says, in his preface, is to give the student a few brief and practical directions respect- ing the management of ordinary cases of labor ; and also to point out to him in extraordinary cases whea and how he may act upon his own re-ponsibility, and when he ought to send for a8sisti4^e. — N. T. Medial Journal, May, 1870. \TINCKEL [F.), Professor and Director of the Gynacological Clinic in the University of Rostock. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M D. In one octavo volume. {Preparing.) Henry C. Lea's Publications — {Midwifery). TEISHMAN [WILLIAM), M.D., Regius Professor of lliiJwifery in the. Universi'y of Glasgoie, &c. A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. In one large and very handsome oc- tavo volume of over 700 pages, with one hundred and eighty-two illustrations. Cloth, $5 00 ; leather, $6 00. {Now Ready.) "A Complete System of the Midwifery of the Present Day," and well redeems the promise. In all that relates to the subject of labor, the teaching is admi- rably clear, coucise, aud practical, representing not alone British practice, but the contributions of Con- tinental and American schools. — N. Y. Mtd. Record, March 2, 1S74. This is one of a most complete aud exhaustive cha- racter. We have gon? carefnlly through it, 'and there is no subject in Obstetrics which has not been con- sidered well and fully. The result is a work, not only admirable as a text-book, but valuable as a work of reference to the practitioner in the various emer- gencies of obstetric practice. Take it all in all, we have no hesitation in saying that it is in our judgment the best English work on the subject. — London La7i- cet,A\\g. 2.:i, 187.3. The work of Leishman gives an excellent view of modern midwifery, and evinces its author's extensive acquaintance with British and foreign literature ; and not only acquaintance with it, but wholesome diges- tion and sound judgment of it. He has, withal, a manly, free style, and can state a difficult and compli- cated matter with remarkable clearness and bi'evity. — Kdin. Med. Journ., Sept. 1873. The author has succeeded in presenting to the pro- fession an admirable treatise, especially in its practi- cal aspects ; one which is, in general, clearly written, and sound in doctrine, and one which cannot fail to add to his already high reputation. In concluding our examination of this work, we cannot avoid again saying that Dr. Leishman has fully accomplished that difficult task of presenting a good text-book upon obstetrics. We know none better for the use of the stu- dent or junior practitioner. — Am. PrUctitioner, Mar. 1874. It proposes to offer to practitioners and students The work of Dr. Leishman is, in many respects, not only the best treatise on midwifery that we hHve seen, but one of the best treatises on any medical sn In- ject that has beeu published of late years. — Lond. Practitioner, Feb. 187-1:. It was written to supply a desideratum, and we will be much surprised if it does not fulfil the purpose of its author. Takiug it as a whole, we know of no work on obstetrics by an English authorin whichthe student and the practitioner will find theinformati>in so clear and so completely abi east of the present stale of our knowledge on the svLb]%ci.~ Glasgow Med. Journ., Aug. 1873. Dr. Leishman's System of Midwifery, which has only just been published, will go far to supply the want which has so long been felt, of a really good modern English text-book. Although large, as is in- evitable in a work on so extensive a subject, it is so well and clearly written, that it is never wearisome to read. Dr. Leishman's work maybe confidently recommended as an admirable text-book, and is sure to be ItU-gely used.— Lojid. Med. Record, Sept. 1873. UAMSBOTHAM [FRANCIS H.] D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDL CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, &c., in the Jefferson Medical College, Philadelphia. In one large and handsome imperial octavo volume of 6,50 pages, strongly bound in leather, with raised bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. To the physician's library it is indispensable, while to the student, as a text-book, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior. — Ohio Med. and Surg. Journal. When we call to mind the toil we underwent in acquiring a knowledge of this subject, we cannot but envy the student of the present day the aid which We will only add that the student will learn from !t all he need to know, and the practitioner will find It, as a book of reference, surpassed by none other. — Stethoscope. The character and merits of Dr. Ramsbotham's work are so well known and thoroughly established, that comment is unnecessary and praise superfluous The illustrations, which are numerous and accurate are executed in the highest style of art. We cannot i this work will afford him. — Am. Jour, of the Med. too highly recommend the work to our