DUPLICATE HX00019780 9^: Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/pathologytherapeOOmart PATHOLOGY AND TllERAFEyilCS DISEASES OF WOMEN. LECTURES GIVEN TO PHYSICIANS DURING THE VACATION COURSES DR. AUGUST MARTIN, INSTRUCTOR IN GYNECOLOGY IN THE UNIVERSITY OF BERLIN. titf) 210 MEoot)rut&. TRANSLATED FROM THE SECOND REVISED AND ENLARGED EDITION, WITH THE APPROVAL OF THE AUTHOR, WITH NOTES AND APPENDIX, BY DR. ERNEST W. GUSHING. SECOJSTD A]MERICJ\.K HUITIOHf, BOSTON, MASS.: PUBLISHED BY E. W. GUSHING, M.D» I 090. Copyright, iScjo, By EKXEbT W. CUSHING, M.D., Boston, Mass. PRESS OK ROCKVVKLI. AND CIIURCIIIM, UOSTON. PREFACE TO THE SECOND EDITION. The completion of the revision of my book has been delayed by many detentions much beyond the limit desired by the publishers. May this new edition in its present form meet the approval of its readers ! For active assistance in preparing this edition, most of all must I thank Dr. OrtJnnann. He took special charge of the illustrations, and as far as possible prepared new drawings from new specimens. In addition I must also thank the following gentlemen, Drs. Czcmpin, Lajigcr, and Nagel, for the assistance which they were always ready to render me in the correction of proof and in the collection of material for statistics. I am gratified to see that my book has gained recognition out- side of the domain of the German language. It has been already translated into Russian and Spanish, and now other translations are in preparation. • A. MARTIN. Berlin, Feb. 22, 1SS7. Dr. E. W. Gushing. Boston: — Mv Deak Friend, — When two years ago you informed me of your intention of translating my work on the " Pathology and Therapeutics of the Diseases of Women," it was with the greatest pleasure that I offered you my best wishes. During a long residence with me you learned my methods of work, and as a most diligent student attended my courses, so that you were in a position, as few others were, to translate into the idioms of the English language this book — the condensed expressions of the teachings of your teacher. It would have given me great pleasure to have been able to have helped you in this. You know, however, how scanty is the time left to us after fulfilling our duties as teacher and physician ; you know how the distance which separates us renders it impossible for us thus to work to- gether. All that I could do, then, was to send you all my articles which have appeared meanwhile ; by accident it has happened, howev^er, that during the last years these have been mostly on obstetrical subjects. On the other hand, I have willingly consented to have you add to my text such notes as referred particularly to the development of our specialty in America. With pleasure and confidence I contemplate the progress of my little book under your guidance, now that it is thus completed and perfected in English translation. As thus equipped in English guise I see with pleasure and confidence my little book sail forth under your guidance at the helm. May our good Welshes help it to be useful to its readers, and thereby bring blessings to those who are intrusted to their care ! With this greeting, I remain, yours sincerely, A. MARTIN. Berlin, Feb. i, 1890. TRANSLATOR'S PREFACE. In determining to translate the work of Dr. Martin into English I was influenced not only by a desire to show my appreciation of the many favors and courtesies which I received at his hand during a somewhat pro- longed sojourn in 1SS5, but more particularly because the pathological theories advanced and the surgical treatment recommended differed so materially from what I was familiar with in current theory and practice in this covmtry. On entering on a very active surgical practice in a large hospital, in 1886, I was able to demonstrate the great safety and convenience of the treatment recommended in this work ; and although many of the proced- ures have since that time come into general use, and most of the views maintained have now gained a foothold in current literature, yet at that time they were innovating. I will mention in this cormection, as instances, the regular use of the dorsal position ; the constant employment of sublimated irrigation in operating, the free use of the sharp curette, followed by flushing of the uterine cavity in endometritis ; the abolition of the use of wire and shot in all operations ; the accurate views as to endometritis, and the disposition to regard the congestion and heaviness of the uterus as secondary to the endometritis, instead of vice versa, as was then commonly believed in this country. The free use of operative measures in prolapse of the uterus, the in- troduction of vaginal hysterectomy for cancer, and the correct pathology and operative treatment of salpingitis, are elements of progress in gynae- cology for which the profession is largely indebted to Dr. Martin, not as an inventor, but as an early advocate and a brilliant operator. This book is so largely the record of the teaching and practice of the author, that I have not felt at liberty to avail myself of his permission to add many notes, as a consistent comparison of the views of the author with those currently received would have required that each chapter be supplemented by a chapter of notes and references, while it is hardly to be supposed that the readers of this book will not already have read some one of the excellent text-books which are common in this country. viii TRANSLATOR'S PREFACE. These notes, therefore, are cliieflv confiiiecl to the portions of the work rehiting to ahdoniinal surgery, where tlie art has advanced with great rapidity withiii the last few years, and where the personal skill and experience of the surgeon modify very materially his method of operating. All who have seen Dr. Martin's operations know that he possesses a singular dexterity and rapidity in the use of the needle ; and where minutes are of importance, methods which do not presuppose these qualities are far preferahle for all surgeons who have not the highest skill. Thus in vaginal hysterectomy the use of the clamps is far easier and safer for most men than Dr. Martin's method with ligatures ; likewise in supravaginal hysterectomy, the extra-peritoneal treatment of the stump is preferable for beginners. The use of flushing of the abdomen after many abdominal operations, and the judicious use of the glass drainage-tube, rest on such a foundation of authority and experience that I have thought it necessary to call attention to their use ; but, with the exception of a few notes on such subjects, and the introduction of photographic figures illus- trative of the text, I have not attempted to compare the theory and prac- tice of Dr. Martin with that current in this country. In the Introduction to the work the author has added such comments as the progress of our art during the last two years seemed to him to re- quire. The chief interest and greatest value of the work for Americans lie in the information it furnishes of the personal views and methods of one of the most learned of teachers and successful of operators, and as such it has been a pleasure to me to employ what time I could snatch from pressing duties, during the last two years, in translating it for the benefit of those of the profession who prefer to read it in English. It is interesting to note that the work has already been translated into French, Italian, Russian, and Spanish, showing the wide appreciation of its character. The translator is confident that it will meet with the same favor from the Englisli-speaking profession. E. W. GUSHING. Boston, Feb. 22, 1890. PREFACE TO THE SECOND AMERICAN EDITION. BY THE TRANSLATOR. This work was originally translated and published in English as a supplement to the "Annals of Gynaecology," in monthly fasciculi, and on its completion a large number of complete sets of the fasci- culi which had been printed in excess of the subscription were bound, with the addition of photographic plates from that journal, similarly provided. This second edition being reprinted from the electro-plates, it has seemed appropriate, in accordance with requests from many sub- scribers, to illustrate the work with a much larger number of plates, which originally appeared in the Annals, inasmuch as the illustrations were made or procured with infinite trouble, under the continual inspiration furnished by the translation of this book, and inasmuch as many of them are unique, and impossible to obtain elsewhere, since the rapid growth in the number of subscribers to the Annals has caused a demand for sets of the back numbers of the latter, which has now nearly exhausted the supply on hand. The photographic plates are inset in the appropriate places, according to the context, and are explained in an appendix, using largely the text which originally accompanied them in the Annals. The microphotographic illustrations all represent the results of the pathological and photographic work of the translator, except two, which were photographed by Dr. Parker, to whose kind assist- ance the former is much indebted for an introduction to the pleasures of this agreeable change from more serious duties. These plates possess an additional interest from the fact that the earlier ones appearing in 1887 were probably the first application of the half-tone process, then recently invented, to the illustration of X PREFACE TO SECOND AMERICAN EDITION. a medical journal, and were certainly the first attempts to use this process for niicrophotography, thus rendering it possible to repro- duce in large editions microscopic pictures, which had formerly been restricted to a very limited range of publication by processes which, although beautiful, could not be used in steam-presses. The rapidity with which the first edition has been exhausted shows the esteem in which this valuable work of Dr. Martin is held by the profession, — an esteem which is fully warranted by that com- bination of sound pathological knowledge, clear operative directions, and judicious advice as to therapeutic measures, which distinguishes the writings of the noted author. i68 Newbury St., Boston, June i, 1890. TABLE OF CONTENTS. Introduction by the Author xiii I. — Physical Examination of the Patient ...... i A. Situation of the pelvic organs ....... i B. Methods for the physical examination of the patient ... 8 1. Palpation. Combined examination ..... 8 2. Inspection. Speculum ....... 12 3. Importance of the neighboring organs during the examina- tion 14 4. Examination during anaesthesia ...... 17 5. Examination with the sound ...... 18 6. Examination of the interior of the uterus .... 22 II. — Physiology AND Pathology of Menstruation and Conception . 33 1. Menstruation ........... ^o 2. Derangements of menstruation ....... 37 A. Amenorrhoea ......... 38 B. Menorrhagia ......... 41 C. Djsmenorrhcea ......... 44 D. Conception .......... 44 E. Sterility .......... 45 III. — Pathology of the Vagina and Uterus 47 A. Anomalies of development and modifications of form and position ........... 47 1. Defective development of the vagina and uterus ... 47 i. Malformation of the sexual organs .... 48 ii. Atrophy of the uterus ...... 63 iii. Hypertrophy of the uterus ..... 72 2. Changes of form and position of the uterus and vagina . 74 i. Versions and flexions of the uterus .... 74 Ii. Anteversions and anteflexions . . 77 d. Retroversions and retroflexions ... 89 ii. Descent and Prolapse of the uterus and vagina . 112 iii. Laceration of the perineum. Restoration of the perineum ........ 160 iv. Inversion of the uterus ...... 172 B. Inflammation of the mucous membrane of the genitals . . iSo I. Inflammation of the vulva ....... 185 TABLE OF CONTENTS. III. — P.\TH<»LociY OF THE Vaoina AM) Uterus. — Continued. I. Inrtaniniation of the vagina .... 3. Iiillamination of the uterine mucous membrane a. Vaginismus .... b. GonorrhcEa in women c. Polypi of the mucous membrane. Follicul trophy of the cervix C. Inflammation of the uterine parenchyma 1. Acute metritis .... 2. Chronic metritis .... D. Tumars of the vulva and vagina . 1. New growths of the vulva 2. New growths of the vagina . E. New growths of the uterus i. Myomata; Fibromata ii. Malignant new growths of the uterus a. Adenoma of the uterus b. Carcinoma of the uterus i. Carcinoma of the cervix ii. Carcinoma of the body c. Sarcoma of the uterus d. Tuberculosis of the uterus . IV. — Operations ix the Vagina I. Vesico- vaginal fistula .... . 2. Recto-vaginal fistula .... 3. Resection of the external urethral orifice V. — Operations on the Uterus 1. Discision of the external OS 2. The annular wedge-shaped excision of the ce 3. Operation for laceration of the cervix 4. Amputation of the cervix 5. The high excision of the cervix 6. Extirpation of the uterus through the vagina VI, — DiSE.\SES OF the Tubes .... 1. Salpingitis. Hydro-Hiemato-Pyosalpinx 2. Diseases of the tubal walls 3. Tubal pregnancy ..... 4. New growths of the tubes VII. — Diseases of the Broad Ligaments 1. Parametritis ...... 2. Extra-peritoneal hiematoma 3. New growths of the broad ligaments VIII. — Diseases of the Pelvic Periton.kum . 1. Perimetritis ...... 2. Intra-peritoneal H;ematocele . IX. — Diseases of the Ovaries .... 1. Inflammation of the ovary 2. New growths of the ovary hy|)er- TABLE OF CONTENTS. Xlll IX. — Diseases ok the Ovaries. — Continued. 3. Dermoid tumors of the ovary 4. The soliti tiimor.s of the ovary a. Fibroma of the ovary . b. Carcinoma of the ovary c. Sarcoma of the ovary . d. Tuberculosi-s of the ovary 5. Ovariotomy .... Complications After-treatment 6. Castration .... Page 495 498 498 499 501 501 502 5H 518 527 APPENDIX. Explanation of plates reprinted from "Annals of Gynx-cology," a list of which is given on p. xxii. .......... 777 Index of Authors . Index of Subjects . 675 679 LIST OF ILLUSTRATIONS. Fig. I.- Fig. 2.— Fig-3-- Fig. 4. Fig 5-- Fig 6.- Fig. 7-- Fig 8.- Fig. 9-- Fig. 10. Fig. II. Fig. 12. Fig. 13- Fig. 14. Fig. 15- Fig. 16. Fig. 17- Fig. 18. Fig. 19. Fig. 20. Fig. 21. Fig. 22 Fig. 23 Fig. 24 Fig. 25 Fig. 26 Pagk Section through the pelvi.s with both bladder and rectum empty, according to Pirogoff. (From E. Martitis Hand Atlas. Sec- ond edition of A. Martin) . . . . . . ... 2 Section through the pelvis with the bladder filled, according to Pirogoff 3 Section through the pelvis with the rectum filled, according to Pirogoff 4 Section through the pelvis with both bladder and rectum filled. Section according to Kohlraitsch ...... 5 Normal position of the uterus, according to C. Ruge ... 6 Position of the pelvic viscera, according to Moreau .... 7 Examination table .......... 9 Combined examination, according to Schroeder. (Handbook of the diseases of the female sexual organs. VII. edition) . . 10 Cylindrical speculum .......... 12 - Duck-bill speculum, according to Kristeller . . . . . 12 - Simons speculum .......... 13 - Side piece, according to Heger ........ 13 -Bullet- forceps, according to Heger ....... 18 ■ Sound, according to .£^. J/(r7;'//« . ....... 20 - Arrangements for operation ... . .... 21 • Position of the patient for an operation in the vagina ... 25 ■ Curette, according to Roiix ........ 28 ■Mucous membrane of the uterus, according to 6'c,^;-£j«?(^('A- . . 36 Menstruating mucous membrane of the uterus, according to Schroeder ........... 37 •Cold-speculum, according to Kisch ....... 42 •Development of the female genitals, according to Schroeder. Po- sition of the parts, before the union of the outer reduplication with the allantois and the rectum ...... 47 • Formation of the excrementorj system ...... ^7 Formation of the perineum. Development of the uterus and the genito-urinary sinus ......... 47 Atresia (corresponding to Fig. 21) . . . . , . . 48 Atresia with separation of the allantois from the rectum . . 48 Congenital distention of one side of a double uterus and vagina with blood. (H;ematocolpos and ha'matometra unilateratis congenita.) From one of my preparation-^ .... 51 xvi LIST OF ILLUSTRATIONS. Page. Fig. 27. — Double Uterus and Vagina. From E. Martins Hand Atlas. Edition 2. Table XXXVI. an — Double entrance to vagina; b — Orifice of urethra ; c — Urethra ; dd — Double vagina ; ee — Double os uteri; ff — Double cervix; gg — Double fun- dus; hli — Round ligaments; /'/ — Fallopian tubes; kk — Ovaries ......... 54 Fig. 28. — Atresia with imperforate hymen. Ihcmatocolpos congenita . . 57 Fig. 29. — Atresia of the vagina. Haematocolpos and ha^matometra con- genita 58 Fig. 30. — Atresia of the external OS uteri. Hjematometra .... 59 f'g'3'- — Acquired hicmatometra ......... 60 ^'g- 3-- — Primary atrophy of the uterus, according to Virchozv ... 64 Fig. 33. — Infantile uterus observed in an adult ... . . 64 f 'g- 34- — Scarificators, according to Mayer . . . . 67 Fig. 35. — Intra-uterine stem pessary, according to E. Martin, a — Intra- uterine portion; b — Vaginal portion ...... 6S Fig. 36. — Subdivisions of the cervix, according to Schroedcr. a — Portio vaginalis ; b — Portio media ; c — Portio supravaginalis ; p — Peritoneum; bl — Bladder ....... 73 f'g- 37- — Anteflexion of the uterus 77 Fig. 38. — Anteflexion of the uterus, with elongation of the supravaginal portion of the cervix ......... 78 Fig- 39- — Puerperal anteflexion of the uterus, from E. Martin's Hand Atlas. Table XL. Placental tissue adherent to the placental site on the posterior wall ......... 86 Fig. 40. — Congenital retroflexion of the uterus, according to C. Rugc . . 90 Fig. 41. — Incarcerated retroflexion of the gravid uterus with formation of a diverticulum, from G. Veit. Volkmann'' s collections, No. 170 . 97 Fig. 42. — Puerperal retroflexion of the uterus, according to E. Martin. Placental tissue adherent to the placental site on the anterior wall 98 ■ Retroflexion of the uterus ......... 102 - Retroflexion of the uterus, from F. Winkel's photographic Atlas. a — External OS uteri; b — Rectum ...... 103 - Hodge's retroflexion pessary ....... loS • Schultzcs figure-of-eight retroversion pessary. {Ilcgar and Kalten- bac/i. Operative Gynaekol. II. Aufl.) . . . .110 •Sled pessary, according to Schultzc . . ... 110 ■Section through the floor of the pelvis. For the demonstration of the layers of muscles and fat, and also the urethra, vagina, and rectum ........... 1 13 ■ Prol.'i,pse of the vagina and uterus . . . . .115 Prolapse of the uterus with open vulva . . . . . .116 - Prolapse of anterior vagina, with cystocele . . . . ,117 ■Prolapse of the anterior vagina, with a cyst of the anterior vaginal wall 118 Prolapse with enterocele of the anterior vagina . . . .118 Prolapse with enterocele of the posterior vagina . . . .119 Fig. 43- Fig. 44. Fig. 45- Fig. 46. Fig. 47- Fig. 48. Fig. 49. Fig. 50. Fig. 51- Fig. 52- Fig. 53- Fig. 54- LIST OF ILLUSTRATIONS. f^'g- 55- — Prolapse of the posterior vagina, with rectocele . . . . Fig. 56. — Prolapse of the anterior vagina with cystocele, of the posterior vagina with rectocele, and prolapse of the uterus with elon- gation of the supra-vaginal portion of the cervix 'f^'to- 57- — Prolapse of the cervix uteri. Elongation of the infravaginal por- tion of the cervix (from Froricf's Copperplates. Weimer, 1S42) Fig. 58. — Prolapse of the uterus. Elongation of both infra- and supra-vaginal portions of the cervix ......... ^'g'- 59- — Prolapse of the anteflected uterus. Ectropion of the os uteri, according to Frenud ........ Fig. 60. — Retrot^exion of the prolapsed uterus, according to Spiegelberg Fig. 61. — Prolapse of retroflected uterus. Inversion of the vagina, cystocele rectocele .......... Fig. 62. — Pedunculated pessary. ........ Fig. 63. — Method of operation for prolapse, according to Winkcl . Fig. 64. — Posterior colporraphy, according to Wiiikel .... Fig. 65. — Method of operation for prolapse, according to Neugebauer Denuded surface ......... Fig. 66. — Colporraphy, according to Neugebauer ..... Fig. 67. — Denuded surface for posterior colporraphy, according to Simon Fig. 68. — Posterior colporraphy, according to Simon .... Fig. 69. — Posterior colporraphy, according to Zf5.in) 395 — Pyosalpinx. Communication between the tui)e and the suppu- rated ovary. {Orihmaiiii) ........ 396 — Development of a tubo-ovarian cyst, according to Ihiriiicr. (Zeit- schrift f. Geb. u. Gyn. V.) 397 — Later stage of development ........ 398 — Later stage of development ........ 399 — Tubo-ovarian sac .......... 400 — My own preparation of a tubal pregnancy. Drawn by C. Huge . 407 LIST OF JLLUSl'RATIONS. Fig. 19S. Fig. 199. Fig. 200 Fig. 30I. Fig. 202. Fig. 203. Fig. 204. Fig- 205. Fig. 206. Fig. 207. Fig. 20S. Fig. 209. Fig. 210. Page Preparalion of a niiitiiroci tubal jiregiiancv, according to Bcigel (Atlas der Fraiicnkrankliciten) ....... 4J0 Vertical section tliroiigli the pelvis, according to Baiidl . 412 Perimetritis with i-etroflection of the uterus, according to Winckel, 430 Perimetritis with retroflection of the uterus, according to Winckel, 430 Perimetritis with retroflection of the uterus, according to Winckel, 431 Spencer Wells' trocar ......... 507 Nelatons forceps . . • . . . . . . . . 50S Position of the patient, operator, and assistants for a laparotomy . 509 Table for a laparotomy, according to Frau Horn .... 510 Clamp for extra-peritoneal treatment of the stump. . . . 511 Carriage and stretcher for the sick, according to Frau Horn . 514 Abdominal supporter, according to Beely. Anterior part . . 519 ■ Posterior part of the same ........ 519 LIST OF PH()T0(;RAFHIC ILLUSTRATIOXS TAKl'.X FROM "ANNALS OF' GYN.FCOLOGY." (See A]>i)etuiix.) Plate I. — Double Vagina Plate II. — Monstrosity; three legs, double vagina Plate III. — Congenital atresia of vagina . ...... Plates IV. to VIII. — Exainjiles of prolapse of uleru>; (operations . Plates IX. to XIV. — Ectropium of the cervical mucous nicuibrane, ant pathology of the same ..... Plate XV. — Fibrocystic tumor of the uterus .... Plate XVI. — Multiple myoma of uterus ..... Plates X\'II. to XXV'III. — Pathology of incipient cancer of cer\ix ute Plate XXIX. — Vesico-cervical fistula Plates XXX. to XXXIV. — Cancers of uterus removed- by hxstcrei (vaginal) ...... Plates XXXV. to XLII. — Histology and pathology of Fallopian tube Plate XLIII. — Double pyosalpinx and sac of ovarian abscess . Plates XLIV. to XLVI. — Salpingitis Plate XLVII. —Hydrosalpinx Plates XLVIII. to LV. — Extra-uterine pregnancy .... Plate LVI. — Lithopredion ........ Plate LVII. — Myxo-sarcoma of Fallopian tube .... Plate LVIII. — Perimetritic adhesions . . ' . Plate LIX. — Ovarian abscess ........ Plate LX. — Hematoma of right ovary; abscess of left ovary Plate LXI. — C^'st of broad ligament and cystoma of ovary . Plate LXn. — Dermoid cyst of ovary and tubercular salpingitis Plate LXIII. — Colloid degeneration of dermoid cyst of ovary Plate LXIV. — Fibroma of ovary Plate LX\'. — Ascites from solid tumors of ovaries with liissL-minatc point of infection of peritonseum ...... Plate LXVI. to LXVIII. — Tumors from case shown in j)re\ ious plate . I'ACK ij6 lyS 300 3^6 3S4 394 396 396 400 40S 408 410 430 4,=;8 45S 46S 496 41/. 49S 500 500 LIST OF ILLUSTRATIONS IN APPENDIX. A-B. Double vagina and uterus ........ 540-541 C-D. Monstrosity; three legs, double genitals ..... 546-547 E. Varieties of hymen ........... 550 F-G. Hypospadiasis and absence of vagina ...... 554-555 H-N. Tubal pregnancy 638-640 and 64S, 651 O-P. Tubal pregnancy, frozen section ....... 652-653 Q^ Normal pregnancy, frozen section ........ 654 R-S. Lithopjcdion 662-663 T. Nerves of uterus and broad ligament ....... 667 xxii INTROr3UCTION BY THE AUTHOR. During the two years which have elapsed since the pui)lication of the second German edition of this work, there have been many advances in gyngecology, and I take this opportunity to point out the most impor- tant of these, in order that the American edition may fully represent the state of our specialty to-day. Dilatation of the Cervical Canal. ^ Among the methods of dilatation of the cervix, that recommended by VuLLiET* has recently come very much into favor. It consists in the dilatation of the cervix by systematic packing xvith strips of iodoform gauze. The procedure has been published in extenso by Cordes at the International Medical Congress in Washington, and by Landau in Volk- mann's pamphlets. More recently Duehrsen has employed the same extensively in obstetric practice, for the purpose of checking haemorrhage, with the best results. The cervix is fixed by means of a bullet-forceps, after it has been exposed in an appropriate manner, and then small strips of iodoform gauze are pushed up as high as possible into the cervical canal. After these have remained for twelve to twentv-four hours, thev are removed and replaced by new ones. When this is done a striking relax- ation of the cervical tissues occurs, and thereby a dilatation, which, after this procedure — which, according to authors, is entirely without danger — has been repeated two, thi^ee, or even four times, will lead to such a degree of dilatation as to admit the passage of the finger. It is certainly worth while to employ this procedure in an extensive manner in gynajcol- ogy, and it appears to deserve the preference over the disagreeable cir- cumstances connected with dilatation by means of sponge and laminaria tents, as well as over that of the tupelo-pencils and dilatation by means of dilators. In how far it may also replace incision of the cervix, I leave undecided. I myself have had only a very modest experience with the method, and will not conceal the fact, tliat in one case, which lately came under my care, the dilatation, by means of the iodoform-gauze tamponade, rendered accessible the intramurally situated myoma ; but 1 See p^im- i-,. 2 Rev. d. la Suisse, Trim. 2, iSSj. xxiv INTRODUCTION. septic infection had already occurred when the physician turned the patient over to me, after he hatl attempted in vain to enucleate this myoma. Treatment of Chronic Metritis. Recently the excision' of erosions and treatment of endometritis and also metritis chronica by this means has been recommended by many, and tlic priority is ascribed to Cakl vox 1?raun on the one side, and to ScHKOEOEK on tlic other. As the polemic discussion which followed the reading in Cassel, in 1S78, of my paper, and was directed against the propo- sition made therein regarding this treatment, was exclusively aimed at me ; and as I, in spite of all contradictions and inimical attacks, have carried out consistently this procedure, and, as I believe, that by doing so I have introduced among gynascologists this so beneficent procedure in the treatment of chronic metritis which was formerly considered incurable, as is well known, — it seems to me perfectly justifiable for me to make a few remarks iiere to settle the priority. Carl von Braun's recom- mendation, which was supported only by Fuerst, was directed against hypertrophy of the cervix, induration, and congestion, as thev essentially were regarded as precursors of new-growths. Schroeder at first spoke vehemently against the excision of the cervix as a method of treatment of chronic metritis, and only later on he very gradually accepted the per- formance of the operation as a remedy for chronic metritis. In how far chronic metritis may be cured by electrotherapv. is at present entirely a subject of investigation. If we take into consider- ation that in electrotherapy the mucous membrane is caused to form an extensive eschar, antl that cicatrization, according to this manner of treat- ment of the mucous membrane, extends to the muscular tissue of the uterus, then the hope that the uterus is also caused to shrink by electro- therapy is only founded on the somewhat vague representations concerning the action of the galvanic current, in regard to resorption of tissues by the so-called electrolysis. It still remains incomjjrchcnsiblc and has not been explained yet by the adiierents of the electrolytic method, wherein the lysis proper consists ; in how far the uterus is healed by way of this process of shrivelling by making eschars b}' means of electrolytic treat- ment seems yet, however, very doul)tful in one point. It would go on then to cicatrization, and the development of cicatricial tissues in the uterus is just what is at least of very doubtful advantage for the resorption of this organ and for its later developments in an eventually occurring pregnancy, and so I should advise to make only the most cautious experiments in the treatment of chronic metritis by means of electrolysis. 1 See page 242. INTRODUCTION. xxv Ventho-fixation of thk Utf,rus. To the chapter treating of the therapy of retroflexion and the treat- ment of prolapsus uteri are to be added the new proposals, which are directed towards ventro-fixation of the uterus, and which endeavor, in an analogous manner, to secure the elevation of the uterus. Ventro-fixation was first suggested in Germany by the proposition of Petkr Mueller,^ for the purpose of curing prolapse. (Meeting of natural- ists in Baden-Baden, 1879.) Mueller's proposition was received with but little favor. A further suggestion to bring the uterus in contact with the abdominal wall, and thus prevent the falling downv\^ard or the falling backward of this organ, has been made by Alexander, after vv^hom the operation for shortening the round ligaments is also called Alexander's operation.^ The operation for fixation of the corpus uteri to the posterior surface of the abdominal wall has taken the place of the shortening of the round ligaments. Its first advocates in Germany were Olshausen " and Saenger.'* Since then a number of authors have interested themselves in this procedure, especially Leopold ; " and at present this procedure is practised to quite an extent. Simultaneously with these experiments there appeared a proposal by Schuecking to double the uterus on it- self, and fasten it by means of an iron wire or metallic suture, and to fix it in a position of anteflexion. This latter procedure, which, with- out any control, is left to a guidance by the fingers in the depths of the pelvis, — which, however, is rather unreliable, — appears extremely un- certain, and at all events has found favor only in a limited measure with the German gyniecologists. In the same manner nearly all German gynae- cologists have remained reserved towards Alexander's operation. The shortening of the round ligaments in itself is certainly quite a simple procedure. Incision in the groin over the inguinal canal, searching for the terminations of the round ligament, tracing them back without injuring the peritonaeum, sewing them in by one, two, or three sutureSt and closure of the wound. Entirely irrespective of the fact that this opera-, tion has occasionally been rendered impossible through a deficient develop- ment of the round ligaments, and in other cases has oflered vexatious obstacles through the accidental ditticulty connected with the finding of the terminations of the round ligaments, want of confidence in the lasting 1 Correspondenz Blatt f, Schweitzer Aerzte, 1887, No. 13. -The treatment of backward disphicement, Lond., 1SS4. — Verhandl. d. i. Cong-, d. deutschen Ges. f. Gynaekol., 18S6, p. 252. 3 CentralbJatt fur Gyn., 1SS6, No. 43. *■ Ihid., 188S, Nos. 2 and 3. = /*/rf., iS38, No. II. xxvi , JNTRODUCriON. qualities of these ligaments, which otVer so little resistance, is apparently the cause of the rejection of this procedure. The author himself has had no experience witli it, but has had opportunity to examine again two pa- tients whom he had seen before, upon whoin the shortening of the round ligaments had been performed by others. In both cases, after the lapse of about half a year, he Found the uterus in exactly the same position in which it had been before ; so that in both cases, if indeed shortening of the ligaments had been performed at all, the effect rapidly passed away, and a stretching of the ligaments, with falling backward of the fundus uteri, resulted. Also the warm recommendation of Dolkkis, of Paris,' has con- tributed nothing to rehabilitate this operation, although Dolkkis, after he had spoken at first vehemently against the operation, acknowledged that he was convinced of the value of the same through later individual experi- ence. Ventro-fixation as performed by Olshausen, Saenger. Leopold, and others is different only immaterially as to whether the fundus uteri itself, with or without freshening up of its peritoneal covering, is sutured to the abdominal w^alls, or whether this suturing is caused by fixation of the ends of the Fallopian tubes to the abdominal wall. In a very interest- ing paper read before the Obstetric Society,- I. Veit has communicated his experience, and has collected that of other authors on this subject. On the whole it seemed that the results of ventro-fixation were of only short duration in the practice of the Berlin gynaecologists. A. Martin himself has not as yet, on the whole, found any inducement to perform ventro- fixation, on account of too complicated retroflexion. After he had already performed it earlier for perimetritic adhesion, he has now performed it systematically in five cases. In one case the patient died from penetration of the virulent pus from the tube into the abdominal wound. Of the four others, one who was afflicted with perimetritis, in whom he extirpated bilateral tubo-ovarian tumors, six months afterward already had the uterus again in fixation upon the pelvis, and the result of the operation here is to be regarded as unsatisfactory. In one case a retroflexion gave induce- ment to perform ventro-fixation, in which, in spite of a very successful colporraphy performed by another operator, there existed continually a feeling of pressure and sinking downwards. This feeling became the more troublesome through the development of a tumor of the size of a pigeon's egg at the place of flexion of the uterus upon the posterior surface, and the operation on this lady, who is the wife of a physician, was particu- larly for the relief of the annoyances caused by this little tumor. The uterus was lifted out after laparotomy, and it was seen that at the place of flexion there existed an encysted peritonitic exudate resembling a cyst ' Nouvelle Arch. d. obsletr. et de Gyn., iSS6. ' November, 18S9. JNTRODUCTION, xxvii imbedded in callosities. Possibly a dislocated hydatid of Morgagni was here in question. This place was excised, the wound sewn up, and then the uterus was sutured at tlie fundus to the abdominal wall. The patient has been freed from her troublesome symptoms, which also radiated towards the stomach, and after a longer after-treatment has regained her entire health. The uterus, according to the last reports, nine months after the operation, still rests on the abdominal wall, so that in this case a complete success was attained. In each of the other cases also the uterus was separated from perimetritic callosities, and after extirpation of tubo- ovarian tumors was sutured to the abdominal walls. Also there the result is not favorable yet, but the period of observation is too short to allow of a final decision. In botli cases, after half a year the uterus still rested upon the abdominal wound, and the patients enjoyed a satisfactory state of health. The latest method proposed to fix the uterus upward was brought for- ward by A. W. Freund, at the meeting of naturalists in Heidelberg, in 1879. In a case of unusual prolapse of the vagina, with great bulging downward of Douglas' pouch, he opened the latter, and from there sutured the cervix to the promontory, so that then the utei^us was fixed at the promontory, and in a position of anteflexion. Then obliteration of Douglas' pouch was accomplished by iodoform-gauze tamponade. In a similar manner he has operated upon two other cases ; and in all three cases he has obtained a retention, which, however, is not as yet of long duration. The author replied, in the discussion which followed this paper, that it must, however, appear of doubtful utility to carry out such an inci- sion in Douglas' pouch in the depth of the pelvis, unless unusual circum- stances are present, as in Freund's case, to facilitate such a procedure. The author emphasized the fact that it probably would be better to per- form the fixation of the uterus to the promontory after laparotomy ; and such a procedure seems to him well worthy of consideration. Should it become apparent that the uterus being fixed by ventro-fixation always again slides back, then, however, Freund's procedure, in all cases in which an operative procedure is necessary, should receive due considera- tion, with the modification that it should not be performed from below, but should be preceded by laparotomy. Accordingly the author is not yet at present in a position to pass final judgment on this procedure. He has fixed the uterus in such a wav that the needle, entering through one side of the abdominal wound, passed to quite an extent through the fundus, and then through the edge of the abdominal wound on the other side. Three silk sut- ures were inserted each time ; the interspaces were closed by catgut xxviii . INTRODUCTION. sutures. The silk sutures ate alluweil to remain as long as possible, up to two and a halt" weeks, and then removed. The tear that the so-dislocated uterus will act impedingly upon the bladder instead of on the rectum, as it did in the position of retroflexion ^ has apparently been realized in only a few cases. However, in such cases the uterus had to be again separated from the abdominal wall. Pregnancy has not occurred yet in the uterus fixed t(j the abdominal wall, as far as the author knows. ATassage of the Uterus. Among the adjuvants of gynaecological tlierapy, massage is more and more recommended. The most recent author on gynaecological massage, Arndt,' speaks most favorably of it. Tiie massage should essentially be performed through tlie al^dominal wall ; and the hand, being introduced into the vagina, should only serve to fix the uterus, and form a base upon which the different rubbing and pushing movements are made. According to former communications, especially those of Schultze, Von Preuscher, and Profasber, the author has also tried to practise this massage, although to a limited extent; and it would certainly not be justifiable to deduce a final decision already from the experiments, how- ever carefully conducted. He confines himself here to reference to the above-mentioned works, and at the same time also to expression of his doubts whether every certainty of diagnosis which is indispensable for this massage is not absent only too often. For if, even in those well skilled in gynaecology, this difficulty is probably done away with, it is to l)e feared that by a generalization of this method only too often inflamma- tory processes of the surrounding region, with not yet sacculated pus, and especially purulent contents of the Fallopian tube, will be unfortunately distributed by the massage, and driven out from the sacculation just mentioned. The results of massage, especially in conditions of relaxa- tion of the floor of the pelvis, are confirmed by so many that it would consequently be unjust to doubt their statements. The objection of the author regarding this was especially directed against the employment of massage in affections of the perinaium, which latter cannot be cured by it ; moreover, hyperplasias of the walls of the vagina, which always again protrude from the gaping orifice of the vagina, do not disappear under massage, and in the removal of the same he sees an essential advantage in the operative treatment of these things. ' Berlin. Klin. Wchnschr., 1S90, Nos. 1 and 2, JN'J'RODUCTION. xxix On thk Electro-therapeutics or<^ Myomata. The cases of successful treatment of p.iyomata by electro-thera- peutics' have lately accumulated in an extraordinary manner. It is espe- cially Thomas Veit who, in his report of one hundred and six cases, has again given a powerful impetus to electrotherapy- The experience of the author at present is limited to ten cases, and also in these his judgment is limited by the fact that, especially in the last three cases, the number of the seances is not yet large enough. Among them there are three tumors of considerable size ; the others are smaller, reaching the size of a fist. The results in these ten cases show that haemorrhage, the most troublesome and dangerous symptom of myomata, may usually, indeed, be controlled ; in fact, in those large multiple tumors, which apparently were situated intramurally, and included the fundus, haemorrhage ceased nearly entirely. Several small tumors were not influenced in the same manner, and the hjEmorrhages continued unchanged in spite of very frequent sittings, so that here the result must be regarded as a v^ery doubtful one. Dne patient, who had a myoma of the size of an ostrich ^%%-. had such violent pains after seven sittings, that she insisted upon being operated. The operation was performed, and the patient recovered. A second symptom, often so frequently complained of, is the phenomena of pressure. These disappeared in all of nine cases, so that in this respect the result is very satisfactory. An essential decrease in size of the tumors has, up to now, not been obtained in any case. The author would not neglect to communicate these experiences at present, and he will not let himself be discouraged from making still further experiments with the procedure. Supra-vaginal Ampittation of the Uterus. After the author had operated a series of successful cases by the method of amputation of the collum uteri, described on p. 381, the result of the operation proved again to be less favorable. The stump of the collum seemed to be in many cases the point of departure of very unfortu- nate terminations. To be sure, haemorrhages of an extent worthy of mention originated thence less frequently than did, undoubtedly, septic germs penetrate from here into the abdominal cavity, developing peri- tonitis. Under these circumstances he performed extirpation of the collinn ; indeed, he first used a combined procedure resembling that of Freund in extirpation of the uterus for carcinoma. First he performed laparotomy, • See page 375. XXX INTRODUCTION. amputated the corpus, secured the stumps of the ligament ; afterwards closed the abdomen, and then performed excision of the stump of the cervix, as in total extirpaticni per vaginam. One cannot deny that there- with the duration of the operation is unavoidably long, and hence the author has, since operating on about fifteen cases, decided upon the following procedure : laparotomy is performed, the tumor dragged up to the abdominal wound, the ligamenta infundibulo-pelvica ligated, the coUum constricted bv means of a piece of rubber tubing, and then the corpus amputated. After space is obtained in this manner, an assist- ant makes the posterior vaginal fornix tense; thereupon the knife is passed through the insertion of the pouch of Douglas on the uterus. After opening the posterior vaginal fornix the lo\ver border is first sutured up towards the pouch, and then step by step through this open- ing the ligamenta lata and the vaginal fornix arc ligated, the needle Ijeing introduced from the peritonaeum into the vaginal fornix, and from there again towards the peritonaeum. Then both the ligaments are severed ; next the collum is separated from the bladder itself, being, if necessary, separated manually, and the sutures brought through exactly as at the sides. With this the loss of blood is minimal ; a drainage-tube is placed in the w^ound, running down through the vagina, and the abdominal wound closed. Reaction is to be regarded as entirely favorable in these cases, which is shown by the statistics added. Of sixteen patients, eleven had an uneventful recover}' ; one died of septic peritonitis ; two perished from kinking of an intestine ; one most extremely ansemic patient died in collapse a few hours after a bloody operation. For those cases in which suppuration of the tubes had taken place with perfoiation, especially into the rectum, the author has given a pro- cedure which, up to now, has been used in six cases with very satis- factory results, after he had, at difterent times, with results but little satisfactory, tried separating these pus-sacs from the rectum and closing the intestine by endorrhaphy. On these cases and the procedure itself he had Horatio Bigelow report in the "American Journal of Obstetrics," XXI., Aug., 1888, to which he refers. Tubal Pregnancy.' The number of tubal pregnancies reported has increased extraordi- narily during recent vears. Investigations with regard to those cases, how- ever, in which not the ovum, but only a haemorrhagic efi'usion into the tube with a rupture of this eflusion, was found, render it doubtful whether the 1 See page 406. INTR OD UCTION. xxxi condition here in question really be tubal pregnancy, and whether it is justifiable in simple hasmatosalpinx alwa3's, and without further considera- tion, to think of pregnancy. The investigations, especially of Orthmann, lead one to suspect that often enough, apparently, villi of the tubal wall have been taken for placental or chorion villi. Also the investigations of Keller and Karl Ruge in this direction are of extreme value; so that to-day, if the diagnosis of tubal pregnancy be made, one must de- mand the proof of chorion villi or of parts of decidual tissue to a greater extent than has hitherto been furnished. That in spite of that, tubal pregnancy is relatively very frequent, remains, however, undoubted. Even those cases are increasing in number in which a woman becomes pregnant in one tube, and after her life being saved by an operation be- comes pregnant in the other, which observations were probably formerly held to be hasmatocele formations of a high degree. Those cases are in- creasing in number in which, by early operations, or also by bursting of the tube, the women have been saved ; and finally the cases are accumulating where, from the developed tubal and extra-uterine sac, living children are extracted, and with presei'vation of the mother and child this so dangerous operation is brought to a fortunate end. But not only in an operative manner have a large number of women been saved in the last few years. The statements of Winkel especially (Gesellschaft fur Gynakologie, Halle, iS88) have again directed the attention of physicians to the old method of treatment of Friedreich, consisting in giving injections of morphine, thus killing the foetus, awaiting the shrinking, respectivelv the evacuation of the sac. The cases published by Winkel are astonishingly favora- ble, and under certain conditions this treatment will have to be imi- tated. Unfortunately, in all these experiences the diagnosis of tubal pregnancy has hitherto not gained in absolute certainty ; we are always limited to proving that a growing tumor is situated near the uterus ; that a certain development of blood-vessels takes place in the pelvis, a certain softness of the tumor is remarked, shreds of decidua are seen to pass away occasionally ; and, on the other hand, one may observe that peculiar con- traction which precedes rupture. When extra-uterine pregnancy must be admitted, and the injection of inorphine is not desirable, on account of the great inaccessibility of the tumor, then the following points are to-day accepted by many : — I. As soon as the diagnosis of an extra-uterine pregnancy is well founded, the removal of the sac is justified. 3. If the tumor has ruptured, then laparotom\' immediately performed is essentially more favorable than expectant therapy. 3. If the sac be so large that one must suspect a viable child therein, xxxii INlRODt-^CTlON. then ((pcniii'jj of the sac seems jiistil'ied as soon as one mav hope that the chiUl eaii live on, outside of llic uterus. To cause such a fullv developed child to perish does not seem justified. .(. lu small tumors, hence in pregnancy but little advanced, extirpa- tion of the whole is justified, as the author proposed at the International Congress held in Loiuhju, iSSi. 5. Whenever possible, one shoidd also extirpate the sac in further developed tumors. 6. Ligation of the placenta should ])e attempted, and, if possible, carried out, so that the sac may be either entirely extirpated, or, after drainage towards the vagina, it may be closed at least from above, so that the laparotomy may be finished. 7. If this does not appear practicable, then the placenta should be left, the cavity having been filled out with iodoform gauze, in order by this internal pressure to prevent separation of the placenta and haiinorrhage until obliteration of the vessels has taken place, so tliat the placenta may either fall ofl', or perhaps may be removed. The author himself, up to now, has had opportunity to perform laparotomy, on account of extra-uterine pregnancy, twenty-two times. Twenty-tv.o cases were operated ujDon ; eighteen recovered. Two w'erc septic previously, and even after the removal of the suppurating sac could not be saved ; two were, in consequence of the rupture, extremely anaemic, and died in collapse, to be sure, with a rise of temperature imme- diately preceding death. Upon post mortem examination no cause could be found. Moreover, I would refer to the investigations of Orthmann, which will appear in the Zeitschrift f. Geburtsh. und Oynak. Vaginal Extirpation of the Uterus.' Among the procedures which desei've to be mentioned among the modifications of vaginal extirpation, reference mav here be made to that of Richelot, where, instead of performing ligation of the ligaments, they are only placed in clamps. Richelot's j^rocedure is especially defended in Germany by Landau and Thieme (meeting of naturalists, Cologne, 1888). The author himself has had no experience with this method ; he has only modified his own procedure, so that after separating the uterus from its surroundings, which have previously been ligatcd, when the uterus with its adnexa moves downwards, he grasps the latter before ligation, with strong Indlet-forceps ; then the uterus is separated, and the stumps sutured into the vault of the vagina, before removing the bullet- forceps. As to the results of vaginal extirpation of the uterus, it does 1 See page 366. INTRODUCTION. xxxiii not yet, at this tunc, appear justifiable to form statistical tables from which further conclusions can be deduced. The procedure is recognized as legitimate ; to conclude as to the actual duration of the period of freedom, and the extent which women afflicted with carcinoma may be saved, will seem justifiable only after an observation of such cases extending over about ten years. Yet so much is clear, that by means of total extirpation we gain more for the unfortunate patients than by all tlie other methods with deep and partial removal, and that, in the majority of cases, it includes a fortunate state of good health, even if sometimes only a relatively short period of freedom is secured for the woman. On the Technique of Laparotomy." With reference to the technique of laparotomy in later years, progress has been made above all in this direction, that the use of the spray has been abandoned. The extensive inhalations of carbolic acid occasioned by the spray have, to the author, also proved dangerous to health, for violent perspirations follow the strong action of carbolic-acid inhalations, and in the course of the latter, rheumatic affections of the joints develop. The antisepsis is conducted ia the following w^ay : The room which is selected for laparotomies is scoured, on the day before the operation, with lye ; then a ten-per-cent. carbolic-acid spray is allowed to run down all the walls for two hours, while the room is shut oft", and is only opened again before the beginning of the operation, mostly twelve hour? after the use of the spray. In order to sterilize any objects, they are heated above 313° F. in an oven heated by gas, and vvhich has between its walls layers of asbestos. The cleansing of the hands and instruments is done, above all, by the very free use of soap. The hands are washed in carbolic-acid water, and soaped, then rubbed off with alcohol, and at last put into a i : 3000 sublimate solution. In the same manner the abdominal wall is cleansed, the patient having taken a bath previously ; the sponges are cleansed in the old way, and are also to-day prepared separately for every patient. Every patient receives her own sponges, which all are sterilized by boiling in a carbolic-acid solution. Pouring of carbolic-acid water or sublimate solution into the abdominal cavity is not resorted to any longer. The sopping out is done by means of these sponges, which are dried, so that thereby no great amount of fluid is carried into the abdominal cavity ; also the sopping out is done to the same limited extent as before. As a peculiar modifica- tion, the author has adopted a procedure which was proposed to him by his matron, Mrs. Horn, and which has for its object to prevent, if possible, ' See page 507. xxxiv INTRODUCTION. the agglutination of the hilcstincs to the abdcMiiinal wtnuul. A sponge dipped in sterilized oil is placed under the abdominal wcnnid while it is being sutured, so that a stratum of oil separates the intestines from the abdominal wound. However, up to now I have not had an oppor- tunity to observe by comparative experiments in how far this hinders adhe- sions to the intestines. Then in cases in which pus had poured into the abdominal cavity, and in which extensive wound-surfaces had to be left in the depths of the pelvis before closing the abdominal wound, a sponge dipped into oil was pressed on the raw surfaces, and then the abdomen closed. Three times in this manner patients in whom there were cocci certainly viable, although of an uncertain character, recovered without the accession of a peritonitis. In seven other cases, in which pus not having viable cocci obtained entrance into the abdominal cavity, recovery took place in the same manner. As it then impressed one that this sterile oil was unfavorable to the development of the cocci and the ptomaines, ex- periments were made in order to see how far this fact, so found, could be pursued. The result of these experiments has not been concluded, as yet ; but the author, having used it in ten cases alreadv, does not hesitate to publish it, and to recommend it to his confreres in analogous cases. PATHOLOGY AND THERAPEUTICS DISEASES OF WOMEN. I. — PHYSICAL EXAMINATION OF THE PATIENT A. — POSITION OF THE PELVIC ORGANS. Knowledge of the topographical anatomy of the pelvis has for a long time been at fault, because the revelations of the autopsy table have been taken as a basis for our ideas about the corresponding conditions in the living woman, while experience shows that the results found there are very often in marked contrast. The attempt to obtain sections of the hardened subject after opening the peritoneal cavity has led to the origin of the so-called Kohlrausch's section. This corresponds indeed to a physiological condition, but it is worth nothing as a basis for our observa- tions. It shows us, to be sure, the position of the pelvic viscera when the bladder and i-ectum are most completely distended. As a starting-point for our observations, we require knowledge of the i-elation of the parts to each other when the bladder and the rectum are empty. It follows, there- fore, that sections of frozen bodies must be regarded as the most typical representations of the topographical anatomy of the organs of the pelvis. Of such frozen sections Fig. i shows the position of the organs with the bladder and rectum empty, the subject lying on the back ; Fig. 3, the same when the bladder is filled ; and Fig. 3, the same when the rectum is filled. If these conditions found in the cadaver are contrasted ^ with the results of examinations of the living woman, it then appears that the 1 Compare B. 6". SchuHze,'^sn^\%c\\c Zeitsch. f. Med. u. Natunviss, 1S64, u. 1S70. Monatsschrift f. Geburtsh. xxxii., 1S6S. Die Pathologic und Therapie der Lageverilnderungen der Gebannutter. Berlin, iSSi. 2 PATHOLOGY AND THERAPEUTICS i;terus has no very fixed position, and that in consequence of its connec- tions with the neighboring organs, it is dependent upon their conditions. When these organs are full, the uterus descends so far into the pelvis that Sectionthrough the pelvis with both bladder and rectum empty, according to Pirogoff. — U. Uterus. S. Symphisis pubis. C. Os coccyx. R. Rectum. V. Bladder. M. Mens veneris. /. Intestines. P. Promontory of the sacrum. the cei-vix nearly touches the conjugate diameter of the pelvic outlet, w^hile the fundus descends into the pelvis by gravity, and approaches the sacrum. When the bladder is full the uterus is pushed backwards and upwards, and when the rectum is full it is pushed high up above the conjugate diameter of the pelvic outlet and it approaches the anterior abdominal wall. When both bladder and rectiun are filled, the uterus OF THE DISEASES OF WOMEN. Fig. 2. approximates by its position the relations as represented in Fig-. 4, accord- ing to the KoHLRAUscii's section. Fig. 5 is a diagram which we must show, because it will be generally useful as a foundation for our conception of topographical anatomy. It is according to the drawings of the physiological position of the uterus pre- pared in Schroeder's clinic by Carl Ruge/ and in future we shall base our observations of the physiological and pathological relations of the pelvic contents upon this. There the uterus lies upon the floor of the pelvis with the fundus turned toward the symphisis, the cervix being more or less markedly shortened and bent in the direction of the coccyx. The fundus rests on the contracted bladder, and the cervix projects into the va- gina through the cleft in the floor of the pelvis, which runs obliquely forwards and downwards from upwards and backwards. The whole uterus lies only slightly above the conjugate diame- ter of the outlet of the pel- vis, and Douglas' cul-de-sac is so widely open above that it might become filled up with coils of intestines. The empty bladder seems to be almost covered by the body of the uterus. The uterus is by no means so firmly fixed in this position, that every deviation from these relations to the pelvis and to the neighboring organs as described acquires a pathological significance. Although this conception pi'evailed temporarily, to be sure, in gynaecology, it corresponds in no way to the condition of those structures which definitely influence * ^ Compare Sckroeder's Lehrbuch der Frauenkrankheiten. 7 Aufl. 1SS6. 2 Compare O. Kiistner, Untersuch. iib. d. Einfl. der Korperstellung- auf die Lage des nicht gravi- den, bes. des puerp. Uterus. Archiv. f. Gyn. xv. — Lately His (Ueber Praparate zum Situs vies. Archiv. f. Anat. U.Physiol. Anat. Abth. 1S76) and fFrt/rf^yt'r ( Anatomischer AriEeiger. I.Jahrg. 1SS6. Nr. 2) have interceded for these conceptions of the normal position of the uterus in healtliy women. Section through the pelvis with the bladder filled, according to Pirogoff. — U. Uterus. V. Bladder. R. Rectum. C. Os coccyx. S. Symphisis pubis. M. Mons veneris. P. Promontory of the sacrum. PA 77/ OL OGY AND Til ERA PR UTICS Fig. 3. tlic position of the uterus. There is, indeed, at present no longer any doubt that the broad ligaments and the round ligaments support the uterus as little as the sacro-uterine ligaments do alcMie. All these ligaments are insignificant when in a healthy condition, and cannot be felt stretched by the weight of the normal uterus when the Ijody is in any position, so that we consider it impossible for thcni to be supjoorters of the organ. They allow the uterus a wide latitude of movement, and do not exercise an in- fluence on its position, until pathological proc- esses have developed in them, which produce a disadvantageous eflect on tlieir form and elasticity. Others believe that the inter-abdominal pressure is what holds the uterus in position. I n d e e d , changes in the intra-abdo- minal pressure do produce a distinctive influence on the uterus itself, as we can observe, for instance, when we breathe. We cannot recognize this intra-abdo- minal pressure, however, as the only supporter of the uterus, since it can produce onl}"- a general influence on the uterus as well as on the whole floor of the pelvis. Thus the Jloor of the pelvis re- inauis as the supporter and carrier of the uterus. From this, \\o\\- ever, we must not imagine that the uterus falls out at once as soon as the floor of the pelvis is destroyed. It then descends somewhat, and is pushed down as far as the ligaments and the intra-abdo- minal pressure allow. With all changes in the position of the woman, the floor of the pelvis is always the actual support for every change in the position of the uterus, and on this account we must consider it as the proper supporter of the uterus. This supporter, however, is itself by no means a rigid, immovable body. It also is dependent, to a Section through the pelvis with the rectum filled, according to Pirogoff. — U. Uterus. V. Bladder. R. Rectum. C. Os coccyx. .5". Symphisis pubis. M. Mons veneris. P. Promontory of Ihe sacrum. OF THE DISEASES OF WOMEN. 5 certain extent, on the intra-abdominal pressure. We must consider the uterus as physiolog^ically Jixed within the lirnits of the mobility allowed by its ligaments and within the limits of the mobility of the floor of the pelvis. The uterus cannot be considered to be pathologically situated if it descends somewhat, together with the floor of the pelvis, when the Fia. 4. Section through the pelvis with both bladder and rectum filled. Section according to Kohlrausch. — U. Uterus. P. Peritoneum. A. Anus. Va. Vagina. Ve. Bladder. R. Rectum. individual is standing upright ; if it inclines towards the sacrum when the woman lies on her back ; if it seems pushed toward the inlet of the pelvis in the knee-elbow position ; or finally, if it approaches either side in a side position. Such sorts of displacements are no more pathological than the positions caused by the filling of the bladder and of the rectum. The adnexa of the uterus since it is thus inclined forward lie less on the side of it than posterior to it. The ovaries, as they are represented PA T//OL OGY AND Til ERA PR UTICS ill Fig. 6, lie sonicwhat in :i line drawn fioni tiie top of the fmuliis of the uterus tovvarcls the articulation of the sacruiu and ischium. 'J'lie ovaries, indeed, have so much motion on account of the way in which they are inserted, that the condition of fulness of the intestines undoubtedly exercises an essential influence on their position. The Fallopian tubes, as Fig. 6 shows, are contained in the lateral portion of Douglas' cul-de-sac, together with the ovaries, and they lie ^'9" ^" at times deeper and at times higher, according to the amount of space in the pelvic basin occupied by the lull bladder or the full rectum. In a consideration of the topographical relations of the floor of the pelvis, it must be emphasized that finally be- tween the fascia and the must cles, in a dissection of the pelvic organs of a healthy woman, there is inserted a tissue extra- ordinarily rich in fat, which by its peculiar firmness contributes \ery essentially to the steadiness of the whole floor of the pelvis. Atropliy of this fat, as occurs often and sometimes to a sur- prising degree in the puerperal condition and in general dis- eases, permits the physiological significance of this mass of fat to be clearly seen. The union of the uterus with the posterior vaginal vault and the relation of this to the peritoneum is always represented in a schematic diagram as very slight, and yet there is a great diflerence in its degree. Sometimes the tissues between the posterior vaginal vault and the portion of the peritoneum that lies nearest is only half a centimetre in thickness, and at other times it is very thick, and, indeed, I have found it to be four centimetres in thickness without any pathological change or growth being noticed. There are also similar deviations in the extent of the union of the uterus with the bladder. This varies l)etween one and four centimetres, Normal pusilion of the ulerus, according to C. Kuge. OF THE DISEASES OF WOMEN. 7 and, indeed, the bladder may be attached to the uterus directly over the cervix so that the fold of peritoneum anteriorly is ri.lal — but such frightful hasmorrhages are also brought about by these damages, that the collapse of the unfortunate patient is only prevented by the most decisive measures. On the consequences resulting from these examinations in the case of new growths, I shall speak more at length in the description of ovarian tumors and diseases of the Fallopian tubes. Bullet-for- ceps, 23 centi- metres in length. 5. Examination' with the Sound. At present I no longer use the sound in the establishment of the diagnosis, although it was considered especially important not very long ago. The method of bimanual examination gives us sufficient information concerning the position, form, and consistency of the uterus, and also con- * Vo/A-mann's Saniinlg. klin. Vortr. 105. 2 Wiener Med. Blatter 1S79, Nr. 44, 45. OF THE DISEASES OF WOMEN. 19 corning those facts which we formerly believed had to be ascertained by means of the sound. At present I only employ the sound in order to de- termine the condition and the length of the uterine canal and the compar- ative length of the cervix and the body of the uterus ; and to ascertain the position of the uterine canal itself, and the thickness of the walls of the uterus, also the contents of the uterine cavity, the site of any changes in the mucous membrane ; and last of all, I use it occasionally in especial pi^ocedures which I am going to undertake with the uterus. I consider the sound to be a very valuable instrument, and in some- what skilled hands, wholly without danger. In the teaching of gynae- cology one ought to have an excellent opportunity to employ it in the case of women who have a slight degree of sensibility of the genitals, as is frequently the case. The use of the sound is thoroughly contraindicated : — First., when pregnancy is only suspected. In this respect one cannot be too careful in practice. We can protect ourselves from mistakes in this respect, only by taking into consideration before each use of the sound the time of the last menstrual period, and also the results of combined examination. It is not true, however, that every case of pregnancy is terminated by the introduction of the sound. This result, however, is the rule, and in every case where doubt exists we should abstain from the use of the sound. Secondly., the sound should not be employed so long as the tissues sur- rounding the uterus are found to be sensitive by the method of bimanual examination, and also where peri- and parametritic inflammations e>iist in the early stages or only in a more or less active form. Particularly especial attention must be given in this respect to the posterior vault of the vagina before the use of the sound, because we very often find the remains of inflammation here in the sacro-uterine ligaments or at the bottom of Douglas' cul-de-sac, while the rest of the surrounding tissues appear to be completely healthy. The neglect to consider such remains of inflammation may put us in danger of exciting an irritation which cannot be wholly avoided when using the sound, as has been observed often enough in the historv of its use. Such consequences are then put down as the result of the employ- ment of the sound as such, while indeed they were only the consequence of a vague examination premising each use of the sound. Thirdly., the sound should never be employed, according to mvidea, when there are active inflammatory processes in the uterus itself, and also in the case of women who are menstruating, or who have not entirely com- pleted the menstrual flow ; for otherwise there may easily be excited PATIIOLOGV AND THERAPEUTICS Eig. 14. nioiv tliaii a motlcratc liaMiiorrhai^c, as is apt to l)c the case by every in- troduction of the sound when the canal i.s narrow and denuded of its mucous membrane. In the past, sounds have been presented by Kiwiscn,' vSimp.sox," HuGiER,^ and Sims,' and hitely various other forms have been introduced, and the most various kinds of metals for their manufacture have been recommended. Of all the number of sounds diflbring in shape and in the material of their construction, for my own part I use only the stifl" sound of E. Martin (Fig. 14). With this instru- ment I have been able to examine every uterus into which I have wished to introduce the sound up to the present time (and how many thousands of these there are, I have no idea) , so that I have no desire to use any other instrument in its stead. With this sound I have always been able to determine most satisfactorily the course of the cervical canal and the length of the uterus, the thickness of its walls and all other questions which depend thereon. I will not completely detract from the value of the sound which has such manifold uses, and which is so differently prepared, and I w^ill only say that for my own part I have not found its use to be absolutely essential. I cannot make ujd my mind to bend the sound accord- ing to the supposed form of the uterus every time that it is to be introduced, for this must always need a precon- ceived idea of that which I will first determine with the sound, z'.e., the form of curve which is necessary ; while on the other hand the influence of the peculiarly bent course of the cervical canal on the flexible metal can only give a doubtful idea of this course. The sound should be introduced when the patient is lying on her back on an ordinary bed, with one finger placed on the posterior lip of the OS uteri, antl the head of the sound is guided into the os on the \()lai" sur- face of the finger. When the sound has approached tlie neighborhood of the internal os, it is necessary, on account of the physiological position of the uterus, to lower the handle considerably in order to introduce it into the cavity of the uterus itself. The course and the form of the uterine cavity is recognized from the way in which the sound advances. If there are folds in the cervical canal which oppose the advance of the sound, the ' Kl. Vortr., 1845. ' Monthly Journal, June, 1S43, and Obst. Memoircs and Contributions, 1S55. 3 De I'hystcrometric, Paris, 1S55. * Loc. cit., 1S66. Sound accord- ing to A". ]\Iartin. 28 cm. in length. OF TJIE DISEASES OF WOMEN. 21 hindrance is overcome by carefully moving the handle of the sfniiid back and forth and up and down. If the uterus is fixed Ijy the sound held in one hand, then the examining finger of the other hand can make out through the vault of the vagina the thickness of the uterine walls and the boundaries of the uterus with the neighboring organs. If the soimd is moved up and dovv-n in the interior of the uterus, the con- tents of the uterine cavity can be approximately determined. Finally, tlie fiijger which is introduced into the vagina when laid on the sound will give the length of the uterus itself. In order to determine the length of Fig. 15. the cervical canal, the sound must be fixed at the instant when its point glides through the internal os, which is usually easily recognized as a nar- row passage. If the uterus is retroflexed the sound can also be introduced into this retroflexed organ, unless there is connected with this a real dislocation, and of this we can easily assure ourselves by the examination. In a case of retroflexion, the sound is introduced in the usual way until it has reached the neighborhood of the internal os uteri, then by a revolution of the handle of the soimd in a wide circle before the genitals, the concavity of the sound is turned backwards when as a rule it glides into the uterine cavity, while it is pressed close against the symphvsis pubis. This intro- duction of the sound into the uterine cavitN encounters the fewer diifi- 22 PATHOLOGY AND THERAPEUTICS cultics, tlic more (Icfiiiitcly the position of the same is previously detennincd by the iiiethod of bimanual examination. vSounds, and other instruments like the sound, can be employed as therapeutic means in addition to the diagnostic purposes, which have jusr been described partly for the purpose of dilatation of the canal, and partly for replacing the rctroflexed uterus. In order to dilate the uterus it is necessary to introduce successively larger sizes of the sound. I never use tliis sort of dilatation, because I attain the desired result in a manner v^'hich is much more simple, according to my idea. I do not make the reposition of the retroflexed uterus by the use of the sound exclusively, wliile, on the other hand also, I do not absolutely reject this method of reposition.' In most cases, certainly, it is very easy to replace the movable retro- flexed uterus without the aid of the sound ; but whenever the narrowness of the vagina or the sensitiveness or awkwardness of the patient render difficult the reposition by the hand, then I have learned to consider the sound as an excellent means of assistance. Particularly does the sound seem to be the proper means for reposition of the uterus in those cases in which it is advisable to determine whether the uterus is bound down in its rctroflexed condition by cicatrices or by adhesions to the peritoneum, and whether it can possibly be accomplished without danger. In discussing flexions of the uterus and perimetritis I shall consider this question further. 6. Examination of the Interior of the Uterus. Dilatation of the cervical canal to the degree that the finger could be introduced into the interior of the uterus was looked upon at the begin- ning of the advance of gynaecology as one of the most frequent of matters of gynaecological technique. It was thought impossible to get along without investigating the cavity of the uterus itself, without examining the mucous membrane of the uterus, witliout removing the remains of tumors or new formations contained there, and especially without apply- ing medicaments to the inner surface of the uterus. From these points of view so many indications arose for the dilatation of the uterus, that the great number of methods offered to accomplish this cannot be sur- prising. While this dilatation was formerly attempted by the use of steel instruments, something in the way that strictures of the urethra are divulsed, the use of tents came particularly into the foreground later under the influence of Sir James Simpson.^ 1 Compare also Winckel, Lehrbuch d. Frauenkninkh. S. 355. 2 Monthly Journal of Med. Sci., 1S44. Edinb. Med. Journal, 1S64. OF THE DISEASES OF WOMEN. 23 The compressed sponge, which was especially advocated at the beginning, was soon replaced by the laminaria digitata. Together with the laminaria tent there came, not to mention others, the tupelo tent. Opposed to these means, dilatation by the use of rubber apparatus and of metallic instruments have been recommended of late. While some opera- tors have discarded this sort cf dilatation entirely, others have either limited the indications therefor to a diminishing number of cases, or they have allowed division of the cervix with a knife to take the place of dila- tation. For a long time I used many of the compressed sponges and laminaria tents ; but several years ago I left off using them, and of late I do not dilate with the instruments of steel or rubber. With an amount of gyna2cological material, that has been by no means small, I have suc- ceeded in the desired end in the majority of cases without dilatation. Then when it is unavoidable, I prefer division of the cervix. To those, however, who are less experienced in the technique of gynaecology, I recommend the use of the laminaria tent. The compressed sponges are thoroughly finished with a high degree of technical perfection, and they can be easily disinfected, and they swell rapidly. On the other hand, it should not be misunderstood that their intro- duction, when the cervical canal is modified somewhat, is rendered diffi- cult, because the tip swells up so quickly, and also because the pt'operty of swelling up, which the compressed sponge has, is often lost, on account of too great resistance of the cervical tissues. The laminaria tents undoubtedly swell up much more slowly, and also when disinfected and perforated they have been used very exten- sively. They swell up less in volume than the compressed sponges, and for this they require a longer time, yet, in the main, they act much more energetically. Therefore, when several tents are introduced side by side, the dilatation of the narrow place can frequently be accomplished satisfac- torily at a single sitting. The tupelo tents, according to my experience, swell up very perceptibly quicker than the laminaria digitata, but their increase in volume, however, is much less. Among the instruments made of steel for dilatation I shall mention, be- sides the older forms of Priestley, Scanzoni, and Ellinger, only the metranoicter of Schatz.' The dilatation instruments of Atthill and Hegar,^ and the knob-shaped sounds of Schultze ^ and Fritsci^,^ are constructed after the style of Simon's urethral dilators. All of these instru- ments, which are made of different kinds of materials, cannot possibly 1 Arch. f. Gynak. xviii. S. 445. 2 Kasprzik, Allg. Weiner med. Zeitschr. iSSo, Nr. 12. sMonatschr. f. artzl. Polytechnik, 1SS3, iii. 4 Centralbl. f. Gynak. 18S0, Nr. 21. Wiener Med. Bl. 1SS3, Nr. 14, u. ff. 24 PATHOLOGY AND THERAPEUTICS work in any other way than by tearing the cervix ; and whenever the tissues of the cen'ix must be divided, I prefer the smooth-cut surfiice to the torn surface. The rubber dilators can only be used when the existing opening will allow their introduction. Since this can generally be accomplished only when the finger can be almost admitted, the use of rubber apparatus does not seem to me to be essential, entirely aside from the expense of the same and from the accident which has often happened to me of having the rubber balloon burst at the most important moment. When the opportu- nity comes, I shall return to the question of the manner in which I have found it necessary to introduce my finger into the uterus, which is an aid in occasional instances. In the majority of cases, however, the intro- duction of the finger is unnecessary, and then the sound answers my purpose in part and the curette in part. I formerly accomplished the introduction of the dilators which swell up, with the patient in the side position ; but now I do this no longer, and, wdien it is necessary for it to be done, I introduce them with the patient in the usual position on her back (Fig. i6). After the vagina has been suf- ficiently disinfected, the posterior vaginal wall is pressed back with a Simon's speculum, the cervix is seized with a pair of dressing-forceps or bullet-forceps, and the uterus is drawn down as far as possible without using force. The uterine cavity is washed out with a weak antiseptic solution by means of a pointed irrigation-tube inserted into the cavity. Then the tent is introduced into the cervical canal until the lower end lies at the external os uteri. All threads and bands attached to the tents ap- pear to me to be dangerous as carriers of infection, and hence I always have them removed before use. Then I place a wad of cotton under the cervix, and, after I have removed the bullet-forceps, I push the uterus back into its place, remove the speculum, and put patient to bed. The compressed sponges swell up sufficiently in about six to eight hours, arid the laminaria tents require about ten houis on an average. Then I have the patient aniesthetized and raised on to a suitable support, generally a table, and after repeated disinfections I remove the cotton- wad and the swollen tent, so that the fingers can be introduced into the ililated canal at once. In the same way the tupelo tent and other substances which swell up are employed. Aside from the fact that the action of these tents often necessitates an uncomfortable delay, the disadvantage cannot be denied that in the eyes of the laity there have to be two operations. But the method of slow dilatation has still greater disadvantages ; for the danger of Intense inflammation and of septic infection is unmistakably to a higher OF THE DISEASES OF WOMEN. z^ deforce connected with tliis operation than with any other method, which produces the end directly under appropriate antiseptic measures. This evil is particularly liable to occur in the dilatation with compressed sponges, although improvements of many sorts have rendered the dangers of this method less and less. The removal of the tents, which have been introduced, is attended at times with peculiar dithculties, since they become so firmly encircled by Appearance of the cervix. Exposure of the same with the patient in position on her back. Attitude of the assistants. the tissues which have been dilated with difficulty, that the portion reaching up into the uterine cavity swells up much more than the portion lying at the internal os uteri. Under such circumstances the compressed sponge breaks oft' and the laminaria tent draws out in threads, when an attempt is made to draw it out by the aid of the bullet forceps or any other pointed forceps. Then the only thing that can be done, is division of constricting portion. I have come to the conclusion, after one such experience with a laminaria tent, that I would attempt the removal of these with dressing-forceps or similar instruments, and by drawing on the tent with these with a twisting motion. Sometimes if several laminaria tents are inserted side 26 PATHOLOGY AND THERAPEUTICS by side, one of them slips up into the uterine cavity. I have never ex- perienced any difficulty from this. After complete dilatation the tent is seized during the examination of the uterus, and removed without ditticulty. The dilatation of the cervical canal with steel dilators, with the above- mentioned apparatus and with sound-shaped instruments, I have accom- plished in a similar way during anaesthesia by chloroform and witli the patient lying on her back. It always requires rather considerable force, and every time I was obliged to render harmless by sutures, the tears which have been made by this dilatation. For division of the cervix also, I operate with the patient lying on her back. It depends upon the indications for which the uterine cavity is made accessible, whether the uterine arteries should be ligated before the division of the os or not.' In order to ligate these arteries the uterus should be firmly pushed toward one side after the patient has been put under the influence of anaesthesia and placed in position lying on her back, and the vault of the vagina has been exposed by means of a Simon's speculum. The position of the uterine artery, which can generally be felt pulsating, is then determined, and a moderately large needle, which is quite sharply curved, is thrust into the tissues of the vagina about a finger's-breadth laterally from the cervix and on a line nearly corresponding to the anterior border of the cervix. After the needle has passed through an amount of tissue as large as practicable, it is again guided backward through the wall of the vagina, on a line corresponding with the posterior surface of the cervix, and then the suture is tied with great force. We must take care that the open- ings made by the needle, as it goes in and comes out, are somewhat near together, in order that the suturing may not cause too great tears in the vagina itself. After the artery on the other side has been ligated in the same maimer, the cervix is drawn down by a pair of bullet-forceps secured in its anterior lip. Next I divide the cervix with an ordinary bistoury up to the insertion of the vagina, and then I endeavor to insert the finger into the uterine cavity. If the tissues still give too great resistance, they should be further divided on both sides with merely superficial cuts by a probe- pointed knife, until the finger can be introduced into the interior of the uterus. After the desired examination or perhaps emptying of the uterine cavity has been accomplished, the 'wound is to be seTved up. For tliis purpose a needle should be thrust through the cen'ix from the vault of the vagina clear up to the internal os uteri, first through the anterior portion and then from within outward through the posterior portion through the vaginal wall out into the vagina. After the sutures 1 Compare also Schroeder. Zeitschrifl. f. Geburtshilfe u. Frauenkrankheiten. VI. S. 2S9. OF THE DISEASES OF WOMEN. 27 have been passed up to the internal os uteri on both sides, the cut surfaces arc restored in apposition at this spot. In a similar manner the wound is gradually closed downward until the lips of the os are united by suturing at the lateral commissure. Great care should be taken wdien doing the latter that the sutures lie on the edges of the wound in the mucous mem- brane of the cen-ix, so as to avoid a narrowing of the lumen of the cervical canal. The results of the division of the cervix are not universally favorable, so that the general introduction of this method should be only attempted with great caution. My own occasional accidents with the method, however, have been less in consequence of the division itself, than on account of the diseases for which the division was undertaken. Instances of this have been disintegrating myomata of the fundus, which had to be enucleated ; or remains of a placenta, on account of which a disastrous general infection had already commenced ; or such an extreme degree of ancemia, that the patients died, although they lost no blood either by the division itself or by the emptying of the uterus. These were, therefore, cases in which neither a slow nor a foixible dilatation could have ever given any better results. I would at any rate qualify my recommendation of division of the cervix, in presupposing considerable jDractice in suturing m the depth of the vaginal vault and the uterus as an essential prerequisite toward it. Whenever this is wanting, it seems to me that the laminaria tent is the best of all methods of dilatation. The diseases of the adnexa of the uterus are disastrous to all dilata- tions., and, independent of septic infection, they undoubtedly produce very many more of the evil consequences of dilatation than all the rest. When- ever it is possible, we should assure ourselves before every dilatation, that there exists no disease in the adnexa, no peri- nor parametritis, salpin- gitis, oophoritis nor perioophoritis. Whenever any trace of such disease can be discovered, the attempt must be made to accomplish the purpose without dilatation of the uterus ; but this should be undertaken only in those cases in which there is an indication on the part of the uterus of vital importance. ScHULTZE ^ has endeavored to overcome these difficulties in a certain direction by means of his "probe-tampons," by which the necessity for dila- tation can be ascertained or excluded. I must agree with Schroeder - and Winckel'' in not being able to recognize the value of these probe- tampons. According to my own experiences we can limit the indications tor dilatation at present, to a very small nutnber of cases. Only ^^■hcn it 1 Centralbl. f. Gynakologic iSSo, Nr. 17. = Loc. cit. S. 122. » Loc. cit. S. 50S. 28 PATHOLOGY AND ThERAPEUlJCS Fig. 17. becomes necessary to remove large masses of tissue or the remains of pregnancy from the uterine cavity, or to take away new growths, have I found it necessary during later years to dilate the cervical canal. During this periotl, the scraping out of the uterine ca\ity with the curette has shown itself perfectly sufficient for diagnostic purposes in hundreds of cases, and likewise the dilatation of the cervical canal associ- ated with this curetting has been sufficient, on an average, for all thera- peutic measures that could come into consideration. Considering the fact,- that not a very long time ago, the introduction of any fluid whatsoever into the uterus w^ithout previous dilatation was looked upon as a most exceedinglv dangerous procedure, I would insist upon one thing : whenever curetting precedes the injection of fluids, the internal os uteri and the whole cen'ical canal attain such dimensions, that not onl}^ the introduction of the fluid itself meets with no obstacles, whether it be done with a Braux's syringe or with a simple irrigator ; but also the retuin of the surplus fluid occurs without hinderance. Thus uterine colic, and the troubles associated with it, which were formerly often observed with such injections, are no longer noticed at all, or only to a very slight degree. Anaesthesia is not unconditionally necessary for curett- ing ; but especially iia private practice I always am glad to avoid giving the woman any pain whatever, and so I gener- ally make use of chloroform. The patient should be placed in position lying on her back at the edge of the operation table that has been described (Fig. 15), with both legs drawn up on the body, the posterior vaginal wall drawn down bv means of a Simon's speculum, the anterior lip of the cervix secured with a pair of bullet-forceps and drawn down as far as it will go toward the entrance to the vagina (Fig. 16), and then after thorough disinfection, and finally, also, after the in- jection of carbolized water, a blunt curette is inserted into the uterus (Fig. 17). The introduction of this curette is generally very easy, even into the virgin uterus, and it is even easier if the women have already borne children. But even in those cases in which the firm walls of the cervix yield slowly before the advance of the curette, it requires the use of only a very little force to press it into the uterine cavity. It is, therefore, important to know exactl}- the course of the cervical canal, and the posi- tion of the body of the uterus, before the introduction of the curette, and so I always introduce the sound again after I have put the uterus into its proper position. If the direction has been determined in which tlic in- Curette accord- ing to Roux, 27 centimetres in length. OF THE DISEASES OF WOMEN. 39 strument is to be inserted, tlie introduction into the uterine cavity extrenielv seldom meets with difficulties, which appear cither on account of the nar- rowness of the canal or of overlying folds of the plica; palmatcC. By means of gentle pressure and appropriate fixation of the uterus, the end of the curette should he carefully moved backwards and forwards, in order that it can overcome any folds present or press through the narrow por- tion. If the narrow j^assage in the course of the cervical canal is un- yielding, it can be incised without danger by means of a probe-pointed knife so much as is necessary for the introduction of the instrument. The ivhole 7iteruie imicous membrane is the)i scraped out with this ci/rette., i.e.., single strips and little pieces are not alone taken away, but the whole mucous membi'ane is removed. On this account the instru- ment must be twisted around and turned in the various directions, corre- sponding to the shape of the cavity of the uterus. The construction of the instrument is such, that there is no doubt at any instant about the direction of the cutting edge. When the mucous membrane has been removed, the interior of the uterus is washed out with the irrigator, which has been employed from the beginning in a continuous irrigation of the whole field of operation. (See Fig. 16.) Then, with a Braun's syringe, I inject two or three grammes of undiluted liquor ferri persulphatis, and then I wash out the excess of it and any coagula lying free in the interior of the uterus, until all bleeding stops and the wash-water returns clear. Only now are the bullet-forceps removed, and the bleeding, caused by their points, is stopped by a suture, if necessary ; the uterus is pushed back into place, and the speculum is taken out. The patient must remain in bed for four or five days after such a curetting, just the same as after every dilatation of the uterus. During this time, the vagina should be washed out two times a day with a 2 per cent, solution of carbolic acid, or with a i 15000 solution of corrosive sublimate, and, if necessary, a cold, moist compress should be laid on the abdomen. If the cervix is viewed through a speculum on the sixth day, no trace of the operation can be found. Serious objections iiave been raised on two sides against this method of curetting the uterus. The first, which is ad- vanced, is that // is /lot possible to establish an accurate microscopic diagnosis from these masses of mucous membrane^ that have bee/i scraped out . I will not attempt to decide how thorough have been the operations of curetting b}- those gynaecologists, who have repeatedly expressed these doubts. According to my own obsen-ations, I cannot recognize this as a valid objection ; for, in the first place, I am ver\' oftei^ able to submit for examination the whole lininir of the uterine cavitv in its entirct\', and in 30 PATHOLOGY AND THERAPEUTICS this way I may assume, that I make it possible to acquire a complete picture of the microscopic changes in the mucous membrane of the uterus. Moreover, I have occasionally been able to verify the working of this method, by means of a total extirpation performed shortly after the curet- ting, showing that the entire superficial mucous membrane had been really removed, and that the diagnosis made from this mucous membrane had been completely confirmed. It is self-evident that an exact knowledge of the physiology of the mucous membrane must be presupposed, in drawing conclusions from the i-esults of this method of examination, and that for this all the peculiarities wdiich modern technique in microscopy offers, must be employed. The portions of mucous membrane that have been removed are ex- amined, partly with the aid of the freezing microtome, and partly after hardening in absolute alcohol, and then some of the various methods of staining are employed. As is proven by the investigations of Duevelius,'^ one of my pupils, the entire thickness of the mucous membrane is not destroyed even after the most thorough curetting. The deepest layers remain behind, and with them the ends of the glands which are situated here. As a rule, the regeneration of the mucous membrane follows directlv from these ends. Naturally we must not overlook the fact that the diseased conditions in the mucous membrane can be again repeated from these. On the one hand, the destruction is made much more thorough by the injec- tion of the liquor ferri persulphatis after the curetting ; but, on the other hand, up to the present time, we do not know any means that will per- manently prevent new disease in the mucous membrane. The other objection to this method of curetting consists in the assertion, that on account of it, as soon as the whole mucous membrane is removed, the possibility of the -woman s conceiving is^for a long tinic^ impaired. In opposition to this, I can only go to show that, so far as I have been able to observe during the last five years, over ninety of those women who had been curetted, became pregnant, for the most part, very soon after the operation, and that a great number of these are progressing in the course of an apparently normal pregnancy, and others have been normally delivered. A percentage cannot be established from material, which is partly from the polyclinic, but at any rate the percentage is so high, that we cannot con- sider these cases as the exceptional ones. It would surely be entirely WTong, if those cases in which pregnancy did not occiu", should be declared to be on account of the scraping which had taken place in the mucous membrane ; for of how many circumstances is the coincidence 1 Zeitschr. f. Geburtsh. u. Gynakologie. X. S. 175. OF THE DISEASES OF WOMEN. y. necessary, in order to permit the occurrence of pregnancy in any case. DuEVELius has thrown a good deal of light on this subject, and by his investigations, he has shown with certainty, that the regeneration of the mucous membrane which has been curetted and cauterized by the liquor ferri persulphatis, is extremely rapid and complete.'- I have frequently made an exploratory operation of curetting when tlie indications have been urgent, in cases when there exists peri- or para- metritis, diseases of the ovaries or tubes, and if I have used the most extreme care in the disinfection with the women, and if I have covered the abdomen with ice immediately after the curetting, then it is only in the most exceptional cases that any sort of a reaction is induced, and, at any rate, it is much more rarely than formerly after the most careful dila- tation. After the large number of operations for curetting which I have per- formed, I can designate this with great certainty, to be an excellent sub- stitution for gradual dilatation and the subesquent application of medica- ments. This combines easy practicability, safety, and permanence of effect more than any method of dilatation, and it permits the diagnois to be established with great certainty. Under the chapter of the therapeutics of the diseases of the mucous membrane, I shall have more to say con- cerning the significance of curetting. A great number of gynaecologists prefer to dilate the canal until it is possible to introduce the finger. Others, especially Schroeder," find the employment of the sound to be an important aid in making a diagnois of diseases of the mucous mem- brane. With due consideration of the fact, that the use of the sound can only too easily produce uncomfortable consequences, in case an appar- ently mild perimetritis is present, I do- not consider this method so simple that I could recommend it without exception. I here conclude the consideration of our aids in establishing a diag- nosis. The method of bimanual examination and the introduction of the speculum will be sufficient in the majority of cases, for the general gynas- cological practice. The introductioii of the sound and the examination by the rectum, and then the examination during anaesthesia by chloroform, together with the appropriate fixation of the uterus and delimitation of the neighboring organs, should be much less frequently employed, and still less often the curetting of the uterus for the establishment of the diagnosis by the microscope. On the other hand, all the other conceivable further means of assistance can be employed occasionally for gynaecological diagnosis also. 'Compare also Benicke, Zeitsch. f. Gth. ii. Gyn. XI. S. 411. 2 Zeitschr. f. Geb. und Gyn. X. and Ilandbuch Ed. vii, S. 121. 32 PATHOLOGY AND THERAPEUTICS In particular, we not unfrcqucntly make use of auscultation and percus- sion, and the most thorough palpation of the parts above the brim of the pelvis. All of these, however, are familiar to every physician, and they need no special explanation here. At the proper place T shall return to them, as well as to the chemical and microscopical examination of pieces of tissue and of fluids. OF THE DISEASES OF WOMEN. 33 PHYSIOLOGY AND PATHOLOGY OF MENSTRUATIOxN AND CONCEPTION. I. MENSTRUATION. The essential changes of opinion, which have lately happened in the explanation of the occurrences at menstruation, justify me in devoting an entire chapter in these clinical observations to the physiological processes. We know that the secretion of blood from the uterus (menstruation) recurs at regular periods of about twenty-eight days ; that it fluctuates according to climatic and various other circumstances; that its appearance may be delayed in the same latitudes, according to the circumstances of the person's nourishment, and partly also according to the development of civilization ; that the duration of this secretion of blood is for nearly thirt}' years ; and that in the latitude of Germany, it generally commences at about the fifteenth year, sometimes suddenly without any disturbances, but sometimes after long- continued abdominal pains. It often disappears just as rapidly as it developed, but it is often delayed and irregular be- tween the fortieth and fiftieth year. The flow of blood continues for three to seven days, seldom less, but often more. It is preceded by an abundant mucous secretion, which frecjuently, also, follows the completion of the flow in considerable quantity for several days. The amount of menstrual l)lood cannot, in general, be estimated (100 to 21^0 grammes). The secre- tion is composed of blood and the products of the glands of the uterus and vagina. Its coagulation is prevented by the acid secretion of the vagina. It often has a very strong and peculiar odor. According to some authors, the ajDpearance of the menses is followed by a rise of the tempei'ature, occasionally for about a degree (C) ; but, according to others, it falls together with the frequency of the pulse-beat. These statements I cannot recognize to be in the least regular, according to often -repeated observations. The suflerings of women, which accom- pany menstruation, vary extremely in individual cases. Many women feci only the inconvenience of the flow, together with the recognized SN'mptoms of shooting pains in the abdomen and in the sacrum : the irri- tation of the external genitals; the frequent desire for micturition (the 34 PATHOLOGY AND THERAPEUTICS secretion ot' urea is diininishccl), and the various scjrts of nervous (listurl>- ances. I liavc often lieard women complain, in paiticular, tliat, at every time of menstruation, the digestion is accomplislied with more irregularity than before, and the sensation as if the genitals were open, is developed as well in married women as in virgins. At this time the sexual feeling is often intensely increased ; most women " feel unwell." Although what is essential to the clinical appearances of menstrua- tion can be outlined in these general statements, the anatomy and physi- ology of menstruation, and the relation of it to ovulation, has given us inducements for highly interesting studies. The idea of Pflueger, that the periodical maturing of the Graafian follicles causes a reflexive arterial congestion of the genitals, and that the rupture of the follicles (ovulation) coincides universally with the exuda- tion of blood from the mucous membrane of the uterus (menstruation), has been really shaken, at least, by investigations which are capable of demonstration. The maturing of the ova is not of an exact monthlv tvpe. This proceeds gradually, and the rupture of the follicles may occur at any time ; and also the possibility of the woman's conceiving is not confined to a special period of time. These changes in the ovaries always pro- duce an extreme irritation of the genitals, in consequence of which there is a periodicallv' increasing blood tension, and a swelling of the mucous membrane and of the parenchyma of the uterus. If the ovum becomes impregnated, this mucous membrane is developed still further, into a de- cidua ; but if pregnancy does not occur, at the height of the reflexive swelling of the mucous membrane, there is rupture of the vessels, a haemor- rhage, and then a return of the mucous membrane to its normal condition. The haemorrhage, therefore, is not a sign of the commencement of the ma- turing of the ovum ; it designates the completion of the period of reflexive irritation, during which conception has not occurred. If pregnancy occur, the ovum of the last menstruation is not developed (for this was destroyed during the last menstruation), but the one which matures after this one (Sigismund,^ Loewexhakdt,- and Reichert ^) is developed. It is evident that the establishment of these relations is of the greatest importance in determining the occurrence of conception, and in judging the duration of pregnancy. Menstruation and ovulation, or the activitv and development of the elements of the ovary, always exert a very essen- tial causal relation to the activity of the uterus. An attempt to explain this has been made in vain, and although it has been pointed out by Beigel* that after complete extirpation of both ovaries, haemorrhages still > Berl. kl. Woch. 1871. Nr. 25. » Arch. f. Gynak. III., S. 456. 3 Akad. d. Wissensch. Berlin, 1S73, S. 6. * Wiener Med. Woch. 1S7S. Nr. 7 u. S. OF THE DISEASES OF WOMEN. 35 come from the uterus, and, therefore, a menstruation still occurs; yet these, according to many reports in the literature and my own experience, are not regular, and they seldom continue for the period of more than one year. P'^or a judgment of these cases it must be thoroughly established, above all things, whether both ovaries had been completely removed by the operation ; for even the most minute remnants of the tissue of the ovary can contain Graafian follicles, which may come to maturity, even if they have apparently been tied oft' by the ligature which has been used, as I must conclude from an experience of my own Still, a greater change has taken place in our ideas concerning the a)mtomical processes of mcnstrjiation. After Kundrat and Engelmann ^ had published the results of their admirable examinations on this subject in the year 1873, the occurrences have been investigated by different authors ^ in a long series of preparations, which represent every day of menstruation and of the intervals between menstruation. However much the ideas of these authors differ in essential points, yet many of them are imited, concerning the facts that the mucous membrane of the uterus becomes swollen at the time of menstruation, and that its superficial layers become fatty degenerated and separated, whether primarily or secondarily, after the vessels, which are situated superficially and are much distended, have burst and given rise to the bloody exudation. All of these investigations have been made on cadavers, and in this fact only, lies the explanation of the thoroughly varying results of C. RuGE and MoERiKE,^ who, by means of a sharp curette, removed the mucous membrane in living and healthy joersons, both during menstrua- tion and during the intervals between menstruation, and who examined these preparations, in part while fresh, and in part after they had been hardened. It is proved beyond doubt, by Moerike's work, that during menstruation the mucous membrane of the fundus of the uterus is not generally destroyed, either in its entire thickness or in a large extent of its surfice ; but rather, on the contrary, it always retains its ciliated cylindrical epithelium. Further, it must be considered to be settled, that the intcr- glandular cells do not appear to be increased in numbers or size, and that fattv degeneration can be proven, if at all, to only a slight degree. The vessels become dilated and considerably distended, and in the uppermost layers of the mucous membrane, extravasations of blood are developed. The homogeneous intei"-cellular tissue always appears to be increased. 1 Strieker's Med. Jiihrb. 1S73, H. 2, S. 159. 2 Williavis, Obst. Journ. of Great Britain and Ireland, Aiijj., 1^7.), Nov. and Pec, 1S75. — LcopolJ, Arch. f. Gvnak. xi. u. xxi. — Wyder, Arch. f. Gynak. xiii., Zeitsclir. t'. Geb. 11. Gyn-ik. ix. — Dc Sinily, Arcli. de Tocoiogic, iSSi. 3 Zeitschr. f. Geb. w. Gynak. vii.— Centralbl. f. Gyn-ik. iSSo, Nr. 13. 36 PATHOLOGY AND THERAPEUTICS Fig. 18. Therefore, it will he accepted that the menstrual secretions occur, only partly on account of ruptures of the vessels, and partly through the uninjured capillary walls. After the menstruation, the swelling of the vessels subsides, and the excessively hypertrophied mucous membrane of the uterus is restored to its normal condition, (Figs. iS and 19.) The ovaries generally become verv preceptibly swollen at the time of menstruation. Under favorable circumstances (thin abdominal walls, a slight degree of sensibility, and a wide, distensible vagina), the situation of the follicle, which is just maturing, can be felt. If the follicle has ruptured, in which case a minimum amount of hoemon-hage generally- finds its wa}- into the abdominal cavity, the swelling of the ovary sub- sides as the corpus luteum develops out of the rem- nants of the follicle, and with it the Fallopian tubes subside, which, at the time of the general hyperaemia, c o r ]• e s p o n d i n g to the swelling of its mucous membrane, could be felt appreciably thick- ened. Mucous membrane of the uterus with ciliated cylin- drical cells in the deep utricular glands of the uterus. According to Schroedcr's Handbuch, Ed. vii. Without any demonstrative analogous connection with a maturing of a follicle, women sometimes feel the discomforts of menstruation, t/ie menstrual inolime?i^ between two menstrual periods, without the appear- ance of any real bloody secretion. These molimena are sometimes ob- sened in full intcnsitv ; but in other cases, however, the women declare that they have this kind of discomfiture to only a slight degree, and still others endure abdominal or sacral pains, or stomach and head aches, at this time to a degree that is almost typically regular, while still others have onlv the sensation of openness of the vagina and of bearing down in the genitals. Sometimes the hitcrvoiing paifis become so intense (not unfrequenth' are they developed first in the course of sexual life, and sometimes, too, they are lost at this time), that the women seek the advice of the physician on account of tiiem. OF THE DISEASES OF WOMEN. 37 Having been instigated by the works of Fasbender,^ I have proven a relative frequency of sucli pains during the intervals, but most people, however, can themselves give only a very incomplete account of them. I can only show that there is a pathological character to these pains in the intervals in such cases, in which the symptoms are increased on account of diseases of the uterus. When necessary, such complications must be combated with thera- peutic means first of all. If the suf- ^i<3.^Q. ferings then con- tinue in a similar manner, bleeding can be employed shortly before the time for them to come on, and also derivative stimula- tion of the bowels and the external skin should be promoted. Some- times, if the suffer- ing is very great, an improvement can be made by the use of intra- uterine supposito- ries. In the most extreme cases of disorder, extirpation of the uterus and ovaries should be considered as the last means of help. Menstruating mucous membrane of the uterus. According to Schroeder. 2. DERANGEMENTS OF MENSTRUATION. We cannot, in general, understand as disturbances of menstruation, those disorders of which sensitive women so often complain during the course of menstruation, so long as they remain within the limits which are considered physiological for these processes. Therefore the question cannot be concerning menstrual disturbances, when there is a general feeling of being unwell, occasional transitory sensations of pain, a moder- ate variation of the amount of blood that is lost, or a variation in the 1 Zeitschr. f. Geburtsh. u. Franenkrankh. 1875, S. 126. 38 PATHOLOGY AND THERAPEUTICS (lunition of inciistniation of one or two days, or a secretion of mucous lasting for some (lavs bevond the course of menstruation. Actual anomalies of menstruation^ then, we have to assume onlywlicn the amount of blood lost is essentially diminished or increased, and when such fluctuations are frequently repeated, and, further, when the pains continue with a regular recurrence, and when they attain a regularly recurrent high deofree. The forms of derangements of menstruation which have the greatest clinical significance are a7ne7iorrhoca^ 7ne7iorrhagia^ and dvsmenorrJicca . Concerning these disturbances of menstruation, I should like to limit myself to a reference to the followMUg chapters, concerning every sort of disturbance of development and disease, in which these disturbances can be named as symptoms. I think, however, that I shall act according to the ideas of my readers, if I give, in the following pages, certain connected observations concerning these groups of clinical symptoms, which are so frequently peculiarly prominent, to which I can then refer in their respect- ive places. A. — Amenorrhcea. AmenorrhoBa, consisting either in a diminished flow' of blood or else a complete absence of the same, may be obsen'ed in different forms. I shall not consider in this place amenorrhcea during pregnancy and lacta- tion ; since, although a physiological hcemorrhage similar to menstruation is observed during the former, but only in the early stages, and even then with extreme rarity ; during the latter these occur ver}^ often. The varia- tions in these physiological processes is explained by the fact that ovula- tion ceases during pregnancy, and even before the mucous membrane of the whole uterus has been involved by the growing ovum. During the period of lactation ovulation is not unfrequently reestablished and together with it the possibility of conception. Pathological amenorrhcea is to be differentiated according to wdiether it depends on a defective development of the genitals, or of the whole body, or on constitutional diseases, or on diseases of tJie genitals themselves. In the first form, we must take into consideration the great dif- ference in the development of the body which determines the time at which the young girl arrives at puberty. It is by no means always the case, that with delay in the commencement of ovulation, there is associated a correspondingly incomplete development of the body. It cannot be doubted, also, that ovulation can exist a long time before menstruation appears. In this connection, I am reminded of the authenti- OF THE DISEASES OF WOMEN. 39 cated cases of conception without any preceding menstruation.' Compara- tively frequently in such cases of amenorrhoea, menstruation at the beginning occurs very irregularly, so that, perhaps, in the course of years, there is once a flow of sufficient significance to be called a menstruation. The most of such cases are chlorotic maidens and women in whom men- struation comes, in regular course, only after this condition had been overcome. Moreover, there are sufficiently numerous cases cited in the literature in which menstruation has never occurred, although the genitals have developed to an apparently normal degree, and, indeed, pregnancy has taken place. I shall discuss here, cases of amenorrhcea where the genital organs have been incompletely developed., only so far as discharges of blood, simulating menstruation, occur from completely developed genitals, and the appearance of haemorrhages from a cornu of the uterus or other parts of the genitals which are in a condition of atresia. I will consider these cases further when I discuss atresia. The second class of cases of amenorrhoea, in which there are wasting general diseases or diseases of special organs., can hardly demand a gynae- cological treatment. In these cases the amenorrhcEa is only a symptom of the other diseases, and it requir.es only the treatment directed toward the other complaints. A peculiar form of amenorrhcea may be observed when there is an excessive general development of fat., which may be sufficiently remark- able to cause a disappearance of the menstrual flow, even to a degree of complete suppression of the menses.