COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00038792 RGlOl M5 College of ^fjpjsicians; anb burgeons; Hibrarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/systemofgynaecolOOallb A SYSTEM OF GYNECOLOGY ^^^y^- A SYSTEM OF GYNECOLOGY BY MANY WRITERS EDITED BY THOMAS CLIFFORD ALLBUTT M.A., M.D., LL.D., F.R.C.P., F.B.S., F.L.S., F.S.A. EEGIU8 PROFESSOR OP PHYSIC IN THE UNIVERSITY OF CAMBRIDGE, FELLOW OF GONVILLE AND CAICS COLLEGE AND W. S. PLAYFAIR M.D., LL.D., F.R.C.P. PROFESSOR OF OBSTF.TRIO MEDICINE IN KING'S COLLEGE, AlTD OBSTETRIC PHYSICIAN TO KLNG'S COLLEGE HOSPITAL Ncto Hork THE MACMILLAN COMPANY LONDON: MACMILLAN & CO., Ltd. 1897 All rights reserved MS Copyright, 1896, By the MACMILLAN COMPANY. Set up and electrotyped October, 1896. Reprinted October, 1897. Koriuooli ^rrsss J. S. Cuihiiig k Co. - Hurwlck & .Smith Norwuoil Mail. U..S.A. PEEFACE In the earlier treatises on medicine diseases of women were included, but were of necessity imperfectly described. Of late years this department of medicine has grown so largely that the Editor of the new System of Medicine found it would be better to deal with it, as a whole, in a volume especially devoted to the subject; in the preparation of this volume I have assisted him as Joint Editor. The advances made within the last few years in Gynaecology are perhaps more remarkable than in any other branch of medicine. The whole subject is one of recent development. Even the work of its pioneers is within the recollection of the older amongst us : a treatise on gyngecology written twenty years ago is ab- solutely useless as a guide to the practice of to-day, and does not contain even a reference to many of the topics now known to be of primary importance in connection with diseases of the reproductive organs in women; on the other hand, many opinions and methods of treatment, then largely taught and practised, have justly passed into oblivion. Much of this great progress is undoubtedly on the surgical aspect of the subject. The increasing frequency of abdominal sections has directed attention to the diseased states thus revealed, and to methods of treating them, previously quite unknown. Unbalanced zeal has had its inevitable result of injudicious practice, which is to be regretted ; against adventure of this kind protests have been made by the more conservative minded SYSTEM OF GYNECOLOGY members of our profession, often justly, sometimes unjustly. Xor is it in this country alone that this adventurousness is seen. Any one familiar with current gyna?cological practice, both on the Continent and in the United States, must know that the same spirit is active there. Indeed, it is probable that gyusecologists abroad are apt to impute to their British colleagues a backwardness in adopting methods of treatment largely practised by themselves ; many of us think, too largely. Conservatism of this sort may have its faults, but, on the whole, it is not to be regretted, and it is surely better than to err in the opposite direction. It is obvious that a collection of independent essays, written by men on topics Avhicli they have specially studied, must carry more weight, and be more useful than any work compiled by a single writer. An endeavour has been made to entrust the several subjects to thoroughly representative men; and it is hoped that the results of their combined labours will give an accurate exposition of gynse- cology as it is taught and practised amongst us. I am myself alone responsible for the selection of the contributors, which my co-editor has left to my judgment; but I am not in any way responsible for the opinions they have expressed, — some of them, indeed, I do not share. In a work by various authors differences of opinion will necessarily be found ; some condemn methods of practice which others approve and recommend. This does not appear to be objectionable ; it is surely better that in vexed and disputed ques- tions both sides should be fairly considered. W. S. PLAYFAIR. CONTENTS The Development of Modern GrxiECOLOGY. M. Handfield-Jones . The Anatomy of the Female Pelvic Organs. D. Berry Hart Malformations of the Genital Organs in "Woman. J. "William Bal lantyne Organs. "W Playfair Robert Milne The Etiology of the Diseases of the Female Genital Balls-Headley ..... Diagnosis in Gynecology. Robert Boxall Inflammation of the Uterus. A. H. Freeland Barbour The Nervous System in Relation to Gynecology. "W. S. Sterility. Henry Gervis ..... Gynecological Therapeutics. Amand Routh The Electrical Treatment of Diseases of Women. Murray ...... Disorders of Menstruation. John Halliday Croom . Diseases of the External Genital Organs. "William J. Smyly Displacements of the Uterus. Alexander Russell Simpson Morbid Conditions of the Female Genital Organs resulting from Parturition. George Ernest Herman Extra-uterine Gestation. John Bland Sutton Pelvic Inflammation. Charles James Cullingworth Pelvic H.ematocele. "William Overend Priestley Benign Growths of the Uterus. F. W. N. Haultain Hysterectomy. J. Knowsley Thornton . vii 1 31 63 11-2 151 187 220 231 240 300 339 372 393 425 451 485 524 561 611 SYSTEM OF GYNECOLOGY Malignant Diseases of the Uterus. TV. J. Sinclair Plastic Gynjecological Operations. Jolin Phillips Diseases of the Fallopian Tubes. Alban Doran Diseases of the Ovary. W. S. A. Griffith Ovariotomy. J. Greig Smith ... Chronic Inversion of the Uterus. Edward Malins Diseases of the Female Bladder and Urethra. Henry Morris PAQB 643 743 782 836 872 911 927 INDICES 959 ILLUSTRATIONS FIG. 1. Brim of Bony Pelvis ...... 2. Diagram of Bony Pelvis and of Pelvic Floor . 3. Sagittal Mesial Section of Female Pelvic Floor 4. Virgin External Genitals with the Labia Majora separated . 5. Rectal and Vaginal Mucous Membrane 6. Sphincter Ani in full-time Foetus .... 7. Axial Transverse Section of right half of Female Pelvic Floor 8. Axial Transverse Section of Female Pelvic Floor 9. Axial Coronal Section of right half of Female Pelvis 10. Blood-supply of Uterus ...... 1 1 . Lymphatics of Uterus ...... 12. Lymphatics of Uterus and Pelvis . . 13. Nerve Diagram . . 14. Relations of Uterus and Ovaries viewed through Brim 15. Sagittal Lateral Section of Female Pelvis 16. Uterine Mucous Membrane showing relation of Glands and Stroma 17. Cervix and upper part of Vagina showing Rugae 18. Seal's Ovary showing Cortical and Medullary Layers 19. Sagittal Lateral Section of Genital Organs in 3^ months' Foetus 20. Pelvis and Contents from above .... 21. Perineal Region ....... 22. Sacral Section of Pelvic Floor ..... 23. Diagram of Genu-Pectoral Posture showing Vaginal Distension 24. Dissection from behind ...... 25. T. S. of Wolffian Bodies in six weeks' Foetus . 26. T. S. Pelvis, six weeks' Foetus ..... PAGB 32 32 33 34 36 38 39 40 41 42 42 43 44 45 46 47 47 49 50 52 54 66 66 58 69 59 SYSTEM OF GYNECOLOGY 27. T. S. of six Tveeks' Foetus showing Genital Cord 28. Section of Ovary and Wolffian Body, Human Embryo, third month 29. L. S. of 3i^ months' Fo3tus to show development of Hymen . 30. Diagram of developing and fully formed Genital Tract 31. Anterior View of right Uterine Appendages .... 32. Congenital absence of outer two-thirds of right Fallopian Tube 33. Uterus Didelphys 34. Uterus Bicornis . 35. Uterus Septus 36. Uterus Unicornis, posterior view 37. Atresia Vulvae Superficialis 38. Anus Vulvalis . 39. Pseudo-Hermaphroditism, Perineo-Scrotal Hypospadias 40. Female Generative Organs of Halmaturus .... 41. Two completely separated Uteri of many Rodentia . 42. Single Uterus continued into two separate Cornua of the Insectivora Carnivora, Cetacea, and Ungulata .... 43. The single Uterus of the Simise and Man .... 44. Section of a Catarrhal Patch on the Vaginal Aspect of the Cervix . 45. Healing of a Catarrhal Patch treated by Astringent or Antiseptic Injections 40, 47. Schroeder's operation for excision of the Cervical Mucous Membrane in Cervical Catarrh ....... 48, 49. Section of Tissue removed by Curette from a case of Interstitial Endometritis ...... 50. Section of the Glands from a case of Glandular Endometritis 51. Section of the Uterine Tissue in a case of Chronic Metritis 52. Leiter's Coils 53. Application of Leiter's Coils 54. Bath Speculum . 