readers. — St. | Sciences. Louis Med. and Surg. Journal. I nnURGHILL [FLEETWOOD), M.D., M.R.I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With notes and additior s by D. Francis Condie, M. D., author of a "Practical Treatise on the Diseases of Chil- dren,'' &c. With one hundred and ninety- four illustrations. In one very handsome octavo volume of nearly 700 large pages. Extra cloth, $4 00 ; leather, $5 00. These additions render the work still more com- plete and acceptable than ever; and we can com- mend it to the profession with great cordiality and pleasure. — Cin Hnnati Lancet. Few wtirk? on this branch of medical science are equal to it, certainly none excel it, whether in regard to theory or practice — Brit. Am. Journal. Ko treatise on obstetrics with which we are ac- quainted can compate favorably with this, in re- spect to the amount ofraaterial which has beer gath- ered from every source. — Boston Med. and Stirg. Journal . There is no better text-book for students, or work of reference and study for the practising physician than this. It should adorn and enrich every medical library. — Chicago Med. Journal. MONTGOMERY'S EXPOSITION OF THE SIGNS i AND SYMPTOMS OF PREGNANCY. With two | exquisite colored plates, and numerous wood cats. In i vol. 8vo., of nearly 600 pp., extra cloth. $3 75. SlaBY'S SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American I edition. One volume octavo, extra cloth, 422 pages ^12 50. DEWEES'S COMPREHENSIVE SYSTEM OF MID- WIFERY. Twelfth edition, with the author's latt improvements and corrections. In one octavo vol- ume, extra cloth., of 600 pages. $3 60. Henry C. Lea's Publications — (Surgery). flROSS {SAMUEL D.), M.D., '-^ Professor of Surgery in the Jefferson Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in leather, with raised bands, $15. {Just Ready .) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respect fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one-fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount ol matter is condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, renders it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. It mu.st long remain the most comprehensive work on thisimpurtam part of medicine. — Boston Medical and Surgical Journal, March '23, 186.5. We have compared it with most of our standard works, ouch as those of Erichsen, Miller, Fergusson, Syme, and others, and we must, in justice to our author, award it the pre-eminence. As a work, com- plete in almost every detail, no matter how minute or trifling, and embracing every subject known in the principles and practice of surgery, we believe it stands without a rival. Dr. Gross, in his preiace, re- marks "my aim has been to embrace the whole do- main of surgery, and to allot to every subject its legitimate claim to notice;" and, we assure our readers, he has kept his word. It is a work which we can most confldently recommend to our brethren, for its utility is becoming the more evident the longer it is upon tie shelves of our library.— Cawada Med. Journal, September, 186.5. The first two editions of Professor Gross' System of Surgery are so well known to the profession, and so highly prized, that it would be idle for us to speak in praise of this voik.— Chicago Medical Journal, September, 186.5. We gladly indorse the favorable recommendation of the work, both as regards matter and style, which we made when noticing its tirsl appearance.— .Briii*/* and Foreign Medico-Chirurgical Review, Oct. 1865. The most complete work that has yet issued from the press on the science and practice of surgery. — London Lancet. This system of surgery is, we predict, destined to take a commanding position in our surgical litera- ture, and be the crowning glory of the author's well earned fame. As an authority on general surgical subjects, this work is long to occupy a pre-eminent place, not only at home, but abroad. We have no hesitation in pronouncing it without a rival in our language, and equal to the best systems of surgery in Any language. — N. Y. Med. Journal. Wot only by far the best text-book on the subject, as a whole, within the reach of American students, but one which will be much more than ever likely to be resorted to and regarded as a high authority abroad. — Am. Journal Med. Sciences, Jan. 1865. The work contains everything, minor and major, operative and diagnostic, including mensuration and examination, venereal diseases, and uterine manipu- lations and operations. It is a complete Thesaurus of modern surgery, where the student and practi- tioner shall not seek in vain for what they desire. — San Francisco Med. Press, Jan. 1865. Open it where we may, we find sound practical in- formation conveyed in plain language. This book is no mere provincial or even national system of sur- gery, but a work which, while very largely indebted to the past, has a strong claim on the gratitude of the future of surgical science. — Edinburgh