^ Amenorrhcea, in consequence of diseases of the genitals., may, at times, be observed as a mere symptom of such forms of disease. Thus we know that amenorrhoea may sometimes occur hi the commencing stages of acute metritis and endometritis. Furthermore, the menses may disappear in cases of intense chronic diseases of the uterine parenchyma and parametrium, even if this is not particularly noticeable in immediate con- nection with such forms of disease. Diseases of the ovaries are some- times associated with amenorrhoea ; but more frequently the opposite is the case during the commencing stages of degeneration of the ovaries. Isolated cases have been observed^ in which physical influences have led to a suppression of the menses. The cases which have been observed by me, and which can be considered in this connection, concern girls and women with incipient mental diseases. Not so very seldom is the aid of ' L. Mayer, Berl. Beilr. zur Geb. und Gynak. II, S. 124. - Kisch, Berl. KUnischc Woch. 1867, Nr. 20. — Wien. med. Pr. 1S70, Nr. 15-20. s Parvin, Aiiier. Practitioner, Sept., 1S72. — Raciborski, Arch. gen. de med. 1S65. 40 PATHOLOGY AND THERAPEUTICS the gynaecologist desired in cases of patients of this sort, in whom the development of the other disturbances of the mind has not yet made the disease of the nervous system more prominent, in the eyes of the laity, than the diseases of the genital organs. Leaving out of account those cases in which there is a primary want of anv flow, amenorrhcca is not generally developed suddenly, but more frequently the flow of blood becomes, at first, more scanty ; then it re- turns, after intervals which continually grow longer, and it is of very short duration. One or two periods of menstruation may be passed over, or, after a later period, it may return to normal ; or, again, it may become regular after an interval of five or six, or even seven or more weeks. In the former class of cases, in particular, intense appearances of congestion often occur at the time of the expected menstruation. Pains in the head and sacrum, pressure in the breasts, and pains in the abdomen are fre- quently associated m these cases of such regularly recurring disorders, with hiEmorrhages from the rectum, from the nose, and also from the stomach. In general, we must be very careful how we pass judgment concerning these so-called vicarious haemorrhages. Very frequently, at the time of the expected period, we find, locally, that the secretion of the mucous membrane of the uterus is increased. At the commencement, also, there is often a marked turgidity of the organ ; also swelling and sensitiveness, while, after a long time of this condition, all such appear- ances may be completely lost. I have often seen a climacteric prematurely developed, with wholly analogous symptoms, and, with it, shortly after or even before the thirtieth year of age, I have observed involution of the genitals, with disorders of this sort, lasting for years. The special indication for treating amenorrhoea, as such, may be on account of the painful symptoms of congestion in other organs. I have decided to employ local treatment, only when such disorders were present, while for the rest I am accustomed to manage by means of nourish- ment, or other adequate means for the strengthening of the body. For such invalids sojourns in the country, sea-baths, and excursions into the mountains and forests, are to be especially recommended. Among the forms of amenorrhoea in consequence of general diseases, mention may especially be made of obesity, for which the results of saline cathartics, especially the Marienbad springs, are really remarkable. For a very long time I have not employed the so-called emmenagogues alone, for the relief of amenorrhoea. Of these, I now make use only of aloes in obstinate cases, since in this way 1 excite the action of the intes- tines which, in these cases, is almost always troublesome. I expect better results, however, when there are no other particular indications fur- OF THE DISEASES OF WOMEN. 41 nishecl by other special diseases of the genitals, from stimulations, which, according to my experience, excite the mucous membrane and parenchy- ma of the uterus. For this purpose, I consider as best of all the employ- ment of scarification, which, in cases of persistent amenorrhoea, I repeat th(M-oughly, sometimes every second day, and in other cases every day, at tlie time when menstruation should be expected. Then, I also employ the sound, intra-uterine pessaries, cold sitz baths, and, finally, irritation of the skin over the hypogastrium and the inner surface of the thighs. B. Menorrhagia. Under the head of menorrhagia, we understand those menstrual liEemorrhages from the uterus, which aftect the condition of the health, partly on account of their intensity and partly on account of their long duration. It is often very difficult for us to estimate a superabundance of the flow of blood, since we have no means of measuring the amount of blood which comes away, and hence \ve cannot establish the relative quantity of a normal menstruation. Sometimes, when menorrhagia has been complained of, I have caused the flow of blood to be caught on cloths, and then I have examined them myself. In this way I was not a little surprised, to find that some women would consider a comparatively small amount of blood to be an excess, which other women, of a somewhat similar con- stitution, would consider to be normal. Only very seldom does it assume the character of a real flow of blood from the genitals similar to a menstruation, but generally, however, it flows away intermittently, fre- quently mingled with coagula, which usually frightens the women very much. Since I made these observations I have never allowed myself to consider a menstrual flow as profuse without investigation, and before I make this diagnosis, I am always accustomed to investigate for myself what amount of blood is lost. A menorrhagia voy seldom occurs xvithotit some important disease of the geiiitals. We occasionally meet delicate women who are poorly nourished and who live irrationally, who have lost blood very extraordi- narily by menorrhagia, without the existence in the genitals of any occasion for these haemorrhages, which can be discovered. Several of these patients whom I have had under observation for a long time, I have most carefully examined concerning the condition of their genitals without finding, in this way, any evident pathological condition. Sometimes such men- orrhagia is found in consumptives, and I have observed such a condition in patients suftering from diseases of the heart, liver, or kidneys. Also obese persons sometimes have menorrhagia in contradistinction to tlie 42 PATHOLOGY AND THERAPEUTICS amenorrhoca, which is more frequent. In all of these, the general condi- tion of the patient requires the entire attention of the physician. The menorrhagia gets well of itself, coincident with the changes in the affected organs, or, at anv rate, becomes relatively unimportant in com- parison with the organic disease. In the treatment of such menorrhagia, abstraction of blood shortly before the appearance of the menses curiously enough is very efiective, and sometimes we can decrease the menorrhagia by a mcxlerate scarification shortly before its appearance. In other cases a cessation of the hjemor- rhage can be accomplished occasionally by employing ergot or the fluid extract of hydrastis Canadensis, in doses of fifteen drops four times a day, by keeping the body quiet and avoiding every exertion, even Fig. 20. jf necessary by rest in bed at the time of the menorrhagia. As a means of controlling the haemorrhage I recommend, particularly, hot vaginal injections^ at a temperature of 40° R. (222° F.), from which I have seen better results than from the employment of cold, whether it was in the form of injections of ice-water, or in the form of long- continued irrigation through the well-knowfi cooling ap- paratus (Fig. 20), or in the form of cold sitz baths. In the case of consumptives, I have never received any benefit from the hot injections, so that I cannot recommend them ^ ,,^ , for such patients. Onlv very seldom, and in isolated Cold Speculum. ^ . " . According to cases, does menorrhagia, without any special anatomical Kisch. reason, resist an energetically continued local treatment of this sort. Occasionally, however, such cases are observed. In these, there are very slight changes in the mucous mem- brane with a quite insignificant enlargement of the whole uterus. For such desperate cases, extirpation of the ovaries has been rec- ommended ; and in one similar case I have myself extirpated the normal ovaries of an unfortunate woman, who had been incapacitated from earning her living in consequence of her hamiorrhages, and who had for many years sought aid in vain in many diflerent hospitals. In this case, I had previously for years employed in vain every means of treatment known to me. In consequence of this, however, the menor- rhagia did not entirely disappear, and after the person had satisfactorily recovered from the castration, she flowed afterwards as before, to a large amount, as I frequently satisfied myself. Finally, I decided to extir- pate the uterus in the case of this patient, who was 37 years old, and now I see this unfortunate person at times, and she always assures me 1 Bertram, Zeitschr. f. Geb. u. Gynak, viii. 18S2, S. 150. OF THE DISEASES OF WOMEN. 43 that only now, after having been an invalid for many years, is she again able to work. Naturally, I consider such a procedure as warranted, only in the most extreme cases, and I am full}- conscious of the responsibility of this treatment, which was special in this case. Menorrhagia is a most common symptom when the ge7iital organs are diseased^ whether the mucous membrane is also affected or not. Al- though, when the uterus is diseased, a simple explanation is found in the hyperiemia associated with it ; yet it is more difficult to understand how diseases of the uterine adnexa, for instance, of the ovaries and Fallopian tubes, can exert a precisely similar influence. In nearly all of the follow- ing chapters I shall have to refer to menorrhagia. The treatment of it forms a portion of the treatment of all forms of disease. C. Dysmenorrhcea. We cannot consider as dysmenorrhcea those troubles which most women suffer at the time of menstruation, viz. : pains in the sacrum, discomfort, a feeling of heaviness in the body, a sensation of being open, a desire to micturate, and others. These are the accompaniments of menstruation which are sensibly endured by most women, as associated with this occurrence. Only when these troubles render the woman unfit for any duty at the time of menstruation, do they deserve consideration. These pains ai'e very much increased by diseases of the genital organs, both by endometritis, metritis, perimetritis, and particularly by new growths in the uterus. Especially in the case of perimetritis, the rupture of the Graafian follicles may be accompanied with severe pains, which always have a certain importance as signs of this disease. The really dysmenorrhoeal troubles, are the pains like colic, which commence frequently before the flow of blood, in the character of labor pains, and they disappear when the flow commences, while in other cases they continue during the whole tim.e of the menstruation. These uterine colics may be repeated, when there is an abundant secretion independent of the menses, and they occasionally appear during the pains in the menstrual intervals which were mentioned before. These pains appar- ently arise on account of the hinderance to the escape of the blood, and of the secretions of the mucous membrane. Such a hinderance may be caused by a flexion of the cervical canal, in other cases the obstruction may be due to swelling of the mucous membrane, stenosis, or new growths. It must be assumed that the pent-up secretion, as a foreign substance in the uterus, excites more or less energetic contractions until the obstacle has been overcome. The objection which English authors 44 PATHOLOGY AND THERAPEUTICS (M. Duncan * and Playfair) give to this explanation : that such a stop- page of the uterine contents cannot be found on the autopsy table, appears to be little applicable ; for I have myself repeatedly seen such retained masses in the uterus, when opportunity was offered for an autopsy ; and, moreover, it is a fact very often observed that foreign substances may be pressed out of the uterus during the death agony, or by post-mortem con- tractions. Why, then, should we not assume such an expulsion in these cases, which, moreover, so rarely give occasion for an autopsy? The peculiar form of dysmenorrhoea, which reaches the acme of its development in the expression of the superficial mucous membrane of the uterine cavity, accompanied by strong colic-like pains, is frequently con- sidered, in a chapter by itself, as exfoliative or me7)ibranous dysmen- orrJicea, This is only a peculiar form of endometritis, and it will be explained in that chapter. The general treatment of dysmenorrhoea is carried out together with that of the local disease. Only very seldom are we obliged to do anything to the uterus itself. In cases of obstruction of the uterine canal, on account of anomalies of form, I have occasionally seen great ameliora- tion of the joatient occur while wearing an intrauterine pessary; while in other patients the colic pains become very much increased on account of the presence of the foreign substance. Such local treatment is precluded when there exists diseases of the neighboring- tissues. D. Conception. I will not go into any detail here, concerning the different hypotheses regarding the circumstances of conception. In the intciest of the woman, I will only state that the presence of a spermatozoum capable of causing generation, is essential for the process of conception ; and we must, there- fore, avoid ascribing the blame, in an unjust manner, to the woman alone, in cases of sterility. It has been shown with sufficient certainty, by the investigations of Kehrer,'^ that about a third of the cases of marriages without issue, are occasioned by the lack of generative power in the man. Only occasionally have I been so situated that I could examine the sper- matozoa in such cases, and I do not venture to place the results of these investigations in the balance in deciding these questions. From the ante- cedents of such men who are married and ha^e not produced children, I think tliat I can draw the conclusion, that Kehrer's statements are in accordance with the facts. Therefore, before we ascribe the cause of the ' Edinh. Med. Joiirn., May, 1S72. — Fecundity and Sterility, 1S73. 2 Zur Stcrilitatslehre. Beilr. zur kl. u. exp. Geburtskunde u. Gyn. ii, I. S. 76. OF THE DISEASES OF WOMEN. 45 sterility to the woman, and attack some diseased condition or other of her genital organs for the removal of the sterility, it seems to be advisable to decide with certainty concerning the potency of tlie man. I am fully convinced how great difficulty there is in tliis in practice, and I regret that I do not know any means of establisliing the reproductive powers of the man, without the inconvenient examination of the spermatozoa. The spermatozoa pass very quickly deep into the genital' organs; but, under conditions of the vaginal and uterine secretions favorable to their long life, they retain their power of fructification in the uterine cavity for a number of days, so that we need not assume that conception always immediately follows cohabitation. The occurrence of conception is not infrequently recognized immediately, by peculiar changes in the feelings of the woman. At times, conception appears to be closel}' connected with a voluptuous sensation, which, as a rule, occurs rather seldom in women, and generally, only after long-continued excitation ; this sensation is analogous to that connected with the emission of semen. In other cases mental symptoms are observed as soon as conception takes place ; while other women assert that they experience a peculiar feeling of warmth from this time forward ; and, finally, some women not infrequently show the characteristic troubles of the commencing stages of pregnancy from the time of the occun-ence of conception. Whether a conception is more readily caused by a cohabitation shortly before the period of the return of the menses or soon after, the same appears to me, as far as I have been able to investigate the question, to be incapable of decision from clinical observations. E. Sterility. The final causes of the conditions, which occasion sterility, are not by any means simple and clear. If we leave out of question the entire absence of the organs producing the oviuTi, or a complete closure of the passages leading to them, we can hardly prognosticate an absolute sterilitv in the woman, even when there is a great degree of development of patho- logical processes in the genital organs ; for how often have the conditions most frequently supposed to cause sterilit}-, nevertheless allowed concep- tion to occur, although perhaps accidentally. I recollect, in this con- nection, the cases of cribriform and imperforate hymen," the cases of the greatest degree of stenosis of the external os uteri, as I have repeatedly observed myself, and cases of lasting disease and advanced degeneration ' Lott, Zur Anatomic und Physiolog-ie des Cervix uteri, 1S72. - C. V. Braun-Fcrtizvald , Wiener mod. A\'ocli. tSS2, Xr. ^5. 46 FATJIOLOGY AND THERAPEUTICS of the ovaries in which pregnancy has, nevertheless, occurred. There- fore, it would be very incautious, in presence of such changes, to make the prognosis absolutely unfavorable as regards conception. Especially with regard to the stenosis of the external os uteri, I have become very careful, since, in spite of all theories, I have seen conception occur in women who had the opening of the os only the size of the point of a pin. And, yet, in general, the probability of conception in such cases, may be estimated as very small, especially when there are diseases of the uterus or ovaries. The possibility of conception seems to me, to be the most improbable, when those changes appear in the female genital organs, which have been caused in connection with infection, usually gonorrhoeal in the Fallopian tubes, the parametrium, and, perhaps, in consequence of this, also in and about the ovaries themselves. These cases of chronic oophoritis, perioophoritis, perimetritis, salpingitis, and simultaneous chronic uterine catarrh, I have seen so far, with only rare exceptions, as- sociated with permanent sterility. But, since we should not despair of the possibility of curing these conditions until after long-continued consecutive attempts at treatment, we have to be very cai-eful in speaking in regard to a prognosis. I shall, however, return to this question, in considering the special forms of diseases of the genital organs. OF THE DISEASES OF WOMEN. 47 III. — PATHOLOGY OF THE VAGINA AND OF THE UTERUS. If I make the attempt in the following chapters to summarize the pathology of the vagina and the uterus in their varieties of arrested development, changes of form and position, and in mentioning the forms of inflammation, it is w^ith the design to discuss and explain, connectedly, whatever is correspondingly related from an etiological, pathologico- anatomical, and therapeutical point of view. In particular, the etiology and therapeutics of these diseases of the different parts of the genital tract, are so often closely related, that I hope to render the discussion of them easy, considering them together, and so to avoid much repetition, while the peculiar, pathologico-anatomical changes are considered in a satisfac- tory manner. A. ANOMALIES OF DEVELOPMENT AND ALTERATIONS OF FORM AND POSITION. I. — Defects of Development of the Vagina and of the Uterus. The development of the sexual organs can be easily understood with the assistance of the annexed diagrammatic drawings which I have taken Fig. 21. Fig. 22. Fig. 23. ^ Fig. 21. — all. The AUantois, afterwards the bladder. r. Rectum, m. MUller's duct, afterwards the vagina, a. The external reduplication of skin which will form the opening for the anus. Fig. 22. — The external reduplication of skin has become perforated and now forms the cloaca. ( Gaz. des hopit. 142, 1S56. ' Arch. f. Gyn. ii. S. 92. ^ I^ndon Obstetr. Transactions, V, S. 2S4. * Graf, Virchow's Archiv. 19, S. 548. " For instance the case ynywrt (Zeitschrift f. Geb. u. Frauenkrankh. S. 130) which Jaqurt had the kindness to show me in due time. [Annals oi Gvn.i'.c'oi-ogy, Uoston, Ucccmbcr, iSSS. J III CONGENITAL ATRESIA OF VAGINA. OF THE DISEASES OF WOMEN. SI vcloped, ought to offer no difficulty, if an appropriate history is possible. The absence of menstruation by persons for the most part youthful ; the pains occurring periodically ; the finding of a mass which is generally globular, which we can feel by die rectum and bladder ; or, when the atresia is higher up in the genital canal, between the vagina and the hand which is placed exteriorly, is hardly to be confounded with any other form of illness, even if the genital organs are not proven to be normally developed. Also, IV hen the atresia Fig. 28. is acquired., the history of the case, which gives us informa- tion concerning d i ffi c u 1 1 confinements in the past, or diseases of the genitals, or gynaecological operations, gives the proper interpretation of it. I have seen congenital atresia hymenalis (hcemato- colpos) six times ; once in a well-developed young girl, fifteen years old, who, in the course of the last half year, had had menstrual disturb- ances four times, without any loss of blood (Fig. 28). The second case was in a very poorl3'-fieveloped girl of nine- teen years, who began to suffer about a year previously. The third was sixteen years old, and had had difficulties for about five months ; and the fourth was fifteen and a half years of age, and had complained for about three months. The fifth case was a well-developed girl of seventeen vears, whose first troubles were when she was fifteen years old ; who had attacks every three weeks after a year and a half, and these finally extended into continuous pains. The sixth case complained of difiiculties similar to the fifth. In all of them there lay a great sac in the pelvic basin, which reached up into the pelvis above the brim, and here above, could be felt a projection which nearly corresponded to a virgin uterus. This sac bulged into the orifice to Ihe vagina, and pressed forward a hymenal septum, the color of which was a dark bluish red. Congenital hL\?niatocolpos. ^s PATHOLOGY AND THERAPEUTICS Fig. 29. The acquired forms of atresia develop, for tlie most part, gradually from stenosis of the canal ; and indeed, comparatively speaking, atresia occurs only rarely, in proportion to the frequency of stenosis of high de- gree. In this class belong most all of the striking obserN'ations in the case of pregnant and cliild-bearing women ; in whom, according t<; nearly all accounts, the flowing or trickling away of the liquor-amnii is observed, while an opening cannot be found. Such stenoses, and the atresias derived from them, are observed after typhoid fe- ver, scarlet fever, cholera, diphtheria, syphilis, or in the case of new growths. Cases of atresia occur rarely after apparently simple catarrhal inflammations. Those are more frequent, which are in consequence of injuries at confinement, by which the cervix and the vault of the vagina is desti^oved. Finally, atresias are formed in consequence of operative measures, espe- cially those in which the appropriate use of mucous membrane is omitted or im- practicable, and after the use of caustics. Corresponding to this etiology, acquired atresia has its situation more frequently in the upper portion of the vagina, in the vaginal vault and in the cervix, and onlv rarely does it develop high lip in the cervix at the internal os uteri. In the case of absoicc or closure of the lower end of the vagina (Fig. 29), the uterus itself is appreciably dilated only rarely, and only very late, on accoimt of the pressure of the blood wliich it contains. It appears as a nodule or projection from the surface of the bulk of the tumor, being hard and frequently exceedingly easily movable. The tumor itself rises up into the peritonial cavity out of the pelvic basin with a broad base. It lies in the median line like a tumor of the uterine adnexa on the jjeri- Congenital hoematometra and hivmatocolpos. OF THE DISEASES OF WOMEN. 59 toncum, and it can be felt smooth-walled, tense, and elastic. On the upper part is attached the above-mentioned projection. Whefi blood is retained by an atresia developed in the titerus itself ( /nvf?iato?netra )^ the uterus, on account of the retention above the external OS uteri, is distended, at first violin-shaped, and then round (Fig. 30). I have only seen such cases of atresia of the uterus proper when they were acquired. In one case, the cervix uteri had been destroyed during a severe attack of typhoid. In another case the atresia had Fig. SO. developed after a high excision of the cei'vix, without suturing of the mucous membrane. In this case, the rounded fundus, of the size of a small apple, lay above the cicatricial cervix. In the third case, the young lady (Mrs. K.), who was 21 years old, had previously men- struated regularly, but not ex- cessively, corresponding to the slight development of her mus- cular system and her delicate constitution. Since her mar- riage, a year previously, the menstruation became gradually more scanty, and finally it ceased altogether, so that she was believed to be pregnant. The patient sought medical advice on account of severe pains. It was proved that a tumor with a rounded lower border filled the pelvis and misplaced the vagina, right behind the orifice. The tumor extended to the navel, and had here a cap which appeared to be like a thickening of the wall of the tumor (Fig. 31 ). It ended below in a broad mass filling the entire pelvic brim. The bladder and tlie rectum lay firmly compressed, the former before and the latter behind the tumor. There was nowhere any opening on that portion of the tumor which could be seen per vaginam. I incised at the vault of the vagina and evacuated a very large amount of typical, thick, tar-like contents. The condition of thincjs in the interior of the cavit\-, could soon Haematometra. 6o J\l J JiOL O G y AM) THERAPF UTICS be perceived to be a sort of contracted ring. The posterior uterine seg- ment and the cervix appeared hi Heppner, Pctcrsb. med. Woch. 1872, H. 6, S. 552. ' Simon, Bt-rl. kl. Woch. 1875, Nr. 20. 3 Amussat, Observ. sur unc op^r.ition de vagin artificiel, 1835, Paris. OF THE DISEASES OF WOMEN. 63 ting, by means of the forceps, the scalpel handle, or the finger. I have bored through the remains of the septum, partly with a trocar, partly with a knife, and partly with a sound, and then I have gradually dilated the opening in the necessary manner. In the further course of treatment, however, it is very important to think of the extraordinary contraction of the cicatrix which usually occurs in these places. The cicatrix may indeed, after a few weeks, produce a new atresia. Therefore I have immediately united, with a suture, the mucous membrane of the retention cavity with the outer skin or with the sound mucous membrane, which lie nearest, and by this means I have prevented the possibility of a new atresia. When the atresia is more deeply situated, I have first introduced a drainage-tube, and then after the patient has convalesced, I have under- taken the excision of the whole cicatrix, and the union by suture of the mucous membrane of the retention cavity with the mucous membrane of the vagina. In the case after typhoid fever, the retraction of the scar nevertheless recurred. In consequence of often repeated passing of the sound and dilatation, the scar remained wide open for a very long time. Then, however, when pregnancy occurred, and every sort of dilatation was therefore forbidden, this scar contracted to a stenosis of high degree, so that it had to be divided in a thorough manner, for the purpose of the delivery of the child at term. In my last case of acquired hcematometra, I immediately undertook the suturing as above described, and I observed healing without any i^e- action. Continuous disinfection, and, if necessary, the employment of hot irrigation, for the purpose of involution of the cavity, are much recom- mended for this sort of operations for atresia. In order to prevent the danger of contraction of the scar, Heppner {loc. cit.) has proposed to sew in the flaps of the H -shaped cut. B. Crede has advocated a transplantation of an external flap of skin (Arch. f. Gynak. 18S4, xxii. S. 239). Breiskv is surely right in emphasizing (Krankheiten der Vagina. Billroth-Lucke, 60, 1SS6, S. 49) that a peri- odical dilatation is of advantage in preventing a stenosis. An exhaustive communication of my observations pertaining to this subject has been prepared by Mr. Kiderlen. II. — Atrophy of the Uterus. To the consideration of the incomplete development of the genital organs in generaj, I will add a short chapter concerning the special forms of atrophy of the titerzis. In this class, I consider those cases in which 64 FA niOLO G y A A D TJIERArE L 7 ICS Fig. 32. Atrophy of the uterus according to /7rf/w7<:'. oi. Internal OS uteri, oc. External os uteri. the (Icvclopincnl of the uterus, a.s a whole, is incomplete, while the form of the uterus lias developed wholly typically ; and also those in which tiie uterus has become atrophied during the child-bearing period, either with or without previous diseased processes. A. — In the case of the so-called con- genital atrophy^ the uterus appears either in the form and size of its development in infancy (Figs. 32 and 33) or we find it in the infantile form of the organ at pubert}'. Until puberty is established, atrophy causes no symptoms, and even afterwards m a n y women with such infantile uteri (and the number of these is not so small as we often suppose) remain entirelv free from diffi- culty. In external appearance, they have a very well marked female type and feminine sensibilities. I have repeatedly seen such women between 30 and 40 years old, who had always enjoyed uncommonly good health, and had been happily married, and had no complaints except the absence or the irregularity of men- struation and sterility. They are frequently disposed to be markedlv obese. Others preserve a virginal exterior until late years of life. The functional symptom of the development of the uterus {nienstruadioii) frequently appears peculiar. In some cases there are established at long intervals, frequently dependent on the circumstances of climate and weather, in other cases dependent on external conditions of life, the so-called infantile Uterus. menstrual moliniena^ which last one day or more, and then disappear again, without anv loss of blood from the genitals. Among these molimena are luiderstood colic-like pains in the hy- pogastrim especially in both sides, increase of the secretions, pressure on the bladder and rectum ; a high degree of nenousness ; frequent, also in- creased sexual excitability. Occasionally, instead of these molimena, Fig. 33. OF THE DISEASES OF WOMEN. 65 more or less localized in the hypogastrim, another sort of difficulties occur, especially on the part of the stomach, and also in the form of violent pains in the sacrum, migraine, rheumatic complaints and sudden illnesses. Then there occasionally occur violent hasmorrhages from the nose, from haiinorrhoids, and also, indeed, from the stomach, and also marked swell- ings of varicose veins on the lower extremities. Others complain of ex- treme congestions and perspiration at this time, and similar disorders. In this way women affected with atrophy of the genitals can pass through many years, without having their complaints excessively increased, and, indeed, these often disappear quite gradually, and there is developed a premature old age. In other cases there occur irregular flowings in- terruptedly ; sometimes in the course of sevei'al years ; sometimes once in the spring, and once in the autumn ; while in still other cases I have ob- served tiiore frequent, and then, indeed also, very abundant flowings. Many times these flowings have been considered to be abortions. Such irregular flowings then, indeed, first of all, cause these poor women to seek medical aid. The condition of atrophy of the utertis can often be proved only with very great difficulty. Either the women are especially difficult to examine on account of great sensitiveness and fear, or they have very thick abdom- inal walls, a vagina which has been developed very narrow and peculiarly long; and since just these women suffer from obstinate constipation, the fulness of the intestines makes an exact examination very difficult. On this account, especially in these cases, it is frequently necessary to com- plete the examination under the influence of anaesthesia. We find in them, at the end of the vagina, which is for the most part hardly penetrable, a small, nipple-shaped prominence, with a small opening, and we feel above this little prominence a small fleshy mass, which lies in the depths of the cavity of the sacrum, and can only be brought with difficulty between the two hands for an exact palpation. Then we find sometimes, a very small fundus uteri, about a centimeter long above a thin cervix, which may be three centimeteis long. The fundus is sharply flexed, and it hangs down either before or behind the cervix. In other cases we find a body corre- sponding in its form to the uterus after pubert}', which is above a corre- spondingly small cervix, which lies occasionally sideways or retroverted. This condition can be most definitely determined through the vault of the vagina, or by the rectum. Jnst for these cases, the examination with a sound appears to be very essential in differentiating the relative length of the cervix and fundus. As a rule, the use of the sound itself in this form of the uterus has caused me no difficulty, if I had previously instructed myself concerning the direction in which the sound is to 66 PATHOLOGY AND THERAPEUTICS advance. The walls of the uterus are not unfrequently lax and soft ; at other times, liowever, they are peculiarly thick and hard. TJic diagnosis of atrophy of the uterus depends entirely on palpa- tion. If the women are well developed in other respects, then, as has been explained above, their sensitiveness, the deposit of fat in the abdom- inal walls, the narrowness and the shortness of the vagina, oppose really considerable difficulties to the palpation of the uterus. On the other hand, such women seek the physician on account of previous haemor- rhages or severe acut^ disease, and then they prejudice the examiner with conjectures of previous abortions, and of active inflammations, with abundant formation of exudations. I have had to examine and treat several ladies, in whom remarkably diverging opinions by the examining physicians were caused on account of such suppositions. The prognosis of this sort of defective development of the uterus, is represented in the text-books as somewhat bad, and I must confess that ii really depends, at any rate, on the fact whether such women come under treatment at an age which is still comparatively youthful, whether they have the necessary patience to undergo a treat- ment v\"hich is very tiresome and not always comfortable, and also whether outside conditions permit, in an appropriate manner, such a long medical treatment. If these conditions are combined in a favorable manner ; that is to say, in the case of relatively young women, under favorable external surroundings ; then I have seen in a percentage, which was modest, to be sure, not alone an actual relief of the sufferings occur, but I have also observed a development of the uterus ; indeed, in two cases even preg- nancy up to a normal completion has afterward ensued. Therapetitics. — At first, it appears indispensable that these con- ditions be established by a thorough digital examination ; for a successful treatment is, indeed, only conceivable if the patient consents to such an examination, a point whicli, as is well known, often affords great diffi- culty in practice. As soon as anomalies of the development of the above-mentioned kind are complained of, especially the absence of menstruation, w'hich cannot be explained for any other reason, or as soon as an appropriate treatment does not accomplish the purpose inside of a year's time, together with other simultaneous indications, I am inclined to refuse all further treatment if a digital exploration is not allowed. If the uterus is found to be atrophied in one or the other forms, then I earnestly recommend not to postpone the local treatment. It is self- evident that this must go hand in hand with an appropriate general treat- ment. Under this general treatment, I mean less the employment of OF THE DISEASES OF WOMEN. 67 Fig. 34. preparations of iron, than much more a universal attention to the strength- ening and development of the body. I withdraw such girls from any school instruction and any other sedentary occupation. I cause them to exercise very freely in the open air, and walk as much as possible, and also ride, skate and take frequent baths. Then, finally, I look out for regular digestion and a strengthening diet, for which I consider of especial benefit the use of good beer, milk, and meat in all forms. At first I einploy locally only simple, lukewarm injections of water, allowing the irrigation fluid to fall from a considerable height; and, finally, sitz-baths to which salt has been added. Whenever it is possible, I send such patients to the sea-shore or to the mountains, where, cer- tainly, very satisfactory accommodation and atten- tion at the selected places is an indispensable condition. If an excessive deposit of fat is associated with such anomalies of development, a removal of the fat is the first step in the treatment. The " cures " at Marienbad and Kissingen not unfre- quently have a very favorable influence on the menstruation. I have, several times lately, secured with good results, a very carefully directed cure for the removal of fat according to Oertel. I continue such a treatment for several yeai's, and I also recommend the temperate employment of chalybeate baths, sojourns at the sea-shore, and, in case the result is not attained, a further local treatment. If the question is concerning older individuals, then I at once combine a local treatment with these general directions. Young girls are only to be subjected to an immediate local treatment, when the atrophy of the uterus is accompanied with severe general disturbances. The local treatment must first attempt to act by increasing the blood- supply, and by developing the muscular tissue and mucous membrane of the uterus. We very frequently attain this result .by scarification of the vaginal portion of the cervix^ which is performed at first daily and then after various long intervals of time. I do this with the well-known Mayer's scarificators (Fig. 34), and with them I scratch the mucous membrane of the cen'ix in all directions from the external os outwards. At first the bleeding is not very excessive, and therefore I attempt to in- crease it, by directing the patients to go about for a quarter or a half of an Scarificators according to C. Mayer. 68 PATHOLOGY AXD J'JlJiRArJWTICS hour after tliis .scaiiflcati(in, rather than to he dcjwn cjuictU iiiiinechatclv afterwards. The hiL'inorrhage grackially becomes more al)un(lant even if the scarification is superficial. Then it is necessary that the patients remain quiet for an hour or two after the scarification. In case there is still more abundant bleeding, we must direct such patients to take injections of a strong solution of pyroligneous acid. As soon as the hemorrhage becomes excessive, I do not repeat the scarification more than every two or three days at first, and then once a week. I frequently introduce the sound up into the fundus in order to act on the mucous membrane of the uterus in an irritating manner. The uterus and the whole contents of the pelvis become really less sensitive by means of such preparations, while sitz-baths are taken with decoctions of bran, or brine. About six weeks after Fig. 35. the commencement of the treatment, we can gener- ally consider the introduction of an intrauterine pessary (Fig. 35, a^ to establish a continuous irri- tation in the uterus. This pessary often accom- plishes a very intense stimulation of the walls of the uterus. Very frequently, the uterus swells quite appreciably under its influence, without becoming sensitive, however, in all cases, or without pro- ducing acute pains. This swelling not unfrequently Intrauterine pessary and lasts beyond the period during which the pessary support. Js in jDosition, and from this by further use, I have seen produced a vigorous development of the muscular tissue and mucous membrane of the uterus. The material for these pessaries is either iron or a combination of zinc and copper, such as my father used to a great extent. I consider that these pessaries of zinc and copper exercise a very peculiar, intense stimulation of the mucous membrane of the uterus ; for when these pessaries have been worn a cer- tain time, it occurs that the zinc has lost its smooth surface, as if it had been corroded ; indeed, after very long use of the pessary, I have found the zinc side completely destroyed ; however we may explain the chemical pro- cesses in these changes, yet it must be admitted that this process exercises an influence on the covering of the pessary also, and, according to my ex- periences, it seems that this influence is of very great value in attaining the desired end. The thickness and length of the pessary are determined by the lumen and the length of the uterus. The pessary must be about a half of a centimeter shorter than the uterus itself. The introduction of the pessary occasionally meets with very great difficulties, on account of narrowness of the parts, the length of the vagina, OF THE DISEASES OF WOMEN. 69 and the impossibility of easily fixing the small uterus. By proper prac- tice and patience, however, it is possible to introduce the pessary. For this, I generally proceed in the following manner : Always acting on the supposition that the uterus itself and its surroundings have become tolerant to the introduction of the sound, I insert it, and by means of it I bring the whole uterus as near as possible to the orifice of the vulva, and I fix it here with my right liand, wliich holds the sound. Then the pessary, which I have secured between the thumb and forefinger of my left hand, is shoved forward along the sound up into the external os uteri, and with its tip in the os uteri it is pressed into the vagina, while tlie sound allows the uterus to slip back until the button of the pessary has passed the vulva. Now the sound is drawn back, and by pressure of the left fore- finger on the button of the pessary, it is pressed forward into the canal where the sound was. We often have the sensation as if the sound had been sucked in by the uterine canal, so quickly does the instrument glide forward into the cavity of the uterus. In other cases, we easily succeed in pressing the pessary as far in as the internal os uteri, while the introduction into the fundus appears to be almost impossible. The obstacle at this spot is caused either by the narrowness of the os, when we must use a smaller pessary, or the flexion of the fundus on the neck prevents any further pro- gress. In these cases, we must raise up the fundus through the anterior vault of the vagina ; if it is antiflected, and through the posterior, if it is retroflected, until the fundus and the cei-\'ix lie approximately in a straight line. Then the introduction of the pessary easily succeeds. By proper practice and thorough preparation, the introduction of the pessary is ac- complished without injuring the mucous membrane or the occurrence of any haemorrhage, although the latter would be of no particular importance, under the supposition that decomposing seci^etion is not present or un- clean pessaries are not employed. If necessary it is evident that we can very much facilitate the introduction of the instrument by means of anaesthesia. The pessary generally remains in position without further support. The vaginal wall sustains the button, so that this lies pressed against the lips of the cervix. If, on the contrary, it sinks down out of the canal, then it must be fixed, and for this purpose we can employ the second instrument. (^'ceFig. 35, (5.) The broad plate should be placed under the intrauterine pessary while the handle protrudes from the vulva. The instrument is held so that the plate can be placed perpendicular to the entrance, while the handle fastened to it, lies over on the side. Then the plate is pressed into the vagina, and here, somewhat at the height of the vault of the vagina, it is placed transversely. The point of the handle then still looks out of 70 PATHOLOGY AND TJ/ERAPFM77CS the orifice, and prevents the turning of the plate. The button of the in- trauterine pessary moves about unhindered on the hitter. After the pessary has been introduced, the patient is obli<^ed to remain quiet for several days, although absolute rest in bed is not necessars . Then, when it has been proven that the uterus and its surroundings are not sensitive, I allow the patients to go about their household duties. 1 also allow them to go to their home with these pessaries, and now I continue to employ everything for the improvement of the general condition, which I formerly employed. Ever}- time after the introduction of these pessaries, I have observed a periodical flow of blood occur, and, indeed, in more than half of these cases these periods have occmred verv abundantly, and very advantageously for the general condition. Then, T have removed these pessaries again, after a period of three or four months, and then in about a quarter of my cases I have found the uterus in a very satisfac- tory condition ; and, indeed, among these women pregnancy has repeatedly occurred afterwards, with delivery at full term. In other patients, the uterus was at first in good condition and the slight redness which enveloped the OS uteri, after the removal of the pessary, disappeared. The periods continued regular for a time, and then after a half year or more they be- came irregular again. Then I have repeated the treatment with the pes- sary, and I obtained lasting benefit, in some cases at least, for longer time, while the uterus remained tolerably developed. In other cases the result has been less satisfactor}-, and this was especially true with such women as came for treatment at a more advanced period of time, that is to say, above the age of twenty-five. In these cases, indeed, I have obtained improvement also, as long as the pessary was worn, and under the influence of this treatment, the uterus is developed more powerfully and perma- nently ; but in these cases I have never attained the restoration of the men- struation, and together with it, therefore, the complete cure. These women always feel much pleased with this special general regime, and by occasionally repeated local treatment of this sort. These cases of atrophy at times appear to be still complicated by the appearance of catarrh of the vagina, of the uterus, and especially of the perimetrium. Then every local treatment has to struggle with difficulties. The removal of inflammations of this sort must be considered of paramount importance. Aside from the general treatment which I have described above, h^cal interference should only be made when these catarrhs, and these remains of peri- and parametritis have been completely healed. Indeed, as long as these processes exist in the neighborhood, I will here very emphatically advise, that no local treatment be undertaken, unless under the most urgent conditions. Among these urgent circumstances I have OF THE DISEASES OF WOMEN. 71 found, in particular, violent pains in the stomach, in the head, and in the sacrum, together with mability to walk. If these difficulties cannot otherwise be removed, and if on account of these the condition of the patient is unbearable, then, indeed, I have attempted to bring about the tolerance of the uterus by the introduction of pencils of sulphate of zinc and morphia, with the simultaneous use of narcotic suppositories, in order thus to render possible the introduction of an intrauterine pessary. I have repeatedly succeeded in making the uterus insensitive, and thus essentially alleviating the difficulties of the patient by the use of intrauterine pessaries. In other cases there occurred such a violent reaction in the old sites of inflammation of the vicinity, that I was obliged to abstain from every attempt, even the use of scarification. In general the form of atrophy, which has just been described, occurs so seldom that, for instance, in the last two years I have been only once in a position to employ the treatment with an intrauterine pessary for the re- moval of it. B. — Atrophy of the uterus in the piierperhim occurs on account of those conditions which govern puerperal involution, and leads to very note-worthy changes in two peculiar forms. In the first, a high degree of laxity of the musctilar tissue of the uterus is developed ; for this is almost entirely fatty degenerated. In these cases the whole uterus does not always appear to be reduced in length, but rather in thickness. The muscular tissue is fatty degenerated and the whole mass of the uterus has lost its tone, so that difficulty is experienced, by palpation, in finding it and in delimiting its surroundings. On this account very great care should be exercised in the attempt to establish, by means of the sound, the uterus which is difficult to palpate ; for these are the cases in which pei-foration of the uterus occurs without the use of any violence. The uterus can then be distinguished, generally, merely more slender in shape. It is only rarely shrunken to a high degree in places, perliaps in the neck or in the fundus. The neck is generall}' conspicuously thin, and reduced in circumference to the size of a lead-pencil, while the fundus appears above it like a little knob. Sometimes it can be distinguished to be hard, but generally it is very lax. Such a form of atroph}- is found especiall}' in very decrepit women, who have been broken down by disease in other organs, especially when they are prev^ented from renewing their dimin- ished forces, owing to continued suckling, with insufficient care and nourishment. The other form of puerperal atrophy leads to a shri/ihage of the uterus.^ which reminds usof the conditions of the climacteric. Then we find the uterus diminislied almost a third of its volume. ParticularK' strikinsf 72 PATHOLOGY AND rHEKAPhUJJCS is the high degree of atrophy of the vaginal portion of the cervix, which projects into the hnncn of the vagina like a nipple-shaped body of hard consistency. This atrophy of high degree I have fountl soon after child- birth, especially in such women as nursed their children, and did not menstruate again, and also had refrained from sexual intercourse. During palpation this form appears extremely striking. It is easily recogniz.ed to be markedly pathological, and yet, in general, it is only a most extreme degree of the normal puerperal involution. This last form disappears together with the cessation of the nursing, the return of the menstruation, and the continuation of sexual intercourse ; and the uterus is then developed, in a very short time, to its normal size, form, and con- sistency. The last form of atrophy gives no occasion for therapeutic measures. In the lirst, on the contrary, we must put a stop to the lactation as soon as possible, and according to the indications which are given by the changes in the rest of the organs, we must stimulate the nutrition of the patients. For the development of the sexual functions w'e must also pro- vide, in these cases, by means of sitz baths and lukewarm douches. I have most surely seen these patients, nearly all of wdiom are found treated in policlinics, succumb under the bad influences of the external conditions and diseases of other organs. The occurrence of a new preg- nancy, which seldom fails to occur, most especially contributes to such a result in these cases. C. — Another form of atrophy is developed not only in consequence of diseases of childbed, but especially also, independent of the latter, by a form of disturbance in the nutrition of the uterus on account of cica- tricital formation in the parametrium. I will enter into the details about \.\\\s parametritis ivhich causes atrop/ty^ in the chapter on parametritis. Long after the duration of the acute irritation, the existence of the remains of inflammation in the mucous membrane, in the parenchyma, and in the neighborhood, continues to operate very disastrously in bringing about all these forms of atrophy. III. — Hypertrophy of the Uterus. Strictly speaking, only those cases should be considered as hyper- trophy of the uterus, in which a symmetrical development of all the histological elements of the uterus without intercurrent inflammatory processes takes place. ^ This sort of hypertrophy can increase the volume 1 Klob (Pathol. Anat. d. weibl. Sexualorg., S. 124 u. 203) would classify here chronic metritis, yet nearly all gynsecologists are of a contrary opinion. OF THE DISEASES OF WOMEN. 73 Fig. 86. f)f the uterus very considerably. It Is developed in the organ as a whole, or in portions of it; and yet, only very rarely, are actual anatomical hypertrophies met with. The changes in the volume of the uterus most frequently occur at the expense of the connective tissue, which is inserted between the bundles of muscular fibres, and most frequently under the influence of the stimulus of inflammatory processes. For my own part, after a rigid examination of my material, I cannot specify one case of actual hypertrophy. The change of form which is induced by partial hypertrophy leads to peculiar conditions, according to the descriptions m the literature.' With- out any inflammatory processes a form originates, as I shall have to sketch in the consideration of metritis and endometritis, viz. , an elongation of the neck, an hyper- tiophy of the vaginal portion of the cervix, even to such a degree, that the hypertrophic mass presses forward out of the entrance of the vagina. In these cases, likewise, the peculiar deformity of the neck of the uterus may be brought about, in which not only the portion above the vagina, but also the vaginal por- tion, is considerably elongated, and then that peculiar division of the cervix into three portions seems war- ranted, in which we distinguish a medium portion, between the supravaginal and vaginal portions, as is shown in the accompanying figure (Fig. 36).^ The symptoms of hypertrophy are dependent in part on the increase- of weight of the organ. They consist, then, in a sensation of fulness of the abdomen, and a troublesome downward pressure. This sensation is very burdensome, as soon as pressure and tenesmus <-, Supravaginal por- in the bladder and rectum are associated with it. tions. As further development goes on, the uncomfortable symptoms of commencing, or even fully developed, prolapse are brought about. Moreover, there is developed, hand in hand with this increase in volume, a development of the mucous membrane, which occasions an increased secretion, and frequently, also, an increased flow of blood during the menstruation. T/icrapcutic measures must be adapted to these special difficulties. The sensation of fulness is often diminished by a thorough emptying of Subdivisions of the neck of the uterus ac- cording to Schroder. ) ; then the anterior and posterior vaginal wall remain firmly united, and at the same time so shortened that the whole mass passes back into the entrance. The prolapse itself, however, does not come out again. It is undeniable that this procedure of Nki'- GEHAiER is com- paratively very sim- ple. From one case, operated on by some one else, which I had seen after- wards, and from one operation of my own of this kind, I can completely confirm this result as a fact. ^ ' In the case operated upon by me the sur- faces of union of about six square c e n t i m etre s had grown together so firmly that the whole extraordinarily large prolapse was imme- diately held back by it. This m c d i a n colporrhaphy acts like a T bandage by the bridge w h i c h is formed between the anterior and posterior vaginal wall : but both these cases which I have seen confirm for me the objection which I from the first raised against it, that the women are thereby seriously deformed. Their capacity for sexual intercourse is, to a certain extent, destroyed, although in some cases which Neugebauer reported pregnancy occurred. In these cases delivery was said to be easy, although once the physician in attendance, who was unacquainted with the previous history, cut through the bridge, and in another case it was torn away. By this Refreshment, according to Nciigebmicr. OF THE DISEASES OF WOMEN. Fig. 66. median colporrhaphy parts arc united with each otiicr which physiologi- cally do not belong together. Violence is offered to nature where we might reach our ends without such violence. I would, therefore, desig- nate this procedure as one not to be used for all cases of prolapse, although it yields good service in the hands of other specialists. As long as those methods of radical treatment are sufficient which leave the natural relations of these parts to each other unimpaired, I prefer them unconditionally. Where these last have failed, a trial of the procedure of Neugebauer iscertainlventirelyjustifiable, and then median colporrhaphy, after the method of the latter, is warrantable as the last resort, and it is to be hoped that the results will be good. The case which I myself observed was that of a woman who came under treat- ment suffering from a prolapse as large as the two fists. I performed on her, first, colporrhaphy, after Hegar's method, with insufficient success. Then I performed the operation for prolapse, which I shall describe later, and obtained a complete \ union of the wound by first intention. The patient, who was a very strong woman of 31 years, was completely cured, and was therefore discharged, to return to her surroundings of great poverty. Neverthe- Colporrhaphy, according to Neuge- less, the prolapse remained relieved only bauer. {Fritsch,\oc. 6x.) for a short time ; this may have been on account of the necessity for severe labor, or of the ill-treatment suffered from her husband, or of want of appropriate nourishment. In this case, before the prolapse arrived at its former size, I performed Neugebauer's operation. The patient then passed six months in her home, and was very well satisfied with the result of the operation ; the vaginal entrance was patulous, and in it were to be seen the anterior and posterior vaginal Vv'alls with the nev/Iy-made line of union between them, but no other parts of the genital passage. The lateral openings were very small, and up to that time had not been stretched by co- habitation. Then the destitute woman had to commence again to perform all her laborious work. At the first attempt to carry a full bucket of water the scar, which had seemed so firm, broke apart; I saw the raw surfaces while yet bleeding, and could satisfy myself that they were very large. The prolapse immediately returned in its former dimensions. ^38 PATHOLOGY AND THERAPEUTICS Tlie inetliod of operation wliicli was first introducctl by Simon* is of a diHcrent character. Simon wislied to remove the hypcrtrophied pro- jecting folds of the vagina, especially on the anterior vaginal wall, and then by refreshing the post, vaginal wall he desired to " form a pedestal on which the uterus and the anterior vaginal wall might rest." This opera- tion of Simon, therefore, combined the procedures of narrowing the va<'-ina with the formation of a support for the uterus and the other organs which are pressing down (Figs. 67 and 6S). The surface to be refreshed Fig. 68. Fig. 67. ^^^^y/. Refreshment for Colporrhaphy post., according to Simon. Colporrhaphy post., according to Si- t/ion. (^Fritsch, \oc. c\t.) a. The pedes- tal formed of post. vag. wall. is situated on the posterior and lateral vaginal walls. Its boundaries pass rather abruptly from the median line upwards on to the lateral walls, run forward along these about half-\vay up. and end at the entrance of the vagina. This refreshed surface is then united by sutures placed close together, and forms a long prominence on the jjosterior vaginal wall, which rises abruptly from the vault of the vagina, and certainly furnishes an admirable support, in the first place, for the vault of the vagina and for the uterus itself, and, moreover, ofiers a very firm point of resistance for the anterior vaginal wall. Simon's figure of the surface to be refreshed has been ' Mittheilungen aus dem Rost. Krankenhaus, i86S. Prager Viertel-Jahrschr. 1S75, II. Band. Engelhardl, Retention des Gebiirmutter Vorfalls durch die Colpor. post. Heidelberg, 1S71. OF THE DISEASES OF WOMEN. 139 somewhat modified liy Lossen' by somewhat extending the line of refresh- ment at the lowest part. Simon's method of operating- as ahove achieved the first successes, and they attracted great attention. In point of fact, the operation was often enough unsuccessful in the hands of others. Where the surfaces united there afterwards occurred such severe contraction of the scar that the above point of resistance quickly lost its importance, especially when the retroverted or retroflexed uterus pressed down in front of the long roll of tissue which projected into the vagina, and then wedged Fig. 69. Refreshment according to Simon, modified by Lessen. Colporrhaphy post., according to Fritsch. itself into the narrowest place. Fritsch - also has lately described a similar plan of operation for posterior colporrhaphy (Fig. 70) . By making an angle in the lateral lines of the surface to be refreshed, according to Simon, Fritsch desires to obviate the tension to which I refer below, concerning the suture, according to Hegar. Fritsch him- self admits (loc. cit.) that thereby a depression is formed at after slie has been disinfected a.ul lias h.d a thorough movement of the bowels. She is put in the lithotomy nositi..n. Two assistants liold the legs, drawn upwards, and arc ready ^ to hold for me Fig. 75. the instruments for exposing the field of opera- tion. (Compare page 25, Fig. 16.) Then, after {Jirsi) the afn- p7( tat 1071^ or it may be excision^ of the cervix has been performed (see operations on uterus), for c o m m e n c i n g {^second) the an- terior colpor- rhaphy{J\Z'15)^ the uterus is drawn down, and in this way the anterior vaginal wall is made tense, either by traction on the ends of the sut- ures (not yet cut off) which unite the stump of the amputated cer- vix; or, in order to obtain appropriate tension, I seize with a bullet- forceps the tissues just in front of the portio-vaginalis, or, it may be, m the anterior vault of the vagina, according to the conditions ol the case. I further steady the vaginal wall by bullet-forceps, of which the upper Anterior colporrhaphy. . Attempted use of a merely local anaesthesia. /.... by means of cocaine, reheves ne.lher pat.en norphys.cianfron. all those aifficulties which are inseparable from such an operation, wh.ch must always last about forty nunules, and under son.e circumstances considerably longer. OF THE DISEASES OF WOMEN. 145 Fig. 76. oiiL' takcs its hold close l)clo\v the ure- thral tubercle ; on each side I insert a bullet-forceps at the fold between the anterior and the lateral vat^inal walls, and I have the whole field of operation put on the stretch between these four instruments (Fig. 75). Then I make an incision around an ovoid figure, the point of which is close under the urethral orifice, and which includes, in a greater or lesser extent, the anterior wall of the vagina, particularly' also the rolls of mucous membrane, which we so fre- quently obsei've close to the external opening of the urethra. After cutting around this surface I dissect oft' the mucous membrane, and use for this pur- pose a knife rounded out at the end, and sharpened all around the extremity (Fig. 76). This knife, which was invented by Mrs. Horn, who has been my intelli- gent assistant for many years, permits of cutting in every direction ; I came to use it because the simple bistouris, which w^ere formerly used by me in this operation, wore oft' at the point only, and soon were rendered useless on this account, while the rest of the edge was very little worn. I dissect up, as I have seen Hegar do it, at once the whole surface which has been marked out w'ith the knife, working from every side to- ward the middle. For this purpose I use the instrument represented in Fig. 77, and also invented by Mrs. Horn. The flap is fastened on the teeth of this, and then rolled up. By this means the boundary of the tissue, which is to be cut through, is very conveniently put on the stretch. The flap is dissected Fig. 77. A knife for colporrhaphy, devised by Mrs. Horn. Natural size. A rake for rolling up the flap of the mucous membrane. Invented by Mrs. Horn. Full size. 146 PATHOLOGY AND THERAPEUTICS off essentially in one piece, although, of course, any corners and in- equalities of the tissues, which have remained, must be removed with Cowper's scissors. As a rule, the raw surfaces of this kind produce but little bleeding. I do not ligate any vessels which spurt, but I have one of my assistants compress such with the finger, if possible by pressing the flap of skin upon them. If the surface is then completely smooth I pass on to the suturing. After the w^ound in the mucous membrane has been united in a straight line, the uterus and anterior vaginal wall is replaced. In doing this great care should be taken that the uterus should come into its normal position, if it is possible. If it does not easily succeed, I use the sound also, in order to make sure of the right position of the uterus. Then I pass on to the posterior colporrhaphy. My method of operation corresponds to the physiological relations of the vaginal canal ; it originated in observation of the drawings of Freund on restoration of the perinaeum.' Freund first called attention to the fact that, on account of the H-shaped form of the vaginal passage (Fig. 78), we must seek for the denser masses of tissue on the anterior and posterior vaginal walls. The latter w^alls have remained as remnants of the ducts of Muller, the union of which in the median line, before and behind, produces masses of tissue per- meated by abundant fibres ; these we can clearly see and feel during extra-uterine life, in the columna ruga- rum anterior (urethral protuberances), and the columna rugarum posterior, so long as the folds of this have not been obliterated by frequent cohabitation and many births. But even when the folds of the vaginal mucous membrane are flattened out, we can still dem- onstrate here these fibrous elements on section. In consideration of this I lay out the surface to be refreshed on the posterior vaginal wall in such a manner that these fibrous elements are not removed in refresh- ment, as occurs in the method of Simon and Hegar ; nor yet do I dissect up this flap as Bischoff does. On the contrary, / utilize these Jibrous constitiie7its for the support of the newly formed posterior vaginal ivall^ cutting into the wall of the vagina on both sides, and so freeing the vaginal mucous tnembrane on both sides, from this point about half- way up the lateral vaginal walls. By this means there are formed in the posterior vaginal wall, above the entrance of the vagina, two raw sur- faces, nearly corresponding to the lower fokl of the remnants of the ducts of Muller. If I then sew up these raw edges, the edges of the columna rugarum acquire a position about half-way up the lateral vaginal walls (Fig- 79)- 1 Naturforscherversamlung, Wiesbaden, 1873. OF THE DISEASES OF WOMEN. H7 The coIumn;i ru- ga r u m posterior Fig. 79. itself, with its dense mass of tissue, is ]) r o u g h t into a higher position, and I have it entirely under iny control to adapt this eleva- tion of the posterior vaginal wall to the condition of the case. If, then, the vagina itself is nar- rowed in this way, and, hy the raw sur- faces which have been made on each side, a very strong traction of the tis- sues in the floor of the pelvis towards the median line has been obtained, — a traction which, since it is divided between two parts, is less disadvan- tageous t o union than if it were all directed towards a single line, — then I complete this operation by appropriate strengthening and increase of the perineum. A'ly method of posterior colporrhaphy consists, therefore, of izuo operations^ which are performed one after the other ^ — a double lateral sewing up of the vagina {eiytrorrhaphia) , and an increasing of the perina3um i^perineauxesis) . In order to carry out this operation I draw dovs'n the posterior vaginal wall and fix the lower end of the columna rugarum posterior (a. Fig. 79). Even in very old cases of prolapse this can be determined by the sense of touch, if not superficial!} , nevertheless below the surface. Surface refreshed in colporrhaphia posterior, after the method of A. Martin. — 1-2, incision along the side of the co- lumna vag. post. 3—4, incision in the lateral vaginal wall. /, end of the refreshed surface in the entrance. A-A, B-B, a-a, h-b,c-c, d-d, (3-a-(3, J-rf, y-y, designate the points which are to be united with each other. 14^ PA THOL OGY AND TJIERAPJ: U'J JCS Fig. 80. Then I fix the upper end of the columna with one bullet-forceps, as Fig. 79 shows, or with two, of which one can be seen in Fig. So, at x. I likewise so fix the end of the part to be refreshed on the lat- eral vaginal wall, at each side (Fig. 79 at 4, Fig. So at y) , about at the lower border of the vaginal canal. Thereupon I first make an incision on one side, in a straight line, along the edge of the columna down to its lower end (Fig. 79, 2-1), and then I make an incision around the surface to be refreshed from its upper end along the folds of the vaginal wall (Fig. 79, 3-4) down to the bullet- forceps, which is at- tached here. The flap of the mucous membrane thus marked out by tlie knife (between 1-2- 3-4^ Fig. 79) is dis- sected off and the First part of Martin''s operation for restoration of posterior - vaginal wall (elytrorrhaphia duplex lateralis), interrupted suture. — a, the flaps of skin, which are dis- sected off; X is the position of the bullet-forceps at the upper end of the columna rugarum; v is the position at the side. The left side is refreshed and sewed up, right side is re- freshed. The sutures are represented. wound immediately firmly united, so that thus A-A lie together (Fig. 79)- In the same manner I then make incision around the folds on the other side, dissect them off, and apply the suture {B-B^ Fig. 81). There- upon the bullet-forceps which had been attached at the ends of the inci- sions, which up to this time had been upon each side, are removed ; the elytrorrhaphy is finished. Immediately the building up of the perinrcum {pcrineauxesis) is begun by carrving an incision crosswise around the columna rugarum OF THE DISEASES OF WOMEN. 149 posterior from the lower end of the sutures just tinislied (at ///, Fig. Si). From the ends of this incision others are carried to the neighborhood of the lower border of the nymphaj on each side into the vulva (/^-/, Fig. 79, and ///-/, Fig. Si). On the border of the vestibule the incision is completed by carrying it around the entrance of the vagina (a, <5, c, d^ Fig. 79, and /-//, Fig. Si), so that this incision falls at the ends of the above lateral incisions, the lower border of the nymphge (Figs. 79 and 81). The tissues included in this incision are refreshed, carefully smoothed, and sewed together. Fia. 81. II. Part. — Parineauxesis after the completion of elytrorrhaphy. — /-/, the ends of the lateral refreshment at the entrance. //, is the middle of the incision round the posterior commissure close before the anus. ///, lower end of the columna rugarum posterior. The suturing begins with the union to eacn other of the incisions on the lateral vaginal walls {III-I^ Fig. Si). For this purpose strong sutures are inserted in the lateral vaginal wall at the point where the outlines of the incision form the angle between the refreshment in the vagina and the refreshment in the entrance («-3, Fig. 79, and ///, Fig. 81). The first Ko PATHOLOGY AND THERAPEUTICS suture is carried under the whole mass of the tissue, and is brought in the lower border of the columna («) at about its middle point ; then it is in- serted again close to the latter point, and is carried under the whole raw surface to the corresponding point between the lateral refreshment of the vagina and the lateral refreshment of the entrance on the other side, where it is brought out. This suture is tied, and by this, and l)y possibly a sec- ond suture, which is inserted close to it, the columna rugarum posterior is completely covered at its lower extremity ; the union of the surface re- freshed in the entrance, hereby begun, is now completed (/^-a-?, }-;, /-/, a-a^ b-b^ c-c^ Fig. Si). The patient is brought to bed, with her legs tied together, without the application of any further dressing. Until the autumn of 18S5 I used, for the sutures, braided silk (Turner's patent), and can speak with satisfaction of the good results obtained with this. Disadvantageous to the operation was the great amount of silk used, and the necessity of. having the assistant thread this large number of sutures during the operation, and particularly, more- over, the taking these sutures out again from the vagina, which has been made so extraordinarily narrow, would necessarily occasion suffering to the patient. Even if the latter has come from a distance, she would have to present herself months afterwards for such removal, since con- sideration for the delicate cicatrix made it appear unadvisable to take them out sooner. On general principles I consider it to be a very great Fig. 82. The suture-tying forceps, according to Baumgdrtner. natural size, b, the ends armed with threads. ■a, the forceps, one-half its advantage to use catgut for tliis operation. My attempts with catgut were, however, unfavorable until I used juniper catgut, prepared by E. Kuester's method (8 days in sublimate solution i: 1000; then pre- served in oil of juniper). I learned of this from the recommendation of Schroeder.' Schroeder likewise recommended the suture with con- iGesellsch. f. Geburts. u. Gynak, zur. Berlin, i8 Zeitschr. f. Geb. u. Gyn. Bd. II., S. 213. OF THE DISEASES OF WOMEN, 151 tinuous threads for these plastic operations. I have pul)lisiied ' a report of the use of continuous catgut in prohipse operations in twelve cases (from a report of my prolapse operations before the Society for Obstetrics and GyntECology at Berlin, in December, 1885). Since then I have had occa- sion to convince myself continually more and more of the extraordinary results of this method of suturing. At present I use nothing but this in the deeper parts of the raw surfaces, and in the vaginal wall, while I still Fia. 84. Fig. 83. Anterior colporrhaphy, continu- ous suture in layers. — a, upper, and b, lower end of the threads. First part of the Martin operation for restoration of the posterior vaginal wall (prolapse operation). Elytrorrhaphy dupl. lat. continuous sutures in layers. — a. The flap of mucous membrane where it has been dissected otif. occasionally close up the 2Derina;um with interrupted catgut sutures. With continuous catgut sutures, of course, just as little as with interrupted catgut sutures, does one have to undergo the above-mentioned inconven- iences of the sutures with silk ; moreover, the danger of haemorrhage, which at the time I set forth emphatically in my communication, has no 1 Deutsche med. Wochensch., No. 2, 1SS6. ^5^ PATHOLOGY AND THERAPEUTICS Fig. 85. longer been experienced, with increasing practice in the operation. The following is the mode of procedure for these cases : The needle, armed with a long catgut suture, is inserted at the upper angle of the wound, carried under tlie raw surface, and brought out a corresponding distance at the other side ; and now the thread is tied near its distal extremity, the short end beyond the knot is held fast b}' the assistant, for which purpose the pincers of Baumgaertner are admirably adapted (Fig. 82, a). Then the needle is inserted in the wound, and about half of the raw surface is taken up on the needle, and the thread carried through and tightened. While the assistant holds the thread and draws it tight, the needle is again similarly inserted near the former stitch, and carried through ; and this goes on until the deep part of the raw surfaces are sewed from one end to the other oppo- site end. At this opposite end the needle is again brought out through the external border of the wound. If by this sewing up of the deep part the raw sur- face is so far reduced that the external edges of the wound can be brought together without dif- ficulty, then the union of these is accomplished at once, with the same thread, in stitches which, running backwards, seize on both sides whatever parts of the raw surfaces still stand apart. The stitches are carried under this so far and so close together that the edges of the wound are united to each other quite smoothly. The end of the thread can be tied to the other end, which is held fast with the forceps at the upper end of the wound, or in a knot resembling a veterinary knot ; Lc.^ it can be so fastened that the part of the thread which forms the loop in the eye of the needle can be tied to the free end (Figs. 83, 84, 85, '^(i). If the raw surface which lies above the deep suture is still too great, Continuous sutures in layers in perineauxesis. OF THE DISEASES OF' WOMEN. 153 Fig. 86. then a second layer i.s easily inserted, which brings the thread again to the npper end of the wound, and from here the suture is carried through the external edges of the wound. Such layers bring about a very extensive union of the raw surfaces, and by this means and the avoidance of tension they secure very completely the healing of the wound. The buiied catgut sutures, recommended by Wertii,^ are hereby made superfluous. As the union of the edges of the wound proceeds, the bullet-forceps are to be taken oft', beginning with those on the sides. The catgut sutures sometimes are found to be not long enough ; in this case a gut can easily be inserted just before and tied to the end of the first ; or the first can be tied finally, and a completely new suture can be commenced with a new gut. The juniper catgut is less apt to break by traction than by being touched by the edge of the needle, how- ever slightly. If it happens to break, the suture is by no means lost. The gut is caught up, pulled out and tied to the new gut, which is inserted at the point to which the end of the suture had been brought. If . . Second part of Martin's prolapse operation, the raw surface IS so far reduced „ . . t-i . i. ,.• j 1 1 renneauxesis. — a a. JLlytrorrhaphia dupl. lat. /-, that the external edges come Upper end of the catgut, c. Lower end of the same close together, the union of the thread, wound can be accomplished with interrupted catgut sutures. Lautenstein has made a proposition- to carry the threads entirely under the surface, so that no threads and no stitch-holes interrupt the continuity of the edges of the wound. On trying this, the procedure seemed to me too artificial, and the disadvantages from omitting it are too slight to warrant any prolongation of the operation. 1 Centralbl. f. Gyn., 1S79, No. 23. 2Centralbl. f. Gyn., 1SS6, No. 4. 154 PATJWLOGY AND THERAPEUTICS Fig. 87. Fig. S3 represents the course of the sutures in anterior colporrhaphy. I advise that the raw surfaces be not made too great, since afterwards difficulty is readily encountered in replacing the organs, in case the entire vaginal wall has been made improperly tense in this manner. In using interrupted silk sutures it is the rule to begin from above. One silk thread is inserted under the whole raw surface, then alternately one more superficial, and in tliis way, as the threads are generally tied imme- diately, the union of the raw surface is accom- plished as quickly as possible. The more the raw surface is diminished the more superfluous is the tension of the bidlet-forceps, and the ones on the sides are taken oft' first. If the deep threads can- not be tied in such a way as to completely unite the edges of the wound, and if the tissues are put on the stretch in a way prejudicial to union, then, according to Hegar's method, superficial sutures are to be inserted, first on one side of the deep thread, and then on the other ; and when, by means of these, the edges of the \vound are brought well to- gether, the deep thread is to be tied (Fig. 87). At last, in this manner there is formed a straight line of union, which is held together by a great number of threads. Finally, the ends of these and of the sut- ures used in the amputation of the cervix are to be cut oft', and the uterus and the anterior wall of the vaginal wall are to be replaced ; in doing this, par- ticular attention must be paid to getting the uterus in the proper position. In posterior colporrhaphy^ according to my method, -when cojitinuojis catgut sutures are used^ each separate surface which is refreshed is immediately closed. Thus, first, A^ Fig. Si, then B. In order to form the connection betv.'een the peri- neauxesis and the elytrorrhaphy, I still use a silk thread, thus, /^-«-3 (Fig. 81). This is inserted at the left, beside the end of ^4, in the lateral wall of the vagina, carried below the raw surface out through the point of the columna rugarum ; then close to the point of exit it is inserted again, and brought out in the lateral wall beside the end of B. This thread has to support strong traction ; if necessary, I strengthen it with a second silk thread inserted close beside it ; 7, or it may be the next stitch is the first to be made with continuous catgut sutures, and from here to just before the anus a first layer is inserted in the deep part of the wound. Generally Interrupted silk suture in colporrhaphy anterior. OF THE DISEASES OF WOMEN. ^DD Fig. 88. the second layer goes back again as far as the edges of the wound, which arc turned to the vagina, and now first the external edges are united by means of the same thread ; this is then to be tied externally, close to the lower end of the refreshed portion. Where perineauxesis is of slight ex- tent, the external edges may be sewed together as soon as the first layer is finished, then the knot remains in the vagina. When silk sutures are used, the threads are inserted as usual, in A and B ; a and ,? lie in the same place as when catgut is used ; like- wise }, (5, e, etc. (Fig. 8i). The ends of the sutures are cut off* short if necessary ; when inserted they are brought out once in the median line, in order to avoid taking too much tissue on the needle at once. If the entrance is closed quite up to the nymph^e (Fig. Si) there remains in the prolongation of the raphe perinaei a superficial slit, for the union of which a small number of superficial sutures suffices, a, <5, c, d (Fig. Sr). The figure of the sutures at the close of the operation is represented by Fig. 88. The whole operation is performed under continuous irrigation, with a weak luke- warm carbolic solution i i^ per cent., or sublimate solution I : io,ooo. I have never yet seen any disadvantages from this, but found that it is quite peculiarly agreeable to work under this uninterrupted irri- gation of the field of op- eration. The subsequent treatment is as far as possible expectant. The patients must for three weeks remain on the back, with the legs firmly tied together. For attending to their necessities, low bed-pans are put under them, and, if there is difficulty in passing the urine, the catheter is introduced very cautiously by a practised hand. After the fourth day defecation is assisted by castor-oil. The vagina is not to be irrigated ; only after every passage of the urine is the vulva to be irrigated externally, between the legs only slightly separated from each other. The lines of incision remain entirely uncovered. After from twelve to fourteen days, when silk sutures are used, the external threads (/^toC, Fig. 88) are partially removed, while the patient still remains on Profile view of colporrhaphy post., according to Martin; interrupted sutures. — A—B. Elytrorrhaphy. D-F and C~E-F. Perineauxesis. 156 PATHOLOGY AND THERAPEUTICS her back, and then, moreover, the \'agina is to be irrigated. After twenty days the i-;;tients can sit up, and then after twenty-one or two days they are taken out of bed. As a rule the patients suffer for some days from the effects of keeping the bed so long, but recover their strength very quickly, since the disappearance of former difficulties permits very much freer motion. It is easy to remove, after twenty-four or five days, the one or two silk threads from the vagina, when the rest of the sutures are con- tinuous catgut ; wdien there are interrujDted sutures I do not hurry myself. With very great caution I take out presently the threads which lie low down in the vagina, as far as they can be got at ; those which arc in the wound of amjDutation and in the upper section of the refreshed part of the vagina remain in place for months, at anv rate until the cicatrix is con- solidated, and runs no danger of tearing when the vagina is opened with the speculum. The permanent irrigation during the operation explains the rare occurrence of decomposition and of surgical fever ; but, if some- thing of that kind comes to pass, I keep the patient quiet in bed, presup- posing that if no septic material has been brought into the wound it is not necessary immediately to give up hope of the union of the wound. I have in fact repeatedly, even when there were long-continued elevations of temperature after colpon-hapliy, yet observed complete permanent union, so that I must decidedly advise against too soon giving up the result of the operation as lost in such cases. If union does not occur, the union of the granulating surfaces is said to give prospect of healing, according to a proposition of J. Veit.^ I have made only one attempt in this directicm, and that was a failure. The women, as a rule, do not obtain full freedom of motion until two months after the operation. I recommend cnipliaticall\- to avoid sexual intercourse for a considerable further time, and to refrain from hard labor. For the rest I have the patients, as soon as they are dismissed, at the end of the fourth week, use, themselves, injections in the vagina, of course with requisite caution. For this purpose I use, as an addition to the water, rec- tified acetum pyrolignosum, or some other weak disinfectant or astringent. Sitz-baths are only used after four weeks more, and they prove very agreeable to t!ie patient. For this operative procedure I claim, in the first place, the advantage over those known up to this tinic^ that it is adapted directly to the anatomical relations of the parts. Further- more., the operatio)i is no more complicated tha?i the other procedures ; in fact, it is more simple, since the surfaces to be refreshed in each section of the operation are smaller. Therefore the operator, even with little experience, will run less danger of being unable to bring the edges of the » Gesellsch. f. Gerburtsh. u. Gyn., iSSi. Deutsch med. Wochenschr, iSSi, S. 2S0. OF THE DISEASES OF WOMEN. '57 wound sufficient!}- into aj^position. T'/i/s method is less serious^ since in each consecuti\e ])ortion of the operation the raw surface which is exposed is smaller than in the otiier mode of operation, and thereby any great hicmorrhage can be avoided. Finally, hcalhiff in the vag-itia occurs -with great regularity ; this alone is a great advantage, even if union fails in the raphe perinjei, as in fact occasionally may occur, owing to accidents, 6'.^'-., premature sitting up of the patient, or unskilful mancEuvres of the attendants. I have made a report concerning my experiences with this method, in a communication to the Society for Obstetrics and Gynsecologv at Ber- lin, on December ii, 1885 (compare Deutsche med. Woch., Nr. 2, 1SS6). By bringing the numbers of this report up to the date of the conclusion of this manuscript, there are forty-two operations which I have formerly performed, according to Hegar, four according toWiNCKEL, five accord- ing to BiscHOFF. I have then performed the prolapse operation, as I understood it, two hundred and twenty times, using especially the method of colporrhaphy posterior which 1 had proposed. In hardly four per cent, was the uterus so far normal that I w^as not obliged to treat it ; the endo- metritis, metritis, and changes in position and form of the organ were appropriately attacked by operative measures, whereby the pouch of Douglas was opened eleven times, without further unpleasant conse- quences. Permanent cure of retroflexion was observed seventeen times after amputation and reposition, preceding the prolapse operation on the vagina. In the other cases (moi"ethan ninety per cent, suffered from retro- flexion) this malformation recurred sooner or later, but only five times did ring pessaries have to be worn on account of this ; the others had no diffi- culty of any kind therefrom. In the case of three women the uterus lay so deep in the everted vaginal sac that total vaginal extirpation was nec- essary before a permanent retention could be obtained by colporrhaphy. In anterior colporrhaphy I attached more importance to the restora- tion of a normal tension in the lower part of the anterior vaginal wall than in the vault of the vagina. Thus I always remove the prominent rolls of mucous membrane below the urethra, while I do not make the general surface to be refreshed too large. Htemorrhages after operation occur very seldom, if the raw surfaces are accurately adapted to each other. When silk threads are used, there is no difficulty in this, continuous catgut sutures must be drawn just tight enough ; but where large varicose vessels lie close under the surface, or are, in fact, pricked by the needle, it is advisable to insert a couple of strong silk threads under the whole raw surface, and enclosing evervthing. In seven of the two hundred and seventy-one cases a more or less 15S PATHOLOGY AND THERAPEUTICS extensive parametritis was developed, accompanied with permanent elevation of temperature ; nevertheless, in five of the seven cases a very satisfactory union occurred. Once at least a sufficient increase of the recto-vaginal septum was obtained. Twice there followed a protracted softening of the exudation. One of these cases was cured by some one else, by incision, about nine weeks after the operation. If we consider how often prolapse is complicated with old scars, chronic para- and peri- metritis, and displacements of every kind, the above results must certainly be described as very favorable ; especially if we reflect that these are com- plications which occurred among so large a number of cases, where there were so extensive raw surfaces and pathological conditions in the pelvis, already so variously complicated. Of the whole number of two hundred and seventy-one cases, only about eighty have been, owing to their age and domestic relations, in a position to become pregnant after the operation. The average age of my prolapse patients is something over forty years. I have heard of jDregnanc}' occurring after the operation in fifteen of these cases, but only a small number of them have been obsen-ed by myself or by my assistants, at delivery ; the others I have either had an op- portunity to examine again, sooner or later, after they had recovered from childbirth ; or, in other cases, I have only heard indirectly about their pregnancy. Those whom I myself have seen during or after deliv- ery have passed through this trial of the success of the operation, leaving the cicatrices of the operation intact. With few exceptions the labor was perfectly normal. If we consider how often one obtains information con- cerning these results of his treatment only very indirectly and circuitously, and how often no information at all is received from patients who have recovered, especially among a clientele where most of the patients do not live at the same place with the physician who treats them, the above re- sults must certainly be described as very satisfactory. At any rate, according to these experiences of mine, I can claim for my method of prolapse operation the same which has been claimed by other operators for their procedures; viz., that by this method of treating the prolapse neither the sexual life of the women nor their ability for propagation is impaired, and that also in this respect a sort of restitutio ad integrujji is obtained. I should regard it as a sin of omission if I did not report also those cases in which the results have lasted only for a sliorter or longer time, so that relapse of the old malady has occurred. I have received informa- tion concerning eleven cases in all, in which relapse has taken place ; among these were some in which tlie occurrence of the relapse was probable, I might say a priori^ partly on account of complications, such OF THE DISEASES OF WOMEN. 159 as the use of catgut, which was probably insufficiently prepared, or on account of haemorrhage and the tamponning made necessary by the latter, or on account of the want of sufficient care of herself by the patient during convalescence. Six of the eleven cases are to be accounted for in this way, and with these I class, also, a woman in whom the relapse occurred within three months after the operation, after that I had achieved, with continuous catgut suture, results which were at first apparently ideally good ; the cicatrix in the vagina and on the perinaeum was also to be recognized as admirably healed. A peculiar oedema was developed, com- mencing from the right side ; this perhaps is nothing else but the effect of traction on the floor of the pelvis, which, indeed, had not been before observed, and is of transitory importance; but, nevertheless, it causes the sensation of relapse to be very painful, and also, on straining, permits the right wall of the vagina to appear in the opening. Three times where there was progressive senile involution of the whole body, with apparently very insufficient nourishment and want of care in every respect, the corre- sponding emaciation of the genitals became more noticeable, and now led to a secondary relation of the various parts in the floor of the pelvis, and to the occurrence of a renewed inversion of the vagina, and eventually to the return of the prolapse. In two women I have been able to find no reason for the occurrence of the relapse after absolutely ideal union of the wound caused by the operation. In the majority of the cases of relapse I was able to observe that the cicatrix in its various sections was very well preserved, and especially striking were three cases of relapse, where during a quiet supine position of the patients there was a complete closure of the external genitals, and only on straining down did the walls of the vagina protrude anew. In some of these women I have from the beginning refrained from repeating the prolapse operation, and have provided the women with vaginal supporters. In other cases where the disposition to new prolapse was observed early the treatment sufficed which is in effect generally employed in the early stage of puerperal prolapse ; i.e.^ tampons of glycerole of tannin, astringent injections, rest, sitz-baths, and the greatest avoidance of every physical exertion. Very particularly important seems to me in all cases the prohibition of sexual irritation of these parts. Only in two cases have the women submitted to a second prolapse operation. One of them was completel}' cured by this, and made capable of continuous work at the washtub ; between the first and second operations there was an interval of five 3'ears. The other had been operated upon by me originally, according to Hegar's method, by colporrhaphy post. ; this first operation is, therefore, not included among the two hundred and i6o PATHOLOGY AND THERAPEUTICS twenty cases. I performed the second operation according to my method ; the result was apparently completely successful. The patient, a very intelligent woman, refrained from all severe work during three months, and only assumed the labor of keeping house wlien the parts seemed strongly healed, and I permitted her to return to her household occupa- tion. Already, in six weeks, she complained of a sensation of descent, and after si.\ weeks more a complete prolapse of the anterior and posterior vaginal walls was developed. I then made the operation according to Neugebauer on this woman, who was apparently very robust, and 30 years of age. I thereby achieved a result apparently verv satisfactory, when, however, the patient, who was apparently cured by this sort of prolapse operation, after about four months lifted a bucket of water for the first time, the cicatrix burst open with violent pain, and as the patient, lamenting, presented herself before me I could observe the freshlv bleeding surfaces. As may be imagined, the woman would not submit to a fourth operation, and contents herself with retention by a pessary with a stem. III. — Laceration of the Perix.eum. Restoration of the Perix.eu-M. The injuries of the perinaeum arise in a great majority of cases during childbirth, and only seldom apart from those conditions, on account of injuries which may occur on occasion of a fall or a blow, or in removing tumors situated in the genital passage. An attempt should always be made immediately after the occurrence of perineal laceration at birth to close the same, but such an attempt often meets with many difficulties. These may be caused by the immediate danger of the parturient or ruptured woman, or it may be that conditions dependent on child-bed interfere with union of the tissues which have been violently separated. This may be the reason why luptures of the perinseum so frequently come under observation and eventual operation comparatively long after their occurrence, and when the}- have been long skinned over. In other cases, the fact that the mother is nursing is stated to be a contra-indication for such an operation, and therefore the rupture of the perinaeum which has occurred during childbirth, espe- cially after an attempt to close it immediately after the birth has failed, has been delayed for a long time under the influence of this precaution. In other cases the procrastination of the patients is the cause of post- ponement of an operation, and the patients only seek for relief when further consequences of the defect in the floor of the pelvis make them- selves apparent. OF THE DISEASES OF WOMEN. \Cn Fig. 89. For desciiption in this place it is sufficient to divide the ruptui'es of tlie perinieuin into incomplete and complete, i. TJie anatomical rela- tions of iiicomplete rupt7ires of the pcri- ncrum sliow almost al- ways a separation of the posterior commis- sure of the vulva and of the raphe perinaei. Into the vagina the tear runs usually in the median line as far as the lower end of the columna rugarum pos- terior, and then runs around this on one or both sides. As a rule the laceration runs along on the side on which the occiput was born. It is very sel- dom that this separa- tion passes through the columna rugarum and tears off part of it on one side. When this skins over spontane- ously there appears in place of the commis- sure a tough cicatricial tissue, generally noticeable for its whiteness. Frequently the surrounding parts are drawn out of place quite irregularly by projections radiating from the scars, so that thick protuberances of skin are developed between the radii of this cicatricial tissue. This scar may, even when the bowel is uninjured, decidedly diminish the dilatability of the anterior aspect of the rectum, and so, to a certain extent, may impede the evacuation of the intestine. Almost always the opening of the vulva is greatly altered by the cicatricial contraction, especially when the tear extends high up into the vagina, and the scar has then led to distortion of the columna rugarum posterior and of the lateral vaginal wall. Then, again, in cases where the function of the anus is impeded by Superficial rupture of the perinasum. 1 62 PATHOLOGY AND THERAPEUTICS Fig. 90. the scars, rectocele very often supervenes, and there is developed under the influence of these a protrusion of the posterior-vaginal wall going on to complete procidentia. If the injury has included the intestine {complete rupture of the perincsum) the rectal canal lies open, usually in the middle of the anterior circumference. Higher up the rent follows the direction w h i c h the laceration takes in the vagina itself. The cica- tricial contraction leads to a wide separation of the torn intestine, the mucous membrane of which protrudes, scar- let in color, at the end of the remainder of the % 'I^r- rectal vaginal septum ; it may even come to an extensive prolapse of the mucous mem- brane (Fig. 90). Comparatively sel- dom can these rents be traced higher up into the rectum than two inches (5 cm.). Much more frequently only the sphincter ani is torn through, so that the rectum is open to the extent of about 3 cm. (It is noticeable how seldom prolapse of the uterus is developed in connection with just such high lacerations of the periniEum anil these extensive injuries ; perhaps because the womb, and with it the whole floor of the pelvis, is held firm by exudations which develop in connection with the diflicult delivery.) Very seldom the rupture does not enter the intestine in front, but passes around it at the side, so far that the opening of the rent in the intes- tine lies quite in the median line ; even more seldom must the cases be in which, as I have seen it once, the injury leaves the rectum completely Laceration of the perineum and rectum. OF THE DISEASES OF WOMEN. 163 intact, and extends at the side of the bowel far backwards to the neighbor- hood of the OS coccygis. The symptoms of rupture of the perincBum are by no means con- stant, even in cases where the injury is of comparatively equal extent. Only very seldom do rujDtures of the perinaium lead immediately to profuse haemorrhages. Even in cases where the injury is very great, some women are seen to get over all difficulty as the cicatrization goes on, and, as soon as they again can control the intestine and the floor of the pelvis, the symptoms of the injury of the rectum disappear completely, even when the women labor actively ; in contrast to this, other patients make complaints even when there are very slight injuries of the perinseum ; before chronic irritation in the lower part of the vagina, or still less real prolapse of the same has come on in consequence of the patulous condition of the entrance, they complain of intolerable difficulties, which prevent them from walking and standing, which make them incapable of working at all, and which only allow them a tolerable existence wdien they rest quietly on their backs. The sufl^erings from laceration of the perinaeum are essentially connected with the destruction of the floor of the pelvis. If the latter, in consequence of such an injury, is no longer adapted for supporting the uterus, the bladder, and the intestines, and if the walls of the vagina itself are inverted into the cavity of the vagina, then there is developed a sensation that the vagina is open, and a fear that the vaginal walls will slip out, which distresses the woman most extremely. The symptoms of descent, and finally of prolapse of the vagina and of the uterus, are especially observed in cases of incomplete rupture of the perinjEum ; it is just in such women that prolapse of the posterior vagina with rectocele is frequently developed. When the passage is open, and there is added an irritation of its lower part from dust, which gets into the vagina, and from soiling by urine and faeces, in such cases even incomplete perineal rupture can give rise to ver}^ decided suffering. This difficulty, however, frequently increases until it is intolerable, in cases of complete destruction of the perinccutn^ where the women have lost con- trol of the sphincter of the rectum, and pass from the passage not only masses of faces, but especially flatus, even if it is onl}' occasionally uncontrolled. Besides the real suffering, such women are most intolerably disturbed in their social relations by this malady, and often sink into a condition of melancholy. An improvement, without restoration of the normal relations of the parts to each other, is not to be expected, and thus the prognosis of the injuries of the perinaium, where very considerable 1 64 PATJIOLOGY AND THERAPEUTICS sufl'erings have been developed in consequence of the hitter, is essentially dependent upon operative treatment. Incomplete lacerations, however, are sometimes seen to heal com- pletely without treatment during the puerperium. For the operation of perineal laceration various rules are of value, according to whether the malady comes under treatment soon after its origin, or a long time afterwards. I. The fresh rupture of the perinaeum is undoubtedly best overcome by uniting, in their former relation to each other, the parts wdiich have just been separated. If it is possible for the purpose of this operation to anaes- thetize the patient, this is certainly preferable ; often, however, the women are already so exhausted that they do not experience any pain from the operation, or, if they do, they bear patiently the few stitches which are neces- sary. Anaesthesia permits that in such cases the patient be laid comfort- ably, it may be on a table, and this offers certain advantages for the suture. Then the raw surfaces must be thoroughly cleaned, both by permanent irrigation, to remove any blood which may stick to them, and by the scis- sors, to take away any torn fragment of tissue. The parts which belong together are to be adapted to each other, and to be united by deep sutures, which must not lie too closely together. Especial care must be taken that no cavities remain between the raw surfaces, and that these surfaces are accurately closed. Corresponding to the track of the rent, the suture passes ai'ound by the side of the columna rugarum, just as the wound runs around it, from both sides, and closes the middle line of the perina.'um, and the posterior commissure ; it must always unite the separated raw surfaces^ in their whole exte?it., and very Jirmly . Yet simpler is the suture with continuous catgut, whereby great advantages arise from shortening the operation on the exhausted and perspiring woman, and from the great immunity from irritation by threads which remain and are bathed in lochial secretion. The direction of the suture is determined according to the extent of the tear ; the bottom of the wound is united in one or several layers before the external part of the wound is closed.^ These fresh puerperal wounds had better be only irrigated externally. The convalescent must keep the bed for two weeks ; from the tenth to the twelfth day the external threads are removed, in case silk was used for sutures. Vaginal irrigations had better be entirely avoided. II. For ruptures of the perinasum of long standing the procedure varies according to their extent, (a.) In the operation for incomplete laceration of the perinasum many consider the same rules to be valid » Brose, Centralblatt. f. Gyn., 18S3, S. 777. OF THE DISEASES OF WOMEN. ,65 which have been described in tlie operation of posterior colporrliaphy. I will, therefore, not refer to this again here. I will, moreover, not enter upon the method of formation of the flap, which has been described first by Von Langenbeck,^ then in other forms by Wilms, ^ Staunde,'' and Lawson Tait,'* because I have no experience of my own on this question. I have for a long time made use of the rules laid down by Hegar ' for cases of incomplete rupture of the perinceum, and simply perform colpo- perineorrhaphy according to his rules. During the last six years I have in a great majority of cases operated according to the principles -wdiich Freund^ has published on this subject, and from which I have developed my own method for prolapse as described above. The essential point of this opei'ation consists in uniting all parts which here anatomically belong together, while sparing the support which is furnished to the posterior vaginal wall by the columna rugarum. After thorough evacuation of the bowel, unxJer anaesthesia, and appro- priate disinfection, and in the position of the ^^^- ^^• patient corresponding to Fig. 15, the upper ex- tremity of the injury of the perinaeum is seized with bullet-forceps, and drawn down as near as possible to the entrance ; if this extremity lies on the side of the columna rugarum, then the bullet- forceps is applied to this lateral fold ; if it lies in the median line, the instrument must be inserted in this point ; then w'ith two bullet-forceps the vagina is put on the stretch where the rent runs into the median line at the lower end of the columna rugarum posterior ; be- tween these l)ullet-forceps an incision is made around the scar, which is dissected away, and the raw surface, which has been made smooth and even, is immediately sewed together (Fig. 91). When this closure has been carried to the median line, at the point of the columna rugarum, ' Biefd, M.f. Geb. XV., :86o, S. 401. ^ Giiterhock, Arch. f. klin. Chirurgie, XXIV., 1S79. 3 Zeitschr. f. Geb. u. Gyn., V., 1S80. < Obst. Soc. of London, XXL, 1S79-1SS0. 5 Operative Gynakologie, S. S02, Ed. iii. c Arch. f. Gyn., VI., 1S73, S. 317, N.aturforscherv. vov. Wiesbad'H. Interrupted suture in superficial rupture of perinjEum. [66 PATHOLOGY AND THERAPEUTICS Fig. 92. the bullet-forceps are removed, the vagina i.s pushed back, and now from the point of the columna rugarum to the lower end of the nympha;, on each side, an incision is made around the flap, which ends below, just above the anus, and encloses the whole cicatrix of the perinatal laceration lying in the posterior commissure ; after this place is appro- priately refreshed and smoothed, the vagina is closed. As soon as the nymphae are united below, the newly-formed raphe has its edges brought so near together that there is no difficidty in uniting them. If the columna is sur- rounded by cicatricial tissues on both sides, they are to be refreshed one after the other, just as in the prolapse opera- tion. The whole operation is performed under irrigation with weak disinfecting solu- tion ; after it is complete the patient is put to bed with the legs tied together. A continuous suture can here be carried out with juni- per catgut, corresponding to the above-mentioned success with continuous catgut sutures. In this case the seat of the laceration in the vagina on the side of the columna ru- garum can be closed with one thread, and then the rest of the wound can be united, as in building up the perinieum (Fig. 92), in which case a very thick mass is furnished by this union in layers of the raw surfaces. The subsequent treatment is similar to that described under prolapse operation. (/;.) In the operation for complete rupture of the perina-um the rectal and vaginal tubes have to be restored, and the perinieum lias to be formed anew. The refreshment may be extremely difficult if cicatricial formation is very extensive, and if the mucous membrane of the intestine is verv much distorted and bleeds easily, and if, in consequence of insuf- Superficial rupture of the perin?eum. Con- tinuous suture in layers. — a. Upper end of the thread in Baunigdrtner'' s forceps, h. The thread which is used in sewing with the needle. OF THE DISEASES OF WOMEN. 167 ficient preparation, the patient is continually discharging- the intestinal con- tents during the operation. Preparation is, therefore, indispensable, pre- cisely as in cases of complete rupture of the perinaium ; after they have been purged very energetically for several consecutive days, I give them from the evening of the day before the operation until the time of the oper- ation only fluid food, and in small quantities, and I have them bathe repeatedly in disinfecting solutions and use injections ; I have given to them in the morning about four or five hours before the operation a large enema of lukewarm water. In the dorsal position of the patient the edges of the wound are first fitted together anatomically, and then refreshed where the vaginal lacera- Fig. 93. Interrupted sutures in laceration of the peringeum and rectum, according to Hcgar and Kaltenbach. (Operative Gynaecologie, Ed. iii.) tion, which, as a nde, reaches up higher than that of the intestine, passes around the columna rugarum ; here, therefore, the refreshed surface is made laterally in the vagina. This must run pretty high up into the vagina, in order that the recto-vaginal septum may here be thickened as much as possible, before the extremity of the rent in the intestinal canal is reached in the further course of the suture (Fig. 93) . The thinness of the septum in this place makes tlie suturing extremely difficult of itself, and, as experience shows, frequently endangers the result i6S PATHOLOGY AND THERAPEUTICS by the development of a recto-vaginal fistula. In its further course the re- freshed surface must reach down to the lower end of the vagina into the neighborhood of the entrance, following ver}- closely the conditions of the injury. In the entrance itself the refreshed surfaces pass upwards, on both sides, again to the neighborhood of the lower border of the nympha;, in order that from this part a broad perinaeum may be formed. I. — Continuous suture with catgut^ commences at the upper angle of the wound, as in colporrhaphy posterior : then first I close the intestine with stitches, which are inserted from the mucous membrane of the intes- tine, passing over in the raw surface, and being brought out again into the Fig. 94a. Fig. 94i. Kefreshed surface and continuous sutures in deep laceration of the perinaeum. a. Lowest layer, b. Transition to the second layer. intestine. When the intestinal canal is closed throughout its whole extent to the anus, the first layer is formed in the raw surface, running back with the same thread, until it comes out in the vagina near the upper angle of the wound. If this layer is sufficient, the closure of the refreshed edges of the perinaeum follows that of the external line of incision in the vagina ; if the raw surface is still too great, a second layer must be formed, and only after this can the external wound be closed (Fig. 94a). Very lately I 1 Schroeder first emphatically recommended the use of continuous sutures with juniper catgut (loc. cit.) for old deep laceration of the perinaeum. I entirely agree with him as the result of my per- sonal experience. OF THE DISEASES OF WOMEN. 