55. Syijhon Douche . 56. Bed Bath 57. Ointment Carrier (Matthews Duncan's) 68. Diverging Speculum (Neugebaur's) 59, Playfair's Probe 60. Uterine Tenaculum Forceps (Sims') 01. Intra-Uterine Canula (Atthill's) ; Platinum Canula, with Stilette 62. Uterine Scarifier ...... PAGE 60 60 61 62 70 71 75 76 78 79 92 94 104 114 114 114 114 196 201 202 208 208 214 267 258 258 259 260 263 263 264 264 265 266 ILLUSTRATIONS FIG. 63. Steriliser for Instruments (Harrison Cripps') 64. Glass Jar for Sponges, Wool-Pads, etc, 65. Steriliser for Ligatures . 66. Catgut or Silk sterilised in Alcohol 67. Junker's Inhaler 68. Griffin's Speculum 69. Cusco's Speculum 70. Gauge Applicator (Whalebone) 71. Forceps to introduce Gauge 72. Cervical Speculum (Bantock's) 73. Duckbill Speculum (Sims') 74. Barnes' Tent Introducer 75. Chambers' Tent Introducing Forceps 76. Uterine Dilator (Hegar's improved) 77. Uterine Dilators (Hayes') 78. Uterine Dilator (Matthews Duncan's) 79. Clover's Crutch . 80. Teale's Forceps . . ■ , 81. Budin's Tube 82. Graily Hewitt's Uterine Tube . 83. Goodell's two Parallel-bladed Dilator 84. Uterine Dilator (ElHnger's) 85. Sims' Three-bladed Dilator 86. Palmer's Two-bladed Dilator . 87. Dilator (Priestley's) 88. Uterine Dilators (Reid's) 89. Scissors, Uterine (Kuchenmeister's) 90. Sims' Metrotome 91. Simon's Uterine Scoop . 02. Sims' Pliable Curette . 93. Double Uterine Curette (Gervis') 94. Kecamier's Curette 95. Uterine Scoop, or Spoon Saw (Thomas') 96. Dredging Curette (Bell's) 97. Uterine Flushing Curette (Auvard's) 98. Routh's Flushing Curette 99. Vertical Section three months after Curcttin SYSTEM OF GYNECOLOGY FIG. PACK 100. Vertical Section of the Uterine Mucous Membrane fifty-five days after tlie application of a Caustic ...... 298 101. L^clanche Cell ......... oOl 102. Carbon Rheostat . . . . . . . . .30-3 103. Edelmann Galvanometer ....... 304 104. Weston Milliampfere Meter ....... 305 105. Intra-Uterine Electrode ....... 305 106. Apostoli's Carbon Electrode ....... 306 107. Adjustable Platinum Electrode ...... 306 108. Electrode for Puncture ....... 306 109. Vaginal Electrodes ........ 307 110. Portable Battery with Collector and Galvanometer . . . 300 111. Spamer's Induction Coil . . . . .' . . 310 112. Sledge Induction Coil ........ 310 113. Regulator Switch Board for Continuous and Induced Currents . . 311 114. Switch Board for regulating Lighting Currents by means of Re- sistances ......... 312 115. Diagram of Switch Board for regulating Lighting Currents by means of Shunt ......... 313 116. Switch Board for Shunt Regulation ...... 313 117. Descent of Perineal Hernia in front of the Broad Ligament . . 380 118. Reposition of the Retroverted Uterus with the Sound . . . 418 119. Hodge Pessary in the Vagina retaining the Uterus zn st7?t . . . 419 120. Profile on Section of lacerated, but healthy, Cervix Uteri . . . 427 121. Profile on Section of lacerated and inflamed Cervix Uteri . . . 427 122. Lacerations of Cervix Uteri and Vagina ..... 428 123. Laceration of Vagina forming a " Pocket " ..... 430 124. Central Rupture of Perineum ...... 4.']4 125. Diagram showing different kinds of Fistula ..... ^37 126. Annular sloughing of Cervix Uteri, upper surface .... 438 127. Annular sloughing of Cervix Uteri, lower surface .... 439 128. Slough in one mass of Cervix Uteri, upper part of Vagina, and base of Bladder 440 129. Dilated Abdominal O.stium . . . . . . .454 1.'50. Gravid Tube ......... 455 131. Tubal Mole in Section .....-.• 4.^ l.'}2. Microscopical Characters of Chorionic Villi in section, in Blood-clot . 457 ILLUSTRATIONS KIG. PAGE 133. Diagram to show the early relations of the Amnion and Chorion and the Subchorionic Chamber ....... 458 134. An early Tubal Embryo, showing the Polar Disposition of the Villi . 458 135. A Gravid Tube with patent Ostium ...... 460 136. Fallopian Tube and Ovary ; Mole and Corpus Luteum from a case of complete Tubal Abortion . . . . . .401 137. Uterine Decidua ; from a case of Tubal Pregnancy .... 465 138. Transverse Section of the Pelvis of a Woman with an Embryo and Placenta of the fourth month of Gestation occupying the right Mesometrium ........ 466 139. Sagittal Section of a Cadaver, with a Mesometrium Pregnancy at Term . 467 140. Tubo-Uterine Gestation ....... 470 141. Injected Uterus with Fibroid ....... 566 142. Microscopic Section of soft Fibromyoma ..... 507 143. Microscopic Section of common Fibromyoma .... 568 144. Section of Fibroid Uterus ....... 569 145. Diagram of Growth of Uterine Fibroids ..... 570 146. Encapsulated Submucous Fibroid becoming Polypoidal ■ . . .571 147. Submucous Polypus ........ 572 148. Uterus, showing Subperitoneal Fibroids ..... 575 149. Submucous Intravaginal Cervical Fibroid ..... 582 150. Subserous Cervical Fibroid, tilting Uterus above Pubes and bulging Posterior Vaginal Wall . . . . . . .582 151. Advanced Fibrocystic Degeneration of Stalked Subperitoneal Fibroid, with partially Twisted Pedicle ..... 587 152. CEdematous Interstitial Cystic Fibromyoma .... 588 153. Microphotograph of CEdematous Fibroid, showing Endothelial Lined Spaces ......... 589 154. Complete l\upture of the Perineum and the lo^Yer Portion of the Recto- Vaginal Septum ....... 746 155. Relations of Levator Ani to the Rectum and Vaginal Walls ; normal Condition ........ 746 156. Relations of Levator Ani to the Rectum and Vaginal Walls ; injured Condition ........ 747 157. Perineorrhaphy ; preliminary Incisions ..... 749 158. Perineorrhaphy ; Denudation ...... 749 159. Purse-string Suture ........ 750 SYSTEM OF GYX.-ECOLOGY TAGF, . 750 . 750 . 751 . 752 and Side View 753 160. Perineorrhaph)' ; Repair of the Recto-Vaginal Septum 161. Section of torn Sphincter .... 162. Perineorrhaphy ; Recto- Vaginal Septum repaired . 163. „ (Simon-Hegar Method of Suture) . 164. „ ,, ,, ,, 2nd Stage 165. ,, Alexander Duke's Method ..... 754 166. Surface View of Posterior Vaginal Wall with Right and Left Lateral Sulci 755 167. ,, „ „ ,, ,, with both Lateral Vaginal Sulci sutured ......... 755 168. Elytrorrhaphy (Sims') . . . . . . .757 169. Anterior Colporrhaphy ;; Denudation and first Layer of continuous Suture completed ........ 758 170. Anterior Colporrhaphy ; Passage of second continuous superimposed Suture ......... 759 171. jVnterior Colporrhaphy ; Passage of third Layer of superimposed Suture . 759 172. Lefort's Operation ........ 760 173. Colpoperineorrhaphy, first stage ...... 760 174. ,, ,, second stage ...... 761 175. „ ,, third stage . . , . . .761 176. Stoltz's Operation for Cystocele . . . . . .762 177. Urethrocele ......... 762 178. Vaginal Fixation ........ 764 179. Emmet's Scissors (left angular) ...... 766 180. ,, ,, (angular and curved) ..... 767 181. Operation for Subinvolution ....... 767 182. Amputation of Cervix ; Hegar Method ..... 770 183. „ „ Marckwald Method . . . . .770 184. Vesico- Vaginal Fistula Knives (Sims') . ' . . . . 774 185. Uterine Hook (Emmet's) for making counter pressure . . . 774 180. Wire Adjuster ......... 774 187. Mode of freshening the Edges of a Fistula by "Flap-splitting" . . 775 188. Mode of passing Sutures in Vesico- Vaginal Fistula . . . 775 189. Mode of applying Counter Pressure to the Point of the Needle by means of a Blunt Hook (Emmet's) . . . . . .776 190. Method of fixing and twisting the Sutures (Sims') .... 777 191. Juxta-Cervical Fistula (superficial variety) ..... 779 192. Kolpokleisis ......... 781 ILL US TRA TIONS xv FIG. PAGE 193. Section of a healthy Tube from a young Subject .... 784 194. One of the Plicae in Fig. 193 as seen under a 1 inch objective . . 785 195. Section, near the Ostium, of an inflamed Tube .... 786 190. Section of a Plica, showing the earlier Changes seen in Salpingitis . 787 197. Section showing the free Surface of the Interior of a Tube which had been obstructed and dilated for a long period .... 787 198. Section of an inflamed Tube, in its Middle Third, showing active Inflam- mation ......... 788 199. The free Surface of the Interior of a suppurating Tube . . . 789 200. Section of a suppurating Tube, showing advanced Disease . . 