Med. Journal, Jan. 1865. A glance at the work is sufficient to show that the author and publisher have spared no labor in making it the most complete "System of Surgery" ever pub- lished in any country. — St. Louis Med. and Surg. Journal, April, 1865. A system of surgery which we think unrivalled in our language, and which will indelibly associate his name with .surgical science. And what, in our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it is at the same time one of the most valuable trea- tises which can be put into the hands of the student seeking to know the principles and practice of this branch of the profession which he designs subse- quently to follow. — The Brit. Am.Jowrn., Montreal. UT THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In 1 vol. 8vo. cloth, with illustrations, pp. 468. $2 75. 8 ;eY'S OPERATIVE SURGERY. In 1 vol. 8vo. jloth, of over 650 pages ; with about 100 wood-cuts. *3 2.5. COOPER'S LECTURES ON THE PRINCIPLES AND Pkactice of SuRiiER y. In 1 vol. 8 vo. cloth, 750 p. $2. GIBSON'S INSTITUTES AND PRACTICE OF SUR- ] QERY. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vel- 1 umes, about 1000 pp. , leather, raised bands. $6 60. M ILLER {JAMES), Late Professor of Surgery in the University of Edinburgh, &e. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. $3 76. B T THE SAME AUTHOR. THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra cloth. $3 75. SARGENT {F. W.), M.D. O^ BA^DAUI^G AND OTHER OPERATIONS OF MINOR SURGERY. Newedition, with an additional chapter on Military Surgery. One handsome royai l2mo. volume, of nearly 400 pages, with 184 wood-cuts. Extra cloth, $1 75. Henry C. Lea's Publications — (Surgery). 27 ASHHURST {JOHN, Jr.). M.D., Surgeon to the Episcopal Hospital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, extra cloth, $6 50; leather, raised bands, $7 50. {Just Iss^ted.) The object of the author has been to present, within as condensed a compass as possible, a complete treatise on Surgery in all its branches, suitable both as a text-book for the student and a work of reference for the practitioner. So much has of late years been done for the advance- ment of Surgical Art and Science, that there seemed to be a want of a work which should present the latest aspects of every subject, and which, by its American character, should render accessible to the profession at large the experience of the practitioners of both hemispheres. This has been the aimof the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- torily. The plan and general outline of the work will be seen by the annexed CONDENSED SUMMARY OF CONTENTS. Chapter I. Inflammation. II. Treatment of Inflammation. III. Operations in general: Anaesthetics. IV. Minor Surgery. V. Amputations. VI. Special Amputations. VII. Eflfects of Injuries in General : Wounds. VIII. Gunshot Wounds. IX. Injuries of Bloodvessels. X. Injuries of Nerves, Muscles and Tendons, Lymphatics, Bursae, Bones, and Joints. XI. Fractures. XII. Special Fractures. XIII. Dislocations. XIV. Effects of Heat and Cold. XV. Injuries of the Head. XVI. Injuries of the Back. XVII. Injuries of the Face and Neck. XVIII. Injuries of the Chest. XIX. Injuries of the Abdomen and Pelvis. XX. Diseases resulting from Inflammation. XXI. Erysipelas. XXII. Pyaemia XXIII. Diathetic Diseases : Struma (in- cluding Tubercle and Scrofula); Rickets. XXIV. Venereal Diseases; Gonorrhoea and Chancroid. XXV. Venereal Diseases continued : Syphilis. XXVI. Tumors. XXV 11. Surgical Diseases of Skin, Areolar Tissue, Lymphatics, Muscles, Tendons, and Bursae. XXVIII. Surgical Disease of Nervous System (including Tetanus). XXIX. Surgical Diseases of Vascular System (includ- ing Aneurism). XXX. Diseases of Bone. XXXI. Diseases of Joints. XXXII. Excisions. XXXIII. Orthopaedic Surgery. XXXIV. Diseases of Head and Spine. XXXV. Dise.Tses of the Eye. XXXVI. Diseases of the Ear. XXXVII. Diseases of the Face and Neck. XXXVIII. Diseases of the Mouth, Jaws, and Throat. XXXIX. Diseases of the Breast. XL. Hernia. XLI. Special Hernise. XLII. Diseases of Intestinal Canal. XLIII. Diseases of Abdominal Organs, and various operations on the Abdomen. XLIV. Urinary Calculus XLV. Diseases of Bladder and Prostate. XLVI. Diseases of Urethra. XLVII. Diseases of Generative Organs. Index. Its author has evidently tested the writings and experiences of the past and present in the crucible of a careful, analylic, and honoiable mind, and faith- fully endeavored to bring his work up to the level of the highest standard of practical surgery He is frank and detiuite, and gives us opinions, and gene- rally sound ones, instead of a mere resurne of the opinions of others. He is conservative, but not hide- bound by authority. His style is clear, elegant, and scholarly. The wi rk is anadmirable text book, and a useful book of reference It is a credit to American professional literature, and one of the first ripe fruits of the soil fertilized by the blood of oar late unhappy war.