169 Fig. 9B. have several times sewed the external skin with interrupted catgut sutures. In using interrupted sutures two or three stitches must first be passed through the wall of the intestine, and tied on the side of the mucous membrane, and then, corresponding with the progress of this union, the vagina is also sutured. If, then, the stitches are further in- serted from the vagina and intestine, so that they lie with their deepest portions between each other, and the rectum itself is restored, there remains, as a rule, only the union of the lower portion of the entrance in order to completely close the wound in the vagina. At this stage of the operation the edges of the wound, which must be united for the raphe perinsei, approximate very closely, and may be closed without any trouble, with superficial sutures, from the external skin ; the only point to be noticed, thereby, is that no cavities should remain deep in the wound. The threads are cut oft' short, the wound completely cleaned, and then the patient brought to bed with legs tied together. If the columna rugarum is sur- rounded by the scar on both sides, so that the lower end appears as if torn oft", allowance must be made for this condition during the refresh- ment. The suturing goes on corresponding to the drawing (Fig. 95). For the operation of complete rupture of the periniEum many modifications have been pro- posed, especially in the mode of introducing the sutures. Thus the attempt has been made to avoid tying the threads on the intestinal mucous membrane, and a figure of S has been inserted, so that the threads are tied in the vagina itself. Heppner^ has made the figure of 8 of metallic wire corresponding to Fig. 96, and has twisted them on the side of the vagina and of the intestine. I myself have had no experience with this procedure, yet it has been used a great deal, as I hear, in Russia. Interrupted sutures, accord- ing to Frennd. — o,p, q. La- ceration of the vagina around the columna. /, z. Suture, down to the entrance, s, y. Perinreum. From y up is cicatrix in the intestine. Fig. 96. Suture, according to Hepp- iirr. — (i. The vagina. /'. The fissure, c. The rectum. 1 Langenhcck's Aichiv., Btl. X. >i. XV. I70 PATHOLOGY AND THERAPEUTICS Then the attempt has been made to put stitches only very super- ficially into the wall of the intestine, and beginning just below the uppermost vaginal stitch, all the stitches are inserted into the peri- naium and brought out there again, so that the perina^um and vagina are closed by them. Similar to this procedure is that which Hilde- brandt' and J. Veit '■' propose for the operation of fresh laceration of the perinseum, in which also the stitches are to be inserted from the perina^um. The tcnv attempts which I have made with this manner of inserting the sutures make me believe that the objections are not whoUv unfounded which have been raised against this method, /.lc soil for the development of the germs. In advanced life, finally, the special causal con- ditions become particularly prominent which are connected with the shrinking and involution of the genitals. We frequently see the mucous membrane become diseased under the influence of growths in the uterus or in the other organs pertaining to the genitals ; further, we must not conceal from ourselves the fact that the occasion for the development of inflammations of the mucous membrane is often enough given by our gyniccological examination, and by various methods of treatment, especially those by cauterizations and those by pes- OF THE DISEASES OF WOMEN. i8i sarics. Finally, catching cold, especially when at the time of menstruation, is considered to be a not unfrequeiit cause. It cannot escape notice that many women, usually in consequence of an unsuitable dwelling, show a peculiar disposition to catch cold exactly at this time, during their early youth, and that tlien the unwillingness to have this physiological condition observed by others prevents many girls and women occasionally from taking such care of themselves as they are otherwise accustomed to do. I must admit that the influence of catching cold in itself is not quite com- prehensible to me. The suppression of menstruation, which is frequently suggested as the cause, is undoubtedly only a symptom of the disease which has already occurred, not its cause. Qiiite apart from these aetio- logical conditions, the inflammations of the mucous membrane certainly occur very frequently in connection with disturbances of digestion, with an unsuitable habit of life, and with the so-called abdominal plethora con- nected therewith. The significance of gonorrhoeal infection of the female genitals has only very lately received the attention which it deserves. I will consider this chapter separately, as a continuation of the subject of the diseases of the mucous membrane. (a) It is evident that the diseases of the vulva are the most frequent, for here there is the first contact of all those irritations which aftect the genitals ; and yet the inflammations of the vulva and of the lower sections of the urethra are not frequently a prominent subject of complaint by our patients, since these parts can be treated by the patients themselves, and their diseases usually cause so much suffering that the women are accus- tomed to attempt to treat them by domestic remedies, and especially by cleanliness, avoiding everything injurious. A great number of affections of the vulva are commonly classed together under the name pruritus. It is clear that here only the most prominent symptom is considered, whether the parts in question are inflamed in consec^uence of infection by external irritants, or in consequence of constitutional diseases, among which dia- betes plays a great role. (yb) The inflammations of the vagina are very seldom entirely iso- lated ; we most frequently find that they have developed under the influ- ences of pregnancy, or it may be of labor and childbed, where the greatly dilated genital canal, with its very richly \'ascular mucous membrane, is irritated and injured by disturbances of involution, by contact with the secretions of the uterus which stagnate here and are disposed to decom- position, and finally by becoming soiled with substances which occasion- ally get into the vagina through the patulous entrance, e.g.^ faeces and urine. Abusus coeundi, irritation from masturbation, and quite particu- 1 82 PATHOLOGY AND THERAPEUTICS larly gonorrhccal infection, may be considered as the causes of inost diseases of the vagina which are not puerperal. A cjuite peculiar form of vaginal disease is seen to occur in connection with senile atrophy, — a disease which seems even more troublesome to the elderly patients, since it very often occurs in women who were formerly quite healthy, and then it causes such intense sufferings that they seek medical aid, even although with great reluctance. (c) The diseases of the uterine mucous ?ne?nbrane are in the great majority of cases first observed after the occurrence of full sexual devel- opment. If we omit the forms of endometritis which occur in childhood in cases of constitutional diseases, especially scrophulosis, it is only in quite isolated cases that the uterine mucous membrane is seen to become diseased before the period of menstruation, under the influences of par- ticular injuries. The periodical change in the uterus, which is connected with menstruation, undoubtedly goes on not without troublesome dis- position towards further alterations in the mucous membrane itself, especially in its glandular apparatus, so that even in unmarried girls, who live in a relatively healthful manner, these changes at menstruation furnish an opportunity for inflammations of the mucous membrane wliich must not be underestimated. The diseases of the uterine mucous membrane are by no means always equally distributed over the whole internal surface of the uterine canal ; we see not only isolated diseases of the mucous membrane of the cervix occur by the side of those of the mucous mem- brane of the corptis^ but also we even observe the formation of circum- script spots of disease in the separate sections. The diseases of the cervical ?}mcous mc?nbra?ie are certainly the most frequent, since the cei'vix first receives any injurious influences entering the vagina, and by its valvular folds many hindrances are oft'ered to the further progress of the disease, and since, moreover, during the conditions of childbirth the cei-vix suffers a much more injurious dilatation, and very often, also, solutions of continuity. On account of this laceration, more- over, and the cicatricial formation necessarily connected therewith, there are changes of place and form which expose the cervical canal f;ir above the external os uteri to the injurious influences entering from the vagina. Endo?netritis corporis is, with extraordinary frequency, a conse- quence of pregnancy. The separation of the decidua is often incomplete, especially if pregnancy comes to an end before the normal time. Those rags of decidua which are retained exert a permanently injurious influence on the surrounding mucous membrane and on the involution of the mucous surfaces covered by them. A considerable part of the diseases of the membrane of the corpus are consequences of constitutional diseases. OF THE DISEASES OF WOMEN. 1S3 Finally, in so far as the diseases do not arise from the gradual spread of the exciters of disease from the cervical canal, the glandular apparatus of the uterine cavity, through its disposition to alterations and new growths, must be considered as the source of primary endometritis corporis. {d^ The diseases of the tubal imicous membrane arise apparently, with few exceptions, from an extension of the affections of the mucous membrane of the uterine cavity itself; this does not, however, exclude the possibility that also in the tube, perhaps under the influence of consti- tutional diseases, the mucous membrane swells and secretes excessively ; that the secretion is retained here, and that thus a condition arises such as we usually find under such conditions in affections of the mucous mem- branes. (This will be explained more minutely in considering the diseases of the tubes.) If I formerly mentioned the frequent transition of acute disease into chronic in the vulva and in the mucous membrane of the lower part of the vagina as a peculiarity dependent on the conditions of the parts, and if I emphasized the fact that we comparatively seldom have opportunity to observe virulent or other catarrhs of these parts in their early stages, this is true, also, to a certain extent, of the corresponding affections of those parts of the mucous membrane which are more remotely situated. We do sometimes see acute colpitis, endometritis, and salpingitis, but yet very seldom in comparison with the great frequency of this disease. The acute stages, which are usually accompanied by very violent symptoms, run their course rather rapidly, as far as I have observed, if we consider the cessation of the first severe pains and of the febrile reaction on the general health as characterizing the end of the acute stage of the malady. We usually have the opportunity of seeing these catarrhal forms in the stage of an abnormal secretion, of course after they have been complicated, also, by long-continued more or less severe pains, by disturbances of men- struation, and especially by haemorrhages. In considering the pathological anatomy of the iftjlammations on the surfaces of the genital organs we must first take notice of the fact that in the vulva and in the lowest part of the vagina a whole series of diseased conditions run their course, which remain localized here, and which may become chronic in case they do not get well after the acute stage. The dis- eases in the deeper parts may likewise be localized in single sections ; but the further the processes extend inward the more they have the tendency to extend over the whole area in question. The minuter changes in these inffammatory processes are naturally divided according to the very different structure of the parts diseased. The affections of the vagina, which has a scanty glandular system and a moderate covering of flat 1 84 PATHOLOGY AND THERAPEUTICS epithelium on the vaginal wall, naturally run their course in marked analogy to the diseases of the vulva, or, in foct, to those of the external skin. On the other hand, the diseases of the cervix, the corpus, and tubes have peculiarities in their original course, and convalescences dependent on the extraordinary development of the glandular system under a very delicate covering of cylindrical epithelium. I omit here any reference to the erysipelatous, croupous, and diphtheritic diseases, and to the syphilitic aflections, since these not only have a course analogous to the corresponding affections in other parts of the body, but, moreover, they very seldom occur apart from childbed and from such constitutional diseases as usually make the importance of the general disease much greater than that of the local. Here there is a v^^ide field open for examinations for micro-organisms, yet the many experiments which have been car- ried on by various investigators (also, in my establishment, Dr. Orthmann has worked on this subject in the laboratory arranged for this purpose) have not yet given conclusive results. The syitiptoms of the diseases of the mucous membrane of the gen- ital canal may be very violent in the acute forms of these diseases. With febrile symptoms there may be violent pain of the diseased parts. In all cases, however, the alteration of the secretion and the occasional influence on menstruation is equally characteristic. The diagnosis of the diseases of the mucous meinbrane of the gen- ital canal can no longer be based merely on examination by the unaided eye. Although the picture furnished by the parts which can be readily seen only exceptionally gives rise to doubts as to its meaning, yet even here, as more particularly in diseases of the more remote portions of the mucous membrane, we must consider the microscope as an aid indispen- sable for diagnosis. The use of a tampon for collecting the secretion, as recommended by Schultze (Centralbl. f. Gyn., iSSo, s. 117), is not available as a diagnostic measure on account of the continued uncertainty as to the source of the secretion. Therapeutics. — The prophylaxis of the diseases of the ?nucous membrane of the genital canal requires a rational care of the body, and particularly a thorough cleanliness in these organs. It should be a serious duty of mothers and nurses to carry this out understandingly, for only too often errors are committed from want of knowledge or neglect. Cer- tainly no woman is spared occasional symptoms of irritation of these organs, whether the occasion of this is a so-called catching cold, or the changes which depend on the occuiTence of menstruation, or the first period of marriage, or births, or special exciters of disease. Usually, intelligent women, by cleanliness and care in the beginning of sue)- irri- OF THE DISEASES OF WOMEN. 185 tations and inflammations, prevent tlic furtlier development of the same. If symptoms of inflammation occur in the genitals in connection with general disturbances of nutrition, the former get well, as a rule, with the improvement of the general condition, and disappear completely and spontaneously under appropriate care. Where such disturbances do not disappear at once, they are often improved by an increased stimulation of the digestion, by tiie enjovment of fresh air, and the avoidance of physical exertion and of sexual irritation of these organs. In consideration of the above, it is certainly advisable to look after girls carefully during their school years, at the time of their development, and to let girls and women, if it is at all possible, occa- sionally change residence, air, and mode of living. Pi-ecisely for these early stages, if the conditions of the patients permit it at all, is a residence at a watering-place, or a visit to forest, mountain, or seaside, of an im- portance which must not be underestimated. Among the baths suitable for such weakly women who are disposed to catarrhal disease, the brine- baths and the weak chalybeate springs are to be recommended. Yet hei'e the course of treatment should be rather adapted to an improvement of the general condition than to a local treatment, for which in these cases life at the baths seems little suitable. If the inflammations do not yield to a mild treatment as above, or if we have the acute stages to treat, in which the disease has got beyond the action of such general regulations as are directed chiefly to the mode of life, the treatment must certainly be more vigorous and local. Then, first, we have to employ the therapeutics of acute inflammatory conditions, rest, warm fomentations, or energetic refrigeration, if necessary with iced compresses, or abstraction of blood on the hypogastrium, or derivation towards the intestinal canal. In the more chronic forms the diseases in the mucous membrane of the genital canal require also a regular local treatment. I . — Inflammations of the Vulva. In the injiammations of the vtilva., swelling and redness come on first; especially the nymphai may swell up into great, thick red rolls. The tumefaction completely closes the opening of the vagina ; there is secreted a moderate amount of pus, at first thick, afterwards thinner, usually very malodorous. The cutaneous glands at this part participate in the inflam- mation, and then frequently appear as small pustules, or, when there is a greater infiltration, as tense swellings, which, indeed, in the majoritv of cases are resolved, but less frequently go on into formation of extensive abscesses. In all these diseases the glands of Bartholini ma\- be in- 1 86 PATHOLOGY AND THERAPEUTICS flamed, as well as the others which are situated here. The eflerent ducts of the former, which are situated in the vestil^ule, appear then clcaiK as a depression, usually colored grayish-red, on the summit of a little dark-red swelling (Fig. loo). The gland itself is greatly swollen ; there is usully a retention of the secretion, which is discharged from time to time in considerable quantities. In other cases the gland suppurates ; then for a long period the gland itself may alone be diseased while the surrounding parts remain free. A glandular swelling of this kind may also occur without any obstruction of the efferent duct ; the secretion is discharged when the external parts are moderately compressed, during sitting, walking, or coitus. In other cases the gland swells rapidly, the external cutaneous covering grows thin, the tense gland breaks externall}' and discharges its contents, which usually have a foul smell, like carrion. ^. ,^^ Sometimes an increase Fig. lOO. and diminution of the swell- ing of the glands occur, almost coincident with the course of menstruation ; there may then be a dis- charge everv time, either through the duct or by breaking of the sac. and the patients surter from this process, as an extremely painful complication of menstiTjation. I have usually seen the inflammations of the glands, which are not gon- orrheal, on one side only, yet the glands on both sides may become diseased simultaneously, or one shortly after the other. Beside the inflamma- tion of the glands of Bartholini there may occur an irritation of the hair, sebaceous, and sweat glands, in which hypcr-secretion, or even obstruction, or formation of abscess, may follow. WiNCKEL^ describes very minutely vulvitis dialietica, of which 1 have seen six cases without bein Lehrb. ber. F. Fraunkr., 1886, S. 50. OF THE DISEASES OF WOMEN. 187 period. The skin is red, like copper, and swollen. In spots the skin seems as if sprinkled with powder ; in other places there is a watery exudation, and here and there, there are haemorrhages caused by scratch- ing. The tissues are dry, harsh, wrinkled, but somewhat stiff to the touch. The affection soon creeps on to the folds of the thighs, and on to the mons Veneris, yet more frequently it extends backwards, around the anus. The intensity of the changes varies with the diabetes itself; sometimes the vulva seems paler and heals up, but sooner or later the old appearance recurs again, according to the condition of the disease. Breisky^ has described a very peculiar form of disease of the vulva as kraurosis vulvae. The skin and the mucous membrane in the region of the labia majora and minora, of the perinajum and of the entrance, shrink up, grow dry, and acquire a whitish appearance, and are covered with a thick layer of epidermis. The number of sebaceous glands is diminished, the papillary body becomes cicatricial, the con- nective tissue sclerotic. Thereby the skin becomes tightly stretched, so that it tears extremely easily, so that even the pressure of the finger in examining makes deep rents. Especially in elderly ladies, and often in old spinsters, there is a great swelling of the papillary layer of the vulva, especially to be observed on the internal surface of the labia, which gives these parts an appearance as though they were covered with frog- spawn. In these cases the marks of scratches variegate the appearance with little haemorrhages and cracks. Such papillary hypertrophy is certainly not always of gonorrhceal origin, and the swelling goes down after a longer or shorter duration unless acute symptoms necessitate active treatment. Fever is seldom present among the syniptoins of acute disease of the vulva; violent pain, on the other hand, as a rule, is especially noticeable. The swelling of the labia leads to pain from tension, which in part spreads to the neighboring cutaneous regions, and in part extends to the urethra, and here occasions a very painful sensation of burning at every exami- nation, unless a simultaneous metritis, arising from the same cause, occa- sions corresponding difficulties of the urine. In these cases there is usually an increase of the viscid secretion of these parts. The secretion is excoriating, annoys the women extremely by running down on the thighs, and leads them into rubbing and scratching the parts ; only too often has a catarrh of this kind, although quite innocent in itself, given rise to an irresistible stimulus to masturbation. CJironic catarrJis in this place sometimes give rise to a continuous annoying pain, which may bring these patients to desperation, and, since they only find these pains tolei"a- I Zeitschr. f. Heilkund., vi., S. 69, 1885. i88 PATHOLOGY AND THERAPEUTICS ble when they are perfectly quiet and avoid all irritating articles of food, these unfortunates are excluded from social relations with others, and abandon themselves wholly to their pain and their woe. The pains increase rapidly if the glands of Bautholini participate in the inflammation. The intensity of these difficulties varies according to the circumstances mentioned above. There is very seldom a complica- tion with swelling of the inguinal glands wlieii the vuKitis is not gonorrhceal. The diagnosis of the injiammation of the mucous }ne?nbrane of the vulva presents no essential difficulties, since the parts aflected are visible. The redness and swelling in the acute stage, the increased secretion and the tenderness in the chronic forms, hardly permit of a doubt concerning the nature of the malady. The appearance presented by in- flammation of the vulva in diabetes seems characteristic enough of itself to require an examination of the urine, even if this is not already indicated on account of other symptoms. Concerning the origin of gonorrhceal vulvitis information is said to be furnished by the microscopic appearance of the secretion, by the demon- stration of the presence of gonococci. On the other hand, however, such an aetiology cannot be entirely excluded, even when these cocci are absent. Especially frequent in gonorrhoeas are the complications with disease of the glands, both of those of Bartholini and of the inguinal glands. Therapeutics. — In diseases of the vulva, washings and vaginal douches by means of a simple irrigator are always found to give great comfort. In such lukewarm injections there should be used additions, as, for example, of aq. plumbi (a tablespoonful in one quart of water), cojjper sulphate or cuprum aluminatum or zinc sulphate (three to four scruples to the quart of water), acet. pyrolign. rectif., aq. creosoti (three to five tablespoonfuls to the quart), and others similar. The injections are em- ployed two to three times a day. If the external parts are raw, or even if they are very sensitive, the sufferings in the labia are alleviated by appli- cations of zinc or lead ointment, cold cream, a weak iodoform ointment, or also one made with silver nitrate, or an ointment composed of liq. Hol- landici (3.0) with lanolin (20.0). Sitz-baths, either made with a decoction of bran, or simple, without addition of medicaments, taken before going to bed for ten minutes, at a temperature of 81° F., which, if necessary, can be cooled down more, exert a further favorable influence on these sufferings, which are often increased bv the warmth of the bed. OF THE DISEASES OF- WOMEN. 189 Colpitis granulans acuta. C. Ruge. 3. — Inflammations of the Vagina. The inflammations of the vagina are found to extend over the whole vagina in other cases than in severe infectious processes. They are char- acterized by the swelling, dilatation of the superficial vessels, and great relaxation of the tissues, which are peculiar to inflammations of the mucous membranes. Sometimes the inflammation is seen not to extend continuously over the Fig. 101. -^ lower third ; further in, deep in the vaginal vault, it occurs local- ized in disseminated spots and extensions. The flat epithelium becomes thin and is cast oft'; below this the papilla3 of the subepi- thelial layer project as firm nodules on account of an infiltration of small cells (Fig. loi). There are groups of sevei'al such " granula," which have led Carl Ruge' to designate this form of vaginal inflammation as granular colpitis. The granules are sometimes arranged in rows on the summits of the folds of the mucous membrane ; sometimes they are united in groups in the walls of the vagina, and also in the vault of the vagina. The small-cell infiltration may lead to an abundant formation of larger nodules. The latter may be pushed close under the surface and be very vascular ; they mav even appear free on the surface after the epithelium over them has been cast oft'; then they appear bright red and prominent above the level of the surrounding tissue. In their further course, the level of the surface may b e again estab- lished by the involution of this infiltration under the epithelial covering, which grows over it again (Fig. 102), so that these granules are now only distinctly per- ceptible to the touch. In this form, chronic graftular colpitis may continue for a longtime. In these cases the secretion becomes extremely profuse, so that this vaginal Fig. 102. Colpitis granularis chron. C. Ruge. 1 C. Ruge, Zcitschrift f. Geb. u. Gyn., iv., S. 153. 190 PATHOLOGY AND THERAPEUTICS inflammation always yields a very abundant muco-purulent secretion. This secretion is naturally apt to be retained, partly in the folds of the vaginal wall and partly behind the tightly closed or swollen entrance, and then decomposition of these secretions soon occurs, with an enormous development of bacteria in the latter. By the decomposed excoriating condition of this secretion, as in the well-known catarrhal secretion of other mucous membranes, severe erosions may be caused on the skin of the vulva and of the nates, the healing of which is often prevented for a long time by the natural defilement with faeces, urine, sweat, and dust, and by the friction of the surfaces on each other and against the clothing. At an advanced age of women, generally after the climacteric, but frequently also as early as the thirtieth year, seldom earlier, there is developed a form of vaginal inflammation, in which the flat epithelium is lost, or it may be reduced to a few layers, with an appearance of Fig. 108. -iVw^iU. Chronic adhesive colpitis. many ecchymoses and formation of the above-mentioned granulations. These processes are found localized as well in the vaginal vault as in the w'hole vagina ; they commence with a peculiar pallor of tlie surface and a dryness of the secretory apparatus, and are characterized by the disposi- tion to adhesions of the surfaces of the vaginal canal which are in contact with each other. Such folds may completely envelop the vaginal portion, so that this appears as if retracted into the vault of the vagina. These adhesions, however, occur also in the other portions of the vaginal canal, and may lead to a complete obliteration of the lumen of the vagina. Old women are only seldom found without any adhesions or agglutinations of OF THE DISEASES OF WOMEN. 191 Fig. I04. this kind. This form of disease is ahnost typical for the senile involution of the vagina ; it occurs with only the most varied symptoms, and when irritations of all kinds are avoided it usually terminates in a narrowing of the lumen of this canal, if the women cease marital intercourse ; it is called colpitis adhccsiva chronica vetidaruni (103^). Naturally, besides this form of agglutination and adhesion there are also found in the vagina those which have arisen from phlegmonous or other ulcerative destruction. These are found with greater comparative fre- quency in the lower part of the vagina, and are free from the peculiar irritative symptoms connected with the development of the granules as mentioned above. Very lately attention has been called first by Winckel- to another form of vaginal affection, colpo-hyperplasia cystica, which occurs chiefly during pregnancy, but also at other times, and causes the vagina to appear as if sprinkled with hard nodules. In these nodules there are developed cystic cavities with gaseous contents. According to the investigations of Carl Ruge ^ in this peculiar form of disease the air lies in the spaces of the connective tissue, so that the expression em- ployed by Zweifel'* of colpitis emphysematosa seems well adapted for such cases (Fig. 104). This form of colpitis often exists without small-cell infiltration, often in com- bination with it ; then there are found close un- der the surface larger or smaller extravasations of blood, from the decom- position of which the development of gas is thought by some to pro- ceed. Various investigations concerning the manner of this development of gas have been undertaken, and yet up to the present time they have not yielded any satisfactory conclusions. Such gas-spaces occur close under the surface, with a very evident di'ying up of the epithelium which covers ' A''aginitis ulcerosa adhaisiva. Hildebrandt, Monatsschr. f. Geb., xxxii., I3S. -Arch. f. Gyn., ii., S. 406. 8 Zeitschr. f. Geh. u. Gyn., ii., S. 29. * Arcli. f. Gyn., Bd. xii., S. 39. 192 PATHOLOGY AND THERAPEUTICS tlicni, and they are easily felt as peculiarly dry, and sometimes also quite hard places in the mucous membrane of the vagina ; they are frequently united in larger or smaller groups, and are very often found by accident on examination. Symptoms. — The catarrhs of the vagina may run on almost with- out symptoms as soon as they have passed the painful, acute stage. Many women are scarcely disturbed even by a profuse secretion, unless their attention is led to this condition bv the decomposition of stagnant secre- tion and the odor dependent on it. as well as by the irritation of the external parts which is caused by the former. The secretion is of very varying character ; sometimes yellowish, ow- ing to the preponderance of pus in the mixture ; sometimes it is mucous; numerous micro-organisms are always found in it. Often, indeed, by accidental admixture of blood, there is a dark discoloration of the secretion. In the latter there is also always found large amounts of epithelium, mucous coagula ; occasionally, also, particles of dirt. For the examination of the micro-organisms which can here be found with special frequency, a fruitful stimulus has been given by Hausmax's ' studies in E. Martin's clinic. The form of vaginal inflammation, which has been described as peculiar to old women, is chiefly characterized by the frequency oi violent burning paitis. Colpitis vetularu?n may certainly also run its course almost without symptoms, even to complete obliteration of the lumen of the vagina ; more frequently, how'ever, it causes such severe sufferings that the unhappv patients are tormented by them unceasingly. The mucous membrane is shiny, without being covered by an abundant secretion. It appears pale, with reddish spots, which may even appear bluish. Diagnosis. — The recognition of the inflammations of the vagina is much facilitated by the alteration in the appearance and the sensitiveness of the vaginal wall. The microscopic examination of the secretions can certainlv give information about the real nature of the disease ; neverthe- less, as is well known, the absence of gonococci is not as yet a satis- factorv evidence that the character of the disease is not virulent. If the granular form and that of adhesive colpitis are, as a rule, easy to recognize, yet the emphvsematous form more easily escapes diagnosis if the air-spaces ai-e small and lie scattered far below the surface. In the cases which I have observed the dryness of the vaginal mucous membrane over the air- spaces was particularly noticeable. The treatment of vaginal injiammation should always commence with an appropriate cleansing of this passage, which contains so many •Die Parasiten des weibl., Geschl., iSyo. OF THE DISEASES OF WOMEN. 193 folds. Constitutional diseases, such as scrofula, chlorosis, etc., of course require an appropriate medication at the same time ; the local difficulty then not infrequently disappears under such treatment. All very active local treatment, especially with pessaries, appears to be quite particularly inopportune in cases of vaginal inflammation ; while, on the other hand, the latter is very often only terminated by the cure of a uterine malady. I have all married women use, as a part of their toilet, vaginal injec- tions with tepid or cold water. To the latter, in case of inflammation of the vagina, the additions are then made which I have recommended above on page 1S8. As adjuvants of these, sitz-baths are valuable, during which, in order to bring the dis- eased parts in contact with the fluid of the bath, I have bath specula used, i.e.^ cylindrical instruments with perforated walls, selected of an appro- priate size for the vagina. Ointments with alum, or tannin, or similar substances I have used very seldom. Mild cauterizations with acet. pyrolignosum rectific, tincture of iodine and solution of the acid nitrate of mercury, which are applied through the speculum, have seemed to me more fitting; especially in senile colpitis the acet. pyrolig. i"ect., as recommended by C. Meyer, ^ is a very effectual medicament, the success of which HoFMiER " has demonstrated with accuracy. If the vaginal inflammation resist also such cauterizations, which are to be employed two or three times weekly, the above medicaments can be made to have a more continuous action, either by glycerine tampons or in the form of balls of cacao-butter, which are even easier to introduce than the former and do not need to be removed. If the vaginal secretions still persist in spite of the above cauteriza- tions, I have employed also for these forms of disease the treatment with glycerine tampons with addition of tannin, iodine, or iodoform. Balls of cotton as big as a little apple, made of pure absorbent cotton, tied tightly together, wrung out in water and thereby essentially diminished in volume, are introduced by the women themselves, after being thoroughly soaked with the glycerole of tannin. Most women can do this very well, so that it is very seldom necessary for the physician himself to apply the cotton tampons, or to have them put in by midwives, or to give the women the well-known tampon-applicators, which I have seen, particularly at the English instrument-makers. Such cotton-balls should remain eight to twelve hours in the vagina, and then be drawn out by the threads which are attached to each. The coagulations caused by the medicament must be removed by regular vaginal injections. 1 Bcricht dcr Ges. fur Gcburtsh, Berlin, iS6i . - Zeitschr. f. Geb. und Gyn., v. s. 331. 194 PATHOLOGY AND THERAPEUTICS Adhesive colpitis sometimes heals with surprising rapidity under cauterization with acct. pyrolig. rect. ; the fluid is poured into the specu- lum, the wood-vinegar acts for some minutes on the diseased parts which are exposed. In other cases narcotics cannot be wholly omitted in the early stages. The treatmoit of the forms of vulvitis and colpitis^ which occur with vaginismus as the principal symptom, will be described further on. With simultaneous use of mild laxatives and an appropriate diet, in which the use of alcoholic drinks is to be limited as far as possible, with sexual rest, and regular exeixise in the open air, the difficulties disappear as a rule, so that it is not necessary to employ the cauterizations of the diseased places which are to be seen in the vulva and vagina, too long nor too often. I like to use tincture of iodine in those forms of vulvar and vaginal inflammation in which the papillae rise above the surface, almost like warts, and as a rule after such treatment I see that these little warts dry up quite rapidly. The pain which is caused by the application of iodine disappears as a rule very soon ; in very sensitive women I have, however, mixed the tincture of iodine with equal parts of glycerine. In rare cases the papillae resist such cauterizations, and must be le- moved with knife or scissors.^ I have seen the parts heal after excision of small hypertrophic sections ; in other cases the scars caused suflering for a long period. If the irritation of the vulva and vagina appears as symptomatic of dia- betes, a cure of the former is only to be expected under the simultaneous use of apppropriate courses of treatment, especially that of Carlsbad. 3. — The Inflammations of the Uterine Mucous Membrane. I. — The pathological atiatomv of the inflammations of the uterine mucous membrane presents — A. — In acute forms of the disease, the alterations which we observe in all acute diseases of mucous membranes : severe swelling of the relaxed and oedematous membrane, and intense redness, sometimes also little ecchymoses, and, moreover, an excessive increase of the activity of the glandular apparatus. Precisely this last peculiarity helps to render more difficult the diagnosis of the disease in its separate stages. While the secretion of the cervical mucous niembrane in a hcaltliv condition is a tenacious mass, while the secretion of the uterine cavity is a scanty, watery serum, in conditions of acute disease there is secreted from the 1 Schroeder, Zeitech. f. Geb. u. Gyn., Bd. xi., 1885. Kuestner, Centralb. f. Gyn., Nr. ii., 1885. OF THE DISEASES OF WOMEN. 195 corpus likewise, after loss of its epithelium, bloody mucous masses, usually, however, in small quantities with admixture of pus ; these Fig. 10s. Fig. 106. Erosions of the vaginal portion, after C. Riige and J. Veit} masses contain usually, beside the cast-off groups of epithelia,also glandu- lar tubes to a greater or less extent. The secre- tion then appears corre- spondingly yellowish- red, or rather purulent, and even on the surface of the mucous membrane the glandular pockets still filled with this secre- tion appear as yellowish or whitish points. B. — In the chronic disease^ the so - called catarrh of the titerine mucous membrane^ the swelling may last for a long time, as also the abundant vascular devel- opment, with occasional formation of ecchy- mosis ; almost always the secretion of this mucous membrane re- mains increased after the Microscopic appearance of Fig. 105. 1 Centralb. f. Gyn., 1877, No. 2. Zeitschr. f. Geb. u. Gyn., ii. u. viii. 196 PATHOLOGY AND THERAPEUTICS disease has continued for a considerable time. The catarrhs of the cervix {a) difVer in their anatomical development in a very peculiar man- ner from the catarrhs of the corpus {b). Although the two fre- quently enough are combined, it is nevertheless of great importance to consider the forms of disease in the separate sections of the mucous Papillary erosion, after C. Ruge. membrane separately, in order to gain a right idea of these inflammatory processes. (a.) In chronic catarrh of the cervix the most prominent symptom is a strong disposition to alterations in the epithelial surface. While the individual cylindrical epithelia are transformed and increased in num- ber, the surface itself of the mucous membrane is considerably enlarged by the great thickening of the folds, especially of the plicas plamate ; the mucous membrane itself swells, and especially protrudes below from the OS, and appears here as a soft, deep-red mass which secretes excessively ; on the Other hand, tlie cylindrical epithelium, replacing the covering of flat .epithelium, grows out from the os uteri over the normal boundary of the epithelial covering, so that the whole portio vaginalis, and even beyond this the surface of the vault of the vagina, appears covered with cylindrical epithelium, with a depth of one or a few layers, instead of with flat epithelium in many layers. Beside this manner of increase of the surface there is developed a great increase of secreting surface ovoing to the very abundant excava- tion of glandtdar structures under the surface of the vaginal portion (Fig. 105). OF THE DISEASES OF WOMEN. 197 These pockets, which are lined with delicate cylindrical epithelium, may bifurcate further down, forming further reduplications, and here, as also in the cervical canal itself, they may permeate the muscular sub- stratum of the mucous membrane very extensively. Such territories, covered with cylinder-epithelium, and extending superficially, are the erosio7is which have lately been so much discussed. Fig. 106 shows the microscopic picture of the previous figure. The flat epithelium, which is still retained in the lower section, is transformed in the diseased parts which are split up and divided by glands. This shows on the surface longer and shorter glandular canals, which often branch again. The glandular structures lying deep below the surface are cross- sections ot occluded ends of analogous reduplications. Various kinds of this form of disease can be clearly distinguished, which clinically are usually included under the general term of erosions. According to the degree to which the stratum lying between the glands participates more predominantly in the further development of these glandular i-eduplications those cases must be separated into a class in Fig. 108. Follicular erosion, after C. Ruge. which the stratum of connective tissue protrudes like papillae between the pockets which burrow downward, with the regularity of palisades (Fig. 107) , forming the papillarv erosion, or as Ruge has called it the fapillarv tilcer. Kwo^^&\^ ioxxw \% \\-\& follicular erosion (Fig. loS), in which the glandular pockets, deep below the surface are distended to great follicular spaces by the secretion which stagnates there. Then, under the pressure of these follicular spaces, the bundles of inter-glandular connective tissue with the whole surface are usually stretched apart so that the accompany- 198 PATHOLOGY AND THERAPEUTICS inj; picture of follicular erosion is formed. \\'ith this alteration of the surface there is combined in many cases a further permeation with {:^lands. even of the proper stroma of the cervix. The growth of such redupli- cations into the substratum of muscular and connective tissue gives rise to a violent irritation, which, in combination with the corresponding and often very extraordinarily abundant development of vessels and enormous small cell infiltration, becomes noticeable, even to the unaided eye, by a decided increase of volume (Fig. 109). Especially, when there is already a solu- tion of continuity of the lateral commissures of the os uteri, the mucous membrane of the cenical canal protrudes greatly, so that it appears to cover Fig. 109. Fig. 110. Ectropium of the cervical mucous mem- brane (as seen in the speculum), after C. J\uge, loc. cit. Excised piece of the cer\'ix, after C. Ruge. the external surface of the portio {ectropiu7n of the cervical mucous tncm- brane) . If the surface of the cervix, altered by such an endometritis, and by the metritis which so often complicated it, is aflected by any injury, there may occur, owing to the loss of the undermined surface, a defect which gives a picture (Fig. no) which clinically corresponds com- pletely to that of carcinomatous disease of the cervix. The greatly increased secretory apparatus, and the viscid discharge connected with the latter, are, as a rule, complicated by a very prominent disposition to hccmorrhages. If then the cervix appears split into sec- tions, and if the infiltrated, hard bundles of connective tissue i)rotrude greatly in these split spaces, it is only too frequently that the plicae pla- matas, which can be felt hard and almost nodular over them, complete the similarity of the whole to malignant ulcerations. The erosions ?nay be I^ANNALS ok (JVN.Kt01,()(.V, linstoil, ()cl(>l)L-r, 1SS7.] IX Fig. 2. Fig. 3. Fig. 5. [Annals ok GvN.licoLoc.v, lidston, October, 1SS7.J Fig. 6. Fig. 7. Anxai.s ok C,\>!.va (ti.ix.y, liosloii, Oilohur, 1SS7. XI Fig. 8. Fig. 9. [Annals ok (;vn.kc-ol()(;> , H<)-,tc)ii, Oclohir, 18S7.J XTI Fig. 10. Fig. 11. IAnnai.s oi- (Jv.n.kcologv, Hoston, Octobur, 1SS7.J XllI Fig. 13. [Annals ok (iv.\.Kcoi.()(;^ , Roslon, OLti)l)er, 1SS7.] XIV Fig. 14. ~\ ^# Chronic interstitial endome- tritis, (x 250), after Schrceder, Handbook. Glandular endometritis, after C. Ruge. p. 119. From these islands the inflammatory processes spread over the whole of the mucous membrane (Fig. iiS). Or instead of the puerperal involution there occurs an inflammatory condition of proliferation. In these cases, according to C. Ruge (loc. cit.), there is developed especially the interstitial form, with which, however, in its further course, there may be associated a participation of the glands. 5. In exfoliative endometritis there occurs, without any cause as yet discoverable, a separation of the infla?ned mucous membrane in the form of large membranous pieces., or also of a cast of the ichole uterine cavity. It occurs not verv infrequentlv l)oth in some virgins who, almost from the beginning of menstruation, have such membranous dis- charges at nearlv every menstruation, as well as in individuals who have had children. Generally more extensive separations of membrane occur at considerable intervals of time ; it may be, indeed, only at intervals of years that the separation of a large portion of the mucous membrane all in one piece is repeated, while the intervening menstruations take place OF THE DISEASES OF WOMEN. 203 without any discharge of this kind. In other cases there is only quite infrequently a discharge of such membranes, also sometimes after preg- nancy has preceded. In other cases again the exfoliation of membranes keeps becoming more evident toward the change of life. It seems natural to explain these membranes (Fig. 119) as caused by abortive processes, since they consist of the well-preserved superficial layers of the uterine mucous membrane, with utricular glands and inter-glandular tissue. Peculiar, and significant for the differential diagnosis, is the ab- sence of the large, irregular decidual cells. The pieces themselves show on one side the smooth surface of the mucous membrane, while they are uneven on the other side ; on the internal surface furrows and glandular openings may be clearly recognized. It is important to finally give up the idea that peculiar morbid pro- cesses are present here, as has been supposed by many up to this time in regard to this so-called membranous dysmenorrhoea, and to hold firmly to the fact that in these cases there is simply an inflammatory process, with Fig. 117. Fungous endometritis with preponderance, on the left, of the glandular; on the right, of the interstitial form, after C. Ruge. a peculiar exfoliation of the inflamed parts of the mucous membrane. These membranes represent an interstitial endometritis, in which the in- tercellular tissue is more aflected than the cells of the stroma. The frame- work is thickened and permeated by abundant bundles of elastic fibres. The cells have sometimes enlarged nuclei, and an increased cellular body, so that what appears like an early stage of transition to actual decidual cells might be thought to be present (C. Ruge ^). In the further course of all forms of endometritis corporis, recovery 'Compare also Loehlein, Gesellsch. f. Geh. u. Gyn., Feb., iSS6. Zeitschr. f. Geb. u. Gyn., s. 465. 204 PATHOLOGY AND THERAPEUTICS may occur, with letuni to the further normal condition. In other cases there takes phicc in the tuucous tnembrane a sort of cicatricial yormation. The ciliated epithelium, cast oft' very early, is not again replaced, but the inner surface becomes linetl with low cells, almost similar to flat epi- thelium. The glands are flattened out, with dilatation of their openings, and appear finally as simple depressions, the secretion diminishes, so that finally the inner surface may appear as if lined with a layer of simple con- nective tissue. It always requires a very extensive practice in the interpretation of these microscopic figures, such as I myself have been able to acquire under the instructive guidance of Carl Ruge, in order to make a certain dlag- Fig. 118. Bli ^^&-^ ^f!^'^ Endometritis after abortion, after Schrceder, ed. vii. — d, d. Decidual islands. nosls from the tangled labyrinth of glands and vessels, and from the ap- pearance of the interstices. The whole picture may contain scarcely anything except sections of glandular canals, so that the denomination of this form as chronic adenomatous endometritis seems entirely appropriate, particularly as these glands, in their disposition to recurrence, and (as I infer from observations which will be mentioned later) on account of their undeniable disposition to later malignant degeneration, must claim a quite peculiar significance. II. — The special symptoms of htflammatlon of tJie uterine 7nucous membra7ie in the acute stage are violent pains in the lower abdomen, sen- sations like labor pains, a feeling of heaviness, of distension, with rectal and vesical tenesmus, also symptoms of peritoneal irritation. As these diminish there appear the alterations of the secretions and the disturb- OF THE DISEASES OF WOMEN. 205 Fig. 119. ances of rnenstruatioii which are peculiar to the chronic catarrhs. Here also the discharge is not immediately increased equally ; the secretion is found to be extraordinarily varied in diseases of the mucous membrane. The tenacious secretion of the cervix is generally altered by abundant muco-purulent admixtures, and is often mingled w^ith blood ; cast-off epithelia, and especially parts of glands, are then found in it. Moreover, these secretions decompose quite readily, and then give off a very un- pleasant odor. Especially in interstitial endometritis there is developed a very marked disposition to hcemorrhages also between the menstrual periods. As a rule menstruatio7i is disturbed in catarrhs of the uterine mucous membrane. The stage of development of this malady, before the occurrence of the haemorrhages, is associated with violent pains. Then, when the flow comes on, sometimes an excess of blood is secreted, and sometimes it is passed with pains like those of labor ; there is an interrupted discharge, which is associated every time with exacerbated pains in the abdo- men, in the genitals, or in the small of the back. Under the influence of the catarrh of the mucous membrane there may also super- vene a diminution of the amount of blood passed, yet in such patients I have usually had the impression that some disturbance of nutri- tion coexistent with the catarrh, or especially the disease of the deeper parenchyma of the uterus itself, which so often complicates such disease of the mucous membrane, had an important influence on this peculiar disturbance of the menstruation. A distinction must here be made between the symptoms of the ca- tarrhs : I, Of the cervix; 2, of the corpus. I . The catarrhs of the cervix. (a.) The acute catarrhs of the cervical mucous membrane run their course with the symptoms of all analogous processes ; after the secretion has first been suppressed for a short time, there follows an abundant thin discharge, sometimes discolored with blood. If the catarrh occurs at the time of the menses, the swelling of the cervical mucous .■nembrane cannot indeed occasion an interruption of the extravasation of menstrual blood, for this membrane does not itself secrete this blood, but its evacuation may be hindered by the obstruction of the canal in consequence of the swelling, Cast of the uterine ca\dty in exfoliative endometritis. (Membranous dysmenor- rhoea.) 2o6 PATHOLOGY AND THERAPEUTICS so that thereby an interruption in the discharge of the blood is occasioned. The usual accompanying symptoms are pain, often with chill and elevation of temperature, sensitiveness to pressure in the pelvis, vesical and rectal tenesmus. {b.) The chronic catarrhs of the cervical mucous membrafie lead to more important symptoms through the peculiar alterations of the glandular apparatus. The greatly thickened mucous membrane, which protrudes through the external os uteri, is so changed by its swelling and by being permeated with glandular pocket that haemorrhages easily occur, especially if after a lonsT duration there is disinte^^ration and ulceration, then everv movement of the body, ever}^- shock, every difficult defecation, every co- habitation, may occasion bloody discoloration of the discharge, which in combination with the disturbances of the general condition caused by the pains, and by the profuse discharges, especially in the later years of life, may well cause the clinical symptoms of malignant disease of the cen-ix. Attention has lately been called to the peculiar mutual reaction between uterine catarrhs and the solutions of continuity of the cervix, the so-called lacerations of the cervix, which are so frequently found in connection with childbirth. I agree with the views of those ^ who are of the opinion that the catarrhs are by no means to be considered as necessary consequences of these lacerations, for in fact one often has opportunity to observe such lacerations without catarrh.- Since I believe that a specific cause for the catarrhs will yet be found, perhaps through the progressive development of our methods of examination, I am of the opinion that the cervical lacerations simply furnish an opportunity for the entrance of such exciters of disease, and that during the existence of such lacerations the cervical catarrhs are made decidedly worse, by the opportunity of extending the mucous surface involved over the part which is lacerated ; for then the greatly hypertrophied mucous membrane either protrudes over the surface of the portio, although confined to its old limits with great alteration of the subjacent layers, and really rolls out the lips which have been de- prived of their point of resistance in the intact os uteri — cvcrsion of the lips — or the process creeps through the point of laceration to the external surface of the portio, and passes over on to the neighboring parts or on to the vaginal vault (see Fig. 109). ' The chronic catarrhs of the cervix^ through swelling of the mucous membrane, sometimes bring about a complete occlusion of the efferent ducts of the deeper glandular elements which were more particularly 1 Schrceder, Charit^-Annalen, vi. 2 Transactions of the Boston Gyn. Soc, Dec, 1SS5. Communication of A. Martin to the society, ^ Compared Freund, Die gynakol. Klinik in Strassburg, iSSs- Czempin, Zeitschrift f. Gch. und Gyn., 1SS6, B. xii., s. 2S7. OF THE DISEASES OF ■ WOMEN. 207 described above on page 201. The reient ion-follicles de.\e\o]ie(\ in this manner irritate the vicinity by pressure, and thereby occasion pains, light indeed but continuous, in the lower abdomen. These pains may then grow very distinct, if the limit of the mucous membrane at the external os uteri has led to the formation of a stenosis., by the adhesion of the edges which are opposed to each other, and if the secretion is retained behind this. Then there is developed a peculiar elongation of the sufra-vaginal portion oj tJie cervix and a dilation of tJie cervical canal. If in its further course the catarrh gets better, and with atrophy of the mucous membrane the secretion diminishes, there remains besides the stenosis in the external os that which is most important, the supra-vaginal elonga- tion of the cervix. I have not only had occasion to observe this retio- logical connection in virgins, but also repeatedly in women wdiom I formerly had to examine in connection with labors or other maladies I have been able to demonstrate the supra-vaginal elongation of the cervix clearly and immediately during its development later in life. In these cases the stenoses are of very secondary importance, for if the acute stages with their consequences, especially the abundant secretion, have got well, the secre- tion which is now scanty can be discharged from the external os uteri without trouble, and especially without pain, so that often enough in these cases one could hardly speak any more of an obstruction of the discharges. In rare cases the stenosis is so rigid that only a fine sound can be intro- duced ; generally it is easy to push in the thick head of the sound, and in such stenoses I have only rarely found any noticeable difficulty in the in- troduction of the curette. The supra-vaginal elongation caused by these stenoses appears as a much more important cousequence of the disease of the mucous membrane. As far as I have now observed this first under- goes involution during the climacteric, or during a puerperal period, but precisely the occurrence of conception appears to be essentially hindered by this alteration of the cervix. 2. Catarrhs of the corpus. (a.) The acute catarrh of the mucous membrane of the body occasions violent pains, which in part must be considered as a consequence of the swelling of the mucous membrane, the enlargement of which is impeded by the uterine walls. The suppression of the menses is not the cause, but the consequence, of the acute disease of the corporeal mucous membrane which is set up by the catarrh. Usually this suppression is followed by a much freer haemorrhage, sometimes after hours, sometimes after days, and this causes an alleviation of the pains. The pelvic viscera take an important part in the process, the whole pelvis becomes sensitive, and especially the bladder and the rectum occasion severe sufferings. 2o8 PATHOLOGY AND THERAPEUTICS (d.) All forms of the chronic diseases of the mucous membrane of the corpus^ which have been described as diffuse hyperplastic fu7igous en- dometritis and ^% glandtdar endometritis, cause as their most prominent symptoms increased secretions and hcBtnorrhages. These indeed usually maintain the type of menstruation, yet during further development they also very often occur between the menstrual periods, so that then secretions of blood occur apart from menstruation. In these cases the uterus becomes swollen, and, although in all forms of diseases of the mucous membrane there exists a very pronounced disposition of the subjacent parenchyma to participate in the inflammatory process, such a complication with chronic metritis occurs almost constantly, precisely, in the fungous and glandular diseases of the mucous membrane. The above-mentioned pains occur also frequently, although not con- stantly, as symptoms of affection of the corporeal mucous membrane. These are often only dull and occasional, in other cases they also occur only a short time before and during the period, while again in other cases the patients are plagued continually by these sensations, localized deep in the lower abdomen. Sterility is mentioned as one of the most prominent symptoms of the diseases of the uterine mucous membrane ; undoubtedly the vitality of the spermatozoa may be destroyed by the condition of the secre- tion at the very commencement of their contact with the latter. Then it is very conceivable that an ovule catmot take root in such an irritated mucous membrane, and in the secretion covering it, and that also later in chronic catarrhs when the mucous membrane has finally lost its ciliated epitheli- um, in partial spontaneous recovery of the inner uterine surface, the mucous membrane loses its ability of development into decidua. Accord- ing to my own observation I am, however, led to the opinion that it is precisely the peculiar elongation of the cei"vix, elongatio colli supravagi- nalis, which I consider as a consequence of the catarrh, that is to be held essentially responsible for the sterility. This connection is supported, in my opinion, by many and repeated observations : if at first the endome- tritis or the stenosis alone was attacked, success was wanting; but if the supra-vaginal elongation was then removed, conception followed. In the exfoliative form of endometritis the sufferings occur almost without exception only at the time of menstruation. The discharge of membranes is almost always associated with extra- ordinarily violent colicky pains; often, especially when they are dis- charged sporadically, an intense feeling of distention and discomfort is experienced even for weeks before this menstruation, until with suffer- ings like labor pains severe hiemorrhages come on, in the course of which OF THE DISEASES OF WOMEN. 209 the membrane is expelled. In other cases menstruation is delayed for days and weeks, so that the patients indeed consider themselves pregnant, until, sometimes apparently under the influence of unimportant injuries, the well-known pains and flow of blood again occur. The discharge of the membrane seldom goes on entirely without pain. Membranous dysmenorrhoea is frequently associated with sterility ; cer- tainly pregnancy could very seldom go on, as long as such exfoliations keep occurring. If, in spite of the existence of the latter, a pregnancy takes a normal course, it must be supposed that in these cases conception has been developed in one of the longer pauses of membranous separation. III. — The diagnosis of catarrhs of the uterus may be very difficult if the diseased parts lying in the depths of the cavity are inaccessible to ob- servation. But even here the part which is most frequently diseased, the cervical mucous membrane, is so situated that it protrudes in its swollen hypertrophic condition out of the os uteri, whether the latter is lacerated or still tightly closed. The erosions which grow out over the border of the OS, and occasionally the disintegration of the tissue which has appeared on the surface of the portio, are diagnostic points, in regard to which doubt is only seldom to be entertained. Doubts whether we have to do with a simple catarrh or with an incipient new-growth are removed in the same way which we have to follow in order to settle the diagnosis of the special form of disease in the sections which lie deeper. For the latter the se- cretion and alteration of the menstruation is certainly characteristic to a certain extent. Owing to the frequently acute sensitiveness of the diseased parts a diagnostic point which is often very important is given by touching the latter with the sound. Nevertheless only the microscope gives a full insight into the nature of the condition present. It has been recommended, in order to clearly determine the conditions of the mucous membrane, to divide the lips of the os uteri, with or without a previous ligation of the parametria ; but I believe that in regard to these deep-lying parts we ought to trust very little to the naked eye, since it is incomparably more im- portant to bring these parts under the microscopic examination. Then the division is hardly necessary, since without it we can obtain what is requisite for microscopic examination. The diagnosis of the partictdar disease of the mucous membrane of the cervical canal and of the uterus can only,' in my opinion, — ^and this is based upon the very extensive ex- periences which I have had in hundreds of cases, — be thoroughly made by curetting the mucous membrane (abrasio mucosie), concerning which I refer to what has been said above. In regard to the differential diagnosis of exfoliative endometritis we 1 Compare Schrxder, Handbook, ed. vii., p. 122. 2IO PATHOLOGY AND THERAPEUTICS must remember the fact that during the expulsion of decidual membranes, which are superficially very similar to the menstrual ones, tufts of the chorion would very seldom be found wanting; finding the latter seems much more important than the decision between somewhat larger or smaller so-called decidual cells. IV. — The prog7iosis of the diseases of the 7iterine mucous membrane is not unfavorable in acute catarrhal attacks. Also the more chrofiic alter- ations which occur on getting up too early after labor, or as symptoms of general diseases, such as chlorosis, scrofula, etc., recover often with sur- prising rapidity under appropriate treatment. Less favorable are the forms in which an iftterstitial or glandular proliferation has taken place, and where erosions have developed on the cervix, with a spread of the proliferations of the mucous membrane over the border of the external OS uteri. It is one of the characteristic peculiarities of these diseases of the mucous membrane that they frequently vary in their intensity, the periods of quiescence alternate with more or less violent exacerV)ations. On the other hand, in these diseases the stroma itself of the uterus and its peritoneal covering become affected with extraordinary frequency, so that we meet with chronic metritis and perimetritis as frequent accom- paniments of the affections of the mucous membrane. Then the proliferations at the fundus extend, they affect the whole internal surface, they pass over into the tubes and get beyond the reach of treatment, they disturb the general condition continuously, and make the women miserable and tired of life, sterile, and a burden to themselves and others. This dismal prognosis is made w^orse by the dispositioti of the catarrhal processes to relapses^ which remains more or less in spite of all sorts of treatment ; least of all perhaps after curettement with sub- sequent cauterization. But even in this case there remain morbid glandular branches which reach into the muscular tissue, and become points of origin of relapses. On the other hand, the original injuries, such as conjugal intercourse, perverse sexual irritation, or infection, only too frequently and too soon again exert their influence, so that the result of treatment is again endangered. A new pregnane}' is extolled by many as a panacea, also, for the dis- eases of the mucous membrane of the uterus ; certainly the transforma- tion of tissue of the uterus which is connected with it often works favora- bly ; but, if all the disturbances are considered whicli arc only too easily associated with this physiological condition, it is not surprising that this panacea often fails, and therefore the prognosis is not improved. If we take into consideration that the nature of the diseases of the OF THE DISEASES OF WOMEN. zw mucous membrane, if at all severe, always consists in proliferations, partly of the glands, and partly of the interstitial tissue, it is undeniable that in this disposition to new formation there lies also at least a predis- posing impulse for malignant proliferation. The uterus is indeed one of the localities most exposed to malignant disease in woman. V. — Therapeutics, (a.) The treatment of the cervical catarrhs in their early stages, of course, resembles that of the vaginal catarrhs. I employ, especially in fresh cases, besides the vaginal irrigation with the above-mentioned additions, first, superficial scarifications repeated from three to five times, and then the above-mentioned cauterizing agents in the speculum. Under this treatment the surface of the mucous membrane, which is inflamed and denuded of its normal epithelium, grows dry, healthy epithelium grows over it, under which the diseased portions of the mucous membrane become healthy. If we succeed in keeping all injuries away from the genitals for a considerable time, by regulating the further condition of the patient definitely and rationally, results which are completely satisfac- tory and permanent can be obtained by the above treatment, especially in the beginning of the malady. Unfortunately, however, the conditions requi- site for such success are only too often wanting in practice. The manner of living of the women is just what we are unable to alter to a sufficient ex- tent ; we are not able to permanently avert the injuries of conjugal life, and thus the inflammatory processes return again in a proportion of cases which is not very small, even if the recovery appeared to be complete and thorough. Specialists in particular often have an opportunity to see such cases, in which the treatment of the attendant physician, which was entirely appropriate in itself, always kept removing the trouble as long as treatment lasted, although a permanent recovery was not obtained. In order to explain this last fact we must recollect that the diseases of mucous membrane everywhere have an extraordinarily strong disposition to re- lapse, and that the above-mentioned mild medicaments hardlv suffice for the cure of processes which are going on in the depths of the folds and glandular pockets. In such cases, then, in which a thoi^ough success is not obtainable, or has not been obtained by the above-mentioned treat- ment, and in cases where the persistent malady gives rise to a profound disturbance of the general condition, and, finally, where the external cir- cumstances require a restoration of ability of the patient to work as soon as possible, the treatment, both of the so-called erosions and of the cervi- cal catarrhs, must consist in a thorougli destruction and removal of the diseased mucous membrane in this place. I have also formerly attempted to accomplish this destruction with deeply-acting cauterizing agents. Since, however, l^oth in my own practice and in that of others, I have 212 PATHOLOGY AND THERAPEUriCS seen cicatricial stenoses arise only too frequently from such cauterizations, I only now subject patients to treatment of this kind in case strict contra- indications against a radical procedure exist in the general condition or in the external circumstances. In all other cases I excise the diseased mucous membrane^ and with it as much of the tissue of the cervix as is necessary for the removal of the seat of disease, and for a profound influence on the upper part of the cervix, or it may be of the corpus, of which we shall learn more from the descrij^tion of the plastic operations on the portio. (<5.) In treating the diseases of the mucous tnembranc of the corpus it seems in the first place entirely proper, while applying appropriate general treatment, to attempt to use the means which are generally indicated in diseases of the genitals : rest, cleanliness, vaginal irrigations, derivation towards the intestine, sitz-baths, and also ergotine or hydrastis. In obstinate cases cauterizations are by many employed in the form of in- jections or with the cauterizing agents in solid form, with or without pre- vious dilatation of the cervical canal. For applying the cauterizing agents there maybe used pencils, atomizers, and apparatus by means of which the medicament is brought in contact with the endometrium after the removal of the mucus which adheres to the surface. I have tried thoroughly the majority of the apparatus of this kind with which I am acquainted. Be- sides cases of rapid improvement and recovery there were, however, always many others in which recovery, or even improvement, when attained was only temporary. B. ScHULTZE ^ has recently recommended the treatment of the diseases of the corporeal mucous membrane by means of long-continued systematic irrigation - and mild cauterizing agents, and this has been extolled as very successful by various authors on account of their favorable experiences. Personally I have not made any very extensive trial of this method of treatment. In the limited number of cases observed by me, however, the result was obtained very slowly, and then it was also of very little perma- nence, so that I have entirely given up this manner of treatment. As soon as it is found that the corporeal mucous membrane does not get well under regulation of the general condition, and appropriate cleanliness and repose of the genital organs, with vaginal douches and sitz-iiaths if necessary, I e7)2ploy the ctirette for the removal of the diseased masses of mucous membrane. With this I remove the diseased parts themselves at one sit- ting, without needing any previous dilatation of the cervix, and in thisw^ay ' Arch. f. Gyn., xx., s. 275. * P. Ruffe has described an instrument admirably adapted for this as a modification of Fritsch's catheter, at the October meeting of the Ges. f. Gab. in Gyn. zu Berlin, 1SS6. OF THE DISEASES OF WOMEN. >i3 Fig. 120. at the same time a secure basis is obtained for forming an opinion as to the diseased parts, and for a later treatment if necessary. I have no intention or desire hereby to condemn the other methods of treating the diseased corporeal mucous membrane. I have had extensive experience in cleaning out the uterus vv^ith cotton, and application to the mucous membrane of astringent fluids by means of Braun's syringe, in the intro- duction of medicaments by means of the so-called uterine pistol, in the introduction of pulverized medicaments by means of Clay's pulverizer, and in the cauterization of the inner uterine sui'face by caustic pen- cils ; these methods have given me so little permanent satisfaction that I have alv^^ays been ready to adopt new^ ones. But neither these nor Schultze's method have so regularly given me good results as curette- ment ivith subsequent cauterization^ of which I have a very long series of observa- tions lasting more than six years. All other methods appeared to me decidedly more troublesome, their success, as far as I have been able to follow it up, was not thorough, with the same frequency and to the same degree as in curettement, from which, on the other hand, I have not seen any injurious influences of a serious nature. I have above refuted (page 30) the accusa- tions which have been made against cu- rettement.^ When the sharp spoon is used there may be a possibility that single parts of the mucous membrane will remain behind, and perhaps it is especially the diseased ones which are liable to be left ; if, however, the dull-edged curette is used with appropriate skill the whole internal surface of the uterus can be removed with certainty. Thereby, of course, any healthy layers of tissue which may lie between the diseased spots will be also removed. It seems to me doubtful whether these spots and islands can be really always distinguished without the microscope. Experience teaches Piece of mucous membrane re- moved by the curette. Duevelius, Zeitschr. f. Geb. u. Gyn., x. 175. Compare Schwartz Arch. f. Gyn., xx., s. 345. 214 PATHOLOGY AND THERAPEUTICS that a complete regeneration of the mucous membrane, as seen in Fig. 121, ensues even after a very thorough scraping out, such as Fig. 120 shows. This ajjpcars to me to prove that even by such a procedure the restoration of the normal conditions of tlic mucous membrane is not impeded. Cica- tricial formation does not in fact occin, but regeneratio}i of t/ic Fig. 121. Natural size of the section. l^^<^ -'-: ■ fe^^SL i Mucous membrani , nr • \\ formed after curettement. Duevelius, loc. cit. 7iiticous itiembratte. It is undeniable that in this new-formed mucous membrane pathological processes may also grow again out of the morbid glandular tubes which lie in its deepest layers. Relapse may thus occur, entirely apart from anv new irritants which may exert their action here ; but at present there is no procedure whatever which could definitely ex- clude relapses of the diseases of the mucous membrane, unless by the complete and pennanent removal of the mucous membrane itself. We OF THE DISEASES OF WOMEN. 215 have to limit ourselves to successes which are only relative. These, how- ever, as far as my own experiences and those of members of the profession with whom I am intimate extend, are decidedly more favorable after curettement and cauterization than after all other methods of treatment. The objection that sterility is caused has been answered above (page 31). The necessity of a cauterization also after the curettement is indeed generally recognized,^ the only question is whether this cauterization should immediately follow the scraping ; I consider that as the simplest way, and cannot see why the new-formed mucous membrane should only be cauter- ized days and weeks afterwards. The local treatment can be essentially completed at one operation, and now the general treatment comes into use. I can only add that, if we consider the occasional troubles which are associated with all kinds of utei'ine treatment, a procedure which removes the malady in as thorough a manner as possible at a single operation, even if this is somewhat energetic, in my opinion, deserves perhaps in practice the preference to other modes of treatment which require sittings repeated for a long time, and aot without discomfort, and thereby causing a rela- tively much greater disturbance in the domestic life of the patients. Since chronic endometritis, moreover, is very frequently complicated with chronic metritis, in such cases the amputation of the cervix must very frequently be added to the curettement and cauterization, in order that thereby trans- formation of the tissues of the whole uterus may be stimulated. I have not been able to tve?i.t exfoliative e?tdometi' His w\th. a constantly permanent success. I have usually in such cases treated the mucous mem- brane with the most varied cauterizing agents ; I have scraped it out thoroughly and destroyed it, in the hope of accomplishing a regeneration of the mucous membrane thereby, but usually the success did not last longer than a year and a half I have heard indirectly from various patients after a year or more "that they were doing well." Whether definite recovery is meant thereby I could not determine. I have also at- tempted to induce an active transformation of the tissues of the whole uterus by means of amputation of the cei'vix. In spite of the fact that in one such case the uterus became very decidedly smaller, and that an in- volution could be inferred with certainty from the clinical appearances, the membranous dysmenorrhoea returned here also, although only after a con- siderable period. There remains therefore in such cases only quiet rest in bed at the time of the pains, good care, and the use of narcotics. These sufferings get well naturally at the time of the change of life. In extreme cases of exfoliative dysmenorrhoea, which cause the un- happy patients every time to suffer pains until they faint, it is natural to 1 Compare latterly Veit, Naturforscherversammlung, i8S6. 2i6 PATHOLOGY AND THERAPEUTICS attempt to use empirically everything which gives the slightest promise of help. Occasionally intra-uterine pessaries are of assistance, even if only temporarily ; so in other cases are active abstraction of blood, and similar means, used each time shortly before the menstruation. Finally, where there is profound reaction on the constitutional condition, the question of the removal of the ovaries, even if not diseased, or of the vaginal extir- pation of the uterus, has to be considered, and the answer must depend entirely on the condition of the individual case. I myself have not yet observed these desperate cases. From the description of the diseases of the mucous membrane I have separated that of vaginismus, of gonorrhoea, and of the mucous polyps, since a consideration of these separately seems to correspond better to their importance in practice. a. — Vaginismus. By vaginismus is understood an abnormal irritability of the ex- ternal genitals, which may occasionally develop into a spasmodic con- traction of the constrictor cunni and of the muscles of the whole pelvic floor.i This trouble usually affects virgins, and becomes chiefly noticeable in newly-married women ; then there exists as a rule an unusual narrowness of the entrance, often, moreover, a very rigid constitution of the hymen ; but vaginismus does occur also when the vaginal ring can be stretched with comparative ease. Those women appear predisposed to it in whom the vulva extends far forward over the symphysis, so that the urethral and hymenal apertures are situated over the symphysis or over the lig. ar- cuatum.^ The vaginismus occurs on the first attempts at cohabitation, because coition is made difficult either by the extreme sensitiveness of the greatly excited young wife, or bv the large size of the penis, or the incomplete erection of the latter. So far as my observations go, in the cases of all the patients suffering from this trouble, immission of the penis had not taken place, and consequently the hymen was not fully ruptured. Spasms of the constrictor cunni do occur, however, also after the occurrence of im- mission, as is shown by the well-known cases of penis captivus.' If the newly-married couple are not so greatly distressed by such difficulties that they at once seek medical assistance, on renewed attempts 1 Sir James Simpson, Edinb. Med. Jour., Dec, iS6i, p. S94- Sims, Lond., Obstet. Tr. v., iii. 1862. Debotit et Michon, Bui. de therapeutique, 1S61, Nr. 3, 4, 7. Budin, Progr. med., 16S1, Nr. a. * Schrccder, Handbook, vii., s. 525. 8 Hildebrandt, Arch. f. Gyn., iii., s. 321. OF THE DISEASES OF WOMEN. 217 there may occur severe inflammatory irritation of the genitals, in cases of the peculiar anteposition of the latter. Injuries of the ojoening of the urethra in particular occur, owing to which the latter may be so far dilated that cohabitation may be performed through the urethra. The irritable sensitiveness then occasionally becomes a very serious matter, by continued unsatisfied attempts and unwillingness to tell the trouble to the ph3sician ; the parts become inflamed, there occurs a Bartholinitis or urethritis, in fact I have repeatedly in such chronic cases observed endometritis for which I could not discover any other cause. A very usual consequence is a profound depression of spirits of the married couple, of whom the wife especially suffers from fear of the nightly approaches of her husband, and from the feeling of her own incomplete womanhood. The irritation is then increased to such an extent that whatever touches the external genitals causes violent pains, and finally also without such contact the sufferings occur on excitement, exertions during defecation and urination. Naturally such women are usually sterile, and yet, as is know^n, con- ception may occur from the mere emission of the sperm on the external genitals, and thus pregnancy may ensue in spite of continued vaginismus. In fact Benicke ^ has observed vaginismus as an obstruction to labor. The sterility as a rule disappears when the vaginismus does. Finally, I would here call attention to the fact that such spasms of the floor of the pelvis, especially of the levator ani, may also occur from catching cold, a cause which also leads to contractions in other muscular structures. It is, however, frequently uncertain whether masturbation and other perverse sexual excitement do not come into play here. The opinion which has often been maintained that in all these cases a gonorrhoea is present, I do not accept. For the development of vaginis- mus there need not be present even an evident morbid alteration of the part. The symptoms of vaginismus certainly appear in all diseased condi- tions of the genitals temporarily. The vaginismus is only an exacerbation of the pains which are occasioned by these diseases themselves ; thus in Bartholinitis, in vulvitis, and in urethritis, during the course of the disease there is a very extraordinary increase of the sensitiveness, which may show itself under the form of vaginismus. In the same way we must also explain the fact that vaginismus occasionally occurs in women who have already borne children, and quite transitorily in all phases of life. The diagnosis of vaginismus is made, as a rule, from the consequences 1 Zeitsch. f. Gteb. u. Gyn., ii.. S. 262. 2iS PATHOLOGY AND THERAPEUTICS of even the slightest touching of the external genitals with the finger, the point of the sound, or even with a tuft of fine cotton. Violent contrac- tion of the muscles of the floor of the pelvis then occur, the vagina appears closed, the vulva also becomes unapproachable, since the contrac- tions extend even to the nates and thighs, and prevent any approach, owing to the extreme sensitiveness of the woman. The spasmodic contractions are, as a rule, of short duration ; those which last for a long time must be extremelv rare. Anatomical changes are extremelv seldom found in cases of vaginism.us ; then thev usuallv consist mereJy of little, warty growths, which cover the surface and appear to be abnormally sensitive. In other cases the patients localize their pains in the carunculas myrtiformes, although the latter show no particular changes in their structure. Not very infrequently an examination shows that the supposed vaginismus is only a svmpton of perimetritis, and that therefore the pains are caused not by touching the entrance, but only by contact with the vault of the vagina. The treatineut should consist, in my opinion, less in a violent rupture of these muscles than in diminishing the sensibility, and in gradually accustoming these parts to a sufficient dilatation. The treatment must therefore insure, in the first place, as complete repose of these parts as possible, the avoidance of every kind of irritation, and the removal of the painful sensations which are connected with the latter. This is accom- plished, above everything, by narcotics in the form of suppositories with morphine (o.oi), about J/^ grain, belladonna (o.oi),and similar substances, bv brushing with cocaine, by lukewarm sitz-baths with decoctions of wheat-bran, bv lukewarm injections with infusions of hemlock (herb, conii maculat.), with cherry laurel water, or with flaxseed tea and other mucilaginous decoctions. Of course it is to be understood that the young couple must be forbidden to make any attempt at coition, that care must be taken for abundant evacuation of the bowels and for an unirritating diet ; above evervthing alcoholic drinks must be avoided. If, then, the irritation in the external parts, the fissures, and the ulcerating wounds dependent on the latter, have been healed, and if the sensitiveness independent of direct irritation has passed awav. coition, directed in a manner correspond- ing to the anatomical relation of the parts, may be attempted, or, what seems to me to be better, the treatment may be begun by gradual dilata- tion by means of the so-called bath-specula, used in sitz-baths, which, at first in their smallest sizes, and well oiled, are introduced by the young women themselves. Even although awkward in the beginning, they learn, as a rule, quicklv, the manipulations which are necessary for this purpose, and after using the bath-specula four or five times they can pass on to OF THE DISEASES OF WOMEN. 219 the larger numbers. When a speculum has been inti'oduced of a size equal to that of the penis, the approach of the husband can be again per- mitted ; usually, as is well known, it occurs even sooner, and with success. Some authors have not succeeded with such a simple mode of treat- ment, and have been obliged to split the entrance and introduce appro- priate tubes, while others have removed byexxision tlie hymenal ring, and, above everything, also the sensitive caruncles and condylomata at the entrance of the vagina, and whatever else could be found as a cause of the sensitiveness. I have up to the present time got along without such operative interference, although I have in some very rare cases, in order to establish the diagnosis, made a thorough examination under anaesthesia, and thereby stretched the entrance sufficiently. In these cases, to be sure, the hymenal ring was usually torn, and thereby the further introduction of dilators, or, as it happened, of bath-specula> was made jDOssible. Only very lately I have twice found the hymenal ring so hard, like cartilage, that I had to excise it ; then cohabitation soon became tolei'able. b. GONORRHCEA IX WoMEN. The consideration of gonorrhoea in women in a separate chapter is made difficult by the fact that, in the whole tract of the genital canal, w^e meet with fateful traces of gonorrhoeal disease, while, on the other hand, the course of the disease at the point of infection in the female sex differs only in unimportant particulars from the corresponding disease in the male. I devote, however, some connected obsei-vations to this subject, partly in order to state definitely my position on the question, which at present is much discussed, as to the importance of gonorrhoea for women, and j^artly to call particular attention of the profession to this subject.^ The significance of gonorrhoea for women is very variouslv estimated. By some it is decidedly underestimated ; others lay very special emphasis on the influence of this disease on the function of the female genitals, and then, indeed, they attach too much importance to it. The question of gonorrhoea in women was brought prominently under discussion by Noeggerath's article on Latent Gonorrhoea, when this was published. NoEGGERATH found an immense number of gynaecological maladies to be caused by gonorrhoea, and from this fact he deduced consequences which, when abruptly stated, were naturally astonishing. The propositions of NoEGGERATii of course excited opposition from many sides. Nevertheless the gynaecologists seem to become more and more convinced that these are accurate to a very great extent, although not in their most extreme deduc- >• Noeffgerath, Die latente gonorrhoea. Bonn, 1S73. 220 PATHOLOGY AND THERAPEUTICS tions, and that the gonorrhcEal infection of women niiist be considered as a much more serious matter than was usually the case previously. Espe- cially the consequences of the extension of gonorrha>al disease to the internal genitals cannot be estimated too seriously, and thus I am wu\. far from the standpoint of Noeggeratii in estimating the importance of this form of disease, although, to be sure, I am not in a position to form an opinion as to the extension of gonorrhoea in men and its latency during many yeai's. Gonorrhoeal disease of women is very variously described by syphi- lologists, in regard to its occurrence and its frequency. Undoubted gonor- rhoeal inflammations of the vulva and vagina are more frequently observed without urethritis than complicated with the latter. An estimate as to the frequency is made difficult by the nature of the disease of the urethra. According to my observations it appears to me that not infrequently the external orifice of the urethra, and also the immediate vicinity of the latter^ participates in the inflammation in the beginning ; that, however, on ac- count of the infrequency of glands in this mucous membrane, the disease remains limited to the surface, and gets well very quickly, while the dis- ease of the vulva and vagina still persists. If this observation is accurate, the relative infrequency of urethral gonorrhoea in women, compared with the frequency of vaginal gonorrhoea, would be explained in a very natural way. For only the severe cases of the urethral gonorrhoea come under our treatment at all. That the latter may extend in the mucous membrane of the urethra, and here lead to an ulceration and profound destruction, is undeniable, as well as is the fact that gonorrhoea may extend to the blad- der, with all the consequent symptoms which occur in gonorrhoea of the male urethra. In the majority of cases the urethral disease in women, as far as I have obsei'ved it, does not extend beyond the urethra. The symptoms of Jii'ethral gonorrhxa^ with all its possible extensions, seldom last longer than two weeks. There remains then a chronic, ana- tomically slight, condition of iritation, which, however, annoys tlie women with very extraordinary obstinacy, and in isolated cases may resist all treatment for years. Gonorrhoeal infection of the viilva a?id vagina causes very intense irritations. In the secretions of the jDarts I have often been able to demon- strate gonococci. In the great majority of such diseases no characteristic peculiarity has been noticeable. In these cases either the confessions of the husband, the occurrence in immediate connection with cohabitation, the extension to the urethra, the vulva, and into the depths of the vagina, were the only facts which permitted the diagnosis to be established with rea- sonable certainty. OF THE DISEASES OF WOMEN. 221 A not infrequent complication consists in the disease of the glands of Bartiiolini, whether originating from the fact that by the inflammation in the fossa navicularis the efferent ducts of the former are occluded, and thereby a retention is developed, or because the disease extends along by way of this duct, until it reaches the gland itself. A further and not in- frequent form of the disease consists in a proliferation of_ the papillary layer in the external genitals and in the vagina. These papillary hy- pertrophies may extend over the whole genitals in the form of condylo- mata acuminata ; usually they are situated in the navicular fossa, collected in small groups, and they only appear in large collections on the external parts as far as the nates. As is well known, these condylomata acuminata may develop into great rolls ; I have myself extirpated such warty masses from a girl of nineteen years, which, in rolls as thick as four fingers, covered the labia far backward over the margin of the anus, and resisted every other kind of treatment. This form of papillary proliferation is so evident that it will hardly escape the attention of the examiner. A form of papil- lary hypertrophy is very much less prominent, which extends over the inter- nal surface of the nymphae, the vestibule, and also a part of the vagina, in the form of very flat little warts, and which even more seldom occurs on the labia majora. The surface then seems little altered, and it requires a very exact observation to recognize the fact that such hypertrophic papilla are present. Not infrequently the parts then appear as if covered with frog's spawn ; in other cases the papillce appear quite discrete ; while in others, again, they cover the whole surface, standing closely together. This form of papillary hypertrophy occurs, indeed, not exclusively in con- nection with gonorrhoea, but yet I have generally found it in women in whom there was no doubt of the presence of gonorrhceal infection. The further extension of gonorrhoea beyond the place of infection is observed partly in the form of swelling of the inguinal glands, partly in the extension over neighboring regions of mucous membrane. Thus such papillary growths are seen to occur also in the vagina ; they can, how- ever, be very well distinguished from granular colpitis, which is described above. Such swollen papilla may extend over the whole vagina, and occur on the portio, although such an extension is one of the greatest rarities. If gonorrhoea remains limited to the region of the vulva and inguinal surface it is always of subordinate importance; but as soon as it has be- come established in the vagina it usually becomes much more obstinate. From gonorrhoeal colpitis there is by no means always a further exten- sion of the process to the internal genitals ; cases of further extension are certainly in the minority, but it is particularly important to consider them. 232 PATHOLOGY AND THERAPEUTICS since this extension presents that form of gonorrhrral disease in women which is, beyond all comparison, the severest. Not unfrequcntly in such cases the course of the disease of the ex- ternal parts, antl also of the vagina, has been very short. The symptoms pass away under simple treatment, so that the patients think that thev are getting better, until suddenly an acute endometritis and metritis are devel- oped, usually with violent fever and pains. Here also the stage of acute inflammation, in the cases which can be accurately observed, is of rela- tively short duration, either because recovery really soon occurs, or because the symptoms of further disease come decidedly into the foreground. The development of disease of the tubes ^ which is a very serious complica- tion, is as sudden in its occurrence as it is threatening. Chill, violent pains, and also symptoms of peritoneal irritation, disturbances of the in- testines and of the bladder, are symptoms of this complication.' From here ensues an exacerbation, owing to the acute peritonitis^ which appears as a sudden and unexpected complication ; this runs its course with a renewal of violent pain, with great distention of the abdo- men, nausea, and fever. As far as I have jet seen, the peritonitis, as a rule, remains circumscribed ; it is localized in the abdominal ends of the tubes, and forms an exudate which, as it is apparently very thick, covers the ovaries, the tubes, and the immediate vicinity. These exudates may occur on one side, or also bilaterally (in nearly half of the cases). In one case I have seen the development of the process on the other side about five weeks after the first disease, occurring in exactly the same man- ner. The fui'ther symptoms are then those of chronic peritonitis and perimetritis ; after absorption of a part of the exudate there remains a chronic pelveo-peritonitis and perimetritis, with all their characteristic peculiarities, their injurious influence on the position and the mobility of the pelvic viscera ; on the nutrition of the individual, her capacity for mo- tion and for work ; and with the exacerbations which so frequently occur on the slightest injury, sometimes at every menstruation ; in these patients a profound cachexia occurs only too early. Even if, in the course of long treatment, the peritonitic conditions get better, and imdergo a sort of involution, such women remain with their usefulness very seriously im- paired, since the adhesions which result from these acute conditions lead to a painful and permanent disturbance of the normal mobility of the uterus, especially to an impediment of defecation, and to similar symptoms. Another form of extension of gonorrhoeal . infection is that aloiig the lymphatics. As a consequence of the gonorrhccal infection, swellings of 'Compare also Sanger, Arch, of Gynakol., xxv., und Xaturforsclierversammlung- in Magde- burg, 1S84. OF THE DISEASES OF- WOMEN. !23 the lymphatic f^hmds in the broad ligament arc developed, usually very insidiously, so tliat these swellings may be found at the side of the uterus, arranged in rows, like moderately large pearls on a string. I shall have to speak fui'ther, in considering parametritis, concerning the consequences of this feri-uterine adenitis. Diseases like the above are very serious, and, moreover, they are so frequent ; so great a number of formerly healthy women pass in this way from the beginning of marriage into a long and severe wasting dis- ease ; the marriages which are apparently so favored in external conditions are with such relative frequency, owing to this disease, not only childless but also disturbed by the continual sufferings of the wife, and especially by her sexual incapacity, which so soon occurs, that the prognosis of gonor- r/icea in women is by no means to be made light of. This becomes even more serious, if we observe how frequently during the course of the severe disease which is established by the peritonitis, the unhappy women are prostrated by trivial injuries, and how decidedly their power of resist- ing the accidental diseases of daily life is impaired. The treat77ie7tt is to be carried out with a corresponding thorough- ness ; the treatment of the infections of the vulva and vagina coincides with that advised for the other diseases of these parts ; it is to be recom- mended that precisely such patients be kept as quiet as possible, and until their recovery be relieved as far as possible from their customary occupa- tion. I treat the catarrhs of the urethra with good effect with injections of a five per cent, solution of zinc sulphocarbolate, which are employed once daily b_v the physician ; afterwards I have the j^^^tients use sitz-baths, and vaginal irrigations with w^eak carbolic solutions, and at the same time drink water which is strongly alkaline. In the more obstinate cases I have introduced into the urethra weak solutions of iodine in potassium iodide ; in others, again, pencils of iodoform 0.15 (nearly two and one-half grs.), or white zinc oxide 0.15, made with cacao-butter. I have these made of about the same length as the urethra, and put them into the latter every tlay or ever}' second day. When there is great sensibility a small quanity of morphine or cocaine, or something similar, is added to these pencils. In this way I have, cured urethral affections of this kind, as a rule quicklv ; a jDrolonged treatment was very seldom necessary. I have as yet seen no indications for using the heroic measures which Emmet ^ has suggested for treatment ot chronic urethral affections. If, in spite of this mode of treatment, the infection has extended to the deeper organs, I have as yet learned of no means of combating such 1 Text-hook, tliinl I'dition, ]>. 740. 224 PATHOLOGY AND THERAPEUTICS an extension ; every surgical procedure seems to be contra-indicated in view of the danger that the spreading irritation will only be increased thereby. Only symptomatic treatment remains, therefore ; especially rest and absolute freedom from injury ; the incipient peritonitis and periuterine adenitis are to be treated antiphlogistically, or with a course of inunction, according to their mode of occurrence. c. — The Polyps of the Mucous Membrane. Follicui-ar Hypertrophy of the Cervix. The follicles of the cervical mucous membrane, which become dis- eased under the influence of catarrh, not infrequently in the course of their distention j^i'ess close under the surface, or even protrude upon the latter. In the cervical canal these structures, which are known as Ovula Nabothi, may remain for a long time unaltered, or they may burst, discharge their contents and heal over, or, as pockets, they may form rather extensive cavities under the surface. Especially in the neighborhood of the external orifice of the uterus they often protrude as nodules, which can be distinctly felt, and which, with their tenacious, clear, or purulent contents, are also visible under the external surface of the portio. These follicles may, on the other hand, protrude, more and more constricted at the base, and being covered with mucous membrane may appear to be suppoited by the latter as by a pedicle. On such a pedicle, then, one or several follicles may depend as polyps in the lumen of the cervical canal ; they protrude from the external orifice, and hang into the vagina, either single or in groups composed of several, or in a growth like a cock's-comb. Such growths may become enormously enlarged where there is a severe irritation of the tissue of the portio, so that they may give rise to a follicular hypertrophy of the lips^ which finally may even hang out from the entrance of the vagina.^ The tissue of these hypertrophic masses is arranged in immense follicular spaces, and is moreover entirely permeated by the elements of the mucous membrane which covers them, and from which these structures have been formed. More seldom the participation of the follicles is less noticeable ; especially in the so-called hypertrophy of the lips the whole appears as a hyperplastic mucous membrane, composed of glands and dilated vessels. Such polyps of mucous membrane, and such hypertrophied masses protruding from the surface, easily take that form which is given to them bv the more rigid parts around them. They may appear as divided ; they are also found with several pedicles, and sometimes even adherent to the » Stratz, Zeitsch. f. Geb. u. Gyn., xii., iSS6. OF THE DISEASES OF WOMEN. 325 neigliboring pails by their extremities. Also in these the follicles pass through the above-mentioned alterations ; they burst, empty themselves, give rise to large, empty spaces, or protrude greatly as bunches on the surface, and become noticeable because their contents of various colors show through the surface. These polyps and hypertrophic masses always have abundant vessels in their interior. In the connective tissue there is generally dense small-cell infiltration. On a basis of protuberant out- growths of this kind the mucous membrane is not infrequently in a state of great irritation ; the border of the cylindrical epithelium moves out over the portio, even on to the vaginal mucous membrane ; actively proliferating erosions are seen to develop. Everywhere in this region follicular spaces are formed, these also having a strong tendency to polypous growths, so that this condition, in connection with the clinical appearance, may give the impression of malignant degeneration. The symptoms of polyps in the mucous mem- brane are a decided increase of the secretion, often with bloody admixture, profuse menon-hagia, and not infrequently considerable pain. These symp- toms are occasionally observed rather suddenly, especially in elderly women ; generally they are developed gradually in connection with the symp- toms of chronic catarrh, so that the discovery of the polyp or of the follicular hypertrophy is acci- dental. In other cases the abundant menses, fol- Follicular polyp, after lowing each other rapidly, become noticeable ; in yet others the pains become prominent. The latter, especially, seem sometimes to have something characteristic, since they are con- nected with the uterine contractions which come on to expel the polyp, which swells during the menses or otherwise accidentally. This feeling of pain may last for a long while ; it may also be devel- oped in attacks which follow one another very quickly. Particularly in cases of elderly ladies, I have often heard complaints merely of violent pains in the sacral region without haemorrhage or increased secretion. The diagttosis is involved in no serious difficulties, as soon as a careful examination is made. The structures hanging loose in the OS uteri (Fig. 132) are then felt, in case they have alread_y come out there. Ovula Nabothi, and the early forms of polvpous development, in case where these structures have not yet left the cervical canal, can only be reached in case the os uteri is open ; sometimes they are felt with unusual distinctness during the menstrual relaxation of the tissues, so 226 PATHOLOGY AND THERAPEUTICS that in such doubtful cases it has been advised to examine (Hiring the menses. The treatment can only consist in the extirpation of the polyps, with or without the neighboring mucous membrane. Wholly isolated struct- ures should be seized as near as possible to their base with the dress- ing-forceps, and torn out with the roots ; this procedure so constantly leads to recovery, without any disturbance, that it can be performed in the physician's office without apprehension, and even without the pre- vious knowledge of patients, who, otherwise, would be easily excited. The vessels of the pedicle retract rapidly, and are so rolled up when torn ofi" t.hat as a rule they scarcely bleed. The pedicle itself shrinks quickly. For greater security the stump of the pedicle can be covered with a tuft of cotton soaked in liquor ferri, and a tampon be placed under it. If the pedicles are harder, provided with abundant fibrous tissue, thick and massive, it is better to pass a needle through them as near as possible to the base, and to ligate the pedicle on both sides from this perforating stitch. The polyp is then cut off not too near to the ligature ; the stump atrophies regularly. If the vicinity of the polyp, its basis, or the mucous membrane which lies around it, are greatly irritated, or if a follicular swelling of the lip has occurred, this whole diseased mass must be excised. According to the circumstances of each case, the cennx is split, and the basis of the disease is dissected out, the defect being closed by sutures. Not infrequently such structures return, /.c, new follicles push their way to the surface and develop into polyps. For this reason the thor- ough removal of the diseased mucous membrane by excision is to be urgently recommended. C. — INFLAMMATION OF THE UTERINE PARENCHYMA. I. — Acute Metritis. Acute disease of the tissue of the uterus is but seldom observed, ex- cept in connection with childbed. It occurs most frequently after labor, in consequence of septic infection, and then leads to such severe consti- tutional symptoms that the unhappy patients usually perish. Apart from the puerperal condition, acute metritis is most frequently found asso- ciated with menstruation. The intense congestion of the uterus during this process then furnishes the occasion for tlic alterations which occur in acute inflammation ; especially catching cold, and injuries, or excessive sex- ual intercourse, at this time lead to acute inflammation. A frequent cause is gfonorrhaial infection, and all diseases of the mucous membrane from OF THE DISEASES OF WOMEN. 227 similar causes, which run a very violent course. Acute metritis has further been described as a consequence of inappropriate gynaecological manipulations ; this form also is not unknow^n to me, but I lay the blame for causing it not on the manipulation itself, but on an infection in conse- quence of the latter. The pathological and anatomical changes ai^e, first, intense conges- tion derived from the arterial and venous vascular systems, a decided swelling, small-cell infiltration of the inter-muscular tissue, swelling of the muscular bundles themselves, and larger and smaller extravasations of blood. In acute metritis a simultaneous disease of the mucous mem- brane and of the perimetrium is seldom wanting. These changes may so far recover, by resorption, that the uterine tissue returns to its normal condition ; in other cases chronic metritis is developed from this acute stage, although we must always remember that such a connection can be satisfactorily demonstrated only in comparatively isolated cases. Abscess is very seldom the result of such an acute inflammation of the uterine tissue. Cases of this kind have been observed very exactly in connection with the various above-mentioned causes ; the course of such abscesses also has been sufficiently determined, both by the further obser- vation of involution, as also of their discharge.^ I myself have not yet had such an experience. It must be very exactly determined in such cases whether there is not present a myoma, which is either suppurating or in- volved in a sort ofretrogade change, such as I have occasionally observed, and one of which, a large one, I have also described. - The symptoms of acute metritis, which may come on with a chill and run its course with elevation of temperature, consist in violent pains in the abdomen and sacrum, and in very distressing suffering referred to the bladder and rectum. If the cause of the acute metritis is catching a cold during menstiaiation, the latter usually ceases suddenly, just as in acute endometritis, and in fact the latter is seldom absent ; after several davs menstruation returns with greater or less abundance. Here also the sup- pression of the menses is only an early and striking symptom of the dis- ease. In other cases a profuse menorrhagia is developed simultaneously with the invasion of the acute metritis ; considering the depletion of the so greatly congested organ which follows the menorrhagia, the latter is perhaps to be considered as by no means the least fortunate event. The further symptoms are partly more closely connected with the secondary diseases than with the acute metritis itself, thus in gonorrhoea! infection the simultaneous disease of the tube and of the peritoneum, and in acute 1 Schrdder^s Handbuch, Ed. vi., S. 8$. - Berliner Beitr., zur Gcb. u. Gvn., iii., 1S73, S. t^t,. 2 2S PATHOLOGY AND THERAPEUTICS metritis dependent on septic infection, the general scpticcemia, become far more prominent, and easily cause the acute metritis to be completely over- looked. The diagnosis of acute metritis is founded on the intense swelling of the uterus, which as a rule occurs simultaneously in the cervix and in the corpus. Moreover, an extraordinary sensibility is characteristic of acute metritis ; the lightest touch of the finger, the gentlest attempt at a bimanual examination, causes extraordinary pain. Nevertheless, if it is possible to palpate the uterus, under anaesthesia, for instance, its volume appears especially increased in thickness, and also the neighborhood seems ex- tremely sensitive, even if there is as yet no exudation there. The uterus, which is thus thickened and sensitive displays, moreover, a striking soft- ness, corresponding nearly to that of pregnancy. In the acute stage the secretion is at first, indeed, always diminished ; but as soon as the acute hyperaemia begins to pass off", there is an abundant increase of secretion, in which bloody admixtures frequently occur, besides the menorrhagia which appears when the acute metritis has developed anywhere in the course of the menstruation. The prognosis of acute metritis is always pretty serious. Rapid resolution and consequent recovery may, indeed, follow the acute stage of inflammation. The possibility of a further extension of the disease, which has first appeared in the form of acute metritis, must, however, make the prognosis appear doubtful until the cause and the course of the dis- ease can be distinctly recognized. Finally, the prognosis is also clouded by the possibility, even remote, of the formation of an abscess, and by the disposition to relapses. The treatment is decidedly antiphlogistic, corresponding to the acute condition of the disease ; the measures which are immediately indi- cated are the greatest possible quiet, and applications of ice, with un- broken rest in bed, ample abstraction of blood from the hypogastrium, and disinfecting cooling injections, besides the use of morphine or other narcotics, of chloral, cocaine, or extract of belladonna. If the acute stage runs its course without further extension of the inflammatory process to the neighboring parts, the abstraction of blood from the uterus itself by scarifications maybe repeated ; then sitz-baths, soothing injections, and, above all, an energetic derivation toward the intestinal canal may be employed. The latter is not always sufiiciently accomplished by castor- oil and similar mild purgatives, so that occasionally the use of drastic means cannot be avoided. When acute metritis is developed in connection with menstruation, the ice treatment is not infrequently ill borne, and in this form of acute metritis it is preferable to employ warm fomentations OF THE DISEASES OF WOMEN. 