790 201. Ovary and Tube, showing Obstruction of the Ostium by a Perimetritic Band which forms a Deep Pouch ..... 792 202. Tube showing Obstruction of the Ostium from inflammatory Swelling of its Coats ......... 792 203. Tubes and Uterus from a Patient who died of Phthisis three years after Incision of Peritoneum infected with Tubercle . . . 797 204. Cystic Pibromyoma of the Fimbrise ...... 802 205. Microscopical Section of a Papillomatous Outgrowth from the' Left Tube . 804 206. Papilloma of the Fallopian Tube . . . . . .808 207. ,, ,, ,, Sections of an outgrowth under high and lov,' Power , . . ' . . . . .809 208. Primary Cancer of Fallopian Tube ...... 814 209. ,, ,, ,, ,, in Section, with Tubule-like Structure 815 210. Dr. CuUingworth's case of Primary Cancer of the Tube . , . 819 211. Dr. Essex Wynter's case of Cancer of the Tube .... 822 212. Diagram to show placing of Table, Surgeon, Assistants, Nurse, and In- struments in Ovariotomy ...... 870 213. Tait's Modification of Wells' Catch-Forceps . . . .877 214. Catch-Forceps (J. Greig Smith's Model) . . . . .878 215. Blades of J. Greig Smith's Forceps . . . . . .878 216. J. Greig Smith's Peritoneal Catch-Forceps ..... 878 217. ,, ,, Large Pressure-Forceps ..... 879 218. Wells' Large Forceps, bent . . . . . . .879 219. ,, ,, ,, straight . . . . . .879 220. ,, ,, Pressure-Forceps, Rectangular Blades . . . 880 221. Thornton's T-shaped Pressure-Forceps ..... 880 222. Wells' Clamp-Forceps .881 xvi SYSTEM OF GYNECOLOGY FIG. 223. N61atou's Cyst-Forceps 224", Sydney Jones' Cyst-Forceps . 225. J. Greig Smith's Scissors 226. „ „ Eeel Holder . 227. TV ells' Large Cyst- Trocar 228. Wells' Small Cyst-Trocar with Fitch's Dome 229. Tail's Cyst-Trocar 230. Sydney Jones' Pedicle Needle 231. Wells' Pedicle Needle . 232. J. Greig Smith's Forceps for placing Ligature on Pedicle 233. Keith's Glass Drainage Tube . 234. Glass Drainage Tube . 235. Sponge Holder .... 236. J. Greig Smith's Suture Instrument . 237. Tail's Staffordshire Knot 238. Triple interlocking Ligature, Threads inserted, Loops divided 2.39. ,, ,, ,, Threads interlocked ready for tying 240. ,, ,, ,, Threads tied . 241. Screw for aiding in the Delivery of Solid Tumours . 242. Aveling's Repositor for producing Elastic Pressure . PAGB 881 881 882 882 883 883 883 884 884 884 884 885 885 885 889 890 890 890 896 923 LIST OF AUTHOES Ballantyne, John Win., M.D., F.R.C.P., F.R.S. Edin., Lecturer on Midwifery and Diseases of "Women, Medical College for "Women, Edinburgh. Balls-Headley, "W., M.A., M.D., F.R.C.P., Lecturer on Midwifery and Diseases of Women, University of Melbourne. Barbour, A. H. Freeland, M.A., B.Sc, M.D., F.R.C.P. Edin., Lecturer on Mid- wifery and Diseases of Women, Edinburgh Medical School. Boxall, Robert, M.D., M.R.C.P., Assistant-Obstetric Physician and Lecturer on Practical Midwifery and Gynsecology, Middlesex Hospital. Groom, John Halliday, M.D., F.R.C.P. Edin., Physician to the Royal Infirmary, Edinburgh, Clinical Lecturer on Diseases of Women, and Lecturer on Mid- wifery and Diseases of Women at the Medical School. Cullingworth, Chas. James, M.D., D.C.L., F.R.C.P., Obstetric Physician and Lecturer on Midwifery and Diseases of Women, St. Thomas' Hospital. Doran, Alban, F.R.C.S. Eng., Surgeon to the Samaritan Free Hospital for Women. Gervis, Henry, M.D., F.R.C.P., Consulting Obstetric Physician to St. Thomas' Hospital. Griffith, Walter, S.A., M.D., F.R.C.P., Assistant-Physician Accoucheur to St. Bartholomew's Hospital. Handfield-Jones, Montague, M.D., Obstetric Physician and Lecturer on Midwifery and Diseases of Women to St. Mary's Hospital. Hart, David Berry, M.D., F.R.C.P. Edin., Lecturer on Midwifery and Diseases of Women, Edinburgh Medical School. Haultain, F. W. N., M.D., F.R.C.P. Edin., Lecturer on Midwifery and Diseases of Women, Edinburgh Medical School. Herman, Geo. Ernest, M.B., F.R.C.P., Senior Obstetric Physician and Lecturer on Midwifery to the London Hospital. Malins, Edward, M.D., M.R.C.P., Obstetric Physician to the Birmingham General Hospital, Professor of Midwifery at Mason College. Morris, Henry, M.A., M.B., F.R.C.S., Surgeon to the Middlesex Hospital. SYSTEM OF GYNECOLOGY Murraj-, Robt. Milne, M.A., M.B., F.R.C.P. Edin., F.R.S.E., Lecturer on Mid- wifery and Diseases of Women, Edinburgii Medical School. Phillips, John, M.A., M.D., F.R.C.P., Assistant Obstetric Physician to King's College Hospital. Playfair, W. S., M.D., LL.D., F.R.C.P., Professor of Obstetric Medicine in King's College, and Obstetric Physician to King's College Hospital. Priestley, Sir AV. Overend, M.P., M.D., LL.D., F.R.C.P., Consulting Obstetric Physician to King's College Hospital. Routh, Aniand J., M.D., B.S., M.R.C.P., Obstetric Physician to out-patients to Charing Cross Hospital, Physician to Samaritan Free Hospital for Women. Simpson, Alex. Russell, M.D., F.R.C.P. Edin., Professor of Midwifery, University of Edinburgh. Sinclair, W. Japp, M.A., M.D., M.R.C.P., Professor of Obstetrics and Gynajcology, Owens College, Victoria University. Smith, Jas. Greig, M.A., M.B., F.R.S. Edin., Professor of Surgery, University College, Bristol. Smyly, Wm. J., M.D., F.R.C.P. Ireland, Master of the Rotunda Hospital, Dublin. Sutton, John Bland, F.R.C.S., Assistant Surgeon to the Middlesex Hospital, Sur- geon to the Chelsea Hospital for Women. Thornton, J. Knowsley, M.B., CM., Consulting Surgeon to the Samaritan Free Hospital. In order to avoid frequent interruption of the text, the Editor has only inserted the numbers indicative of items in the lists of " i?e/e?'ences " in eases of emphasis, where two or more references to one author are in the list, where an author is quoted from a work published under another name, or where an authoritative statement is made without mention of the author's name. In ordinary cases an author's name is a sufficient indication of the corresponding item, in the list. THE DEVELOPMENT OF MODERN GYNECOLOGY Great as the progress has been during the last fifty years in every domain of medicine, in no department has it been so marked as in that which embraces the diseases peculiar to women. Indeed, in tracing the developments of modern gynaecology, it is difficult for the student of our times to estimate the value of each claim to progress, and to set a just price on each alleged advance ; for it must be allowed that among many brilliant achievements many false starts have been made, and the boasted triumph of yesterday has been ranked among the failures of to-day. Sir William Priestley, in his address before the section of Obstetric ^Ledicine and Gynaecology, says : " Looking back on forty years of gynaecological practice, I can recollect what has been termed a craze tor inflammation and ulceration of the os and cervix uteri. During its ]n'evalence, it was said of some devotees that every woman of a house- hold was apt to be regarded as suffering from these affections, and locally treated accordingly. Shortly afterwards came a brief and not very creditable period when clitoridectomy was strongly advocated as a remedy for numerous ills. This, fortunately, had a very limited currency and "was speedily abandoned. Then followed a time in which displace- ment of the uterus held the field, and every backache, every pelvic dis- comfort, every general neurosis, was attributed to mechanical causes, and must needs be treated by uterine pessaries. Again we had an epoch when oophorectomy was not only recommended, and largely practised as a means of restraining haemorrhage in bleeding fibroids, but also as a remedy for certain forms of neurosis, even when the ovaries were healthy or not seriously diseased. Ere long it was discovered that removing the ovaries for neuroses, even if safely accomplished as far as life was concerned, Avas freqxiently followed by more serious nervous penalties than those for which it had been used as a remedy; that, in fact, it often entailed a loss of mental equilibriinn, and sometimes ended in insanity. Close upon this, again, came an ardour for stitching up rents in the cervix uteri following child-birth, rents which were described as producing many hitherto iniknown evils, and frequently