— aV. Y. Med. Record, Feb. 1, 1S72. Indeed, the work as a whole must be regarded as an excellent and concise exponent of modern sur- gery, and as such it will be found a valuable text- book for the student, and a useful book of reference for the general practitioner. — N. Y. Med. Journal, Feb. 1S7-^ It gives us great pleasure to call the attention of the profession to this excellent work. Our knowledge of its talented and accomplished author led us to expect from him a very valuable treatise upon subjects to which he has repeatedly given evidence of having pro- fitably devoted much time and labor, and we are in no way disappointed.— PAt/a. Mtd. Times, Feb. 1, 1S72. P IRRIE ( WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, &c. In one very handsome octavo volume of 780 pages, with 316 illustrations, extra cloth. $3 75. H AMIL TON ( FRA NK H. ), M.D., Professor of Fracture.),- and Di.ilncations, ice, in Bellevue Hosp. Med. College, New York. PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS. Fourth edition, thoroughly revised. In one large and handsome octavo volume of nearly 800 pages, with several hundred illustrations. Extra cloth, $5 75 ; leather, $6 75. {Just Issued. ) rable treatise, which we have always considered the most complete and reliable work on the subject. As a whole, the work is without an equal in the litera- ture of the profession. — Boston Med. and Surg. Journ., Oct. 12, IS?]. It is unnecessary at this time to commend the book, except to such as are beginners in the study of this particular branch of surgery. Every practical sur- geon in this country and abroad knows of it as a most trustworthy guide, and one which they, in common with us, would unqualifiedly recommend as the high- est authority in any language. — N Y. Med. Record, Oct. 16, 1S71 It is not, of course, our intention to review in ex- tenso, Hamilton on "Fractures and Dislocations." Eleven years ago such review might not have been out of place ; to-day the work is an authority, so well, so generally, and so favorably known, that it cmly remains for the reviewer to say that a new edition is just out, and it is better than either of its predeces- sors. — Cincinnati Clinic, Oct. 14, 1S71. Undoubtedly the best woi-k on Fractures and Dis- locations in the English language. — Cincinnati Med. kfpertory, Oct. 1871. We have once more before us Dr Hamilton's admi- 28 Henry C. Lea's Publications — {Surgery). PRICES EN [JOHN E.), -*-• Professor of Surgery in University College, London, etc. THE SCIENCE AND ART OF SURaERY; being a Treatise on Sur- gical Injuries, Diseases, and Operations. Revised by the author from the Sixth and enlarged English Edition. Illustrated by over seven hundred engravings on wood. In two large and beautiful octavo volumes of over 1700 pages, extra cloth, $9 00 ; leather, $11 00. {Just Ready.) Author'' s Preface to the New American Edition. " The favorable reception with which the ' Science and Art of Surgery' has been honored by the Surgical Profession in the United States of America has been not only a source of deep gratifica- tion and of just pride to me, but has laid the foundation of many professional friendships that are amongst the ngreeable and valued recollections of my life. ■' "I have endeavored to make the present edition of this work more deserving than its predecessors of the favor that has been accorded to them. In consequence of delays that have unavoidably occurred in the publication of the Sixth British Edition, time has been afforded to me to add to this one several paragraphs which I trust will be found to increase the practical value of the work." London, Oct. 1S72. On no former edition of this work has the author bestowed more pains to render it a complete and satisfactory exposition of British Surgery in its modern aspects. Every portion has been sedu- lously revised, and a large number of new illustrations have been introduced. In addition to the materinl thus added to the English edition, the author has furnished for the American edition such material as has accumulated since the passage of the sheets through the press in London, so that the work as now presented,to the American profession, contains his latest views and experience. The increase in the size of the work has seemed to render necessary its division into two vol- umes. Great care has been exercised in its typographical execution, and it is confidently pre- sented as in every respect worthy to maintain the high reputation which has rendered it a stand- ard authority on this department of medical science. These are only a few of the points in which the ; states in his preface, they are not confined to any one present edition of Mr. Eriohsen's work surpasses its portion, but are distributed generally through the predecessors. Throughout there is evidence of a j subjects of which the work treats. Certainly cue of laborious care and