229 on the abdomen, and in some cases the use ofliot injections into the vagina (40° R., 122° F.) ; here, also, narcotics are to be employed early, and in suffi- cient quantities. If symptoms of suppuration develop, the first violent phenomena very seldom last long ; when there is a rise of temperature with decided evening exacerbations and morning remissions, and with distressing pains, caused by tension, an attempt must be made to search for the place where the abscess is forming, and to evacuate the pus, if pos- sible. I have no experiences of my own on this point, but it seems to me that it may be extraordinarily difficult to find the abscess in such cases. If the acute symptoms of the first days are past, if the fever, which probably is seldom wanting at the invasion of the acute disease, has dis- appeared, the manner of treatment is to be changed to that which I will explain more fully in considering chronic metritis. We are hardly in a position to prevent the development of attacks of acute perimetritis, and for these the appropriate treatment is to be em- ployed which is described in considering perimetritis. 3. — Chronic Metritis. By chronic metritis we understand hyperplasia of the connective tis- sue, associated with increased sensitiveness.^ In regard to this we admit, however, that chronic metritis, as thus defined, does not completely cor- respond to what we understand as a chronic inflammatory process in other places ; and yet I am also of the opinion that we have a right to designate this hyperplasia of connective tissue as a chronic inflammatory condi- tion, since, in the course of the development of this hyperplasia, inflam- matory attacks almost always occur, and since this disease, likewise with few exceptions, is associated with inflammations of the mucous lining of the uterine cavity and of the serous covering of the uterus. It is not un- important, finally, as favoring the retention of the definition of this con- dition as a chronic inflammation, that we have to treat it essentially on antiphlogistic principles. CJrronic metritis is developed very frequently in connection ivith pregnancy^ labor ^ and childbed. Disturbances of the puerperal involution cause the muscular structures to go only incom- pletely through the process of fatty degeneration and absorption ; they cause the bundles of connective tissue, which have been developed in the course of pregnancy, to escape involution, and finally cause the vascular system also to be not transformed in the manner which happens during the puer- peral period, when the involution is not disturbed. Such a disturbance of involution, which very frequently occurs at the normal termination of ' Definition of Schroder, liand-book, vi., p. S. 330 PATHOLOGY AND THERAPEUTICS a pregnancy on account of insufficient care during childbed, or of inter- current inflammation of the mucous membrane, or of premature and im- moderate sexual irritation, and which is favored by insufficient attention to nutrition and digestion, also occurs with peculiar frequency after premature termination of pregnancy. Chronic metritis occurs extraordi- narily often after abortions, not only because the women do not take suitable care of themselves, since they think that a pregnancy which is interrupted too early does not require the same attention as one that ends normally, but especially because this premature interruption of pregnancy is very frequently associated with insufficient evacuation of the cavity of the uterus, and permanent disturbance of the function of the mucous mem- brane. Chronic metritis, finally, is developed with peculiar frequency in connection with the puerperal condition, when the latter is complicated with diseases, whether these are attributable to a septic infection, or are dependent on injuries during labor. Schroeder (loc. cit.) calls attention to the fact that the want of the stimulus of suckling the child favors an imperfect involution after abortions. Apart from childbed chronic metritis is most frequently induced by disturbances of menstruation^ such as aie caused bv alterations in posi- tion and shape of the uterus, or in long-continued imprudence at such times, as, for example, senseless want of care at school, social considera- tions, or catching cold, and which pass over on to the wall of the uterus as complications of diseases of the mucous nieTnbratie. Chronic metritis is a very frequent consequence of itnproper or excessive sexual irritation^ of onanism, or also of intercourse with impotent men ; finallv, we must consider as causes tuhich furnish occasion for the development of chronic metritis all those disturba/ices of the digestion and of the vascular supply of the lovoer albumen which, by their continued action, increase the vascularity of the uterus also in an abnormal manner, and give occa- sion to extravasations and exudations which in themselves are, perhaps, unimportant. The frequency of chronic metritis is strikingly variously estimated ; sometimes it is spoken of as the most frequent disease, and sometimes as a raritv. Winckell ' has found chronic metritis isolated in alwut four per cent, of all cases among some six hundred and fifty sections of female cadavera ; according to my obsei"vations tlie isolated occurrence of chronic metritis is certainly not more frequent, but among numberless com- plications chronic metritis would be found in a higher percentage of diseased women. The pathological anatomy of chronic metritis is characterized by » Lehrbuch, 1886, S. 524- OF THE DISEASES OF WOMEN. 231 liypcrplastic thickening of the connective tissue, between vvhicii the uter- ine muscular fibres^ are partly in a state of fatty degeneration, and partly constricted into irregular bundles ; the vessels lie impeded in their regular function, sometimes by varicose dilatation and sometimes by dense con- strictions. The section of a uterine wall altered by chronic metritis usually shows a strikingly pale surface, in which the hard, white, shining bands of connective tissue lie tangled between reddish vascular masses ; among these there are often small ecchymoses. Such alterations may be found equally scattered throughout the uterus. In other cases the hyperplasia of the whole tissue is markedly- developed only in one part of the uterus ; it can occasionally be limited to the cervix or to the corpus. Then, when one section is diseased, the other may present relatively normal features, although, however, as a rule, an increased development of the vessels and a striking increase of succulence may be noticed. The picture of chronic metritis is quite constantly associated with that oi chronic etidometritis., and not seldom with that o{ chronic perimetritis. Especially when there is a complication of chronic endometritis, the branches of the glandular apparatus become noticeable, and permeate the layers of the mucous membrane adjacent to the uterine tissue. Nodules are then developed, which occasionally can be recognized as occluded glandular elements, as retention cysts, and follicles. Especially if so-called erosions have been developed, associated with diseases of the mucous membrane, we find the sub-mucous tissue permeated to a marked degree by the glandular branches. This permeation can extend to a surprising distance into the uterine tissue, and here present an almost alveolar appearance, which it is sometimes very hard to ditier- entiate from that of malignant disease. Cotirse. — The hyperplasia of the connective tissue may remain more or less unaltered for a long time, in a manner varying much in different cases, while occasional inflammatory attacks make the traces of inflamma- tion either of the whole or single parts more prominent. In other cases a sort of involution occurs, the vessels wither, the muscular tissue disap- pears, and only the thick, tough bundles of connective tissue remain, which on section occasion a distinct creaking of the knife, and make the cut surface appear white and non-vascular. The localization of the disease in the cervix or in the body seldom ' Finn (Centralbl. f. d. med. Wissensch., Sept., 1S6S, S. 564) asserts that the cicatrization of the it.uscular fibres is the cause of the enlargement of the uterus. Sini-ty, on the other hand (Annates de Gynecologic, 1S7S, ix., p. 129), found tlie essential factors to be a decided dilatation of the normal lymph spaces, a hyperplasia of the perivascular connective tissue and disease of the mucous mem- brane. 233 PATHOLOGY AND THERAPEUTICS leaves the unaflected part completely intact, permanently. When the corpus is greatly enlarged the cenix may appear almost virginal ; as a rule, however, it shows analogous changes, although only to a slight degree. When the cervix is diseased the corpus may participate so little in the process that it appears as a slim appendage beside the cei'vix, whicli is vastly developed. The appearance of that form of cervical hypertrophy w^hich I have described as supravaginal elongation of the cervix (p. 79) is frequently characterized precisely by the fact that the corpus hangs down over the greatly elongated cervix, usually on its anterior surface, and then is not seldom smaller than the latter in the proportion of about 2:1, while the opposite corresponds to the normal position. A further and peculiar deformity occurs in chronic cervical metritis^ if it is associ- ated with a solution of continuity in the external os. The lips of the lat- ter may, in unilateral disease, appear as if curled back, starting at the rent in the cervix ; when there is a rupture of the latter on both sides the lips separate as if they were rolled up, and resemble a mushroom in shape. The insignificant remainder of the cervix appears then like a stem, on which an almost infinitesimal piece of corpus seems to be set. (Compare below the chapter on lacerations of the cervix.) The symptoms of chronic 7netritis in their early stages frequently cannot be accurately defined. As chronic metritis only seldom occurs as the result of an acute process, the changes are developed gradualh, and only reach the degree which makes them seem decidedly characteristic when there is a considerable development of the local changes. If chronic metritis is a result of defective puerperal involution^ recovery of health does not properly return after childbed. Instead of gaining in strength the recently delivered women experience a feeling of profound exhaustion ; the puerperal involution is not terminated two or three weeks after labor, with a pause in the general emaciation, such as we so fre- quently see occur ; it continues and leads to a disappearance of the adipose and muscular tissues, which is often very rapid. During this, pains in the sacrum and in the hypogastrium are experienced on every exertion ; the discharges continue and increase ; the feeling of a secure closure of the genitals is lost ; the women complain of a sensation that the latter are open. The patients have violent vesical tesnius, and they are obstinately constipated. ^Menstruation is abundant ; it occurs at short intei"vals, also in the periods between the latter a bloody discharge occasionally occurs. These symptoms may persist with variable intensity ; on apparently slight causes the difficulties become worse, and then again persist to a slighter degree for weeks or months, and in every case prevent the patient from feelinj; that she is recovering. OF THE DISEASES OF WOMEN. 233 Altliough in this form of development of the disease the women resist for a varying time the feeling of being ill as a result of their childbirth, and frequently only after a new pregnancy, and when the disease still continues, admit that which their friends had long suspected most decidedly, vet in the non-ptierpe?-al J~ortft of chronic metritis the symptoms develop 7nore insidiously . Young girls especially, who fall a prey to this disease as a result of the diseases of the mucous membrane and disturbances of men- struation, often endure the difficulties of their trouble for long years before the source of the malady is recognized and brought under treatment ; in these cases the symptoms of anaemia appear ; the enjoyment of work and of life is lost ; an insurmountable weariness is developed, associated with an intense emaciation, which in a varying period makes out of the maiden, who was blooming on her entrance into puberty, an unattractive, sickly- looking, lean creature, taking equally little pleasure in work and in 3-outh- ful enjovments. Then these girls must pass their menstrual periods in bed, or endure them with painful suffering and greatly diminished ability to work. The sufferings of which the patients complain are usually not localized in the pelvis itself; sometimes there are sick-headaches, and some- times dyspeptic symptoms, which are chiefly complained of; and only seldom is it admitted that above everything it is the pains in the hypogas- trium, the feeling of heaviness and pains in the sacrum, and attacks of cramps before and during the period, and the discharges, which contribute more to the feeling of discomfort than do the want of appetite and the other pains. The result of exatnination in chronic metritis shows a considerable increase in the volume of the uterus, especially in thickness. Such a thickened uterus may be almost without sensitiveness, while in other cases it is also found extremely tender, especially on introduction of the sound. A distinct increase of sensitiveness is always present during the acute attacks, during which the uterus swells ; and at such times it ahvavs shows a decrease in hardness, and even a doughv consistency, reminding: one of pregnancy. Only when the process has run its course is an equally distributed hardness of the diseased parts observed ; then, with cicatrization, the increase in size of the uterus also occasionally disappears ; it becomes small and hard as cartilage. The sensitiveness may then completely disappear, or be very much diminished, corresponding to the more in- frequent occurrence of the acute attacks. The result of examination when the corpus alo?te is diseased, above the healthy or slightly diseased cervix, is especially characterized during the height of the morbid process by the simultaneous disease of the endome- trium, since an extreme sensitiveness on touchingf the mucous membrane is 234 PATHOLOGY AND riJERAPEUTICS associatetl with the tenderness to external touch. The sensitiveness of the serous covering is comparatively less prominent in disease of the perime- trium in comparison with that found in tlie diseases in Douglas' pouch, in which the pelvic floor and the region of the sacro-uterine ligaments are especially noticeable, owing to their excessive tenderness. This sen- sitiveness becomes somewhat less marked when the disease is quiescent, so that only a direct touch, or the attempt to move the uterus out of place, or its displacement by hard fecal masses, or during coition, give evidence of the simultaneous disease of the perimetrium. The result of examination when the cervix is diseased show's the increase of volume of the latter in a manner which is very prominent on bimanual examination. The condition of the mucous lining of the cervical canal and of the lips of fhe OS uteri are further characteristic of the state of aflairs. If when fhe uterus is touched a mass of mucus, often tenacious, pours out ; if enlarged follicles, transformed into spaces retaining fluids, are forced close vmder the surface, — this result of examination becomes particularly noticeable and striking. If there is no disease of the mucous membrane ; if this is not thickened, or if it is already getting well, the cervix, espe- cially the vaginal portion, is found sometimes club-sliaped, sometimes pe- culiarly conical, when the shape of the os uteri is preserved ; it may be hard, or, on the other hand, especially in the earlier stages, it may have the softness characteristic of pregnancy. Among the further symptoms the most prominent are the distu7-b- ances of ?nenstruatioH and of conceptioti. In the puerperal form of chronic metritis menstruation is almost always extraordinarily alnnidant ; especially during the early part of the disease abundant quantities of dark blood, mixed with clots, are discharged at very short intervals ; the period lasts much beyond the customary time, and not infrequently does not wholly disappear. Only gradually is there any improvement, so that the quality and the color of the blood which is discharged again becomes sim- ilar to what was formerly usual, and only the abundant secretion during the intervals indicates the continued existence of the disease. In the non- puerperal forms of chronic metritis we see menstruation run its course very variously. It remains for a long time in a regular type, every three or four weeks ; but it comes on w'ith violent spasmodic pains, Avhich some- times cease on the appearance of the blood, and sometimes jjersist during the whole time of the flow. Menstruation becomes continuously more abundant, so that at the height of the disease great quantities of blood, sometimes clotted, are discharged. In other cases, under the influence of chronic metritis, the flow of OF THE DISEASES OF " WOMEN. 235 blood becomes always scantier, nicnstiuation occurs at continuously longer intervals, and the blood, small in quantity and usually bright red, is dis- charged in a few hours only ; after this the patients, who are usually tor- mented by a feeling of abdominal distention and by violent congestions of the heart and head, feel relieved and improved in their condition, although only for a short time. In all forms of chronic metritis it is occasionally observed, on the termination of the morbid process, that the menstrual dis- charges almost cease to appear, and amenorrhosa comes on, usually pre- maturely, which often torments these unhappy women extraordinarily. The change of life may finally establish an equilibrium in this respect also, and bring about spontaneous recovery, even if this only ensues after years of suffering. The influence of chronic metritis on conceptioti is certainly not con- stant, and seems to depend less on the development of changes in the uter- ine parenchyma than on the complications with diseases of the mucous membrane and of the appendages. Only in this way can the fact be ex- plained that in chronic metritis, especially in the puerperal form of the disease, many women conceive at almost every cohabitation, while others remain sterile ; as do also, with peculiar frequency, girls who have chronic metritis and who then marry, even if the husband is entirely potent. These last are sterile essentially on account of complications with endometritis, catarrh of the tubes, perimetritis, or perioophoritis. The injluence ofpreg'nancy on chronic metritis is not always so favor- able as is by many supposed, and as is sometimes indubitably the case. Women who have chronic metritis abort quite frequently, either because the mucous membrane is incapable of developing into a normal decidua, or because the uterine parenchyma remains unsuitable for enlarging into a receptacle for the foetus. According to my own experience a pregnancy of normal termination results particularly in those cases in which the com- plicating diseases of the mucous membrane have been successfully removed. If, then, the woman receives rational care during the puerperal period, the chronic hypertrophy of the connective tissue may actually get well, so that pregnancy is rightfully described as a means of cure for chronic metritis. A differential diagnosis betw^een chronic metritis and other diseases is hardly possible by palpation alone. The most common error is the serious one oi confounding it ivith pregnancy- The increase in volume, the softness, a certain tenderness, are peculiar to both conditions ; and yet, when the uterus is pregnant, even in the earliest stages, I have found means of making a different diagnosis, at least as a rule, in the pulsation of the vessels, the relaxation of the floor of the pelvis and of the vagina, and. above all, in the history of the case. 236 PATHOLOGY AND 7'HERAPEUTJCS Hegak ^ has, during the hist few years, repeatedly called attention to a very noticeable rclaxaticni which, at the beginning of pregnancy, occurs at the junction of the cci'vix and the l)ody, and which is said to be character- istic for these early stages. In this connection he has referred to analogous observations which I " have published, where I found a supravaginal elongation as a complication of pregnancy, and pointed out the possibility of confounding this with tumors, such as are found connected with the cor- pus uteri by short pedicles. These cases are essentially different from Hegar's ; in the latter the corpus uteri is felt as if relaxed in its lower segment, with a softness which is characteristic, as I can testify. In the cases described by me the important factor is the supravaginal elongation of the cervix. This may likewise be a product of an alteration of the tis- sue corresponding to cervical metritis, and it requires a very exact palpa- tion in order to find the junction with the corpus, and not to take the elongated cervix for the corpus itself. In all cases the possibility of a complication of chronic metritis with pregnancy is to be kept in mind, and this requires particular caution in consideration of the danger of premature interruption of the pregnancy. The development of Jibroids seldom goes on m such a manner that the thickening of the whole uterus, or even of the whole corpus alone, could be perceived. Precisely the occurrence of this formation in separate foci leads, as a rule easily, to a diagnosis, although in isolated rare cases confusion might be possible. T\\e. prognosis of chronic metritis is not so bad as ScAXZOxi ^ repre- sented in his time. The puerperal form is more easily remediable than the other, but also in the latter, with moderate patience of the woman, and with reasonable favorable external circumstances, a transformation of the uterine tissue and a satisfactory, even if incomplete, recovery may be at- tained if the diagnosis of the malady is made at a proper time. The prognosis is very uncertain only in those cases in which associated diseases of the mucous membrane of long standing at first resemble malignant dis- ease in appearance. I cannot undertake to estimate how far the disposi- tion to malignant degeneration is already present in such cases, and yet we are warned to be very cautious by cases in which the patients are brought to us after they have been treated for years for chronic metritis, and in which the microscope then reveals a malignant disease. Less serious as to life, and yet very grave as far as concerns complete health, are the cases of chronic metritis in which the malady is compli- > Reinl. kl. Berl. Woch., 1885, Nr. 13. 2 Zeitschr. f. Geb. und Gynakol., vi., H. i, iSSo. ' Die chronische metritis, 1863. OF THE DISEASES OF WOMEN. 237 catcd with disease of the peritoneum and of the appendages. This only too often establishes an ever-failing source of painful and acute dis- turbances. The change of life may bring spontaneous recovery also in these cases ; but then these women are not infrequently so reduced in the state of their feelings and in their vitality that even spontaneous recovery only permits an incomplete enjoyment of life. Treatnioit. — Corresponding to the development of chronic metritis very special importance must be laid on careful attention during the puer- peral period, as a prophylactic. Besides a thorough observation and stimulation of the involution of the uterus and of the genitals, attention to the diet of the puerpera is very important. The diet of childbed should therefore not consist in that scanty nourishment which is even to-day ordered by physicians, in a traditional manner, but rather in an exhibition of nourishment as strengthening as possible, suitable to the circumstances. As a fact puerperae support such feeding very well if we correspondingly ex- cite the activity of the intestines from the beginning. In this case I have never yet seen bad results from such a course, but, on the contrary, the stage of exhaustion is constantly very essentially shortened ; even after a few weeks the patients have passed the difficulties of this period. By local care I mean cleansing and disinfecting douches, even in the early days, as soon as the lochia ceased to be bloody, with addition of wood-vinegar or tannin, or also douches with hot water (133° F.). When the women have then got up, if their seci^etions are no longer bloody, sitz-baths, especially those with decoction of oak-bark, stimulate involution powerfully, and soon bring the external genitals into a condition of involution which excludes all the difficulties of which women otherwise complain after childbirth, such as the feeling of falling of the womb and of being open, of entrance of the air, of noises made by the vulva (garrulitas vulvae), and similar symptoms. The prophylaxis of the other forms of chronic metritis consists in an energetic stimulation of the physical development at the time of puberty, by means of abundant exercise in the open air, in suitable cases compris- ing bathing and gymnastic and horseback exercise, by liberation from compulsory attendance at school, which impedes the development, and by effectual precautions against the intestinal inactivity which so often appears, and against the very injurious habit of retaining the urine from social con- siderations. At the time of menstruation girls and women should con- tinue in their customary manner of life, but with avoidance of everything which leads to violent jarring of the abdomen, and whicli gives occasion for catching cold, and for disturliances of the course of menstruation. 238 PATHOLOGY AND TJIERAPEUTICS For young nianiccl people, in order to avoid disease, it is emphatically reconi mended to avoid excess in sexual enjoyment, and too great activity of the young wife in household affairs, and to take an intelligent care of the body. If chronic metritis has developed, the treatment depends essentially on whether we find it in an early stage, or are only called upon to remove it after it has run its course for years. In the early stages rest of the body in general, and of these organs in particular, is first to be recommended. Especially if intercurrent diseases have developed, a quiet rest in bed for several days, with cold compresses, or even an ice-bag on the abdomen, is extraordinarily efficacious. In fact, under some circumstances, a per- severing treatment with ice of itself aflbrds alleviation. Then the intes- tinal canal must be actively stimulated, and measures must be taken for relief of the suffering, and for removal of the abundant secretions by cleansing, disinfecting, and astringent vaginal injections. Among the means of stimulating the intestinal canal, a whole series of cathartics must be kept ready, in consideration of the possibility of having to continue their use for years. I employ particularly the neutral salts in cases of simultaneous stomach trouble ; where such salts are not well borne, and especially where there is want of appetite, I give prefer- ence to an infusion which is made from senna and black-alder bark (rhamnus frangula), and which contains, as a corrigent, an addition of herba millefolii and rhizoma graminis in equal parts, an infusion to be made with a teaspoonful of each in a cupful of hot water, and to be drank fasting in the morning. When senna is well borne, I alternate this infusion and one of senna leaves 25 : 160, and sodium tartrate 25, licorice juice 15 ; shake well, and take one tablespoonful in the morning. It is only unwillingly that I permit the continued use of castor-oil. Where the other means are ineffectual, I take one drop of croton-oil to one ounce of castor-oil, and have one teaspoonful of this taken hourly until it acts. Besides these 1 like to use preparations of rhubard in pills or in vinous tinctures. In the use of these, as of all other cathartics, I \voul(l warn against aloes, which, it is true, is occasionally very willingly taken by the women, and also acts admirably in obstinate cases, but not infrequently it excites uterine haemorrhages, or, at least, increases them, and then it is found extremely injurious, preciselv in these cases where a disposition to men- orrhagia exists already. Among the other laxatives I mention, moreover, cider, syrup of buckthorn (rhamnus cathartica), tamarinds, Vienna drops, and the compound electuaiy of senna, with which it is very often neces- sary to alternate ; I also have massage of the abdomen used, with good effect. A great many women who suffer with metritis find a very great OF THE DISEASES OF ' WOMEN. 239 relief in the systematic use of encmata. I do not like to have these used peruianeutly, and like to make changes both in the quantity of the water which is to be employed and in its temperature, and in the substances added to it. 1 greatly like to use irrigation of the rectum in complica- tions of chronic metritis with perimetritis, where the former exercise a very favorable influence on the sensitiveness of the peritoneum. If the evacuation of the bowels has been stimulated by such means, the attempt must always be repeated from time to time to keep up the activity of the intestines by simple regulations of the diet, which may consist either in the use of water on the empty stomach, or of cofTee, milk, or fruit, etc. Only when there is excessive sensitiveness, and when perimetritis has come on during the course of chronic metritis, do I resort to the use of narcotics, especially the use of morphine, usually in the form of supposi- tories (one-sixth of gr. to thirty grs. cacao-butter). If morphine is not well borne, I like to use instead of it the extract of belladonna in equal doses, or cocaine one and one-half grs. I have become very cautious in the use of morphine in these cases, since I have already repeatedly had great difficulty in preserving such patients from the habit of using it secretly after they had employed it only for a short time. As I consider vaginal irrigations as a necessity for cleanliness in every woman, I, of course, order for all patients suftering from chronic metritis douches from an irrigator, at a moderate height ; for this lukewarm water is generally used with a disinfectant or astringent addition, such as carbolic acid, sublimate solution, or lead water (a tablespoonful), wood vinegar, or tar water (two to four tablespoonfuls), and similar means. In simultaneous complications with endometritis, the other medicaments come into use which were mentioned under this head. After the subacute intercurrent attacks are overcome, local abstraction of blood is found extraordinarily useful in the forms of endometritis which are essentially uncomplicated. For bringing about the local bleeding I use Mayer's scarificators (Fig. 34, p. 67), with which, however, I do not puncture the uterus, but always scratch tlic mucous membrane, .start- ing from the cervical canal, and according to circumstances I make a greater or a smaller number of such superficial wounds of various depths. The scarifications cause a great alleviation ; I prefer them to the application of leeches on the portio, since in scarification we have the bleeding much more in our power, and since attendants with little knowl- edge are excluded from the use of this means. The scarifications should be repeated in the beginning at short intervals, according to the general nutrition of the patient and the congestion of the uterus ; at lirst the 240 PATHOLOGY AND THERAPEUTICS amoiint of blood wliicli ilows away must always be kept under observation. If such a scariHcatioii-wound bleeds immoderately it can, as a rule, be easily matle harmless by touching it with wood-vinegar, or, if necessary, with tufts of cotton with liquor ferri and by tamponning. Only when haemorrhage is excessive need the wound be closed by a suture in extreme- necessity. A peculiar I'esult can be obtained by these scarifications, if when the uterus is very vascular tliey are used some days before menstru- ation ; then the amount of blood which is discharged at the subsequent menstruation is diminished. Whenever the bleeding from the scarifications is abundant, it is well to have the women stay lying down for one to two hours after the latter. If the bleeding, on the contrary, is slight, as occurs particu- larly in the stage of cicatricial contraction in chronic metritis, I prefer to have the women walk about immediately after the scarification. In these cases the bleeding very seldom fails to cease almost immediately, so that only a little blood is discharged after the removal of thespeculum. The sufferings in chronic metritis are alleviated by sitz-baths^ frequently in a very favor- able manner. I have these used either with simple water, or with additions of brine, wheat-bran, or decoctions of oak bark, beginning at 90^** F. I instruct those who do not know how to use a sitz-bath tub, that they are to place the latter beside the bed, then, after they have warmed the bed well with a hot bottle, they are to seat themselves in the bath from six to ten minutes, get into bed and cover themselves up while drying themselves off. Many women support cooler sitz-baths ill, but some find an essential alleviation if they diminish the temperature ; and in these cases, while the woman is sitting in the bath, the temperature of the water can be dimin- ished to (i(f F., or less, and the patient can remain for some minutes more in this cool fluid. The removal o'i \\\& pains in chronic metritis is further assisted by the application of irritants to the skin near the uterus, especially by the appli- cation of vesicatories or sinapisms, by the use of Priessnitz' wet packs, and by rubbing in narcotic or irritant ointments. If an appropriate care of the general system is combined with such a local treatment, if it is possi- ble to induce the women to rest occasionally, even in the daytime, and especially if sexual irritation can be kept away from them, an involution of the uterus will be obtained, particularly in fresh cases originating in childbirth. This result is yet more easily attained if only a comparatively short time has passed since the childbirth, and if the uterus can therefore be excited to contractions bv the exhibition of ergot, repeated frequently three times daily in doses of i ^ grains, or by subcutaneous injections of ergotine, and by vaginal injections of hot water of 122" F. In the non-puerperal for ffis^ besides a general and local treatment of OF THE DISEASES OF WOMEN. 241 this kind, attention must be given in every case to the condition of the uterus, and of the neighboring parts, to the chronic catarrhs of the mucous mem- brane, and also to any impediment to the circulation, which ma}- be present, caused by the flexion of the corpus on the cervix, and to similar disturbances. It is often very long before it is possible to establish a diagnosis of this kind, since the young girls and w^omen are afraid of an examination ; and yet the disease is far too serious to warrant the making of a diagnosis based simply on certain symptoms, without local exam- ination, or the omission of every direct treatment. Unpleasant and painful as it is, I hold it to be our duty in all such cases to establish the result of local examination before giving treatment, as soon as the consti- tutional condition and the local difficulties fail to be improved imme- diately and manifestly by regulation of the diet and manner of life. The treatment in these cases is to be carried on in a manner generally analogous to that used in the other forms of chronic metritis ; here, also, the involution and cure of the hyperplasia of the connective tissue is brought about by abstraction of blood, by douches and sitz-baths, by wet packs after the manner of Priessnitz^ and by hot injections into the vagina. Since 1S76 I have used' iodme extensively. I paint the vaginal por- tion with tincture of iodine undiluted, or mixed in equal parts with glyc- erine. It is only with caution that I use iodoform in the vagina, since I have frequently seen poisonous effects. After very small doses sprinkled on cotton and pressed against the portio, there occur so often feelings of discomfort, headache, depression, even loss of strength, yellow coloration of vision, and other such symptoms, that I think it is advisable to be very cautious in putting iodoform on the mucous membrane. I avoid intense cauterizations, especially with silver nitrate^ or with the hot iron, on account of the very severe cicatricial formations which occasionally follow such applications. The great relaxation of the uterus not infrequently disappears under the use of tampons of glycerole of tannin, the use of which I have already explained in treating of endometritis. Ergot, also, and extract of hydrastis canadensis prove very useful in just these cases. Qiiite lately an attempt has been made to employ massage for the cure of chronic metritis. Besides various reports of Swedish lay mas- seurs, favoi-able accounts have been given by Bunge' and Proc/iownik.^ 1 Also, Breisky, Centralbl. f. Gyn., 1S7S, S. 301. yoliaiiov.'sky, Prager \'ertelj'sch., 1S-9, S. SS. 2 Berl. kliu. Woch., 1SS2, 11. 25. •^ Natiirforschervers. in Magdeburg-, 1SS4. Centralbl. f. Oyn., 1SS4, 42. Compare, also, Hegar dc Kalienhach, ed. ii., S. 176 242 PATHOLOGY AND THERAPEUTICS For several years, in cases which were not complicated by perimetric irri- tability or recent attacks in the endometrium, T have used the so-called massage by pulling and pushing (Zugdruck-massage), and the kneading of the uterus between the fingers introduced into the vagina and the liand lying on the outside, and precisely in chronic metritis, in the four cases of my observation, I have been well satisfied with the final result. It requires, however, a very patient and cautious use of this method, which wearies both parties ; so that the success, w'hich moreover can hardly be expected before five or six weeks, seems dearly enough bought. The treatment of chronic metritis is very essentially aided by appro- priate courses of bathing' and drinking of natural mineral waters, or in some cases by residence at the sea-shore, or in the woods and mountains. If an involution of the chronic metritis has been brought about by the above-mentioned local means, I prefer to terminate the local treatment when the women go off' to a spa ; in general, the treatment lasts for from four to six weeks. Then I choose for courses of waters to be drunk, pre- ferably those which act decidedly on the activity of the intestinal canal. For very weak women I advise sea-bathing, or to resort to chalybeate springs ; and I prefer to send to the former bathing-places women with a defective appetite, and with scanty menstrual secretion, while I send to the chalybeate waters those who suffer from profuse menstruation, provided that their stomachs will bear it. If the w^omen are very much reduced by their malady, I prefer to have them reside in a healthy mountain and forest air, and only allow them to use mineral waters and baths when there are very distinct indications in the given case. Especially in the cases of development of chronic metritis, in connection with puberty. I have seen very good results from the use of brine baths. In spite of the best care and of systematic use of the above-mentioned means of cure, there is not infrequently no pause or involution of the malady ; especially a treatment of this kind is seen to fail where the ex- ternal conditions for appropriate care are wanting, where the injuries con- tinue to act unhindered, and where the treatment is first adopted after the malady has lasted for years. In suc/i cases I consider the afnputation oy the cervix or the excision oj" appropriate portions of the latter as the means of cure -which is indicated. We know from the examinations of RoKiTANSKY and C. von Braun,' and from numerous other clinical observations, that a transformation of the tissue of the whole uterus, such as we see occur in childbed, may occur in connection with such an operation on the portio, and also that it very often does occur. Since, on the other hand, such an operation, when properly performed, has not the 1 Zeitschr. A. Ges. d. Wiener Aerzte, 1S64, S. 43. C. Fiirst, Wiener med. Presse, 1866. OF THE DISEASES OF WOMEN. 243 liigh dignity as an operation wliich is still attril)uted to it by many, I do not hesitate to fnosi emphatically recomtnend the amputation of the cer- vix for tJie treatment of obstinate cases of chronic tnetritis. The recommendation is made more emphatic since, by such an operative treat- ment, we can simultaneously act energetically on the disease of the mucous membrane also. The recommendation on my part is grounded on an imposing series of many hundred observations ' of such cases. The article of C. von Braun, which received little attention, was founded on cases of hypertrophy of the cervix and on operation with the galvano-caustic apparatus, or with the ecraseur. I believe that these surgical methods are being more and more abandoned, since the operation with the knife and subsequent suture, in addition to all other advantages, offers particu- larly the possibility of exact adaptation to the individual case. My recom- mendation of amputation on account of chronic metritis, which was very unfavorably received in the beginning, seems nevertheless at this time to have obtained full recognition. - In the majority of cases, a configuration of the lips of the os uteri can be obtained very closely resembling the normal condition. The uterus undergoes involution, the chronic metritis gets well, and very often there is obtained by this means, not only relief from the immediate suffering, but also a very favorable effect on the general condition. The women bloom again, and recover health and complete ability to j^erform their duties. This method of treatment has also a very favorable influence on the removal of sterility, as I conclude with certainty from the great number of pregnancies which have run their course normally after such amputations in women who had been sterile for many years. D. — NEW-GROWTHS OF THE VULVA AND VAGINA. I. — New-Growths of the Vulva. In our latitude there are seldom observed on the vulva those forms of hyperplastic elephantiasis which occur in tropical lands, and especiallv in the East,"' with great frequency. These may arise from the whole mass of the vulva, or from quite circumscribed parts, especiallv the clitoris, and grow to be large tumors, which obstruct the entrance and hang down as immense growths. These masses usually arise in connection with iNaturf. versam'ir in Cassel., 1S7S, S. Arch. f. Gyn. u. Centralbl. f. Gyn., auch Bcrl. klin. Woch., 1S7S. - Schroder, loc. cit., p. 105. ■'• Aubenas, des tumeurs de la viilvc. 'riiesc. Strassburg, 1863. L. Meyer, Berl. Beitr. z. Geb. ii. Gyn., 7S72, i., S. 363. Winckel, Lehrbuch, 1SS6. 244 PATHOLOGY AND THERAPEUTICS diseases of the lymphatics ; ' in other cases they grow on a syphilitic basis. Abuse by masturbation may not infrequently give rise to this development, especially to the hypertrophy of the nymphic (so-called Hottentot apron). Papillomata are observed with great frequency among the new-growths of the vulva, as I have already stated above in speaking of the inflammations of the latter. KLOB^has seen these not connected with the sebaceous glands ; Wixckel' has found them especially often on the mons veneris, growing like flat mushrooms on short stems ; he has also found them on the labia majora and minora. These are distinguished from condylomata Ijy the fact that the latter may appear everywhere, while papillomata only proceed from pieexisting papillae. In regard to the swellings of the glands of Bartholitii^ I refer to what has been said above at page i86. I have frequently found lipomata, once larger than the fist, in the labia majora ; in other cases there were glatids -which ivere densely injil- trated. Fibromata of the vulva have frequently been described which, arising from the labia majora, have attained a considerable size. As a rule, they could be easily shelled out ; in other cases it was very difficult to remove them. Lupus of the vulva has, up to the present time, been described in only very isolated cases ; primary carcifiomata are more fre- quent. As a quite peculiar occurrence, I have found and removed, ten years ago, a growth as large as a cherry from the left labium majus of an elderly spinster ; this proved to be a melanoma. As far as I have heard recently, this patient is still in good health after more than eight years. Since these masses occasionally sw^ell considerably at every menstru- ation, and cause the greatest inconvenience to every kind of motion and work, since they also cause a very annoying secretion, and quite frequently hinder sexual intercourse, their removal is often necessary even very early, at any rate as soon as the malignant character is plain. The operation is complicated by the great vessels which usually run to these hypertrophic masses. We can therefore either proceed by sepa- rating the mass by degrees and sewing up in sections the defect which is thus caused, or by provisional ligation of the vicinity by deep sutures be- fore beginning the removal. For larger masses I have preferred this last method, since in this manner I could more securely control the form of the cicatrix. For some years I have rubbed the wound-surface itself with iodoform powder, and then closed it carefully with some deep-set sutures, and with superficial ones lying between them. It is advisable to arrange ' Virchovj, Geschwulste, i., S. 320. - Pathol. Anat. d. weibl. Sexualorg, S. 401. •• Loc. cit., p. 25. OF THE DISEASES OF WOMEN. 245 that the wound, when sewed up, is as far as possible from the vagina later- ally, and also not to tie too tightly the section of skin in the immediate vicinity of the entrance. The linear wound, made in this manner, can be protected by a compress and bandage from becoming soiled, especially if, for the first six days, the urine is drawn with the catheter, and the bowels are kept constipated. Qiiite lately I have also controlled the haemorrhage in these cases by ligating the blood-vessels separately, and after rubbing iodoform into the surface of the wound, I have sewed up the skin quite superficially over a small drainage-tube, and kept the f?ap in position by compress and bandage. In tliese cases, also, union resulted very satisfac- torily. In one such case in an elderly lady, besides the carcinoma of the vulva I have simultaneously removed a degenerated inguinal gland of the size ot a hen's egg. The patient has remained free from relapses, as far as the reports of the family go, for over five years. In another case I had to excise the whole vulva, and more than a third of the lower part of the vagina, with the urethral tubercle, which had been attacked by the new-growth during the five weeks while she was under observation. The extirpation suc- ceeded completely ; union by first intention resulted ; two years later the patient became pi-egnant and was delivered spontaneously. Since that time I have no further knowledge. In two other cases the patient first came to operation when the whole vulva with the bulb of the urethra was diseased. The radical operation was performed here, but in only one case was there a permanent success. The other died of further carcinomatous disease after a year's respite. In the one who recovered, the influence of the cicatricial contraction on the contents of the bladder had to be repeatedly counteracted by plastic oper- ations. II. — New-Growths of the Vagina. I. The Non-malignant Nezv-Groxvths.- — The mucous membrane of the vagina, as a natural consequence of the slight development of its glandular elements, is comparatively little disposed to new formations.' Fibromata are found either in the form of hard nodules, such as I once have extirpated from the posterior vaginal vault in an elderlv virgin, or as polyps. I have seen one such fibrous polyp in a new-born infant, hanging down into the lumen of the entrance, and I was able easily to tie off the pedicle and remove the polyp. These fibromata may reach a foi"- 1 See computations of frequency in Winckel, text-book, p. 157. 246 FATJIOLOGY AND TJIKRAJ'EUTJCS midablc size, giving rise to symptoms of pressure on neighboring organs, then perforating the vaginal wall ; generally they grow slowly, and as soon as they are discf)vered they can he removed, either by peeling thein out or by tying them oH'. The cysts of the vagina are relatively more frequent, and so is primary carcinoma of the vagina, although both these forms arc very sel- dom found. Cysts of the Vagina. — Cystic formations may originate : (a) as retention cysts from the glands of tiie vaginal wall. v. Preushen has described such as broad crypts of tubular reduplications.' {h) Cystic spaces originating from injuries and exti'avasations (f blood haye been described by H. Kaltenbach,- Gotthardt,^ and others, (c) Cysts originating in lymph-spaces and lined with endothelium have been first described by Winckel.'' ((/) A final category of these cysts arises, according to G. Veit,^ from Gaertner's ducts (primitive renal ducts), or from rudiments of the Wolfian bodies. It must still remain unsettled how far the little pockets in the urethral tubercle participate in these cases, concerning which Skene i^eports obsen'ations," as also Klein- WAECHTER,' KocKS,* and DOHRN." Pathological Anatomy. — These cystic spaces frequently have a low cylindrical epithelium, a well-developed envelope of connective tissue, and clear, almost viscid, contents; occasionally, also, they are lined with ciliated epithelium. In other cases the cysts, owing to the want of epi- thelial lining of their wall, appeared as simple clefts in the tissue, in which a clear, serous fluid had collected. They are found in all sections of the vagina, sometimes isolated, sometimes united in groups, and by their growths they may occasion difficulties which resemble those of descent or prolapse of the vagina. I have extirpated extensive vaginal cysts fifteen times ; the majority of them had given rise to complete procidentia. The translucent elevation of the vaginal wall, on straining, presses into the en- trance., or even through it. This feeling of annoyance was usually the only complaint which was caused by these vaginal cysts ; in some cases the im- pediment to conjugal life was distinctl}- mentioned as a subject of com- plaint. I saw a peculiar action of a cyst as large as a walnut, on the left, in the vault of the vagina, in a young and sterile woman ; in this case the a])ove structure, which projected into the lumen, pressed on the os uteri like a cover, both on digital examination and on introduction of the cylin- * Virchoiv's Archives, Ixx. " Amer. Jour. Obstetrics, 1880, p. 265. 2 Arch. f. Gyn., v., S. 138. ' Prager med. Wochenschr., 1S86, Nr.9. ' Wiener Med. Wochenschrift, 1889. " Arch. f. Gyn., xx., S. 487. * Archiv. f. Gyn., ii., 1S71, S. 3S3. •' In the same, S. 328. ^ Diseases of Women, ed. ii., 1S77, p. 544. OF THE DISEASES OF WOMEN. 247 drical speculum. The further history of vaginal cysts shows but very rarely a putrefaction and supjDuration of tlie contents ; personally I have not seen any other results of this cystic formation. The fl-peratioii fo7' vaghtal cysts cannot consist in the simple divis- ion of the tissue, w^hich is usually firm, by which the cysts are separated from the surface, for these cystic spaces are not obliterated at once ; the wound unites and the cysts fill up again. In consideration of this fact and also of the sufferings from pro- lapse occasioned by the cysts, an extirpation of the latter is indicated. Under appropriate irrigation, under anaesthesia, and on the back, I split the vaginal wall over the cysts, and then dissect out the cystic sack, wherever possible, in one piece. Where the cysts are large the wound extends readily into the peri-vaginal tissue, and occasionally also into the immediate vicinity of the rectum and of the bladder. After the cyst has been completely enucleated, the wound is closed by deep sutures running under the whole raw surface, or better yet, by continuous sutures of juniper-catgut. Among the fifteen cases I have removed sometimes isolated vaginal cysts, and sometimes several cystic structures lying grouped together from the size of a hazel-nut to that of an egg. One of the largest la}^ in the prolapsed anterior vaginal wall, and w^as enucleated with this during anterior colporrhaphy. In all cases union resulted without disturbance. In five Avomen in particvilar, cysts in the anterior and pos- terior vaginal walls could be considered as the essential cause of pi'oci- dentia, inasmuch as they j^ressed into the entrance and continually occasioned the feeling of annoyance from which the patients attempted to free themselves by violent straining. Another proposition for operating on such vaginal cysts has come from Schroeder,^ who resects them on the level of the neighboring tissue, that is essentially through the wall which is turned to the lumen of the vagina, and sews the basis of the cysts thus laid bare to the vaginal wall on all sides, so that in any case the cyst is secure against a new obliteration of the outlet and filling up again. Very disagreeable complications may occur through cystic forma- tions, which, without having arisen in the immediate vicinity of the vagina, yet in the progress of their growth thrust themselves under the surface of the vaginal wall just like vaginal cysts. Such cysts, which fre- quently must be explained as caused by the retention of contents in incom- plete foetal structures, may develop into great tumors, which, lying in the floor of the pelvis, press the peritonaeum strongly upwards and are found as extra-peritoneal tumors of large size.- 1 Zeitsch. f. Geb. u. Gyn., iii., S. 434. - G. Veit, very large vaginal cysis,, '^eitschr. f. Geb. u. Gyn., 1SS2, viii., S. 471. — G. Wegner according to Stern, D. in Berlin, iSSo. 24S PATHOLOGY AND THERAPEUTICS Such tumors have liithcrto heen usually attacked from the vagina, and have repeatedly been left to obliteration after simple division and appro- priate sewing into the vaginal wall. In case such an operation meets with difficulties I would have no hesitation in making a laparotomy for the removal of cysts of this kind also. In such a case the peritoneal covering must be split, the tumor enucleated, and the defect which arises in tills way must be cared for. After resection of the upper part of the tumor, the part which is irremovable can be drained from below and shut oft' by suture from the peritoneal cavity. After such operations in the vagina, as well as after idceration in diphtheritic, puerperal, or syphilitic inflammations, there are occasionally developed stetioses of the vagina^ such as also arise in consequence of malignant formation, or also finally as accompaniments of senile colpitis. I will not consider here the congenital, incomplete development of the vaginal passage. The obstructions of the vagina by adhesions^^ wherever thcv may be situated, lead, when full}- developed, to an impediment to the discharge of the uterine secretions, and to the evacuations of the intestine and bladder ; on the other hand, they impair the sexual functions. The latter disturbances, however, do not occur to the extent that might be expected in cases of stenosis, since the vaginal walls are so very extensible that, even when stenosis or even atresia exists, a suitable receptacle is formed v\diich prevents the obstruction of the vaginal passage from being noticed. Such an obliteration, therefore, can be quietly left to itself as long as diffi- culties of retention and a reaction on the bladder and intestines do not lead to considerable complaints. In all the cases which I have yet seen the lumen of the vagina could be recognized as an opening which was often, however, very small. From this point the operation could be commenced by splitting the stenosis. In these cases there is always a danger of injuring the rectum or the bladder ; therefore, the division is generally made bilaterally ; that is, in the loose connective tissue situated at the sides of the vagina. The bleeding maybe very considerable in these cases ; in order to prevent this, sutures may be employed. These sutures must be extended further so as to close the raw surfaces, for all such vaginal injuries have a very noticeable tendency to rapid adhesion and severe cicatricial distortion. The latter can only be prevented with some security if the wound is closed so that the line of union corresponding to the line of defect in the wall of the vagina cannot lead to an occurrence of this stenosis. It is even more advisable to com- pletely excise the whole mass of the stenosis, the firm cicatricial ring with ' Compare Breisky, Diseases of the Vagina, 1S86, S. 58. OF THE DISEASES OF WOMEN. 249 its environment, and tlien to unite the healthy edges of such a defect ex- actly to each other. When there is a nearly complete obliteration, such as I have seen similar to congenital atresia, the difficulties of discision are quite extraordinary. The proximity of the bladder and of the intestine makes the greatest caution necessary, — any advance is rendered very difficult by the position of the atresia in the depths of a narrow vagina, and by the haemorrhage which readily occurs. In such cases the incision is made transversely in the occluding vaginal wall, and it is made in the beginning as large as possible ; then, by deep sutures in the vicinity, the edges of the incision can be secured, both from severe haemorrhage and also from displacement during the course of the operation, while the way is dug deeper in through the slit which is kept open by these sutures. The advice to make the further separation with dull instruments — e.g.., with the handle of the scalpel — seems to me not very fortunate, for at this depth the scalpel cannot be well used ; at any rate, it Is better to continu- ally make the parts at the bottom of the wound tense by means of bullet- forceps, and to cut in between the latter. In extreme necessity, as when behind the atresia there lies a distinct collection of blood after a thorough incision of the scar, I open the retaining cavity at the bottom, either with a trocar or with a dull insti"ument — e.g.., with the sound — by boring through the last remainder of the wall of the adhesions which cannot be reached for division by dissection ; and from the passage so made I en- large the opening towards each side with a probe-pointed knife. In these cases, also, the cicatricial contraction is greatly to be feared, and it can best be avoided by complete excision of the cicatricial tissue wherever possible, and by union of the edges of the vagina with each other from above and below. According to Heppner,^ a flap of the external skin can be sewed into the wound, as B. Crede has done." After all these operations in the vagina, the further formation of cica- trices is to be regulated in a manner similar to that used in analogous disease of the rectum, by the introduction of bougies. There are tubes of all possible materials and of various calibres, which are to be intro- duced by the patients themselves, if necessary, in a sitz-bath, and are to remain in place for some time for dilatation of the ring, which tends to a stenotic formation. Finally, conjugal life is to be particularly considered in relation to these cases. 3. The Malignant JVeiv- Growths of the Vagina. The rarity of the development of tnalignant new-growths in the 1 St. Petersb. med. Wochenschr.,. 1872. Heft. 6, S. 552. - Arch. f. Gyn., 1SS4, xxii., S. 229. 250 PATHOLOGY AND THERAPEUTICS vagina, on which much emphasis was formerly placed, has been so modi- fied by the great mmiber of striking observations, that we now know that jjrimary carcinoma of the vagina is certainly comparatively infrequent ; it comes under observation in the most varied forms, either in the develop- ment of small nodules lying disseminated in the vagina, or m the form of larger or smaller ulcers, with a densely indurated base, or finally in the form of tumors, which are developed in the vaginal wall itself and ob- struct the passage. On further development, a whole section of the vaginal tube may then degenerate in a ring ; so that the vagina is com- pletely invaded by the new formation throughout a more extensive region, or the development is localized on one side or the other, and spreads deeply to the floor of the pelvis before it invades the whole v^aginal tube. I will only speak in regard to the treatment of these primary vaginal carcinotnata^ not of those cases in which the vault of the vagina is at- tacked, and where usually the uterus also shows signs of disease. These last cases belong to the chapter of malignant diseases of the uterus. The cetiology of the vaginal carcinomata is still obscure ; it may, however, differ from that of uterine carcinomata, since in the vagina there is neither cylindrical ephithelium, which predisposes to development of new-growths, nor, on the other hand, are those glandular apparatus present, to any great extent, which play such a fatal role in malignant disease of the uterus. The primarv vaginal carcinomata are relatively frequent in young persons (one-twelfth of all the cases known were in patients under twenty years old) . According to my observations," which I have since pursued further, one vaginal carcinoma occurs in about one thousand gynaecological cases. The .vvw^/owj- of vaginal carcinoma maybe so slight that the un- happy victim of these growths may be surprised at discovering them quite accidentally ; in other cases there are violent pains, radiating widely, or profuse malodorous secretions with bloody admixture ; or, finally, unmixed discharges of blood. In extensive development, disease of the bladder or of the rectum becomes noticeable comparatively early. In some very pe- culiar cases I have seen the malignant infiltration growing exclusively in the vault of the vagina, upwards, at the side of the uterus. In one I had to clear out a great cavit}- in the right broad ligament, by the side of which the uterus lay quite intact. The diagnosis must be established by microscopic examination, in case all doubts as to the nature have not yet been removed by disintegra- tion of the tissue, by the infiltration, and by the secretion. ' Kiistner, Arch. f. Gyn., ix., S. 279. ^Bruckner, Zeitsch. f. Geb. u. Gyn., iSSi, vi. OF THE DISEASES OF WOMEN. 251 The treatment of vaginal carcinoma can only be undertaken with any prospect of success if the diagnosis and examination take place at a very early stage of the disease.' Then tlie diseased place must be excised with as wide a margin as possible of healthy tissue, and, above everything, the basis of the disease must be most thoroughly removed. In such cases I make an incision as widely as possible around the tissue which is to be extirpated, I dissect out the vaginal tube in the vicinity, and from there burrow under the base of the new-growth, partly with knife and scissors, partly with the points of the fingers, until I have separated and removed the whole. It may be very difficult to sew up this wound, on account of the neighboring organs, but it is yet more difficult to unite the edges of the wound if it has been necessary to remove the tumor from the depths of the vaginal vault. I have in such cases, although occasionally with great difficulty, always passed the needle under the whole raw sur- face, and accomplished an accurate union of the parts lying opposite each other. During the last few years I have first introduced these deep sutures there, and rubbed the raw surface with iodoform before tying the former. The result was completely and surprisingly favorable, as far as concerned healing by first intention ; union went on without disturbance, and led to cicatricial formation so firm, that already, in eight or ten days, on removing the sutures, the deep cavity which had previously been made was found to be completely united. I have not seen iodoform in- toxication occur from these cases, and therefore I entirely recommend this form of using iodoform for promoting the union of the wound in a place where it is always endangered by the sti'ong traction on the tissues, by the continued moistening with uterine secretion, and by the peculiar dispo- sition of the vaginal secretion to decomposition. 'Y:\\& prognosis of vaginal carcinomata is very sad, at least according to my observations, although the cases do so well as far as concerns first intention. All my patients suftered from relapses, although I am con- vinced that I operated wholly in healthy tissue, at least in the majority ot the cases. 1 The recommendation oi Kaltenhach (op. Gyn. v. Hegar^^nA. Kaltenhach, ed. iii., 7S2) to operate also without regard to bladder and rectum as long- as the neighboring lymphatics are free, does not meet with my entire acceptance, in view of the difficulty of proving the latter fact. I would only operate at the risk of injuring the neighboring organs, if the expectation of life for the patient could be secured thereby. 1 have, however, several times seen injuries of the bladder close spontaneously by the subse- quent proliferation of the tissues. 253 PATHOLOGY AND THERAPEUTICS E. — NEW-GROWTHS OF THE UTERUS. I. — Myomata. Fibromata. It seems desirable to consider the myomata and fibromata of the uterus together, not only on account of the similarity of their clinical symptoms ; I believe that also from the point of view of their pathologi- cal anatomy, very slight objections can be offered to such a course. Tumors wholly composed of unstriped muscular fibres exclusively have been observed only in very isolated cases ; at any rate they are very rare, and, on the other hand, in fibromata muscular elements can usually be found, although in small numbers. The development of both forms goes on similarly, the sufferings caused by both are identical, and at a certain point of their development both kinds of tumor lequire nearly the same treatment. An attempt has been made ^ very recently to elucidate the aetiology of these new-growths by study of a comparatively abundant material, although no conclusions of really practical value have been estab- lished. It seems as though myomata could develop in the uterus very early ; in fact some authorities say that they consider the local seeds of the disease as congenital. However, in most cases, they cause serious diffi- culty only in riper years ; i.e.^ after the thirtieth year of life. The myomata develop, according to reports, with peculiar frequency in certain races, for example in the negroes. In Germany there is an impression that myomata occur w^ith greater relative frequency among women who are comfortably situated than among the so-called lower classes, who have to contend with weighty cares, and among whom, on the other hand, carcinoma more frequently occurs. - Marriage has demonstrable influence on the development of myomata. Among my patients, I also have found the latter with relative frequency in virgins, or in persons who were married late, and, as it appears, after the tumors were already very far advanced. Pregnancy is not excluded by this form of new-growth, but its development seems also not to be favored by them. If pregnancy occurs, the transformation of tissue, which takes place in childbed, exerts a very noticeable influence on the tumor, unless the latter is removed from the action of the puerperal involution by a sub- 1 Winckel, Volkmanri's Sammlung kl. Vortrage, 98. Engelmann, Zeitschr. f. Geb. u. Gyn., i., S. 130. * Schroder, Handbook, vi., S. 21 S. OF THE DISEASES OE WOMEN. ^>3 serous location, or offers a continuous resistance to these processes by reason of its growth. xinatomy. — The tumors show smooth, muscular fibres, intermingled with peculiar bundles of connective tissue, arranged like waves. These elements are present in very varying proportions, so that sometimes the myomatous, and sometimes the fibrous, character predominates. Between these elements lie numerous blood-vessels of very various dimensions, as well as lymphatic vessels more or less abundantly developed. The anatomical relations of myo- mata to the neighboring parts are ^*3' ■'^^' extraordinarily various. If such tumors may develop, as some observations show, from points which cannot be accurately delineated, yet we see in other cases scattered through the uterine wall innumerable little buds, which must be regarded as incipient myo- mata. In the course of further development, these tumors may re- tain their isolated character, and their nutrition may be maintained by a moderate number of vessels by means of a bridge of connective tissue, which is often very limited, which lies between the new-growth and its environment, the so-called bed or capsule of the tumor. Then the latter may grow to an in Lichtdruchabbild, 1881. enormous size ; and while it remains in its bed, completely diftei'entiated, and only joined w^ith the environ- ment by a loose connection, it may alter and transform this environ- ment in a quite iiTegular manner. In other cases the myomata are developed from more diffuse beginnings, and it takes a long time (the tumor may meanwhile have attained a considerable volume) before an isolation of the tumor occurs by differentiation of the surrounding parts, and then the same relations are established as in the other forms of myomata. If owing to this fact there is a noticeable difference in the shape and development of these tumors, so also is the size and form of the uterus, moreover, often made quite irregular by the fact that only very seldom do Multiple myomata in a uterine body, after VVincktl. Pathol, der. weib. Sexualorgane 254 PATHOLOGY AND THERAPEUTICS the buds of these tumors occur singly, but that they are generally mutiple, and often enough, especially in oki women, a great number of such myoma buds are found disseminated throughout the uterus (Figs. 123 and 124). A further diflerence in the development is occasioned by the location of the tumor ; its situation in the body or in the neck naturally varies greatly the relations of tlie tumors, especially to the peritonieum. From this fact is derived a definite subdivision of the tumors for practical purposes. The differentiation of the myomata in their bed can only be established during life by an operation on tlie tumor, but we have frequently enough an occasion to diagnosticate exactly the location of the tumor even earlier, especially in cases of myomatous formation which are still of small extent. The majority of myomata is probably developed in the wall of the uterine body inter stitially and intra-parietally ^ and they pass through the first stages of growth about eciually distant from the serous and from the mucous covering. When they grow large, however, these tumors seldom remain intra-parieta/, although here also considerable growths may finally occur, — in fact, intra-mural tumors of sixty-three pounds have already been proved to exist. Generally, in the further course of their development , they push their way to a position on the external or internal surface of the uterus. Then they pass to a position under the peritoneum, and w'hile they develop further and grow out of the former bed, they may come to be wholly sub- peritoneal, while their former location closes again behind them, the uterine wall is renewed, and afterwards a more or less thin pedicle still remains in connection with the former point of development in the uterine wall. These subserous tumors grow out from the uterine wall, and develop without restraint, so that they become much larger than the uterus itself, fill up the whole abdominal cavity, press the uterus downward, thrust it to one side, and often by pressure induce its complete atrophy. Such large subserous tumors may then pass through all the various phases of existence, which will be hereafter considered ; in fact, these are the ones which, in consequence of the insufliciency of their nutrition or of a torsion of their pedicle, cither lose their uterine connection completely, or become inflamed, and then acquire adhesions to all the organs with which they come in contact. The tumor may also move and get under the mucous tnembrane in a manner analogous to that in which it may push itself under the peritoneum ; in the former case it may completely fill up the uterine cavity, and wiien it OF THE DISEASES OF WOMEN. 255 is very large it may grow toward the internal os uteri, and then may occupy the whole wall or the whole mass of the uterus. Very often the subtnucoKs tmnoi-s push the mucous membrane before them to such an extent tliat the latter, tightly stretched over the tumor, becomes extremely tense, and may be so over-stretched as to slough. Then it may happen that the tumor pushes its way out from its original bed in the uterine wall, through the gangrenous place into the cavity of the uterus or into the cervical canal, and in this way, by growing and separating itself more and more from its bed, it is finally born ; z.e., ex- Multiple mjomata in and beside the uterus, after IVinckel, loc. cit. — a, Intra-parietal; b, Intra-ligamentous; c. Submucous; (/. Subserous. truded. For, finally, such tumors acting like foreign bodies excite uterine contractions like labor-pains. In this stage of development a sort of spontaneous cure may be effected by the self-enucleation of the tumor. Before, however, this extreme result occurs, — which, when it happens, must be called a very favorable one, — the tumor, covered by the uterine mucous membrane, may protrude as a polyp into the uterine cavity, so that sucli a uterine mvoma or fibroma, originally intra-parietal, and then submucous, may fill the uterine cavity in the form of a fibrous or fibro-myomatous polyp, and then may occasion the difficulties characteristic of the latter. The myoniata of the cervix uteri may pass through stages of develop- ment analogous to these stages of the fibro-myomata of the uterine body. 256 PATHOLOGY AND THERAPEUTICS They are, as a fact, very much rarer than the corresponding tumors of the body of the uterus, but they may also develop interstitially (intra-mural), and remain as such in that situation, or grow in the neighborhood of the cen'ix as subserous tumors becoming thus intra-ligamentary^ or thev may move between the cervix and bladder, or finall}', in the form of polyps, thev may get into the cervical canal and the vagina. Then they pass through all the further stages of development like the submucous myomata of the corpus. The cervical myomata develop not infrequently in the easily disten- sible space of the broad ligaments, the folds of which they press apart and so fill up the whole pelvis, in doing which they emerge from the limits of the cervix proper. They push themselves also between the layers of the pelvic floor, and in this way they pass out beyond the broad ligament under the peritoneal lining of the pelvis. In fact, as I have frequently observed in such cases, they may extend between the separate organs con- tained in the pelvis, in the same way as they do under the peritoneum of the greater pelvis. Then they lift up the whole pelvic peritoneum. The pouch of Douglas and the vesico-uterine fold disappear, while the vagina, urethra, and rectum, irregularly obstructed and greatly impeded in their functions, pass beside the tumor to the openings where they discharge their contents. Other forms arise from the development of the myomata in the vaginal portions of the cervix. The nodular hardness on one hand, and on the other hand the size, and finallv also the sloughing of the over- distended capsule of mucous membrane, with formation of deep necrotic ulcerated surfaces, may make it very easy to mistake this for carcinoma. Besides such peculiar processes of development there occurs in fibro- myomata a furtlier series of peculiar alterations^ oivlng to the trans- J'ormatlo?is of their own tissues which those tumors undergo} As these tumors in their histological composition correspond to their bed, the uterine wall, they can also, like the latter during the climactery, undergo involution, shrink, and completely disappear, except a cicatricial residue, after the manner of the senile atrophy of the uterus. In such shrinking subperitoneal and interstitial tumors, calcification occurs not very in- frequently. The deposit of salts of lime usually occurs in the form of irregular lines, which, after maceration of the parts which are not calci- fied, occasionally represent a peculiar framework, or a single solid mass may be formed. - Another kind of transformation — x'v/..^ fatty degeneration — leads to nearly the same result. This kind of alteiation apparently occurs with par- 1 Schroder, loc. cit., S. 220. * Compare Lehnerdt, Zeitsch. f. Geb. 11. Gyn., iii., 359. OF THE DISEASES OFWOMEN. 257 ticular frequency when pregnane}' has taken place, hi spite of the myoma ; and, when under the puerperal influence, the new-growth undergoes puer- peral involution just like the tissue of the uterus itself. It can hardly be doubtful that even large myomata may undergo involution in this \vay. I have personally seen a puerpera in ^vhom the new-growth was developed to nearly the size of the two fists. ^ At the autopsy, nearly eight weeks after delivery, its contents were found changed to one mass of fatty pulp. It is certainly not doubtful that this pulpy liquefaction may lead to resorp- tion and so to involution of the tumors." In mvomata there may further occur q. development of cedenia^ which may permeate the whole tumor, and which apparently also leads, finally, to a sort of liquefaction, as is the case in myxomatous degeneration^ in which an abundant mucous tissue develops between the muscular bundles, and occasionally, by disintegration of the latter, leads to the formation of large cavities filled with broken-down tissue. A liquefaction of this kind, which, owing to the conditions of the case does not attack the tumor quite equally, leads to the peculiar form of development which is designated as fibrocystic tumor ^ or as cystic myomaJ" (Fig. 125.) In the latter a serous fluid and a mass which is no longer compact, permeated by intact fibrous strands of muscular and connective tissue, lie in cavities of irregular shape and enclosed by walls which are apparently not definitely preformed. The fibrocystic tumors, by the great number and the extent of the cystic spaces, may lend to the whole case the character of a multilocular ovarian cyst ; and often enough they have been mistaken for ovarian tumors, even until the operation ; especially, if by tapping a serous fluid has been evacuated from such myomatous cysts. Again we find, although in fact not very frequently, a transformation of tissue in these tumors induced by an enormous dilatation of the vessels, which has caused these new-growths to be designated as cavernous, or as teleangiectatic mvomata} In these cases, great dilated vessels may lie between the bundles of muscular and connective tissue fibres, which are soaked with serum ; and thus there may be an enormous proportion of blood in the tumor. The myovia teleangiectodes sen cavernosiim contains large capillaries, trans- formed into spaces filled with blood, the calibres of which may grow to be as large as a pea. Between these the muscular and connective tissue remains onlv in very slender strands. The cavernous transformation usually only extends 1 Berl. Beitr. zur. Geb. u. Gyn., iii., S. B. S., 33. 2 LohUin Zeitsch. f. Geh. u. Gyn., Bd. i. • ' Heer, Ueber Fibrocysten, Ziirich, 1874. Grosskopf, D. i. Miinchen, 1SS4. ■• VirchoTV, Geschwiilste, Rd. 3, S. 107. 358 J'ATHOLOGV AND TJJKRAPEUTICS over certain sections, and seldom over the wliole extensive new-growth ; and it explains the enlargement and diminution of the latter at the time Fig. 128. After Schroder. Handbuch der Kr. der weib. Geschlechtsorg. — C. M. Cystic myoma. S. M. Subserous mvoma. of menstruation. Analagous to this is the development of the myoma lymphatigiectodes^ by the dilatation of the Ivmphatic vessels. Other myomata fall a prey to a process of suppuration^ which, in- duced by decomposed throinbi, or by exciters of suppuration, of whatever kind, may likewise lead to a liquefaction, which goes on to the complete dissolution of the tumor. Then there may occur an inspissation of the pus, or more frequently an evacuation towards the exterior, either into the genital canal or into the vicinity of the uterus. I have described a very ' Leopold, Arch. f. Gyn., vii., S. 531. [Annai.s ok (ivN.ia ()i.c)i,\ and 1'.i;di \•^<^ , Muixli, i^i^ XV FIBRO-CYSTIC TUMOR OF UTERUS. Aa Stump still encncUd by lublif r tulie and transfixed by needles. Its size in eomparison with cut surface or uterus slinws Imw nnuli it shrank before coniinu- away. B, Aperture of cervical canal. C, Small myoma; bf>th in cut surface. D, Cati;iit with whicli the pedicle of the tumor opposite £ ^^'-'s sewed ort. i^ANNAI.s Ol- GV.N.ICCOLOCV AND I'.KIJI A TK V, .Mlircll, lSyO.| XVI MULTINODULAR MYOMA OF UTERUS. A. Apcrliirc ot" cci\ ic;il caii;il. B. Cakureou.s iiotlulf, laid i)pen. OF THE DISEASES OF WOMEN. 259 characteristic case of this kind in the Society for Obstetrics and Gynae- cologv, at BcrHn, on May 28, 18S6. The myoma had suppurated, had broken throui^h the uterine wall, and was beginning, in the region of the promontor\^ to ulcerate the sacrum, to which the uterus was firmly ad- herent. The disintegration had led to a general suppurative peritonitis, which could not be remedied by laparotomy and supra-vaginal ampu- tation.' The possibility of a malignant degeneratio7t of a myoma is in itself, of course, not excluded. In October, 1886, I have operated on such a case,' in which the myoma had undergone sarcomatotis degeneration ; from this had originated wide-spread sarcomatous infiltration of the glands. The mucous membrane in the corpus was quite atrophic and healthy. In other cases a carcinomatous degeneration has originated in the mucous membrane. The cases of this kind have been collected by ScHROEDER ; ^ to thcsc I Can add one observation of my own. The tumors of the cervix may, of course, pass through entirely anal- ogous changes. Those cases are of particular significance in which the tumor develops between the folds of the broad ligament and under the pelvic peritoneum, because they cause very violent sufferings, and it is only recently that that they have become amenable to treatment. The most jfreqttent term.ination of Jibro-myomata is probably that of cessation of growth and shrinking. Next frequent is the occurrence of a submucous development and the formation of polyps., which again have a history of their own, according to their nature. Such polyps are distinguished from the commoner simple polyps of mucous membrane, the so-called follicular polyps, by the fibrous or fibro- myomatous substance of which they are composed. "* Their volume is ex- traordinarily variable, as is likewise their shape, which is frequently moulded by the form of the uterine cavity and of the cervical canal, during the long abode of the mass in the one or the other. The fibrous polyps have a pedicle which is usually slender, because its point of connection with the original bed of the tumor has been elongated by traction during the growth of the latter and its passage out from the substance of the uterine wall ; in fact, it may happen that the tumor emerges entirely from its bed, and then the place which connects this so peculiar form of tumor with the uterine wall — i.e.., the pedicle — is covered almost wholly, or wholly, with mucous membrane. It has been already stated that the ped- icle may be torn oft", and thus furnish occasion for an extrusion of the 1 Compare also Larcher, Arch, general, 1S67, 2, S. S4S and 697. 2 Comp. Orthmann, Gesell. f. Geb. u. Gyn., z. Berl., Nov. 12, 1S86. »Ed. vii., S. 228. ■* Hildebrandt, Volkmann's Sammlung, 47, 1S72. 26o PATHOLOGY AND THERAPEUTICS tumor analogous to childbirth. In other cases the pedicle remains pro- vided with a dense core of fibrous and muscular elements. The pedicle itself is spread out over the uterine wall, and, by its widely extended in- sertions may keep a \'ery large surface of the wall in connection with the polyp. If such pediculated polyps arc then extruded by uterine contrac- tions, they occasionally invert the corresponding portion of the uterine wall, and may finally bring about a complete inversion of the whole uterus. (See above, Figs. 97 and 98.) The vascular supply of the pedicle is as variable as the proportion of solid elements in the composition of its tissues. The vessels are usually of rather large calibre ; seldom is the nutrition of the polyp supported by a single vessel. During further development, however, the vessels may be so stretched and distorted that disturbances of circulation and thrombi are developed in them, so that the nutrition of the polyp is interrupted, and it is disintegrated, partly on its surface, partly in its interior ; it softens down in some places, and a general disintegration commences. This process may lead to a complete liquefaction of the polyp, unless the reaction on the general condition of the patient is previously fatal. The condition of the mucous membratie becomes very peculiar indeed in these myomata.^ Probably on account of the irritation which is occasioned by the new- growth while still in the midst of the abdominal wall, there frequently occurs a marked hyperplasia throughout the whole endometrium, with immense development of the glandular apparatus in particular. The vol- ume of the mucous membrane is very decidedly increased, so that this seems to be over 2 cm. (^ in.) on the average. On the other hand, the glands of the mucous membrane in the neighborhood undergo cystic degeneration, or there is developed a hyperplasia of the interglandular tissue, which leads to complicated forms of tumor. ^ When there are myomata in the uterine wall, larger or smaller polyps of mucous mem- brane are found in the uterine cavity with striking frequency. If the tumor comes to lie below the mucous surface this is greatly stretched and • Wyder Archiv. f. Gyn., b. xiii, S. 35, and v. Campe Ges. f. Geb. u. Gyn., January, 1S81. Wyder, in Munich, 18S6, at the Gynaecol. Congress, and in Archiv. f. Gyn., Bd. xxix, has used as a target for very severe observations a quite incidental remark occurring in my article on myomotomy at Magdeburg, 1SS4, according to which, in recounting all the various indications for operation on myoma, I mentioned the possibility that disease of the mucous membrane may run into malignant degeneration. What I say here, which is but little more detailed than in the first edition, may convince Dr. Wyder that as indica- tions for the operative treatment of myoma I do not recognize the above mentioned alone, which was, moreover, referred to by me at that place quite incidentally, and ;is the last indication of all, so that I must designate his observations as in page 40, in the place before mentioned, as merely blows in the air, and not quite well informed at that. I shall, moreover, soon be able to publish a contribution to the study of these alterations as the result of the collation by Orthmann and myself of the histories of my cases. OF THE DISEASES OE- WOMEN. 261 strained, it grows thin, and this explains the great friability of the surface of the vessels, and the disposition to profuse hsemorrhages. The menses often become profuse even before the tumor stretches the mucous surface, because the hypertrophic mucous membrane contains correspondingly delicate vessels, and, on the other hand, the retracti(m of the vessels and the consequent closure of their openings is impeded by the firm subjacent tissue of the tumor. To Schroeder's cases of malignant degeneration of the mucous membrane in myoma, which have been mentioned by Boetticher in his dissertation (Berlin, 1884), I can add another case, which proves a great deal ; this case is one observed by me personally, the de- tails of which I hope to be able to publish soon, together with other studies. The symptoms o^ the fibro-myomata of the corpus are, of course, very various, according to the seat of the tumor and its development. Myo- mata may run their course for a long time, almost entirely without symptoms, especially if they lie intra-parietal, and are only of small size. Such a comparatively slight reaction on the general health of the patient may continue if, finally, the tumors develop toward the sero7is surface., and if the stretching of the peritoneum goes on so gradually that symptoms of irritation here do not occur. According to the tonicity of the uterus, even small subserous tumors may laave a decisive influence on the position of this organ. Larger growths give rise to all the symptoms which are occasioned at all by tumors of the lower abdomen ; they influence the neighboring organs, and disturb the digestion and the excretion of urine. If they grow up into the abdominal cavity, they give rise to traction and the well-known symptoms of pressure ; from pressure on the nerves radiating pains may arise ; from pressure on the vessels come cedema of the ex- tremities and of the external genitals. The increase ot the abdominal fluid, which often occurs in these cases, is partly a product of this pressure, partly, indeed, it originates from the irritation of the peritoneum. Further, of course, there may be false connections and adhesions with neighboring organs, and then symptoms of incarceration, such as are connected with the development of such tumors in the pelvic cavity. The suberous tnyoinata may swell at the time of menstruation, and diminish again afterwards ; the fibro-cystic tumors in particular show such a variation of size. With this, then, vary also the symptoms relating to other organs; e.g.., to the bladder. The insterstitial myomata exert a certain influence on the position of the uterus even if they are small, so that the uterus lies retroflexed when ' Schroiier, Ilandbuch, vii., 228. 202 PATHOLOGY AND THERAPEUTICS there is an interstitial myoma of the anterior wall, and vice-versa. If they grow, their surface must naturally press more or less to one side or the other, coming under the serous or mucous membranes ; then, accord- ing to the circumstances, irritations of the peritoneum, shown especially by pains, arise, or a peculiar form of disease of the mucous membrane, \vhich is not unlike the immense increase of its volume at the beginning of pregnancy. The principal symptoms are hcemorrhages and abundant discharges. The former are partly, indeed, induced by the irritation of the tumor, but partly by the fact that the vessels in the mucous membrane, which is stretched over the tumor, cannot contract at the termination of menstruation, while, moreover, as was stated above, such vessels seem more easily torn than under normal conditions. In cases oi submucous myoma., the haemorrhages also usually occur in the beginning with the type of menstruation ; thev may, however, also be atypical from the very first, and at whatever period they occur they may lead to quite extraordinary degrees of a7ice??iia. The latter is the more serious for the patient, the vnoYC gradually it reaches its climax. Then the blood loses its charac- teristic color, the red blood-corpuscles become few, the white ones seem to be enormously multiplied, the whole blood seems like a thin plum- juice, in which little masses are suspended. Frequently in these cases, with a high power I have observed, lying in the white blood-corpuscles, which are greatly preponderant in numbers, pec»iliar bodies which almost made me think of specific microbes. As soon as the submucous myomata reach a considerable size and become polypous, they begin to act on the opposite wall of the uterine cavity, and to induce contractions (pains). In some cases the pains may be entirely absent, or be only very weak, so that they may be described as pains in the sacrum ; usually they attain an extraordinary intensity. At first they come on particularly at the time of menstruation, afterwards they may become permanent. The course of me7istruation in cases of myoma is at any rate as a rule painful., be- cause the uterus at the increasing menstrual congestion can not swell equally. The discharge of blood often occurs with evacuation of great clots, which occasionally are passed in a decomposed condition. In other cases the blood flows away with little change of color. In more advanced cases haemorrhages occur also at the intermenstrual periods, and then, even if they are not permanent, they may come on with every jar of the body, every difficult defaecation, every coitus, every strong emotion. By no means always, but often enough, ^profuse secretion is discharged in the pause between the haemorrhages ; on further development of the submucous tumor, the secretions acquire an admixture of blood, until finally they consist essentially of blood. OF THE DISEASES OF WOMEN. 263 The myotnata of the cervix are constantly complicated with severe affections of the mucous membrane. In these also the menses are, as a rule, very profuse ; apart from the latter, however, haemorrhages usually only occur on sufficient irritation, such as coitus, awkward vaginal injec- tions, or evacuation of hard faeces. Dysmenorrhoca is the rule also in these ; they also may swell with every menstruation, and then shrink again afterwards. All forms of fibro-myomata offer a very effective impediment to the occurrence oi coitception^ — the subserous the least, and the submucous the most. By no means, however, do they always and certainly exclude con- ception. Sometimes, when a myoma has existed for a long time, preg- nancy occurs very late, and quite unexpectedly. The gestation may also go to its normal term ; then, after a child- birth, which is usually much impeded, puerperal involution may take place in the myoma also. As a rule, when the location of the tumor is intra-mural, the uterus is likely to be incapable of developing into a receptacle for the foetus, so that abortion occurs early. However, in just this complication, the course depends entirely on the situation and size of the tumor. The symptoms^ which are occasioned by fibrous polyps, are often almost latent, so long as these structui"es still lie at the level of the sur- rounding raucous membrane. Even when such polyps have become quite large, the only essential symptoms are profuse secretions and haemorrhages, besides an annoying feeling of fulness in the hypogastrium, and bearing down. As soon, however, as the polyps, owing to their size, cause ex- pulsive pains, the suffering connected with the latter becomes very intense ; they lead, occasionally, very quickly to a dilatation of the cervical canal, so that this stage, as a rule, gives notice of an approaching extrusion. It is necessary to do more than mention the fact that polyps, if they become hardly larger, like all other tumors of this kind, may lead to violent symptoms of pressure. In fact, exactly like a pregnant uterus, polyps may lead to great relaxation of the vagina and vulva, or to formation of varices ; as also sufferings connected with the rectum and bladder, with all their con- sequences, may be occasioned by the pressure of the uterus, which is filled by the polyp. Such influences on the general condition of the patient are very often essentially modified by the alterations in the tumor itself, espe- cially in the case of a polyp. The latter dies to a certain extent, becomes gangrenous in consequence of insufficient nutrition, or strangulation by the internal os uteri, and then there is a putrid, stinking discharge, with fever from absorption ; in fact, under some circumstances, death follows in consequence of pyaemia. 264 PATHOLOGY AND THERAPEUTICS The course of the disease^ during the development o{ Jibromata and 7)ivoniata^ is so extremely varied in individual cases that it would be diffi- cult to <^ive a general sketch of it in a few sentences. Jf at a certain pohit iti tlicir g^roxvtJi the tumors uudcrgo involu- tion^ the whole disease mav run its course, leaving hardh' a trace. The mvomata may diminish, either by the senile climacteric involution, or by fatty softening; i.e.^ during the i^uerperium. Then, at the time of ces- sation of the disease, there comes first a pause in the growth, then shrink- ing and involution, until finally only a residue of bony hardness is left. This also may completely disappear. In other cases the cxtrjision of the tumor is originated, in one way or another, by its development. The subserous ones may shrink from obliteration of their nutrient vessels and become quite harmless structures ; the subviucous o.n<\ polypous may be expelled through the vagina without any further injurious influence. These attempts of nature at elimination must be called welcome, even when, after shorter or longer labor-pains, the tumor comes down and is expelled, either with a spontaneous involu- tion of the pedicle, or after such an exposure of the latter that it may be separated without difficulty. In the course of such an expulsion again, to be sure, many intercurrent complications may be observed, such as haemorrhages, decomposed secretions, erosion of the external genitals, or inversion of the uterine wall, especially when the tumor is inserted at the fundus. Only where the polyp is very large, orw'hen it is sloughing, would danger of deleterious constitutional reaction be connected with such an expulsion. Under what circumstances, when the nutrition of the tumor is disturbed, a simple involution occurs, and under what there is inflammation, suppuration, and sloughing, cannot be foreseen at present , it is sufficient to remember that suppuration and necrosis of a myoma is the most serious of all the various terminations of this new-growth. In fact, in consequence of a softening of the mucous membrane and of the evacuation of the products of inflammation through the cervical canal, recovery may, to be sure, yet ensue. The symptoms, however, which ac- company such an inflammation of the tumor are, as a rule, extraordinarily stormy ; and the patient, who is already weakened by profuse losses of blood and previous sufterings, is apt to jDcrish at the beginning of this change. The diagnosis of fbro-mvomata is by no means always so easy as it is occasionally, if we feel the tumor rising from the mass of the uterus, or if we feel its surface from the cervical canal : or also in case the whole mass of the uterus, permeated by larger or smaller myoma-buds and nodules, can be felt through thin abdominal walls on bimanual examina- OF THE DISEASES OF WOMEN. 265 tion. Interstitial myomata, especially when they are small, are occa- sionally very hard to recognize. They are to be diagnosticated when the enlarged uterus is felt to be thickened in certain places, and when, on passing the sound, this thickening is shown to be a circumscript, hard place in the elsewhere soft uterine wall. If the interstitial tumors grow larger, they frequently very essentially alter the shape of the uterus, although occasionally they enlarge the cor- pus, just as a pregnancy does. If the new-growths are not so extensive, and if there are several present, the uterus acquires an irregular shape, which will always permit the question to remain doubtful, whether in a given case there is a tumor present, lying outside the uterus and inti- mately conjoined with it, or whether there is one situated in the wall of the uterus itself. In just these cases, the course of the uterine canal, which may be determined by the sound, is usually of great importance. The uterus is almost always elongated by the myoma ; genei'ally, when the latter is situ- ated interstitially and is even of moderate size, the uterine cavity is pushed to one side, and, if the sound has been introduced with some difficulty, it is then possible on bimanual examination to determine the form and position of the new-growth between the extremity of the sound and the external hand. The very fact of distortion of the uterine canal is of great diagnostic importance for these cases. The diagnosis between myomata and fibromata, on the one hand, and a normal pregnancy., on the other, is, as a rule, made certain by the changes peculiar to pregnancy. But precisely in cases of myoma, symp- toms frequently occur which lead to great embarrassment, especially if the history of the case gives no grounds for an opinion concerning pregnancy. All attempts to make sure of the existence of pregnancy, in these cases, involve a decided danger of interrupting the latter. Form and consist- ency are not sufficient in these cases ; neither is the color of the cervix, nor the pulsation of the vessels in the vault of the vagina. Moreover, the diagnosis is frequently made more difficult by irregularity of menstru- ation. In such cases observation of the growing mass is of the greatest importance ; when life is in danger, direct palpation of the uterine con- tents must be enforced ; this usually occurs in cases of severe hicmorrhage, and here it is, indeed, of comparatively little importance what the nature of the contents of the uterus may be ; when antemia threatens lite, the uterus must be emptied, whether it contains an ovum or a new-growth. The diagnosis of subserous myoma is comparatively easy when the tumor is small. Often there may be difficulty in determining which of the various nodular structures is, the uterine body, and which the uterine 266 PATHOLOGY AND THERAPEUTICS myoma. In such cases the sound decides. The difFerential diagnosis in regard to the intra-peritoneal tumors, the ovarian tumors, exudates, and htematomata, may, under some circumstances, be extraordinarily difficult, especially if extensive adhesions liave developed as a result of former inflammations, and if new attacks have then occurred. On this account the diagnosis may be quite impossible. Nev'ertheless, according to my experience in such cases, palpation under anaesthesia and the use of the sound are of such very essential assistance that the diagnosis can be established, at least as a rule. If vv^e reflect that in a great many cases of this kind the conditions are so complicated that at the autopsy it is diffi- cult to distinguish between them, we must console ourselves if we have occasionally made a diagnostic error during life. Only in case of fibro- cystic tumors could anything be expected from puncture ; at any rate, it Avould involve danger of decomposition, or of haemorrhage, and it would also not always lead immediately to a clearer diagnosis. Submucous myo7nata may very easily be mistaken for pregnancy, especially also for retention of portions of the ovum, and for simple chronic metritis and endometritis. If the history in such cases gives no information, nothing remains to do except a direct palpation, and, if neces- sary, a diagnostic curettement. There is a peculiar form of suppurative disintegration of small sub- mucous myomata in elderly women ; thus I have lately seen in rapid succession three women — 52, 54, and 61 years old — in whom the menses returned, with little pain, after a pause of many years, during which it was said that no secretion from the uterus had occurred. The kind of haemorrhage and the bad odor of the blood discharged seemed to distinctly indicate carcinoma, while the microscopic exami- nation showed that it was merely a case of suppurating moma-buds. The three women recovered without fever, and apparently completely. The cervical myoniata are usually felt very easily by the examining finger, through the os uteri or in the vagina ; it may, however, be very dif- ficult to find the uterus around and beyond these tumors, and to establish the relations of the tumor to the corpus. Here, however, an examination under anaesthesia, with a little patience, usually leads to a successful result. The polyps^ as long as they are small and situated in the uterine cavity, may offer the greatest possible difficulties to diagnosis. Their presence will be often suspected and only hypertrophic masses found, while, where other symptoms only point to an endometritis, polypous growths will occasionally also be discovered. In such cases, by the curettement of the uterus^ information is also obtained concerning the polypous proliferation of the mucous membrane, while during this opera- OF THE DISEASES OF WOMEN. 367 tion the presence ev^en of a larger structure is demonstrated, which may be projecting into the uterine cavity like a polyp. If the polyp is felt with the finger, or if its pedicle is circumscribed with the sound, there can hai"dly be any further doubt as to the diagnosis, especially if the structure is examined with the finger or the sound or by twisting it round several times with a bullet- forceps. When the polyps are larger, they generally press down into the vagina, or they lie in the os uteri in such a manner that they can hardly escape a thorough and cirxumspect examination. It only remains doubtful whether the polyp consists of outgrowths from the mucous membrane, or whether it contains a fibrous or myomatous nucleus, more or less fully developed. If the po/vps slough at the extremity, and then become completely gangrenous, through thrombosis of the places constricted by the os uteri, there is a possibility of confusion with malignant degeneration, which can only be settled by the microscope. It has been advised, when the presence of polyps is suspected, to ex- amine during the menstrual period, because at the time of the menstrual congestion the polyps often come down and are pushed outwards. I have only once succeeded in demonstrating the presence of a polyp in this manner, if I exclude the cases in which I examined during continuous haemorrhage, and was then able to distinctively observe the presence of the polyps during the latter. In case of polyps of large size, especially if they have developed from submucous myomata, great caution must be used to determine in how far they may invert and draw down with themselves the uterine wall, especially the fundus. The differential diagnosis between polyps, with their further developments, and inversion of the uterine wall is stated by authors to be particularly easy by means of the sound. I should think, however, that the sound would readily give occasion for errors in inex- perienced hands, and I have had practical experience of several such. I con- sider it better in such cases, b}' bimanual examination, under anaesthesia, to search out the uterine body, and, if necessary, to make out the inversion funnel b}^ touch, either from the abdominal sui"face or from the rectum. The prognosis of myofnata is doubtless not f such a nature that direct danger to life is occasioned by the majority of them. If, however, some authors go so far as to assert that myomata are entirelv benign, in the sense that they never lead to death, I hold such an opinion to be en- tirely inaccurate ; for wherever myomata mav be situated, and whatever their size may be, they occasion often enough, if not always, very violent suflerings, especially very threatening haemorrhages. If these hiemor- rhages persist, and lead to such a degree of anaemia as I have often seen, it hardly requires an additional observation, where a woman bleeds directly 268 PATHOLOGY AND THERAPEUTICS to death, as I liave also seen happen, in order to make the benignity of myomata seem thoroiighlv ilhisory in this respect. These women, how- ever, perisli from the suspension of their power of resistance to the injurious influences of daily life, much more frequently than from the incessant htemorrhages and the anaemia resulting therefrom. Their circulatory apparatus becomes insufficient (as E. Rose^ was lately able to prove from a long series of observations) , so that the patients are disposed to throm- boses, as I must conclude from several of my own cases. The nutrition of such patients ceases entirely ; little affections of the mucous membrane, slight diseases of the bronchi or of the intestinal canal, are so serious for such patients, that they occasion the death of the woman afflicted with a myoma. Disease of the myomata themselves, which is apparently not frequent, and their malignant degeneration will be further emphasized below. It is a justifiable question, how'evcr, whether we ought to de- termine our prognosis only according to the greater or less degree of mortality, or whether we must take into account the, in this connection, vitality of the patient, her ability to earn her livings and finally, also, the possibility of her leading aft endurable life ', and from this standpoint, emphasizing the ability to work and enjoyment of life, the prognosis of myomata is itiidoubtedly unfavorable under an absolutely expectant treatm,ent. If the sufferings are considerable, either from aniemia or from secretion or from symptoms of pressure, when such new-growths are present, we are fully justified in interfering. The interference itself must, of course, be such as is appropriate to the magnitude of the suffering which is occasioned by the new -growth, and may be determined accord- ing to the same. On the other hand, the prognosis of myomata must be stated to be favorable, in so far as their removal is accomplished, always with greater safety, owing to the increasing perfection of technique. At the meeting of the German Gyaencological Society in iSSS I have reported the results of a study of two hundred and five cases of myoma of the uterine body, which I have removed by operation, not counting among these the cases in which I have only observed the myoma clinically and treated it medically, nor the cases of cervical myomata, nor yet the cases in which I found a myoma at the autopsy, — such, for example, as the case of fatty degeneration of a myoma in a puerpera, which I described in 1873, and which has been so often quoted. In col- lating these two hundred and five cases I will not yet report the final conclusions here ; I will limit myself to relating the results of a histo- logical studv of the specimens in question. ' Deutsche Zeitschr. f. Chirug., xix., Bd. i. II. Dolim, Zeitschr. f. Gcb. u. Gyn., xi., S. 136. OF THE DISEASES OF WOMEN. 269 In the first seventy cases I have not observed any striking alterations except the processes of involution and transformation of tissue which accompany the menopause ; afterwards, however, the specimens showed an extraordinary variety in this respect. First, the cases were noticeable in which the processes of fatty degeneration were prominent, sometimes in small, isolated foci, sometimes as fatty degeneration of whole nodules, so that they were in fact cases of liquefaction, such as I have described in a puerperal woman, in 1873.1 These conditions of fatty degeneration are certainly to be considered as one of the favorable terminations of this whole pathological new-for- mation. Seven times I have had occasion to observe very extensive fatty degeneration of large myomata ; that is, of cases where the whole tumor seemed more or less permeated by it, so that an advanced stage of involu- tion was present. Allied to these are three cases, in which the myomata were in the stage of calcification ; these calcifications were in some cases noticeably limited merely to the surface of the tumor, and this was pai- ticularly striking in the case of an old lady who carried such a calcified myoma which was pediculated ; it was situated on the upper part of the uterus, and necessitated an operation, owing to the extraordinary sufferings which the woman was enduring. There were, however, among these no such large myomata as are recorded in several instances. My cases had induced the most important clinical symptoms, owing to the effects of pressure, and had thereby made their removal advisable. Quite different were the ten cases in which, suppurative processes were present ; and this occurred not only in such myomata as lay close under the mucous membrane, intra-parietally, and having caused atrophy of the former had thus come in contact with the micro-organisms of the cervical canal and of the vagina, or had been exposed to the entrance of the latter by a lesion caused by examination or by treatment ; but there were also cases among them, where the myomata lay completely embed- ded, evidently far from the uterine cavity, laterally ; there were even some which were on pedicles and entirely outside of the whole corpus uteri. The suppurative processes were observed in various stages of develop- ment ; in some, — and these were particularly the cases of suppuration of myomata which were embedded intra-parietally, — there was a purulent infiltration of the whole tumor ; in others, decomposition had evidently occurred only at the end of the myoma. But there were also some cases among them where the whole myoma, transformed into a great suppurat- ing mass, had perforated the serous coat, so as to invade the abdominal 1 Beitr. ziir Geb. u. Gyn. v. d. Berlin, gebuitshilflich. Gesell., Bd. ii. 270 PATHOLOGY AND THERAPEUTJCS cavity, and here had led to adhesions with the sacrum and with the neighboring abdominal viscera. Laparotomy was then only a last attempt to save the septic jDatients, — an attempt which, however, did not result favorably. Beside these ten cases of suppuration, I have eleven times seen exten- sive formation of oedema in the myoma. This condition, which is to be considered as a result of a stagnant circulation, was generally in extraor- dinarily anaemic women, who were reduced by prolonged haemorrhages. The tumor, as a rule, shook peculiarly when struck, like jelly. When cut across, a peculiar serous infiltration was noticeable ; it seemed as if the serum lay in preformed spaces. We have not succeeded in find- ing ectatic lymph spaces, and we could only determine that there was an intense and marked development of collections of serous fluid. Just this condition appeared to be associated with quite peculiarly profuse hsemor- rhages, or perhaps it was a consequence of tlie latter ; at any rate, the patients who had such myomata had been sufferers from extraordinarily profuse attacks of bleeding, and it had not been possible to stop or to essentially limit the latter by any kind of treatment. Beside these (Edematous myomata, I have eight times found cystic ones ; these were, in part, cases in which w^e found in the middle of the tumor great knobs of stony hardness, or several larger or smaller cysts ; in part, cases in which, between these cystic transformations, one great knob was found, up to the size of a man's head, while beside this there were others, which were relatively small, or showed the usual formation of these struc- tures. These cystic transformations then led either to the development of very large spaces, which it had been possible to recognize even before the operation, or they were first found after the operation was finished, when the tumor was split open. In these spaces we found a yellowish, strongly albuminous fluid, but we have not succeeded in demonstrating, in all the spaces, an equal and decided distention ; in fact, in some cases we have sought for this in vain, while in others, especially in small ones, a pave- ment epithelium could be demonstrated, which had undergone partial fatty degeneration. Three times the myomata were teleangiectatic to a marked ilegree. All three were very large tumors : one was attached by a pedicle to the fundus ; both the others comprised the whole body of the uterus. These teleangiectatic tumors contained spaces consisting of dilated vessels, which varied in size from that of a grain of millet to that of a walnut ; the tissue lying between these cysts was permeated by capillary vessels ; in the spaces themselves great masses of clots were found ; in some there was blood yet fluid. Just this form seemed to me to be highly worthy of OF THE DISEASES OF WOMEN. 