conducing to the establishment of malignant disease. Lastly, we have had what has been described as an epidemic of operations for the excision of tlie utei'ine 1 B SYSTEM OF GYNAECOLOGY appendages ; and even now, though this operation has but recently come into vogue, there is a reaction against its too frequent performance, and a demand in its place for more conservative methods, which shall leave these parts of the generative system a chance of still performing their important functions." "Whatever may have been the mistakes or the delays in true progress, it is, at any rate, pleasant to know that the age of mere speculation and ignorant mysticism has passed ; and that the accurate knowledge and fuller certainties of the present day have been won by anatomical and pathological research, and by patient clinical observation both in the sick-room and the operating theatre. It will always be a pleasant task to acknowledge the deep debt of gratitude which gynaecology owes to Sir Joseph Lister ; for without his scientific discoveries and brilliant teaching the successes of modern pelvic and abdominal surgery could never have been won. The groundwork of all true development in any branch of medical science must lie in the establishment of an accurate knowledge of anatomical detail, and a correct appreciation of pathological changes. It may be well to review the advance of our knowledge in these sub- jects; and first in anatomy. Anatomy. — The bloocl-supjoly of the uterus, by the uterine and ovarian arteries, has been well known and described by anatomists for many years past ; but the manner in which the blood is distributed to the organ had been less minutely studied: until Sir John Williams wrote his now classical paper " On the Circulation in the Uterus, with some of its Anatomical and Pathological Bearings," our knowledge of this important subject was extremely imperfect. Sir John Williams pointed out that the provision for the flow of blood into and out of the uterus is such, that the process could with difficulty be disturbed by mechanical causes. The entrance and the exit take place at the sides of the organ at numerous points, and not at its extremities ; while in the uterus the direction of the current is transverse to its length and perpendicular to its surface : a ligature might therefore be placed round the uterus at any point without affecting the circulation above and below. The only ligature which could materially interfere with the flow of blood into the uterus, or out of it, is one surrounding the broad ligaments (their Tipper ))fH'ders V^eing included within it), together with a portion of the uterus. In this case the inflows to the jjarts above or within the ligature, and the outflows from them, would be diminished or stopped. Conditions similar to this are found when the uterus foi'ins a hernia, either in the inguinal canal or in the (tanal or pouch of Douglas. Whcm the fundus of the uterus is found in the pouch of Douglas the condition is spoken of as a retroflexion or retroversion ; but it is really a great deal more than this : it would be as correct to speak of the condition found when the uterus is in the inguinal canal as anteflexion or anteversion. liotli are true lierni.'B, and the symf)toms are due in great y)art to tlie constriction at the neck of the sac — in j)osterior h(!rniaby the sacro-uterine ligaments. THE DEVELOPMENT OF MODERN GYNECOLOGY 3 There is another condition which may interfere Avith the return of blood from the uterus, namely, procidentia. Here all the veins of the broad ligaments may be so stretched that their channels may be considerably diminished, and all the channels for the return of blood from the uterus may be so narrowed that the organ must consequently suffer from passive congestion. These two conditions, hernise of the uterus and great procidentia, appear to be the only displacements of the uterus which can give rise to congestion of the organ. To those who remember the period in the development of gynaecology when uterine displacements were made to explain endless ills, it will be clear that the publication of the above essay made an enormous differ- ence in the value attributed to so-called mechanical causes. Nowadays a more rational view is taken of the importance of alterations or devia- tions from the ordinary position of the womb ; and it is recognised that very considerable changes in the position of the uterus are perfectly compatible with the enjoyment of excellent health. The outcome on the clinical aspect is easy to imagine ; pessaries are no longer recklessly inserted for every slight misplacement, but are retained for those more severe cases in which relief to an embarrassed circulation is clearly called for. The Pelvic Peritoneum. — Good work has been done in the past years by those who have increased our knowledge of the anatomical and obstet- ric aspects of the pelvic peritoneum. Thus Polk and Barbour have shown that in the full-term pregnant uterus the peritoneum in front and behind has the same relations as in the non-gravid uterus ; whereas, at the sides, the peritoneum is so lifted up by the growing uterus that the base of the broad ligament is on the level Avith the pelvic brim. Stephen- son concludes that the ligamental portions of the pelvic peritoneum offer considerable and permanent resistance to stretching beyond the limits of their elasticity ; and that the tension thus thrown on them is sufficient to undo their attachment to the pelvic walls. The peritoneum covering the uterus, hoAvever, instead of borrowing from neighbouring parts, undergoes a gradual yielding to an unlimited extent — growth supplying the additional material necessary to prevent thinning. The contrast is great between the unlimited expansion of the uterine peri- toneum, under the gradual increase in bulk of the ovum and its intol- erance of a rapid dilating force — a contrast aptly illustrated in the history of the induction of premature labour by tlie rupture of the uterus on the injection of but a few ounces of water. The peculiar property of the uterine peritoneum of gradually yielding under a small but persistent force, while breaking under a sudden one, confers upon it something of a plastic character. Dr. Stephenson remarks : " Such being the properties of the serous coat, it is evident that it must play a part in the dynamics of the uterus. It furnishes a part of the persistent pressure inside the organ. It is also capable of taking a share in the retraction of the uterus. Whatever be the state of the muscular fibres of the uterus when labour is over, they are surrounded and supported by SYSTEM OF GYNAECOLOGY an elastic capsule, ^yitll which any force tending to produce dilatation has to reckon. This idea is strongly supported by the anatomical fact that, in the portion of the uterine walls where reaction is manifested, the peritoneum is firmly attached ; whereas the parts where uo active retraction occurs have either no peritoneal covering, or that membrane is but loosely attached thereto." The knowledge of this behaviour of the pelvic peritoneum under the disturbing influence of pregnancy is of immense importance to the gynaecological surgeon; for it enables him to estimate the probable changes in the anatomical arrangement of the membrane, when fibroid tumours or broad ligament cysts have developed in the pelvis, and have materially affected the relations of its parts. Again, in the rupture of tubal gestations, or in the formation of pelvic heematoma from other causes, the effect of the peritoneal resistance on the development of these swellings is made clear. The Connective Tissue of the Pelvis. — We are greatly indebted to the good work done by Hart and Barbour for our accurate knowledge of the manner in which the connective tissue of the pelvis is distributed. This tissue, lying subperitoneally, surrounding the cervix uteri, and spreading out between the layers of the broad ligament, is of the highest patho- logical importance, as in it, and in the pelvic peritoneum, occur those inflammatory exudations so common in women. Of late years our knowledge of the