solicitude in seizing the passing! the most valuable sections of the book seems to us to knowledge of the day, which reflect;, tlie greatest be that which treats of the diseases of the arteries credit on the author, and much enhances the value J and the operative proceedings which they necessitate, of hiswork. Wecanonly admire the industry which '■ In few text-books is so much carefully arranged in- has enabled Mr. Erichsen thus to succeed, amid the , formation collected. — London Med. Times and Gaz., di.stractionsof active practice, in producing emphatic- \ Oct. 26, 1872. ally THE book of reference and study for Britisli prac- ; Ti,e entire work, complete, as the great Engli;1GEL0 W [HENRY J.). M. D., -*-' Professor of Surgery in the Massac.httsetts Med. College. ON THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With numerous original illustrations. In one very handsome octavo volume. Cloth. $2 60. {Lately Issiied.) TAWSON [GEORGE), F. R. C. S., Engl., ■*-' Assistant Surgeon to the Royal London Ophthalmic Hospital, Mnorfields, See. INJURIES OF THE EYE, ORBIT, AND EYELIDS: their Imme- diate and Remote Effects. With about one hundred illustrations. In one very hand- some octavo volume, extra cloth, $.3 50. It is an admirable practical book in the highest and best sense of the phrase. — London Medical Timet and Gazette, May 18, 1867. Henry C. Lea's Publications — (Surgery). 29 -jDRYANT {THOMAS), F.R.C.S., ■*-' Surgeon to Guy's Hospital. THE PRACTICE OF SURGEPY. With over Five Hundred En- gravings on Wood. In one large and very handsome octavo volume of nearly 1000 pages, extra cloth, $6 25; leather, raised bands, %1 26. (Just Issued.) Again, the author gives us his own practice, his own beliefs, and illustrates by liis own cases, or those treated in Guy's Hospital. This feature adds joint emphasis, and a solidity to his statements that inspire confidence. One feels himself almost by the side of the surgeon, seeing his work and hearing his living words. The views, etc , of other surgeons are con- sidered calmly and fairly, but Mr. Bryant's are adopted. Thus the work is not a compilation of other writings; it is not an encyclopajdia, but the plain statements, on practical points, of a man who has lived and breathed and had his being in the richest surgical experience. The whole profession owe a debt of gratitude to Mr Bryant, for his work in their behalf. We are confident that the American profession will give substantial testimonial of their feelings towards both author and publisher, by speedily exhausting this edition. We cordially and heartily commend it to our friends, and think that Di) live surgeon can afford to be without it — Detroit Review of Med. and Pharmacy, August, 1S73. . As a manual of the practice of surgery for the use of the student, we do not hesitate to pronounce Mr. Bryant's book a filrst-rate work. Mr. Bryant has a good deal of the dogmatic energy which goes with the clear, pronounced opinions of a man whose re- flections and experience have moulded a character not wanting in firmness aud decision. At the same time he teaches with the enthusiasm of one who has faith in his teaching; he speaks as one having au- thority, and herein lies the charm and excellence of his work. He states the opinions of others freely and fairly, yet it is no mere compilation. The book combines much of the merit of the manual with the merit of the monograph. One may recognize iu almost every chapter of the ninety-four of which the work is made up the acuteness of a surgeon who has seen much, and observed closely, and who gives forth the results of actual experience. In conclusion we repeat what we stated at fir.^t, that Mr. Bryant's book is one which we can conscientiously recommend bi)th to praclitiuuers and students as an admirable work. — Dublin Joiirn. of Med. Science, August, 1S73. Mr. Bryant has long been known to the reading portion of the profession as an able, clear, and graphic writer upon surgical subjects. The volume before us is one eminently upon the practice of surgery and not one which treats at length on surgical pathology, though the views that are entertained upon this sub- ject are sufficiently interspersed through the work for all practical purposes. As a text-book we cheer- fully I'ecommeud it, feeling convinced that, from the subject-matter, and the concise and true way Mr. Bryant deals with his subject, it will prove a for- midable riral among the numerous surgical text- books which are offered to the student. — N. Y. Med. Record, June, 1S73. This i.