271 notice in regard to its relations to the vascular system, in view of the dis- position to thrombosis and embolism. It happened also that one of the patients, on the 26th day, after I had let her get up with great caution, sank dying in my arms from embolism at the moment when I was going to send her home. These processes are such as have run their course in the tumor itself, and perhaps belong more or less to the peculiarities of this kind of growth ; but I have, in six cases., had occasion to demonstrate the fo?'mation of sarcoma in myomata of the corpus. Twice there was that form of fibroid sarcoma which has been described by Schroeder and Gusserow in which no formation of capsule can be shown, where there is a sort of pedicle, and the whole tumor consists of sarcomatous masses. In four cases the sarcomatous degeneration of the myoma could be shown directly. These were tumors which were distinctly encapsulated. They were allied to the cases referred to by Gusserow in his last edition, of which the most striking was the one described by Winckel. They usually lay submucous, but sometimes also, as my cases showed, intra-peritoneally. Two were distinguished by the fact that their capsules had been ruptured, and that metastases had developed. It was further noticeable that two of these patients, after they had been freed from these myosarcomata, had relapses of general sarcomatous degeneration, which led to the death of one of them in seven weeks, and of the other in four months, after the opera- tions. This sarcomatous degeneration seems to me to be more worthy of attention, from the fact that in all these cases the patients had been for a long time under treatment, and especially in these cases ergotine had been employed very extensively. In them the abnormal haemorrhage had been completely overcome ; the tumors themselves, after an apparent reduction of their volume in the beginning, could not be restrained in their trans- formation. Turning now to the complication of myoma with carcinoma, I am not in a position to present and demonstrate a specimen of the destruction of a myoma by carcinoma. All investigations directed to this point, like those formerly made b}' others, have been completely unsuccessful. Although the opinion was formerly entertained that carcinomata and myomata do not occur together, this proposition has been disproved long ago. The question seems to me, however, illustrated in yet another direction by the material at hand. I have in nine cases had occasion to observe the complication of myoma with carcinoma, and among the nine there were only two cases of cervical carcinoma or of cancroid of the vaginal portion ; in the other seven cases of extensive cancer of the mucous membrane of the corpus, 272 PATHOLOGY AND THERAPEUTICS the carcinoma had In sonic cases extended entirely in the cavity of the uterus, without standing in any demonstrable relation or connection with the mvoma. In other cases the myoma itself had been implicated in tiie degeneration. T am bv no n^.eans of the opinion that any conclusion is warranted from these cases alone. It has seemed to me. however, worthy of notice that these observations on the last hundred of my cases have not only shattered the old maxim of the immunity from carcinoma of patients with myomata, but also the belief that it is very rare for carci- noma and myoma to occur simultaneously. Of the two hundred and five myomata of the corpus, therefore, only ten showed pronounced conditions of involution ; thirty-two were under- going a transformation which must be designated as very serious for the women afflicted with them, six were in malignant degeneration, and nine showed a fateful complication with carcinoma. If we leave the latter cases out of consideration, as being " accidental complications," the fact remains that yet thirty-eight out of one hundred and nuiety-six (205 less 9), or out of one hundred and eighty-six (if we subtract the cases of involution of the tumor), thirty-eight, that is, 20t^ per cent., showed changes which certainly represented the opposite of that which is called ' ' benigti . " Of course, the question of the treatment of a myoma only comes up when the tumor has given rise to symptoms, and even then it depends essentially on how far these symptoms threaten the life of the patient, or impede her ability to earn her living or to perform her conjugal duties. The only treatment which has a certain result is that aimed at the com- plete removal of the tumor. Since, however, such a radical treatment is, even at present, surrounded by many difficulties, the operative treat- ment only comes into question at once in a limited number of cases, while in a greater number it is certainly justifiable — in fact it is a duty — to make always an attempt to stop the increase of the new-growths, or to bring about their involution, as far as experience shows this to be possible. In this last respect all the various attempts to exert an influence on the tumors by the administration of arsenic, phosphorus, or potassic iodide, by the use of mercurial or starvation cures, and by other similar means, have given far less favorable results than the long-continued use of mineral springs containing iodine, such as Kreuznach, Tolz, Hall in Upper Austria, Salzbrunn, from which such favorable reports are sent by the physicians of the baths. In my practice, up to the present time, I have seen only isolated and very limited successes from such treatment bv courses at baths. The injections with ergotine, wdiich Hildebkandt has OF THE DISEASES OF WOMEN. 273 recommended in 1873/ enjoy more confidence. By the ergotine the ves- sels of the uterus are said to be made to contract, and, by the anaemia or disturbance of nutrition thus induced, the fatty degeneration and shrink- age of the myoma are said to be brought about. Not only Hildebrandt himself, but a whole array of authors have obtained quite evident results with these ergotine injections ; so that no doubt can prevail concerning the possibility of bringing about involution of myomata in this way. Since, however, in a likewise considerable number of cases failures stand in sharp contrast to these results, it must certainly be supposed that success can be attained by ergotine injections only in a quite definite sort of myomatous formation. It is probably in the richly vascularized tumors of small dimensions that complete shrink- age is obtained under the long-continued use of ergotine. In some seventy myomata, part of which I treated myself with ergotine, and part of which came under my obsei"vation after they had been treated for long periods with ergotine by others, I have myself not met with sucl:i results.- I will not, on this account, reject the attempt to combat myomata with ergotine injections, since I know of cases in which, to be sure, a radical cure was not accomplished, but yet a cessation of the hsemorrhages, if only tem- porary, was obtained. This is, in fact, a great gain in such cases, where the tumors are still small, or where the ability of the individual to enjoy life and earn a living is not completely suspended. I therefore recom- mend the employment of such ergotine injections in cases where the tumor is still in the early stages of its development, is of a soft consistency, and at the time only causes moderate symptoms. In order to obtain any results whatever with injections of ergotine, it is necessary to continue their use for a very long time. If more than one hundred injections have not restrained the growth of the tumor, if the sufferings are only increas- ing instead of diminishing, I would certainly advise against any continua- tion of the ergotine treatment, and recommend the operative treatment of the tumor as the only certain one. In using injections of ergotine it is of the first importance to employ a suitable preparation. The solution of Bonjean, as far as I have ob- served, causes violent pains, is readily decomposed, and very frequently gives rise to abscesses. Of all the various preparations, I have found the best to be the dotiblv purified ergotine^ and the solution of Bombelon. This last preparation 1 Berl. klin. Wochenschr. Nr. 25. Sec Schroder, Text-book, vii., S. 246. Delore (Gazette hcbd. 1S77, N''- '^) a^nd Schiickinff advise making- the injection of ergotine into the tumor itself. 2 Compare yiigcr, D., i., Berlin, 1876. '^Wernich, Berlin klin. Wochenschr., 1S74, Nr. 13. 274 PATHOLOGY AND THERAPEUTICS is very little injurious in its secondary effects, and I therefore prefer to use it, although its composition is a secret of the manufacturer. A gramme of it is to be injected each time. The doubly purified ergotine is employed in the dose of o. i (i^ v(\^ ) in a lo per cent, solution. These injections are made in the skin of the abdomen, concentrically around the navel. The patient remains lying down for a half-hour after the injection, the place of puncture is covered with a cold-water compress, and it is observed how the absorption of the solution which has been injected goes on ; and in general how the patient endures this kind of injection. Sometimes very evident contractions of the uterus occur ; in other cases, the pains at the point of injection preponderate. Myomata are often diagnosticated before they have occasioned such very severe symptoms. Then it is important, in so far as an attempt with ergotine cannot or need not be made, at least to treat the symptoms, and especially the most prominent among them, — the hconorrhages. These come under consideration, practically, onh" in cases of submucous tumors, very much more seldom in interstitial tumors, constantly in all kinds of cervical myomata. In these cases the haemostatics,^ which otherwise have proved valuable often, are inefficacious ; neither absolute rest nor cold employed externally nor the well-known vaginal injections are of permanent value. The only thing remaining to do is to bring the styptic fluids on to the bleeding places ; that is, to the mucous membrane investing the myoma. Among the fluids which can be used for this purpose, the liq. ferri ses- quichlorati and the tincture of iodine stand first ; such injections can also be occasionally made with acetum pyrolignosum. It depends on the passibility of the uterine canal whether or not it is necessary to dilate the latter before the injection. For this it is always necessary that the uterine cavity be readily accessible, in order that coagula may not stagnate behind any constriction, and, instead of permitting recovery, act as foreign bodies, exciting contractions and thereby hcEmorrhages and pains. The dilatation can be made with appropriate instruments, or also with sounds or similar blunt apparatus. The excess of fluid injected is to be washed out with the long-pointed nozzle of an irrigator. In cases of obstinate hcefnorrhage^ in which this treatment has been of no service, it has been proposed to sear the mucous membrane by the actual cautery, either with the porcelain burner or with the Paquelin. I have made no extended trials of this method ; the results were too little » The observations concerning; the action of fluid extract of Hydrastis Canadensis (fifteen drops to be taken four times daily) in cases of myoma are not yet completed; they seem, however, to he not unfavorable. OF THE DISEASES OF WOMEN. 275 satisfactory. I have, however, employed another means occasionally, which was recommended long ago for such cases ; namely, the incision of the mucous membrane over the myoma. ^ If we appreciate the fact that the mucous membrane which is stretched over the myoma, and which is already inflamed, is under great tension, and that its vessels cannot retract, we must see that the relief of the ten- sion of this mucous membrane is a means of stopping the haemorrhage, for now the vessels in the mucous membrane can retract. I have also occasionally succeeded in controlling the hsemorrhage in this way. In fact, spontaneous recovery may be induced by this incision, as is occasionally very distinctly indicated by the further course of the devel- opment of the tumor, and by its occasionally occurring immediately after such incisions ; as a rule, namely, after the incision contractions of the uterus occur, which force the myoma into the slit in the mucous mem- brane ; by its further growth and by these contractions it may gradually be extruded through this slit. It would, however, be very rash to reckon on this extrusion with so much certainty as to be contented with this simple splitting of the mucous membrane in pressing cases. Another proposition for stopping the heemorrhage is to scrape off the mucous mem- brane with sharp or dull curettes. This procedure, also, sometimes brings relief for the moment, and may be recommended for the removal of a haemorrhage which is at the moment threatening. Very recently a whole literature has arisen concerning the results of the electrolytic treatment of myomata.- I have at my disposition no per- sonal observations of this method of treating myomata ; but, while v. Rabenau was assistant at my institution, I made with him very thorough electrolytic experiments in cases of carcinoma. The utter want of success of the latter has deterred me from further experiments. If the above-7nentioned measures, when tised again at every co?i- siderable hcemorrhage, are effectual, if the sifferings are thereby diminished or overcome, if the new-growth occasiotis no symptoins o_f pressure, or if the general condition strictly contra-indicates all further attempts at a radical treatment, an expectant attitude seems entirely Justifiable. This is by so much the more the case if the patient is v>'ell advanced in life, and, therefore, the menopause may soon be expected. On the other hand, however, there is an accumulation of obsen-ations of extensive disturbances under the influence of alterations in tlie tumor 1 Amussat, M^m. s. I'anatomie des tumeures fibr., 1S42. Ailee, Amer. Journ. of Med. Sci., April, 1845, October, 1S56. Spiegelherg , Arch. f. Gyn., v. i, H. Gussero-o, Monatschr. f. Geb., xxii., S. S3, u. d. Neubildungen des Uterus, 7S-S6. 2 Aposioli, Acad, de Sc, Paris, 1SS4, xcix., 177. Internat. Med. Congress in Copenhagen. Zzvei- fel, Centralbl. f. Gyn., 1SS4, Nr. 50. Bayer, Zeitschr. f. Geb. u. Gyn. xi., S. 132. 276 PATHOLOGY AND THERAPEUTICS itself; there are the immediate consequences of the growth of a great tumor, and of continual loss of blood, the reaction on the heart, the diges- tion, and the nervous system, etc., and also the consequences of malignant degeneration of the myomata, so that it must be well considered how far it is right to wait. At any rate, myomata do not belong altogether to the benignant tumors. Matthews Duxcax, in his expression, at the Inter- national Medical Congress at London, in 1S81, that no one dies of a fibro- myoma, must have quite neglected the experiences of others. The more observations we collect, the more doubtful is the prognosis of the tumors themselves. On the other hand, the more we develop our technique, the better we succeed in the extirpation of the tumor ; this loses more and more the serious character of an operation which is fatal in the majority of cases, and, therefore, it is to be employed by so much earlier. The great difficulties which occasionally accompany the ablation of myomata and the hitherto rather unfavorable results of this operation have given rise to the idea of accomplishing indirectly that which is occasionally seen to occur at the normal climacteric ; viz., the Involution of the tumor. From this point of view Hegar first attempted to induce the premature change of life by the extirpation of the ovaries even when not diseased, and has proposed the castration of women, on the ground of theoretic dis- cussions and of extensive experience.^ In consequence of this, and of the similar proposition of Battey, a great number of castrations have been performed, and that, too, with a preponderance of fortunate results, ac- cording to the reports of the latter which have been published, often, to be sure, quite prematurely. On account of the above indications, I have myself performed castra- tion seven times already, in each case after every other mode of treatment had failed. In the first case the menses ceased immediately, and at first there was an involution of the tumor ; then the latter swelled at times temporarily, diminishing by and by under the use of salines, so that the lady, who was operated on over seven years ago, states that she has been well since three years. The second patient lost her menses at once, and a very distinct shrinkage of her myoma could be perceived. This patient is also now in the seventh year since the operation, and at very long inter- vals (five to seven months) she has profuse haemorrhages, partly from the uterus, partly from the rectum, the bladder, or the stomach, but no menses : other difficulties, having no connection with this, keep the patient under continuous medical treatment. In three other cases the 1 Compare the Uteratnre and history in Hegar and Kaltenbach, ed. iii. Also under the article "Castration," in Eulenburg's Real-Encyclopxdia, ed. ii., by A. Martin ; compare the closing chapter of tliis book. OF THE DISEASES OF WOMEN. 277 menstruation has returned from one to three times, the tumors have under- gone involution, and after the patients overcame the symptoms of the cHmacteric, which occurred with great violence, such as congestions, headaches, palpitations of the heart, swelling of the legs and of the face, etc., the results in their cases also were satisfactory. The last patient but one of this kind was seen again by me a year after the operation, and I was able to establish the fact that the tumor had undergone a thorough involution while the patient had been in good health otherwise. It is too early as yet to determine the final result in the last two patients. My own experience, therefore, speaks in favor of castration in cases of myoma. I consider the number of my cases, however, as yet too small for deducing stable conclusions from them, and I hesitate still more to do so since I have not observed the occurrence of a similar involution of the uterus after castration for other causes ; in these cases I have finally had to resort to extirpation of the uterus itself in order to put an end to profuse heemor- rhages which threatened life. I would then recommend castration as an operation not usually very difficult in cases where the extirpation of the tumor itself cannot be attempted. The latter operation seems to me to be always more radical and more certain, and in this the ovaries of course must also be removed, since leaving them is of no use, but involves various dangers, especially those of haemorrhage and of degeneration. T'ke Operative Treatment of Myomata. The tumors may be attacked in various ways, according to their situation and their development, as above. 1. In cases of cervical myomata (if they are not too large, and have not developed as subserous tumors into the floor of the pelvis) , and in cases of fnyomata of the corpus., which have become polypous or have grown quite close under the mucous membrane, and have led to a dilatation of the OS uteri, when they are of moderate size., extirpation is to be under- taken yrc;;? the vagina. 2. If the location of the tu7nor is subserous or intra-parietal., or if its volume is so great that a removal of it throtigh the vagina is only possible by very violent stretching., or even tearing, of the latter., and is thus associated with severe injuries of these parts., consequently ifi the majority of myo7nata of the corpus., I consider the operation through an abdominal incisio?i to be the best and safest. I . The attack from the vagina of course depends on the part of the genital canal in which the tumor is situated. If the latter has already come down into the vagina, it often requires only energetic traction in order to 27S PATHOLOGY AND THERAPEUTICS twist ofVoi- to tear off the pedicle, which is often very slender, and tlien to deliver the tumor. In other cases the connection of the pedicle cannot be separated so easily, and the extirpation of the tumor is on this account rendered essentially more difficult. It may then cause enormous diffi- culties to try to get beyond the tumor to the pedicle and to sever the latter. For these cases the ecraseur will always be a very convenient instru- ment, although some prefer the galvano-caiistic loop. In every case of this kind, however, it is to be emphatically recommended to obtain infor- mation before the operation concerning the relations of the tumor to the uterine wall. This may often be very difficult, so that a clear idea is only obtained with trouble : anaesthesia, pulling down the tumor with hooks, introduction of several fingers into the vagina or rectum, and such expe- dients, are sometimes unavoidable. Otherwise the danger would be too easily incurred of separating the inverted uterine body, or some other structure, at the same time with the pedicle, and then getting a haemor- rhage which would often be controllable only after a very difficult and tedious process of drawing out the tumor. The larger the tumor the more difficult is its extraction. Often enough, in such cases, it is neces- sary to use obstetric forceps, or the tumor is seized with the cephalo- tripter. Perhaps it is better to diminish the large tumors by excision, within the vagina itself, of as large pieces as possible ; in this case, as far as my experience goes, severe haemorrhage is hardly to be expected, and no danger is incurred of seriously injuring the vagina and the entrance. I will, however, not omit to mention here the fact that after such difficult operations for the extraction of tumors or polyps, the results as to recovery are less certain than would be expected. I have in some cases observed myself, and in others I have seen in the practice of other surgeons, that these women who are always very aenemic, are extremely liable to collapse, and become septic and perish, partly under the influence of extensive injuries in the vagina and uterus. If the pedicle of the tumor is accessible, I have, during the last few years, ligated it deep in behind the tumor, sometimes after transfixing it and sometimes without previous transfixion. Of course, the method by- transfixion is by far safer, for after the ablation of the tumor, the pedicle is very apt to slip back, and then we must avoid trying to hold, by the ligature, the pedicle, which has been only tied around. Finally, I have seized the stump of the pedicle with the bullet-forceps, held it fast, and then, after ablation of the tumor, I have transfixed it with ease, and thereby tied it securely. If the tumor, which is accessible from the vagina, is still covered by a more or less thick layer of mucous membrane, or by a yet thicker cap- OF THE DISEASES OF WOMEN. 279 sule, this must first be incised. If the tumor lies in the cervix, there is little trouble in doing it; if it is situated higher up, such an incision may- cause great difficulty. The slit in the mucous membrane, as a rule, gapes widely apart, and the finger can be introduced between the tumor and its bed, the very loose connection can be separated, and if the slit has been made long enough, the tumor thus enucleated can be extracted by means of strong forceps. There remains then a great cavity, which, however, con- tracts rapidly. Such an enucleatioit • of intra-parietal myomata of the corpus is not, as a rule, immoderately difficult in case of tumors which are situated very low down. It only becomes so if the tumor is situated in the corpus itself ;y(?r these cases I have e?nphatically 7-ecommended only to attempt enucleation from below., if pains have already been excited by the further development of the tumor., and if by these con- tractions the way has been, prepared for the enucleation of the ttitnor., and if the latter has itself been pressed against the internal os uteri. In fact, I should like to go further in this respect, and only recommend the enucleation from below of such a tumor, if the uterine contractions are pressing the latter downwards, and have already led to a dilatation of the cei-vical canal, so that the process of birth will be completed by the inci- sion of the mucous membrane and the enucleation after the real extrusion has already proceeded to a certain point spontaneously. I have acciden- tally, in the very beginning of my gynaecological operative activity, had oc- casion to operate on a great number of such tumors, and finally came to the conclusion that this way is only preferable to laparotomy, and to the other methods which are to be considered here, in case the tumor is already pressed down by violent uterine contractions, and is conveniently acces- sible from the vagina. The enucleation of such a tumor from the depths of the uterus is a work of enormous trouble, and requires great endurance and strength on the part of the operator. Finally, there is danger in this, because in enu- cleation deep in the uterus it can be only imperfectly estimated whether the peritoneal investment of the womb is strong enough not to tear ; in other words, whether there is any security against a rupture of the uterus. In two such cases in my own experience this injury was fatal to the patients, both of whom, to be sure, came under treatment in a desperate condition of anaemia. I have enucleated large myomata, after division of the capsule, twenty-seven times. I have reported the first five cases in ^ Amussai, Revue med., Aout, 1S40, and Memoire, 1S43. Hegar, Virchozv's Arch., 1S69. Aftznnel, Prager Vierteljahrsch, 1S74, ii., 24. A. Mariiti, Breslauer Naturforscherversammlung', 1S74, und Zeitschr. f. Geb. u. Frauenkrankheiten, 1S76. Frankenli'duser , Correspondenzbl. schweiz. Aerzte, 1S74. Jakubasch, Charite-Annalen, iSSi. Lomer, Zeitschr. f. Geb. u. Gyn., ix., S. 277. 2So . PATHOLOGY AND THERAPEUTICS 1874, in Brcslau, at the meeting of the Investigators of Natural Science. Of the twenty-seven, there died five: two perished from the injury of the peritonaeum ; two (Hed septic before the era of antisepsis ; one died in col- lapse. Once I enucleated the ball of new-growth out of the corpus imme- diately post partum. / have abandoned this kind of vaginal enucleatio)i in all cases where the tumor is very large and is in the corpus, even if it is half born. In the summer of 18S6 I caused an example of a case of this kind to be published by Dr. Nagel ; ^ the great tumor was extracted from above, after laparotomy and incision of the uterus ; its bed was cleansed, the uterus sutured ; the union and involution of the uterus proceeded in a thoroughly satisfactory manner. - I have not observed serious htemorrhages after enucleation in my cases. The great bed of the tumor in the corpus collapses, its covering of mucous membrane becomes adherent or is cast off as a slough. In enucleations in the cervix, I have indeed resected the wall of the capsule so far that by sewing the remainder together I could avoid any formation of pockets in the depths of the wound. Moreover, all these operations are to be made under continuous irrigation ; if necessary, the cavity is to be again thoroughly disinfected with a concentrated solution, and perhaps drained also, and thus the result can be made certain. 2. Myotomy . After a long series of attempts to extirpate ^ myomata from the abdom- inal cavity, with varying results, Pean " has first given a secure foundation to the operation, by the successive removal of portions of the tumor, which had been constricted one after the other ; this method was comparatively free from haemorrhage, and was the first to give acceptable results. By it, however, the stump had to be treated extra-peritoneally, and the method itself was too difficult in execution. A typical procedure of this kind was first elaborated by Schroeder,* who, under the protection of a thorough- going antisepsis, and using the constriction with india-rubber tubing, which was first employed and recommended in myoma operations by me,* per- 1 Centralbl. f. Gyn., July, Nr. 31. 2 Compare also Hager^ Centralbl. f. Gyn., 1S86, Nr. 40. 3 Koberle, Gaz. indd. de Strasbourg, 1S64. * Pi-an et Urdy, Hystdrotomie, Paris, 1S73. •'• Zeitschr. f. Geb. u. Gyn., viii., S. 141, und x., S. 156. " Naturforscherversammlung- in Cassel, 1878. The first operation performed with it (Frau Mar- tin, wife of a street-sweeper, twenty-seven, vii. 1S7S, in the attic where the patient lived) was almost without hsimorrhage. The patient died septic. The stump was found at Ihc autopsy uniting well. Schroder mentions Kleeberg as the author of this method of constriction. Kleeberg, however, only drew rubber strings through the tumor in place of the wires of Pi-an, while I introduced the constric- tion on the principle of the rubber tuba of Esmarch. OF THE DISEASES OF WOMEN. 281 formed the removal of the tumors and the formation of a proper stump with great success, and by the intra-peritoneal treatment of the stump raised the operation for myoma approximately to the height of ovariotomy, although the results of the two operations did not become quite equal. The ditl'erence was certainly in part owing to the severe disturbances of the general system, which occur as a consequence of the haemorrhages. In part it may be due to the operation itself, which invades so vascular an organ ; or, on the other hand, to the difficulty, in view of the communica- tion with the vagina, of securing the entire exclusion of the germs of de- composition. At any rate, the method of suturing the stump and treating it internally must seem to be the basis of the further development of the operation. Hegar and Kaltenbach, it is true, in the new edition of their book, still support the extra-peritoneal treatment ; but they acknowl- edge that the intra-peritoneal method in itself is better, just as the operation with the displacement of elastic ligatures, which has been recoinmended by Olshausen,^ is inferior to the procedure principally employed by ScHROEDER and by myself. The operation on myoma ^ after previous laparotomy^ is performed up to the point of exposing the tumor, exactly as in ovarian tumors, with all the well-known antiseptic precautions. If the tumor is so large that it has pressed the intestines upwards, I operate without eventration of the intestines ; if coils of the latter press forward and obscure the field of oper- ation, they are eventrated and kept lying on the upper abdomen, covered with a warm, moist linen cloth. Then it depends on how the tumor has developed whether it {a.) Is situated wholly subserous^ and attached to the litems by a pedicle ; (b.) Whether it etnbraces the uterine wall itself^ and forms a laro-e tumor, so that the uterine body must be enucleated from it ; or, (c.) Whether the tumor ^ lying in the wall of the uterus^ can be peeled out of its bed there and removed entirely^ while the titer ine body can be preserved ; finally, (a?.) Whether the tumor in its developmetit has grown under the peritontBum of the pelvic floor and there extended further^ lifting up the parietal layer of the peritonce?im. (a.) In the cases of sifnple subserous development, where there is a pedicle, the operation becomes a pretty simple and very safe one. As soon as the tumor can be brought up through the abdominal wall, so that the pedicle becomes accessible, the latter is transfixed, and either the 1 Deutsche Zeitschr. f. Chirurgie, iSSi, S. 171. 2S2 PATHOLOGY AND THERAPEUTICS tumor Is cut away after a superficial ligation of the pedicle, which is afterwards secured finally at leisure, or the pedicle is excised by wedge- shaped incision, after provisional ligation of the neighboring parts in the uterine body. This incision itself is carefully sewed together to the bot- tom, after removal of the tumor. In this last method, deep sutures are Fig. 126. Amputatio uteri supra-vaginalis. The constriction is applied over the Lig. infundibulo-pelvica. first carried under the whole raw surface, and the edges of the wound are brought into intimate union ; then between these deep sutures superficial ones are inserted, which secure the most exact coaptation of the peritonaeum. This completes the operation, and the toilette of the peritonaeum, the replacement of the intestines, and the closure of the abdominal wall can be performed according to the rules established for laparotomy. If necessary, the body of the uterus may be encircled OF THE DISEASES OF WOMEN. 283 with a rubber tube temporarily, until the sutures of the bed of the pedicle are in place. Up to the present time I have had occasion to operate on twenty myomata, which were developed thus subscrously. Of these twenty Fig. 127. Amputatio uteri supra-vaginalis. On the left side the constriction is applied over the Ligam. infundibulo-pelvicum. Ovary and tube are ligated and separated. On the right the broad ligament is first tied in two places and cut betvi^een the ligatures, and then the constriction is applied. patients, fifteen recovered ; of these, thirteen were consecutive cases. Of the five who died, two were pregnant, and died in the collapse, when the ovum was expelled on the fifth and seventh day respectively after the operation ; one patient had double purulent tuberculous pyelonephritis ; two others died septic (at a time when antisepsis was not vet completely elaborated in my institution, the last in March, iSSr) ; one died in col- 284 PATHOLOGY AND THERAPEUTICS lapse, in consequence of preexistent anzemia ; four of the twenty were pregnant ; two died on expulsion of the ovum ; the third aborted and re- covered ; the fourth went on to full term.' (^.) If the corpus uteri itself is the seat of the tumor ^ and if the latter is protuberant in several places and cannot be separated from the uterine body^ the supra-vaginal amputation of the uterus must be per- formed. Pean seized the first accessible portion of the tumor between four loops of wire, cut it away, seized a new portion, which he lifted up with the first wires, and so proceeded until he reached the stump of the cervix ; the latter, with its constricting ligatures, was sewed into the abdominal wound. Much simpler than Pean's constriction is the use of Esmarch's rub- ber tubing, as I first employed it in the year 187S. In this kind of myoma the cervix becomes the pedicle ; the tissues of the broad ligaments offer no impediment to such a constriction with the rubber tube (Fig. 126). For this constriction I employ to-day also a simple rubber tube, as thick as the little finger, and I tie this under strong traction, tucking the end under the loop, since the clasps with which I am acquainted, which are meant to replace the knot, seem to me to involve a danger of cutting their way through the rubber. If the broad ligaments appear to be stretched too tightly to permit of such a constriction, these can be first ligated, in two places on each side, and cut through between the ligatures as far as the cervix, before the constrictor is applied. Fig. 127 shows this manner of applying it on the right side, on the left the tubing lies over the ligament. When the cervix uteri is secured in this manner, — and it is of no importance whatever whether or not a piece of the bladder is in- cluded under the constriction, — I split the tumor in the median line froin above, down close to the rubber tube ; the hjemorrhage is ver}- slight, only the blood of the tumor itself is discharged. On the pale surface of the incision, according to the situation of the tumor, appears the cavity of the uterus, which is cleansed and rendered harmless with a concentrated sub- limate solution. Ifmyomataand myoma-buds are scattered through the uterine tissue so abundantly' that a separate enucleation no longer aftbrds any (c) prospect of j:)reserving the body of the uterus, I proceed to the amputatio uteri supra-vaginalis . In the supra-vaginal amputation of the uterus I first divide one- half, usually the left. Before doing this I ligate very carefully the left tube and the broad ligament, as far as it can be seized above the ligature. This caution is due to the experience that the cut end of the broad liga- » Compare also Longer, Berl. klin. Wochenschr., July, iS86, Nr. 29. OF THE DISEASES OF WOMEN, 285 Fig. 128. ment is always apt to slip out from under the rubber tube. Only when the insertion of the latter on the side in question has been made secure do I cut the mass from the pedicle l^y dividing the peritona;um trans- versely about three fingers' width above the constrictor, but dissecting out the mass of the uterine body in a deep wedge, so that the point of the wedge lies only about 3 cm. (|^ in.) above the constrictor. If the cervical canal or the uterine cavity is opened, it is at once very thoroughly swabbed with a concentrated sublimate solution (yoq), then excised as far as practicable, and closed deep down by a separate cobbler's-stitch, the ends of which, cut off short, are buried at the bottom of the whole funnel-shaped excision. Only after this do I insert three to five deep sutures for closing the latter ; these are introduced into the peritonseum close above the rubber tube, and carried through from before back- ward under the whole raw sur- face, and I at once draw these deep double threads so together that the peritoneal investment wholly covers the stump. The other half of the tumor is treated in the same manner. After exactly uniting the surface of the stump and covering it with peritongeum, the edges of the latter are united closely and quite accurately by superficial sutures, which ai'e often quite numerous (Fig. 13S). In thus covering in the stump I have latterly made only the deep sutures with carbolized double silk threads. In the interstices I have usually united the peritonaeum with single silk threads, occasionally also with juniper catgut, using a suture which, introduced on the outside, comes out again before reaching the edge of the wound, enters again on the other side, likewise at a little distance from the edge of the wound, and passes under a portion of peritonaeum. In doing this, to be sure, the peritonaeum sometimes tears through, if the sutures are drawn too strongly ; then the only way is to close these intei'stices also with deep sutures. At the corners I join together the peritona3um of the stump and that lying above the ligatures of the broad ligament with continuous Suture of the stump after supra-vaginal amputation. — a. Suture of the cervical canal. 286 PATHOLOGY AND THERAPEUTICS catgut sutures.' Only after this is the constrictor of rubber tubing loos- ened, and any bleeding from the stump again and finally controlled with the greatest care. Sometimes it is necessary again to insert deep threads, sometimes a few superficial ones are sufficient ; very often further sutures are not necessary at all. In case of necessity the stump of the uterus and of the ligaments may be encircled again with ligatures in mass. In contrast to the procedure in ovariotomy I do not leave to itself this stump and the abdominal cavity which has been freed from its pathologi- cal contents, since I have found that a rapid and abundant exudation from this stump usually occurs. The interruption of so vast a vascular system furnishes a very satisfactory explanation of this fact. While after ovari- otomies any transudation which may occur is evidently resorbed with facility, I have acquired an impression, from a long series of obsei'\-ations, that after a supra-vaginal amputation, such a resorption only too often fails to occur, or is completed with difficulty. Since more than four years, in these cases, I have relieved the pouch of Douglas of the neces- sity of such a resorption, by means of prophylactic drainage. In supra- vaginal amputation^ I always i?n?nediatelv car^y a drainage-tube through the pouch of Douglas into the vagina. A strong dressing- forceps is thrust through, at the deepest part of the pouch of Douglas, into the posterior vault of the vagina, while two fingers in the latter stretch the vault and receive the impact. I push this dressing-forceps down to the entrance of the vagina, place between its blades a simple rubber tube with a cross-piece, and draw the latter back into the abdominal cavity (Fig. 129). Then the tube is pulled down until the cross-piece rests on the floor of the pelvis, the uterine stump is turned back over it, the abdominal cavitv is superficiallv cleansed, returning any intestines which may have been displaced, and the abdominal wound is closed. As a rule, a very astonishing amount of blood-stained fluid, which often has a bad odor from the beginning, flows through the drainage-tube, as soon as, at the end of the first or in the course of the second day, the drainage-tube (which for the first day is doubled up, and, if the vagina stands open, is protected from access of air by a tampon placed in the entrance of the vagina) is undoubled outwards, after removing any tampon which may be present. The end of the drainage-tube is kept sur- rounded with salicylated cotton, which is frequently renewed. The fluid which continually trickles down through the tube prevents the access of air to the peritoneal cavity. As a rule, on the third and fourth day there comes on an unpleasant sensation in the umbilical region, and > Concerning the preparation of the pedicle in operations for myoma. Ueberdie Stielversorgung bei Myomoperation. Deutsche med. Wochenschr., 1885, Nr. 3. OF THE DISEASES OF WOMEN. 287 then the drainage-tube is removed, usually with ease. Since I have em- ployed this method of treatment, the results of supra-vaginal amputation have become essentially better and surer ; in fact, since that time, the only cases which I have lost after this operation were those in which the result could be indicated as doubtful in advance, owing to disintegration of the blood in consequence of extreme anaemia, or to advanced age, or to other very severe complications. The difficulties of supra- Fig. 129. vaginal amputation may be very considerable, especially if the mass of the tumor obstructs access to the remainder of the uterus, that is, to the cervix, or if the tumor extends into the cervix itself, and thus makes it difficult to constrict the latter with the rubber tube. Among a great number of such operations, however, I have as yet found no case in which the operation had to be abandoned for such reasons. If the tumor, on account of its size and shape, cannot be at once lifted entirely above the constricting ligature, the extir- pation may be performed, in the manner described above, as far as circumstances permit ; and then either the rubber tube may be applied lower down, and afterwards all the tumor may be removed, or, after pioperly tying the broad ligaments and uterine and spermatic arteries by sepai^ate liga- tui-es,^ after ligating the cervix uteri also, if necessary, the constrictor may be taken off, the remainder of the tumor be enucleated, and then the stump may be made and finished as described above. If the stump has been sewed together and seems much reduced in size, and if blood oozes from the needle-wounds, I like to perforate and tie the stump in mass. A strong needle with a fourfold thread is thrust through it in the median line from before backward, and from this point Formation of the stump, and prophylactic drainage. 1 Schroder, Zeitschr. f. Geb. u. Gyn., viii., S. 141. 288 PATHOLOGY AND THERAPEUTICS it is tied both ways around the whole stump. Such a ligature ininass seems not quite superfluous, owing to the great loosening of the sutures which occurs while the sewing is going on, in consequence of rapid shrinkage of the stump. The mass of the latter which has been tied off has never yet been found to have sloughed at such autopsies as I have had occasion to make. I have performed such supra-vaginal amputations eighty-five times. The first six, in which the patients all died for want of sufficiently exact antisepsis in the operations, I omit from any further computation. Of the remaining seventy-nine, four died among the first ; two of them being septic, and two in consequence of chronic anaemia. Since that time I have employed prophylactic drainage, and at the same time, at all events, have carried out antisepsis with the most scrupulous rigor, and there have died fifteen out of eighty-six, that is, 23 per cent. Of these, six died of sepsis, which must have occurred during the operation ; one operation was performed during an attack of septic peritonitis, suppuration of the myoma, and perforation ; two were operated on during purulent dis- integration of the myoma ; six succumbed to the preexistent anaemia or to embolism or cachexia. The record contains a series of sixteen consecutive recoveries. Hop— MEIEK, in his article in 1S84 °^^ ^^^ myomotomies of Schroeder, has pointed out that making an opening into the cavity of the uterus is serious for the prognosis. If I tabulate my cases in regard to this point, it yS seen that of one hundred and thirty-nine myomotomies which are admittedly aseptic, and of which thirty were fatal, thirty-three were operated without opening the uterine cavity, with seven deaths. But the cases of removal of such tumors, which lay subserous on the corpus, above and outside the appendages, have only the significance of simple ovariotomies, and have too gi'eat an influence in such a computation of the prognosis to permit such an estimate to be of any value. The simple comparison, however, of the cases which had prophy- lactic drainage and of those which were not drained, also gives a result of little use ; we can only get one of value by classifying the cases them- selves, as I am attempting to do. (c.) In a limited number of cases, the myoma is found still com- pletely intra-parietal in its situation, so that, at any rate, it presses out the serous and the mucous coats to a degree corresponding to its size, although the cavity containing the tumor is still separated fro?)i the perito9iceum or the mjtcous membrane by a layer of tissue more or less thick (Fig. 130). Especially if tumors so situated are found quite isolated, and if, on palpation of tlie uterine body, nodules of myomatous formation OF THE DISEASES OF WOMEN. 289 Fig. ISO. are nowhere to be felt, a procedure may be adopted which perhaps may be designated as ideal from the point of view of conservative treatment ; namely, the uterus can be brought out through the abdominal wound and its neck constricted with a rubber tube, whereby a field for operation is secured, and all serious haemorrhage is prevented. Then the serous coat over the tumor is split, its bed is laid bare to a large extent, the tumor itself is enu- cleated, and the cavity thus formed, together with the split in the perito- naeum, is united by sutures^ (Fig. 131). I have now had opportunity to operate in this manner sixteen times, and the results have been on the whole very satisfactory ; in one case a myoma developed again subsequently, which required a further operation, and this time, in- deed, a supra-vaginal amputation. Enucleation of an intra-mural myoma, after the method of Martin. ^'3- ^^^- Since infection may certainly occur ver}' readily from the uterine cavity, the cases where the latter is not opened appear to be more favorable; but even where an opening through has been made, recovery has gone on without accident. In these cases I ha\'e closed the mucous membrane with a cob- bler's stitch, and then united the cavitv left by the myoma, just as thougli there had been no injury of the mucous membrane. In one case I considered that the opening into the uterine cavity was too large to be closed in this way, therefore I drained it toward the Application of the sutures after "terine cavity and the cervical canal, and enucleation, according to il/ar/'w. carried the thick drainage-tube, which was 1 Compare the publications of my assistants, BtirkharJt, Deutsche ined. Wochenschr., iSSo, Xr. 27; Czempin, Ges. f. Geb. u. Gyn. zu Berlin, Oct. i, 1SS6. 290 PATHOLOGY AND THERAPEUTICS requiiccl for this, out through the external os uteri into the vagina. To secure the cavity left hv the tumor itself, I insert large needles under the whole raw surface, and sew the walls closely together by these, while between the deep sutures supeiiicial ones adapt the peritonaeum exactly. This kind of enucleation can be done quite extensively, even in case of great tumors, which leave behind widely gaping cavities. In these cases, so much of the walls of the cavities must be resected as cannot con- veniently be utilized in applying the sutures. In five cases there were such large cavities, and such extensive injuries, that in these I also em- ploved prophylactic drainage of the pouch of Douglas. In other cases, especially when the tumor had developed between uterus and bladder. I have simply secured the accurate apposition of the edges of the cavity by means of deep sutures. In mv first cases, on enucleating the tumor, I immediately removed the ovaries also. In one of these cases the latter had both undergone cvstic degeneration ; in another case, I removed only one ovary, which was diseased. This castration seems to be possibly superfluous, and, in subsequent cases of this kind. I have not always performed it. I would, however, recommend the extirpation of the ovaries in all this class of cases, whenever there is any uncertainty as to the entire freedom of the uterus from any further myomatous nodules. Those first cases have re- covered perfectly, and are now in excellent health ; in others, however, who were operated later, there occurred occasionally profuse menses, in some cases, and in others there were violent attacks of dysmenorrhoea. I have already performed such enucleations sixteen times.' The last ten cases recovered consecutivelv. Of the fatal cases, one was operated on during an attack of advanced decomposition of the tumor, with fever : two died of acute sepsis, after the performance (jf the operations, on one of the hottest days of the year 1SS3. (fl?.) Quite extraordinary difficulties mav arise in performing the operation on the last group, which I mentioned above. — that o^ wvomata which have groivn into the broad ligament and iittder the pelvic peri- tonceum ; that is, in the operation on tumors -vhich have grown into the Jloor of the pelvis. This class includes those cases which were formerly designated as inoperatable ; and thev are in fact difficult to attack, since, on the one hand, the haemorrhage is hard to control, and on the other, the danger cannot be excluded beforehand that the tumor is not perfectly dif- ferentiated, especiallv at the lowest part, and that therefore a complete enucleation of the tumor cannot be accomplished without injuring the neighboring parts. Finally, if we separate these tumors from their beds, > Compare Czeinpin. OF THE DISEASES OF WOMEN. igx there remain great cavities, aiul operators liavc l)ecii particularly afraid to leave the latter behind. Nevertheless, experience, at least such as I have had on fifteen cases ah'eady, since my first operation on a tumor of this kind,' now causes me to no longer shrink from the extirpation of such tumors. ScHROEDER also considers the enucleation of such growths as practicable, and as the means indicated for the cure of these new.-growths, which occasion such severe suffering's. Int ra-ligamentary myoma; enucleation. Suture of the sac. Drainage into the vagina. For the extirpation of these tumors, which are . szibserous or intra- hgamenta>'y in their development., I divide the peritonceiim extensively over tJie summit of tJie tumor (Fig. 133). The consequent haemorrhage is, as a rule, slight, even if the spermatic and uterine arteries are not first ligated, as is advised by Schroeder. With the finger I work mv way Ml between the growth and the periton;eum, and shell the tumor out. pull- ing the latter upwards meanwhile with the forceps of Mu/CEi^x. In this way I have always brought this kind of tumor out. In other cases the ' Fr;m Bradcinann, 20, vi., iSSo. 292 PATHOLOGY AND THERAPEUTICS tube, which is adherent to the tumor, fl.oli^■, Hiislon, April, iSSS.] XVII Fig. 1. '- m^>m.^^ik^-^^^ Mmm^ Fig 2. [Annals ui- Gvn.kc(ji,()^'iii^ iV- .. :r .-. ■. Fig. 7. Fig. 8. [Annals ok Gvn.ecolo'jv, IJ.jhton, May, iSSS.J XXI ■^^KVi i,^'-^-'-';.;^ Fig. 9. [Annals of Gyn.hcology, Boston, May, iSSS.] XXII Fig lO. [Annals ok Gyn^kcologv, Boston, .M:iy, iSSS.J XXIII Fig, 11. [Annals ok GvN.iicOLOGV, Boston, May, iSSS.j XXIV Mm c U Fig. 12. [Annai.s ()]. (ivN.KcoLOGV, Boston, June, iSSS.J xw Fig. 13. [Annals oy GvN.iicoLoov, IJosIdh, Juiii;, iSSS.] XXVI Fig. 14. [Annals ok Gvn.i-.i oucjciv, ISdsIdii, June-, iSSS.J XXVII A B C Fig. IS. [Annals oi- Gvn.i;collon, June, iSSS.] XXVI II Fig. 16. OF THE DISEASES OF WOMEN. Fig. 137. 301 Microscopical picture of the foregoing figure after C. Ruge and f. Teit. p. flat epithelium, e. erosions, k. carcinomatous nodules, c. cervical canal, J. point of transition. J.J. central ■cracks, x. remaining glands. 302 PATH O LOGY AND THERAPEUTICS own observations have given mc the impression that the third form is more frequent than this second one. At any rate I retain the classification adopted by Schroeder as being the best yet proposed. III. The third form, as designated by Schroeder, consists of a car- cifio/natous nodiilc of the cervix^ which has developed as a circumscript tumor, under a mucous membrane which is normal, or is apparently only strongly irritated, but without malignant disease. This nodule is situated in the substance of the vaginal portion, some- times under the external surface, — that turned toward the vagina, — some- times under that of the cervical canal ; it grows, disintegrates internally, and then first perforates the previously intact mucous membrane (Figs. 140 and 141 ) . Fig. 140. Carcinomatous nodule in the collum. After ('. Ruge and J. Veil. (I have a specimen removed by me, and (juite similar). ,('«. Carcinomatous nodule. <;. Orificium externum. <;. Defect from use of a sharp spoon. The resulting loss of substance becomes a carcinomatous ulcer, which sometimes appears first on the external surface, sometimes first in the cervical canal, and then by the infiltration of the neighboring parts, it sometimes attacks the whole cervix, sometimes the vagina. The further development of these three forms of carcinomatous dis- ease of the cervix shows rather peculiar varieties, however similar the OF THE DISEASES OF WOMEN. 303 final result may be, especially in regard to their further extension toward tl)e va'^-ina, the uterus, and the pelvic connective tissue. Fig. 141. After C. Rugc and J. Veii. 0. Orificiuni externum, c. Cer%'ix. ./. Cervical glands. g. Incipient degeneration of the glands. X'. Carcinomatous nodule. 3"4 PATHOLOGY AND THERAPEUTICS In all forms of the disease the vagina is invaded early and compara- tively frequently ; sometimes the carcinoma spreails on the surface over the point of duplicature in the vault of the vagina ; sometimes the disease spreads under the surface along one wall of the vagina, and appears there as an apparently isolated nodule. Fig. 143. Carcinoma colli et corporis et vesicae, e. Martin's Hand-atlas, ed. ii., by .-/. ALirfiu. The walls of the bladder are likewise thickened bv carcinomatous infiltration. The extension of the carcinoma colli to the corpus uteri (Fig. 142) occurs relatively seldom, or at least later in cancroid of the portio vagi- nalis, more frequently in the other two forms. Since, in such an event, an early disintegration of the new-formed mass takes place, either a cavity OF THE DISEASES OF WOMEN. 305 is formed nx the collum, with sharply dcHiied edges at its upper part, or, on the other hand, — and this is especially the case in carcinoma of the cervical mucous membrane, — the extension occurs in the manner that separate peg-shaped projections invade the mucous membrane of the uterine cavity, and the tissues lying between them are only attacked afterwards. The invasion of the surrounding connective tissue of the floor of tlie pelvis by the disease either follows the course of the lymphatic vessels, or takes place bv an uninterrupted progressive infiltration of the neighboring parts. In the first form, in the very beginning, — thai is, in the earliest stages susceptible of observation, — minute nodules are formed as large as a split pea ; these extend under the peritonaeum, usually backwards, and then they can be thoroughly palpated ; they resemble bodies strung together like pearls. Great importance has formerly been attributed to the presence or absence of affection of the inguinal glands by the disease. It is necessary, however, to point out that this group of glands, as a rule, is affected only very late and secondarily, when the deep lymphat- ics have already been infiltrated for a long time and very extensively.' The invasion of the disease by continuous infiltration so distends the immediate neighborhood that the cervix appears to be greatly thickened. Sometimes the infiltration takes place equally around the cervix, but more frequently it extends more to one side, and finally forms a hard connection between the uterus and the side of the pelvis. Among the organs which are invaded during the further extension of the new-growth, the bladder and the ureters on the one hand, and the perltonceu7n on the other, are of special impoi'tance. The infiltration of the whole cervix, and of the vagina, and of the parts surrounding the latter, as soon as it comes into the vicinity of the bladder occasions irregularity of the functions of the latter, and leads to extraordinarily painful symptoms of irritation of the bladder even before the vesical mucous membrane is itself attacked. Beside the bladder, the vicinity of the uterus, as soon as it becomes diseased, is the point of origin of severe symptoms. By obstruction of the ureters, a retention of urine is induced, which very often leads to a rapid loss of strength, but, on the other hand, to that peculiar symptom of comfort (euphoria) which occa- sionally is met with to a very striking degree in carcinomatous persons, and which depends on uncmia. Disease of the peritoiKvum is almost always indicated by the characteristic symptoms of irritation in cases Blati, T>, in Berlin, 1S70. 3o6 PATJIOLOGY AND THERAPEUTICS where the infiltration lias reacheil the peritoiueuni. either in the ftjrm of little nodules in the lymphatics, or in that ot" a hard infiltration extending uninterruptedly. The infiltration in the vault of the vagina and in the neighborhood of the cervix extends posteriorly somewhat less frequently than anteriorlv ; in such cases it then attacks the rectum also. \^ disintegration of the )ic~u:-gro-juth occurs, large gangrenous places are formed, which sometimes are situated entirely on the external surface of the collum toward the vagina, and sometimes are closed if the shape of the lower part of the vaginal portion is preserved. These ulcerating surfaces are usually covered with a layer of a foul, waxy, discolored substance. If the disintegration progresses, it leads to destruction of the tissues lying between the disease and the bladder and the rectum. From the fistula thus originating there are discharged, as through a cloaca, the contents of the bladder and of the intestine, with the secre- tions of the uterus. Even when the destruction is very extensive, it does not readily open into the abdominal cavitv, since in advance of the invad- ing new-growth there occurs very early an adhesion of the peritonaeum with the neighboring structures in this place. It is comparatively seldom that secondaiy invasions of remote organs develop in connection with this form of carcinoma. Most frequently wart-like excrescences occur in the peritonaeum at some distance off; these finally increase to large centres of disease. The sy77ipto7)is of carcinoina of the cervix in its early stages are by no means definitely characteristic. Some women, from the beginning, and even before the existence of malignant disease can be demonstrated, complain of violent pains, pro- fuse hcemorrhages^ and excessive secretions. Besides these, we find others who remain exempt from all suffering, even when the infiltration is very far advanced, and in whom the disease is detected quite accidentally, since neither pains nor haemorrhages nor even secretions have become noticeable, even in patients who are comparatively attentive to these matters. The hceinorrhages in the beginning retain the type of menstruation ; then they occur also apart from this period, and are increased by every irritation which affects the genitals, such as coition, difficulty of defeca- tion, exertion, etc. Then more abundant haemorrhages may occur quite early. More frequently there appears only a bloody admixture of the mucus, which is discharged in large quantity ; the latter, thus discolored, excites the attention of the unfortunate women. OF THE DISliASES OF WOMEN. 307 The most characteristic feature of the secretion is its putrid stench. This may, however, be absent, even when the disease is far advanced, while it may be present in cases of non-malignant disease. Especially when the surface is destroyed, the secretions may be very abundant and simply purulent. If disintegration has commenced, the secretions be- come foul through admixture of blood and shreds of tissue, and they assume that peculiar foul odor, usually indeed accompanied by a dirty, tlark-brown discoloration. The amount of pain is quite extraordinarily variable ; sometimes this is entirely absent, even until the final catastrophy ; sometimes, from the very beginning, pain is the most prominent difficulty. Not infrequently the pains have been described as uterine colics ; others describe them as pains in the small of the back ; in others again they occur in the form of peritoneal sufierings, or as light, but continuous, gnawing pains. These are accompanied by the other consecutive symptoms according to the ex- tension of the disease and the general cachexia, the emaciation, and the loss of strength. Schroeder calls attention to a peculiar hardness of the abdominal muscles. Besides this alteration in the abdominal walls, which is, at any rate, very characteristic for the later stages of the disease, I have long ago been struck by the peculiar dryness and harshness of the skin of the whole trunk and extremities in patients who were suffering with carcinoma. I have above referred to the symptoms resulting from communication with the bladder. The symptoms of invasion of the rectum are those which we always observe in cases of obstruction of the intestinal canal. It is especially noticeable that such patients comparatively often suffer from restlessness and insomnia, often long before extensive disease is discoverable ; in fact, it is not seldom that the patients are heard to boast of an improvement in their condition only when, after long-con- tinued insomnia, somnolence and lethargy come on in consequence of the beginning of uraemic intoxication. Most patients with carcinoma are plagued by an absolute loss of ap- petite ; their nutrition is disturbed by retching and nausea. It is a peculiar fact that in carcinomatous persons the sexual appetite is not infrequently found to be rather increased than diminished, and this explains the tact that conception often occurs in spite of advanced destruction of the cervix. It is extremely difficult to estimate the duration of the disease. Beside cases of very rapid progress, in which I have seen the disease run its course from the first perceptible beginning to the final catastrophy in a few weeks, I have made records of several observations, in which it lasted nearly five years, with frequent pauses in the tlevelopment, to be sure,, which were the result of operations. 3o8 PATHOLOGY AND THERAPEUTICS The diagnosis of carcinomatous disease offers no difficulties in cases of extensive disintegration and in clearly marked forms of disease ; the age, the course, the result of examination, then speak so plainly that errors are excluded. To be sure, these are usually cases in which the dis- ease has passed beyond the cervix, and has already caused extensive de- struction in the neighboring parts. The recognition of the early stages^ on the contrary, occasions very extraordinary difficulties. All the clinical symptoms which are referred to as indicating malignant disease may fail us, no peculiarity of the result of digital examination helps to give the necessary certainty,' which at pres- ent we can gain only by microscopical examination. Even comparatively small pieces, cut or scraped out of the mucous membrane, or out of the nodules, may make the diagnosis certain, when they have been properly hardened and mounted. Just on account of the similarity of the results of clinical examination in advanced forms of chronic metritis, when in such cases there is extensive infiltration and profound alteration of the mucous membrane and of the vagina, great im- portance must be attached in practice to the warning against wishing to make a diagnosis based on the results of digital examination and on the clinical symptoms. This warning is of value both in regard to the possi- bility of a cure, when malignant alterations are recognized early, and also in regard to the ti^eatment of simple benign affections. If we learn more and more to make an early diagnosis of incipient carcinoma, assuredly not only will the aetiology of this so fatal affection be elucidated, the prognosis must also become more favorable if we can clearly recognize the earliest stages, and then employ suitable therapeutic measures. ScHROEDER claims for cancroid of the vaginal portion a character essentially different from and milder than that of the other forms of cancerous degeneration : viz., carcinoma of the cervical canal, and cancer- ous nodules in the cervix. Certainly the histological difference to which RuGE and Veit have called attention must be admitted ; the tendency to extension and the local curability also cannot be called in question since M. Hofmeier's investigations. On the other hand, however, Schroeder concedes that even in cancroid of the portio the possibility of a relapse is not excluded." Quite peculiarly serious, according to Schroeder's experience, is also 1 Stralz (Zeitschr. f. Geb.u.Gyn.,xiii., H.i) states, as a particularly important symptoni, that the diseased place is sharply bounded bv the border of the surrounding tissues, that it is on a different level, that it always has a light-yellowish color, and that it usually prc".ents a finely granular, yellowish- white, shining elevation. 2 Compare Gesellch. f. Geb. u. Gyn., Sitzung, v., 24 November, 1SS5. OF THE DISEASES OF WOMEN. 309 the complication with pregnancy. This opinion is corroborated by my own last case of high excision, which was for cancroid of one lip of the OS uteri in a woman five months pregnant ; a relapse occurred in two months. From the relatively favorable prognosis which Schroeder attributes to cancroid of the portio vag. I cannot therefore draw the same conclu- sions ; while I admit that it is relatively better than in the other forms of carcinoma colli. I must yet remain convinced that it is requisite to remove the entire organ, even when only a part of it is affected. HoFMEiER ' has established the fact that of the women treated by Schroeder by partial excision, 41.3 per cent, remained free from relapse for four years. Schroeder- concludes, as the result of his whole experience, "■ that cancer of the cervix uteri is curable as long as it is limited to the uterus and the vagina. In cancroid of the vaginal portion, the supravaginal excis- ion of the cervix suffices, but frequently the greater part of the cervix must be removed. The patients who have been operated upon are to be considered as cured if they remain healthy for a year after the operation. '' In carcinoma of the mucous membrane of the cervical canal, even in the beginning of the disease, the cancer is so often developed far upward that total extirpation must always be performed. The carcinom- atous nodule readily grows into the body of the uterus, so that it is only exceptionally that the excision of the cervix can suffice in these cases." Dr. Nagel has begun to collate my own experiences with the various methods of treatment of carcinoma, but the final result could be deduced as yet only for the cases of extirpation, owing to the difficulty of obtaining information about the subsequent history of the cases. In view of the great difficulties of diagnosis, it must in any case be required in all reports of recoveries that the actual condition be determined bv the help of the microscope. I fear that if this were demanded a not inconsiderable part of the older observations of this kind would have to be rejected. In later times cases of definite cure have been more frequently"* published. I have myself, in the first edition of this book, reported that up to the middle of the year 18S4, out of sixteen cases of extirpation on account of carcinoma, in eight — that is, in 50 per cent. — recovery had lasted for more than two and a half years. The number of vaginal extirpations has increased immenseh' since that time. Out of one hundred and thirty-four vaginal total extirpations 1 Centralb. f. Gyn., iSS6, Nr. 6, und Berl. klin. Wochenschr., 1886, Nr. 6, u. 7, und Zeitsch. f. Geb. u. Gyn., xiii., H. 2. - Loc. cit., 309. "Compare also Ptiu>lih, Wiener Klinik, 12 December, iSSi. 3IO PATHOLOGY AND THERAPEUTICS which have Ween pcrtormcd in my institution up to the middle of ]anu- arv, 1S87, '^'^ \vhich Dup:\'KLIL?s made nine, and I tlie rest, the opciatioii was performed on account of carcinoma ninety-four times. Sixty-six times the new-growth was completely removed witii the uterus ; in twentv-eight cases the latter was indeed removed, hut traces of more widelv extended disease remained behind ; for in these twenty-eight women there were discovered during the operation glands more or less remote, or infiltrations lying ofi' at the side which could not be removed. Oul of the first group of sixtv-six. in whom the operation was thorough, eleven died under the influence of the operation. Of the surviving fifty- five, I have information which I can use in the cases of forty-four ; the last cases operated on since the end of 1885 can, of course, not be reckoned here. Of the forty-four. I know that thirty-one have remained free from recurrence of the disease, while thirteen have suftered relapse. That gives, therefore, a result as to cure of more than 70 per cent, of recoveries of car- cinomatous patients after total extirpation. The final result' is arranged according to vears in the followiny^ table : — Vaginal extirpation of the uterus, zu/ierc the tissues surrounding the organ removed ivere healthy ', not including the cases ~uhere death resulted from the operation. i Cancroid of the portio vaginalis. Carcinoma colli. 1 1 Carcinoma corporis. Year of the operation. Num- ber. Of these there were at the end of iSS6. Num- ber. Of tliese there were .It the end of iS86. Num- ber. Of these there were at theendof 1SS6. 1 Healthy. Relapsed. Healthy.! Relapsed. Healthy. Relapsed 18S0 .... 2 6 6 2 4 S 1= I 2 4 23 1 4 4 6 .1 2 1 1 1 1 ' iSSi . . 1 1 1 1SS2 . ■ . . 5 ■• '* 1SS3 . . 3 2 1 3 1SS4. . . 1SS5 .... 2 1 =• I i I Total . . . 3 2 -•^ 17 1 1 i.> '•J ' 1886. .. . .887. .. . I 7 a 1 iComp.-ire Ges. f. Geb. u. Gyn. zu Berlin, 18S7, 14 January. - Died I V, yc-.irs ;il"tiT operation of phthisis pulm. ^ " 3'. ■ < " 4 '• '• " " carcini)in;i i>f ovarv. OF THE DISEASES OF WOMEN. 311 Amonf. The edges at the vagina. OF THE DISEASES OF WOMEN. 3^5 this method of applying the sutures requires a certain piactice in the use of the needle. Such practice is by so much the more necessary, inasmuch as in these cases very considerable haemorrhages sometimes have to be encountered. For applying the sutures, I employ in part the common so-called fistula needles, in part larger, strongly curved ones, which, like all needles, I in- troduce with the simple needle-holder of Langexbeck. I usuallv first introduce all sutures which run under the whole raw surface and pass through the part of the uterine stump which remains intact ; and then I tie them, after sprinkling the whole surface of the wound with iodoform. In cases which are somewhat favoi^able, a stump is obtained in this way which is firmly sewed to the neighboring structures, and which, as a rule, heals in this position without any disturbance. A part of the wound, to be sure, often remains uncovered. We must be glad if, by the use of the sutures in the vicinity of these uncovered places, the htemorrhage from them is com- pletely controlled. Lately I have touched such cavities, as a rule, with iodoform or liquor ferri sesquichlorati, and packed them with salicylated cotton. In the other method the sutures are inserted i>i the -whole Jloor of the pelvis., which is secured over a large area., as zuith a niattrass-stitch. If, namely, the mobilit}' is so limited that the wound cannot be even par- tially stitched to the stump of the uterus, and if, as indeed always oc- curs in such cases, the gaping cavity is immovably fixed at the bottom of the vagina, I have preferred for these cases also of late years to secure the wound by sutures, rather than to employ any other method of con- trolling the hcemoiThage. T then sew aroimd the deep crater from the va- gina, so that a continuous line of firm sutures lies in the anterior, posterior, and lateral walls of the vagina, all around the opening (Fig. 144). If it is possible to apply these stitches external to the border of the infiltrated mass, this seems to me to be the most efiectual method. If, however, sutures can no longer be applied in this way, I carry these threads even through the infiltrated masses, however troulilesome it may be to tie them. The gaping cavity is swabbed with iodoform or with Fiy. 144. Stilching rouml ttie loss of substance in the \ault (if the ort;an. 3i6 /\i/7/()LOG)' .-iXI) THER.U'EU'/ICS liquor ferri, ami completely filled with cotton. In applying sutures in this way, I like to leave all the threads of full length, in order to have them to hold 1)\ in case there he a h;emorrhage afterwards. The coil of threads is to be laid over the cavit\ which has heen filled with cotton, and, Hnallv. the vagina is also to lie Hlled with the latter. For this purpcxse 1 use the prepared cotton, since this lias given me less trouble than any of the similar materials. Experiments with jute or gauze, or, finally, with wood- wool, gave less satisfactory results, so that I alwavs came back to the use of the cotton. riie after-treatment following suture is as simple as possible. In the cases wliere the wound has been completely sewed together I let the patients lie quiet for eight to ten days, after any tampcjiis which may have been in- troduced have been removed on the second day, or the third at the latest ; then the threads are gradually removed. During this time cleansing, dis- infectant douches are used, in the manner usual for patients lying- in bed ; care is taken of the digestion, while at the same time the patients receive concentrated nourishment. If necessarv, anv pains which occur are sub- dued by the ice-bag or by morphine injections. In all cases where the cavity which has been made has been stufled with cotton, this remains in place for fortv-eight liours, and is then removed : it is replaced by a new tamponnade only in cases where there is a strong disposition to hicm- orrhages ; in all other cases the patients are put to bed again without fur- ther dressings, and they remain there for five or six days longer, under con- tinued use of disinfectant injections, before the further cicatrization of the wound is stimulated bv touching it with tincture of iodine or with liquor ferri, or by covering it with sublimated wood-wool or with pledgets of cot- ton witli iodoform. Not infrequently in such cases of advanced carcinoma symptoms of recurrence appear even before complete cicatrization has oc- curred. Only where these have occasioned haemorrhage and profuse secretion have I again immediately performed curettement and cauteri- zation. It is not seldom that the recurrence takes the form of nodules, or appears as a general infiltration under the surface, wliich has remained intact; and this seems to me to be a result of some importance in the treatment of these so-called inoperable carcinomata, for in these cases the patients finallv perish, without having anv open wounds appear in the vagina. Often I have in this manner kept such unhappy persons free from sloughing and bleeding, and sometimes even from pain, until the end of their lives. The frightful odor of the masses which are discharged cannot alwavs be overcome by iodoform and sublimate, but is much^ OF THE DISEASES OE WOMEN. -t.i'i moi-c pc-nnanently removed l)y doucliing' witli peroxide of hydrogen (3 per cent.) and with-thvmol (i : 1000). In advocating the operative treatment of such cancers, which can no longer be radicallv extirpated, I am led on the one hand by consideration for the feelings of the patients, and on the other by the observation, which has frequentlv been made, that by operative interference the suffer- ings of the unfortunates can be kept within limits, in certain respects. I onh' refrain from such interference when the infiltratirm has progressed into the immediate A'icinitv of the bladder and rectum, and an injurv of these structures in the course of the operation seems not unlikelv. I have not considered injuries of the peritonceum as of so much importance, and quite often I have rendered such injuries harmless, either by immediately sewing up the wound in the peritonaeum or by di'aining it toward the vagina. In the cases of more extensive infiltration there remains nothing but appropriate injections with acet. pyrolign. rectif. , or liquor ferri, with sublimate carbolic acid, and similar substances, together with the thorough use of iodoform, morphine, and such medicaments. Not infre- quently lukewarm sitz -baths and rectal enemata contribute to the alleviation of the sufferings of these women. In deferring until now the consideration of the mode of treating the inoperable carcinomata, which I certainly believe to be the one most fre- quently employed, — namely, that w^ith cauterizing agents, — I by no means desire to reject in principle the propositions which have been made in this direction. I have personally a very extensive experience in the use of both the actual and the potential cautery. The results obtained by them are, in the first place, undoubtedly often satisfactory, and their use is compara- tively much easier, in a great number of cases, than that of the procedure which I have described above. I have, however, for various reasons, given up the use of the cautery and caustics. In the first place, 1 found very considerable difficulty in controlling the hEemorrhage immediately with these agents ; in fact, sometimes the loss of blood during the operation, or from the haemorrhage which came on soon afterwards, led to quite threatening symptoms : twice death occurred at the extreme point of this aniemia. Since I employ the sutures I have neither observed very considerable losses of blood during the operation, nor any ha'inorrhages afterwards, wliich were dangerous to life. Secondly, the use of caustics has the great disadvantage that we cannot properly control their action. Thus I have repeatedly seen inju- ries of the bladder and the rectum during early convalescence, especially after cauterization with zinc chloride, which made the malady much more intolerable than it would otherwise have been, presumably, for a time at i.S /'AT/fOLOGV AND THERAPEUTICS least. Thirdly, cicatrization is much more rapid and complete after the use ot' the sutures, according to my experience. Some years ago sucli peculiar ohservations were pul)lishe(l in America concerning the electrolytic treatment' eyen of carcinomata, that I felt it my duty to test these assertions. I have subjected a yery considerable number of such cancers to p"'a- 1^3. electrolytic treatment ; the final result of the latter was always entirely nega- tive, ^o tiiat I have aban- doned further experiments in this direction. The complication of pregiiancy and carci- noma onh' justifies total extirpation, in my opin- ion, in case the cancer can be ccjmpletely removed.' Tlien T consider the extir- pation of the uterus with the (j\um as indicated. Palliative operations on so-called inoperable car- cinomata in pregnant women seem to me only justified if bleeding, sloughing, and pain make the condition of tlie preg- nant woman intolerable. Thereby the continuance of the pregnancy is cer- tainly greatly endangered ; for beside the few cases of complete tolerance of such operations by tiie uterus, a large percentage of these cases nevertheless seems to respond to the operation on the cervix by the expulsion of the foetus. "* rarcirnjma Coriwris. Extirpated Feb. 28, 1882. No recurrence as vet. > Americ. Jour, of Obstet., 1881. -I have not yet had occasion to act according to' this indication. One patient who belonged to this category refused thi; operation. See, finally, Z.(j«rfn«-(?o«.f<:/;(i/^, report of the Obstet. Society, 14th of May, 1S86. ^ Benike, Zeitsch. f. Geb. u. Gyn., Bd. i, 1S77. Compare also Fromind, Zeitsch. f. Geb. u. Gyn., V. 15S, and Stratz, Zeitsch. xii. H. 2, and Sitzungsbericht d. Ges. f. Geb. u. Gyn., 1SS6. OF THE DISEASES OF WOMEN. 319 Fig. 14-6. At the end of pregnancy the treatment must depend entirely on the extent of the carcinoma colli. If tiiis i.s limited, delivery -per vias iiaturales may indeed take place : and even when the degeneration is very far advanced an unexpected relaxation may occur quite at the last period, so that there remains no impediment to the natural expulsion of the foetus. If, however, the whole of the pelvic contents are degener- ated, and if it is to be expected that all the soft parts of the pelvis will be crushed in case the child is made to pass through them, 1 prefer to de- liver by means of the Caesa- rean section, w^hich offers far more favorable chances for both mother and child, if performed at the most suitable time and with proper preparation. II. — Carcinouia Corporis. The comparative rareness of this affection of the corpus stands in peculiar contrast to the frequency of carcinoma colli ; nevertheless, the fre- quency of the former has certainly been under- estimated formerly, for since we possess an exact method of making a diagnosis, by the ex- amination of particles which have been scraped out, the number of observations of this form of disease has increased in a striking manner. Carcinoma corporis develops with pro- nounced frequency in elderly women at the period of the climacteric, and verv rai"ely has this affection been obsei-ved before the thirtieth year. It is just in elderly women that it is found, on a base which clinically appears healthy, in women who have withstood the senile involution without a trace of suffering, and now, in the absence of any exciting cause, '' begin to flow again." This peculiarity explains to some extent the tact that carcinoma corporis occurs comparatively oftener in nullipane than in those that have borne children. Cross-section of the specimen of Fig. 145. 320 PATHOLOGY AND THERAPEUTICS In regard to the pathological anatomy of carcinoma corporis, we know that in the great majority of cases, if not always, the malignant de- generation originates in the glandular apparatus,' whether the latter itself is in a morbid condition or not. In the course of this development, the carcinoma certainly not infrequently arises from glandular endometritis, so that from this fact a peculiar light is cast upon the latter disease (Figs. 14=; and 146). Just in these cases the transition from adenoma into carcinoma has frequently been proved microscopically. As a rule, carci- noma corporis runs its course as a diffuse infiltration : it is seldom that in such cases there occurs a decided prominence of circum.scribed portions ; that is to say, a polypoid form. The further development of carcinoma corporis is characterized by rapid disintegration, so that deep, ragged ulcerations occur, in the vicinity of which the infiltrated uterine tissues are prepared for disintegration . In this way, apparently, carcinoma corporis extends much more fre- quently to the peritonseum and attacks the latter before it extends to the collum, at which point it becomes accessible to the examining finger (Fig. 146). In June, 18S6, I have showed to the Obstetrical and Gynae- cological Society, at Berlin, a case quite similar to the one here repre- sented, and very characteristic of the disease. The symptoms of carci?iojna corporis are h(Bmorrhage and increase of secretion. The former may occur in the type of menstruation in younger women ; in those who are older it comes on in the form of a bloody admixture in the discharges, which finally increases to an abundant haemorrhage. The secretion differs in the beginning very little from that of endometritis ; later it acquires a peculiar stench like carrion, and it con- tains very frequently larger or smaller particles of the ulcerated surface. It may occasionally be pent up in the corpus or in the cervix, and thus form a great cavity without implanting the malignant new-growth on these parts. ^\\& pains Ao not depend so much on the extension of the new-growth as on the fact that the uterus is hindered by the infiltration in its efforts to expel its contents, and that, on the other hand, the disease attacks the peritonaeum, and then symptoms of peritoneal irritation are associated with the appearance of malignant infiltration of this surface ; this leads to adhesions with the neighboring organs adjacent to the place affected. No one of the clinical symptoms suffices to establish the diagnosis of carcinoma corporis. Of coiuse, when irregular discharges of blood occur in women during or after the climacteric, the fact is worthy of r. Ruffe and J. Veil, Zeitschr. I. Geb. u. Gyii., vi. 261, anil r-f), in order to make the border separate widely. Finallv, the uterine cavity is rinsed with the irrigating fluid and injected with 2-3 grammes of liquor ferri ; the superfluous liquor flows also over the raw surface in the collum and stops the bleeding there. In all cases very thin discs of cotton, thin as paper, wet with the liquor ferri, are laid between the gaping lips of the vaginal portion, the bullet- forceps are removed, the vagina cleansed, and, finally, if the haemorrhage ceases, a thick tampon of cotton is pressed against the portio before the vaginal dila- tors are remo\'ed. The haemorrhage must certainlv be controlled before the patient is put to bed ; if necessary, the discs of cotton must be renewed. Personally, I have always succeeded, up to the present time, in stopping these haemorrhages in the above manner. If, however, there should be difficultv in controlling the bleeding, the latter could, in any case, be overcome bv sutures passed through tlie cervix. After- Treahnent. — The patients must lie quietly in bed for two days, and the catheter must be used, in case they cannot pass their urine while lying down. On tiie third day the patient is to be taken out of bed and placed in the dorsal position on the operating table, where the tampon and the cotton, impregnated with liquor ferri, are to be removed. If tiiere is no bleeding after the irrigation of the vagina, whicli is then given, the patient is placed in bed again, without any packing, to lie quietly for twenty-four hours more. If there is bleeding, and it does not cease, the liquor ferri is applied again, on cotton, and is only removed after twenty- four hours more, — after which time I have always seen the bleeding cease. On the day after the removal of the last of these packings, the real after- treatment commences. This consists in irrigating the vagina through a cylindrical speculum, and then introducing between the lips of the wound Discision. OF THE DISEASES OF WOMEN. 343 suppositories of cacao-biittcr, which are retained in position by a tampon. By means of this oily layer the lips of the wound are prevented from contracting undesirable adhesions, and heal, as a rule, forming an os, whicli is widely patulous and not distorted by cicatricial contractions. During this process it is usually necessary to repeat the application of these cacao suppositories ten to fourteen times. I let the patients take out the cotton tampons themselves after six hours. Cleansing irrigations are given morning and evening. If cicatrization is tardy, I cauterize the surfaces of the wound with tincture of iodine before introducing the suppository. During this whole time the patients must not leave the bed-chamber. Discision, performed in this manner, has as yet presented no compli- cation to me, and has regularly furnished a well-formed orifice. I must, to be sure, emphasize the fact that I am not accustomed to perform disci- sion as long as there is a condition of acute inflammation of the mucous membrane, or any sensitive remains of chronic inflammation in the neigh- borhood of the uterus. As long as the latter, in particular, are not removed, I decline to perform any operation, and consider my own favor- able results to be due to just this circumstance. The disastrous eflects of discision, as described b}- other authors, are, in my opinion, to be attributed only in part to any sepsis which has been introduced by acci- dent. In the majority of cases the complication with recent or old peri and para metritic inflammation ought to bear the blame for such mis- fortunes. I, therefore, urgently advise, whenever possible, to avoid the performance of discision when such disturbances in the vicinitv of the uterus are present, since just this operation must be designated as one which is very seldom urgent, and a temporary postponement of it, on account of the inflammation in the neighborhood, can hardly encounter serious opposition. 3. — Circular Wedge-shaped Excision.^ Among the methods which have been proposed for the formation of a widely patulous os uteri, instead of discision, the procedure suggested by Simon,' of a circular •wedge-shaped excision., certainly takes the first place as a surgical operation. By this the stenosis is radically ciu'ed. and as those who have in later times practised Simon's method — especially ' Die kegelmantelformijj^ige excision; i.e., excision of ;i piece shaped like the hollow trunc.ited cones, having a wedge-sliaped section, which charcoal-burners use to cover conical stacks of smoulder- ing wood. - Marc/cxva/J, Arch. t'. Gyn. viii. CDiiiparc StItroJt-r, C'harite-Annaleii, iSSo, S. 54.3. 344 PATHOLOGY AND THERAPEUTICS E. KuESTER {^loc. cit.) — have stated, by this means, in a simple ancl safe way, a method of treating the hypertrophy of the collum at the same time is oflered. As above stated, I cannot admit the pretext that discision does not fiwnish a sufficient guaranty for the formation of a patu- lous OS uteri. The other part of the recommendation of the circular wedge-shaped excision is, in fact, warranted ; namely, that thereby it is possible to influence the neck of the uterus in a permanent manner. I practise this operation in cases of moderate stenosis in which an elonga- tion of the cervix is in process of formation, while the cervical catarrh has been arrested early. In this last point lies the difficulty, which in mv opinion contra-indicates an extended use of this operation. This kind of excision leaves the mucous membrane of the cervical canal intact, and presupposes that it is not necessary to exert an action on the condition of the mucous membrane by this method. Now such cases are compara- tively rather rare ; usually in cases of stenosis the inflammation of the mucous membrane is already far advanced, and requires almost more than the former, and than the elongation or hypertrophy of the collum, a thorough transformation, such as ought to be induced by operative treat- ment. For this reason I consider that the form of excision in question is indicated in only a comparatively limited number of cases. For performance of the circular ivedge-shaped excisiojt, after appro- priate disinfection, under anaesthesia, and in the dorsal position, the perinaeum of the patient is retracted with a speculum, the collum is drawn down by means of one bullet-forceps, and w^ith another, under continuous irrigation, the posterior lip is seized at its most prominent part. With a rather narrow knife the lips of the os uteri are first slit on both sides, close up to the vaginal insertion. Then the lip is incised at a suitable distance from the cervical mucous membrane, and this incision, according to the development of the collum, is carried with a depth of i, 2, or more centimetres (f-f of an inch or more) around the os uteri, from the commis- sure of one side to tiiat of the other. Then a second incision is likewise carried from one commissure to the other, at about the junction of the lower and posterior surface of the portio vaginalis. This incision is on a plane oblique to that of the first, whicii it joins at a suitable depth. The piece thus excised is, in fact, shaped like the cover of a ciiarcoal- stack (Fig. 159). Then the sutures are carried under the wdiole raw- surface, using a moderately large needle ; occasionally the threads Vw in the mucous membrane of the cervical canal, but in general their place should be just outside the junction between the cylindrical and the flat epithelium. The wound is then suitably closed by tying the sutures. OF THE DISEASES OF WOMEN. 345 The excision of tlie anterior lip is then performed similarly, carrying the incision from one commissure of the lips to the other, first parallel to the cervical mucous membrane, then above this incision another is made along the border between the inferior and anterior surfaces of the portio. If the wound has been united here also by sutures running under the whole raw surfaces, and if the incisions on each side have been sewed together firmly, the result of the operation is as represented bv the accompanying figure (Fig. i6o). The operation itself can be performed very easily and rapidly, the conti'ol of the haemorrhage is very sure, and Fig. 169. Fig. 160. Circular wedge-shaped excision, after Simon. Suture after the circular wee shaped excision. no difficulties usually disturb the imion of the wounds, unless the threads- cut throvigh the cervical mucous membrane, and thus give rise to irregular cicatricial formation. I have these patients also keep the bed for seven or eight days. Dur- ing this time they are catheterized if necessary, and on the fourth day they receive castor-oil. As subsequent treatment, vaginal irrigations with weak disinfectant solutions are employed. On, or soon after, the ninth day the sutures are removed, and then for consolidating the cicatrix injections are given containing acet. pyrolignos. rect. (three tablespoonfuls to the quart of water), or a solution of tinct. iodine, 25 parts: potass, iod., 5 parts; water, 170 parts (one tablespoonful to the quart of water). In two or three weeks the union is usually covered w'ith epithelium ; the w'idely patulous orifice allows the mucous membrane of the cervix to appear at the OS. 346 PATHOLOGY AND THERAPEUTICS 3. — The Operation' for Laceration oi- the Cervix. In comparison with the applause which, for a time, was accorded to discision of the colhim, it made at Hrst a peculiar impression, that Emmkt derived an indication for an operation on the portio from the very tact of a patulous condition of the os uteri ( 1874).' Emmet assumes that the open state of the collum, of which Roser- has furnished a very accurate description, is the source of a very large number of maladies of the genital system ; he sees in these lateral lacera- tions of the cervix the cause of chronic endometritis and metritis, of dysmenorrhcea, of sterility, and of extreme sensitiveness, and he advises the removal of even the slightest injury of the collum, whether the same is to be considered as the foundation of the disease or as a possible occa- sion of the latter. The operation for the repair of laceration of the cervix, which was taken up with such extraordinary enthusiasm by Sims, has been greeted with much less approval in Germany : in tact, a very decided opposition to this operation has not failed to manifest itself. ' I became convinced that cervical lacerations are at any rate not always matters of slight importance ; but I have also not infrequently observed such rents, which were noticed quite accidentally, and were causing no trouble; and in these cases 1 have found the widely gaping halves of the cervix Iving beside each other without any trace of disease ; the women suffered no disturbances either of sensation or function on this account. On the other hand, lacerations of the cervix are found in cases of intense catarrhs and of advanced chronic metritis, and ther. it can be very definitely determined that these cervical injuries are of decided importance in regard to the hiemorrhages, the pains, and all the other sufferings of these patients. From all these observations, I conclude that lacerations of the cervix, in themselves, certainlv need not necessarily lead to severe disturbances, and that, in fact, their later course may exert no influence at all, just as their origin may give rise to no symptoms. If, however, from other causes there are developed catarrhs, chronic metritis, or irritations in the mucous membrane and in the floor of the pelvis, these lacerations of the cervix favor a very rapid extension of these diseases, and on account 1 Americ. Journ. of Obstet., November, 1S74. Americ. Practitioner, January, 1S77. - Arch. f. Heilkund, ii. 7, 1S61. " Breisky, Prag. nied. Woch., 1S76, Nr. iS, lately AUg. Wien. iiiccl. Zeitschr., 1SS2, Nr. 5^- O/.t/fOKSfW, Centralbl. f. Gyii., 1S77, Nr. ij. Spiegelberg, Brtslauer jirzt. Zeitschr., 1S79, Nr. 1. Then Ilovjitz, Gynaek. og obstetr. Meddelelser, Bd. i, Heft 3, and Kaarsberg, Kopenhagen, 18S4. Schriider, Americ. Journ. of Obstet., July, 1SS2. OF THE DISEASES OF WOMEN. 347 of tJie cicatricial contraction in their vicinity they may become a 7iever-f ailing source of irritation., and, therefore, of the continuance of such diseases. In accordance with these observations, I consider the lacerations of the cervix as insignificant, when the other conditions of the genitals are healthy, and I sec in the former no indications for inter- ference. If disease develops in their neighborhood, I consider tlie re- moval of the cervical lacerations as also requisite in order thereby to abolish this source of continual disturbance.' The cervical lacerations are, with few exceptions, to be found at the sides of the collum. Generally the portio vaginalis lies open where they are situated, sometimes on one side (Fig. i6i), sometimes bilaterally ; and Fig. 161. Fig. 162. Cervical laceration of the right side {Emmet). Rent of cervix and of roof of vagina (laqiiear). there may be a thick, hard, and sensitive scar at the junction with the vagina. If the rents go above the junction of the vagina with the collum, they usually extend with a point running toward the cervical canal far beyond the scar which corresponds to the simultaneous lesion of the vault of the vagina (Figs. 163 and 163). Seldom does tlie latter lie open beyond the vaginal insertion ; usually there is developed at the side of tlie neck of the uterus (Fig. 163) a very tense, stellate cicatrix which can be traced for a considerable distance in the vaginal vault and in the pelvic floor ; this often extends to the side of the pelvis, and then later ma\ draw the uterus to one side, and may fix it there. 1 My cases have been reported by Arning, Wien. med. Wochensch., iSSi, Nr. 32 and 33, and by Czempin, Zeitschr. f. Geb. u. Gyn., 1SS6, Bd. xii. I luivc myself furthoi' exphiined iny slandpoiiU in .i communication to the Best. Gyn. Soc, 1SS5 (Journ. Am. Med. Assoc). 348 PATHOLOGY AND THERAPEUTICS Fig. 163. Rent of cenix and roof of the vagina (laquear) on the right side. If these cervical lacerations and the consecutive scars in the vaginal vault are unilateral, tlie colluni lies open on this side to such a degree that the portio vaginalis ap- pears everted to such an extent that it is unrecog- nizable. If the lacerations are bilateral, and if morbid processes are developed, the coll urn rolls out to such a degree that, partly on ac- count of the changes in the mucous membrane, partly through the alterations in the uterine tissue itself, a quite astonishing shape of the uterine neck results ; then over the split collum, of which the vaginal por- tion presses into the vagina like a cauliflower growth, there is found the small ante or retro fleeted uterine body, to the lower end of which the rujDture extends (Fig. 164). In all these cases the rent as such is not the cause of tiie deformity, for very many lacerations, even considerable ones, are ^'0- ^®'*- seen to exist w ithout anv in- iin"ious consequences what- ever. When there are lacerations, however, dis- ease of the mucous mem- brane or of the parenchyma makes its appearance much more frequently. The symptoms are caused only too frequentlv by these diseases which complicate the cervical lac- erations. A very peculiar shape is acquired by the cases in which the rent has sundered the vault of the vagina at the same time as the collum {retit of Eversion of the lips in bilateral laceration of the cervix. OF THE DISEASES OF WOMEN. 349 cervix and lagueai'). It is not only that the rent in the colluni then stands open further up than tliat in the vaginal vault, the scar of which often covers in nearly one-third of the cervical laceration, but, moreover, the cicatrix in the vault — or, better said, in the pelvic floor — fixes the uterus to the pelvic wall, drawing it out of place in the most irregular manner, and thus makes the malady severe enough to deeply affect the nutrition of the pelvic organs. The atrophic parametritis, which is ex- cited and maintained thereby, is further explained in the chapter on that subject. When there is decided cicatricial contraction in the collum, the health of the unfortunate woman may become completeh- ruined, and she may present the appearance of the most profound cachexia, owing to the contin- uous pain and to the sufferings which accompany every motion, every defecation, and every attempt at urination. If the mucous membrane is simultaneously diseased, it protrudes greatly through the vawning crater of the cervix, it may push its way beyond the cervical laceration itself, and then, by its extraordinarily increased secretion, its great tendencv to haemorrhages, and ks varying consistency, it may strikinglv resemble malignant disease, so that only a microscopic examination can shov.- that behind these alterations there is only an intense endometritis. In rents of the cervix and roof of the vagina^ the impediment to the movements of the pelvic organs in relation to each other, and the disturb- ances of the vessels which nourish them, become of the greatest promi- nence, and the poor women are unable to walk or to work, the evacuation of rectum and bladder is impeded and painful, and the menstruation may become more or less scanty. The diagnosis of lacerations of tlie cervix in itself involves hardly any difficulties ; it requires only a very accurate attention in order to avoid any errors in regard to the relations of the collum and of the corpus. The depth of the cervical rent can then be very easily measured and determined with the finger and the sound, as well as the heiglit to which the rupture extends, especially behind the scar in the vaginal vault. The treatment of cervical lacerations, according to my views, as ex- plained above, will depend first on whether the laceration comes under treatment during labor, and immediately after its origin, or only after its cicatrization. Fresh and extensi\e rents in the cervix, reaching up to above the insertion of the vagina, usually cause serious hasmorrhages immediately after their occurrence ; that is, just after delivery ; and unless the bleeding ceases immediately, owing to the puerperal contractions of , the uterus, they require that the edges of the wound l)e united at once, which is to be performed as will be described immediately. 350 PATHOLOGY AND THERAPEUTICS If the cervical lacenition is found when it is already cicatrized, and' if there is no complication with endometritis, metritis, and parametritis, the rent in itself does not require operative treatment, and I particularly avoid the latter when tlie patients with such a rent conceive and carry children easily ; when, therefore, the injury of the collum has had no injurious influence on the development of the uterus during preg- nancy, and on the course of labor, if iiijlainmatory processes are localized in the vicinity of the rent^ and if the cervical laceration is a source of continual excitation^ of para or endo metritis^ or of fnctritis^ which I regard as accidental^ and as not necessary accom- paniments of the rent itself^ I consider the removal of the latter sitn?cltaneously -vith the treatment of the above-mentioned processes as urgently indicated. The diseased mucous membrane does not get well of itself before the diseased parts are removed from the influence of the frequently recurring irritations originating from the vagina, by means of the restora- tion of the normal shape of the collum. A chronic metritis is, in fact, hardly relieved by the union of the cervical rent itself; but, on the other hand, the treatment of the chronic metritis by excision at the collum may very easily be arranged so that the deformity of this rent is thereby re- moved, and then a configuration of the vaginal portion approximating the normal is attained. Even more definitely have I been able to estab- lish the secondary action of a cure of the cervical laceration, in cases of chi-onic parametritis, on cicatrices in the vault of the vagina. If tlie scar-tissue is excised from the uterine neck, and thereby the continually recurring irritation of the uterus and of the mucous membrane is relieved, or if in other cases the scar in the floor of the pelvis is dissected out, and thereby the vault of the vagina and the uterus are united by a properly formed cicatrix, not only does this parametritis get well simultaneously with the uterus, but there ensues a speedy recovery of the emaciated woman. Therefore, I would recommend the operative treatment of lacerations of the cervix^ with sensitive cicatricial contraction in the uterus^ and of such as co7>iplicate chronic catarrhs., or as complicate rents and scars in the vault of the vagina. The treatment of cervical lacerations must not be limited to merely always removing the rent by refreshing the original torn surfaces, and to trying to restore the shape of the collum. According to whether disease of the mucous membrane, or of the uterine parenchyma, or of the para- metrium has been developed, such a restoration as has just been described must be abandoned, and the reunion of the defect must be combined at once with the removal of the altered masses f)f tissue. OF THE DISEASES OF WOMEN. 351 Accordingly, the operation may take various forms; either: i, as simple closure of tJie cervical laceration ; or, 2, as excision in the collunt and in the rent; or, 3, as ofieraiion on the colluni and on the vault of the vagina. I. I perform the operation on the colhini in the dorsal position, under anaethesia, after appropriate cleansing and preparation. I seize the collum, when exposed, by the anterior lip, with the bullet-forceps, at a point where the edge of the os uteri is to be made ; in the same manner I seize the corresponding spot on the posterior lip, and with a lance- shaped knife I make an incision around the edge of the rent, so that I dissect off in one piece the whole surface which is to be refreshed Fig. 165. Emmet's operation. Trachelorrhaphy. (After llcgar and Kalhnihach^ (Fig. 165), and at the same time I refresh the edges of the os uteri. To dissect out the whole piece of tissue referred to, especially at the upper angle of the rent, is occasionally extremely difficult, where there is a very firm cicatricial distortion ; but just by means of thus dissecting out the required strip in one piece, a good control over the result of the refreshment is obtained. The haemorrhage is usually not considerable. The raw surface is carefully smoothed, and then is so united that the uppermost sutures are introduced from the vaidt of the vagina through the edge of the refreshment in the cervical canal which is to be estab- lished, and from there they are brought out through the corresponding opposite edge of the cervical canal again into the vault of the vagina. I then tie each thread immediately, in order to be able to control the exact adaptation of the raw edges of the mucous membrane. As a rule, four 352 PATHOLOGY AND THERAPEUTICS or five such deep sutures are sufficient tor uniting the surfaces down to the point of the newly formed portio. Between these I also introduce superficial catgut sutures, in order to unite the external covering of the portio in a straight line. Often the excision must extend even further on the vault of the vagina, if the chronic catarrhal changes have already gone so far (Fig. 165). This operation is also usually preceded bv cu- rettement and cauterization of the mucous membrane of the colhmi and of the corpus, bv means of liquor ferri. After the completion of the suture I Hgain introduce the tapering point of the irrigator into tlie cervical Fig- 166. RefreshmeiU and introduction of sutures in bilateral laceration. ^\fter Emmet.) canal, in order to test its size. For sutures I formerly always used silk ; recently I have only employed silk for the deep sutures, using catgut for the superficial ones. If bilateral lacerations are to be closed, a hrst suture is to be intro- duced at the upper angle of one side, after refreshment, in order to con- trol the bleeding, which is here sometimes rather profuse ; the other side is then refreshed, and now the sutures are introduced alternately in one or the other side, until the commissure of the lips of the os uteri is formed (Fig. 166). In the bilateral operation, the cervical canal only too readih' becomes too narrow, and tlie portio too pointed : tiierefore from the be- irinningf the refreshiiK-nt must not bi- made too extensive, and as broad an OF THE DISEASES OF WOMEN. 353 external orifice of the uterus as possible must be left. The after-treatment is not an active one, as, in all these plastic operations, only from time to time vaginal irrigations are given. The threads remain in place until the eighth or ninth day, and then are gradually removed. 2. If the cervical laceration is complicated by chronic endometritis and metritis., and if the removal of portions of tissue from the collum itself is necessary for inducing involution of the diseased uterine para- metrium, I modify the refreshment by excising corresponding pieces out of the lips. In unilateral lacerations, in case the posterior lip cannot be drawn far down, as it can be in bilateral rents, I make it possible to draw it down, if necessary, by splitting the other commissure; then I make an incision from the upper end of the cervical laceration on both sides around the piece of mucous membrane which is necessary for forming the cervical canal ; then I cut transversely into the posterior wall of the collum at the point w^here I intend to form the os uteri, near the lower end of the col- lum which has been drawn down ; starting from this point I excise, after the manner of Hegar's amputation, as large a piece as is desirable, and immediately suture this wound so that the bleeding here ceases entirely. Now I draw down the anterior lip, make an incision here also around a piece of the cei'vical mucous membrane as large as seems necessary for the canal which is to be formed, and before I make the incision of the anterior lip I dissect out the scar of the cervical rent as far as the upper end of the rupture. Now without further difficulty I can excise and sew up the anterior lip and finally close the open slit on each side, quite sim- ilarly to the union of these surfaces which has been described above. From this kind of operation there results an exact configuration of the portio. 3. In cases o^ parametritic cicatrices., not only must this scar-tissue itself be removed as far as possible, but, above all, the fixation of the uterus must be relieved (Fig. 167a). For this purpose I seize the uterus and draw it as far as the continuity of the parts permits towards the side opposite that on which it is fixed ; then I separate the scar from the ex- ternal surface of the collum uteri by a semi-lunar incision around the side of the collum. As a rule, I thrust a double-edged, pointed, lance-shaped knife beside the collum from the outside, and with it I make around the uterus an incision of such breadth and depth that no more tense cicatricial bands can be felt. Then, as a rule, the wound gapes very widely. The uterus sinks distinctly into the middle of the pelvis. I can now dissect out the whole scar from the vaidt of the vagina, and proceed to unite the opening. The cut by the collum runs from before backwards. 354 PATHOLOGY AND THERAPEUTICS On extreme abduction of the uterus, the edges of tlie incision readily fall together, forming a line of union which runs transversely through Fig. 167a. Fig. 167b. Refreshment and suture in unilateral laceration of the cervix. the vault of the vagina, so that contraction of the latter seems thereby to be prevented (Fig 167b). Then the operation for laceration of the cervix is performed in one of the ways described above. The after-treattnent is as expectant as possible. When there are parametritic scars, I have ice applied immediately on the abdomen ; and up to the present time, out of sixteen cases I have seen no injurious effects of such an operation in the parametrium.^ Very smooth cicatrices are usually formed, which permit free mobility of the uterus. The pains have disappeared immediately in all the cases up to the present time, and thereby an immediate relief of the patient from continual torment has been brought about. The uterus remains movable and undergoes involution in a normal manner. 4. — Amputation' of the Coi.lum Uteri. The removal of the collum has formerly been performed by many, especially for carcinoma, by simply cutting it off with a knife at the level of the vault of the vagina. The apparently unavoidable haemorrhage which resulted was often so serious that this operation has been represented as extraordinarily dangerous. It therefore seemed a decided progress when operators learned to apply Chassaignac's ecraseur around the vaginal portion, which projects so prominently from the vaginal roof, and thereby to perform the removal of this part. But the use of the Ecraseur .involved many disadvantages ; 1 Compare Czcmpin, loc. cii. OF THE DISEASES OF WOMEN. 