disposition of this tissue has been rendered much more accurate ; and, accordingly, our discrimination of pelvic inflammatory attacks made much more precise. The most valuable information is obtained by studying sections of frozen pelves. This method gives the precise position of the tissue, its amount and dis- tribution. By injections of air, water, or plaster of Paris, we have learnt the varying attachments of the pelvic peritoneum to the subjacent tissue; and the lines of cleavage, as it were, of the pelvic connective tissue along which lines pus will burrow. The valuable experiments of Bandl, Konig, and Schlesinger have given us the following results : — 1. Water injected between the layers of the broad ligament, high up in front of the ovary, passed first into the tissue lying at the highest part of the side-wall of the true pelvis. It then passed into the tissue of the iliac fossa, lifting up the peritoneum, and followed the course of the psoas, passing only slightly into the hollow of the iliac bone. Lastly, it separated the peritoneum from the anterior abdominal wall for some little distance above Poupart's ligament, and fro]n the true pelvis below it, 2. On injection beneath the broad ligament to the side and in front of the isthmus, the deep lateral tissue became filled first; then the Itcritoneuiri became lifted up from the anterior part of the cervix uteri ; tlieiico the separation passed first to the tissue near the bladder; ultimately the fluid i^assed along the round ligament to the inguinal ring. There it separated the peritoneum along tlie line of Poupart's ligament, and passed into the iliac fossa. THE DEVELOPMENT OF MODERN GYNAECOLOGY 3. An injection at the posterior part of the base of the broad liga- ment filled the corresponding tissue round Douglas' pouch and then passed on as described in the first section. Much might be written to show what extensive Avork has been done to perfect our knowledge of the sectional anatomy of the female pelvis, of the structural anatomy of the pelvic floor, and of the position of the uterus and its appendages ; but the work already quoted will illustrate how full a share anatomy has had in the development of gynaecological science. Turning from the anatomical to the pathological and clinical aspects, it is interesting to note that the enormous strides which the science has made, and which have raised it from a desultory collection of hypotheses to its present high position, have all been taken in the last half century. It is true that in the early part of the century Recamier was advocating the use of the speculum and sound, and by his writing and teachings was given an impulse to the study of uterine pathology ; but it was not until about the year 1840, when Simpson in ]*]ngland and Huguier in France took the field with so much warmth, vigour, and originality, that interest was awakened and the future of gynaecology assured. Recamier, Lisfranc, Kiwisch, Huguier, Simpson, and others had already paved the way for further discoveries, when Dr. H. J. Bennet, in 1845, published the first edition of his work on Inflammation of the Uterus, and roused the attetition of the profession in every country to the pathology which he there set forth. The chief points he insisted upon were the following : — 1. That inflammation is the chief factor in uterine affections, and that, as results, there follow from it displacements, ulcerations, and affections of the appendages. 2. That menstrual troubles and leucorrhoea are merely symptoms of this morbid state. 3. That in the vast majority of cases inflammatory action will be found to confine itself to the cervical canal, and not to affect the body of the utervis. 4. That the disease is properly attacked by strong caustics. It is difficult for the modern student to apprehend the conflict of oi)inions which arose over these assertions of Bennet ; it is sufficient to say that his views were strongly controverted by such able writers as Tyler Smith, Robert Lee, West, and others ; and that in the present day few gynaecologists would be prepared to accept such statements without considerable modifications. Thanks to the study of microbic pathology, much evidence, that in those days seemed misty and conflicting, is read by us now in a totally different sense. The knowledge of septic organisms, the influence of specific microbes, the conditions of tissue-resistances, have opened out for us new ideas and new interpretations ; and it is probably not too much to assert that had l>v. Bennet possessed our advantages much of his pathology would have been rewritten. SYSTEM OF GYNECOLOGY Another landmark in the history of the development of modern gynecology was the publication by Dr. Tilt, in 1850, of his book on the subject of Ovarian Inflammation; later the same writer put for- ward the follo'wing propositions : — 1. That the recognised frequency of inflammatory lesions in the ovaries and in the tissues which surround them, is of much greater practical importance than is generally admitted. 2. That of all inflammatory lesions of the ovary those involving destruction of the whole organ are rare ; while the most numerous, and therefore the most important, may be ascribed to a disease that may be called either chronic or subacute ovaritis. 3. That, as a rule, pelvic diseases of women radiate from morbid ovulation. 4. That morbid ovulation is a most frequent canse of ovaritis. 5. That ovaritis frequently causes pelvic peritonitis. 6. That blood is frequently poured out from the ovary and the oviducts into the peritoneum. 7. That subacute ovaritis frequently initiates and prolongs metritis. 8. That ovaritis generally leads to considerable and varied disturb- ance of menstruation. 9. That some chronic ovarian tumours may be considered as aberra- tions from the normal structure of the Graafian cells. Much of the pathology involved in these propositions of Tilt was sound, and has stood the test of time and more extended research ; and though, as in propositions three and four, his teaching is not nowadays accepted, yet by it a considerable stimulus was given to the study of ovarian pathology, and in testing the truth of his assertions more and more light was gained. Morbid conditions of the tubes had been but little studied in Tilt's time, and the relation of tubal disease to ovarian inflammation was hardly appreciated ; had tubal pathology been better understood, probably less weight would have been attached to morbid ovulation as a cause of pelvic disease. The year 1854 marked a fresh epoch in the evolution of gynaecology ; then it was that the great war of uterine displaceynents and pessary- manufacture b(!gan. Hodge in America, Velpeau in France, and Graily Hewitt in England, stood forth as champions of the immense impor- tance of malposition of the uterus in the causation of pelvic disease. How strongly the tlieory was urged may be judged by Velpeau's state- ment: " I declare, nevertheless, that the majority of the women treated for other affections of the uterus have only displacements, and I aflirm, that eighteen times out of twenty, patients suffering from disease of the womb, or of some other part of this region, — those, for instance, in whom they diagnose engorgfiinents, — are affected by displacements." Graily Jlewitt, again, showed in his writings and teachings the enormous importance he attached to dis])]acements of the womb; in his well-known work on JJiseaaes of Women he formulates the following opinions : — THE DEVELOPMENT OF MODERN GYNECOLOGY ^ " 1. That patients suffering from symptoms of uterine inflammation are almost universally found to be affected with flexion or alteration in the shape of the uterus ; an alteration of easily recognised character though varying in degree. "2. That the change in the form and shape of the uterus is fre- quently brought about in consequence of the uterus being previously in a state of unusual softness, or what may be often correctly designated as chronic inflammation. " 3. That the flexion once produced is not only liable to perpetuate itself, so to speak, but continues to act incessantly as the