«, as the preface states, an entirely new book, and contains in a moderately condensed form all the surgical information necessary to a general practi- tioner. It is written in a spirit couRistent with the present improved standard of medical and surgical science. — American Journal of Obstetrics, August, 1S73. A {^ELLS {J. SOELBERG), Professor of Ophthalmology in King^s College Hospital, &e. TREATISE ON DISEASES OF THE EYE. Second Americar, from the Third and Revised London Edition, with additions; illustrated with numerous engravings on wood, and six colored plates. Together with selections from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume of nearly 800 pages ; cloth, So 00 ; leather, S6 00. (Notv Ready.) The continued demand for this work, both in England and this country, is sufficient evidence that the author has succeeded in his effort to supply within a reasonable compass n full practical digest of ophthalmology in its most modern aspects, while the call for repeated editions has en- aiiled him in his revisions to maintain its position abreast of the most recent investigations and improvements. In again reprinting it, every effort has been made to adapt it thoroughly to the wants of the American practitioner. Such additions as seemed desirable have been introduced by the editor, Dr. I. Minis Hays, and the number of illustrations has been largely increased. The importance of test-types as an aid to diagnosis is so universally acknowledged at the present d;iy that it seemed essential to the completeness of the work that they should be added, and as the author recommends the use of those both of Jaeger and of Snellen for diiferent purposes, selec- tions have been made from each, so that the practitioner may have at command all the assist- ance necessary. Although enlarged by one hundred pages, it has been retained at the former very moderate price, rendering it one of the cheapest volumes before the profession. A few notices of the previous edition are subjoined. In this respect the work before us is of much more service to the general practitioner than those heavy compilations which, in giving every person's views, too often neglect to specify those which are most in accordance with the author's opinions, or in general acceptance. We have no hesitation iu recommending this treatise, as, on the whole, of all English works on the subject, the one best adapted to the wants of the general ^viL.ciiiio'a.ei. — Edinburgh Med. Journal, March, 1870. A treatise of rare merit. It is practical, compre- { the eye hensive, and yet concise. Upon those subjects usually | found difficult to the student, he has dwelt at length and entered into full explanation. After a careful perusal of its contents, we can unhesitatingly com- mend it to all wlio desire to consult a really good work on ophhtalmic science. — Leavenworth Mde. Her- ald, Jan. 1S70. Without doubt, one of the best works upon the sub ject which has ever been published ; it is complete on the subject of which it treats, and is a necessary work for every physician who attempts to treat diseases of Dominion Med. Journal, Sept. 1869. fA URENCE {JOHN Z.), F. R. C. S., Editor of the Ophthalmic Review, &c. A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In one very handsome octavo volume, extra cloth, %'6 00. [Lately Iss7ied.) For those, however, who must assume the care of [ edition those novelties which have secured the confi- diseases and injuries of the eye, and who are too dence of the profession since the appearance of his much pressed for time to study the classic works on last. The volume has been considerably enlarged the subject, or those recently published by Stellwag, and improved by the revision and additions of^its Wells, Bader, and others, Mr. Laurence will prove a author, expresslv for the American edition. — Am. safe and trustworthy guide. He ha* described in this 1 Journ. Med. Sciences, Jan. 1870. 30 Henry C. Lea's Publications — {Surgery, &c.). rPHOMPSON [SIR HENR F), ■*- Surgeon and Profennor of Olinical Surgery to University College Hospital . LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. In one neat octavo volume, extra cloth. $2 25. These lectures stand the severe test. They are in- I tical hints so useful for the siudent, and even more Btructive without being tedious, and simple without yaluahle to the young practitioner. — Edinburgh Med. being dififuse; and they include many of those prac- | Journal, April, 1S69. B Y TEE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OP THE URETHUA AND URINARY FISTULiE. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, extra cloth, $3 60. {Lately Puhlished.) This classical work has so long been recognized as a standard authority on its perplexing sub- jects that it should be rendered accessible to the American profession. Having enjoyed the advantage of a revision at the hands of the author within a few months, it will be found to present his latest views and to be on a level with the most recent advances of surgical science. With a work accepted as the authority upon the I ably known by the profession as this before us, must subjects of which it treats, an extended notice would | create a demand for it from those who would keep be a work of supererogation. The simple announce- I themselves well up in this department of