355 in the first place, in the removal of the coUum, even if not much of it was included in the loop of the ecraseur, injuries of the bladder and of the pouch of Douglas were observed with great comparative frequency. Both of these injuries arc, indeed, not so dangerous as had been believed, as is proved by a rather large number of such experiences ; but they are, nevertheless, serious enough to contra-indicate the use of the ecraseur in the removal of the collum. These injuries resulted from the constriction of the neighboring tissues, as may be explained by their varying capacity for resisting ecrasement. The portio, which is traversed by abundant fibrous bundles, yields like a brittle material to the constriction of the loop, while the mucous membrane, which is permeated with elastic fibres, the vaginal wall, and the surrounding parts oppose a longer resistance to the crushing action of the loop of the ecraseur. Even more important, however, seems to me the objection against the use of this instrument which I have derived from personal observation of a great number of ^crasements performed by my father and other gynaecologists, and finally from my own practice ; and this is, namely, that the control of hsemorrhage by the ecraseur is by no means even approximately sure, and that the cicatricial formation after ecrasement leads to decided distortions and stenoses, and even to atresias. These disadvantages are not completely removed by any of the sub- stitutes for the ecraseur ; both the guillotine and the galvano-caustic loop Fig. 168. Fig. 169. Suture after amputation of the collum, according to Sims. have their own difficulties in addition to these unpleasant results of ecrase- ment, and, therefore, for my own part, I have entirely given up using them. It appears to me that tlie rejection of these apparatus is also unavoidable, owing to the fact that in using them we take away from our- 35^ PATHOLOGY AND TIIERAPFMTICS selves the possibility of modifying the removal of the coUiiin according to the condition of each individual case, and especially of treating the mucous membrane, as is indispensabl)' necessary, in consideration of the high Fig. 170. Fig 171. Suture of the stump after amputation of the coll urn, accorrling to Hegar. importance of the diseases of the latter. The majority of German oper- ators have given up that method of amputating the collum with a knife, which corresponds with the circular incision of the surgeon in an amputa- tion, such as was proposed by Sims,' and is also at present recommended Fig. 172. Sutures after excision (Hegar). by Emmet" (Figs. r68, 169) ; for the covering of the stump with vaginal mucous membrane, after the manner of Sims, oflers too many disadvan- tages ; above all, it involves danger of secondary haemorrhage and un- suitable cicatricial formation. For the real foundation of amputation of the collum we have to thank 1 Uterine Surgery, iS66. - Gynecol., ed. iii., 1SS5. OF THE DISEASES OF WOMEN. y:>i Hegar,' who by means of his method made it possible to adapt the operation to each case most completely, and thereby puts the formation of the cicatrix and the security from haemorrhage entirely into the hands of the operator. The procedure of Hegar consists in bringing down the uterus as far as circumstances permit, and placing it so between the vaginal specula that the collum is easily accessible. Then the lips of the os uteri are split on each side up to the insertion of the vault of the vagina ; and first, a more or less thick wedge is excised out of the posterior lip from the border of the cervical mucous membrane as far as seems necessary in the given case. The sutures are applied by carrying the threads under Fig. 173. Fig. 174. Excision, according to Schroeder. the whole raw^ surface so that the scar comes about at the summit of the stump of the posterior lip. In the same way the anterior lip is excised and sutured ; and, finally, the lateral commissures are firmly united also by deep stitches. The union of the lateral commissures may be accomplished either directly, as represented by Fig. 170, or by making a proper covering of mucous mem- brane, as is shown by Fig. 171- This procedure of Hegar would have appeared completely adapted to its purpose if Hegar had also extended the excision to the cenical canal. This very essential modification was suggested by Schroeder," who recommends that after bilateral disclsioit the lips of the collum 1 Naturforscher-Vers. Innsbruck, 1871, Nr. 7, S. 1S3. Odebrecht, Berl. Beitr. Zur. Geb. u. Gyn. iii., S. 220. 2 Charite-Annalun, 1S7S. Zeitschr. f. Gcb. u. Gyn. iii., S.419, and Miiricke, iii., S. .^zS of the same. 35-^ PATHOLOGY AND THERAPEUTICS uteri should be drawn apart and an incision should be made perpendicu- larly into the wall of the collum, at what appears to the naked eye to be the junction between the healthy and diseased mucous membrane of the cervix (Fig. 173, a). At the end of this incision another is then made from the external surface of the lip (from c), at whatever point the patho- logical changes in the given case seem to require. Union is obtained here also by means of threads running under the whole raw surface, the remainder of the lip being folded in (Fig. 174). After an excision has Fig. 17S. Amputation in cervical metritis. Eversion of the lips. Endometritis. Erosions. been made on the anterior lip, including, essentially, only the diseased mucous membrane, and when the lateral commissures have been closed, the configuration of the line of union is such that the stump of the collum is closed by the mucous membrane of the vaginal vault, which has been drawn over it from above, and that the lower border of the cenical mucous membrane being carried pretty far up into the cenical canal is removed as far as possible from the influences of the vagina. Both of these operations — that of Hegar and that of Schroeder — I usually combine in removing the collum. which T perform in such a OF THE DISEASES OF WOMEN. 359 manner as the indications for tlie operation on the colluni in each indi- vidual case require. If tlic mucous membrane is intact, — which, indeed, is seldom the case. — I make the excision according to Hegar ; if the mucous membrane is diseased, I remove the diseased parts of the latter as far as practicable, and I excise from the lip itself, or from the wall of the coUum, as much as seems necessary for union (Figs. 175, 176)- In this way the operation becomes verv easy and safe, and it can be performed in a relatively short time by one who has some experience in applying sutures. Fig. 176. Amputatio colli. As a rule, I cui-ette the mucous membrane (abrasio mucosae) before performing the amputation, on account of the frequent complication of the chronic diseases of the mucous membrane with affections of the uterine parenchyma. Then I draw^ the uterus down as far as possible, arrange it between the vaginal specula, disinfect the field of operation again, and then, under irrigation with weak disinfectant solutions, I split apart the lips of the os uteri as far as the insertion of the vault of the vagina. At the border of the healthy mucous membrane, wherever tliis may be, I now make an incision nearlv perpendicular to the longitudinal axis of the coUum, and by cutting in suitably from the outside on this first incision, I remove from 360 PATHOLOGY AND THERAPEUTICS the posterior lip as much as is necessary in the given case. The edges are sutured immediately, as far as the os uteri is to extend. Then the excision is performed on the anterior lip in the same way, to do which the bullet-forceps, which fixes the uterus in the position into which it has been drawn forward, should be moved back to a position more anterior, •it the junction of the anterior vaginal vault with the collum. Next follows the union of the lateral commissures by sutures ; the bullet-forceps are removed from the anterior vault of tlie vagina, for the collum can be fixed more conveniently by the sutures which have already been inserted. By these threads, one side of the collum is first drawn down into the median line and sewed together. Here also the threads must be carried under the whole raw surface, and just here they must often lie quite close to each other, since at this place the most frequent and copious haemorrhages occur. In the same way the other commissure is drawn down and united by sutures. As a rule, eight to ten stitches are required in the anterior and in the posterior lip, and three or four on each side. If the hemorrhage ceases completely, and if the raw edges of the cervical and of the vaginal mucous membrane are united accurately, the threads are cut ofl". After another cleansing of the uterus, the latter is put buck into its proper position, and then the patient is lifted into bed. Only exceptionally, when the secre- tions of the uterus have been very malodorous, do I place in the vagina a cotton tampon sprinkled with iodoform ; otherwise only when there is a great laxity of the tissues and a pronounced disposition of the tracks of the needles to bleed is a thick wad of cotton packed against the cervix ; usually there is no need of such an application. The patients are kept seven to eight days in bed ; the vagina is douched daily with weak carbolic or sublimate solution. The catheter is used as long as the women are unable to pass their urine spontaneously w^hile lying down ; from the third day attention is paid to having the bowels moved. .Sometimes they complain, during the first days, of much discomfort, especially in the legs, which comes from keeping them bent in the dorsal position during operation. If these pains are considerable, and the patients become restless in consequence of them, they receive morphine. Usually, however, such medication is not necessary. As soon as they cease to vomit from the effects of the anaesthetic, more hearty nourishment is given. On the second or third day after leaving the bed, the wound is examined in a cylindrical speculum and cleansed, and sometimes some of the stitches are then removed. When the secretions are abundant, a tampon of cot- ton with iodoform is introduced to aid in diniinisliing the former : this OF THE DISEASES OF WOMEN. 361 remains in place until the following clay. In the course of the next clays the rest of the threads are removed. Nevertheless, it does no harm to have tlieni remain for a longer time, and therefore in cases where the Fig. 178. Fig 177. Suture after amputation of colium. Sutures of the upper lip after amputation of coUum. i and 2. Sutures of the lateral commissure. patients had had quite a serious operation, I have frequently left the threads in place for several weeks or even months, and then removed them by degrees. Until the removal of the sutures I have douches of wood-vinegar (acet. pyrolig.) given, to which, after tw'o weeks, is added the solution of iodine mentioned above. The cicatricial formation after this way of performing the operation is regularly good. The configuration of the os uteri is seldom deformed by any cutting through of the thread, and it is only in quite isolated cases, out of more than one thousand of these operations, that I have obser\'ed stenoses afterwards. Firm cicatricial contractions also, and other deform- ities of the lips, are developed only very exceptionallv. For many beginners there seems to be a certain difhculty in the hcemorrkag'e^ which occurs even from the splitting" apart of ihc lips and during the excision of the pieces oj^ tissue. In my first operations I have myself been guided by anxiety about these losses of blood, and, like others, have devised measures to limit or to prevent entirely such haemorrhages during the operation. The proposals which have been suggested for the prevention or temporary control of haemorrhage consist in the constric- tion and compression of the colium uteri above the part to be excised, by 363 PATHOLOGY AND THERAPEUTICS means of an ecraseur or some similar instrument. Emmki- ' applied this compression by means of a watch-spring wire enclosed in a rubber tube which was fastened into a uterine tourniquet. Personally I iiave used a simple rubber tube for this purpose,- by tlirusting a Carlsbad needle above the part which was to be excised, through the wall of the vagina, and transversely through the collum, which had been drawn down, and by applying the tube above the needle. The peculiar advantages of the rubber tube in tliis place are evident; even if a diverticulum of the blad- der, or a part of the pouch of Douglas, which mav extend verv far down, is constricted in the loop, there is no danger of permanent injurv. After completion of the operation the tube is loosened, and if there is any bleed- ing from the needle-tracks it is controlled bv the introduction of stitches. For such a compression of the collum it must be possible to draw the latter down ; by this fact the opportunity of employing it is essentiallv limited. With greater practice iu the application of sutures I have aban- doned the use of this constriction more and more, and now I emplov it in suitable cases principally in order to demonstrate it to my pupils. The loss of blood in an amputation can be very easily limited, for after some practice and under reasonably favorable circumstances, the whole opera- tion requires only six to ten minutes. It is perfectly possible to put the first stitches in the places which bleed most, or to close the corresponding arteries by temporary sutures. I do not tie any vessels separately in the raw surfaces. The objection has been made to amputation that even the application of sutures to the stump does not give security against secondary iicemor- rhages. This objection appears not entirelv unfounded, according to those large series of observations on amputation which were first published. Personally, in the first hundred such operations, I have had only isolated cases of hsemorrhage'^ occurring afterwards, and I attribute this success to the fact that I always carry my threads under the whole raw surface, and tie them very tightly. Of course that is also a matter of practice, and so I have in fact formerly observed haemorrhages after operations by my assistants (who frequently receive from me an opportunity to perform them), when they were insufiiciently informed as to the degree of tightness with which the threads should be tied. Of late years, therefore, in the operations which have been performed by my pupils under my supervision, I have insisted on tying the sutures very tightly, and thereby haemorrhage has been almost completely pre- * Gynecology, Ed. iii., p. 466. 2 Berl. klin. AVochenschr., 1S76, Nr. 4. Lately, X. i''«rj>7 has described needles of liis own for liolding the tube in position. 3 Berl. klin. Woch., 1S7S, Nr. 42. OF THE DISEASES OF WOMEN. 363 vented, even in such operations l)y beginners. The secondary ha;mor- rliages may appear either immediately after the operation, or at the end of the first week, when some threads begin to cut through, and also when the threads are first taken out from the patients who have ah-eady left the bed. When such hasmorrhages occurred during the first eight days, I formerly took pains to control them by astringent injections, and by intro- duction of pieces of ice, or, if necessary, by tamponnade ; later I adopted the plan, whenever the haemorrhage was at all profuse, of immediately putting the patient on the operating-table, and there, after appropriate cleansing, if necessary under anaesthesia with chloroform, of immediately exposing the bleeding-point and securing it by the introduction of new sutures. Up to the present time I have controlled considerable haemor- rhages, such as, for instance, occur on taking out threads, by swabbing with liquor ferri, or, if necessary, by the introduction of a tampon after application of pledgets wet with this solution. Here also, in a case of protracted and serious haemorrhage, I would have recourse to a stitch. Since a very long time I have no longer had to do anything of this kind. Beside this method of operation, various others have been proposed to attain the same end. I refrain from describing them in this place, because most of them have not been introduced generally into practice. When I recommended amputation of the collum as a means of curing chronic metritis (1878), I also suggested an operative procedure of my own, of which the especial feature was the I'emoval of the cei"vical mucous membrane as thoroughly as possible. When I recommended the method then suggested, which consisted in an excision of nearly the whole collum, and a peculiar application of sutures to the funnel-shaped wound of excision, I had used it in no small number of cases, among which no bad results were known to me. It was only later that I frequently saw stenoses and even atresias occur after this procedure. In consideration of this, I attempted to modify the latter, but finally became convinced that such bad secondary eftects could be avoided only by a very complicated way of operating. Under these circumstances, I now only use this method very rarely, and refrain from explaining it more in detail. 5. — The High Excision of the Collum. The methods of operation already described, however possible it may be to adapt them to individual cases, are essentialb* directed against diseases of the collum in its lower portion. In rare cases it may appear necessary to dissect out the whole collum up to the corpus. Such an indication is found in cases of incipient malignant disease in the collum, 364 PATHOLOGY AND THERAPEUTICS or, it may l)e, in the lips of the os ulcri ; and it is to-day still niaintained and defended on the ground of the statistics from Sciikoeder's cases arranged by Hofmeieu.' I liave operated according to this indication up to six years ago frequently, since then occasionally, and in these cases have therefore contented myself with the excision of the collum uteri. I proceeded according to the metliod just mentioned, and in this way dissected out the whole collum. My experiences with this kind of opera- tion were altogether unfavorable as far as concerns radical cure of the carcinoma. I have observed the recurrence of the latter in all these cases ; this occurred about one year after the first operation in the most favorable cases, usually very much earlier, and then developed very rapidly, so that further radical operation was impossible, and the patients finally perished miserably ; therefore I have given yp excision of the whole collum in carcinoma. My last experience was reported above (p. 309). This operation appears in itself to be relatively free from danger, espe- cially if the precautions are employed which Schroeder - has recom- mended. These consist in a temporary ligation of the broad ligaments at a point where these contain the larger arteries^ the uterine^ and^ if possible^ the spertnatic. This ligation, of which I have already spoken in regard to splitting the collum uteri in order to make it possible to enter the uterine cavity, is not only practicable in excision of the whole collum, but is undoubtedly very eflficacious. In the twenty-seven cases '' in which in this manner I have prevented bleeding in excision of the whole degener- ated collum, neither the application of the sutures nor their treatment after- wards seem to me particularly difficult. The extraordinarily intense pains, however, which follow such ligations when the patients came out of their anaesthesia, compelled me to remove these ligatures, and I now usually do this immediately after the completion of the operation. The latter itself — the excision of the whole collum with sucii a tempo- rary ligation of the broad ligaments — is begun like an amputation of the collum. Under anaesthesia and in the dorsal position of the patient, under continuous irrigation, the portio is seized, and first it is drawn strongly to one side, after appropriate exposure between the specula, and after renewed disinfection ; then a moderately large, curved needle, with a strong double-silk thread, is thrust through the vault of the vagina as near as possible to the uterus, so that when this needle, after a sharply curved course, is finally brought out near the point where it was inserted. ' Hofmeier, last in Naturforscher-Versam, Berlin, iSS6. 2 Zeitschr. f. Geb. u. Gyn. iii., S. 419; vi., S. 213. 3 This number increases during- the last years by five or six yearly. Compare the employment of the provisional'liiJfation of the broad ligaments in scraping out inopverable cancers. OF THE DISEASES OF WOMEN. 365 the base of the broad U<^anieiit is encircled !)>• tliis thread. Befoi^e tying the latter, tlic portio must be again pushed into tlie ine(han Hue, in order to properly relieve the tension of the tissues encircled by the thread. In the same manner the other side is tied, if necessary ; also, before or behind these threads, others are inserted, passing through the basis of the broad ligament. Then the collum is split, and pulled apart as far as the upper limit of the proposed excision. The excision of the posterior half of the collum can be commenced and carried on from below, from the point of insertion of the posterior vault of the vagina, or also from above. When the ligatures in the vault of the vagina are w^ell placed, the bleeding is seldom of any importance, especially if there is no delay in uniting intimately and quickly the edges of the wound in the vaginal vault with that in the cervical canal, by sutures carried as deep as possi- ble (similarly to what is shown in Fig. 173). In like manner the anterior wall of the collum is excised, after that the separation of the collum from the bladder, commencing at the anterior insertion of the vaginal wall, has been attained by careful traction, and by pushing with the finger-nail. Here also the edge of the vagina is united with the edge of the cervical mucous membrane by deep-lying sutures. Finally the cervical commissures are united on both sides by stitches, and, after complete cleansing of the field of operation, the liga- tures in the vaginal vault are loosened and removed. At the close of the operation the corpus must have moved as far down towards the vagina as the collum has been removed. Simple as the operation appears to be, it is made extraordinarily diffi- cult by complicatioits., such as are occasioned more particularly by cica- trices in the vault of the vagina. Not unfrequently there is injury of the periton(EU7n., and the pouch of Do7iglas is opeiied. The injtiries of the latter., according to the almost unanimous opinion of authors, do not involve the danger which was formerly usually as- cribed to injuries of the peritonasum. But they are not tri\'ial, in consider- ation of the size of the wound and the extensive damage to the vascular system at the sides of the uterus. Lately, in cases of injury to the peri- tonaeum, if the edges of the wound could not be sewed together sepa- rately, I have made a border around the wound by imion of the vagina with the peritonaeum (as in cases of vaginal extirpation of the uterus) , and I have laid a drainage-tube in the open aperture, which remained in place from three to six days. Thereupon these secondary injuries healed without difficulty. 366 PATHOLOGY AND THERAPEUTICS 6. — Vaginal Extirpation of the Uterus. The removal of the whole uterus, as it had been performed inten- tionally by the elder Langexbeck (1S13), and by Sauter (1S22), had been practically abandoned again ; even the operation performed by Hennig^ (1S76) had not rehabilitated it, when Freund,- in the year 1878, with a new method brought this operation again into practice. Although Freund's method has indeed since that time been aban- doned, because the greater the number of cases reported the worse were the results as published, yet the great service of Freund remains, that he enriched modern gynaecology by the operation of extirpation. Czerny ■' first substituted the vaginal operation for that of Freund. Shortly after him Billroth,'' Schroeder,* Schede," and I," published corresponding cases. The procedure recommended by Fritsch * was extensively employed. Extirpation^ however performed, was first brought into requisition against carcinomatous and sarcomatous diseases of the orgatt. Such malignant diseases can be recognized to-day earlier and more certainly than was possible even at a time not very long ago, and therefore \ve must neither be led astray by the unfavorable opinions concerning this operation, which have been based on ethical considerations, nor yet by the results, which have not been successful everywhere ; for the earlier w-e operate, the more we may hope that the operation will result successfully, not only in regard to immediate recovery, but also respecting relapse. It is only in regard to cancroid (epithelioma) of the vaginal portion that divergent views still exist among German gynaecologists, as to whether it is advisable to perform vaginal extirpation, or to be contented with high excision and cauterization of the stump. Schroeder, with Hofmeier.^ on tlie strength of his statistics, recom- mends the latter procedure, while, on the other hand, the supporters of the immediate radical operation are nevertheless increasing in number.^" I ' Naturforscherversammlung, Hamburg, 1S76. - A. W. Freund, Volkiiiann'sche Saminlung, Xr. 13^^. Ccnlralhl. f. (iyii., Xr. 12, 1S7S Berl. klin. Wochensch., Nr. 27, 1S7S. 3 Wiener mad. Wochenschr., 1S79, 4S~4'^ * Wolffler, Chirurgen-Congress, iSSo. '' Ibidem. '■ Naturforschervers., Danzig, 1S80; see, also, Baiim, Zeitschr. f. Geb. u. Gyn. vi. • Danzig, iSSo, .and Centralbl., iSSi. 'CentralbL, 1SS3, Nr. 57. » Zeitschr. f. Geb. u. Gyn. xiii., 367. '" Brennecke, Berl. klin. W^ochenschr. Slaiide, Berl. klin. Wochenschr. Fritsrh, Arch. f. Gvn., 1S87. OF THE DISEASES OF WOMEN. 367 have explained my views above (p. 310 ct .sv?^.), and I am convinced that an early performance of the radical operation offers, on the one hand, a more favorable prognosis as to immediate recovery, and, on the other, must give better results as to complete relief from the disease. Ten years ago, A. W. Freund inaugurated the extirpation of the can- cerous uterus ; it may be supposed that sufficient material is at hand to decide the two following questions, which may legitimately be asked con- cerning every new method of surgical treatment: — I St. Is this operation practicable, with such immediate success that it promises good results in the hands of others than a few specially success- ful operators? 2d. Does the extirpation of the cancerous uterus give permanent results which force us to recognize that this method is superior to any other treatment of cancer employed up to the present time ? In seeking to answer the first question, if we examine the literature, we are struck with the fact that so meagre and isolated reports about this operation can be found in the journals of English and German medical literature. The fact must be recognized that the vaginal extirpation has obtained decided recognition in Germany. Here the purely vaginal opera- tion of CzERNY and Billroth and Schroeder has been adopted in place of the procedure of Freund, which was a combination of abdominal and vaginal operation. The results of the same have improved in a veiy noticeable manner, with increasing exercise and experience. In 1881, Olshausen collected 41 cases with 39 % mortality. " 1883, Saenger " 133 " 28 % " 1884, Engstroem " 157 " 29 % " " 1886, Hegar " 257 " 33 % " Through the courtesy and kindness of these operators, who, to my knowledge, commanded the greatest amount of material, and who, at my request, placed at my disposal the results up to the end of the year 1886, I am able to construct the foUowine table : — Table I. Up to the end of 1886, the following total extirpations have been per- formed on account of carcinoma uteri : — Fritsch . . . . .60 times, with 7 deaths. Leopold . . . . -42 " 4 " Olshausen . . . -47 " 12 " Schroeder [Hofmeier] . -74 " 12" 368 PATHOLOGY AND THERAPEUTICS Staudr . . . . .22 times, with i death. A. Martin . . . . dC^ " ii deaths. Total ..... 31 1 cases, with 47 deaths. Or 15. 1 %. The total result of vaginal extirpation on account of cancer of the uterus accordingly shows, in three hundred and eleven cases, 15. i per cent, mortality ; and are we not justified in assuming that this percentage of mor- tality will diminish \vith increasing experience, as shown by the improve- ment which may be easily seen in the published tabular results of each of these operators? Already, to date, the total extirpation of the uterus on account of cancer shows better results, so far as immediate mortality is con- cerned, than operation for removal of the breast for cancer. For the latter, Koester, at the twelfth meeting of the German Surgical Society, in 1S83, published seven hundred and seventy-eight cases, with a mortality of 15.6 per cent. ; and who would hesitate to propose to perform the amputation of the cancerous breast as soon as the diagnosis is estab- lished.? I do not hesitate to answer my first question in the affirmative, and to claim for this operation of the vaginal total extirpation of the cancerous uterus a full and equal rank among all the methods for the treatment of cancer of this organ. For the answer to the second question, we will make use of the rela- tively small, but very accurately reported, cases of Schroeder, collected by HoFMEiER, and those of Fritsch, Leopold, and myself. These cases are brought together in the following table : — OF THE DISEASES OF WOMEN. 369 a!. I < U 5 W X fa Z « OS A fa W W fa •SJB3X ^ 1 1 •SJB3X 9 1 M •sa-B3/( S 1 CO •sjBaA 1- 3 -^ I apoplexy. '^1 •siBaX f PI -1- I relapse. 1 nephritis. CI pi •sjBaX z >j-j t^ 6 a, 'V rv.. i;^ to CI '35 •sjBaX ^{i ON I relapse. 4 ? Cl CO a3 \0 " •IB3X I VO t^ CO pi!- •2 uoijsanb 3uiJ9AvsuB ui paaa -pisuoo gq o; s3sbd JO jgquinu SutuiBuia-y^ CO CI :|: en W w H fa •Flox 00 C5 •UAVOU>^U£^ N h-t ■sjuap N • •JB9X }SBd 3l{} uiq^iAV pa^Bjado - ►-< •q}B3a CO N J:^ t-i •S3SB0 JO jaqumf^ M 1 VO ^ 1 Th % vo 1 P-i 3 W J- V-. u w 'g cj r ^ -( u u <1 X t— X OS < ) A. Martin. Berl. Kl. Woch., No. 5, 1881. 370 PATHOLOGY AND THERAPEUTICS ^ ^ CO c >^ 0) (U ^ O T3 •^ " " " M t"! N o O -a U) Ol CC <'5 O) C/3 rr^ tJ- H, ro ^ ■" c/3 to CO (/3 o a> u JJ !^ ?^ >^ "^ _ . . . i- ^- t- — V. hH ."Z. vo vo vo VO CC 03 a, CO CO CO CO < OD CO OO OO CC b£ VO VO to VD 00 00 OO 00 CO CO CO CO c C ,o re '•S bX) K ui D. o u ^ 'Xj a, (U o -E re o ii =: re re (/) P § ^ ' -J' ^ Uh O OOOOOOOOQ c o o o "c 'c t: -c <^ J=. H = o c O w CO CO CO 00 CO CO c - ^ o .2 ^ re rD 1 1 1 {/3 t o to CO 00 10^ ^ ^ fO Th lO (Ai o 00 00 00 P t^ ?^ 00 CO 00 (U o re CO o S l-H HH H o OF THE DISEASES OF WOMEN. 371 Is there any otlier method of treating cancer which, with so small a mortality, can show equally good results? There is no other method for treating cancer of the fundus, and those forms of diseases of the cervix in which the mucous lining of the cervical canal is the point of origin, or in which there are carcinomatous nodules in the tissues of the neck. There is no room for discussion, except in cases of epithelioma of the portio vaginalis, arising from the surface of the cervix ; that is, from a surface covered with flat epithelium and containing very few glands. This form, according to Ruge and Veit and Sciikoeder and Hof- MEiER, has a character essentially less malignant than the above-men- tioned forms of carcinoma of the neck. According to Hofmeier, the high excision for epithelioma of the cervix has shown a mortality con- nected with the operation of 7.4 per cent., and a recovery of 53 per cent. for the first year and 33 per cent, after four years. That relapses are not prevented by this operation is expressly stated in Hofmeier's communication, and, therefore, it cannot be maintained that high excision is a safe means for treating this form of epithelioma of the cervix. My own experience in twenty-eight cases of high excision shows that six died under the influence of the operation, but all of the survivors relapsed in a short time ; only a few lived to the end of the second year. I agree with Fritsch that the observation of cases of progress of the disease in isolated nodules in the mucous membrane up to the fundus, in cases of carcinoma colli, as Binswanger and P. Ruge have described in very well marked cases, is sufficient in itself to show that it is erroneous to claim that in cases of carcinoma of the cervix we should try to save the body of the uterus. The possibility of a subsequent pregnancy is not excluded in cases of high excision ; but Hofmeier himself has declared that pregnancy is a very serious danger in cases of carcinoma ; therefore I am convinced that it is much better to immediately perform vaginal total extirpation in these forms of epithelioma of the cervix. The sooner we operate, the more^ surely we may hope to save our patients from the sad fate of death by cancer ; the earlier we operate, the better are the chances in i-eference to the general state of health of the patient in regard to recovery from tlie operation. The greater the experience with vaginal total extirpations, the more has the ride been proved that ivc shall perform the opcratio)/ only ivhe?i the vicinity of the uterus is e7ttlrelv free from carcinomatous infltration. All attempts to enlarge the boundaries of the operation in this direction have failed. The operation becomes very much more diflicult through such infiltration, the danger of the operation increases, and there can be no hope of permanent cure. The majoritv of operators 37-: PATHOLOGY AND THERAPEUTICS so tar as I can leani, liave concluded, as I have, not to expose these cases to any attempt at a radical operation. If the carcinoma appears in the form of a solid infiltration of the liga- ments and of the walls of the vagina, then the diagnosis and the decision present no difficulties. The progress of the disease by means of the lymphatics is often impossible to discover before the opening of the roof of the vagina. Such cases, then, are not dangerous, so far as the operation itself is concerned, but hopeless in respect to permanent cure. They ought to be put in a separate column in summing up the permanent results of the operation. Cicatrices on account of former inflammations in the floor of the pelvis may make the procedure extremely difficult and aggravate the prog- nosis through the shock of the operation, which is often very serious. At any rate, one should only venture to operate on such cases if there is a very strong indication for interference, and a reasonably great experience on the part of the surgeon. The technique of the operation itself has undergone only immaterial changes, as is shown by the i-esults of different operators using various methods. It is irrelevant whether the uterus be removed by an incision made in front of, or at the side of, or behind, the neck. It is of little importance whether haemorrhage be prevented by stitches introduced before the incision, according to my method, or whether each separate vessel be seized and tied as it bleeds. It is immaterial whether the uterus be turned over or removed by drawing it down and freeing it; whether the opening in the floor of the pelvis remain open, or be closed, or be drained either with the iodoform gauze or with a tube. If it be easily practicable, I advise that the ovaries and tubes be also removed. At all events, bleeding must be entirely stopped ; during con- valescence the parts must, as much as possible, be kept at rest. Washing out the peritoneal cavity does not work favorablv. However the opening in the floor of the pelvis is treated, a smooth scar is finally formed, into which the roof of the vagina curves upward. If the patients do not become septic, or get any other complication, they make an extraordinarily easy recovery. They recover their color and strength, and, after the symp- toms of the sudden change of life have been overcome, they seem to enjoy life fully. There is no obsei'vation showing that after removal of the uterus, with or without the tubes and ovaries, the patients lose their sexual feelings or their peculiar feminine form. / reconi7nend the vag^inal extirpation of the uterus as the operation^ as the means^ which we ought to apply in cases of cancerous diseases of the ziterus^ as long as the disease is limited to the uterus itself. OF THE DISEASES OF WOMEN. 373 The lndicatio7is for extirpation of the uterus have been extended in various directions. I have thought it advisable to perform such an operation in cases of malignant adenoma ; that is, where there was im- moderate growth of the glands of the mucous membrane of the corpus, with disappearance of the intra-glandular tissue. I believe that in consid- eration of the increasing recognition of the importance of this form of disease, the opposition against this indication, which exists at present, will cease, as a more perfect technique makes the operation a safe one. Moreover, I have performed vaginal extirpation in h<^morrhagic endome- tritis^i in women in the climacteric age, in cases where long and patient treatment xvas unable to control the bleedings even although in the particles scraped out of the mucous membrane of the uterus (in one case as many as eight times) nothing could be demonstrated except a condition of intense irritation. In all of these cases, which up to January, 1S87, numbered seven, the women were near the climacteric age, they had been brought into a con- dition of ansemia which was dangerous to life by the continual haem- orrhage, and they had become unable to earn their living owing to their malady. Neither a treatment in the hospital lasting many months, nor yet rational care afforded for a time at home, had been able to rescue them from profound misery. In such cases, some authors^ prefer castra- tion, expecting to bring about involution of the uterus thereby. I have had also one experience with a case of this kind, but the final result was unsatisfactory. The unfortunate patient bled after castration almost exactly as she did before. Finally, I had to perform vaginal extirpation. In this connection it is important to remember that, in fact, in these cases castration is usually as serious an operation as is extir- pation. Besides these indications, furnished by such serious diseases of the uterus, the latter was first extirpated by Kaltexbach" and by me, in cases of prolapse incurable by other means. My own three cases were women who were far beyond the climacteric, in one of whom the large and com- paratively heavy uterus had resisted all eftorts at cure by operative meas- ures in other hands, while in the others the floor of the pelvis, which was in a condition of advanced senile atrophy, was unable to support the organ, owing to the incomplete involution of the latter. In two cases, moreover, the uterus lay retroflexed, and could not be maintained in its physiological position by any mechanical support. The three women were completely disabled from work, owing to the prolapse, and were condemned to lie quiet continually. In view of such severe ' Olxhausen, Naturforschervers., Eisenach, 1SS2. 2 Centralbl., f. Gyn., iSSo, Nr. 11. 374 PATHOLOGY AND THERAPEUTICS symptoms, I consider extirpation of the uterus in old women for prolapse as entircl\- justifiable, especially if in these cases hiemorrhages from the uterus occur which are not dependent on malignant growth. I desire, on the other hand, to declare emphatically that I do not recommend vaginal extirpation of the uterus in general for prolapse, and only consent to do it in extreme cases under the above conditions. Quite a pecular indication for the vaginal operation presented itself to me on Jan. 3, 18S6. In an extremely anaemic person, I had noticed through the open cervical canal that there was a retention of placental fragments. The diagnosis had been doubtful, and so I had the attending physician and my assistants examine after me. As I then was about to undertake the presumably easy removal of the foul remains of the placenta, I found that the posterior wall of the corpus was ruptured, and that particles of the contents had passed into the abdominal cavitv. In view of the fatty degeneration of the uterus, of the undoubted decom- position of the uterine contents, of the impossibility of otherwise combatino- the certain infection of the abdominal cavity, I extirpated the uterus and disinfected the portion of the pelvis which was accessible. The patient recovered without disturbance. Since the middle of June, 1880, one hundred and thirty-four vaginal extirpations have been performed in my institutions, as follows : — lo in the year 1880. 9 in the year 1881. 22 in the year 1882. 20 in the year 1883. 16 in the year 1884. 24 in the year 1885 30 in the year 1886. 3 in the year 1887 (up to Januarv 15). 134, with 23 deaths. Of these there were sixty-six complete extirpations on account of car- cinoma, of whom eleven died. Of the forty-four on whom the operation was performed up to the end of 1885, recovery was demonstrable early in 1887 in thirty-one cases ; therefore, there was permanent recovery in 70.3 per cent., while 29.7 per cent, suffered from recurrence. Twenty-eight others were cases of incomplete extirpation ; of these, eight died. Nineteen ex- tirpations were made on account of adenoma ; of these, two died, and finally there were seven extirpations on account of otherwise incurable hjemorrhagic endometritis, with slight increase of glands and moderate OF THE DISEASES OF WOMEN. 375 polypous proliferation. In these cases the bleeding could not be con- trolled, even by repeated curetting and cauterization ; they all recovered. Two extirpations were performed on account of sarcoma, four on account of myoma, one on account of perforation of puerperal uterus, three on account of great prolapse, making ten cases which all recovered. Among the contra-indications of vaginal extirpation, I mentioned, while speaking of carcinoma, the extension of the infiltration to the neighborhood of the iiterus. Besides this, I recognize two more contra- indications, — one consisting in adhesions of the uterus to the neighboring parts ; the other, in the vohime of the uterus itself. The adhesions with the vicinity, even if they are not of a carcinomous natui'e, make vaginal extirpation quite extraordinarily difficult ; but if this difficulty can also be overcome, and if through the vagina the adhesions can be separated throughout the whole space of Douglas, yet the diffi- culty remains, which is much more important than the difficulty of the operation itself, — that these adhesions represent raw surfaces, which are very ominous for the course of recovery. Heemorrhages and profuse secretion occur only too easily ; moreover, these lacerated surfaces do not heal without inflammatory reaction ; they apparently form a very favorable soil for germs of decomposition which extend from there further over the peritoneum. I have had much to do with just such difficulties vv^ith adhe- sions, and yet in the most cases have finished the operation. The majority of my fatal cases of vaginal extirpation, however, is formed by precisely this group of cases. It is difficult to describe the size of the uterus up to which extirpation through the vagina is still possible. In this connection it is of importance whether the corpus is hard and stiff', or soft and com- pressible ; but particular consideration is necessary in determining the possibility of such an operation, to decide whether the calibre of the vagina is sufficient to let the uterus be brought through it without extensive lacer- ation of the vaginal canal. In all cases where vaginal extirpation cannot be performed, there remains laparotomy and supra-vaginal amputation for carcinomata of the corpus, or the extirpation of the uterus by a modification of Freund's method from below. According to my experiences in carcinomata of the collum, or other diseases of the latter, there is seldom for this reason an absolute impediment to vaginal extirpation ; but in cases of disease of the corpus, the supra-vaginal amputation after laparotom}' appears to me to be the simplest and safest method by which the extent of the extirpation is entirely under control, and if necessary the neck of the uterus can also be removed. Rydigikr ^ has proposed to make an incision through the ^Berl. klin. Wochenschr., Nr. 45, iSSo. 376 PATHOLOGY AND THERAPEUTICS mucous membrane from the vagina all around the portio, and then to complete the operation after Freund's plan. ScmiOEnKR,' in a woman in labor with an immense carcinomatous thickening in the collum, per- formed Cassarean section, dissected out the collum from above, put liga- tures around the uterine arteries and then removed the vault of the vagina, after constricting it with a rubber tube. In a combination of Fig. 170. Opening into Doujjlas' cul-de-sac. Sutures through the vaginal wall. ovarian tumor and intraligamentary myoma, witli carcinoma of the col- lum, I first dissected out the latter from the vagina, on this occasion ligating the vessels in the floor of the pelvis ; then on the next dav, by laparotomy, I extirpated the myoma and the uterus from above. The patient recovered, but had a recurrence within the first year.- My method for vaginal extirpation is as follows : After a complete disinfection of the vagina by irrigation, and a thorough emptying of the ' Ges. f. Geb. u. Gyn. zu Berlin, 1SS5; comp. Zeitschr., Bd. vii., S. 305. 2 Ges. f. Geb. u. Gyn. zu Berlin, 1SS3. OF THE DISEASES OF WOMEN. 2>11 bowels, the patient is placed in position, lyin<^ on licr back and hips, and is brought under the influence of chloroform. The vault of the vagina is exposed by means of a speculum and side-pieces ; then the cervix is seized with bullet-forceps on its posterior border and drawn forward as far as possible towards the symphysis pubis. In this way the posterior arch of the vagina is stretched, so that the insertion of the vagina in the uterus Fia. 180 Sewing the floor of the pelvis. can generally be well determined. Then I make an incision through the entire extent of this insertion, in order to advance into Douglas' cid-de-sac as quickly as possible. If the attachment of the wall of the vagina to the cei-vix has not developed very thick, then the opening of Douglas' cul-de- sac is generally secured by the first cut. But if, however, the mass of tissue which must be cut through is very thick, then this penetration will be very difficult and troublesome ; and, indeed, it is the more so the more 378 PATHOLOGY AND THERAPEUTICS \vc must advance towards the uterus in order to reach the limits of this attachment. When the opening into Doughis' cul-de-sac has heen at- tained, I enlarge the cut so that the forefinger of my left hand can enter, and then with a small needle, which is very much curved, I sew around the entire extent of the border of the cut in the vagina (Figs. 179 and 180). The needle is thrust through the vaginal wall to the forefinger, which at this point presses forward the peritonaeuin, which it now includes, and comes out again into the vagina about a centimetre from the point where it entered. Of such sutures 1 generally use four or five, which unite the peritonaeum of Douglas' cul-de-sac to the vaginal wall, and all bleeding at this point is stopped. Opposite these sutures, if the uterus bleeds very much, I thrust a single great needle through the cut surface of the uterus, and secui^e thereby a restraint against further trouble of the kind. It is only when the haimorrhage is entirely stopped that the operation is further continued. If the opening of Douglas' cul-de-sac presents difficulties, and also if there be considerable haemorrhage, I sew in a similar manner the broad cut surface itself to the vaginal wall before opening into Douglas' cul-de-sac, and then, while I draw this mass of tissue away from the uterus with the forceps, I force my way deeper and deeper along the posterior wall of the cervix uteri. The peritonaeum appears like a delicate glistening membrane, behind which there is sometimes a small amount of fluid. As soon as the opening has been obtained, then the union of the peritonaeum to the vaginal wall is secured throughout the whole extent of the floor of Douglas' cul-de-sac in the same manner that has been described. The heemorrhage must always be completely con- trolled at this first stage of the operation before going any further. Next I sew up the stump of the broad ligament, for which purpose I use large needles armed with a double thread, thrusting them from the vaginal wall toward that place on the side of Douglas' cul-de-sac which my finger within presses towards me. (V. Fig. iSo.) These threads must also unite the peritoneum and vaginal wall. Often it is impossible to draw out the needle again directly through the vagina, without first having thrust it completely through into the peritoneal cavity. In these cases I guide the needle-point, protected by my forefinger, through the open wound, out into the posterior part of the vagina, and while I hold firmly the eye of the needle with one hand, I secure the point of it with a second needle-holder. Only then do I take oft' the needle-holder from the end which has the eye ; and now I draw the whole needle through, in order to thrust it, grasped anew, and again under the guidance of the forefinger, from the peritonaium towards the vagina, and to bring it out here about a OF THE DISEASES OF WOMEN. 379 centimetre from the point where it entered. These threads must be tied by using great force. Generally I use three on each side, by means of which I firmly unite the floor of the pelvis and the vagina as far as the anterior border of the cervix. By this union, the vessels which pass through are secured with greater safety before they are cut. The separation of the cervix from the floor of the pelvis as far as its anterior border, and the further stitching of the same, is often accom- plished without any loss of blood. The knife is thrust directly forward along the cervix until, on both sides, this lies entirely free ; /.\t' imicous inciiilii iiiic :iic tliickeiiuil, and in snnic places form closed pockets, as :it A B. 1'"^ lower part of the lumen is filled by a mass of thickened tissue. Opposite C, above D jflamlular outgrowths have penetrated into llic innscular coat. (See Appendix.) [Annals oi- (jvn.ki ui.uijv, Hoston, July, iSSy.J XXXIX C H CATARRHAL SALPINGITIS. 15" X EnhiriiCHl iiiclurc- nt' llic part ol" IM.ilo \'. .it" tlii; hisl iumiln.-i- wliicli was opposite C ■""' aliove O, f^ B — I'liickcucil folds ill lumen of Fallopian lulu-; between them a mass of tissue infiltrated with small cells and surrounding- a glandular cavity. C to D — Section of muscular wall. g P C> opposite C and above H — Sections of glands which have burrowed into the muscular coat, where no svich glands nornr.illv exist. [Annals ok Gvn.txol.x.v, lu.su.n, July, 1889.J XL CATARRHAL SALPINGITIS. 450 X Enlarged picture of the portion of the last tiifure above H A b" C-^on,plete glunduhtr tubes with cylindrical cpitheliun-.. Opposite D is a so u .ss of cLu,' showing, the earliest stage in the formation of a glandular tube; to the r.gh o th. rcross-seciions of ^wo other such tubes. .hIeU already have a .all of .n,perfect cyl.ndr.ca are cross-;^ epithelium, but are still solid The groundwork of the picture shows nn.s.ular tibr.s, u, between the new glands. th some iiitiltration of small cells [Annals oy (JvN.ict oLo<. v, Helton, July, ]S89.J XLI CATARRHAL SALPINGITIS. 15" X Enlarg-ed picture of the portion <,r I'latu XXXVIII whic:. is opposite A. On the- ri-ht is a thin strip of muscular tissue; the rest of the field is filled by cross-sections of glandular pockets lined by cylindrical epithelium, and divided by septa of connective tissue, infiltrated with small cells, showing a change in the mucous membrane, which makes it resemble tbnt of the uterus in chnmic eiidonietritis. [Annai.s ok (i\ n^'.coLOGV, Uostoii, July, iSSy.J XLII CATARRHAL SALPINGITIS 1 5'' X Pints oi thickened tolds ..(" iimtous iiieinhiane IVoeh tlie same spcciiiieu, from :i point on the left of that shown in Phite XI.I. The coalescence of the folds, forniin<^ pockets or recesses, is well shown at )\^ g. The resenihhince to the hypertrophic form of endometritis is here well marked. E_ -\V q OF THE DISEASES OF WOMEN. 395 Fig. X'^-lO. Catarrhal salpingitis. Chronic oophoritis. (Miss V.) Orikmamt. Half natural size. through the fimbriated extremity. Then this region of the peritonaeimi develops all the changes which are peculiar to it ; there is a formation of exudates, which make the serous coat extremely thick, or cause it to ad- here to the vicinity. With quite peculiar frequency the peritonaeum becomes glued to those places which are in contact with the serous coat of those parts of the tube which be- come prominent when it is coiled and twisted. Thus the tube may become ad- herent in a tangled mass of such coils, which is united with the neighborhood, especially with the uterus and ovar}', in a single tumor, in which afterwards the separate parts can hardly be distinguished from each other. The form, size, position, and condition of the tube vary greatly ac- cording to the condition of the lumen of the latter., and of its contents., and of the invasion oi specific exciters of infianiination., and ol pii.tr ef act io7i. The lumen of the tube, even under physiological conditions, is very materially diminished by the formation of folds. These folds, when inflamed, become glued together, both in the course of the tube and at its ends, and may give rise either to extreme stefiosis or to com- plete atresia. Between such stenoses or atresia the con- tents stagnate, even when the secretion is not materiallv altered, and by the pressure of the contents pockets are Fig. 191. Pyosalpinx. Atresia of the tube. Chronic oophoritis. Cyst of the parovarium. Orthtnann. (Mrs. S.) Natural size. formed, which mav be ar- ranged in a row like beads on a string. Great cavities may, however, also be formed, which change the tubes into tumors as large as a man's head. Particularly serious is the occlusion of the ends, if the inflammation of the vicinity or the occlusion ig caused by a new Yj(> PATHOLOGY AND THERAPEUTICS growth. The closure of the infundibuhim often comes to pass by the adhesion of the border of peritonaeum ; the atretic place is drawn together like a rosette, forming an umbilicated depression on the broad end of the sausage-shaped, tensely distended infundibuluni. A typical example of this sort occurred in a married woman, 19 years old, from whom, on account of violent attacks of pain six months after marriage, I extirpated a gonorrhoeal pyosalpinx of the right side, which probably had been acquired on the marriage night. The left tube was swollen, increasing in size toward the infundibulum to the thickness of the thumb. The end bore a rosette-shaped, depressed atresia. In the hope of preserving for the young wife at least this tube, Fig. 192. Pyosalpinx. Communication between the tube and the suppurating ovary. (Mrs. N.) Natural size. Orthmann. beside which the left ovary lay in apparently healthy condition, in a peri- tonaeum which was only a little reddened, I squeezed the infundibuliun gently. The tube opened at the place of atresia, the swollen fimbrije sep- arated like the petals of a mimosa, and allowed me to look into a tube which contained only serous contents in small amoimt. Mucous mem- brane and muscular coat were both decidedly thickened, apparently in consequence of abundant serous transudation. In other cases the occlusion of the infuiulibulum is caused by the fact that the tube sinks into an exudate, and, as this becomes firmer, it is glued to the ovary or to other neighboring parts. The relations of the diseased tube to the ovary may be very various. Although the latter may lie beside the greatly altered tube, without any connection (Fig. 190), yet, in other cases, both organs become glued [Annals of Gvn-'ec(ji-ti>ii, May, iSSy.) LVU MYXO-SARCOMA OP FALLOPIAN TUBES. [Natural Size.]" A-Ovary. B, C, D -FiiUopiu.i tube, enlarged and thickened by the nialignant disease, as seen at the points of incision. Opposite Q is a. small cyst. I i OF THE DISEASES OF WOMEN. 411 VII. — DISEASES OF THE BROAD LIGAMENTS. 1 . — Parametritis. It is seldom that an idiopathic inflammation occurs in the loose tissue which forms the floor of the pelvis, and which extends between the folds of peritonaeum which we call the broad ligament. The diseases of the latter are by far the most frequently of a septic natui-e, or the result of the invasion of other cocci, such as those of gonorrhoea or tuberculosis. Only occasionally, in contradistinction to this rather severe form, does an inflammation occur which is, so to speak, benign, and which originates in injuries, excessive irritation, especially in consequence of masturbation, or in general prostration in consequence of local or general discharges. In such cases, according to Freund,^ — who, in his various works, has furnished a characteristic description of this form of disease, making it easily recognizable, — the cases of parametritis which are not ifid^iced by specijic exciters of inflammation occur very seldom in comparison with those origiizating in infection ; among these, septic disease is very decidedly preponderant, whether this has been introduced on the occasion of a child-birth or after injuries and operations with unclean hands and instruments. After this form comes first of all the syphilitic and gonor- rhoeal and the tuberculous infection. The remains of such diseases which persist, and their relapses dependent on further affections of the genitals, especiallv, however, their influence on the course of gvnjecological manipulations, make the broad ligaments which have become diseased in child-bed play a very impor- tant role in gynaecology. Parametritis is, indeed, probably in most cases a septic disease, for the reception of which, in child-bed, the greatly relaxed and abi-aded organs seem naturally predisposed. Disregarding here the variable intensity of the virus, and the altera- tions which originate from this infection during the puerperal condition itself, yet a great contingent of the so-called gvn^ecological maladies is fur- nished by the long-persisting remains of puerperal disease. Not infrequently the puerperium has apparently run a ver}' favorable course, and there has been an intei'val, which, to the laity, has seemed entirely free of disease, between the puerperium and the new attack. The remains of puerperal parametritis deserve attention by so much the more, since they may influence the functions of the uterus and the iMonatschr. f. Geburth. 34, S. 3S0. Naturforschervers. Rostoek, 1S71. Die g^'nacol. klinik in Strassburg, 1SS6. 412 PATHOLOGY AND THERAPEUTICS nutrition of the whole genital apparatus, even for long years afterwards^ and then not infrequently an almost insurmountable obstacle is offered by them to all more active attempts at treating such maladies. In a similar way tlie non-puerperal forms of disease may influence the nutrition of tlie whole genital system ; and in fact Fiiel'nd' designates the c/ironic atrophying parametritis^ which he has described, as a disease of essentially non-puerperal origin. Fig. 199. After Bandlr The patJiological anatomv of both groups of parametritis shows, durinsfthe acute sta^-e, an effusion in the broad ligament and in the floor of the pelvis, which, after serous infiltration of the loose, vascular, connec- tive tissue, situated between the peritoneal folds, leads to the development of a gelatinous o'dema (the diffuse phlegmon of Vmcirow''), an acttte piirideiit cede??ia, as it is called by Pirigoff. This (edema is but slightly developed in the non-itifcctioHS forms of parametritis. From it there very rapidly results a cicatricial atrophy of the connective tissue, which draws all the vessels and nerves in the floor of the pelvis into the limits of the wasting and contraction which it sets up. ' Berl. Beilrage zur Geb. u. Gyn., II. i, 1S75. ■- Virchoxu's Archiv. xxiii., 1862. ^Handbuch der Frauenkr. v. Abschn., 1S79. OF THE DISEASES OF WOMEN. 413 In the infectious form there is very soon a formation of pus in this crdema. The masses of exudate may involve not only the basis of the broad liwameiit, that is, the part of the latter situated just above the vaginal vault. (Fig. 199, cavum pelvis subperitoneale) , but also the section of the deli- cate peritoneal fold vsdiich lies higher up, close under the tube, — the broad ligament proper, which is not represented in Fig. 199. The effusion may extend from the border of the uterus to the wall of the pelvis, and as it spreads further, may pass out over the linea innomi- nata to the iliac fossa. It may extend under the peritonaeum along the spinal column, may even separate the uterus itself from its peritoneal cov- ering, and may spi^ead under the space of Douglas and over the vaginal vault to the other side, and may here meet and unite with the exudations originating on the other side. It is comparatively seldom that the parametritic exudates pass between the uterus and bladder, and they may imbed the latter ; just as, when the course of development is as described above, they mav form a wall around the space of Douglas and its contents. In the further course of such exudations, the peritoneal covering of the whole pelvic space itself shows a great disposition to participate in the inflammation. In cases of parametritis which are not very extensive we see localized over them a peritonitis, usuallv simultaneous, and then, as a frequent complication, the peri and para metritis run their course adjacent to each other. There is an increase of vascularity, usually limited, in the section of peritonaeum lying over the diseased part, which occurs with a more or less extensive exudation. The masses effused lie as thick layers on the peritonaeum, or occasion firm adhesions between the ligaments and the adjacent coils of intestine, and form the means of the intimate adhesion of both with each other. Even extensive parametritis may undergo resorption bv means of iu- spissation ; during this process it may apparently remain unaltered for a long time, and then disappear entirelv. In other cases, these exudates cause the neighboring parts to soften down, and they discharge through the perforation and then get well. Seldom does putrid decomposition occur in them. Under all circumstances, such a parametritic exudate is a very serious form of disease, which, even if not leading immediatelv to death, yet occasions permanent displacement and impairment of function of tlie pelvic viscera, and therebv may make the woman an invaTul for life. Besides these exudates, which occupy the whole space between the folds of the peritonaium and the roof of the vagina, which develop in a manner 4 14 PATHOLOGY AND THERAPEUTICS similar to those originating during or afler the puerperiuni, and only too frequently, there is another form of this disease which, according to my observation, is always of non-]3ucrperal origin. We feel, namely, in the parametria, not very infrequently bunches of swollen glands^ arranged as in a chaplet, which extend from the uterus to the side of the pelvis. As far as I know, this peri-uterhie adenitis ' has as yet been care- fullv considered only by French authors. I have observed no small num- ber of these cases under quite definite antecedent circumstances ; and on account of the consequence of these conditions, I think it well to call attention to them. All cases oi this peri-uieritie adenitis which have come to my knowl- edge attacked well-developed women, who, when apparently entirely healthy, had married well-to-do merchants, officers, judges, or manufact- urers ; /.e., young men for the most part in good circumstances, some of whom confessed uni'eservedly that they had lived ^•ery dissolutely in their youth. Only one assured me that he had never been affected with any disease of the genitals. In this case, however, it was found that the wife had been repeatedly infected by other men without the knowledge of her husband. In all these cases the disease occurred almost at the beginning of married life, and all the women were sterile except tv^'o. In both of these the labor had been premature ; one of them had had a foetus sanguino- lentus. In these cases, in the early stages, the little glands were perceptible, usually in a parametritic exudate of no very great extent. In others who came under treatment much later, the exudate could only be felt in the form of a cord or ribbon-like scar, or it was completely absorbed, and then these small nodes lying in the parametrium became distinctly per- ceptible. Usually only three or four lying quite close together could be easily felt on one side of the uterus. More exacc examination, such as (occasionally had to be made in these women, showed that small nodules, which sometimes were in a line like a string of beads, were present in great numbers, usually on both sides, and that these could often be felt as far as at the brim of the pelvis. I classify this form of parametritic disease in the c.hapter on para- metritis with the less hesitation since, according to my observation, large exudates occasionally developed fr(jm these small glandular swellings. Of course I could adduce no experimental proof of the theory, but it seemed to me very probable that the formation of exudate in the para- 1 Courty, ADnal. de Gyn., Paris, iSSi, xiv. pp. 241-257. OF THE DISEASES OF WOMEN. 415 nietrium in general not infrequently originates in such glandular swell- ings. How otherwise can the peculiar clinical observations be explained that at the beginning of the disease, with pronounced febrile symptoms, an intense pain in one or the other side often for several days precedes the appearance of the real exudate, and that this pain seems to be materially diminished at the moment when the exudate can be detected? Is it not natural to seek for an explanation in the supposition that this pain is occasioned by the swollen glands, although it maybe difficult to feel them, as they are deeply situated, and that with the purulent disintegration of the glandular substance, and the perforation of the tunica propria of the gland, the exudate is effused into the folds of the peritonaeum, into the broad ligaments, and the subperitoneal pelvic cavity? In one of my cases of non-puerperal peri-uterine adenitis, which, accoi'ding to the confession of the husband, undoubtedly was attributable to a gonorrhoeal infection just after marriage, and after the glands had been reduced to an almost imper- ceptible size by appropriate treatment, I was able to observe directly the origin of such an exudate. After an impetuous coition there came on a violent uterine catarrh ; intense jDains were developed, which originated in these glands. The latter became greatly swollen, and not quite three days afterwards an immense exudate filled the whole left side of the pelvis. As above mentioned, I have not been able to demonstrate experimentally the development of such processes, and, therefore, \x\y conclusions are as yet based only on clinical observations. The above-mentioned chronic atrophying parametritis of Freund consists in a non-puerperal chronic inflammatory process in the connective tissue of the floor of the pelvis, which leads to a cicatricial contraction and wasting of the same. This cicatricial tissue is situated laterally all around the coUum ; here it constricts tlie uterine vessels, and then by continuous disturbance of the circulation in the uterus, there ensues a slow but always increasing atrophy of the latter. The disease is usually bilateral ; in one case I have, however, found it to be very distinctly unilateral, with a resulting disturbance of the uterine circulation on one side only. In its further course this process of contraction gives rise to disturbances in all the neighboring parts in the lesser pelvis. All forms of parametritis, unless they recover by complete resorption, cause considerable displacements of the uterus, the bladder, and the rec- tum, and thereby occasion corresponding changes both in these organs and throughout all the tissues in the lesser pelvis. Afterwards, especially under the influence of the forms of chronic parametritis, there often occur disturbances of mitrition in distant organs^ among which those in the 41 6 PATHOLOGY AND THERAPEUTICS region of the optic nerve have been investigated and brought to notice by various authors, especially by Foerster ^ and Mooren.^ The symptoms of parametritis are, during the early stages, violent ■palns^ which are caused partly by pressure of the exudate on the intestine, on the plexus of nerves at the sacral posterior wall, on the bladder, and on the other pelvic viscera. These pains may in the very beginning rapidly reach their highest degree, and only disappear when the patient maintains continuous and absolute quiet. In other cases the pains increase paroxysmally, and after that for a time they have been moderate, they increase at the time of menstruation, at any slight disturbance, sudden jar, or similar occasion, until they become intolerable, and force the patient to keep perfectly still. In other cases, again, the pain is developed immediately after the reception of an injury, and this form of develop- ment of the pain occurs especially in cases of relapse of old and para- metric processes, which had apparently healed. It is precisely the relapses which come on with unusual severity Immediately after the reception of an injury. Besides the above-mentioned symptoms of pressure, attacks of parametritis either occasion the symptoms resulting from the further development of the malady, such as hectic fever and the signs of perfora- tion, or the sufferings remain, with slight variations, unaltered for a long time, and only diminish very gradually at the place of the original disease, while from the latter further disturbances arise. As a rule, the utertis is implicated when there is intense disease of the parametrium ; it is dis- placed, its nutrition suffers, there is a profuse secretion which not very infrequently is mixed with blood ; with this it occasionally becomes swollen and sensitive. More regularly than the uterus is the perltonceam implicated. Cases of extensive parametritis hardly ever run their course without implication of the peritonaeum, the symptoms of which — extreme sensitiveness, nausea, and constipation — are then associated with the other sufferings. The ovary also naturally suffers from the development of the intra- ligamentary exudate, since its vessels are obstructed by the parametritic disease. The ovaries, however, suffer more continuously from the com- plicating attacks of perimetritis and peritonitis. Irritation of the bladder is a very frequent concomitant symptom of a parametritic exudate. Continual violent tenesmus prevents the patient from getting any rest, and if besides this there is irritation of the external genitals in consequence of continual urination, there is developed an ex- 1 Archiv. f. Augenheilkunde, 1877. "Die nervosen Stijrung^en bei Augenerkrankung^en, iSSi. OF THE DISEASES OF WOMEN. 417 traordinarily distressing pain in the external parts also at every discharge of urine. Attacks oi hifectious pai'ametritis commence, as a rule, with violent chill and elevation of fe?nperature. The latter almost always rises con- siderably, and in cases of extensive exudates it remains without material remissions, and is associated with great frequency of the pulse, and with an increased frequency of respiration, which may be explained by the degree of pain. This lasts for three or four days ; often, however, very much longer. Then, according to the changes in the exudate, there either occurs a lasting remission, and the fever disappears entirely, or the tem- perature rises to a serious height, to 40° and 41° C. (i04°-io5^° F.), and only falls when the exudate has softened down, and has made its escape on one side or the other, through the adjacent parts. If the exudate does not soften extensively, and if then the intestine, the bladder, or the vagina are implicated, there soon occurs a decided loss of strength, with a very considerable hectic fever. Escape of the pus by no means always brings immediate relief in such cases ; the pus forms pockets in all directions ; especially the legs swell, thrombi are formed, from which particles may be scattered among the various oi'gans ; so that eventually the final catastrophe is apparently induced by destruction in quite remote organs, while the parametritic focus has already made material progress in healing and contracting. The traumatic forms, and especially the recurrent attacks, take another form. In these the effusion is very small, and accordingly the pain from the beginning is very moderate. Here the acute stage is little noticeable ; it runs its course insidiously, but thereby, on account of the very slow and imperfect resorption, there ensues a more pronounced distortion and pathological fixation of the organs in the lesser pelvis. In such cases the patients drag themselves about for a long time, suffering from their maladv. They suffer at every defecation, and accordingly they attempt to postpone every motion of the bowels as long as possible. Besides the disturbance'' of digestion which are inevitably excited thereby, and the headaches which, as a rule, are associated therewith, hcemorrhoidal swellings are also developed. These finally bring about a general condition which too frequently, by its slow development, misleads us into seeking for the source of the evil in disturbances of the stomach, or even in nervous symptoms. If these exu- dates undergo resolution, there mav ensue a condition of tolerable ccmforc, if the manner of life is extremely circumspect ; and this, together with the disinclination of the women to undergo medical treatment, keeps them wasting away, and induces the well-known condition of sicklv, hysterical women. . 41 S PATHOLOGY AND THERAPEUTICS The symptoms of suppuration and of perforation need hardly be here more minutely described. The escape of pus is usually by the rectum, and I have only once, as yet. seen fatal consequences from the compli- cation of the entrance of intestinal contents into the cavity of the abscess; as a rule, these cases of parametritis, after discharge through the rectuin, heal slowly indeed, but without disturbance. Perforation into the vagina is next in frequency, then that under Pou- part's ligament, and the rarest form is that where the exudate passes down through the greater or lesser sciatic foramen into the gluteal region, and finally finds an outlet here. Although in gynecological practice fresh cases of parametritis are certainly not ver}' infrequent, yet far oftener w^e have to treat chronic cases in which the shrinking and retraction of the ligaments has caused dislo- cations of the uterus, fixations of the latter, or complications from impli- cation of the bladder and of the intestine. The symptoms of these chronic cases coincide almost completely w'ith those of chronic perimetritis, and I will, therefore, refer to these cases more at length in the chapter on perimetritis. The symptoms of the above-mentioned peri-uterine adenitis are often almost latent for a long time. In all my patients, menstruation was not immoderately painful ; there was more or less discharge, but always decided loss of strength, lassitude, nervous symptoms, dyspepsia. In many, coition was painful ; in the majority this was not so, however ; in fact, there was in these cases a very lively impetus coeundi, with violent desire for progeny. Similar to these are the cases of atrophying parametritis, as described by Freuxd, except that in the latter the premature ageing of the patient, as w^ell as the premature, usually very painful, cessation of menstruation, become decidedly noticeable. The diagnosis of parametritis is made difficult by the fact that diseases of the broad ligament, if at all extensive, almost always are complicated with changes in the peritonaeum, and thereby the result of examination is very materially influenced. The more moderate exu- dates of the broad ligament lie, to be sure, markedly at the sides of the uterus, between this organ, which is pushed toward the other side, and the wall of the pelvis ; they force their way, as a rule, far down toward the vagina, displace the vault of the vagina, pi'otrude at the side of the portio into the lumen of the vagina ; they extend upwards to the level of the brim of the pelvis, lift the peritonaeum ofi' from the iliac fossa;, and spread along the latter far under the peritonasum, so that finally they may extend to the level of the navel above, and below to Poupart's liga- OF THE DISEASES OF WOMEN. 419 ment immediately behind the abdominal wall and may here perforate externally. For the di^ere?zUal diagnosis of parametritis ixoxw other aftections, the history of the case is of great significance ; moreover, the determina- tion, if possible, whether the space of Douglas is free, and whether the ovaries can be palpated there. In cases of developed parametritis, it is often very difficult to establish such a result of examination, and yet for the purpose of differential diagnosis the attempt must be made to find out these tacts by palpation. I consider it to be entirely impossible to diag- nosticate a parametritis simply by palpation of the abdomen externally, just as I regard, on the other hand, such a diagnosis as untrustworthy when made simply by the introduction of the finger. The limit between the uterus and the exudate itself must always be felt out, and the mobility of the former, in relation to the tumor, or the connection of each with the other, must be determined. The diagnosis is quite materially impeded by simultaneous disease of both sides, and the communication of these two masses of exudate under the peritonjeum before or behind the uterus. Then the latter appears to be walled in between these masses of exudate, and it is often very difficult, and without anaesthesia impossible, to dis- criminate the uterus from the latter by palpation. The prognosis is, in general, not unfavorable ; for cases of parame- tritis are just the ones which undergo I'esorption, with few exceptions, and they are so susceptible of treatment afterwards, that with the necessary patience recovery may be expected with certainty. For another reason I would not make the prognosis of parametritis so unfavorable, and that is because not infrequently the further extension of infection is terminated with the development of parametritis, and finally because the disposition to recurrence is somewhat less pronounced in cases of parametritis than in those of perimetritis. The prognosis only becomes materially worse in case, as a result of long duration of the disease, and especially of the want of timely treatment, contractions have occurred, which permanently im- pair the nutrition and function of the neighboring organs as well as of the uterus. The prognosis of chronic parametritis in general^ and especially of the atrophying form ^ and of peri-uterine adenitis is very itnsatisfac- tory, and is by so much the more serio7is^ as these cases are regularly co?nplicated xvith perimetritis. Treatment. In the acute stage a strict antiphlogistic treatment is to be employed, with abstractions of blood, cold, rest, mild laxatives, and narcotics. As soon as the process comes to a standstill, resorption must be excited and maintained by all means. Here particularly the preparations 420 PATHOLOGY AND THERAPEUTICS of iodine play an important rule, not only by letting the iodine exert its actron through the abdominal walls, but by bringing it into the vagina and painting the vaginal vault and the portio with it. I have used this so-called internal mode of painting with iodine in a great number of cases (since 187S) with very good effect. With appropriate sitz-baths, fomentations, and a concentrated, strengthening diet, fresh cases of this kind can, as a rule, be cured. By the combination of just such a treatment with the use of injections of hot water in particular, and with the employment of iodoform, I have obtained very good results. The treatment of the chronic cases is \ery much more difficult, when in these cicatricial formation has occurred, especially when we have to treat a long-existing exudate, which is limited to a few cicatricial bands. In cases of uncomplicated parametritis, treatment is always more effica- cious than in the ^Dresence of a complication with perimetritis. In such cases I like to use mud-compresses and mud-baths, iodoform in ointments and suppositories, rectal irrigation, tampons with glycerole of tannin, sitz-baths, and all the other means which are employed to strengthen the patient and to promote resorption. Here I especially like to use the well-known iodized mineral waters, sulphur and brine ';aths, and for weakly women, sea-baths. Qiiite lately I have frequently taken occasion to employ massage in such chronic forms of parametritis where there was little exudate still remaining, but severe cicatricial distortion. The number of the cases thus treated is as yet not large, for I have found very considerable difficulty in employing this mode of treatment, on account of the sensitive- ness of the women. In those patients wiio, being less sensitive, endured for a long time massage repeated four to five times every week, the suc- cess was, to be sure, quite pleasing. The cicatrices relaxed, the uterus became movable, and therewith the disturbances in the lesser pelvis dis- appeared, which had often existed for a long time. To perform massage I introduce two fingers into the vagina, and from the vaginal vault I press upwards the part which is to be massaged. With the hand which lies externally the massage of the part is then undertaken, and this is done in sittings of always increasing duration. It requires much practice, both on the part of the physician and on that of the patient, in order not to grow weary too soon of these manipulations. In the cases which resist these methods of treatment there remain, as a rule, only symptomatic indications. In peri-uterine adenitis, besides the treatment with hot water, I have used, with very good results, iodine, iodoform, mud-compresses, and sitz-baths ; and I have also employed inunctions with mercurial ointment, used in small doses, so that the treat- OF THE DISEASES OF WOMEN. 421 meat could be continued for a considerable period. By sucli treatment I have, in fact, removed the sensitiveness of these glands and the irritated condition of the uterus and of the vaginal vault, and have also reduced the swelling of these parts ; but only in a few cases have I cured the ste- rility. A course of such inunctions should be tried in the cases of para- metritic, cicatricial contraction. 2. — Extra-Peritoneal Hematoma. The occurrence of non-puerperal extravasations of blood between the folds of the broad ligament has lately been indisputably established by the results of post-mortem examinations.^ All extravasations of blood are included here which push their way between the folds of the broad liga- ment, and occasionally pass around behind or in front of that part of the collum or corpus which lies under the peritonasum, so that confluescing they form a single great cavit}' filled with blood. The cetiology of these extravasations of blood is usually referable to rupture of a vessel during menstruation. As causes of the sudden appear- ance of the disease are suggested physical exertion, uncommonly violent for such a time, or shocks, ftdls, or excessive sexual irritation. It is true that we cannot always establish quite clearly the history of such exciting causes, for of covn^se those attacks of disease in particular which are connected with sexual life are frequently intentionally concealed from us. The possibility of further reasons for rupture of the vessels is, of course, not to be denied, just as apoplexies in other organs occur without demonstrable exciting cause. The vessels of the broad ligament appear particularlv liable to such rup- tures, owing to their extreme fulness during menstruation, and particularly during labor and child-bed. We visually find these hcematomata in women who have had children. They are rare in virgins, and according to my observations are never found where there is a virginal condition of the genitals. The anatomy of extravasations of blood is established by results of autopsies, and by the insight into the condition of affairs which isf ob- tained at laparotomies. These blood-filled spaces are found in all parts between the folds of the broad ligament and under the peritonaeum, the bladder, and the collum uteri. Smaller extravasations may be situated in the upper parts of the broad ligament without distending the whole cavity of this fold of peritonaeum. Isolated extravasations may occur on each side, completely separated from each other ; they may confluesce and then ^ Kiihn. Ueber. Blutergusse in die breiten Mutterbandcr, Ziirich, 1S74. The author has re- ported cases in the Zeitschr. f. Geb. u. Gyn., viii., and through Diivclitis, Arch. f. Gyn., Heft 23. Since then, Schlesinger, Wiener med. Bl. 1SS4, No. 27-46, and Freitnd, Gynak.-Klinik, Strassburg, 1885. 422 PATHOLOGY AND THERAPEUTICS lift the peritonaeum away from the lesser pelvis, far up along the spinal column, so that pools of blood collect in the iliac fossae. Remnants of vessels are not always found in the cavities of lacerated tissue. I have often seen tags of tissue, containing the endsof vessels, which hung from the sundered walls of the cavity into its lumen like coiled ends of strings; the broad ligaments are often rent asunder with great violence. When the extravasation has lasted for some time, the ragged walls are permeated and matted together with clots, thereby becoming friable. The cavity itself is irregular from numerous pockets in its walls ; not infrequently tougher, resisting bands of connective tissue run far across the cavitv, the separate pockets push their way to the jDclvic wall, through the vaginal vault downward, partly by lifting it away from the adjacent structures, and they dissect up the peritonaeum from the sacrum, while in single prolongations they here extend also into the loose tissue. The blood in these cavities undergoes the changes which such extrav- asations pass through in other places ; it usually coagulates rapidly, and then after resorption of the fluid portions it lies as a thick bloody laver on the walls. The retrograde metamorphosis of these masses often runs a comparatively slow course, so that it must be set down that much time is indispensable thereto. In other cases this metamorphosis is only partial, and only certain portions of the.se extravasations undergo transformation, while others con- tain for a long time the blood, which is onl}- inspissated, but still little altered. Putrefaction of the blood may then occur, and from liquefaction of the blood-filled cavity there may result an abscess, in which all the changes run their course which are peculiar to abscesses. Especially important in this connection is perforation of the wall of the cavity. Even during the development of extravasation rupture sometimes occurs, especiallv of the delicate peritoneal covering of the tumor. The blood may then be effused into the abdominal cavity, and here may either be absorbed, or excite a diffuse peritonitis. • With such hrematomata changes in the neighboring organs also occur ; especially in the ovaries analogous extravasations are found, in the fol- licles, or in the stroma of the organ. Under the pressure of the mass of effiised blood, ocdemas or thromboses are also formed in more remote structures ; quite especially is the uterus altered ; the mucous membrane swells, a haemorrhagic endometritis is developed, and, as a result, there are moderate discharges of blood from the vagina. Among the sy7nptoms of extra-perito7ieal hcematoma^ the most char- acteristic is the suddenness of its origin in women who, up to that time, were apparently healthy. With sudden, violent pains in the abdomen, there occurs great weakness, even to the degree of fainting. I OF THE DISEASES OF WOMEN. 423 These pains are sometimes colicky, sometimes like labor pains ; they recur paroxysmally, at longer or shorter intervals. The first thing noticed by bystanders is the intense anaemia, especially if it is not imme- diately accompanied by corresponding discharges of blood externally. If the extravasation occurs during menstruation, the latter, as a rule, ceases suddenly at first, and then returns and continues abundant. There is violent vesical and rectal tenesmus, although the abdomen is usually only sensitive on deep pressure, and when the tumor is directly touched. Pro- nounced sensitiveness always implies implication of the peritonaeum in the affection. Local examination shows the presence of a tumor which is adjacent to the uterus laterally, and either fills one side of the pelvis or extends before or behind the collum uteri to the other side, or even occupies both sides. According to its magnitude this tumor rises above the fundus uteri on one side ; it appears almost as if it were walled into the lesser pelvis. The crown of the tumor is said to lie in the middle of the brim of the pelvis, which, however, can hardly be established with certainty, espe- cially at the beginning of the formation of its htematoma, on account of sensitiveness to deep pressure. The uterus itself appears soft, as a rule ; not infrequently it can be felt stretched around the periphery of the tumor. The mobility of the latter itself is slight. The tumor can hardly be moved ; it feels in the beginning moderately tense, and occasionally, in fact, rather soft and doughy, and it is sensitive. On the side which is not affected, the finger may be passed all around the uterus ; from the rectum the space of Douglas can be felt to be free. On the health}- side the ovary is usually distinctly to be felt in its normal position. Some affirm that they have felt the crepitation of fresh clots in the tumor itself, a re- sult of examination which I was never able to distinguish clearly. The further condition, as found at examination, will depend on the ■extent of the extravasation and the condition of its contents as to trans- formation ; with increase of resorption the mass of the tumor grows thicker and harder ; it contracts and disappeai's, to obtain which results a period of one, three, or four or even more months is necessary, according to the size of the tumor. If rupture into the free abdominal cavity occurs, the condition usually grows decidedly worse. There is a secondary collapse, at the acme of which death may ensue, or convalescence very gradually comes about, with variable state of health, unless marked peritonitic symptoms domi- nate the condition. Rupture without entrance into the abdominal cavity, and suppuration or putrefaction of the tumor, cause the symptoms, rational and plivsical, which are peculiar to these conditions. 424 PATHOLOGY AND THERAPEUTICS The differential diagnosis must first determine whether there is present an extravasation or an exudatio7t. The latter usually occur very gradually ; they are preceded by a longer illness ; they begin with chill, high temperature, and violent pains. Extravasations occur suddenly after an injury, especially in connection with menstruation. If exudates, like the above, are very frequent in connection with pregnancy and child-bed, this association is entirely wanting in cases of extravasation. If the histor}- of the case shows a sudden origin, and the first exami- nation then reveals the peculiar displacement of the uterus, the freedom of the space of Douglas from implication, and a condition free from fever, the diagnosis of hasmatoma may be pronounced with great certainty. The difficulties increase when the history of the case is imperfect, and the malady has lasted a long time before the date of examination. The first thing to be done, then, is to determine whether the eftusion is intra or extra peritoneal. In recent cases it is said that a change of position of the patient will decide this question, for in a case of fresh haematocele. unless it is strongly abcapsulated, the mass behind the uterus will, as a rule, disappear, while in cases of hiematoma it remains unaltered. Extra-peritoneal haematoma is onlv sensitive to pressure at the beginning, while hcematoceles remain tender on account of the implication of the perimetrium. Hsematoma is always distinctly limited above; haematocele only in case of extensive adhesions in the pelvis. The former is usuallv situated at the side of the uterus, and inferiorly it is uneven and nodular, corresponding to its extension into the intervals of the broad ligament in the subperitoneal cavity of the pelvis. The haematocele presses the posterior vaginal vault downward, forming an oval promi- nence, and in general lies directly behind the uterus ; while hjematoma can almost alwavs be felt at the side of the latter. Later on, febrile symptoms are wanting in ha^matoma if resorption goes on typicallv. Whereas, although they may sometimes be wanting in cases of intra-peritoneal extravasations of blood, they are hardly ever absent in other effusions within the peritonteum. as well as in parametric exu- dates.^ In their further course, also, peri and para metritic effusions remain tender ; haematomata are hardly sensitive at all. ' A symptom sometimes met with in cases of hn;matoma, which is not generally known, is a discoloration of the urine, evidently from resorption of the coloring matter of the blood, which has been effused. Within a few hours of the violent symptoms .attending the haemorrhage the urine becomes very cfark and almost entirely op.ique, even in thin layers. It is red by transmitted light, greenish by reflected light and by lamplight. This condition may last for a week or ten days, the color of the urine becoming gradually lighter. It is not easy to say in what form the coloring matter exists in the urine. The writer has observed two cases of this kind, and in one the urine was examined by an expert. It did not give the reaction of haemin, nor of any definite compound. There were no blood corpuscles or albumen in the urine in either case. — E. W. C. \ I OF THE DISEASES OF WOMEN. 425 Tiiniors of the tubcs^ subserous myomata^ and intra-ligame7ttary cysts may certainly be veiy difficult to differentiate diagnostically from long-existing haemaloma, especially when resorption has failed to occur. If the history of these cases is indecisive, there can generally be recog- nized either a connection like a pedicle between the tumor and the uterus, or a remnant of the tube, or the peculiar manner of insertion in the broad ligament, and from these a differential diagnosis may be made. Nevertheless, I admit that just here great difficulties in diagnosis are encountered, and certainly can only be attained by further observation of the development of the growth in question. The prognosis is in general entirely favorable, for the great majority of these hasmatomata are hardly recognized clearly as such. The patients so affected, after they have recovered from the first violent shock of the effiision, delay the summoning of medical assistance from reasons of indolence or modesty ; the convalescence which then ensues, although slowly, at length no longer requires medical aid at all. But even the severe cases which undergo examination usually overcome the disease with appropriate treatment, and it is only rarely that cases either lead to immediate death through the quantity of blood lost, or through rupture into th^i abdominal cavity, or cause so serious symptoms that they necessi- tate medical attendance. The treatment must accordingly be entirely expectant. Such women may be seen to recover even from very profound collapse, under appro- priate strengthening treatment, as soon as the bleeding into the hasmatoma sac has ceased, and if no further complications disturb the course of resorption. It requires great patience to employ such a treatment directed to promoting resorption. In a small percentage of cases, however, the sufferings increase so much, even with appropriate treatment as above described, and under the influence of the malady there is developed such a threatening constitutional reaction, that it is necessary to interfere more decidedly. The treatment to be employed in such cases usually consists in emptying the blood sac. This evacuation can be performed from the vagina, or from above, after laparotomy. The evacuation from the vagina at first seems simpler ; it, nevertheless, seems doubtful whether this way deserves preference in all cases, if it is reflected how little the walls of the cavity can be freed, by way of the vagina, from the blood-clots and shreds of tissue which stick to them and undergo putrefaction ; and how much danger there thereby is of secondary haemorrhage, and of laceration of the peritoneal covering, and of infiltration of pus into the spaces of tlie broad ligament, which are already torn open. 426 PATHOLOGY AND THERAPEUTICS The other method hxys open the whole region of the cavity, permits of treating the walls of the latter according to their condition, and tiicrel)y secures the removal of a part of the sac, and a cjuicker cure of tht latter. Laparotomv, after appropriate preparation, in itself oflers only slight danger ; we can completely expose the blood-sac, after eventration of the intestines if necessary ; we can incise it at the point which seems to us most favorable, and, after evacuating its contents, we can curette the walls and control any haemorrhage thereby excited ; we can provide for any further discharge of secretions from the raw surfaces by drainage into the vagina;^ and finally, we can close the sac again from above by suture. Such a procedure used in ten cases has given me favorable results in the last nine. The operative treatment of ha;matomata will always remain a rare exception in treating such effusions of blood. - 3. — Xew-Growths of the Broad Ligamext. Among the nexv-groxvths of the Iwoad ligament the most frequent are cystic structures^ the origin of which cannot always easily be estab- lished ; some of them certainly spring from the ducts of the parovarium,'' which are lined with ciliated epithelium ; others from the remnants of the WoLFiAN body, the sexual parts of which are found as narrow canaliculi between the parovarium and the uterus. ■* These tumors are usually only of small extent, have thin walls and limpid contents, containing very little or no albumen. The cysts are lined with cylindrical epithelium, which occasionally bears cilia. They may develop to the size of ovarian tumors, but gener- 1 Drainage into the vagina alter laparotomy has not met with the favor in England or in America which is accorded to it by Martin. It is referred to by our author under so many circumstances that it seems well to recall the fact that, although in the hands of an extremely expert and dexterous operator, it may be well to pass a drain into the vagina, and to close over it the cavity left by a myoma, an abscess, a pyo-salpinx, or a hxmatoma, etc., as hereinbefore described; yet such a course prolongs the operation, necessitates much dexterous work in the depths of the pelvis, requires, therefore, a much longer incision, and in general makes the operation in itself much more formidable. The beginner will find it far easier and quicker, and in his case safer, to use a Keith's glass abdominal drainage-tube, after free use of hot water, in any of the cases where Martin prefers drainage by the vagina. Such a tube should be carried to the bottom of the cavity to be drained, and the latter is then to be kept dry by vigilant attention, sucking out the fluid with a syringe, and absorbing it as fast as formed by means ol a rope of absorbent cotton. If the sac is of such a nature that the edges of the opening can be sewed to the external wound, so much the better. The main point of .ibdominal drainage, however, is the thorough washing out of the abdomen, and the keeping the tube dry and clean. Sometimes one tube is used in the cavity to be drained, and another in Douglas' pouch, outside of the sac which has been evacuated. 2 Another procedure has been reported by Zxueifcl , Arch. f. Gyn. xxii.; compare Gusserozu, Archiv. xxix. S. 3S9. 8 Fischel, Arch. f. Gyn. xvi. * Compare Waldeyer, Eierslock u. Ei., 1S69, S. 14^. OF THE DISEASES OF WOMEN. 427 ally they arc only of limited size. In their development between the folds of the ligament, of course they push aside the neighboring organs, and they lift the tubes, in particular, strongly upwards. They are said to have the peculiarity of healing entirely, after evacuation.^ Solid tumors are also found in the broad ligament which are described as myomata- or fibro-myomata. They are not connected with the uterus, but extend between the epithelial folds of the broad ligament, and from there they may grow towards the abdominal cavity, as great tumors, or downward towards the vagina ; and there they may finally push their way forwai'ds at the side of the vagina towards the vulva, where they occa- sionally are the subject of an operation. •' In rare cases they have thrust themselves through the greater sciatic notch. I cannot report anything from my own experience concerning these solid new-grow^ths on the broad ligament. Echinococci are also not very rarely observed in the floor of the pelvis, and ai-e evacuated from there.* There they may block up the pelvis very considerably, especially in cases of labor ; in other cases they discharge through the rectum, or bladder, or vagina, although spontaneous recovery is probably rare. They must in any case be removed with the sacs, ac- cording to their accessibility. 1 spencer PT^//^, Diseases of the Ovaries, 1S72, p. 30. Later, Sckatz, Arch. f. Gyn. ix. Gusserow, in the same place, x., and Diiplay, Arch, g-endral, 1SS3, ii. p. 386. 2 Virchoiu, Geschwlilste, iii. S. 221. Scenger, Arch. f. Gyn. xvi. 3 Stern, D. i., Berlin, 1876. Schroeder, Handbuch, vii. S. 4S6. * Schatz, in the Beitr. mecklenb. ^rzte zur Echinococcenkrankheit, 1SS5; and Schroder, Handbuch, vii. S. 4S7. Diiveltus,GQS. f. Geb. u. Gyn. April, 1SS6 (an observation of the author). 428 PATHOLOGY AND THERAPEUTICS VIII.— DISEASES OF THE PELVIC PERITONEUM. I . — Perimetritis. The inflammations of that section of the peritonaeum which invests the organs of the lesser pelvis depend very materially on the diseases of these organs themselves ; they are also encountered as local symptoms of general peritonitis, which originates in other causes, but in the majority of such cases the changes in the genitals themselves form the primary factor. The attacks can usually be traced to labor and the puerperal state ; septic puerperal disease, in particular, leads to such attacks of circum- scribed peritonitis, with extraordinary frequency. A further not \e.xy infrequent and fateful source of peritonitic disease is the extra-uterine development of the ovum in all varieties of its course. While on the one hand peritonitis is very commonly prominent as a cause of extra-uterine pregnancy, recurrent attacks of the former attend the de- velopment of the ovum, as one of its most severe complications. Disregarding this form, which is connected with conception, we find i7iJlammations of the pelvic peritoncetun associated with acute and chronic endometritis and metritis, especially by those forms of this disease wdiicli in the acute and chronic stages are disposed to extend to the sur- rounding parts. These may be catarrhal attacks, so called, which there- fore are not considered to be infectious ; not infrequentl}' they are referable to an injury, whether the latter is occasioned by masturbation or by gynaecological manipulations. Gonorrhoeal infection^ is a cause which is not uncommon. All those diseased conditions which, as a consequence, have a decided increase in the size of the diseased organs exert an intense irritation on the peritonaeum, and thus we see in cases of tumors of the uterus, as also in those of the ovary, that inflammatory foci appear at the points of contact of the tumors with the peritonaeum, even although the disease of the former does not extend to its peritoneal surface. Thus very frequently, before the occur- rence of a carcinomatous infiltration and infection of the peritoneum, the latter passes into a condition of chronic irritation. Many authors refer to displaccincJits^ especially of the uterus, as a cause of perimetritis. I could not properly explain why perimetritis is so often absent in cases of displacement, if I were obliged to accept the theory that such displacements alone suffice to set up perimetritis. '^ Nceggeraih, loc. cit. Compare, also, Bumm, Der Mikroorganismus der gonorrh., Schleinhaut- erkr., 1SS5. OF THE DISEASES OF WOMEN. 429 I incline far more to the opinion that in these cases there is an acci- dental complication, in which, to be sure, the displacement is a material complication of the perimetritis. This complication, according to my observations, is so severe, that for most cases I must designate the displacement in itself as immaterial, and the perimetritis as of preponderant importance. Perimetritis .1 tvherever it is found., is almost alxvays the severest atid most serious of all the gyncecological maladies., 7tot only because it involves the danger of further exteizsion of peritojieal disease., but be- catise in perimetritis there remains a very decided tendency to rectir- re7tt attacks., even after co77iplete recovery., and this can often not be completely attained. Beside this thei'e is the injurious effect of these cir- cumscribed areas of peritonitis on the organs of the lesser pelvis and on their functions, inasmuch as thereby the treatment of such further diseases is confined v^^ithin very narrow limits ; for even without direct transfei"- rence of infectious material to the peritonaeum, even from quite insignifi- cant therapeutic measures, such a circumscribed peritonitis may cause an intense inflammation in a previously healthy pelvic peritonaeum ; but where the latter has already been diseased, it yet even more frequently lights up a violent inflammation from old traces which were apparently quite infinitesimal.^ I here entirely omit the consideration - of the form of perimetritis which occurs in diseases of other organs, especially in tuberculosis, as well as of septic peritonitis. Pathological anatomy. The course of disease of the peritonaeum in the pelvis has nothing peculiar in itself. We see there the development of the disease in very different forms, both in the acute and chronic yav\e- ties. There may occur an abundant fibrinous or purulent exudate, which fills up the pouch of Douglas, and even covers the rest of the pelvis, which may be abcapsulated from above, with corresponding displacement of the coils of intestine in the neighborhood, or may, after a longer or shorter time, be absorbed or discharged by perforation. To this category usually belong the septic as well as' the puerperal inflammations. Much more important for gynaecological practice are the forms of disease in which there is no such plastic exudation, but where an effusion 1 Compare the experimental proof of this result of clinical experience by Gra-:'.n'tz, Charite-An. nalen, xi. Jahrgang, S. 770. 2 French authors, in particular, have referred to perimetritis: Grisolle, Arch, general de Med. iii., Ser. T., 1S39. — Nonat, the only work of whom at my disposition is the Traite prat, des Malad. de I'Ut^rus. — Ga//ffrrf, Gazette des Hopi., 1.SS5, Nr. 12S, and Annales de Gynecol., February, iS-^.— Bermiz and Goupil, Archiv. general, 1S57, Mars-Avril, i.p. 2S5. — Aran ,\-.e,<^<3ns, ciliniques, iS6i,p.653. Among other authors may also be mentioned : M. Duncan., A Pract. Treatise of Perimetritis and Parametritis, 1868. — E. Martin, Neig. u. Beugungcn., ed. i. 1S66. — ^//V^t'/^t^z-j"-, Volkmann'sche Samml., 1S71. — /^iV^ywffz/w, Die Entzund. des Bauchfells beim Weibe, \Vien, 1SS3. — Freund, Gyn. Klinik in Strass- burg, 1SS5. 430 PATHOLOGY AND THERAPEUTICS occurs which leads to the development o^ adhesions and unions between tJic pcritonivuni and tJie structures ~vJiich bv chance are adjacent to it. Here also, in the course of the disease, there may be more abundant eflu- sions ; these, however, are enclosed in more or less abcapsulated spaces, and they may fill out the latter, distend the neighboring parts, and push their way in various directions, without passing into the free abdominal cavity. Here, also, conditions of retrograde metamorphosis, such as occur in general with such exudates, may take place ; there may be re- sorption, inspissation, and a sort of cicatricial formation, with which the adhesions indeed usually continue to exist. Fig. 200. Fig. 201. Perimetritic adhesions, after IVinckel. Plates from the photogravure atlas. — B. Blad- der. V. Vagina. C D. Cavity of Douglas. R. Rectum, oi. Internal orifice, oe. Ex- ternal orifice, a. Adhesions. In other cases, particularly in the deepest parts of the pelvis, dis- placements of the organs are occasioned by the cicatricial contractions, whereby their functions are impeded. The functions of these organs themselves cause the peritonitic irritation to recur continually, and thus, by repeated new exacerbations, extensive alterations are occasioned in these regions of the peritonaeum. We find., accordingly., in gyncecological practice., fresh acute forms much less frequently ; in these the perimetritis usually forms only the [Annals op Uyn/Kcology, liostoii, 1S90.] LVill PERIMETRITIC ADHESIONS. y\. Rectum. B C. Ovaries. D. Bladder. The fundus uteri is iu the middle of the picture where lines joining- the letters would intersect. The adhesions between uterus and bladder, and between uterus and rectum, bind down the fundus uteri. OF THE DISEASES OF WOMEN. 431 Fig. 202. last link in the chain uf other diseases ; it comes on in its acute form, only to hasten the final catastrophe. Much oftener wejind o/ily the chronic variety^ in the form 0/ ad- hesions and dispiacct?ients, zvhich affect the organs of the lesser pelvis in a quite nnacconntable manner., by displacing them in their relations to each other., constricting the/n., and impeding their functions. Thus we see the uterus adherent posteriorly, with especial frequency, and fixed, not only by a plastic exudate on the floor of the space of Douglas, but also by the cicatricial contraction in the saci"o- uterine ligaments,^ those reduplications of peritouceum \vhich run from the upper part of the collum uteri to the anterior sacral surface, and which have also been designated as retractor muscles of the uterus, on account of the somewhat variable amount of muscular fibre in them. The ligaments are very apt to ap- pear to be shortened by perimetritic cicatricial formation, and then for a long time after the disease has run its course they persist as tense cords, sharply difl'erentiated from the sur- rounding parts. The displacement of the uterus, occasioned by these bands, may be lateral or directly backwards, accord- ing to whether only one side or both are implicated in the disease. The space of Douglas may be obstructed by the uterus, which has been drawn into it merely by these bands. In other cases, after this afl'ection of the sacro-uterine ligaments, the adhesions between the peritoneal in- vestment of the uterus and the walls of the space of Douglas, or the coils of intestine, remain in tlic form of tliin or stout bands (Figs. 200 and 201), or there results a solid union ex- rerimetritic adhesion between the uterus and the walls of the space of Douglas. ( Winckel.') 1 Compare E. Martin, loc. cit. 432 PATHOLOGY AND THERAPEUTICS tending over a large surface (Fig. 202). It is only rarely that the artection extends also over the anterior surface of the perimetrium, in which case similar adhesions occur also in this place. Turning from these changes in the peritonieum itself, we find that hoth distortions and passive congestions of the titerus occur in consequence of displacement and constriction of vessels. When there are extensive perimetric processes, there occur almost always simultaneous changes in the broad ligament ^ and therewith exu- dations both above and below the peritoneum. The rectum^ in particular, is very considerably influenced in its functions by these perimetric changes. There results a real walling-in of the rectum, which forces its wav through the middle of these plastic exudates, with rigid walls standing widely apart, or is constricted by the ligamentous remains of the atiection, so that it is only opened when either solid faecal masses are pressed against it by energetic peristaltic movements, or when fluid intestinal contents are forced through it. The tubes and the ovaries suffer severely from the perimetric aflec- tion. Impeded in their nutrition and in their function by the remains of exudates, forming strings and bands, or by the deposits on their surfaces, which are the results of pelveo-peritonitis, they become firmly united with the other parts of the pelvic floor, and must then participate in the swelling and shrinking, and in the displacement, of the latter. By these exuda- tions they are sometimes united with the neighboring organs in large masses, sometimes they are fixed in distant parts of the lesser pelvis, and then they are cut oft' from their jihysiological relations to the uterine cavitv. Furthermore, there is a stagnation of the contents of such dis- placed and constricted organs, which may cause either the tubes or the Graafian follicles to be dilated into dropsical sacs, or may occasion chronic oophoritis and haemorrhages into the stroma of the ovaries. In perimetritis just such kinds of changes are prominent in gynaecolog- ical practice; it is true that, in the further course of their development, a sort of involution may occasionally occur spontaneously ; in other cases they continue in a cicatricial condition, and only undergo a sort of relax- ation at the climacteric during the involution of all the pelvic organs, whereby the latter are themselves liberated to a certain extent. The sy?npto}?is of perimetritis vary greatly according to the abun- dance of the exudate^ and according to whether the form is acute or chronic. While in acute perimetritis the well-known fondroyant symp- toms occur, — viz., chill, high fever, and frequent pulse, early distention of the abdomen, with difficulty of moving the bowels, and tympanites, nausea, and collapse, — the symptoms are not infrequently entirely latent when the course is from the beginning more chronic. OF THE DISEASES OF WOMEN. 