cause of the chronic inflammation present." For a long time the teaching and literature of this epoch caused a vastly undue importance to be laid on the presence of every flexion or deviation, however slight. Every gynaecologist or practitioner who claimed special gynaecological merit, felt himself called upon to invent a pessary or to modify some one else's instrument ; and if, to quote Dr. Clifford Allbutt, " the uterus could justly complain that it was always being impaled on a stem or perched on a twig," it certainly could not complain that there was want of variety in the stem or monotony in the contour of the twig. Thanks to a more complete study of the circulation of the uterus by Williams, and to the teaching and practice of Matthews Duncan, a more correct appreciation of the importance of uterine displacement has been arrived at; and we can recognise that it is possible for the uterine axis, as for the nasal septum, to be somewhat deviated without the patient's health being materially affected thereby. The value of a pessary in suitable cases is fully allowed ; but the instrument is no longer thought to be a panacea for every pelvic ill, or even a justiflable placebo to soothe the patient when diagnosis is at fault. Surgery. — The next great era in the j^r ogress of gynoicology dates from the establishment of ovariotomy as a recognised operation; for abdominal surgery, and especially that branch of it which had reference to disease of the uterus and its appendages, received its greatest impulse when it was found that ovarian cysts of the most formidable nature could be dealt with successfully and safely. Much discussion has arisen from time to time as to whom the credit of the first successful ovariotomy belongs, but it is now fairly certain that this honour rightly belongs to Dr. McDowell of Kentucky. The record of this first operation is of interest ; it was performed on a Mrs. Crawford of Kentucky, in December 1809. The tumour inclined more to one side than the other, and was so large as to induce her professional attendant to believe that she was in the last stage of preg- nancy. She was affected with -[lains similar to those of labour pains, from which she could find no relief. The incision was made on the left side of the median line, some distance from the outer edge of the rectus miiscle, and was nine inches in length. As soon as the incision was completed the intestines rushed out upon the table ; and so completely 8 SYSTEM OF GYNECOLOGY was the abdomen filled by the tumour, that they could not be replaced during the operation, which was finished in twenty-five minutes. In consequence of its great bulk Dr. M'Dowell was obliged to puncture it before it could be removed. He then threw a ligature round the Fallo- pian tube near the uterus, and cut through the attachments of the mor- bid growth. The sac weighed seven and a half pounds, and contained fifteen pounds of a turbid, gelatinous-looking substance. The edges of the wound being brought together by the interrupted suture and adhesive strips, the woman was placed in bed and put upon the antiphlogistic regimen. '• In five days," says Dr. M'Dowell, " I visited her, and, much to my astonishment, found her engaged in making up her bed. I gave her particular caution for the future, and in twenty-five days she returned home in good health, which she continues to enjoy." Mrs. Crawford lived until March 1841, and had no return of her disease. She enjoyed excellent health up to the time of her death. It must not, however, for a moment be supposed that the idea of ovariotomy originated with M'Dowell : years before, the Hunters had shadowed forth the possibility of removing ovarian cysts; and John Bell, of Edinburgh, though he had never performed ovariotomy, yet in his lectures dwelt with peculiar force and pathos upon the hopeless char- acter of ovarian tumours when left alone, and upon the practicability of removing them by operation. From this time forward operating sur- geons from time to time undertook the operation : sometimes a solitary case, followed by success or failure, sometimes a small group of cases (as published by Dr. Clay of Manchester in 1842) with a fair percent- age of success, were recorded ; but still the operation had not secured the confidence of the profession, and the records were few and far between. In 1850 Mr. Duffin inaugurated a new era by raising the question of the danger of leaving the tied end of the pedicle within the peritoneal cavity ; and by insisting upon the importance of keeping the strangu- lated stump outside. Of this step in the history of ovariotomy Spencer Wells writes : " Whatever may be our opinions and practice at the pres- ent time, and whatever views we may hold upon the question, whether this extraperitoneal treatment of the pedicle has advanced or retarded the success of the operation, Mr. Duffin's arguments led to great changes and results — to the use of the clamp and to all the modifications of treatment attendant upon it, and ultimately to researches as to the physiological and pathological phenomena of ligatured stumps within the peritoneal cavity, and to the study of the important subject of drainage Vjy Koeberle and others." Much might be said of the excellent work done by Baker Brown, and of his success with the cautery; also of Tyler Smith's revival of the practice of returning the pedicle with the ligature : but the history of the estaVilished and successful practice of ovariotomy dates from the publica- tion of Sir Spencer Wells's first book in 18G4. From this time onward ubdoininal j)elvic surgery has had a continuous story of forward progress. THE DEVELOPMENT OF MODERN GYNECOLOGY g step by step difficulties have been overcome, and each advance has been established on a sound scientific basis. Among the many useful points made clear by Spencer Wells that regarding the union of divided peritoneum was of special interest. From experiments made upon dogs, rabbits, guinea-pigs, and other animals, he was able to give visible evidence that, in the union of the cut surfaces of an abdominal incision, however accurately other tissues might be brought together, if the cut edges of the peritoneum are left free within the cavity they retract, direct union does not take place, and secondary evil consequences result. On the other hand, in specimens where the divided edges or rather surfaces of peritoneum have been pressed together, the smooth, serous, inner coat of the abdominal wall is perfectly restored. The stitches cannot be seen on the inside, though plainly visible on the skin ; and there is no adhesion of intestine or omentum. But in other specimens, where the peritoneal edges were purposely excluded from the sutures, and the animal was not killed for a day or two, intestine or omentum adheres to the inner surface of the abdominal wall, thus com- pleting the peritoneal sac at the great risk of intestinal obstruction ; to say nothing of a want of firm parietal union and subsequent ventral hernia. It was clearly demonstrated that, when skin or mucous mem- brane is divided, the edges must be brought together to secure direct union. If they are inverted, union is prevented. The exact opposite holds good with serous membranes. Their edges should be inverted and two surfaces of membrane pressed together, so that the sutures are not seen. The effused lymph then makes so smooth a surface that even the line of union cannot be seen. To those of us who have been brought up in the atmosphere of modern surgery, when the details of ovariotomy are carried out with almost universal agreement, it is difficult to realise the fierceness of the fights which raged round the comparative merits of a long or a short abdominal incision ; how bitterly the advocates of the intraperitoneal treatment of the pedicle regarded those who treated the pedicle by the extraperitoneal method and the use of the clamp, or how great was the importance attributed by each operator to his own special method of closing the wound ! Bit by bit evidence has been accumulated as to the desirability of using opium freely or sparingly after the