surgery. — ment of another edition of a work so well and favor- | St. Louis Med. Archives, Feb. 1870. -DY THE SAME AUTHOR. (Just Ready.) THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY AND TREATMENT. Fourth Edition, Revised. In one very handsome octavo volume of 'i^bb pages, with thirteen piates, plain and colored, and illustrations on wood. Cloth, $3 75. This work is recognized in England as the leading authority on its subject, and in presenting it to the American profession, it is hoped that it will be found a trustworthy and satisfactory guide in the treatment of an obscure and important class of affections. ^ALES [PHILIP S.), M. D., Surgeon U. S. N. MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical Apparatus, Appliances, and Elementary Operations : embracing Minor Surgery, Band- aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred and forty -two illustrations on wood. In one large and handsome octavo volume of about 700 pages: extra cloth, $5 75; leather, $6 75. /TAFLOR [ALFRED S.), M.D., ■*■ Lecturer on Med. Jurisp. and Qhemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by John J. Reese, M.D., Prof, of Med. Jurisp. in the Univ. of Penn. In one large octavo volume. Cloth, $5 00; leather, $6 00. {Now Ready.) In preparing for the press this seventh American edition of the " Manual of Medical Jurispru- dence" the editor has, through the courtesy of Dr. Taylor, enjoyed the very great advantage of consulting the sheets of the new edition of the author's larger work, " The Principles and Prac- tice of Medical Jurisprudence," which is now ready for publication in London. This has enabled him to introduce the author's latest views upon the topics discussed, which are believed to bring the work fully up to the present time. The notes of the former editor, Dr. Hartshorne, as also the numerous valuable references to American practice and decisions by his successor, Mr. Penrose, have been retained, with but few slight exceptions; they will be found inclosed in brackets, distinguished by the letters (II.) and (P.). The additions made by the present editor, from the material at his couiniand, amount to about one hundred pages; and his own notes are designated by the letter (K.). Several subjects, not treated of in the former edition, have been noticed in the present one, and the work, it is hoped, will be found to merit a continuance of the confidence which it has so long enjoyed as a standard authority. or THE SAME AUTHOR. {Now Ready.) THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two very large octavo volumes, cloth, $10 00; leather, $12 00. This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Ameri- can profession, the publisher trusts that it will assume the same position in this country. Henry C. Lea's Publications — {Psychological Medicine^ &g.). 31 rPOKE {DANIEL HACK), M.D., -*■ Joint atithor of " The Manual of Psychological 3fedicine," d-c. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of toe Imagination. In one handsome octavo volume of 416 pages, extra cloth, $3 25. (Now Ready.) The object of the author in this work has been to show not only the effect of the mind in caus- ing and intensifying disease, but also its curative influence, and the use which may be made of the imagination and the emotions as therapeutic agents. Scattered facts bearing upon this sub- ject have long been familiar to the profession, but no attempt has hitherto been made to collect and systematize them so as to render them available to the practitioner, by establishing the seve- ral phenomena up^n a scientific basis. In the endeavor thus to convert to the use of legitimate medicine the means which have been employed so successfully in many systems of quackery, the author has produced a work of the highest freshness and interest as well as of permanent value. DLANDFORD (G. FIELDING), M. D., F. R.C P., J-^ Lecturer on Psychological Medicine at the School of St. George's Hospital, Sec. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages: extra cloth, $3 25. {Jiist Issued.) This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of more value to the practitioner in this country, Dr. Ray has added an appendix which affords in- formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment be called upon to take action in relation to patients. It satisfies a want which must have beeu sorely felt by the busy general practitioners of this country. It takes the form of a manual of clinical description of th« various forms of insanity, with a description of the mode of examiniog persons suspected of in- sanity. We call particular attention to this feature of the book, as giving it a unique value to the gene- ral practitioner. If we pass from theoretical conside- rations to descriptions of the varieties of insanity as actually seen in practice and the appropriate treat- ment for them, we find in Dr. Blandford's w fn^^c o^l m: 30 ro ^, CD „ ARM M KUO