433 The patients experience a distress which reminds them of uncom- fortable conditions at the time of menstruation, or of the disagreeable con- sequences of a motion of the bowels, or of a catarrh of the genitals, and this troubles them for a long time. The pains are more and more located in the sacral region ; they are always more intense at every menstruation, and not infrequently at every defecation when the bowels are constipated, and at every coitus. An uncomfortable vesical tenesmus comes on, and under the reaction of these symptoms on the constitutional condition, which is often profoundly affected only after a long time, the patients be- come aware that they have a serious affection of the genital organs. I omit in this place the consideration of the course of acute perime- tritis and pelvic peritonitis in their extension to the whole peritonaeum, and in their development to a general peritonitis ; for in such cases there is generally a septic condition, regarding which I have nothing gynaeco- logical to add to the well-known obstetrical descriptions of such puerperal affections. Usually, in this rapidl}' spreading septic peritonitis, such as was formerly associated with gynecological operations, and especially with laparotomies, death ensues within a few days, after an early increase in the frequency of the pulse, and a very inconstant course of the varia- tions of the temperature. The symptom which has been described as that of this form of severest septic peritonitis — the bilious vomiting — has been by no means constantly observed by me. The behavior of the pulse has struck me as the symptom which occurs most regularlv in all the various forms of the course of this affection. While the temperature occasionally does not rise above normal, 38° C. (iooV5°F.), or may even, sometimes, remain subnormal, there is always in septic peritonitis a very early and striking frequency of the pttlse, "which earh' becomes small, irregular, and extraordinarily frequent.^ In these forms of acute perito- nitis and perimetritis I have seldom failed to observe an extremely trouble- some constipation. There are, to be sure, also cases which run their course with profuse diarrhoea ; but the majority commence with the early occurrence of constipation, against which all attempts to obtain defecation are unavailing. Therewith some complain of violent pain, tormenting 1 It should always be remembered that the temperatui-e as taken in the mouth or in the axilla is utterly unreliable, in cases where there is any question of septic peritonitis. Precisely in the cases where a false sense of security is inspired by the normal or even subnormal temperature, and where suspicion is excited by the frequency of the pulse, as described above, the temperature in the vagfina ■will always be found very high (i04'-i07"F.). The greater the difference between the temperature in the mouth or axilla and that in the vagina, the greater the danger. Serious general peritonitis rarely goes on without a decided rise in the vaginal temperature, and it is, therefore, a wholesome and safe rule, after laparotomy, to have the temperature, as recorded by the nurse, always represent the vaginal temperature. Any one who will contrast tlie charts of the temperature of a few septic cases, as taken by mouth and by vagina, — the curves of each person being on one paper, — will notice the wide diver, genccof the tracings. — E. W. C. [Supplement to ".Vnnals of Gynecology," September, iSSo, \'oI. II., Xo. 12.] 434 PATHOLOGY AND THERAPEUTICS thirst, and sleeplessness ; others, on the contrary, enjoy a truly unnatural comfort, which, when the temperature is low, may prove misleading as to the gravity of the danger. The less acute forDis^ which, however, come on with a quite clearly marked commencement of the disease, are introduced by fever and violent pains. The elevation of temperature in these cases is not always equally considerable ; in fact, sometimes it rises in the beginning hardly above 38"Vio° C. (ioiVu° F.), where it remains for a considerable time. It is, rather, the pain which is the prominent symptom of the disease. There are continuous distressing pains in the sacrum, which cause every motion to be intolei'able, which are renewed whenever there is peristaltic motion, which are exacerbated especially under the influence of the processes of menstruation and ovulation, and which increase to an extreme degree on pressure by the bedclothes, or on insertion of the tube of the vaginal syringe. These patients lose strength very rapidly, feel extremely exhausted, are sleepless, without appetite, and not infrequently tormented by con- siderable flatulent distention ; sometimes there is added to the above symptoms a continual vesical tenesmus, which is not alleviated by any attempt at passing urine. The result of examination in acute perimetritis is materially influ- enced by the extraordinary sensitiveness of the abdomen, the tympanites, and the extreme tension of the abdominal walls, which permits only an incomplete palpation of the conditions of the pelvis. From the vagina the uterus is felt to be fixed by a mass — which is often very hard — which extends behind the uterus, and presses down the vault of the vagina. In other cases no material change in the condition of the genitals is at first noticed on examination, and only after one or two days of the affection is an effusion into the space of Douglas noticeable, which commences with a great displacement of the uterus forward, and which causes much pain when touched. The consistency of this effusion is not infrequently from the beginning tensely elastic ; only when the exudate is not abcapsulated its softness is noticeable from the beginning, and its consistency only ap- pears firmer with increasing inspissation. The masses of exudate always lie behind the uterus ; the whole vaginal vault sometimes appears relaxed and oedematous. Almost always a considerable pulsation is found in the roof of the vagina ; the extreme sensitiveness of the parts is always noticeable. In cases of insidious development of perimetritis we usually find at first only a very inconsiderable sensitiveness of the abdominal walls ; on the other hand, there is a very pronounced tenderness of the vault of the vagina, which becomes decidedlv painful on the slightest attempt to push OF THE DISEASES OF WOMEN. 435 the uterus out of its place. Then a cHstiuct thickening of tiie posterior part of the vaginal vault can very often be perceived ; the latter may also, at this time, be already pressed downward, so that a tangled mass of strings and bands can be perceived in it, which are extraordinarily painful when touched. In other cases, on the contrary, the posterior vaginal vault appears to be drawn upward in a peculiar manner, and it is only with difficulty that the finger reaches the junction of the vagina with the posterior surface of the collum. The uterus itself is drawn to the j^os- terior pelvic wall and is fixed there, so that the isthmus of the uterus seems to nearly lie against the sacrum. The peculiar long sui'face which the finger has to pass along, following the uterus, before it comes to the place of fixation, not infrequently feels, on examination with only one hand, like a retroflexion of the uterus, in which the corpus uteri seems to be felt through the posterior vaginal vault ; it is only after a careful bimanual examination that it is found, in such cases, that there is not a peculiar elongation of the collum, but the mistake is rather caused by the peculiar fixation of the uterus in the depths of the pelvis. Usually the uterus is drawn to the anterior surface of the sacrum ; the place of fixation can only be felt with difficulty above ; it is extraor- dinarily sensitive. A more exact examination seems extraordinarily diffi- cult, in consideration of the sensitiveness of the patient. The thickening is felt, which extends from the place of fixation to the vicinity, and the strings and bands 'are perceived, which have been described above, and which are very tender to the touch. In other cases the uterus is found to be, to a certain extent, fastened by one or both sacro-uterine ligaments, and to be drawn upward by these structures, which can be felt as tense bands, and to be displaced backwards, either in the median line or laterally. The result of examination in perimetritis after the acute stage has ru/i its cozirse^ and if gradual involution of the changes in the peritonjeum has occurred, varies very much. If plastic exudations have taken place, tliey may remain almost unaltered for months ; they may form great tumors behind the uterus, and completely imbed the latter, and from behind they may v/hoUy fill up the posterior half of the lesser pelvis. Then the uterus is felt fixed to them ; occasionally the uterine appendages can be palpated on their borders ; more frequently the appendages are for a long time completely imbedded in this exudate, so that it is impossible to isolate them. From the posterior vaginal vault the space of Douglas seems to be tensely distended downwards, having a shape like the large end of an Q^^-. around which the finger can be passed at the roof of the vagina. 436 PATHOLOGY AXP THERAPEUTICS This mass al\va\>> remains, to a certain extent, sensitive, wliether \vc palpate it from the vault of the vagina or from the rectum. The lumen of the latter is not infrequently very considerably obstructed, or pushed to one side, or it is lirmly imbedded in masses of exudate, and seems like an open hole which runs through these masses. The rectum, and also the roof of the vagina, may appear peculiarly soft, doughv, and o^dematous. If further involution occurs, there is a progressive diminution of the tumor on the floor of the space of Douglas. Until it is completely absorbed, there is still a displacement nearer and nearer to the sacrum, or towards one side or the other. Then in course of the involution the ovaries and tubes become noticeable, although dis- turbed in their nutrition, and not infrequently considerably swollen, while the roof of the vagina remains to the last covered with these remains of exudate, and appears thickened, and is often found to be sensitive. If the exudate is discharged^ the mass often, to be sure, shrinks to a small part of its volume ; remains of the exudate, however, remain for a long time, even in such cases, and are always perceptible, especially in the manner described above, through the roof of the vagina, and react in the same way on the neighboring organs. When resorption is complete, the uterus may recover its mobility, and the appendages also, freed from the pressure of the exudate, may again resume their normal condition ; thus the relations of the pelvic organs may return to their pristine state, and therewith recovery is attained; nevertheless, in these cases, there remains for a long time, so far as I have observed, a great tendency to relapses, and permanent recovery of these organs is only secured in such women, after very careful behavior, in the course of four or five years. This favorable event is most fre- quently observed, as far as my experience goes, in just those cases where the exudation is rather abundant. The course of tJie cases of less abtinda?it exudate, but especially of the forms of the affection which have originated -with a chronic de- velopment., is very 7nuch more serious. Not infrequently, to be sure, there is at first a sort of termination and an apparent recovery ; but only too often all that is obtained by treatment is a diminution of the tender- ness and the establishment of a certain mobility of the organs, while tliere is still a layer of exudate on the peritona2um, which remains and per- manently impedes the function of the organs. Of especial importance in these cases is the permanent displacement of the uterus, which does not merely occur in cases where there is extensive disease, and con- sequent broad adhesions, e.g.., of the whole posterior surface of the uterus to the floor of the space of Douglas, or to the sides of the latter. OF THE DISEASES OF WOMEN. 437 Cicatrices which invest the ovary, and quite insignificant adhesions of the intestine in the form of a band or cord, or a cicatricial change in the sacro-uterine ligament, sutfice to resist for a long time all medica- ments and modes of treatment. In such pathological adhesions the uterus and the appendages degenerate together and become contracted, and then the patient may at times enjoy a relative comfort. Then the parts maybe entirely free from tenderness when touched, and their functions of menstruation, defecation, and urination may be performed regularly. A slight disturbance of the general health, however, — even a simple cold, — is sufficient in such cases to bring back the whole series of sufferings, and to occasion a relapse which again fetters the patient with her old troubles for weeks or months, while the recovery from it is only as incomplete as before. Most frequently and constantly the mucous membrane of the utertis suffers in consequence of the severe traction ; there occur very distressing menstrual colics, profuse menstrual haemorrhages, and, as a rule, an abundant secretion, which disquiets the patient greatly.^ Among the further disturbances which occur in these affections 1 would call attention to those peculiar conditions which come on in distant organs, as accompaniments of chronic perimetritis, among which the dis- turbances of vision are especially noticeable, which are associated par- ticularly with long-persistent perimetritic exudations and changes. They consist in decided hyperassthesia of the i^etina, and cause the women great anxiety on account of impairment of visual power, especially by lamp- light, but also on trying to read or sew by clear daylight. - Chronic perimetritis., ivith its insidious development., usually leads to sterility. In regard to this, in the first place, the impediment to coitus seems not unimportant. Then it is worth considering that the contact of sperma and ovum is hindered, if not rendered impossible, by contractions, by deposits on the surfaces, especially of the ovaries, by distortion of the course of the tubes. Not very seldom, nevertheless, an almost immoderate desire for coitus is developed under the influence of this chronic disease of the genitals, in contrast to the complete sexual distaste which occurs in the great majority of cases. ... I have been repeatedly informed by such patients, that although the parts were extremely sensitive to examination by the finger, yet that sexual excite- ment caused them no such suffering at the time, antl that they had to repent of it only some days afterwards. . . . Of course, conception mav occur in such forms of perimetritis, in case the ovaries are not degenerated and the tubes are not occluded, and no secretion has been I Czemfyin. Zeitschr. f. Gcb. u. Gyn., Bd. XII. - Mooren, loc. cit. 43S PATIJOLOGY AND TJIERAPEUTICS developed on the inner surface of the uterus, which is disposed to rapid decomposition. If pregna}icy occurs^ recovery is sometimes seen to take place under the injiuence of gestation^ -with the relaxation which the latter causes in the genital system. There is a complete absorption of the perimetritic layer, the remains of exudates and bands, and if no new injuries occur in child-bed complete recovery may, in fact, take place in connection vvith such a pregnancy. Besides sucli fortunate issues, however, there are often premature interruptions of pregnancy., inasmuch as the development of the gravid uterus and its ascent out of the lesser pelvis are hindered by the persist- ence of the pathological connections of the uterus to its vicinity. In these cases, to be sure, the chronic perimetritis is not alone to blame for the abortion ; the disease of the mucous membrane and the parenchyma of the uterus, which so frequently accompanies, or rather, perhaps, precedes, the perimetritis, is an essential factor. Abortion does not always occur, even when there are apparently very firm adhesions on the occurrence of pregnancy ; even when the uterus cannot develop out of the lesser pelvis ; just in such cases there is always possibifity of the formation of a diverticulum towards the upper free wall of the uterine body. Such a diverticulum may become the receptacle of the foetus while the posterior wall of the uterus remains retroflected and fixed permanently in the lesser pelvis. Quite analogous conditions arise in cases of prolapse, in which the development of the procidentia is restrained by a perimetritic fixation of the uterus. As is known, the proposition has even been made, in cases of considerable prolapse, to induce a fixation of the corpus in the pelvis by means of a perimetritis, in order to cure the prolapse in this way. Under the influence of pregnancy, relaxation may take place, indeed, in such cases, and with the ascent of the uterus every trace of the perimetritis may vanish. If the adhesions are not loosened, and if the condition of fixation remains unaltered, there occurs an incarceration, which, just as in retroflexion of the gravid uterus and fixation by peri- metritis, may lead first to abortion, and then even to death, owing to gangrene of the uterus and rapid consequent peritonitis. In regard to the differential diagnosis., inasmuch as the result of examination has been already set forth at length above, I would only remark that the differentiation of the effused mass from an extravasation of blood in this place is often very difficult, and by so much the more, since, as is well known, the latter not infrequently is developed after previous attacks of perimetritis, by rupture of delicate adhesions. The differential diagnosis could only be reached in some such cases by punc- I OF THE DISEASES OF WOMEN. 439 ture, if it wcic of interest, in difficult cases of this nature, to decide immediately and exactly whether what had been efTused were an extrav- asation or an exudation. Perimetritic abscesses sometimes break and are discharged, even after they have remained for a long time unaltered, like more serious exudations. Effusions of blood are so comparatively sel- dom discharged spontaneously, they rapidly grow thick and are resorbed, even without ever giving rise to the peculiar creaking noise and feeling which has been attributed to them as characteristic of collections of blood. A decisiofi as to wJiether the effusioti is extra or intra peritoneal is usually facilitated by its situation ; the parametritic exudates and the extra-peritoneal hcematomata lie chiefly at the side of the uterus and extend towards the iliac fossa ; they press the lateral part of the vaginal vault downwards and make the sides of the uterus appar- ently thicker. In the other case they apparently only touch the latter, because, on account of their large size, they reach from the side of the pelvis to the uterus. Perimetritic exudates always lie behind the uterus, very seldom also before it. They may be situated so high in the pelvis that they can only be touched with difficulty through the roof of the vagina ; usually, however, they press the posterior vaginal vault down- ward, and push out the floor of the cul-de-sac in the form of an obtuse ovoid, unless the surface has become knobbed, owing to deposits of exu- date in layers and lumps. The prognosis of peritnctritis tmist always be designated as serious. Although the danger of an acute extension over the w^hole peritonaeum is usually soon excluded yet the consequence of the perimetritis, the dis- placement of the pelvic organs and the influence exerted on them, is not infrequently the source of serious j^ermanent suffering. Even abcapsulated masses of exudate, although they usually run a favorable course, must yet be designated as a very serious disease, since they are always liable to perforate into the abdominal cavity ; and, on the other hand, even if they are discharged through the rectum, or in some other w^ay, they may occasion a dangerous putrefaction. The treattnent of the acute form must be strictly antiphlogistic : applications of ice, quietude, care to have the stools soft and abundant, and abstractions of blood from the abdomen, if necessary. When the acute stage is passed, the patient must be kept quiet on her back, and the bowels must be kept freely open, while measures are taken to pro- mote further absorption. In order to stimulate the latter, I like to employ hot douches at a temperature of 123° P., immediately after the sub- sidence of the acute symptoms, and I have warm fomentations substituted 440 PATHOLOGY AND THERAPEUTICS for the ice-bags. Then when the patient is free from fever, and the tenderness has disappeared and the stage of absorption has arrived, I pass to the employment of preparations of iodine, of iodoform, and of sitz-baths. These measures are very successfully combined with tlie application of mud-poultices on the abdomen, also mud-baths for the whole body, and particularly with the use of the iodized sulphurous prep- arations of Krankenheil. Even large exudations may be absorbed in comparatively short time imder the use of these measures, and of an appropriate and strengthening diet. It is only very exceptionally that there is any indication to open them^ — when the contents of the abscess decompose, and the products of the decomposition keep causing fresh fever, and new and violent symptoms. As a rule, the abscesses can be reached and evacuated through the roof of the vagina. In such cases I am accustomed, after properly exposing the parts under anaesthesia, to cut into the vagina, and to sew the wall of the vagina all round, before opening the abscess itself. I then let the cavity empty itself as com- pletely as possible, wash it out with a weak carbolic or sublimate solu- tion, and insert a thick drainage-tube with a ci'oss-piece. Usually the cavity is greatly reduced by the pressure of the neighboring parts, and heals up within a few weeks ; it is seldom necessary to wash it out repeatedly ; in fact, I have only found it necessary to do this, with con- tinued disinfection, in cases where, owing to excessive duration of the disease, the walls of the cavity were greatly decomposed, and had to be exfoliated previous to complete recovery. If the abscess can be less readily reached from the vagina than from above, it would have to be opened from above ; but I should rather believe that just those abscesses which can be most easily reached from above, and are opened from that direction, heal best if a counteropening is made into the vagina in order to prevent stagnation at the bottom of the pus-cavity. Complications of the course of the disease, perforation into the bladder or into the uterus or the vagina, with formation of fistulous tracts, are to be treated according to the conditions of the individual case. In the treatment of the chronic forms it is important, in the first place, to keep the parts as much at rest as possible. Care must be taken to pro- vide for easy, soft evacuations of the bowels, for frequent rest in the; recumbent position, for cautious exercise in the open air, and for absolute abstinence from conjugal intercourse. Every kind of interference by the physician is to be strictly avoided ; minute examinations^ abstrac- tions of bloody use of sounds^ or treatment with pessaries^ are directly contraindicated^ and accordingly forbidden. As long as the pains are still active the patients should lie down by the hour, repeatedly, during the OF THE DISEASES OF WOMEN. 441 day, with cool, 01 lukcwann, or even warm, fomentations on the abdomen ; should take their laxative medicine regularly, and use very cautiously vaginal douches of lukevvarm water, or mucilaginous infusions, with the addition of morphine, or of infusion of conium maculatum/ employing the fluid under very slight pressure. If necessary, suppositories of morphine, extract of belladonna, cocaine, etc., are also to be employed. After some days, sitz-baths of 90° F., or gradually of a cooler temperature, or hot douches of 122° F., are felt to be beneficial. After the pains have disappeared the above-mentioned re- sorbents come into use again. Among the measures which are worthy of further discussion in treat- ment of the chronic form of perbiietritis with slight exudation, I would recommend, above all, the above-mentioned rectal douches of Hegar, which, in gradually increased amount and diminished temperature of the fluid, and longer presence of the fluid in the rectum, exert a very favorable influence on the adherent masses, by stretching them, and thus have a very decided influence in restoring the mobility of the pelvic organs. The observations made everywhere, of exacerbations of pain and of recurrent increase of the local evidences of perimetritis, at the time of menstruation, have suggested the idea of abolishing this source of relapses of the malady by hastening the change of life. Castration has been per- formed on account of this indication, and with success, according to the reports by some English and American authors. In Germany this pro- cedure has as yet met with very little recognition.^ My personal stand-point in this question is, that up to the present time I have not had to extirpate ovaries which were themselves healthy, where there was perimetritic exudate, in order to cure the perimetritis. According to my observations, however, in such cases, disease of the ovaries is not infrequently associated with the perimetritis. Ovaries and tubes suffer under the influence of the perimetritis ; there is retention in consequence of impeded dehiscence of the follicles ; the tubes become occluded, and the constricted portions are dilated, whether the process began originally in the perimetrium, or had its first source in the tube or in the ovary. In such cases I have found the tubes and ovaries imbedded in perimetritic callosities and layers ; they were impeded in their func- tions by the perimetritis, and thereby they had become diseased. My operating is, therefore, not directed against the perimetritis alone, but ' H: Infus. Herb. con. maculati (3 iii to water § xx) § xx. Aqu;c laurocerasi O iv. S. Three tablespoonfuls to the quart for vaginal douche. '^ Hegar, Deutsclic Klinik (Goschen), 1S73, Nr. S. Berl. klin. Wochenschr., 1S74, Nr. 6 u. 7. 'Compare J. Vcit, Ucher Pcriniutritis. Volksw. Sammiy;., Nr. 255, 1SS5. 442 PATHOLOGY AND THERAPEUTICS simultaneously against the chrotiic oophoritis and salpingitis ; the whole mass of these structures, together with the callosities and remains of the exudates, was glued together into a tumor sometimes larger than the rist. Up to the present time I have extirpated the ovaries and tubes, togetl>er with the perimetritic deposits, and obtained recovery in twenty-five patients with such cases of chronic oophoritis, and in seventy-seven cases of diseased tubes. The constant pains disappeared as well as the ex- acerbations at the time of menstruation, and after long and wasting disease the patients have all nearly recovered, so far as I have accurate reports of them ; and at any rate the perimetritis has at first undergone involution. To be sure, several of them suffered relapses afterwards, and have required a long time for their convalescence. It is certainly noticeable that under our present views in regard to ovariotomy and laparotomy, with the perfection of the technique, such a high degree of certaintv in the method should have been attained that this operation is now undertaken just where formerly the strictest contraindica- tions were found, in such cases of pelveo-peritonitis. I decide to operate in such cases, of course, only when the ^perimetritis has not got better in the course of a prolonged treatment, and when by repeated examinations I have ascertained the presence of disease of the ovaries and tubes. For these affections all the therapeutic measures are of value which I have described above ; in such cases I have employed repeated abstractions of blood, ice treatment, vest of the parts, narcotics, hot douches, mud-poul- tices, mud-baths, iodine, and also mercurial inunctions, by the year, before I have determined to operate. 2. IXTRAPERITOXEAL H.EMATOCELE. Free extravasations of blood into the abdominal cavity are only de- fined as hzematocele when they present themselves as an abcapsulated mass in the lesser pelvis, before or behind the uterus. These hemato- celes are, indeed, hardly ever found in entirely healthy women. All have suffered from menstrual disturbances ; the majority of them have borne children, and have also suffered from puerperal disease of the uterus or its vicinity. If that is w'hat the origin of haematocele depends on, we must assume that there is some definite exciting cause of its occurrence, since among the many women who have puerperal affections only a compara- tively limited number fall a prey to intra-peritoneal haematocele. A computation of the frequency is made difficult by the fact that many such patients only come under medical diagnosis of their condition very late, or not at all. The computations of authors, therefore, vary so OF THE DISEASES OF WOMEN. 443 considerahlv thai no acceptable average can l)e deduced from the observa- tions which Ikin'c been published.' The hicmorrhage may occur first from the torn adhesions of the peri- tonasum, disease of which quite regularly precedes the development of hasmatocele, whether in the form of a serous pelveo-peritonitis, or of a pro- cess analogous to haemorrhagic pachymeningitis," in which case a violent displacement of the uterus, either from impetuous coitus, or violent action of the bowels, or from an attempt at gyncecological diagnosis or treat- ment, may then occasion the rupture of a vessel. The ovaries and the tubes may furnish another source of hiemorrhage. Such a superficial laceration is probably frequently associated with the menstrual process and the rupture of the follicle, thereby leading to the eflusion of blood on the surface of the ovary, and from there into the space of Douglas. As a rule, however, the ovaries are implicated also in the perimetritis, which I have already designated as the principal cause of the affection, and thus the hiemorrhage from the surface of the ovary probably furnishes only a part of the blood which is effused on such an occasion. Where there is disease of the tube itself there may similarly be haemorrhages from the latter, like other losses of blood, which are seen to occur from inflamed mucous membranes, and in the majority of cases of perimetritis the tubes are not intact. Tubal affections, and tubal and abdominal extra-uterine pregnancy,^ furnish a very frequent source of intra-peritoneal haematocele. The ^pathological anatomy of hematocele always gives evidence of a more or less extensive blood-tumor on the floor of the pelvis. In the great majority of cases the mass lies behind the uterus, in the space of Douglas ; only very rarely is the eflusion of blood in the vesi co-uterine fold. The cul-de-sac of Douglas is then shut ofl' from above by pseudo- membranes, such as also cover the perimetrium and the lateral and jDOsterior walls of the cavity ; while, above, the masses and layers apply themselves to the coils of intestine which are adjacent to the cul-de-sac. The latter may thereby become an entirely closed space, which is itself divided by the remains of bands and cords, and is filled with blood, which sometimes remains fluid for a long time, and in other cases is partly coagulated, and in others again consists of a mixture of serous fluid and pus. It is hard to decide in individual cases whether these abcapsulatiug membranes have existed before the occurrence of the haemorrhage, or whether they are a consequence of the latter; the possibility of an extrav- 1 Compare the literature in Schroder, Handbk., VII., S. 46S. - Virchoiu, Die krankh. GeschwUlste, 1S63, Bd. I., S. 150. 3 Sciiroder, Krit. Untersuc. iiber die Diagnosis der H^matoc. retr. u. s. w. Bonn, 1S66. Berl. kl. Woch., 1S6S, Nr. 4, ff. 444 PATHOLOGY AND THERAPEUTICS asation of blood into the space before it is closed off is undeniable. Blood which is clliised outside of the lesser pelvis can only lead to the formation of a hieniatocele if it runs into the deepest part, /.«., the cul-de- sac, eitlier continuously for a long time, or repeatedly. The filling up of the space of Douglas is, of course, greatly in- fluenced by tlie relative capacity of this cavity and the varying fulness of the bladder and rectum. Fluid blood, like free exudations, may be pressed out of the cul-de-sac by intestinal coils or by repletion of the bladder and rectum. A haematocelc, /'. DeuUch. Zeitschr. f. prakt. Med., 1SS7, Nr. 34. OF THE DISEASES OF WOMEN. 445 of the elusion of blood. These, also, may be more or less distinct. Beside cases of immediate and very profound collapse, with all the symptoms of acute anixjmia, there are others in which the slow develop- ment of the effusion of blood only very gradually occasion the symptoms of anajmia. Then there is more and more marked paleness of the exter- nal skin of the visible mucous membranes, smallness and frequency of the pulse, palpitation of the heart, oppression of the prtBcordia, buzzing in the ears, fainting fits and nausea, violent thirst, and obscuration of the field of vision. These symptoms may be developed very rapidly, or also gradually, if the bleeding occurs at intervals. If the hcemorrhage is considerable, and the abcapsulation such that the blood in a large mass forms a tumor in the pelvis itself, there are, sooner or later, distinct symptoms o'i pressure on the neighboring organs. Violent abdominal straining, rectal and vesical tenesmus, the sensations of prolapse, of distention, and of extreme discomfort, become noticeable. If these symptoms of peritoneal disease are combined with those of effusion of blood and of the formation of a tumor, the result is a condition of the most profound collapse., which is not infrequently found in these cases. We see these patients with cool extremities, a deathlike pallor, verv restless, anxious, short of breath, tormented b}' a burning thirst, nausea, and a continual abdominal straining. The abdomen is not always tvm- panitic ; sometimes it seems hardly distended ; moreover, the tenderness on pressure is very various. Beside cases of extraoi'dinary sensitiveness at the slightest contact, I have seen other women of this sort who — perhaps under the, influence of the aniBmia — were quite indifferent to pressure. It is seldom that pronounced elevation of temperature is present at the beginning, and this, in such cases, makes a contrast with the coldness of the extremities. On internal exa7ninatio7i the uterus is found to be pressed forwartl by a tense tumor, which makes the cul-de-sac of Douglas bulge stronglv downward ; in other cases the uterus, which is pushed upwards, mav be hard to reach behind the symphysis. The tumor at first appears to be situated closely adjacent to the uterus ; the tenderness of the abdomen of the patient, and her general condition, as well as the pain occasioned bv touching the tumor itself, forbids any attempt, at this early stage, to make a thorough examination, such at, can occasionally be performed with great exactness. The rectum is also obstructed by the tumor, which reaches to the sacrimi, bulging out the anterior wall of the rectum, and onlv leaves a narrow aperture at the side. At an early stage tlie tumor is usiialh' clas- tic. Pronounced fluctuation is seldom felt, more frequentlv the well-known- 446 PATJJOLOGY AND THERAPEUTICS ball-criiiiching (^kuirschcn) can be felt. Gradually the tumor becomes harder, and then sometimes a few nodular constricted places are distin- guished, while in other cases the mass remains even and smooth. The consistence is not always equally altered ; sometimes there are soft spots here and there, which indicate the locations of liquefaction. The differential diag?iosis of intra-peritoneal haemorrhage from that which is extra-peritoneal has been discussed in the chapter on extra-perito- neal hcematoma. The diflerential diagnosis maybe more difficult between hiumatocele and the pelvic eflusions, which must be regarded as the products of perimetritis ; that is to say, the serous and purulent exudates. Such a differential diagnosis is made more difficult by the fact that in old haema- toceles we soon observe the occurrence of changes in the blood-mass itself which are closely similar to the above conditions of exudation. By simple disintegration of the blood and deposit of the solid parts there may remain an almost serous fluid ; while, on the other hand, de- composition and putrefaction of the blood, with suppuration, may ensue in consequence of inflammatory attacks. In such cases the commencement of the disease will give material information. If in the given case menstruation has been missed once or twice, and then the disease has developed suddenly, such a tumor will be properly held to be a hoematocele, and, in fact, one originating in the rup- ture of a tubal pregnancy. Likewise, in cases of previous disease of the pelvic peritonaeum the sudden origin of the attack and absence of fever point very distinctly to the formation of haematocele. To be sure, even in cases of hasmatocele there maybe febrile attacks. Without any decom- position of the blood having occurred, the temperature may rise, and ex- treme tenderness of the abdomen, with meteorism, may develop, just as in peritonitis. In such cases it is probable that, with the blood, an agent which excites fever has passed out of the tube into the peritonaeum, and there occasioned the rise in temperature. The immediate suppuration of the haematocele does not necessarily follow, however. The fever passes off, and a typical retrograde metamorphosis of the blood -tumor takes place. I A very protracted course, where the tumor in the space of Douglas develops gradually, with great tenderness, does not, as a rule, indicate haematocele, but an effusion originati7ig in an inffainmatory process. Especially in cases of longer duration, in which there has been no oppor- tunity to observe the acute origin of the affection, and where there is no definite history of such a commencement, the mass of blood may further give rise to confusion with new-groivths^ or extravasations of blood in other organs, especially in the ovaries and tubes. Some time ago I saw a OF THE DISEASES OF WOMEN. 447 case of this kind in a strong woniaii, who had iiad cliildrcn, in whom some half a year after the hist hibor, with symptoms of anoBmia and peritoneal irritation, which increased rather rapidly, a tumor was formed, which tensely distended the space of Douglas, occupied the whole pelvis, pressed the uterus forward and lifted it somewhat upward. After her former labors the patient had been ill, but otherwise she had always performed her household duties with great energy. The sudden origin of the tumor, the pronounced anaemia of the patient, and the pecu- liar, not clearly dclinablc, consistency of the latter, and finally its complete immobility in the lesser pelvis, led the family physician to make a diag- nosis of hajmatocele. For several months efforts were made to bring about the absorption of this supposed haematocele, without the occurrence of any progress in the state of the patient, or the observation of any clearly noticeable change in the tumor. On the contrary, the strength of the patient failed more and more ; and partly the increasing illness, partly the persistent pains, and the un- changed condition of the tumor as noticed by the physician himself, caused me to be called in consultation. I found the condition just as it had been observed in the beginning by the physician, except that under anesthesia, after very difficult palpation behind the rather fat abdominal walls, I could observe a certain mobility of the tumor in comparison with the uterus. The tumor had not increased during menstruation ; its consistency, although not clearly distinguishable, was yet tensely elastic. I was able to feel a thickening of the right tube, which was swollen, club-shaped, and was apparently connected with the tumor. No ovary could be felt on the right side ; that on the left only indistinctly. I expressed the suspicion that this was probably not a case of haema- tocele, since, if it were such, the mobility of the tumor in relation to the uterus would not be explicable ; the rounded contour of the tumor above and at the side, and its elastic tenseness, made it seem to me probable that there was a new-growth wedged into the lesser pelvis. After I had attempted to excite involution by treatment lasting several weeks, I pro- ceeded to establish the diagnosis by operation, and to remove the tumor if possible, on account of the threatening aspect of the general condition of the patient. I divided the posterior vaginal vault, and could now ascertain that there was no extravasation of blood in the pouch of Douglas, but that there was wedged into the lesser pelvis an ovarian tumor, whicli was, however, filled with blood, and as large as the fist. 44S PATHOLOGY AND THERAPEUTICS I succeeded in separating this hiematoma of the ovary on all sides, working from the vagina, evacuated its thickened contents, and then extirpated the ovarv, together with the moderately thickened tube. I drained the space of Douglas, into which coils of intestine protruded only after the operation was finished. Convalescence proceeded without disturbance. It has been recommended, in similar cases of difficulty of diagnosis, to ascertain the 7iattire of the tumor by puncture. In extravasations of blood, the blood is not then always immediately discharged, but verv frequently a nearly clear serous mass, in which only afterwards and by degrees traces of former haemorrhages appear ; while in exudates there is an absence of bloody admixture ; there is discharged either a clear, serous fluid, or one mixed with pus, and sometimes foul- smelling. Such an explorator\ puncture is, however, an undertaking by no means free from danger, as I know from former observations at the clinic of my father ; so that I should only decide to make sure of the differential diagnosis in this way on account of some very urgent indications. Exploratory puncture appears by so much less worthy of approval, in- -asmuch as in the great majority of cases we can, in a comparatively short period, obtain resorption of liEematoceles, as of most of the exudates of this sort. ^\\& prognosis of hcejnatocele in cases where the blood is extrava- sated into a closed space is favorable as long as this space is Tiot capable of receiving too large an amount, and in so far as germs of decomposi- tion do not exert their activity in too great numbers and intensity. The perforation of the abcapsulated mass, the free discharge into the abdomi- nal cavity, are usually accompanied by very severe symptoms ; but even here the capacity of the peritonaeum for absorption not unfrequentlv triumphs in a most unexpected manner, so that such patients may recover from collapse apparently very profound. Only immoderate, rapid haemorrhage, and yet more the simultan- eous effusion of intensely infectious masses, make the prognosis gloomv for the women who are already very n-juch weakened. The prognosis is similar if the mass of blood is not absorbed, but putrefies. Even in these cases, however, the discharge may follow into neighboring organs, just as in cases of exudation ; this most frequent result, it is true, com- mences with very severe symptoms, but yet afibrds hope of spontaneous recovery. In regard to treatments I refer to what has been stated in consider- ing perimetritis. In hicmatocele the first oliject must be the control of OF THE DISEASES OF WOMEN. 449 liiBmorrhage by :ippi-(;priate treatment with ice, rest, etc. ; then the general condition requires strong stimulation to relieve the collapse. If the first eflects of the haemorrhage are overcome, the haematocele usually passes into the stages of resorption, under the resorptive treatment repeatedl}' indicated al)ove. During this it is difficult to determine the period at which it is necessary to desist from such an expectant treat- ment, and, instead of the latter, to seek the source of the haimorrhtTge or to remove the extravasation by operation. Ever}- such case must i)e judged by itself. Here, however, there remains the extraordinarily important ques- tion., tvhether in hiv?natoceIe, zuhich has oi'iginated from extra-uteritie pregnancy., the treatinent should be expectant., or a laparotomy must be perfor?}ied., in order to lay the affected part bare, and to treat it imme- diately. Although former attempts have afforded results far from favor- able, yet newer observations decidedly encourage such a treatment.' Personally, I have only found it necessary to perforni laparotomv in fresh haemorrhages into the abdominal cavity, v/hen there were ver\' severe symptoms, which depended less on the haematocele as such than on the source of the latter (ruptured tumor), especially when, in asso- ciation with the development of the htematocele, sevei'e febrile symptoms occurred, which showed the life of the patient to be in immediate danger. As is well known, the prognosis of such operations in general is bv no means unfavorable, even in presence of extensive peritonitis and jDerimetritis. Also in cases of extensive effusions of blood recoverv has ensued, especialh' after drainage of the space of Douglas toward the vagina ; only in cases of intense sepsis after previous laparotomy or myomotoni}' have I seen no good results follow a genej-al cleansing of the contents of the pelvis. I would designate the expectant method as the proper treatment for hcematocele. Only when there are severe general symptoms do I determine to open the abdominal cavity. — an operation which, when performed with all antiseptic precautions, still affords prospect of saving the patient, even in such desperate cases. How difficult it is to come to a decision I lately saw in a patient where there was undoubtedlv a case of ruptured tubal pregnancy. Since, however, the patient was in a ' Since the above was written the pathology and operative treatment of extrauterine pregnancy lias been greatly elucidated by Lavjson Tail and his followers. (Lectures on Ectopic Gestation, by Tail. Extrauterine Pregnancy, prize essay, by Strahan.) The rule is now clear to operate immediately in all cases of intraperitoneal hajmorrhage, and to abstain from operating immediatelv where the rupture has occurred between the folds of the broad ligament, forming an extraperitoneal or ordinary hematocele, which latter is distinguished by Martin as haematoma. — E. W. C. 450 PATHOLOGY AND THERAPEUTICS reasonably comfortable condition I advised delay. On the fourth day afterwards she died suddenly, from a recurrence of haemorrhage. The autopsy showed a free etVusion of blood into the abdominal cavity from a ruptured tubal pregnancy. It was very probable that a laparotomy at the proper time would have saved the woman. It is possible to open a way to the extravasate from the vault of the vagina. Owing to the suspicion that there may be a rupture of some structure I prefer laparotomy, and in future shall perform it somewhat earlier. Extravasations which are on the point of perforating outsvard, or into a neighboring cavity, whether they are decomposed or not, have as yet given me no occasion for puncturing them from this cavity. The perforations themselves, since they usually occur into the rectum, the vagina, or the bladder, are of rather favorable prognosis, and they should usually be left to themselves. Puncture or incision for diagnostic purposes would only seem to me warranted in extraordinarily difficult cases ; then, however, I should advise to combine with the former a complete evacuation, disinfection, and drainage of the blood-tumor. In rare and isolated cases a peculiar form of peritoneal disease con- Fronts us, which, as far as I have yet seen, is allied to the tuberculous affections of the peritonaeum, and leads to the development of serous cysts, — Hydrops peritonei saccatus. (See page 487.) OF THE DISEASES OF WOMEN. 45 1 IX. — DISEx\SES OF THE OVARY. In explaining the pathology of the ovary we have to consider as pre- disposed to disease not merely that phase of development of women which gives rise to most of the sexual diseases, namely, the time of puberty and of sexual life, although during this time they are incompara- bly more common. The physiological processes of transformation in the ovary itself proceed in an almost unbroken sequence from foetal life until senescence ; they are so manifold, and they occur with such intensity, and with such powerful changes in the ovary itself, that by them there is given a frequent opportunity for pathological processes in the ovary. It is remarkable enough that the ovaries participate in a striking man- ner in certain infectiotis diseases., particularly in sepsis, while they are not affected, for instance, by tuberculosis ; at least, not particularly so. The ovaries take a prominent part in diseases of the peritonceiitn, whether these occur idiopathically or as a consequence of the extension oi diseases of neighboring- organs ; among these XXiq genitals are of par- ticular importance. Probably the ovaries suffer from the mere mechan- ical injury of unsuitable sexual connection. Together with the uterus, the ovaries are likewise peculiarly liable to new-growths, on account of their intimate relations. Since certain stages of development in the ovary are already termi- nated shortly after birth, there is reason to suspect that pathological conditions also often originate in foetal life., although they onlv show their effects much later. Although even up to the present time we have been accustomed to reckon the most frequent form of disease of the ovar}^, namelv, the cystomatous, among the benign growths, yet some examples indicate with certainty that even the simple cystomata of the ovary have a certain disposition to recurrence. The malignant new-growths of the ovarv have the characteristic of infecting the neighborhood, and particularly the peritoneum, quite early. In regard to the general symptomatology of ovarian diseases it is quite remarkable that we know no clinical symptom which could be regarded as a constant sign of affection of the ovary. We know \\\aX. pain plays only a quite limited role in very many ovarian affections. The pains only occur when the surface of the ovary becomes united with the neighborhood by inflammatory processes; in certain changes in the ovary itselt, however, pains seem to occur, although seldom, as we must con- 452 PATHOLOGY AND THERAPEUTICS cliule from those cases, which are rare, to be sure, where there is a completely isolated disease of the ovar}' without simultaneous afVection of its surface. There is no constant reaction of ovarian diseases on the other genera- tive organs, especially on the uterus and on its functions^ particularly on menstruation. It appears, to be sure, that menorrhagia not infrequently occurs in inflammatory conditions of the ovar}^ ; but amenorrhoea is like- wise observed, especiallv when both ovaries are affected.^ Amenorrhoea occurs comparatively early in carcinomatous destruction of both ovaries. The disturbance of the capability of reproduction^ which would so naturally be expected in ovarian affections, can only be anticipated with certainty when all of the tissues which produce ova are involved in the disease. Since, however, this occurs comparatively very seldom, great caution must be exercised in assuming sterility as a certaintv in ovarian diseases, and only when there is very extensive inflammation or new- growth in the ovary can this consequence be assumed as unavoidable. In diseases of the ovaries a peculiar group of symptoms is developed in the nervous system? In such cases the neuroses present great uncer- tainties ; the pathological anatomy of ovarian affections, just on account of the neuroses, must be designated as so little understood that at present we can only indicate certain neuroses as belonging among the symptoms of diseases of the ovaries, without being able to show their exact con- nection. Entire absence.^ rtidiinentary developjnent^ and too great number t provoking such coiulitions bv means of mechanical external irrita- tions of the ovary. In fact, while considering the course of such cases of severe neuroses, which are connected with the ovary and with its function, the conclusion is occasionally reached that the ovary should be extirpated as the source of the malady, although the changes which are afterwards found ill examining the structures so removed appear to be but slight. The influence ui chronic oophoritis on ine77struation is by no means constant. Not infrequently the flow is profuse, in other cases it is scantv. The most constant symptom is the recurrence at menstruation of violent pains, which are exacerbated with every increase in the severity of the malady, and diminish with the cessation of the changes in the ovary, so that the women then menstruate for a time, even for years, without pain, until one of the frequent relapses of the affection causes the pains also to recur with menstruation.' Among the sv>npto?ns^ accordinglv, must be distinguished tliose which are connected with the organic changes, and are usually of moderate and equal severity, and those which are wont to occur periodically with the menstruation, and then display almost typical paroxysmal exacerbations. It \vill be difficult to determine how manv of the symptoms are to be attrib- uted to the alteration of the ovary itself, and how many to the frequent complication of the affection with inflammation of the surrounding peri- tonaeum. LcEHLEiX" has recently published an observation of a condition which is certainly rare ; for where the surrounding peritoniEum was entirely healthy, he showed that there were slight but constant elevations of tem- perature in the evening, which w^ere only completely removed after abla- tion of the ovaries, which were affected by chronic oophoritis. It is easy to understand that, on account of the aetiology of the affec- tion, the disease of the ovary does not remain isolated, and that not infrequently with a perioophoritis there is found a corresponding disease of the tube. Since the latter structure, with its morbid changes, becomes coiled around the ovarian mass which is altered by chronic oophoritis, the resulting group of symptoms is a combination which makes the differentiation by so much the more difficult, since, in tiic course of the disease, a complete and intimate adhesion and union of the two structures may occur, or, better said, usually occurs. The diagnosis of chronic oophoritis is to be based entirely on an exact bimanual palpation. It does not seem permissible to try to base a diagnosis of disease of the ovary on palpation of the lower abdomen, and particularly of only one hypochondrium. Even if, on increase of the pressure, the group of ovarian symptoms described by Charcot appears, '^ Czetnpin. -Gi's. f. Gi-li. 11. Gyn. Mar. 1SS5. OF THE DISEASES OF WOMEN. 465 the mistake must not be made of forgetting that it is impossible, merely by pressure exerted externally, to touch an ovary lying deep in the pelvis. Only by compression exerted very carefully by the bimanual method can it be hoped to isolate the uterus and the other appendages from the ovary, — an undertaking which even then not infrequently appears quite difficult. It is extremely hard to isolate the ovary by palpation when it is adherent to the adjacent parts, so that it can hardly be distinguished from, them, especially in the early stages, when peritoneal masses of exudate still surround the ovary, so that the latter can scarcely be felt among them. The ovary can often only be differentiated more accurately at a later period, when the shrinking of the exudate allows the separate parts to become more and more prominent. The slighter the disease of the neighboring parts, and the more the disease of the ovary itself predomi- nates, the more hope is there of palpating and isolating the latter. Then the ovary is felt almost always enlarged, rounded, or elongated ; it feels dense, and is usually very sensitive. The figure of the tube which lies in front of and above it can be distinctly distinguished. Not infrequently the ovary seems to be united with the uterus itself, and it lies at the side of the latter, or under, or over it. In other cases the enlarged structure lies deep on the bottom of the space of Douglas, so that in fact some authors have attributed the whole difficult}' to the dislocation of the ovary. The more advanced the involution of the ovary the denser does its structure appear ; occasionally some cystic formations can be felt, which are recognized as tense vesicles, up to the size of hazel-nuts, in the sub- stance of the ovary. Even such a result of examination, although felt ever so distinctly, and associated with clinical observation, would only warrant the diagnosis of "chronic oophoritis." The prognosis of chronic oophoritis is not very favorable as far as concerns complete recovery, but it is better if the question is only as to the recovery from the sufferings, with a probability of sterility and jDre- mature cessation of menstruation. It is indubitable that chronic oophoritis may undergo complete invo- lution under favorable external circumstances and appropriate treatment. In other cases the sufferings increase to such an extent that every mode of treatment fails. In these cases recovery can only be obtained finally by removal of the source of the malady ; that is, by extirpation of the structures which are altered by chronic oophoritis. The treatment of chronic oophoritis consists essentially in energetic abstractions of blood, either from the uterus or from the surface of the abdomen, in the occasional application of ice-bags, in the use of cutane- 466 PATHOLOGY AND THERAPEUTICS ous irritants in the form of sinapisms and vesicants, in active purgatives, and in appropriate treatment of uterine catarrhs, and of other uterine affections. As soon as the subacute symptoms subside, good results are to be expected from the use of vaginal douches of hot water at i22°F., and from injections, into the rectum of water, with progressive dimunition of temperature and increase in quantity ; furthermore, from the employ- ment of preparations of iodine and mud poultices, and, vmder some circumstances, from inunctions of mercurial ointment. During the stage of involution the use of the baths of Kreuznach, of the mud-baths of Franzensbad, and elsewhere, as well as of a course at Toelz or at Hall, in Upper Austria, is especially recommended. An essential prerequisite for recovery is sexual rest and care, with proper attention to the general health and good attendance. In the beginning every bodily exertion is to be avoided, and the return to the usual daily avocations is to be accomplished only gradually. From the use of internal medicaments, even of iodine or the well-known prepa- rations of gold chloride, I have not seen any results worth mentioning. To be sure, my experience in regard to the latter is slight, for all my patients who were treated with it had disturbances of the stomach so early that a continuation of the use of this medicine seemed contra-indi- cated. Finally, when there is a profound reaction of the general health, there remains only the extirpation of the ovaries, which are affected by oophoritis chronica, and which are usually functionally useless. The operation was first performed extensively by Hegar. I myself decided very early to operate according to the above indications. Among others later also Gussero\v.' Up to the end of iSS6 I had reason to operate twenty-five times in cases of oophoritis and perioophoritis. Of all these cases there were only two in whom there were not more extensive complications. In the other cases there wxre present pelveo-peritonitis and salpingitis, the latter of which had sometimes led to simple changes in the mucous membrane ; in other cases, however, to stenosis and atresia, with retention of blood, serous material, and pus. All of these twenty-five patients recovered from the operation. Thir- teen times both ovaries had to be removed ; twelve times only one was found to be diseased, and was extirpated. In two cases one ovary in a state of cvstic degeneration, with the excessively diseased tube, was first removed. One year afterward in one case, and fifteen months afterward in the other case, the remaining ovarv was removed, and was found in a state of chronic oophoritis, although at the previous operation it had been health}'. ' Chnrite-Annalen, ix. OF THE DISEASES OF WOMEN. 467 The eventual condition of tlic patients who were deprived of hoth ovaries will be described later. If in chronic oophoritis the only solution of the difficulty is finally found in the extirpation of these structures, this can, according to what has been said above, not be called " normal ovariotomy," or Battey's ^ operation, for normal ovaries are not removed for these indications, and in so far I must entirely agree with Hegar,^ who makes the presence of a morbid process in the ovary a prerequisite for the per- formance of castration in cases of neuroses and in allied symptoms. For this very reason, however, these cases do not belong to the chapter on castration as such, but they belong, strictly speaking, to that on ovari- otomy. Nevertheless, castration may be considered here in cases where the disturbance of the general health is essentially dependent on the func- tion of the ovary ; that is, where with every new menstruation these suffer- ings appear with ovulation, while their reaction on the general health can only be made to cease by means of the removal of the organ in question, on account of the cessation of the function thereby induced. Ovariotomy in such cases has no more unfavorable prognosis than otherwise. 2. — New-growths of the Ovary. Ovarian new-growths must be distinguished according to the anatomi- cal elements of the ovary from which they originate.^ Accordingly they are to be divided into : — I. New-grovoths of the ovarian tissue itself. ' (a). Netv-groivths of the follicles; that is, after the type of h vdrops folliculi. (6) . Nexv-growths of the glands of the ovary ^ as the type of which the cystoma is to be mentioned. II. New-groxvths originating from the development of remnants of fcetal structures ; the dermoid tu}7iors. ' Atlanta Med. and Surg. Journ. 1S72. 2 Der Zusammenhang u. s. w. 1SS5. ^ Roderer, Progr. d'hydrope ovarii, Gottingen, 1762. — //«^jSe^ i. \ ^^ ^ • *'• ' \ J il mi4.^"^'''*\£a' ^^i^M ^^■HflHK:/\ mp^ CYSTOMA OF OVARY. OF THE DISEASES OF WOMEN. 469 mata, as well as the developiiiciit of the latter in the second ovary after the extirpation of the first, decidedly does not occur very often. This fact is confirmed by an examination of Scanzoni's tables, where, out of the ninety-nine cases, there were only four in which there were cysts on both sides not smaller than a hen's egg.^ In regard to the classification of the new-growths of the ovarian par- enciiyma, the investigations of VValdeyer '^ concerning ovarian cystoma have become authoritative. I. Hydrops folliculi leads to the development of structures which are not usually very large. The hydropic sacs push their way towards the surface of the ovary; they are vei'y prominent under the surface, and may appear as multilocular ovarian tumors, in case several follicles be- come hydropic simultaneously. This hydrops folliculi is formed by reten' tion of fluids, which originates in the impossibility of the natural evacuation of the hydropic sac, for instance, owing to an impediment to the rupture, as by peritonitic layers of lymph, or by the pressure of neighboring organs upon the ovary. According to certain observations, such a retention-cyst may arise from ruptured follicles, or from the corpus luteum. The wall of a simple follicular structure — that is, of a hydropic fol- licle — contains abundant strands of connective tissue, which are frequently reticulated with each other, and it is clothed on the inner surface with a low epithelium, while on the other side it is covered at first by the epithe- lium of the ovary ; but later, as it increases with the increasing distension of the follicle, it bears a low cylindrical epithelium. Through these walls run numerous large vessels, but there are no glandular pockets or papil- lary excrescences in the walls, unless in case of cystic degeneration of the follicle. In these follicles, first Rokitansky (loc. cit.), and afterwards others, have found well-preserved or shrunken remains of the ovum of the follicle under examination. The hydi'opic Graafian follicles seldom reach any considerable size. They generally are as large as the fist ; but some tumors of this kind have been observed as large as a man's head. They are distinguished by the fact that they are all unilocular. Their contents are purely serous, with very little tendency to precipitation. They contain little albumin, and no paralbumin. This dropsv is said to predispose, after a single evacuation, to spontaneous involution and disappearance of the tumor. II. The cvstomata of the ovary are to be considered as adenomata^ with a pronounced epithelial character. Thev are developed from the glandular substance, partly from the connective tissue of the stroma, and partly from epithelium of the glandular tissue. It is not certainly known 1 Schroder, p. 370. = Waldcycr, Archiv. fur Gyn. i, 1S72. 470 PATHOLOGY AND THERAPEUTICS at what period of life this transformation occurs ; probably it is during the earliest years. The cysts arise from central softening of such gland- ular tubules, while daughter-cysts are formed by the development of pockets in the wall, which are lined with epithelium. Such pi-ocesses may go on separately ; there may be several foci coexisting in the same ovary. In consequence of the increase of the contents, and of the pres- sure, the cyst- walls may then rupture, so that the adjacent cvstic cavities confluesce, so that finally a single great unilocular sac is formed. Accord- ing to Waldeyer, the unilocular sacs always originate in this way, and, in his opinion, the remains, which are often only traces, of trabecular form- ation on the walls of large sacs, indicate such an origin. The cysts mav then, in consequence of further development, push their way towards the surface of the ovary, rupture, and discharge their contents into the abdom- inal cavity. The cysts themselves may wither away, even if they keep growing for some time yet by a continuation of cvstic formation. In their further developments, the cysts undergo alterations in two quite distinct directions. By the development of glandular prolonga- tions further and further into the wall, there is formed the cystoma prolif- eruni glandiilare. If the connective tissue keeps grovjing^ and if it pushes its way into the interior of the cyst, or towards the outside, in the form of loops of connective tissue covered with epithelia, there is formed the cystoma proliferum papillare. The substratum of the latter being that of a growth of connective tissue is naturally much denser. These proliferations of connective tissue sprout out like warts on the inner surface, and may here stand widely removed from each other ; while in other cases, being pressed closely together, they unite into larger papillary tumors, and finally, indeed, occupy the whole cavity of the cyst. How far these papil- lomata should be classified with the cystomata in other respects is yet doubtful, in view of the fact that, according to the examinations of March AND, they possess a marked tendency to malignant degeneration. At any rate, ascites and a dissemination of similar formations on the peri- tonseum are very frequentlv found associated with them. Both forms of cvstomata may be combined ; they may occur together in the same ovary, and then coalesce ; they may appear one after the other in the same ovarv, therebv explaining in part, at least, the varieties of struct- ure found in an ovarian tumor. Inasmuch, then, as such growths undergo still further malignant degeneration, those mixed forms of ovarian tumors arise, the composition of which it is often almost impossible to solve.' 1 FriedVdnder, Beitragc zur Anatomic der Cystovarien. D. i. Strassburg, 1S76. — Marchand, Beitr. zurkenntniss der Ovarientumoren, Halle, 1S79.— Coblenz, Virchozv's Archiv. Ixxxii and Ixxxiv, and Zeitschr. f. Geb. u. Gyn. iSSz, vii. — FlatsrhUn, Zeilschr. f. Geb. u. Gyn. vi. and vii. — Rokitansky, Lehrb. iii. p. 4S. OF THE DISEASES OF WOMEN. 471 The variety in the size and in the consistency of these tumors is one of their most j^rominent characteristic peculiarities. Thcv usually grow into the abdominal ca\'ity. Their basis is always formed by the broad ligament, and just at this place they show a peculiar variety of formation. It is seldom that the broad ligament remains unchanged, in cases wdiere the tumor is large, quite independently of the increase of the vessels which are developed here. Generally the broad ligament with the ovarian liga- ment, and usually also the tube, participate in the development of the tumor. It may occur that the basis only serves for the place of insertion of the tumor into the broad ligament ; as a rule, however, the ligament is greatly stretched. Inasmuch as the ovary develops inwardly at its base between its folds of the broad ligament, it occurs not very infrequently that with the development of both folds of ligament, the ovary gets to lie under the tube. The tube itself very frequently participates in the increase of the ovary ; it is extended to many times its normal length ; the fimbriae are inserted flat on the surface of the tumor, or thev communicate also ■with the cystomata ; in fact, there maybe a direct communication between the lumen of the tube and the ovarian cystomata. This particular form of development gives rise to the tubo-ovarial cysts ; the latter may lead to a permanent communication of the ovarian cystoma with the tube and the uterine cavity, so that the contents of the ovary from time to time are dis- charged externally through the tube.^ In other cases there can be found two clearly distinguishable folds in the pedicle, which run toward the uterus, one of which consists of the tube, while the other is formed by the ovarian ligament ; while laterallv, the immensely extended infundibulo-pelvic ligament is developed into a band with clearly defined border. There is a very great difference in re- gard to the length oi this pedicle. Sometimes it is extremely long, while, on the other hand, it is sometimes developed more in a mass ; or various alterations, to which I have to refer later." maybe occasioned bv adhesions of the surface of the tumor with other organs, or finally by torsion of the pedicle. As a rule, the simple tumors have large vessels, branches of the spermatic artery, which enter the mass of the tumor through the basis of "■he ovary. The tumors themselves, owing to the relatively limited extent of their base, acquire a great mobility^ especially in an upward direction towards the greater .abdominal cavity. ^ B/asius, Dc hydrope imirtuonte, ll;illc, 1S34. Fo"" the later literature see Burnicr, Zcitschr. f Geh. u. Gyn. v. p. 357, and vi. p. S7. Sec, also, above under " Diseases of the Tube,"' p. 397. 2 Werth, Archiv fur Gyn. xv. p. 412. 472 PATHOLOGY AND THERAPEUTICS The -Mails of t/ic tumors consist of more or less thick layers of con- nective tissue, which contain vessels in very various number and degree of development. The internal surface of the glancbilar cystoma is in- vested by lovv- cylindrical epithelium, in a single layer ; externallv, the wall of the tumor carries a delicate low epithelium, in as far as it is not covered by the peritonasum or by masses of exudate ; in these walls ramify numerous glandular proliferations, which correspondingly increase the internal surface, and contribute materially to the filling of this great space. In papillary tumors there project from the internal surface wart-like structures, which occasionally also carry ciliated epithelium, and possess a highly vascular substratum of connective tissue. By exten- sion bv throwing out branches they may develop until they fill the wliole internal cavitv. Just such papilltE, exactly after the manner of the ends of the glands, wdiich are dilated like bubbles, may be developed under the external surface of the tumor, and may here give rise to bunches and pro- jections, to wart-like prolongations, and to lumps of various forms. The contents of the cystoi7ia are extraordinarily variable. Sometimes there are only a few drachms of free fluid, and sometimes many litres. In one easel have evacuated three great kitchen buckets full of fluid. The contents are usually quite Jltiid^ foam wdien discharged, have a peculiar colloid consistency, color and stiffen towels, are transparent, of a neutral insipid taste, a low specific gravity, and of a greenish color, shaded some- times more in one direction, sometimes toward the other, and dependent in regard to the color on admixtures, especially of blood. In this mass- are included numerous epithelia, in a state of fatty degeneration ; abundant coagula may make it turbid, and may cover the walls of the vessel in clouds or thick precipitates, or may also sink to the bottom of the glass into which the fluid has been poured. The specific gravity varies between loio and 1025. The solid contents betw-een fifty and one hun- dred per cent. The most complete investigations about the composition of the fluid have been published by EicmvALD, whose scale is still the standard for all these cases.' Among the various elements of the fluid, great importance has been attributed by Spiegelberg, in his time, to the peculiar albinninoid body, which he named paralbumin. This pai-albumin is transformed into albumin-peptone, thereby losing the property of being coagulated by heat. It is said that then the capability of being precipitated by mineral acids is very gradually lost, and that then metalbumin and albumin-peptone are developed. In consultation with chemical authorities I have sub- mitted a great number of undoubted ovarial fluids to an exact examination ; ' Eich-jvald, Colloid entartung- tier Eierstcicke Wvirtzburgr med. Zeitschr. 1S64, v. p. 270. OF THE DISEASES OF WOMEN. 473 and thereby I, as also others, have established the fact that the different forms of albumin are so little constant that no result can be obtained which can be used as a diagnosis for an ovarian tumor. Even vSpiegel- liERG himself has then called attention to the fact that occasionallv the paralbumin is not found ; and from the absence of paralbumin in the fluid he would infer the commencement of a retrograde metamorphosis of the ovarian tumor in question. In this respect, also, my own chemical exam- inations have only been followed by negative results, so that I cannot recog- nize this whole test of paralbumin as one affording any certainty. Under the microscope there is found in the ovarian fluid a mass of epithelial cells, which are often disintegrated, or in a state of fatty or colloid degeneration ; besides these, there is an abundant detritus, granular cells, blood-corpuscles, and pigment masses, the residua of former hemorrhages into the cysts, and cholestearin in the well-known rhombic tablets.^ The fluid is to be regarded as the product of the glands of the cystomata. The latter frequently fill up, owing to the rapid increase of the secreting bodies, with a continual and powerfully increasing pressure of the contents, which may then induce a rupture of the partitions between the single cysts, or also of the single follicles, and may, in fact, occasionally burst the external capsule. It also sometimes occurs that intermittent attacks of increase of the secretions are developed, and that, on the other hand, pauses in the secretion may occur. In regard to the history of the develop meiit of cystomata^ it must, in the first place, be remembered that the majority of them are to be con- sidered as congenital and latent up to the time of puberty. It is only exceptionally that the first stages of development of cystomatous degenera- tion of the ovaries can be shown to occur in the later years of life. In the majority of cases the tumors grow out of the small pelvis as soon as they have entirely filled the latter. This course is prescribed for them, on further development, by the configuration of the pelvis, which opens above like a funnel. Only when there is a congenital intra-ligamentary develop- ment of the basis of the tumor does the latter grow simultaneously into the abdominal cavity, and under the folds of the broad ligament.- The tumors then, lifting the peritonaeum, fill up the whole pelvic cavity, and, as I have observed rather frequently, they are especially disposed to grow under the coecum. On the other hand, they are developed also under 1 Fontenelle, Analyse de quelques substances contenues dans les ovaires. Arch, gen de m^d. 1S24, XV. — Mehu, Ibid. iSS9) xiv, — Ailee, Diagnos. of ovarian tumors. — Spencer Wells, a. a. O. — Wal- deyer, Archiv. fur Gyn. i. p. 266. — Spiegelberg., Vortr. nr. 55. — Huppcrt, Ueber den Nachweis der Paralbuminurie. Prager med. Wochenschr. 1S76, 17. — Foiilis, Edinb. mod. Journ. Aug. 1S75, p. 169. — Knovjsley Thornton, Med. Times and Gaz. April, 1S75, '^^'^ May, 1S76. 2 i^Vt'wwi;, Berlin Klin Wochenschr. 1S7S. nr. 2S. — Kaltenbach, Zeitschr. fiir Geb. u. Frauenkr. 1S76, p. 537- 474 PATHOLOGY AND THERAPEUTICS the short insertion of the sigmoid flexure. Only in very rare cases do the tumors grow forward so that they reach into the neighborhood of the bladder, while development between rectum and vagina has also been ob- ser\'ed, as a case of Olshausen shows. Few tumors are developed .at the same time intra-ligamentarilv and free into the abdominal cavitv. In these the insertion of the peritonaeum is observed like a rufi', and in two cases which I have seen, there was a distinct constriction of the tumor which was as big as a man's head at the place where it projected out of the peri- toneal envelope into the abdominal cavity. In their passage through the abdominal cavity, the tumors^ of course, come in contact with all the structures there situated. In so doing they may lie entirely free beside the latter, and may remain so for a long time without becoming adherent to them. It seems, however, that the majority of tumors are not thus completely free ; at least, if I may form an opin- ion from my own experiences, the number of cases in which no adhesions of the tumor with adjacent parts are present seems smaller than that of those in which the most various and extensive unions have occurred. These adhesions are developed between the surface of the tumor and the parietal peritonaeum, but with especial frequency with the visceral layer of the latter, whether it be with the serous coat of the intestine, or with that of the mesentary. Even more frequently they are found between the surfaces of the tube and of the omentum. The unions are sometimes to be considered as unorganized adhesions, originating from the disappear- ance, under pressure, of the layers of fluid which cover the surfaces ; sometimes with inflammatory reddening of the surfaces in apposition with each other an intimate union is formed. Innumerable vessels, often of quite extraordinary size, run between the tumor and the surfiice with which it is united ; and if, occasionally, free circulation in the pedicle is interrupted, they may carry on the nourishment of the tumor. ^ On further extension of the latter, adhesions may be formed with the liver, and with every organ lying in the abdominal cavity, however distant it may appear to be. In all places these unions may appear so intimate that even on the autopsy table there is difficulty in establishing the line separating the two parts. Finallv, the adhesions mav extend over the whole surface of the tumor, which thereby comes simultaneously into the most intimate vascu- lar union with nearly all organs of the abdominal cavity. If the surface of the growth undergoes this sort of changes, the mass of the tumor., in itself., is by no ?neans unchanged.^ Among these • Hofmeier, Zeitschr. f. Geb. u. Gyn. v. 2 Schroder, Ed. vii. p. 390. — Hegar und Kallenbacli, Oper. Gya. iii. S. ^37- — Olshausen, Cen- tralbl. f. Gyn. 1SS4. nr. 43. OF THE DISEASES OF WOMEN. 475 alterations are to be reckoned not merely the above-mentioned processes ■of transformation, which are developed in the fluid itself. Hcctnorrhages into the cvstic sacs occur not infrequently. The blood is then effused into separate small spaces, but it may also completelv fill quite large cysts. Such haemorrhages are often developed on slight jarring of the whole abdomen, and solutions of continuitv occasioned thereby, or b}' erosion of vessels, owing to disintegration of septa in the cysts, or also owing to direct injuries, punctures, etc. Such an effusion of blood then occasions all the symptoms of internal hcemorrhages and threatening anaemia ; it may also lead to a rapid decomposition of the blood, so that the patients, if they do not immediately die of antemia, perish later under the influence of this decomposition. The contents of the tumoi'., thus altered or unaltered, may., by burst- ing of the cavity .1 he discharged externally ; that is., into the abdominal cavity., or into some organ which has adhered to the tumor. If the sac is unilocular, or formed of only a few cystic spaces, the rupture mav be followed by a sort of recovery, since the fluid discharged by the rupture is usually absorbed by the peritonceum -with unxvonted rapidity. In a case of which I knov^^, where rupture occurred late in the evening, absorption was completed by early morning ; then there was a violent desire to urinate, and the patient with unceasing urgency discharged several chamber-pots full of a peculiar clear urine, of little odor, which, unfortunately, underwent no special examination. That absorption is not always completed so immediatelv nor so com- pletely is easily understood ; in fact, the absorption may cease, whereupon the patient perishes, with the symptoms of collapse, from inabilitv to digest this fluid. Of course, in such ruptures, vessels are occasionallv injured also, so that with the cyst contents, blood is also discharged into the abdominal cavity. The remnants of the sac which are left fall together, shrivel, and undergo involution. In the above-mentioned case, I found the tissue of the cyst as a not very firm thickening on the floor of the space of Douglas. In other cases, especially if the rupture has not led to a complete evacuation of all the cystic spaces, the sac fills up again, so that the size of the tumor will soon be as large as before. The ruptured cysts., which lie close to the surface, are completely everted by the pressure of the little cysts growing behind them, and forcing their way out from below. This occurs especiallv in cases of proliferating papillary cystoma. Here the walls tlius everted then present themselves as immense warts, which rise like mushrooms above the neighboring surfaces of the tumor. Precisely these proliferating warts appear to have a great disposition to infect the peritonaeum, while thev 4/6 PATHOLOGY AND THERAPEUTICS themselves seldom acquire any intimate union with the portions of peri- tonicum with which they are in contact.' Of course the pedicle participates very materially in the changes of an ovarian tumor. This vascular structure, namely, owing to the length to which it is stretched, is greatly disposed to become twisted on its long axis.- The pedicle is often long enough to permit several turns ; its position and extent have only a slight influence on the movements of the tumor, and thus the latter gets turned on its axis by jarring of the abdomen, bv motions of the patient, by violent peristaltic movements, and particu- larly by energetic palpation of the abdomen. Not always, but too often, the result of this torsion of the pedicle is deleterious. Sometimes a pedicle may be twisted several times without injurious effects ; in very rare cases, in consequence of such torsion, an inflammation ensues at the place of torsion itself, followed by formation of a line of demarcation ; the pedicle breaks entii^ely oft", the tumor is more or less completely freed and lies loose in the abdominal cavity. If this process goes on gradually, without violent symptoms, the tumor is not materially changed, especially if a system of vessels, sufficient for its further nutrition, has been developed in the adhesions between the surface of the tumor and the other organs. Very much more frequently, in consequence of the torsion of the pedicle, a rapid decomposition, and further consequences of rapidly deleterious eftect, ensue. More frequently than suck complete separation^ torsion of t/ie pedicle causes an occlusion of the vessels of the pedicle^ and a conse- quent disintegration of the tu?nor itself Haemorrhages into the tumor first ensue in consequence of the torsion of the pedicle ; the contents, increased by the blood thus eftused, decompose and putrefy, although the mode of origin or of access of the requisite exciters of putrefaction is not clear; the walls rupture, the sacs empty themselves into the abdominal cavity. Then the unfortunate vicitms of such tumors perish of haemor- rhage, or sooner or later of general peritonitis. Independently of such toi'sions, inflammations of the cyst are devel- oped, although infrequently ; whereby, likewise, the latter may suppurate and undergo complete decomposition.'^ A complication, which does not appear to be rare, is the communi- cation of ovarian cysts with the lumen of the tube. The latter, in such cases, always seems to be diseased simultaneously with the ovary. The fimbriae of such diseased tubes adhere to the incipient tumor of the ovary, ' Marchand . 2 Wcrlh, Arch. f. Gyn. xv. 3 Schroder, Ilandbuch, Ed. vii. S. 391. OF THE DISEASES OF WOMEN. 477 the septum between them disappears under the pressure of the rapidly growing tumor, until tube and ovary coalesce into a single tumor, a tubo- ovarian cyst, the walls of which display many pockets and other traces of the earlier development.' (Compare for details what has been stated above at p. 197. The tendency of ovarian tumors to grow, which is so pronounced, sometimes disappears spontaneously. The tumors may then pass through a retrograde process. Not only, in such cases, does the tumor cease to grow, it also shows a material alteration of its contents, inasmuch as the fluid loses its solid contents, which are deposited as a firm layer on the internal surface of the tumor. Such withered cysts may also grow smaller by partial resorption of their contents. Another form of retro- grade metamorphosis leads to ya/Zy degeneration of the cystoma. The epithelial cells grow fatty and are incompletely renewed ; those wdiich are ■cast off are disintegrated and dissolved. The same process goes on in the connective tissue of the walls, under the influence of all processes which disturb the nutrition ; such, in particular, as the increase of the contents. Calcareous deposits are rare in cystomata. It has been pointed out above that cystomata may undergo car- cino?natous degeneration, whether papillary excrescences have existed previously or not. A rather high percentage of ovarian cysts becomes •cancerous, usually primarily, seldom with simultaneous cancerous degene- ration in other parts.' The aetiology of this degeneration is as vet unknown ; at any rate, pi'egnancy exerts no such important influence on it as has been asserted by some authors. The cancerous degeneration usually makes very rapid progress ; it spreads over the peritonaeum, aflect- ing the intestines and the mesentery, and leads to the fatal result before the degenerated tumor itself softens dowMi.^ The sympto?ns of ovariati new-grotuths are extraordinarilv incon- stant, up to a certain degree of enlargement of the ovary. Frequently the women are surprised at finding that they have such a tumor, when the increasing distention of the abdomen either attracts the attention of their acquaintances and causes suspicions of pregnancy, so that certainty on this point is demanded, or the discovery is quite accidental, and without any particular reason. In these cases the tumor has existed from the beginning, without causing any suffering, and, even at a period when ' i>7rt5/'a5, loc. cit. Halle, 1S34. — Richard, 'BnWtt. gtin.de therap. 1S57. The same, mem. de la soc. de chir. 1853, iii. — Labbi-, BiiUel. de la soc. anat. de Paris, 1S57. — Hennig, Monatschr. f. Geb. Bd. 2S, S. 12S.— Spencer Wells, loc cit. p. 35. Buriiier, Zeitschr. f. Geb. u. Gyn. v. u. vi. — Ruii^e 1 Thoma, Archiv. f. Gyn. 28, S. 72. 2 Colni, Zeitschr. f. Geb. u. Gyn. xii. Leopold, Deutsche med. Wochenschr. 1SS7, nr. 4. ^ Kijberlc, Gaz. hebdomad. 13 Juli, 1SS6. — ^. Martin, Berl. klin. Wochenschr. 1S7S, nr. 12. 47^ PA2H0L0GY AND THERAPEUTICS the abdominal cavity is almost filled with the ovarian tumor, many women give no definite account of any suffering caused thereby. Others complain from the beginning of a feeling of tension, of discomfort, of being filled up. The slight sufferings which are experienced in con- nection with the functions of the bladder and the intestine often disappear, almost all at once, after the patient has been well purged for a time on account of them ; the tumor has just slipped up from the lesser pelvis into the abdominal cavity, and has there plenty of space to grow. In other cases again, the development of the cystoma is from the very begin- ning accompanied by very severe, and sometimes at intervals by violent, symptoms ; pains shooting into the affected side, sensitiveness in the abdominal wall above it, and other such symptoms, are experienced quite early ; and even if these symptoms disappear with the increasing develop- ment of the tumor, the relief lasts but a very short time, until with the rapid increase in volume suffering from pressure and distention become very severe. If the appendages are attacked, we very frequently see the uterus drawn into participation ; thus with diseases of the ovaries the symptoms of endometritis and chronic metritis are not infrequently found. As one of the most frequent symptoms, the menses often become profuse,^ even although painless. Comparatively seldom have I observed suppression of the menses accompanying cystomatous degeneration. These patients wei'e either phthisical or succumbed rapidly to an intense cachexia. The cases of profuse menstruation have abundant secretion in the free intervals, so that the patients complain of the symptoms of intense endometritis. In rare cases, where incarceration of the uterus has been caused by the growth of the tumor, the menses, which, as mentioned above, are not usually painful, may be accompanied by sufferings which were not formerly experienced. The pressure on the bladder occasions frequent impulse to urinate ; but in these cases, as in pregnancy, the pecul- iar flexibility of the bladder is of service, so that even in case of large tumors the bladder can develop on one side or the other, without having its functions permanently impaired. Only with very large tumors, when all the contents of the abdominal cavity are displaced, an involuntary flow of urine occurs, and this symptom becomes particularly prominent- When the ovary degenerates, the intestine almost always suffers. An annoying constipation is established, which, in connection with the partial obstruction of the lumen of the intestine, disturbs digestion very seriously and very soon injures nutrition. The fact is well known that women with ovarian tumors emaciate. 1 Czempin, loc. cit. OF THE DISEASES OF WOMEN. 479 and especially acquire a sunken countenance, so that a fades ovarica is spoken of. It must, however, remain undecided whether the emaciation is only to be explained by supposing that the ovarian growth takes for itself the nutriment of the body, and thus abstracts it from the other parts, or whether this emaciation is rather a consequence of the persistent disturbance of the digestion. The emaciation very often is in marked contrast with the increase of the abdomen, on the surface of which the well-known network of veins is developed ; while under the influence of the tumor, oedema of the legs, palpitation of the heart, and the appear- ances of general cachexia appear. As a rule, the further sufferings are occasioned by alterations in the surface or in the contents of the tumor. The adhesions of the surface interfere actively with the motions of tlie parts affected ; every movement, even turning over in bed, becomes painful when the tumor is adherent to the abdominal wall. Severe intestinal sufferings ensue, such as colicky pains, gaseous distention, ffatulence, often also vomiting, if there are adhesions with the intestines, and violent continuous pains in the perito- naeum and disturbances of respiration and circulation, if the tumor pushes the diaphragm upwards. Not infrequently the symptoms mentioned above pass through their development and exert their influence on the general health very gradu- ally ; the patient and her friends first have their attention called to the malady or perceive it in its full development when acute disturbances occur. Such intercurrent attacks are occasioned particularly by irritated condi- tions of the peritonceum.f such as are connected with the adhesions and run their course with the well-known symptoms of peritonitis. Evidences of rupture are afforded by the occurrence of very acute attacks of collapse, although the latter do not assume a highly threatening character. Hceinorrhages into the cysts, suppuration^ and decofnposi- tio?t of the contents occasion, of course, very serious anaemia, hectic fever, and rapid prostration of the patient. The course of ovarian tumors is, however, often quite extraordinarily protracted, extending over long years. On the other hand, cases are also observed in which the growth is extremely rapid, with disturbances of the respiration, and espe- cially of the circulation. An access of rapid growth in a case which has been developing gradually depends eitlier on alterations in the tumor or indicates the occurrence of malignant degeneration of a tumor previously benign. Without considering the variations in the health of the patients affected, such as are dependent on the changes mentioned above, it is iiidisputable that the simplest ovarian tumor may lead to the death of the 480 PATHOLOGY AND THERAPEUTICS patient. The latter then perishes of cachexia, or is earried off rapidly by a light bronchial or intestinal catarrh, or by disturbances connected with the tumor itself, such as thi-ombosis, gangrene, or bed-sores. The influence of the new-growth in the ovary on the genital function of the woman is by no means constant, although sterility is often associated with the development of ovarian cysts ; yet in other cases the capacity for conception is not disturbed. In cases of previous sterilitv, I have on several occasions observed the occurrence of pregnancv after the removal of one cystomatous ovary, the other, which was healthy, being left. In one of my cases pregnancy occurred after I had, besides extir- pating one cystomatous ovary, punctured an hydropic follicle in the other almost as large as a walnut. (The partial resection, with preserva- tion of part of the ovary, will be described later.) As long as the ovarian cysts are small, and are not incarcerated in the lesser pelvis, pregnancy can undoubtedly go on quietly beside the ovarian tumor, and the puer- perium may be quite normal. The complication of pregnancy and ovarian tumor only becomes serious when the tumor by its size hinders extension of the gravid uterus, and leads to excessive distention of the abdomen and consequent danger to the patient ; or if, becoming wedged in the lesser pelvis, it impedes the delivery of the child ; or finally, if grave changes occur in the tumor itself. Ovarian tumors appear to grow under the influence of pregnancy. The processes of labor are in them- selves frequent occasions for torsion of the pedicle, for haemorrhage into the tumor, or for decomposition of its contents. Putrefactive processes are developed in ovarian tumors, especially during attacks of fever in childbed. Recent experience, as above mentioned, shows that the carcinoma- tous degeneration of tumors, which in the beginning were what is called benign, is a frequent occurrence. A definite decision of the ques- tion cannot yet be rendered ; but it appears as if not only the papillary forms should be regarded as preliminary stages of malignancy of the growths, but that the glandular forms also have at least a suspicious predisposition to recurrence and to further malignant degeneration. The diagnosis of ovarian tumors has been particularly improved by the introduction of bimanual examination. Above all, it has become possi- ble, with much greater certainty than in former times, to diagnosticate ovarian tumors before they have grown to such a size as to distend the whole abdomen. As long as they lie deep in the pelvis it is usually easy, in the first place, to distinguish them from the uterus. If these tumors? then are movable in comparison with adjacent organs, and if they spring from the situation of the ovary, and if besides them no other structure OF THE DISEASES OF WOMEN. 481 corresponding to the ovary can be found, the diagnosis would quite generally be a sure one. Discrimination will be more difficult if the mass of the tumor cannot be moved with complete freedom ; that is, if the mass, being connected with the uterus, has pushed the latter out of its place, and also if a quite abnormal displacement has occurred with the commencement of rotation on its axis. In these cases an attempt must always be made, first to isolate the uterus, if necessary under ancesthesia, and with the aid of the sound ; then search must be made by palpation at the sides of the uterus for structures corresponding to the ovaries, and after exploration per vaginam, this palpation is finished per rectum. As further aids to ex- ploration, may be mentioned traction on the uterus by means of the bullet forceps, according to Hegar, and lifting up the tumor, according to SCHULTZE.' It is generally possible in this way to determine approximately the position of the tumor, its surface, consistency, size, and the nature of its pedicle. I will not omit to call attention in this place to the fact that such a minute palpation of the separate parts of the tumor, and the attempt to determine the various relations so exactly, must always be performed only with the greatest caution. Crushing, or tearing of tender adhesions, rup- ture of superficial cysts, or above all of tubes or tubo-ovarial cysts, situated at the side of the uterus, are only too easily induced by these explorations ; and too often already I have had to operate, while the patient was under the influence of premature destruction of the tumor, where the endeavor to determine in detail the separate conditions, or the wish to demonstrate the relations most clearly to those present, had led to grave ruptures, and to acute attacks of inflammation. Up to the present time, by means of laparotomy employed immediately on the occurrence of threatening symp- toms, I have always succeeded in rendering innocuous the eftlision of blood or pus, the sundering of adhesions, and whatever else had happened under influence of these too zealous examinations, even although I had to operate ■during recent peritonitis with temperatures of over 104° F., and a pulse of 136 and over. In the interest of the patients, however, attention must be called, with all seriousness, to the fact that it is completely sufficient in the first place to determine approximately the presence of the tumor, its size and consistency, and its relations to the adjacent parts ; more minute ex- aminations appear to me to be warranted and permissible only when the examiner is in a position to immediately remedy any complications whicli I Centralhl. f. Gyn. 1879, Nr. 6, and iSSo, Nr. i. 48= PATHOLOGY AND THERAPEUTICS may arise, bv means of laparotomy performed at once, with all <^iiaraiitees of success. The differential diagnosis of ovarial cysts is in the case of small tumors based on materially different points than those which have to be considered in tumors wiiich hav'e already risen out of the small pelvis. For in the latter, the mobility, and sometimes even the location of the pedicle, is very easily determined ; and for these cases everything which may occupy the abdominal cavity must be considered in regard to the differential diagnosis, while if the tumor still lies in the lesser pelvis, only those conditions need be considered which are possible there. For the smaller tumors, that is, for those which still find room in the pelvis itself, it is requisite, in the first place, to decide whether they are in connection with the uterus or not. An incipient pregnancy only too often furnishes occasion for diagnostic error. It is necessary to use the most extreme care in establishing the diag- nosis between a small tumor and an ifzcipient pregnancy. For some- times, when the genitals are not otherwise materially diseased, a peculiar supra-vaginal elongation of the collum is developed during pregnancy, which permits the corpus to move on the collum with almost perfect freedom.^ The long collum is then felt very distinctly, and there is a temptation to consider this as the whole uterus, because the thin point of connection between the collum and corpus, which, moreover, then usually lies far backward, cannot be palpated with distinctness. Then one seems warranted in supposing that this movable tumor is a neoplasm, and in fact an ovarian growth, since lying quite at one side i*- has apparently pushed the uterus aside, since its mobility is quite extraordi- nary, and since its consistency and surface do not recall the density of uneven fibroids. Confusion with such cases of pregnancy occurs all the more readily, since menstruation has always occurred irregularly ; that is, there had been haemorrhages, at least in the cases observed by me, and since the discoloration and relaxation of the genitals often permits of no- clear decision, and as the foetal heart cannot be heard on account of the earlv stage of the pregnancy, and as in just these cases the general health of the woman is greatly disturbed, with prostration of strength, emaciation, falling out of the hair, sleeplessness, want of appetite, and very annoying disturbances of digestion. Sub-serous fibroids of the uterzis may give results on examinations similar to those described above ; yet in these the supra-vaginal elongation of the collum is very seldom found so pronounced that the corpus uteri ' I have made a report in the Zeitschr. f. Geb. u. Gyn. Bd. v., on the difficulties arising- from this OF THE DISEASES OF WOMEN. 483 cannot be distinctly felt as such by the side of the great tumor. Thereby it must not be forgotten that fibroids generally are developed from several foci, so that even in the uterine body other hard lumps can be felt. These fibroids, moreover, generally have much shorter pedicles than appear to belong to those cases of pregnancy which resemble them. They grow much more slowly than the pregnant uterus or the ovarian tumor. I think that these three conditions of ovarian tunior, pregnancy, with supra- vaginal elongation of the collum, and sub-serous pediculated fibroid, can be distinguished by palpation with sufficient accuracy, by bimanual examination under anaesthesia ; and that, if necessary, traction on the uterus downwards, after Hegar's method, and the tension of the pedicle induced thereby, or the pushing upward of the tumor out of the lesser pelvis, according to Schultze, are sufficient to disclose the points of difierential diagnosis already described. In particular, the consistency, the color, and the pulsation in the collum and in the vault of the vagina are woithy of attention, in order to protect the diagnosis from confusion with pregnancy, in case the atten- tion of the examiner has not been attracted during the examination of the aflection by cessation or irregularity of menstruation, and by other changes in the body, and in the condition of the patient, sufficiently to prevent confusion between the tumor and pregnancy. Among the tumors which lie at the sides of the uterus, the growths in the broad ligament and the tuinors of the tubes must receive special attention. Neoplasms of the broad ligament are decidedly rare ; they are, how- ever, extremely difficult to diflerentiate as such from those ovarial tumors, which are united to their neighborhood over a large extent,^ by exudates or other adhesions. In both cases mobility is sometimes entirely gone, and sometimes it is only illusive. Proof of the presence of an ovary beside the tumor might certainly be decisive ; but, in consideration of the fact that if the compression is at all strong the tumor may burst under the hand, such an investigation must only be undertaken with great caution. In cystic tumors of the broad ligament it would indeed be very desirable to acquire information by puncture and by evacuation of the clear, watery fluid con- taining little albumen, which is distinguishable from the fluid of ovarian tumors precisely by these qualities. I hold, however, the exploratory puncture of these tumors to be by no means wholly free from danger, and even in view of the possibility that if the tumor lie a cyst of the broad ligament, it may collapse after puncture and not fill up again, I would, nevertheless, prefer to perform laparotomy and thus enucleate it ; for those ' Compare also Sanger, Arch. f. Gyn., i6, page 25S. 484 PATHOLOGY AND THERAPEUTICS cysts are really very rare, and I am always more afraid of a deep wound, which cannot be supervised, than of an immediate exposure of the point in question, performed with all appropriate precaution. Tt is often very difficult to make a diagnosis between tumors of the tube and affections of the ovary. In many cases, by bimanual examina- tion between the vagina or rectum and the hand applied externallv, the junction of the tubal sac with the uterus can be felt as a cord as large as a lead-pencil, which, springing from the horn of the uterus, after a longer or shorter and usually tortuous course, is lost in the tumor. The tulxd tumors, moreover, usually present peculiar sausage-shaped tortuous masses with many prominences, which sometimes on one side are coiled spirally, and sometimes, also, when they are very extensive, fill up the whole of the lesser pelvis. In the latter case, of course the examina- tion is extremely difficult ; but until the tumors reach such a size the rela- tions of their uterine end are sufficiently characteristic. In other cases the tube is entirely lost in the mass of the tumor. There would then be great difficulty in making an exact diagnosis between ovarian neoplasms and those of the tube, and perhaps it could not be accomplished without laparotomy, and often enough not even then. The differentiation of the smaller tumors from parametritic and peritonitic exudates is, as a rule, not immoderately difficult ; the para- metritic exudates, the origin of which generally seems to be associated with some previous labor, or it may be with an abortion, or with opera- tive interference, extend in the depths of the broad ligament ; they are seldom so completely limited, and almost always appear completely im- movable. The exudate may surround the uterus, laterally and posteriorly, embedding and fixing it, while the real ovarian tumors in themselves are always rounded and clearly delimitable from the uterus. The diagnosis in this respect often becomes decidedly more difficult if the exudates have shrivelled and now remain as encapsulated remnants in the broad liga- ment, or if the ovarian tumors are complicated with such exudations in the broad ligament or in the peritonaeum. The peculiar form of perimetritic effusion in the space of Douglas renders it easy to differentiate these exudates from the rounded form of an ovarian tumor. The exudate occa- sionally encloses the tumor ; then the diagnosis becomes quite complicated if para- or peri-mctritic exudates are combined with small ovarian tumors. The history, the previous course of the affection, and the more or less pronounced sensitiveness of the pelvic organs have a decisive significance in such cases ; it only remains then to make the diagnosis certain In' longer observation of the further course of the malady. Often enough it may be seen that with the disappearance of the exudate, both extra- and OF THE DISEASES OF WOMEN. 4S5 intra-pcritoneal, the ovarian tumors reveal tlicmselves clearly in their whole extent and form, and now may be readily recognized as such. That /irca/ tumors can be confounded with those of the ovary cannot be entirely denied. Faecal masses may always be recognized by their doughy consistency ; they hardly offer any difficulty to those who always make it a rule to obtain a thorough evacuation of the bowels before such decisive examinations. A diagnosis between ovarian tumors and retroflexion of the gravid uterus, or impacted fibroids, must be made by the history and especially by palpation of the figure of the uterus itself, under anaesthesia, or even by recognizing the uterus of normal size at one side of the tumor. There may be quite extraordinary difficulty in distinguishing between large tumors of the ovaries^ which have risen into the abdominal cavity and other neoplasms. I will not here describe further the peculiar decep- tions which are occasioned by accumulation of gas in the intestine, or fat in the abdominal cavity ; in these cases, examination under chloroform should always lead to a diagnosis. Further, the old and tried diagnostic measures must also suffice for these cases; palpation and percussion, and even auscultation, must first decide whether the abdomen is distended by any tumor at all or not, whether such tumors are occasioned by free fluid or by masses enclosed in a separate wall, and whether such masses have any connection with the genitals. In these cases the most important thing is the palpation of the pelvic viscera under anaesthesia, which is often possible, even in difficult cases, by pressing in the hand close above the sym- physis. In all cases of difficult diagnosis an examination must be made in various positions and postures of the body, and the supposed tumors are to be pushed upwards by pressure from the fold above the symphvsis. If the viscera have been palpated fi'om the vagina and rectum, and even sometimes from the bladder also, auscultation, percussion, and palpation of the abdomen complete the diagnosis. To be sure, there will always be isolated cases in which the difficulties are apparently insuperable. I will not here recall confusion between tumors and the distended bladder, or pregnancy ; let it suffice in this place to mention encapsulated exrcdates., other cysts of the abdo7ninal viscera, and certain tumors of the uterus. Just for these cases it seems particularly instructive to pull the uterus downward with a bullet forceps, and thus to separate it from the tumor itself, so that at least the diflercntiation of these two structures may be made possible. The method proposed by Schultze may also here be used with advantage, which consists in having the tumor lifted upward by an assistant and then palpating the pelvic viscera. It is a rather peculiar fact that these large tumors very frequently cannot be felt at all. or only very incompletely, through the vagina. 486 PATHOLOGY AND THERAPEUTICS Among the affections which are of peculiar importance in leG^ard to the chft'erential diagnosis, the hydrops peritonei saccatus (serous cvst) should be mentioned first. This is found less frequently in simple peri- tonitis — although even in such cases these abcapsulated masses occur — than in tuberculosis and carcinoma of the peritoneum and of the genitals. I have performed laparotomy in eight cases of abcapsulated hydrops of the peritonaeum — three times this was with the expectation of finding ovarian tumors, while in the other cases the diagnosis was accuratelv made. In these cases there was a suspicion of such a condition : but neither the history, nor the general condition, nor affection of other organs, nor even elevation of temperature and sensitiveness, gave any definite information. The symptoms which have been given for such a differential diagnosis, such as an ill-defined limitation, the discovery of cancerous nodules, or abundant ascites, may occasionally not be sufficientlv characteristic. In later cases of hydrops saccatus the abdomen seems to me to be strikingly soft during anaesthesia, the rounded shape of the abdomen, which before had been very pronounced, flattens out more and more. The mass was still clearly evident on percussion, which at the sides .gave an unmistakably tympanic resonance, however the patients were placed. It has been recommended to make an exploratory puncture in just these cases, but I have found that by this means the object is not so easily obtained as by exploratory incision. It is just in exploratory puncture that there is danger, for example, of injuring cancerous neoplasms, and occasioning profuse, or even fatal, haemorrhages. Moreover, the exploratory ificision has the advantage that it can be immediately followed, if necessary, by appropriate treatment. Ovarian cysts have often been mistaken for hydronephrosis and cchinococci. Coils of intestine can usually be felt over hydronephrotic sacs, while ovarian cystomata press the former aside and upward ; but as the reports of cases show, this means of making a distinction is not always as clear as would be desirable. It is certainly important in these cases to examine the urine for pus, alliumen. and l)lood, or even to attempt to elucidate the conditions by catherization of the ureters. vSufticient infor- mation has not always been obtained from exploratory puncture. Where there are ecliinococci. a peculiar tremor on palpation is said to lead occasionally to a correct diagnosis. The number of accurate observations is increasing surprisingly in the most recent times, so that, perhaps, it is possible that a distinct point for differential diagnosis will yet be found. In one of my observations^ great sacs of echinococci lay in the pelvis, so that it seems as if they must be ovarian, and then it was natural to con- • Published by Duvclius, Ges. f. Geb. u. Gyn. zu Berlin, March, iSS6. OF THE DISEASES OF WOMEN. 