operation ; as to the best mode of feeding the patient and maintaining her strength ; as to the use of stimulants ; the modes of entry of septic poisoning, and the after consequences and complications of the operation. Ovariotomy in the course of its evolution taught us great things regard- ing the tolerance of the peritoneum even of rough handling and injury, provided nothing septic be left for absorption. Many details of treat- ment emplo3'ed at present in abdominal surgery were learnt in the school of ovariotomy. In his address on "Abdominal Surgery Past and Present," delivered before the Medical Society in October 1890, Mr. Knowsley Thornton attempted to sum up the causes of slow progress and too frequent failure in abdominal surgery u}) to the year 1876, and to place the various SYSTE.V OF GYNECOLOGY causes in what seemed to him to be their order of importance. He says : •' We have tirst the general want of cleanliness and the lack of all apprecia- tion or knowledge of what constituted surgical cleanliness, then the long ligature and the clamp, both clumsy and unscientific, and both specially suited to make the want of cleanliness more deadly, and then following ■with an appreciable but far different influence, we have delay in operating, tapping, and the long incision. Then I must not forget drainage, for I think it is highly probable that a really good system of drainage, such as we now have, thanks to Koeberle and Keith, would have done much to counteract the evils I have named above, though the frequent use of the drainage tube, with the long ligature and the clamp, Avould have in- troduced new elements of risk, which I shall have to refer to again when I speak of the place which drainage occupies in the successes of to-day." Probably the long ligature and the clamp had less to do with failure than the want of knowledge of antiseptic precautions. At the present day we use a clamp round the pedicle of a fibroid tumour, we fix it in the lower angle of the abdominal wound, and yet we keep the wound and peritoneum perfectly free from septic mischief : moreover, in extir- pation of the cancerous uterus per vaginam we tie broad ligaments with silk ligatures, and leave long ends hanging down into the vagina till they come away ; and yet we do not get septic peritonitis. Probably delay in operating plays a more important part in results than we have hitherto supposed. The early ovariotomists had to under- take a large percentage of cases of long standing, cases in which the patient's strength had been exhausted by years of suffering, and in whom tissue resistance to the slighter or more severe forms of septic attack Avas greatly impaired; cases, moreover, in which dense and difficult adhesions to bowel, bladder, liver, and neighbouring parts had become organised in the long delay. At the present time the majority of these difficult cases have been cleared off, and in most of the cases now under- taken the health is still unimpaired, and adhesions (if present) are soft and easily separated ; moreover, long experience has taught us how to discriminate unsuitable cases of a malignant type, and these we have the wisdom to leave severely alone. No educated surgeon will ever minimise our vast obligations to Sir Joseph Lister; but, in fairness to the early operators, we may notice that Sir Spencer Wells had taken steps at a very early period to prevent the exposure of his cases to noxious influences. He did not allow surgeons who had been in contact with septic cases to be present at his operations ; he kept his wards for abdominal cases separate from wards in which patients with uterine sloughing cancer or other fretid diseases were present; and he himself gave up all work in the post-mortem room. The dawning of better things in the way of surgical cleanliness had thus been shadowed forth before the full light of Lister's teaching had risen upon us. If in descril)ing thus far the growth of ovariotomy the names of many eminent ])ion(!(!rs, such as Clay of Manc^hester, Atlee of America, Keith, and numerous otluM- workers have received scanty recognition, it is Vjecause in the present article no attempt is being made to describe THE DEVELOPMENT OF AIODEKJV GYNECOLOGY ii fully the evolution of ovariotomy, but only to show the place it took in the development of gynaecological science, and to emphasise some of the principal teaching and the elaboration of details which secured for it the present successful position. When once the removal of the ovaries in cases of cystic disease of these organs had become an established operation, it was to be expected that surgeons would consider the advisability of removing the uterine appendages for other morbid conditions : but no special move was made in this direction till about the year 1872, when we find that Hegar, Battey, and Lawson Tait all began to work in this special field. Bat- tey's original idea was to remove ovaries, not in themselves diseased, for the cure of certain nervous diseases, which he believed to be caused or kept up by structural or functional derangements of the ovaries. Hegar must have the credit of introducing the removal of ovaries for the cure of fibromyoma of the uterus ; while to Mr. Law- son Tait belongs the credit of introducing the operations for removal of diseased ovaries and tubes. It is now fairly well established that extirpation of the ovaries for various neuroses is practically a failure : the operation has been recom- mended in cases of insanity occurring at times of ovulation, in cases of hystero-epilepsy, also in hystero-neuroses other than epilepsy of se- vere character, but in very few instances has a cure been reported ; in the majority no good has been gained, and in a certain proportion the patient has been left mentally and physically in a worse condition than before. When, on the other hand, we study the cases in Avhich the ovaries have been removed for the cure of uterine fibromyoma we find that a great step has been gained, and that Professor Hegar has added a val- uable resource to our treatment of these tumours. Knowsley Thornton considers that we owe an immense debt to Hegar for the introduction of this method of dealing with fibromyomas ; that the operation has, of course, its risks and its failures, but that, with care in the selection of proper cases, and with care in the removal of every particle of ovarian tissue, it is most satisfactory in its results, and is one of the most thoroughly scientific and valuable operations in the field of abdominal surgery. When we come to consider the removal of diseased ovaries and tubes, as recommended by Tait ; and try to gauge the degree in which this operation can be called an advance in gynecology, we have a difficult question to deal Avith — a difficulty mainly owing to the in- temperate zeal of many advocates of the operation. In cases in which tubes are filled with putrid or specifically diseased pus, and are dis- placed and badly adherent; or, again, when an ovary has become a mere bag of pus, displaced, and fixed by adhesions low in the pelvis, operation is urgently called for and should be undertaken. There are cases, also, in Avhich the ovaries, for a long time the subject of chronic inflammation, may be displaced and adherent low in the pel- vis; cases in which the tubes may be slightly thickened by mucoid de- generation, or are in an early condition of hydrosalpinx : in such cases SYSTEM OF GYiW-ECOLOGY when the patient is drifting into chronic invalidism, is incapacitated from work, and is nnequal to the duties of life, extirpation is certainly called for; On the other hand, to remove ovaries and tubes for early stages of sub-acute ovaritis, for slight degrees of pelvic peritonitis af- fecting the end of the tube and the ovary, for minor degrees of salpin- gitis, for ovarian prolapse apart from coarse disease, is to bring the operation into well-earned disrepute, and to retard rather than to ad- vance the progress of the science. It is, unfortunately, in the very cases in which the operation is most necessary that the greatest dan- ger arises ; for it is impossible to extirpate tubes full of foul pus or suppurating ovaries without great danger of fouling the peritoneum : moreover, in these cases the intestines are often so adherent, or so soft- ened by inflammation, that a great risk of rupture or of subsequent faecal fistula must necessarily be run. It has been well said that if the mortality could be obtained for all the cases of pyosalpinx operated upon in the United Kingdom since Tait introduced the operation, it would run the natural mortality of the disease very close indeed. There are, moreover, sundry objections to the operation which should be recognised, though they are frequently ignored. The operation does not by any means always lead to a permanent cure : a large proportion of patients operated upon suffer from continuance of the pains which preceded the operation ; sometimes inflammatory products are formed which press on nerves and thus cause fresh troubles, or fix the uterus and thereby cause intense pain ; or grave mental symptoms may ensue ; or the ped- icle may suppurate and the healing of the wound be gravely delayed. Mr. Alban Doran summed up the position of the operation very satisfactorily when he remarked that it was very evident that removal of the appendages was an operation to be avoided whenever possible : and Professor Sinclair has wisely pointed out that operators are dis- posed to regard the woman's escaping with her life as constituting per se a satisfactory result ; whereas more attention should be paid to the ultimate effects upon the general health. In connection with this operation, we may properly consider the work done of late years both in Germany and in England, by which it has been shown that in many instances the mere breaking down of adhesions, without removal of either tube or ovary, is quite sufficient to relieve the patient of all her previous symptoms, and to restore her to an active, useful life. The revival of ovariotomy between 1858 and 1805 led, in the words of Paget, to an extension of the whole domain of peritoneal surgery. This extension, naturally enough, began with the removal of the uterine tumours. The removal of fibromyomas of the uterus has always been a much more serious matter than the y)erformance of ovariotomy : thus up to the end of the year 1883, or thei-eabouts, such eminent operators as Hchroeder, Martin, Tait, and P>antock liad a inortality of 30 per cent, or even higher; and though by improved methods and wider experience Keith has shown that it is possible to have a mortality not much greater THE DEVELOPMENT OF MODERN GYNECOLOGY 13 than that of ovariotomy, still the operation in the hands of the majority of surgeons has not given such satisfactory results. The greatest gain so far has been brought about by Hegar's suggestion of the removal of tubes and ovaries as a method of procuring arrest of growth and subsequent atrophy of these growths. The rising generation of medical students is much more efficiently trained in obstetrics and gynaecology than was the case twenty years ago ; and, doubtless, as fibroids of the uterus are recognised earlier, and cases of rapid growth of them are better watched and understood, Hegar's method will be applied in suitable cases with less delay, and at a time when removal of the uterine appendages is more feasible. We may thus hope less frequently to see large fibroid masses filling the abdomen and calling for abdominal hysterectomy with its greater mortality. It is not Avithin the scope of this article to enter upon the various methods of operating for uterine fibroids, nor upon the various modifica- tions of existing operations ; but it is noteworthy that the most eminent gynsecological surgeons of the present day are not the most ardent advo- cates of frequent operating, and show their skill rather by their judicious selection of cases suitable for interference. Again, there is a decided tendency to prefer removal by abdominal section to any form of vaginal operation ; save in cases where submucous fibroids have already been partially delivered. As to the treatment of the pedicle of the tumour, when the growth is removed by abdominal incision operators are still divided in their choice between the extraperitoneal method and the intraperitoneal as advocated by Schroeder. Probably it will be found that each method has its advantages, and that the choice of method must be decided rather by the nature of the growth than by the fancy of the operator. While on the subject of fibromyoma of the uterus, it is impossible not to refer to the electrical treatment of fibroids which has been brought forward by Dr. Apostoli during the last few years. Many years ago it was asked whether fibroid tumours could be dispersed by the use of the galvanic current, but no satisfactory reply could be obtained. Apostoli lias come forward claiming that he has found a means of applying currents so strong that destruction and shrinkage of the tumour is obtained without any damage to the patient's healthy tissues. According to his method, the operator applies a large clay pad over the abdomen in which is embedded the positive pole of a galvanic battery ; then a sound, made of platinum Avith the lower part protected by some insulating covering, is passed through the cervix into the uterus ; or, Avhere this is impossible, a sharp-pointed steel sound, Avith all but the terminal half inch insulated by a protective coating, is plunged through the vaginal wall into the substance of the tumour : the connec- tions are noAv made, and a current, varying from 50 to 100 milliamjieres or more, is alloAved to pass. With reasonable care currents of this strength can be used Avithout any damage to the Avail of th(>. abdomen. Many cases Avere brought forward by Apostoli to sIioav \is that under 14 SYSl'EM OF GYNAECOLOGY this treatment fibroids commonly shrink down to half or a third of their original bulk, and in many instances are practically destroyed with- out an}^ sloughing or suppuration. The method has been fairly tested by nujiierons oi)erators since its introduction, and it is to their results that we must look in deciding whether this electrical treatment of fibroids is to be regarded as an advance in our knowledge and modes of treatment or not. So far as can be decided at present, the result of the most recent inquiries has led us to the following conclusions : — 1. The majority of fibromyomas (especially those of slow growth) are not reduced by the treatment. 2. Soft fibromyomas are somewhat reduced in size by the use of the current. 3. Haemorrhage due to siibmucous fibroids, or perhaps to the fun- gous endometritis so often associated with them, is greatly lessened. In these cases the positive pole is introduced into the uterine cavity, and the negative is connected with the abdominal pad. 4. Considerable damage may be done to tissues in using this treatment. The opponents of Apostoli's method have pointed out that fibroid tumours of the uterus (especially the soft cellular form) may be reduced quite as satisfactorily by the use of rest, hot douches, and ergot, as by the use of electricity ; and with much greater safety. Also that the shrinkage obtained by the use of the current is by no means permanent. Again, as regards haemorrhage, the happiest results often follow the use of dilatation and curettage, so that there is no special advantage in employing the electrical treatment. Keith and other observers have spoken in terms of warm commendation of Apostoli's work, but so far they have not brought forward results which carry general conviction. More extended observation is needed, but at present it can hardly be said that the electrical treatment of fibromyoma of the uterus ranks high among our gains \yide art. " The Electrical Treatment of Diseases of Women"]. ExtrcirUterine Pregyiancy. — One of the results of the recent advances in abdominal surgery has been to give us a wider acquaintance with the pathology and treatment of those interesting cases in which the foetus is developed outside the uterine cavity. Much of our present knowledge is due to the investigation of Mr. Lawson Tait. Since Tait's first operation in 1S