487 skier the masses which hllcd the greater abdominal cavity as also being a part of the same. Solid tumors of the abdominal viscera always push their way close behind the abdominal walls. If they acquire any consider- able dimensions, they are usually easily distinguishable, from ovarian tu- mors, by the fact that they lie in the upper abdomen and can hardly be touched from the pelvis, while the ovaries can be felt beside them in the pelvis as being in an abnormal condition. Enlargcfnent of the titer us itself, by tumors or pregnancy, has often been confounded with ovarian tumors, as has already been men- tioned. In regard to pregnancy, it is certainly easy to be led astray by inaccurate history of the case ; the perception of the high degree of re- laxation of the portio, in some cases also the discovery of heart-sounds and fcEtal movements, should guard against such errors ; while if the nature of the tumor is yet at all doubtful, the observation of its further growth will give the desired information. Neoplasms of the uterus must always be distinguished from this by palpation, by finding the uterus first, and from thence the new- growths. In such cases, the sound is a useful aid in diagnosis. Subserous tumors often appear pediculated, and even entirely movable in comparison with the uterus itself; in such cases, sometimes, the palpation of the un- changed ovaries, or observation of the pedicle itself, makes the diagnosis certain. This pedicle, on the other hand, may be situated so far to the side that it is not accessible to palpation, and then such a differentiation ma}^ be almost impossible. Since, however, the myomata, fibromata, and other tumors of tlie uterus can only be attacked by laparotomy, I should not consider a diag- nostic error in this respect particularly serious. Tumors of the liver., spleen., and further neoplasms in the ab- dominal cavity should be excluded from diagnostic confusion with ovarian tumors by finding the genitals free, and especiallv by proof that the ovaries are healthy, — if necessary under anaesthesia. It is less easy to differentiate ovarian cystomata from tumors of the mesentery, perito- naeum, and even of the abdo7uinal walls. In all these, a certain degree of mobility of the tumor may exist. They may leave the skin of the abdomen perfectlv free, so that it is apparently movable over the tumor, and they may also in other respects offer all the other symptoms of ovarian tumors. Also for these cases the attempt should be made to find the ovaries, which lie in the smaller pelvis, and usually but little altered, and thereby at least to establish the fact that these tumors are not of an ovarian origin. The above-mentioned points of diagnosis are imdoubtedlv of great 488 PATHOLOGY AND THERAPEUTICS value. Practically, however, their importance is materially diminished by the most various complications, which frequently occur with ovarian tumors. In the first place, the cystomata of the ovary, even if they are not of a malignant nature, are not infrequently complicated \\\\S\ Jiuid free in the abdominal cavity. Moreover, besides such tumors, pregnancy may also exist, as is well known, and, likewise, uterine myomata may coexist with ovarian cystomata. The complications appear more serious which orisfinate from changes in the surface of the tumor itself. Here there mav be the most intimate adhesions, and in the latter such a vascular develop- ment may occur that the tumor derives its nutriment more from these places than from the pedicle itself. There may be connections between the tumor and the intestine, and all the other abdominal viscera, without there being any possibility of making beforehand a diagnosis of such adhesions with any certainty whatever. The question to which side the diseased ovary belongs cannot be al- wavs accurately answered. The question whether the tumor is multiloc- ular or a single cyst may be decided, in cases where the tumor can be i^eadily palpated, by the fluctuation of its contents in great waves, or in limited sections. Unilocular tumors are indeed generally rounded, while multilocular ones appear lobulated on their surface. I have already expressed my objections to the exploratory puncture, and I will not omit here again to insist that, for myself, I reject this punc- ture, on account of the possibility of occasioning thereby haemorrhages or decomposition in the tumor, and thus very seriously complicating the further treatment. The possibility of utilizing the fluid obtained by puncture for decid- ing the nature of the tumor by chemical or microscopic means, I will, of course, by no means deny. Among the means of making a diagnosis, which have been mentioned already, are some which are sufficient to dif- ferentiate the contents of a cyst from a free, ascitic fluid, and the contents of a hydronephrosis, or of the sac of an echinococcus, from the contents of fibro-cysts and cysts of the broad ligament. Often as I have attempted such chemical examinations, I have gained but little information which could be of general use for understanding the tumor, and especially for deciding the question whether the latter could be removed or not. The origin and mode of development of the tumor is just what cannot always be decided with full security from the results of such an examina- tion. The following peculiarities of the various kinds of fluids which are discharged by puncture of ovarian tumors, are to be particularly observed in diflerentiating tliem. The contents of the cystomata are viscid, usually tiark, of high specific OF THE DISEASES OF WOMEN. 489 gravity, abounding in albumen, in which, however, the paralbumen, of which so much has been written, cannot be found with any degree of certaintv. In the precipitate from these fluids are cylindrical epithelia, which usually are no longer intact, and show fatty degeneration and dis- integration. The Jlziid of ascites has a lower specific gravity, and contains less albumen. On standing in the air, after twelve to eighteen hours a gelat- inous coagulation of fibrine is formed, an appearance which is only found in the fluid of cysts after previous hjemorrhages. The microscope very rarely shows cylindrical epithelia in ascitic fluid, in case they have been broken oflT mechanically by the puncture. On the other hand, lymphatic corpuscles are found. In hydronephrosis the peculiar constituents of the urine are found ; but at any one examination they may be nearly absent. The contents of the echinococcus sacs are best characterized by the hooks, or rings of hooks, and sometimes, also, by parts of the cysts. The cysts of the broad ligamefit have extraordinarily clear contents, with a low specific gravity (1004 to 1009), which, under the microscope, show a few isolated epithelial cells. The contents oi fibro-cysts act like blood, coagulating in the air, without having any other characteristic peculiarity. There are four changes of cysts which may cause peculiar diffi- culty of the diagnosis. These are adhesions to neighborijig organs., rupture., torsion of the pedicle., and malignant degeneration. The adhesions of ovarian tzitnors zvith neighboring organs are gener- ally formed very insidiously and without the occui*rence of any symptoms which are clearly recognizable by the patients themselves. In the majority of cases there remains a certain possibility of movement for the neighboring organs. The affection of the latter, which is caused by these adhesions, may come on so graduallv that the first noticeable consequence of the same comes on after some accidental disturbance. In other cases these adhesions are formed with very acute svmptoms, especiallv those ot acute circumscript peritonitis. There are violent pains ; after a chill the temperature rises ; there is vomiting, frequent pulse, severe collapse. Then these symptoms gradually fade ; there remains only the painful place, at which the friction of two rough surfaces on one another can often be per- ceived through the abdominal wall. Such circumscript inflammations are often repeated, and finally, especially where there are adhesions with the anterior abdominal wall, there may be a ver\- intimate union between the surface of the cyst and this wall, so that everv movement of the tumor, and every motion of the body, shows this connection clearly, by the fact 490 PATHOLOGY AND THERAPEUTICS that the skin is drawn in and puckered at the place of adhesion. This fold- ing of the skin does not always occur, and thus disclose the adhesion ; for the abdominal wall may be so fat that the superficial skin is hardly influenced at all by the adhesions, which are deep below, and may even seem extremely movable, while, after incision of the abdomen, an inti- mate adhesion is found to exist. Adhesions with the intestines are often of extraordinary extent. The in- testines may be spread all over the surface of the tumor, and arc united with it over a large extent, and with considerable firmness ; and yet the jDcri- staltic motions may here goon with comparative ease, while in other cases there are, of course, rather severe disturbances and impediments of the same. The adhesions with the bladder- cause great difficulty, for they give rise to incomplete evacuation of urine, and to a tormenting feeling of distention of the bladder. When there are adhesions with the utertts^ disturbance of menstruation is frequently a prominent symptom. This is generally very profuse, and during the intermenstrual period very abundant secretions, and even irregular haemorrhages, occur. In general, the diagnosis of such adhesiojis is certainly of the greatest importance in regard to operation. It cannot be denied, however, that, in spite of every attention, it is occasionally very difficult to discover them. Extensive adhesions with the floor of the pelvis can be felt with com- parative ease, so that whoever does not know how to deal with these adhesions, during an operation, may always consider them as a contra-indi- cation to the operative treatment of ovarian tumor. Adhesions with the intestines, on the other hand, can only be discovered in very rare cases, — when any of the intestines run along the anterior surface of the tumor, and are adherent there, which I have seen in a few cases. In other patients, however, where these adhesions were very extensive and in- timate, the mobility of the tumor was by no means impeded by them ; and the discovery of these adhesions was all the more unlooked for, as a very easy and simple operation had been expected, just on account of the striking mobility of the tumor. Adhesions with the abdominal coverings are usually very easily separable. Firm adhesions are very serious ; for intimate welding together of the two surfaces occasionally occurs, so that the separation of them seems entirely impossible, and then the enucleation of the tumor cannot be performetl without considerable solutions of con- tinuity of the peritoneal covering of the anterior abdominal wall. In regard to the treatment of adhesions, I refer for the rest to what is said in the chapter on ovariotomy Ruptures of cysts occur, certainly not infrequently, partly in conse- quence of increasing pressure within, owing to the development of OF THE DISEASES OF WOMEN. 491 secondary cysts untler the surface, partly after any effects of violence, for •example, a blow, or a fall, or energetic palpation during examination. The contents are usually disharged into the abdominal cavity, without thereby necessarily causing any material disturbance of the general con- dition. When large cysts discharge their contents into the abdominal cavity, they cause, to be sure, at first, violent symptoms of shock. Then the diagnosis is facilitated by very great decrease in the size of the tumor. On the other hand, a rupture which comes on with symptoms of very considerable shock makes every exact examination difficult at first, so that the diagnosis of the rupture can only be made after the peritonaeum has absorbed the cystic contents which have been effijsed. Such an ab- sorption can take place within eight to twelve hours, as the case which I have already related shows. That death may occasionally follow a rupture, I do not consider impossible. A very much more serious complication consists in torsion of the pedicle. Violent pains and peritonitic sufferings appear, accompanied by symptoms of collapse, and with these a distinct increase in the size of the tumor has sometimes been observed. If, after torsion of the pedicle, the latter is not soon untwisted again, and if the consequences of torsion which I have mentioned above are further developed, the symptoms gen- erally increase to a very striking degree, and usually end in death. Malignant degeneration of ovarian tumors has for a long time been pointed out as an especial peculiarity of this sort of growth. How it occurs is apparently not yet explained equally for all cases ; the papil- lary forms of tumor, as Marchaxd {loc. cit.) has shown, are probably already percursory stages of malignant neoplasms. In other cases, malignant degeneration is developed in the remains of the ovary, or in the stroma of the latter, or of the glandular apparatus ; and it not only transforms the tumor itself, but, after penetrating the surface, it infects the peritonaeum also by direct contact. Dii'ect proof of such malignant degeneration can occasionally be obtained if small hard lumps or warty nodules can be distinctly felt either through the abdominal cavity, or from the space of Douglas. In other cases malignant degeneration can be inferred from the rapidly increasing cachexia, and mav be confirmed by the appearance of the ascites, which is always present wuh ovarian carcinoma. It is said that where there is malignant degeneration of the tumor, ^ cellular fragments of the malignant neoplasms and crystals of cholestearin are always found in fluid obtained by puncture from the ascites. The progjiosis of ovarian new-grozvt/is is decidedly unfavorable. I 1 Flaischlen, Zeitschr. f. Geb. u. Gyn. vii. 492 PATHOLOGY AND THERAPEUTICS will certainly not denv that there are cases in which a tumor remains stationary, at a low stage of development, causing no injurious reaction on the general health, and is thus borne w-ithout any symptoms at all, whether it remains inactive or passes through a retrograde metamor- phosis. The majority of ovarian tumors does not remain so harmless ; and if we consider all the dangers which result from the nature of these tumors, and on the other hand the favorable results of a radical treatment, we must conclude that the prognosis of ovarian neoplasms is so serious that we are to advise operation on the tumors as early as possible. The treat7ne7it of ovaria7i cystomata^ of course, had to be entirely expectant or palliative as long as the results obtained from the extirpation of these tumors were decidedly unsatisfactory. It was believed for a long time that the growth of the tumors could be stopped by general treatment of all kinds, by limitation of the diet, by exhibition of certain medica- ments, especiallv of the preparations of chloride of gold and of iodine, or bv mercurial treatment and similar therapeutic endeavors ; but from none of these means were any certain or permanent results obtained. If we occasionally observe that the tumors sw'ell under the influence of men- struation and the concomitant hyperzemia, it seems indeed justifiable to- attempt to retard the growth by diminution of this congestion of the genitals at the time of menstruation ; and from this point of view a treat- ment should not be entirely rejected which consists in scarifications of the uterus, quiet position, and keeping cool, so called, at the time of men- struation in patients who are suffering from small ovarian tumors. Of course the result of such a treatment is always extraordinarily problemat- ical. Among the measures which have been mentioned as a palliative, we have yet to refer to energetic derivation toward the intestinal canal, and vigorous stimulation of diuresis. I have seen many patients in whom this treatment had been instituted for a long time ; the sufferings were apparently kept within bounds thereby, t^ut no influence on the tumor and on its growth was attained. It is very evident that in cases where the small pelvis is quite filled by such growing tumors, they should be pushed upward ; usually, if they are not too extensively adherent to adjacent parts, they rise spontaneously. It would certainly be a great blunder if a general rule in regard to the treatment of ovarian tumors should be deduced from the occasional success of such methods of cure, or from the occasional results which have been obtained with mineral waters con- taining iodine and bromide at certain health-resorts. Besides the isolated cases of satisfactory or passable results, the great majority would tiien delay too long, until the prognosis of operation would OF THE DISEASES OF WOMEN. 493 naturally be made worse ' l)y the profound prostration of strength, bv ex- tensive adhesions, and by all the alterations of the ovarian tumor which have been mentioned above. Up to a time not very long ago, puncture was mentioned as one of the chief means for combating ovarian tumors ; even in the first edition of this book, puncture is described as the most frequent measure used in the treatment of ovarian tumors. Puncture for exploratory purposes has been considered above among the diagnostic measures ; as a means for curing ovarian cystomata, it cannot be seriously recommended. To be sure, cases of dropsy of the Graafian follicles, where a single evacuation had brought about a cure, have been reported not in a very small number. Likewise in the cysts of the broad ligament, which are so rare, cure by a single puncture has been reported by the most various authors. Yet in comparison with the great mass of ovarian tumors, these cases are completely insignificant; and if now, as has been explained above, the evil consequences of puncture are taken into consideration, it is at least doubtful whether any considerable place in treatment should be given at all to such a measure. I myself have sufficient experience with this kind of treatment ; I have assisted at a great number of punctures, and have occasionally myself performed this operation in my practice. Puncture (tapping) can be performed without an£esthesia in a com- fortable position on a chair or table, or in bed ; for it a trocar is used, which either, like that of Thompson, is provided with an arrangement for closure, so that after withdrawal of the stilet the canula is protected against the entrance of air, or the opening is covered with goldbeater's-skin, as in the arrangement of trocars for thoracocentesis. Before puncture, a roll of towels sewed together at their ends is passed around the abdomen. The long bandage thus made is unrolled from both ends, and the latter are then crossed again over the abdomen ; one assistant holds each end, in order to exert an equable pressure on the belly. For the puncture a place on the abdomen is chosen under which fluctuation is perceived with particular distinctness ; it is preferable to make the puncture in the linea alba, after the bladder has been evacuated, and as close above the symphysis as possible. The place to be puncturetl is first disinfected, and then the trocar, which has likewise been disinfected, is introduced with one vigorous thrust. Anaesthesia is usually not necessary, and in consideration of the attacks of syncope, which so frequently occur as the evacuation progresses, it seems, in fact, better to avoid anaesthesia. \'ery great quantities of fluid should never be removed suddenly. It is well to arrange for various pauses, during which stimulants may be administered to the patient ; ^ Bohiet, Mai des Ovaires, p. 114. — Peaslee, loc. cit., p. 1S9. 494 PATHOLOGY AND THERAPEUTICS when the escape of fluid is nearly or entirely ended, the canula is with- drawn, the puncture covered with a piece of sticking-plaster, over which a bandage is applietl antl tigiitly fastened, and then the patient is put to bed. The immediate relief is usually soon lost by a renewed collection of fluid. The refllling of the cyst, which seldom fails to occur, goes on in- quite various ways ; it can either be protracted through months, or may reappear in a few days. The other dangers of puncture have been already explained above ; usually the fluid soon collects again, so that the evacu- ation must be undertaken anew. It is recorded that over a hundred punctures each have been performed on some patients, while the unfor- tunates were approaching their end, with increasing cachexia. In view of this unsatisfactory result of puncture, the attempt began- to be made very early to induce obliteration of the tumor by the injection of fliiids luhich excite inJianiinatio7i^ especially of the tincture of iodine, and occasional successes by this method have been reported. In the cases in which I have assisted my father in such attempts, the reaction was generally very violent ; there was first a very sudden filling of the sac with serous fluid, and after the evacuation of the latter there was at first a sort of shrinkage, which was never permanent. In other cases of this kind, severe symptoms of iodine poisoning appeared ; in fact, in one- case the rapid suppuration of the cyst, and the death of the patient, which soon followed, could only be attributed to a single injection of the tincture of iodine, which therefore I would not recommend, precisely on account of the danger of inflammation of the wall of the cyst ; for although a single puncture does not always hinder further treatment and an eventual ovari- otomy, yet the prognosis for the radical operation is, at any rate, seriously impaired by injections of iodine, on account of the inflammation which is excited by it. I do not wholly agree with the proposition set forth by KxowsLEY Thornton at the congress in Copenhagen in 1SS4, in regard to the injury to the prognosis which is caused by previous simple punc- tures. A third method is the obliteration of the cyst by drainage after in- cision. I have treated several cases by this method, and have also seen recovery ensue thereby. These were cas^s of extensive adhesion of the surface of the cyst with the abdominal wall, in which a separation did not seem practicable ; one of the first cases of this kind I observed, as the assistant of my father, until it was cured by injection of more or less strong solutions of carbolic acid, and I still frequently see this lady now,, after more than fourteen years. Another case of this kind likewise re- covered under the same treatment. I likewise observed until the end a third case in niv father's practice, and two in my own. In the last case of OF THE DISEASES OF WOMEN. 495 my father and in one of mine, sepsis occurred ; in my last case, death ensued from increase of the cachexia ; the patient sank under attacks of colliqua- tive diarrhoja and general debility, although septic aBections had not appeared during the whole of the two months during which the treatment lasted. In this case, to be sure, the cystoma had undergone carcinoma- tous degeneration. Of these six cases, the first four were drained only through the abdominal wound, the last two simultaneously also through the posterior vault of the vagina. In accordance with what I have to state hereafter, in regard to the prognosis of ovariotomy, the treatment of ovarian cystomata caji only consist in extirpating theni^i afid this jnust be done ivithotit zuaiting until the tnmors have attained a dejinite size^ or nntil definite deleteri- ous injlicences have affected the general health; if ive consider all the possibilities which have been related above., in regard to the course of ovarian tumors., as to their changes and to their malignatit degen- eration., we cannot operate too early. The whole number of the cases of ovariotomy, and of extirpation of healthy ovaries, and of excision of cysts of the broad ligament, which is an analogous operation, which have been performed by me up to the end of January, 18S7, includes two hundred and eight cases. Of these, there were, — 136 cystomata. 35 cases of chi'onic oophoritis. 9 cases of dermoid tumors. 14 cases of solid tumors. 12 cases of cysts of the broad ligament. In twelve cases, finally, comparatively healthy ovaries were removed for the purpose of castration. The details of these two hundred and eight cases are at present being collated for publication. Since the latter fate of these patients has to be taken into consideration for this purpose, this is a work of peculiar diffi- culty. Concerning ovariotomy, see page 502. 3. — The Dermoid Tumors of the Ovarv. The dermoids are distinguished from the cvstomata especiallv bv the fact that there is no doubt that in the former, not only the glandular cells of the ducts of Pflueger are afiected, but, as His ' has shown, we must assume that there is a participation of the upper germinal layer. To this ' Arch. f. mikrosk. Anatomic, 1S65, i. 496 PATHOLOGY AND THERAPEUTICS are to be referred the structures formed of external skin, wliich are foi.nd in the dermoid, while from parts of the middle <^erminal layer, which likewise participate in the doubling in of the axial cord, arc derived fatty tissue, bones, teeth, etc. The results of the investigation by Flaischlex ' of a small ovarian tumor, from which the author concludes that the fatty epithelia of the dermoids, w'ith whatever is derived from them, originate in the glandular cells of Pflueger's ducts, has remained, as far as I know, isolated up to this time. The theory of His, on the other hand, essen- tially explains this peculiar structure of the dermoid cysts. The denuoids^ which thus must be considered as congenital in the full sense of the term, seldom reach a large size, unless they swell sud- denly from disintegration of their contents, when they may reach the size of extensive cystomata. The wall, consisting of connective tissue in several layei's, has, on the inner surface of the dermoid cyst, a surface similar to that of the external skin, w'ith thick, horny pavement epithelia, and subjacent nucleated flat and round cells ; in short, the complete structure of skin. The epidermis, or the layer of tissue lying next it. in some places bears distinct papillae, which, however, are not arranged as regularly on the external skin. Under this is found a sort of fatty layer, which connects this skin-like structure with its envelope of connective tissue. In this cutis»lie hair follicles and sebaceous glands, also, in some cases, sweat glands. Friedlaexder- has shown that from these seba- ceous and sweat glands secondary cysts may be formed by retention. Cysts lined with ciliated epithelium, of considerable size, and with sero-mucous contents, may also be found therein. The hairs may be very long and strong ; they are generally reddish, but black and gray hairs may occa- sionally be observed. In old dermoid cysts, the hairs which have been shed are found in masses, and may fill the cystic cavity as a tangled mass. Between these hairs lies a considerable mass of fat, which is sometimes fluid and sometimes solid. Oxalic acid, tyrosin, and leucin, urea, and xanthin, are also said to be found therein. These fatty masses originate in the disintegration of the cells of the epidermis and in the secretion of the sebaceous glands. On suppuration of the dermoid, the whole mav break down to a thick, foul emulsion ; while in other cases these fattv masses float, in the more fluid elements, like barley-grains in gruel. The teeth and bony formations seem particularlv strange. The structure of the teeth is generally rudimentar}', vet whole jaws with teeth are observed, and in fact the number of the teeth mav rise to over one hundred ; and if we may draw' deductions from a specimen of RoKi- ' Zeitschr. fiir Geb. v. Gyn. vi. p. 127. ^ Ffiedlander, Virchov/s Archiv. Ivi. p. 3ient. — In consideration of their frequent adhesions, it has been proposed in such cases to evacuate the dermoid through an enlarge- ment of the opening of perforation. If this is possible from the vagina, or through the abdominal wall, a certain simplicity mav surely be claimed for such a jDrocedure. In all other cases, however, it seems better to expose the tumor under appropriate precautions, and to remove the sac itself after careful separation of the adhesions. In so doing, the pro- cedure which I shall have to describe further on, in considering the adhesions of ovarian cysts, may have to be employed in some cases ; namely, that the wound resulting from the removal of such a dermoid cyst should be sutured otl' towards the abdominal cavity alter drainage has been established toward the vagina. The attempts to obliterate these cysts in other ways should be rejected as unsuccessful. 1 Flaischlen, loc. cit. 49S PATHOLOGY AND THERAPEUTICS Up to the present time I have had occasion to operate on nine dermoid tumors. 4. — The Solid Tumors of the Ovahv. Among the solid tumors of the ovary are included Jibroids, caret- nomata^ and sarcomata, although cystic formations may occasionally be observed in all of these. The solid tumors of the ovary ' are neverthe- less rare, as compared with the cystomata. Leopold reckons the ratio of their occurrence as 1.5 per cent. I myself, out of two hundred and eight cases, have operated on fourteen solid tumors. All of these various kinds have, in the first place, the peculiarity that they occur double>, on both sides, more frequently than the cystomata ; they do not usually reach the size of the latter, and are of a more or less ovoid form, corresponding to the enlargement of the ovary. They usually occasion a peculiar formation of the pedicle, in which the tube is only implicated later than in cysto- mata. They have little disposition to form adhesions, probably because they all predispose in a very high degree to the development of ascites. A. — Fibroma of the Ovarw These tumors, which are very rare, may grow to a colossal size. In June, 1SS6, I removed from a woman both ovaries in a state of fibro- mvxomatous degeneration, and weighing together about 5^ pounds." The fibroids present a regular hypertrophy of the ovary, in which the form and connection with the broad ligament are preserved."' Virchow has found scanty smooth muscular elements in such tumors ; but such an admixture of muscle is very rare, the tumors being usually composed of fibrous connective tissue. In these cases there is danger of confusion with tumors of the uterus ; in fact, Schroeder ■" states that it is yet doubt- ful whether the real fibromyomata do not always originate in the uterus, while only pure fibromata are of ovarian origin. The observation of Waldeyer " of a completely osteoid structure, and the ossification of the tumor which Kleixwaeciiter " has described, are to l)e classed as extra- ordinary exceptions. Rokitaxskv and Klob, and also Jenks,' describe the developments of small fibroids from a corpus lutem. The fibroids do not cause characteristic symptoms, but they are usually accompanied by ascites. In rare cases they may soften or sup- ' T/t. S. Lcc, Von den GeschwUlsten der Gebiirm., Berlin, 1S4S. — Virchow, GeschwUlstc iii. S. iii. — Iiig-ham, Am. Journ. of Obstetr. vi. p. 106. — Spencer JKWA?, Diseases of the Ovaries, 1S70. — Leopold, Arch. f. Gyn. vl. and xiii. — Coe, Am. Journ. of Obstetr. 1SS2, xv. p. 561. - Orthman, Ges. f. Geb. u. Gyn. 25, June, 1SS6. ■'' ll-'alciever, Archid. fur Gyn. ii. 440. •• Spiegclberg , Monatschr. f. Geb. xxviii. S. 415. '' Kleitnviichtcr, Ibid. iii. S. 171. ^ Ed. vii. S. 436. " Amer. Jour, of Obstet. vi. p. 107. [Annals of GvN.ii((ji.oGY and I'.iiui atkv, iSyo.J LXIV FIBROMA OF OVARY. In the centre of tlic picture is seen the insertion of the Fallopian tube into the tumor, at wliat was the hiluni of the ovary. OF THE DISEASES OF WOMEN. 499 purate in spots. Such changes are apt to be connected with the puerperal condition. A diagnosis cannot l)c made with certainty. The prognosis must be considered as not unfavorable, since the fibroids as a rule only grow slowly, or even cease to grow at all. Treatment can only consist in extirpation, by which, moreover, the ascites is usually completely removed. B. — Carcifzofna of the Ovary. The primary carcinomata must be distinguished from those cases in which ovarian cystomata undergo carcinomatous degeneration. Primary ovarian carcinoma is not limited to the later years of life, as much as is carcinoma of other sections of the genital canal. It is either observed as a diffuse infiltration of the stroma, so that the whole ovary is changed into a single cancerous mass, of a shape resemb- ling the ovary, in which case it may increase to a large tumor, or can- cerous nodules are formed, which change the ovary into a knobbed tumor. The papillary fungosities wiiich spring from the surfaces of the ovary, are provided with cylinder epithelium, branch repeatedly, and present cauli- flower excrescences, may be considered as a sub-form of cancerous devel- opment ; ^ they usually soon lead to ascites, infect the neighboring parts, and then reveal clearly their malignant character. Carcino??iatous degen- eration of cystomata likewise occurs in the form of papillary degeneration, or in that of a glandular carcinoma in the tissue of the cystoma itself. The development of carcinomatous foci in the ovary always irritates the peritonaeum to a high degree, so that ascites and chronic peritonitis are hardly ever absent. With greater frequency than is represented by authors, I have observed the occurrence of nodules springing up, widely separated from each other, and apparently independent of each other, which developed further sometimes in the mesentery, and sometimes in the group of retro-peritoneal glands. In these cases I have observed with striking frequency affections of the omentum, sometimes in the form of a thick, callous mass, pushing itself, like a board, between intestines and abdominal walls, sometimes rolled together to a single mass in such a manner that it resembled some peculiar atvpical tumor. For many of these cases it must, of course, remain a question whether the tumors of the ovary, in the form which they are usually found, have occurred primarily or secondarily. - ' Gussero-v u.Ebert, Virchovj'a Archiv. l>ii. 4;, S. 14. — KUbs, Handh.d. path. Anatomie, 1S73. — Birch-Hirsch/eld, Lehrbuch d. path. Anat. iioi. — Marchand, loc. cit., 1S79, Fig. 4. - Olshausen, Krankheiten der Ovarien, 1SS6, S. 428. — Pursier, Verhandl. der Wiirz. phys.- med. Gesellsch. x., S. 34. — Klob, loc. cit. — Thomas, Amer. Jour, of Obstet. iv. — Wittrock, D. i. Erlangen, 1S79. — Compare Cohn, Zeitschr. f. Geb. u. Gyn. xii., 1SS5. — Discuss, in der Gcs. f. Geb» u. Gyn. zu Berlin, Ibid. — Leopold, Deutsch. ined. Wocli., 1SS7, Xr. 4. 500 PATIJOLOGY AND THERAPEUTICS The svmptotus of curcinomatous infection of the ovary are often hitent for a long time. Then there is usually a peculiarly rapid growth, with symptoms of chronic peritonitis, marasmus, and obstruction of the intestine. If the ascites increases considerably, the symptoms of prostra- tion may be masked by the sufferings which are associated with the increase in size of the abdomen. The diag7iosis is usually first made when the masses have already led to the development of a great quantity of ascitic fluid. Sometimes masses are felt in space of Douglas, before or soon after the evacuation of the ascites, and then the peculiar furrows on the ovary can be majjped out very exactlj'. In other cases the nodular character of the parietal peri- tonaeum can be clearly perceived, and therefrom a suspicion, if not a cer- tainty, of a diagnosis can be derived. Up to the present time I have ex- tirpated carcinomatous ovaries eight times, besides two papillomata and one myxoma. Among the twenty-eight cases of exploratory incision with puncture of the tumor, or closure of the abdominal cavity without removal of anything, are twenty-two cases of carcinoma. To be sure, it would be erroneous to emplov these numbers for a statistical computation, because in a great number of these cases the point of origin of the carcinoma could not be determined with certainty. The prognosis of ovarian carcinoma has been illustrated in a very interesting way by the investigations of Cohn, who collated the cases of ScHROEDER. If we add to this the cases collected by Leopold up to the beginning of the year 1S77, it is found that after an early extirpation almost 20 % remained cured for longer than a year. I have not yet been able to arrange my cases with reference to this question. To be definitely settled it requires greater nimibers, but even now it can be stated with all positiveness, first, that carcinomatous affection of the ovary is relatively frequent (16.6%); second, that the possibility of cure after early ex- tirpation is demonstrated: and, third, that for this reason also the extir- pation of ovarian neoplas?fis^ even when they are yet small and cause little trouble^ should be performed as soon as possible^ as Koeberle ' in 1877, and I since 1S78, have urgently recommended. The treatment of carcinoma of the ovary can only have any chance of success when entirely circumscript tumors are removed at a very early period. In one case of my own observation I extirpated from a lady who was yet young, a cystoma of the ovary, which showed quite isolated papillary excrescences ; then I had an opportunity, when the patient per- ished a year later with symptoms of ascites, to observe that the perito- naeum, particularly the place of the stump of the pedicle, was completely ' G;iz. med. de Strasbourg, 1S77, Nr. 3. [ Annai.s ok Cvn.kc ()I.()(,n , Huston, Soptctnber, iSSS.] LXV Fig. 1. ChkONIC PEKITONtAI, EkKUSK)N'. Caused l)y solid tumors of the ovaries, and by i;eneral invasion of the peritoneal surfaces by minute papilloniata (see Appendix). I'lil'/i'slieJ by J>trinissio>i of the patient. [Ann,""drical epitheliunT tl^ rese,nbl.ng g ands. As the papil,. are massed together to form a solid tun,or, the fesen^blle ^ adenomatous degeneration of the fundus uteri hecon.s striUin.: in tact, verv fre, ent.v theTelro wt degenerate into carcinomata. " ' ""--^ =.ro\Mnb OF THE DISEASES OF WOMEN. 501 free. On the other hand, the gall-bhidder was extensively carcinomatous, and death had been occasioned thereby. To be sure, these patients usually come under observation too late. Then nothing more can be done than to draw off the ascitic fluid, and thereby symptomatically combat the suf- ferings. If this is not possible, relief may be also sought by making a wide incision. Wherever the peritonieum is affected, however, every attempt at extirpation must seem extremely dubious, since there seems no possibility of securing a pedicle and of entirely controlling haemorrhage. Olshausen, in his collation of the cases of this kind, calls attention to the bad prognosis of exploratory incision ; yet I cannot agi"ee with him in this respect, according to my experience, for out of twenty-two explor- atory incisions, in cases of cancer of the ovary, I have only seen four die immediately after the operation, while in other cases life was prolonged sometimes far longer than a year. If we consider how the refusal of all interference robs the patients of all courage, so that they feel condemned to waste away miserably, while on the other hand by opening the abdominal cavity relief may undoubtedly be obtained, even if only temporarily, an exploratory incision may be considered as not wholly unjustifiable, even under desperate circumstances. C. — Sarcoma of the Ovary. The very rare form of sarcomatous degeneration of the ovary ^ is de- scribed either as spindle-ceiled sarcoma, originating from the connective- tissue stroma of the ovary, or as round-celled sarcoma, such as has been described by Bkigel and Olshausen." It would usually be difficult to make a diagnosis. A rapid growth, early ascites, and chronic peritonitis, together with a corresponding cachexia of the patient, will arouse suspi- cions of the nature of the degeneration. The treatment is here as doubtful in its success as in cases of carcinoma. Up to the present time I have met with one cystosarcoma. D. — Tuberculosis of the Ovary. A primary and isolated occurrence of tuberculosis of the ovarv has up to the present been described only by Klob and Spencer Wells. ^ As a rule, there is general tuberculosis of the peritonasum and also a simultaneous affection of the ovaries. Hegar"* also, in his work on • Wilks, Transact, of the Path. Soc. London, x. p. 146. — Vircho~u, Geschwulste, i., S. 369. Leopold, Archiv. f. Gyn., vi. - Beigel, Krankh. d. weibl. Gcschl'org;, 1S74, S. 440. — Olshausen, Krankh. der Ovarien, 1SS6, S. 420. — Klob, Path. Anat. der weibl. Sexual organe, S. 372. 2 Klob, Path. Anat. d. weib. Sex. S. 372; Spencer Wells, loc. cit. p. 64. ■• Stulto-art, 1SS6. 502 PATHOLOGY AND THERAPEUTICS genital tuberculosis, out of six cases confirmed by operation. tlescril)es no one of tuberculosis limited to the ovary, although, indeed, the ovaries, which lav beside the tuberculous tube, were usually diseased. These cases are characterized by a disposition to the formation of encapsulated serous collections, and thereby they not infrequently lead to confusion with tumors, and to exploratory incisions. The ovary is then found moi'e or less covered by tuberculous nodules, and, also, the whole peri- tonaeum is similarly affected, greatly thickened, and very vascular, and adherent in a wholly irregular manner to the intestines or other organs. These cases of apparently most unfavorable prognosis, nevertheless, as far as my e.xperience goes, do not ofter such immediate dangers as might easilv be inferred from the nature of the aflection. Up to the present time I have operated on nine cases of this kind ; they all recovered rapidly from the operation, and from three I still hear that they have felt decidedly better since the operation ; they have recovered their strength, and it seems as if the Interference had acted fiivorably on the disease itself. ScHROEDER and KuESTER^ havc had similar experiences ; both of these authors, to be sure, used iodoform extensively in these cases. I have done this only in one case ; in the others I have avoided the use of iodoform, and at present I am well satisfied that I did so, since without the use of this medicament the result has been very satisfactory. 5. — Ovariotomy. The histor}' of ovariotomy is so significant, since this operation, which, like few others, gives certain freedom from a malady dangerous to life, and even in cases of double ovariotomy can give a relative restoration to health, has been developed to its present height in a compara- tively very short time. After Schorkopf^ had already in the seven- teenth century thought of the possibility of extirpating the ovary, and the operation had been accidentally performed by the most various authors, Ephraim McDowell,'' in Kentucky, was undoubtedly the first who performed the operation designedly. He was a scholar of John Bell, in Edinburgh, and had been incited to this procedure by a propo- sition of his teacher to perform it (1S09). The operation was very gradually adopted more and more in America, and was there first, through Atlee, Kimball, and Peaslee,^ made an operation which recei\ed ' Ktisier, Verhandl. der Berliner. Gesellsch. f. Geb., iSSo. 2 Schorkopf, D. i. Basel, 16S5. ' Ephraim McDozvell, Lond. Med. Gaz. v. p. 35. — Ecleetr. reperlorj' and analytical review, Phil., October, iSiS. — Compare also Lazosoii Tail, The pathol. and treatment of diseases of the ovaries, Lon- don, 1S74. * Atlee, Ainer. Journ. of Med. Sci. xxix. — Peaslce, Ovarian tumors, mem. path. diag. and treatm., 1S72. OF THE DISEASES OF WOMEN, 503 general recognition; yet it was not until 1865 that all denial of the justitiability of the operation died out. The only modification suggested by the American operators in this long time of development is worthy of notice. It consisted in carrying the ends of the ligatures out through the vault of the vagina, by means of a needle (A. March) ; for the rest, the pedicle was treated intra-peritoneally there by most operators. In Edinburgh, Lizars^ made the first ovariotomy in 1S24. Beside West, Warxer, and C. H. Clay,^ Bird,^ and Baker-Browx," the operation gained full recognition, particularly through Sir Thomas Spexcer Wells ; ^ the reduction of the abdominal incision to the necessary length, the manner of securing the pedicle extra-peri- toneally, the suture of the abdominal wound, including the perito- naeum, were by him made operative procedures of general use, and by the development of the technique he made himself the teacher of almost all ovariotomists. In Germany, the first operation was performed by Chrysmar, inlsny, in Wiirtemberg, in 1S19 ; many others have ventured more or less on the operation with more or less good fortune, and inde- pendently of each other ; nevertheless, such a sui"geon as Dieffexbach yet rejected the operation as unjustifiable and too dangerous. Stilling recommended the extra-peritoneal treatment of the pedicle in 1841,*^ and, therefore, much earlier than Spexcer Wells. E. Martix," also, employed the same method in 1849 '^"*^ ^^5^ with success. The English- man, DuFFix, likewise used extra-peritoneal fixation, apparently in- dependently of the German authors ; in 185S. Hutchixsox invented the first clamp. France rejected the operation for the longest time, and omitting some not very successful attempts, the first successes which were also very brilliant date from Koeberle,'' who, in 1864, could already report more than twelve operations, of which nine had had a fortunate result ; besides him, Peax'' in particular has performed ovariotomy very exten- sively. If, now, Spexcer Wells by his admirable technique. Thomas 1 Lizars, Edinb. Med. and Surg. Journ., October, 1S24. 2 Ch. Clay, Med. Times, 1S42, vii. •^ Bird, Ibid., August, 1S43. ' Baker-Brown, Transac. Obstet. Soc, London, 1S66, vii. •'■' Spencer Wells, Dubl. Qiiart. Journ. 1S59; Diseases of the Ovaries, London, 1S72. '• Stillhiff, Holscher'^ Annalcn. Xeue Folge, i., Jarg. 1S41, and Extraperitoneaimethode der Ovariot., Berlin, 1S66. ' E. Martin, die Eierstockswassersucliten, Jena, 1S52. " Koberle, Gaz. hebdom, 1S66, vii. ■' Pean, L'ovariotomie peut-elle etre faite .i Paris avec des chances favorable de succes, L 'union med., 1S6S. 504 PATHOLOGY AND THERAPEUTICS Keith ' by cxtraoniiiKirv cine, Peaslee and Koebeule by originality in operating, had obtained very passable results, the attempt wliich SiMS" made in the year iS74to improve statistics by prophylactic drainage of the peritoniEum into Douglas' space resulted badly. In Germany this procedure was opposed at first by Hegar'^ (in op- position to Olshausen ■•), and then particularly by Schroeder/ The popularity of ovariotomy to-day dates from the introduction of the so-called antiseptic method, which, by adoption of the so-called method of Lister, was made the general foundation of ovariotomy, more particularly by Hegar, .Schroeder, and Saexixger. In accordance with this, the exclusion of germs which excite decomposition must be made the basis of every operation, by perfection of the minutest details. Success is more dependent on this than on any particular technicality. The question how to do this shows that it is possible in various ways, as the successes of Thomas Keith and Law'SOx Tait, and those of ScHWARZ in the so-called pi*e-antiseptic times, show by comparison with those of Hegar, Schroeder, and myself. The liberation of ovariotomy from such special maxims, and also from special instruments, is a further advance in a right direction. Ovariotomy is indicated wherever the ovary is degenerated^ whether a large tumor has already developed from it, or whether the growth is still in its early stages. As soon as such a degeneration causes symptoms, and an investigation shows that the enlargement of the ovary does not depend on an accidental physiological swelling, corresponding to menstruation, or on a transitory inflammatory enlargement, but on an increase of its substance, which does not diminish spontaneously, then its removal is justified. Secondly, ovariotomy is warranted in chronic injiammation of the ovary as soon as the physical and mental health of the patient is under- mined thereby, and her vitality is so thoroughly damaged that her ability to earn a living is permanently impaired, and every other means of treat- ment has shown itself unsuccessful. Of course in such a case a poor woman will require an operation much earlier than one in easy circum- stances ; for the former must labor, and is destitute of means for proper care, while the latter can be treated. > Thomas Keith, Brit. Med. Journ., 1S78. 2 \ew York Med. Journ., 1S72-1S73. ^ Hegar, zur ovariotomie. — Volkmann' s ges. Vortr. 1S77, 109. Compare also Ihgar and Kaltcn- bach. Operative Gynaek., Ed. iii., 1&S6. ♦ Olshausen, Berliner klin. Wochenschr. 1S76, Nr. lo and 11. ^ Schroder, Sitzungsb. d. phys. med. Soc. Erlang-en, May 10, 1S75. OF THE DISEASES OF WOMEN. 505 The rich woman can rest and be cared for in every respect while en- joying all possible alleviations. I do not place the removal of the norvial ovaries, castratio7i^ in the same category with these two indications, because here it is not the ovary itself which furnishes the indication, but a disease lying outside of this organ, on which castration is to exert an influence. See the chapter on this subject, page 537. Ovariotomy appears to be warranted on account of these indica- tions as soon as the tumor is perceived., and it is recognized that no other treatment can bring permanent recovery. The prognosis is by so much the more favorable the sooner the tumor is removed, the less the pelvic vascular system is damaged by it, and the less the forces of the patient are consumed by the formation of adhesions, and by alterations in the tumor itself; that is, the less reaction there has been on the nutrition of the patient, and the smaller the disturbances are of the respiration and circu- lation. If we consider., moreover., that ovaria?z neoplas7ns are exposed to the fatal alterations which have been mentioned., and especially that their malignant degeneration is a fact which is observed with ever- increasing frequency., there ?mist be no hesitation in undertaking the operation as soon as possible., even if the patients themselves have noticed comparatively little influence of the neoplasm on their getieral co7idi- tion. The number of operations which are performed thus early will always remain limited ; only too frequently the patients come to the operator only when they are in a very deplorable condition ; but, however sad the state of the health may be, and however much reduced their strength may appear, by reason of exhaustion and adhesions and incurrent attacks of all kinds, operations should be refused only on account of two classes of complications : Hrst, namely, if the maligna)it character of the tufnor is 7inmistakable and the disease seems to be no longer limited to t/ie ovary itself; and, secondly, if damages have occurred in other important organs., which exclude every prospect of alleviation., especially, therefore, in cases of pulmonaiy phthisis, in advanced stages of cardiac affections, in chronic diseases of the kidneys or liver, and in similar conditions. In the absence of these complications I consider it as a duty to operate, even under circumstances which are apparently most unfavorable. For the latter are of such a nature that they will soon terminate the existence of the patient at any rate, while the operation at least offers a chance, if often a slight one, of saving her. (My statistics must, therefore, be considered from this point ot ^•iew. Only in this way can the results be estimated at their true value, since my 5o6 PATHOLOGY AND THERAPEUTICS cases are not selected, l)ut include the most various difficulties : adhesions, general febrile disturbances, etc.) I would call particular attention, moreover, to tlie fact that, in my opinion, ovariotomy should be performed as early as possible^ ivhere there is a co7nbi7iation of ovariaii tumors and pregnancy, in case the tumor is at all voluminous. But even wlien they are not so, tumors should be removed, although small, as soon as they become noticeable by injurious effects oti the gravid ziterus or by sytnptoms of gro~Jcth or of disintegration . For evidently the prognosis of ovariotomy during pregnancy is more favorable than when it is performed during the puer- perium. The latter always offers a very grave prognosis, apparently on account of the various circumstances connected w^ith labor and childbed. In regard to the variations in estimating the prognosis of ovariotomy I refer to the books of Spencer Wells, Hegar and Kaltenbach, Olshausen, and Schroeder, which have been quoted above. The latter relates^ that the mortality hardly exceeds five per cent. It would certainly be inaccurate to take into consideration the earlier reports — for example, that of Leopold,'' who, in his first operations, although they occurred in antiseptic times, had twenty-six per cent, of mortality ; or those of Sla\-- JANSKY,^ who, likewise, had twenty-four per cent. ; or those of C. Braux and Krassow^ski ■* — in such a computation ; it may be assumed with certainty that all these same authors, as is apparent from the report of Leopold, of 18S7, cited above, have meanwhile approximated the figures given by Schroeder, through improvement of their antiseptic precautions and further development of their operative technique." The author relates at the close of the first editions of his book on the pathology and therapeutics of women's diseases (1SS5), ^^^ '^'•'t of 100 consecutive ovariotomies, performed antiseptically, he has only lost one of sepsis. The operations which he has now performed, and which will soon be published at length, show the following figures : 133 ovariotomies on account of cystomata, the first 2S with 6 fatal cases (5 from sepsis), the last 104 with 3 fatal cases; among the last 105 of them there was i death from sepsis, r from embolism, i from carci- noma (3 i^er cent.) ; 2<^ operations for chronic oophoritis (i death, col- lapse) ; 9 dermoids (i death, collapse); 14 solid tumors (6 deaths), 4 of them from sepsis ; i3 castrations (i death from antemic embolism); 12 cysts of the broad ligaments, and 3 vaginal ovariotomies (with no ' Loc. cit. pag. 430, ed. vii. - Leopold, Archiv. Tur Gyn. xxii. ' Slavjansky, Arch, de Gynec, iSSs. * C. V. Brau7i, Wiener ined. Wochenschr., iS86. — Krassowski, Sep. Abdr. s Olshausen, Krnnkheiten der ovarien, S. 240, u. f. — SchriiJer, liandbuch der Frauenkr., iSS<5. OF TIJK DISEASES OF WOMEN. 507 Fig. deaths). A total of 20S with iS deaths equals 8^ per cent. ; of these there died septic 10, equals 4y^ per cent. vSubtracting, however, the 6 cases of sepsis in the first 28 ovariotomies which were performed with defective antisepsis, there rcmaii; 4 cases of sepsis to iSo operations. For the pefjforma^zce of the opei'ation the following axioms are gen- erally accepted at present : — I . The operation must be made an aseptic one. a. The opo'ating-room must be prepared by wash- ing the walls, ceiling, and floor with active disinfectants, of which the most useful at present are the preparations of chlorine and sulphur, carbolic acid, and sublimate ; the air of the room is made entirely fresh, and is satu- rated with the disinfectants by means of atomizers ; and by some operators it is filled with a spray continually, even during the operation. Since 1886 I have no longer used the spray during the operation. The instrumefits and the apparatus are washed in the same way. Everything metallic is heated in the flame, and passed from the latter directly into the disin- fectant sohction xvJiich is prepared for the operation. All water used for the preparations, and during the op- eration, is to be previously thoroughly boiled. Everybody employed at the operation^ both assist- ants and nurses, as well as the operator ., must be sure to be free from every contact with septic material ; all must bathe themselves before the operation, and have on fresh clothing throughout. I have for this 23urpose linen operating garments, which ai-e washed every time they are used. Besides thorough washing with sublimate or carbolic acid, I then request all whose hands will come in contact with the patient to wash them before the operation with fresh lemon-juice, which gives a shining white color, particularlv to the nails. b. The number of assistants must be as limited as possible. Besides the one in charge of anaesthesia, only one assistant is neces- sary at the abdominal wound. The operator himself can cleanse his sponges and reach for his instruments, if there are no trustw^orthv and experienced assistants present. c. The instrtunents and all materials to be used at the operation must be prepared for each separate occasion. The set of instruments consists of one knife, one scissors, several large and small needles, one Trocarof5/./rt'//f. 5oS PATHOLOGY AND THERAPEUTICS Fig. 204. needle- holder, a few bullet-forceps and vulsella, one large dressing-for- ceps, some clamps, and haineostatic forceps. Many operators also use the trocar of Spencer Wells (Fig. 203), and the forceps of Xelaton (Fig. 204), complicated ap- paratus, which I have, however, for this reason dispensed with as superfluous. After these instru- ments have been passed through the flame, they are immediately laid in a lukewarm solution of car- bolic acid of 2\ per cent.' For dr\ ing and cleansing the wound either fine Levantine sponges are used, or clean linen cloths, cotton wool, or .wood wool. The sponges are prepared for each separate occasion by boiling, cleansing with acids, boiling again, washing in car- bolic acid, and boiling again. One or two large ones and six or eight small ones are used ; the latter must be fastened into sponge-holders to be handled conveniently. Since none of the appara- tus provided with sliding-catches can be disinfected with certainty, I use for this purpose large bullet forceps, which have a notched catch, like that sug- gested by Hegar, and these I have arranged with a joint, which permits of taking them apart easily. For sutures and liga- tures silk and catgut are preferably used. Czerxy has given particular directions for the preparation of silk, and Kuester has published a pro- cess for catgut. The plaited silk made by Turner, w'hich I use for all gynaecological operations, is wound on glass plates, and lies in a carbolic solution (i : 40) until it is threaded. d. The patient herself, on the evening before operation, receives a carbolized sitz-bath. The vagina is thoroughly disinfected. When the patient lies anaesthetized, the abdomen is again washed with lemon-juice, and then with sublimate solution (i : 2000). If necessary, I have the pubes shaved previously. Any spectators who are present must likewise refrain from con- tact with septic matters on the day of operation, and must take a bath and change their clothes. The temperature of the operating-room rises so that it is hardly necessary to have it very hot beforehand. The rule was formerlv that an operation should only be undertaken in a room heated to 86° F. Nelaton's forceps. 1 For further apparatus, such as is used for fixation of the pedicle and for burning it off, seeOlshait- sen. Diseases of the Ovaries, iSS<5, p. 214 et seq. Fig. 208. 5IO J'ATHOLOGY AND THERAPEUTICS 2. The operation must go on as rapidly as possible. For this pur- pose all necessary preparations must be made in advance, so that during the operation itself the well-instructed attendants may have everything at hand which is necessary without any delay whatever. An appropriate position of the patient is of no small consequence in allowing the operation to be speedily completed. After trying various postures the majority of surgeons now operate after the manner of Spencer Wells, standing at the side of the patient, the assistant at the operation standing opposite ; the operator has instruments and sponges lying beside him on a small table. I operate sitting down, after the man- Fig. 206. ner of Pean (Fig. 205) ; tlie patient is placed on a table invented by Frau Horn (Fig. 206), at the head of which sits the assistant, who gives the anjEsthetic. I myself sit between the legs of the woman, which I hold on mv knees (Fig. 205) ; but, if desirable, it would be possible to use Fritsch's leg-holders for this purpose. 3. The operation must end with a cojuplctc closure of the abdomi- nal cavity. This will be obtained most completely by the so-called intra- peritoneal treatment of the pedicle : but also when the latter is treated extra-peritoneally the abdominal cavity can be completely closed. When the patient has been properly ansesthetizeil, put in position, catheterized and disinfected, begins the First act of the operation : the abdomen is divided in the linea alba as rapidly as possible. Any vessels which bleed are seized with catch- forceps, and closed by torsion. After the bleeding in the abdominal wound OF THE DISEASES OF WOMEN. 511 Fig. 207. has completely ceased, the peritoiia-uni is lifted between two pairs of forceps and incised. This incision is made at first from four to six inches long ; generally the abdominal wall is incised to somewhat greater extent. The hand is then again cleansed, and passed under the abdominal walls, making them tense for further division. The cut is to be made of what- ever size is required by the individual case. The absolute length of tlie incision seems immaterial ; but if it is too small it may hinder the operator very much.^ Second act of the operation : delivery of the tumor. Tumors which are not adherent, and are of moderate size, can be easily lifted out by means of the hand introduced into the abdominal cavity. In other cases they may be extruded by pressure of the hands laid on the surface of the abdo- men externally and inferiorly, or it may be pushed upward from the vagina. Larger tumors can frequently not be delivered without diminish- ing their size. For this purpose many operators puncture the cvstomata with a trocar, or with other similar instru- ments. In the trocar of Spencer Wells (Fig. 303) the stilet is withdrawn after the puncture, so that its point is concealed in the canula. The cyst wall is then seized w^ith the clasps on the outside of the canula, so that it can be drawn out on the latter. As many others do, I only make the tumor smaller when it cannot be delivered undiminished ; then I no longer use the trocar for puncture, but thrust the knife into the part of the cyst which presents, while my assistant presses the abdominal wall against the surface of the tu- mor, and thus as far as possible prevents the escape of fluid into the abdominal cavity, although I do not attach the greatest importance to the latter fact. When sufficient fluid has run off, the puncture is again closed with an ano- static forceps, and the tumor is delivered with the assistance of a \'ulsellum forceps, or pushed out by pressure from the vagina, which is applied by an assistant. Very frequently the abdominal walls applv themselves so accurately to each other, after the tumor has been pulled out, that the intestines have no disposition to press forward, and only the pedicle of the tumor appears in the abdominal Clamp of Sp. Wells. ' I huve used this table since 1SS4. It was exhibited in the exhibition of the Naturforscher, in 1SS6. The table is of metal, and can easily be kept aseptic. The trap.door allows any kind of bandage to be easily applied after the completion of the operation. If the surgeon prefers to operate standing, it is only necessary to make the legs of the table longer. Then he may also work sitting on a stool between the legs of the patient. 512 PATHOLOGY AND THERAPEUTICS Avound. In other cases the assistant can easily push the intestines back- ward and close the abdominal wound tightly around the pedicle by pres- sure. (In regard to more extensive prolapse of the intestine, see below at page 517.) Third act of the operation : treatment of the pedicle. a. When the stump is to be treated extra-peritoiieally ^ the pedicle is unfolded and seized in a clamp (Fig. 207).' Above the clamp the pedicle is either burned ofl' with a hot iron or Pacquelin, or it is cut ofl' and the incised siu'face is made into an eschar with a potential cauterv. The clamp with its contents is then fixed in or over the abdominal wound. An old method of doing this is that given by E. Martin, in 1852 {loc. cit.) ; for the latter methods see Spenxer Wells and Hegar {loc. cit.). b. The intra-peritoneal metJiod is at present far more frequently used, and to-day it must appear to be the only proper one, since it is the only one which gives the operation an immediate termination, and restores the parts to their natural condition so far as this is possible, so that no particular process of healing the stump of the pedicle is necessary ; and on the other hand there is no traction or dis- placement of the parts in the abdominal cavity. To do this the pedicle is unfolded and tied off in small sections with strong ligatures, which may be applied with aneurism needles or with common needles. The inclusion of large masses in the ligatures is to be avoided, since other- wise, when the pedicle is cut across, the parts at the edges, and especially a part of the peritonteum which has been incised, easily slip out of the ligature. As a rule tlie pedicle is so tied as to include all the structures of which it is composed ; Schroeder {loc. cit.) recommends the ligature of the vessels alone. Th. Keith first seizes the pedicle with a provisional clamp, burns it off thoroughlv, cauterizes the stump, and drops it without further ligature."*' The tube is usuallv removed with the tumor ; therefore a ligature is to be carried around the tube also, at an appropriate distance from the uterus. This special ligation must be carefully performed in order that tubal contents, which mav be purulent, may not pass into the abdominal cavity. Then the tumor is cut off with the scissors or the knife, the stump is obsen'ed for a moment, to see if it remains entirely dry, and if not it is again ligated with deep ligatures eft masse. Besides this simple procedure, and the above-mentioned charring of the raw surface of the stump, another method is frequently employed, by which the stump is completely invested with peritonaeum. By means ' See some of these clamps in Olsliatisfii, Krankli. cIlt Ovarien, p. 2+5 el seq. - Lancet, April 15, 1S76. OF THE DISEASES OF WOMEN. 513 of a running catgut .suture the stump can usually be covered with the peritoniEum on its external surface, which can be freely pulled over its edges. Where the stump is thick, this procedure is to be recommended. In all cases great care must he Jised that the remainder of the stamp above the ligature be not too small. It shrinks considerably, imme- diately after the separation of the tumor ; thereupon the ligatures get loose, so that in some cases immediately, and occasionally some time afterward, haemorrhages occur, which are extremely dangerous. If the bleeding ceases, the hand is introduced into the abdominal cavity in order to examine the other viscera. If the latter are healthy, after looking at the pedicle again, the threads are cut oft', the stump is dropped, and a sponge is passed in to show whether there is any fluid which has run into the pouch of Douglas. If this remains dry, the fourth act of the operation ., the closure of the abdominal cavity., follows immediately. A large flat sponge, or a clean piece of linen, is laid under the abdominal wound, and the latter is closed above this, all except the two middle sutures. The deep sutures, wdiich are introduced for this purpose, enter above two-fifths of an inch from the incision in the skin, pass through the whole thickness of the abdominal wall, and emerge as closely as possible to the edge of the incision in the peri- tonaeum ; then on the other side it enters at the same distance from the edge of the peritoneal incision, and is brought out two-fifths of an inch from the edge of the wound in the external skin. Many operators immediately tie each one of these threads tightly ; others first put in all the threads. If the upper and lower parts of the wound are united as far as the mid- dle, the two or three sutures needful to close the middle part are inserted. Before these are closed, however, the sponge which lies imder the abdominal wound is withdrawn, a sponge on a handle is again carried to the bottom of the pelvis, and finally, if the abdominal cavity no longer contains blood, and the air has been discharged by pi'essure from both sides, these middle sutures are also tied ; between the deep sutures some superficial ones of silk catgut or metal are inserted for accurate adapta- tion of the abdominal skin. In regard to the various kinds of sutures which have come into use for closure of the abdominal wound, see Hegar and Kaltexbach {loc. cit.). I insert, on the average, eight to twelve deep silk sutures, and between each of these one or two superficial ones of catgut. Fifth act of the operation : dressing the abdominal zcound. After most operators gave up the so-called strict Lister dressing, many jjassed to the simplest conceivable kind of dressing after ovariotomy. Many place strips of adhesive plaster transversely across the abdomen, 5^^ PATHOLOGY AND THERAPEUTICS between the sutures, after sprinkling iodoform on the wound ; and then thev cover the abdomen with some layers of gauze or cotton loosely laid one on the other. After the abdomen has been cleansed again, T place a piece of silk protective over the abdominal wound, and lay upon it several layers of salicylic cotton, which is held in place and moderately compressed by roller bandages of gauze. These bandages, which are squeezed out of carbolic water, when they dry become a very firm dressing, which fits closely the shape of the body without materially annoying the patient. Fig. 208. Stretcher and rolling trundle for patients, according to Frati Horn. Now the patient is enveloped in a blanket, — which must be fresh for each case, — and is carried to the bed. For tliis purpose I use a stretcher supported on wheels (Fig. 3oS).' With this tlic patient may be carried as in a rolling chair, and brought through the warm corridors to her chamber. In her bed, which does not need to be isolated, the patient has a large ice-bag laid on her abdomen, and warm jugs placed at her sides, and then she is left under the charge of her nurse. Such a simple ovariotomy requires, from the opening of tlie abdominal walls until com- pletion of the dressing, as a ride, only froni eight to ten minutes. Complicatiotis. — Each of the various acts of an ovariotomy may take a course materially different from the one described above, and each may have complications peculiar to itself. ' See Frau /font's exhibition, Naturforschervers., Berlin, iSS6. OF THE DISEASES OF IVOMEJV. 515 1. In the first place, the abdoininal walls sometimes ofTer very annoying difficulties; not only if the mass of fat is immoderately devel- oped, but also when there are various layers of fat, which are developed between the muscles and fascia, and finally lie in front of the peri- toneum ; thereby the opening of the abdominal cavity may be rendered very difficult, and great caution may be necessary, that the fact be not overlooked that the abdominal cavity has already been opened, or that a very fatty omentum is being cut through, or even that coils of intestine may come in the way of the knife. In such cases I have found some ben- efit in prolonging the incision, and thus being able to open the wound wider ; for the rest, I cut between two forceps what I have lifted up, and seek to open the abdominal cavity as soon as possible. It is compara- tively rare that difficulty is caused by considerable hcemorrhages from vessels in the abdominal walls which have to be controlled by tortion or ligature. 2. If the abdominal cavity is opened, the progress of the operation is often impeded, in particular by adhesions of the surface of the tumor with the neighboring parts. These adhesions can usually be easily sep- arated as far as concerns the posterior surface of the anterior abdominal walls., and there is not generally any considerable bleeding from the divided surfaces. If a solitary vessel here bleeds more decidedly, it is to be separately ligated ; if surfaces bleed, a suture can be used with advan- tage, although with some inconvenience, by which the bleeding surface is sewed around with one thread from four sides. If then this thread is tied, this place rises above the neighboring parts like a fleshy lump, sur- rounded by the encircling thread ; the haemorrhage ceases. Adhesions XV ith the intestines always require extremely careful sepa- ration, which of course must be performed at the expense of the tumor. If, then, fragments of tumor remain attached to the intestine, these masses can be ligated, and thereby rendered innocuous. If, in spite of every care, the serous covering is injured, or if, as I have often seen, even the muscular coat is torn, there is often very great difficulty in even stopping the hasmorrhage, and yet more in diminishing the rent and making it safe. In such cases 1 have brought the edges of the serous coat together with the shoemaker's stitch, or, where that was impossible, I have controlled the parenchymatous bleeding by touching the spot with diluted solution of liquor ferri, or with oil of turpentine. When the vermiform appendix is adherent, I generally make short work of it, for if it cannot be separated very easily, I simply ligate it and cut it off. In case any injuries penetrate all the coats of the intestine, of course the latter must be closed immediately. 5i6 PATHOLOGY AND THERAPEUTICS Adhesio7is vjith the liver are quite rarely observed. I remember par- ticularly a case in the practice of my father, in which the haemorrhage from the torn liver was controlled by touching the spot with liquor ferri, and in which recovery then proceeded without disturbance. It is very much more difficult to treat adhesions when they are in the lesser pelvis^ whether it be that the peritoneal covering of the latter is united with the surface of the tumor, or that the formation of the pedicle proves to be very short and inextensible, so that the insertion lies in the lesser pelvis. It is only seldom that the adhesions cannot be immediately separated by tearing away the tumor, and it is surprising how often there is no bleeding from such a sundered siu-face. Where haemorrhage oc- curs, and does not soon heal spontaneously, especially when the tumor is developed under the serous coat, two methods may be employed for avoiding further loss of blood, and for rendering the raw surfaces innocu- ous, — either the raw surface is sewed together deep in the pelvis by a shoemaker's or a mattress stitch, and then the contiguous uneven edges of the serous coat are brought over the exposed surfaces, or even the uterus itself is used for this purpose by being sewed on there (I have often enough tried this method, and I can recommend it where there are no hin- derances to its employment) ; or the bleeding surface may he cauterized with diluted liquor ferri and draifiedprophylactically into the vagina fro?n the floor of the space of Douglas^ or from the bottom of the cavity which has been made; then the space which has been left with its torn and secreting edges is closed from above by a suture^ or the closure from above is left to the uterus and the i?ttestines^ which are replaced^ and then it is sufficient to lead away by drainage the secretions of this raw surface. Drainage at this place can be very easily accomplished. I thrust a long dressing-forceps through the floor of Douglas' pouch into the poste- rior vault of the vagina, which I put on the stretch b}- two fingers intro- duced into the vagina. The dressing-forceps is carried out into the vagina, is armed with a drainage-tube, and is then drawn back. I employ the same method of prophylactic drainage in those cases in which the tumor has developed subserously ujider the pelvic perito- nceum and veiy large cavities remain zuith ragged walls. Then I split the peritonaeum over whatever part of the tumor is most easily acces- sible, enucleate the latter, secure its pedicle if necessary, and now, after draining the vagina into the cavity left by the tumor, and after cutting away the superfluous walls, I close these ofl' from the peritoneal cavity by a suture. 3. Prolapse of coils of intestine during the operation is described OF THE DISEASES OF WOMEN. 517 as a very dangerous complication. My own experiences do not agree with so serious a view of this so-called complication. Whenever the intestines cafz only be repressed with difficulty., and in all cases in which any ligatures or sutures are to be applied deep in the lesser pelvis., the whole extent of the intestine may be taken out of the abdom- inal cavity without any hesitatio?i. In more than ninety per cent, of my operations I have taken the intestines out of the abdominal cavity, laid them on the upper abdomen, and kept them wrapped in a warm cloth wrung out of weak carbolic solution. They remain lying there until the end of the operation ; if the latter is prolonged, a fresh warm cloth is laid over them. The apprehensions which have been suggested by the experiments of Wegner are practically of subordinate importance, at least according to my experience. 4. If both ovaries are affected it is best to remove both at once. Since this involves cessation of menstruation, and of the capacity for con- ception, the question must of course be very seriously considered whether the disease of the ovary which is present may not possibly get well. Simple hydropic follicles may be evacuated by puncture, and even little cysts may be resected and the remaining healthy part of the ovary be spared. Schroeder first resected cystomata also out of the ovarial tissue, which was otherwise quite healthy ; the women kept on men- struating. I also have afterwards frequently so operated, and likewise SCHATZ.^ The possibility and innocuousness of such a method is indubitable. If only a remnant of the gland remains, the women not only menstruate, but may also conceive, as I have observed in two cases. One of these women had been married several years, but was still sterile when I removed one ovary in a state of cystomatous degeneration ; at the same time I punct- ured a very extensive hydropic follicle in the other remaining ovary. Since that time I have twice attended this woman in labor. In the other case I removed the left ovary, which was affected with chronic oophoritis, together with the hydropic left tube ; then in the right ovary I resected an hydropic follicle with the surrounding parts, which were indurated ; the patient became pregnant, but aborted. I have attempted often enough to leave in place such an ovary which seemed only slightly affected, while the other was degenerated ; and I did this in the hope that it would be possible to keep this ovary innocuous by longer treatment. My own obsei-vations concerning the later condition of these structures 1 Centmlblntt f. Gyn. 1SS5, Nr. 23. 5iS PATHOLOGY AND THERAPEUTICS are not very fovorable to such a conservative method of treatment. Only too often the remaining ovary soon became diseased, with severe symp- toms similar to those occasioned by the one which had been removed, so that in order to save the patient I was obliged to remove the new tumor by a second ovariotomy. These women, therefore, certainly did not gain much by such a conservative method of treatment. I by no means wish to say, however, that I always remove both ovaries when the affection of the second one is very slight : but it seems to me that the question must be very seriously considered, wdiether it is permissible to leave behind ovaries in which little cystomata already appear, or in general those which lie with diseased tubes in a diseased peritonteum. I am disposed to answer such a question in the negative, since already in seven cases I have finallv been obliged to remove these structures by a second laparotomy-, because they occasioned the severest disturbances. 5. Formerly very particular importance was attached to the cleans- ing of the peritonaeum — the toilet — before the closure of the abdominal incision. I have departed widely from this plan. In the last three hun- dred laparotomies I have cleaned out neitlier blood, nor simple cystic contents, nor pus, w'ith that thoroughness which I formerly employed, nor j'et have I poured in whole basins of carbolic solution for washing out the abdominal cavity. I only swab out large clots and pools of fluid ; everv- xhing else is digested without reaction by the peritonasum, if the opera- tion has been aseptic. It seems to me much more important to teriniiiate the operation qicickly^ than to ivash out every fold of that most impor- tant organ of absorption^ the peritoncctun. After-Treatmext. As long as tlie patients vomit or have even nausea or eructations they must fast completely. During this time morphine is given abun- dantly, and evacuation of urine is accomplished by the means of a catheter. As soon as vomiting ceases, and all nausea disappears, the convalescents, who usually suffer from an immoderate thirst, are given by teaspoonfuls coffee, milk, wine and water, lemonade, and even strong ^vines and champagne. Afterwards, if this leads to no vomiting, the}' are nourished with bouillon^ milk, and soup. As a rule the intestines began to act between the second and the fourth day. A favorable sign is an early spontaneous discharge of flatus ; if this does not occur by the third day, a suppository for stimulating the bowels, and, if necessary, also a rectal tube, is applied ; the gases are then often discharged with a loud noise. OF THE DISEASES OF WOMEN. 519 Ow the fourth clay, after removal of the ice-bag, a laxative is given, and for this I generally let them take castor-oil in capsules, in coflee, or in the foam of white beer. It is only seldom that this draught is not digested and is vomited again. Then I either give a tea of senna leaves or Carlsbad salts, or especially those medicines v^diich have previously excited regular defecations w^hen used by the patient. Enema ta often cause vomiting, and therefore I seldom use them. When the bowels have been moved, nourishment with meat begins. This is given in abundance, especially birds, with milk, wine, and whatever else they like. Fig. 209. Fig. 210. Anterior Plate. Posterior Plate. Beely's Abdominal Bandage. The dressing" first is examined between the eighth and the tenth days ; then all the sutures are removed at once, the abdominal \vound is sup- ported by strips of adhesive plaster, and a laver of cotton pressed upon it by a tight bandage made of a towel. Thus the patients remain lying several days. They first sit up in bed between the eleventh and thirteenth days, and get on their feet again according to the return of their strength. For support of the abdomen after laparotomy, the patients receive a firm abdominal bandage, which Dr. Beely ^ has made at my request (Figs. 209 and 310). In the majority of cases healed by first intention, I have no hesitation in letting them go home from the sixteenth to the eighteenth 1 Deutsche Med. Wochenschr., iSSo, Nr. 40. 520 PATHOLOGY AND THERAPEUTICS day. Women who are passing through a slower convalescence because their strength had been previously greatly reduced, or those who have to make a long journey to reach their home, must of course first be strengthened by walking in the street, and by riding out. Lying quietly in bed apparently increases the tendency to the forma- tion of thromboses after laparotomy in women who already have been greatly exhausted by their disease. Since I lost a patient of embolus the first time she stood up after ovariotomy, and likewise one who had already recovered from an operation or myoma the first time she went out^ I like to have the patients lie in bed until the thirteenth or fourteenth day. Various disturbances occur in this normal course of after-treat- ment, and the method of overcoming these can hardly be similar for all cases. Against one series of such disturbances, treatment is even to-day to a certain extent powerless. According to my experience the treatment of septic infection is almost completely unavailing. Although the attempt is always to be made to combat such infections, none of the means at present known can claim to safely and thoroughly overcome this most bitter enemy of laparotomy. Just because the peritonaeum is such a fine breeding-place for the septic germs, the most extreme thoroughness of prophylaxis will always be the only means of excluding septic infection- Most freqiiently sepsis occurs after laparotomies in the form of peri- tonitis ; therefore it is natural to remove the peritonitic exudate, the sup- posed carrier of the septic virus, or at least to disinfect it by cleaning out the abdominal cavity ; that is, by some form of drainage. A further consequence of this idea was the proposition to use drain- age prophylactically in all forms of ovariotomy, even in the typical cases (Sims' loc. cit.). I hold this proposition to be very unfortunate, and with Hegar and Schroeder I also urgently advise against introducing an unnecessary and injurious factor, and a danger of further infection by using drainage in simple cases. Only in the cases which have peculiar complications, where purulent, or at any rate profusely secreting, raw surfaces must be left behind, does the sort of prophylactic drainage which I have described above seem to me to be justified. Moreover, it is not possible to obtain permanent discharge from anything more than the space in the smaller pelvis, or, better said, from anything more than the most ' immediate neighborhood of the drain, since the adjacent parts, and especially the coils of intestine, rapidly apply themselves ai^ound the drainage-tube. Secondary drainage is of no certain advantage, according to my experience, in cases of pronounced septic infection and of extension of OF THE DISEASES OF WOMEN. 521 the disease widely over the peritonaeum, but it can occasionally be em- ployed with success in the very beginning of the development of septic infection. The cases of this nature in my own practice were ones in which an abundant secretion had been exuded soon after ovariotomy, apparently from the stump, or from the surfaces where adhesions had been separated, or where there was an extravasation which that power- ful absorptive surface, the peritonaeum, was vuiable to take up, for no apparent reason. These patients then immediately gave the impression of profound prostration ; the pulse rose rapidly without corresponding elevation of temperature, a sensation of distention was felt in the abdo- men, and in some cases there was very early an abundant vomiting of greenish fluid. I have several times observed the recovery of such women after abundant vomiting or pasty diarrhoea. I presume that in these cases the absorption and the elimination from the body of the exu- date proceeds with these severe symptoms. In other cases, however, these symptoms of absorption do not occur, and therefore, in a few cases, assuming that the power of absorption is here insufficient, under such circumstances I resolved to drain secondarily. To do this I did not open the abdominal wound again, for, as I did not consider that the patients had general sepsis and were in a hopeless condition, I re- garded it as very important to leave the reparative process in the abdomi- nal wound as undisturbed as possible. In such cases, under superficial anaesthesia I divided the vault of the vagina behind the uterus to the periton£eum ; through the latter I thrust a dressing-forceps, and with the latter I pushed a drainage-tube through the opening. Haemorrhage which resulted from the wound was controlled by stitches. In two cases there was no abundant discharge of fluid immediately, but within a few hours a very profuse secretion appeared, and after that the recovery went on normally. I was not so fortunate in other cases, — ^-g-i twice after operations for tubal sacs, — and therefore I will only mention this measure as something which may be used in case of need, and will recommend it for suitable opportunities. Where drainage is used, either the drainage-tube comes away on the third or fourth day, or it is removed at this time. Although the women may have experienced no trouble at all dm^ing the first days, yet about this time they feel a peculiar dragging pain in the umbilical region, and this is always a sign that the tube should be removed. It comes out with gentle traction, and I have never seen any disturbances in the pro- cess of healing in the apertui"e which it leaves.^ 1 For the drainage recommended by Hegar see Volkiiiaiin's Vortrage, Nr. 109, and Centralblatt f. Gyn. 1S82, Nr. 7. 522 PATHOLOGY AND THERAPEUTICS If the septic process has proceeded further, if the pulse has become very rapitl, and the temperature and respiration have risen, as is usual in sepsis, I have never seen the patient saved, whatever measures I mav ha\e employed. Among the other complicatiofis of convaiesccfice after ovariotomv are }et to he mentioned paralysis of the intestines, secojzdarv Jiccmorrhagcs^ amX formation of abscesses in t/ic abdominal xcalls. I. Torpor of the peristaltic motioti \\\^\^ gaseous distcjitioti of the abdomen in itself causes great sufiering ; but it appears that patients after laj^arotomy are particularly subject to such disturbances. The motions of the intestines, which occasionally come on with great violence, occasion very severe pains, so that the patients become very restless until there is a discharge of gas, or the contents of the intestines pass away per anum. Not infrequently the temperature rises rapidly meanwhile, and falls again as soon as the intestine is emptied.^ In certain cases, for 'reasons which are not clear, the peristaltic motion does not take place. The fact that the intestines have remained outside of the abdominal cavitv during the operation has certainly no influence in the matter, according to mv very extensive experience in this respect. I should rather regard those cases as disposed to this condition in which the abdominal walls have become abnormallv lax from former pregnan- cies, or from distention bv the tumor. The patients sink away rapidly under this subparalytic condition of the intestines, the frequency of the pulse increases without elevation of the temperature, vomiting comes oi\, especially of masses stained with bile, and after a long agony deatii ensues. At the autopsy no trace of peritonitis or sepsis is found : there is hardly even a suspicious reddening of the raw surfaces, and culture experi- ments reveal no characteristic cocci. In such cases I have used all kinds of purgatives per os and per anum without anv certain result. The best effect ^vas obtained l)v niassagc, especially when the abdomen was pai?ited zvith oil of turpenti?ie, and h\ faradisation ; as soon as intes- tinal motion ensued, as the result of these measures, the patients were materialh' relieved. With the first subsequent discharge, the anxiety disappears, the fre- quency of the pulse is diminished, the vomiting ceases, and now convales- cence goes on without further disturbance. 3. Hcemorrhag^e. in consequence of loosening of the ligature on the stump, as far as may be learned from the cases published, and from an observation which I made as assistant at an operation which was performed by one of my colleagues, leads so rapidlv to death that every treatment ' CDiTipare :iUn E . Frniiki'!, X:iturl'irsclievers. zu Magdeburg, 1SS4. OF THE DISEASES OF WOMEN. 523 seems quite impossible. The pro2:)er thing to do in such a case would be to open the abdominal wound, and to find and secure the stump ; yet the success of such a procedure appears to me very problematical. Care must be taken to avoid confounding such cases of apparent internal haem- orrhage with those of carbolic poisoning, of which latter I have seen only one very striking case. In this woman I had removed cystic ovaries on both sides, by a very simple and rapid ojoeration. In the course of the afternoon collapse came on, the pulse disappeared, the respiration becom- ing very panting, the hands grew cool, the temperature of the body rose ; the patient furnished a picture of extreme anasmia. I could not believe that the ligature, which had been placed on the pedicle with great care, had vielded, and I determined to administer restoratives and to await fur- ther developments. As great restlessness then came on towards evening, I gave the patient an injection of morphine, and after she had slept in consequence of the same, the pulse reappeared, the clammy sweat of the skin departed, the temperature of the skin became equal on the trunk and on the extremities, and grew normal ; the patient recovered, while the urine acquired the well-known discoloration due to carbolic acid. There was then a very easy convalescence until the time of discharge of the patient. I mention this case to warn against reopening the abdomen too early, on the assumption that there is a haemorrhage from the pedicle. 3. Abscesses of tJie abdominal xualls are found particularly where the latter are very fat, and also where they are violently stretched during the operation. Generally that end of the abdominal wound suppurates which runs down to the ino?zs Veneris. Usually these abscesses cause light pains in the abdominal wound between the fourth and fifth davs, and on the sixth and seventh days they cause a moderate rise of tempera- ture in the evening. In such cases the dressings must be taken oti' imme- diately. I then use a dry treatment of the wound, as I have described above. Often the abscesses only soften down very gradually. ^^':th severe sufferings and elevations of temperature there is a discharge after several days. In these cases I have always found the peritoneal wound healed, and have seen these abscesses limited to the external abdominal wound, unless they were imnecessarily irritated. With a quiet position of the patient, simple and light com2:)ression with strips of adhesive plas- ter, and frequent application of simple salicvlated cotton, these abscesses dry up ^'ery rapidly, unpleasant as they may appear at iirst. I have for- merly tried to disinfect such abscesses with nitric acid, iodine, liquor ferri, carbolic acid, etc., and thus to stimulate them to heal ; yet I have latterh- given this up entirely, after having on some occasions observed cxtcnsi\e 534 PATHOLOGY AND THERAPEUTICS destruction of neighboring parts whicii iiacl apparently healed properly. I only use these medicaments if the granulations seem too exuberant. As a rule, under such simple treatment, even the largest abscesses require only two weeks to dry up completely, so that the getting up of the patient is only delayed by so much. Up to the present time, out of two hundred and eight ovariotomies I have only seen an extensive formation of abscess in the abdominal wall in one case, that of a highly scrofulous individual, who also suffered from a catarrh of both pulmonary apices. I had here performed ovariotomy in order to remove an intraligamentary tumor with purulent contents. Convalescence went on very favorably until the end of the first week, then there appeared symptoms of the formation of an abscess in the abdominal walls. Suppuration proceeded, in spite of the above-mentioned treatment ; I made counter-openings and cauterized the granulation ; baths, preparations of iron, change of air, and continued cai'eful attention were not wanting. Even after fourteen months there were secreting surfaces in the abdominal wound ; yet later her general condition was greatly improved, so that the local appearances became much better. I had a similar experience after the enucleation of a myoma. At the end of the healing of the abdominal wound there sometimes remain some suture-tracks, or some small granulations in the line of the wound itself; these I generally heal by cauterizing them several times with tincture of iodine ; but even here great care must be taken lest the tender cicatrix in the neighborhood be destroyed by the cauterization. I observed a peculiar case of delay in the healing of sucli suture- tracks in the above-mentioned case of carbolic poisoning. After the patient was discharged, a pious parish nurse worked over a moist suture- track with a knitting-needle, until an abscess was formed which reached down to the vault of the vagina ; through this cavity I pushed a dressing- forceps out into the vagina, and inserted a drain, which in four weeks led to the apparent closure of the fistula. The drainage-tube was removed, but had to be inserted again after three weeks, and to remain eight weeks longer before there was complete recovery. After this second insertion of the tube there was dribbling of urine for a short time, wiiich disappeared without further treatment. I advise the patients, after their discharge, to wear the above-men- tioned bandage for months, to refrain from severe work, and to lie down frequently during the day. Even under such cautious conduct, sepa- ration of the edges of the abdominal wound and development of a hernia through the latter cannot always be avoided. In such cases, of course, there is nothing to do except to continue to wear a bandage with a OF THE DISEASES OF WOMEN. 525 suitable pad. Attempts at operative assistance have, as far as I know, as yet always given doubtful results.^ In performing laparotomy a second time^ I have latterly always ex- cised the old scar, which has only a slight disposition to heal, and I have treated thus also a large abdominal hernia remaining after an exploratory incision which had been made by another surgeon. The new wound healed by first intention, and still holds after more than a year's time.' The conira-indications of ovariotoiny have, to be sure, been more and more limited in the course of late years ; but we must, nevertheless, always respect certain limits of the operation as insuperable. Besides the cases o{ advanced malignant degeneration of the tiitnor and of the peritonceuvi., the severe constitutional diseases and those in which the cachexia depetident on the tumor excludes all operations., or the necessity of inflicting very extensive injury., makes interference seem impracticable., the general adhesion of the tumor may compel the abandonment of the operation. In such cases of adhesions., the wall of the tumor may be united with the abdominal wall in a continuous dense mass, so that to separate it would make a large portion of the serous coat raw. Where there are such adhesions it has been advised to ligate " the larger vessels which nourish the tumor. Where this is possible, I should certainly consider such a proposition as plausible. More usually it is necessary to be content with the simple evacuation of the tumor, and then the proposed ovariotomy becomes a sort of explor- atory incision. These exploratory incisions ., M \hQ.y are made sufiiciently aseptic, are quite free from danger, just as also the simple exploratory puncture, in itself, is regarded by many as of little danger. As far as I have observed, in these cases the danger arises rather from collapse, which very seriously threatens these women, who are greatly weakened bv the growth and the extension of their tumor. Decomposition of the wall of the tumor can usually be avoided, and if such tumors are drained again into the vagina, and care is taken for proper disinfection there, after closure of the abdominal incision, a material alleviation of the condition of the patients may be obtained. In the cases of this kind which I have seen, however, the women have sunk luider the advanced cachexia sooner or later after the evacuation, although usually the wounds and the cysts were in a decidedly aseptic condition. It does not seem to me to be verv advantageous in these cases to sew the cyst wall into the abdominal ^ Several successful cases of operation for the cure of ventral hernia after laparotomy have been reported very recently; for two cases by the translator see " Annals of Gynaecology-," \'oI. II., Decem- ber, iSSS, p. 157. A third has since been performed by him with satisfactory results. - Heffar and Ko/tenbacli, ed. iii., S. 336. ^26 PATHOLOGY AND THERAPEUTICS wound, ami to keep the latter in open communication with the sac, in order to supervise suppuration of the contents of the cyst. It will be better to close this abdominal cavity, and if there seems to be danger that a serious condition of things will develop in the sac, drainage should be established between the latter and the vagina. In cases in which extirpation is impracticable, an attempt must be made to alleviate the sufferings of the woman by evacuation of the cyst, either by a simple puncture, sometimes followed by injection of iodine, or by a wide opening and drainage of the cavity and by obliteration of the latter by suppuration and granulation of the cyst. Both procedures have serious disadvantages ; and although in single cases simple puncture may bring about the cure of the cyst, — as, for example, in hydrops of the Graafian follicle, or of the cvsts of the broad ligament, — or if occasionally the cysts are obliterated, yet in the majority of cases the decomposition of •■he contents, or of the internal surface, can hardly be avoided, and the patients perish of collapse. But even when recover}- ensues after such in- complete operations, the further prognosis of these cases always seems very bad ; for these cystic remnants clearly have a disposition to grow again after a longer or shorter period of quiescence, as well as a tendency to malignant degeneration. Frequently, then, yet another attempt has been made to radically remove the masses, which were apparently inoperable. In other cases the patients advance towards the miserable end by slowly wasting away. This Ijeing the case, as thorough a removal as possible at the first operation should be urgently recommended. Formerly laparotomy was greatly dreaded and avoided as long as there was any suspicion of fresh i)iJiajnmatory processes^ and even chroftlc ones; and the subacute exacerbations ivhich are so frequent in these cases were anxiously avoided, hi both classes of cases this fear seems tinzvarranted by presefit experience. It is precisely the recent and non-septic peritonitis which is usually stopped at once by laparotomy ; also in chronic and subacute cases the removal of the seat of disease almost alwavs leads to recovery. In fact, the final means of curing these chronic maladies must not infrequently be sought in laparotomy. With the re- moval of the diseased organs and the disinfection of the seat of disease in the peritonaeum, speedy and complete recovery is then usually obtained. My own experiences in this respect coincide completely with those of Keith, Schroeder, Hegar, and Olshausen.^ If the pus is cleaned out, and the abdominal cavity is disinfected, the temperature falls immediately ; and in precisely such cases this is folhowed with surprising frequency by an easy convalescence. ' Compare die Krankh. d. Ovar., iSS6, S. 399. OF THE DISEASES OF WOMEN. 527 6. — Castration. The removal of the healthy ovaries for the purpose of the suppression of ovulation and menstruation is called castration. This great service of introducing this procedure into the practice of our time belongs to Hegar/ who, in unison with his pupils,^ by thorough studies brought tliis question scientifically and practically to a satisfactory conclusion. At the same time with his first operation were performed the first ones of Battey,^ Trenholme,^ and Peaslee.^ The former of these especially has obtained a literary priority by the time of his publication, which, to be sure, was injured by the inaccessibility of the journal which he used. Among the numerous later authors who have written about castration Laavson Tait ** has acquired a unique position, both by the amplitude of the indications for castration which he accepts, as well as by the individ- uality of his operating, and by his success, and finally by the theory which he has advanced concerning the significance for the sexual life of woman of the ovaries in comparison with the tubes. In the second edi- tion of Eulenburg's " Real Encyklopiidie," in the article on castration, I took the ground that the cases of extirpation of diseased ovaries should not be considered as belonging to this chapter, but that they should be classed as ovariotomies or oophorectomy. If then we limit the term " castration " to the extirpation of healthy ovaries, the question of perform- ing the operation can be better discussed in its full significances, and its value for practice can be better determined. In the seventh edition of his text-book, and in his essay in 18S6, Schroeder has adopted this opinion. If both ovaries are completely I'emoved, — I. Menstruation ceases; bloody discharges indeed occur occasion- ally, sometimes immediately after the operation, sometimes in longer intervals, which are usually irregular ; if normal cicatrices are formed on the stumps of the ovaries menstruation ceases, at any rate as a normal 1 A. Hegar, die Castration der Frouen in Volkmann's Klin. Vortr. Gynak., p. 42, Leipzig, 1S7S. — Extirpation of normal ovaries and of those not degenerated into large tumors, Wiener Med. Wo- chenschr., 1S7S, Nr. 15, and Centralb. f. Gynak., 1S77, Nr. 17, and 1S7S, Nr. 2. — Castr.ation, an essay before the gynsec. section of the Naturforschervers zu Baden Baden, Centralb. f. Gynak., 1S79, ^''- 22. — Die Operative Gynakologie. 3d edit., iSSo, §§ 55-60, with citations there given. — The connection of sexual diseases with nervous maladies and castration for neuroses, 1SS5. " Staid, d. Med. Wochenschr., 1S763 Nr. 50. — Tauffer, Pester Med. Chir. Presse, 1S7S. — Turban and Wiedroxv, D. in Freiburg. — Taiiffer, Zcitschr. f. Geb. u. Gynak. ix. — Schmalftiss, Arch. f. Gynak. Xxvi., S. I. — Compare Operat. Gynak., cd. iii., S. 346. 3 Battey, Atlanta Med. and Surg. Journ., September, 1873 and 1S73. Anier. Praclit., 1875. Amcr. Gyn. Soc, JS76 and 1S77. * Amer. Journ. of Obstetr., 1S76, ix. p. 702. T' Transac. of Am. Gyn. Soc, 1S76, p. 349. " Brit. Med. Journ., 1S79, No. 9S4, p. 730. 52S PATHOLOGY AND THERAPEUTICS finiction. According to my observations lia;morrhages like menstruation, and generally irregular as to recurrence and intensity, occur in those cases where the cicatrices have become a source of peritonitic irritation, or other diseases or new-growths have developed (compare the tables which follow). 1 have frequently observed peculiar differences after operations for myoma and salpingotomies, yet inferences cannot yet be drawn from them. 3, The uterus shrmks^ as in the normal climacteric ; at the same time the other portions of the genital canal go through an analogous involu- tion, and the subjective symptoms occur about which women complain at that time, such as rushes of blood, palpitations, and perspirations. 3. The "vooinen become sterile without therefore being incapacitated for coition. "Y^xQ general zfzdication^ as established by Hegar, reads about as fol- lows in the third edition of his " Operative Gynaecology " (p. 335) : "'Cas- tration is to be performed where there are anomalies and diseases which involve immediate danger of life, or lead shortly to a fatal issue, or have as a consequence a progressive sickness which hinders enjoyment of life and occupation. This presupposes that other milder medical treatment either gives no expectation whatever of success, or has been used unsuccess- fully, while ablation of the ovaries removes the malady." If we accept the above definition of castration, the operation for small ovarian tumors and small cystic degeneration of follicles and stroma are not included in the special indication of Hegar ; these belong to the indications for ovariotomy. Likewise the sixth of Hegar's indications — viz., chronic inflammation of the tube, of the pelvic peri- tonaeum, and the parametrium, whether arising primarily in the ovaries, or maintained by ovulation — is to be classed with salpingotomy, and with the treatment of chronic pelvic peritonitis. On the other hand, it is generally acknowledged that castration is intli- cated where there is defect of the uterus^ or xvhere it is entirely -cant- ing^ or ivhere there is atresia of the genital canal luith norjnal function of the ovaries, as well as ivhere there arc conditions of the uterus and the vagina., which prevent the excretiofi of the menstrual fluid. It is comparatively seldom that ovaries are found thus performing their functions where there is a want of development of the genital apparatus. The want of any prospect of recovery in these cases of im- perfect genitalia makes castration seem entirely justified in such cases (compare cases of 4 and 6 of my table). The same is true for atresia, whether congenital or acquired, when there is no further possibility ot treatment (compare Case 3 of the table). The displacement of tlie OF THE DISEASES OF WOMEN. 539 ■ovariesi, whicli has been cited as an indication by man}- American authors, is only in reality to be considered as such if it is itself irreparable, and if it gives rise to profound disturbances. I cannot so unreservedly accept disease of the uterus as an indication for castration. Trenholme first operated in this way on account of myomata, Battey on account of dysmenorrhoea, and Hegar on account of dysmenorrhoea and ovarian neuralgia. By the latter operation diseased ovaries were removed, and therefore it should not be included in the cliapter on castration, according to the above definition. Since that time castration has been performed on account of uterine haemorrhages (A. Martix and Olshausen), and then on account of chronic hyperplasia, with or without simultaneous displacements, versio-flexion, and endome- tritis chronica.' I myself have operated on account of myomata," and on account of haemorrhages which could not be controlled otherwise.^ / 7io%v only consider castration as -wholly warrantable 07i account •of myoma., if the tumor or tumors are small and supra-vaginal ampu- tation offers pectiliar difficulties . If the myomata are more volumi- Tious, I consider extirpation to be the more suitable procedure. For on one hand myomata are by no means safe from degeneration, without consider- ing the fact that the tumors undergo alteration and involution so slowly that the persistent and tormenting sufferings still continue. On the other hand myomata occasionally first begin to grow after the physiological climacteric, so that it must be assumed a ^r /or/' that they would continue to gi'ow after the artificial and premature change of life. This supposition seems to me to be justified by one of my observations (case 3 of the table) . If the diseases of the uterus are incurable in any other way, the extir- pation of the uterus would seem to be the more appropriate procedure. Cases 3 and 5 of my table also show this. Hegar first pointed out certai?i neuroses as a third indication for castration, and these are described by Tauffer and Fehling as those where severe diseases of the ner-oes or mind are connected ivith the sexual functiotis . Hegar at first opposed castration in those neiuoses in which there are no anatomical changes in the sexual organs. Later, how- ever, such cases have been frequently observed ^ in which results which were not unfavorable have been obtained by simple castration, that is, bv the removal of the normal ovaries for the purpose of suppression of men- 1 Heffar, Oper. Gyniik., ed. ii. p. 34S. 2 Cases I, 2, 7, S, 9, 11. ij "f tlio tabic. 3 Case 5 of the table. * Compare Schmalfuss, Arch. t". Gyii. xxii. § 442; Lcpfimann^ Arch. I". Gyn. x.vvi. § i ; SchroJfr, ibid., xxvi. § 57. 530 PATHOLOGY AND THERAPEUTICS struation and ovulation. According to the various isolated observations, also, which are afforded by our special literature in periodical journals, it seems requisite to await further observation before decision as to this in- dication. The prognosis of castration, as far as concerns operation, has become, since the introduction of antisepsis, as favorable as it is in ovariotomies. The prognosis of the effect of castration is to be considered as en- tirely favorable, as far as concerns i?nmediatc results. If both ovaries are completely removed, menstruation ceases, usually at once, or at any rate in a short time, and the climacteric comes on, often, to be sure, with severe sufferings, but often without such ; so that in general, after a time which corresponds to the so-called change of life of normal cessation, the complete disappearance of the menstrual molimina may be anticipated. The prognosis is less certain in regard to the Jinal result of the oper- ation ; concerning this it must be remembered that want of success may- be occasioned by very various circumstances. The healing of the stumps may take a bad course, which is often only evident at a very late period. Adhesions with the intestines, sloughing of the portions of the pedicles, which are beyond the ligatures, discharge of the ligatures, chronic peritonitic inflammations, formations of fistulas, and finally ventral herniae, which are by no means the least of tlie evils, may substitute for the old sufferings nev^' ones, which are no less distressing. Want of success, as far as concerns the original malady, need not be feared in the Jirst g'roup of indications ; in the second grouf., on the other hand, mishaps of this kind are by no means impossible. Especially the haem- orrhages which are occasioned by uterine maladies are affected to a very variable degree by castration, as was observed by the author in a special case, where he eventually had to perform vaginal extirpation of the uterus itself, in order to enable the unfortunate patient to work. The prognosis of this group has been further explained above. The results of castration in neuroses, as given by Schmalfuss from Hegar's material, show that out of ten patients suffering from so-called lumbar spinal symptoms, eight were cured and two were not. Of eight patients, who, besides these lumbar spinal symptoms, suffered from pro- nounced nervous phenomena in various other parts of the nervous system and of the body (such as cardialgia, pressure in the epigastrium, sensation of distention, eructation, vomiting, and globus), six were cured and two were materially improved. Ten were cured and four iinprovcd out of a third category of fourteen cases, who were suffering from very manifold nervous symptoms and a general neuropathic condition, such as rague or distinct pains in almost OF THE DISEASES OF WOMEN. 531 all parts of the body, vaso-motor flistiirhances, vicarious menstruation, symptoms referable to the larynx, stomach, or intestines, spasms, and epileptic attacks. In regard to castration for epilepsy and hystero- epilepsy, results are better where the ovaries are healthy than were those of Leppmann, which were not satisfactory (cases of Fritcii), — one being unsuccessful, two partially successful, and a third not yet decided at the time of the report. In regard to the operation itself, Hegar, in the beginning considered it necessary to have previously felt the ovaries. He himself, and many after him, have, however, ceased to require this condition. The operation, especially in cases of myoma, has certainly been often begun as an ex- ploratory incision, with reference to the removal of a myoma, and castra- tion has been performed only when it was found that the tumor could not be removed. The jDerformance of the operation is quite analogous to that of ovariotomy, which has been described above. Most operators make the incision in the median line. The incision in the flank described by Hegar could only be desirable in cases where the ovaries are felt free by the side of a tumor which has developed up- ward into the abdominal cavity. Law^son Tait makes the abdominal incision so small that he can just introduce two fingers. I cannot bring myself to operate in this way. For although I admit that the smaller the incision the less is the possibility of a subsequent dilatation of the abdominal wound, yet I regard the want of space to work in as a great danger to the safe performance of the operation. Great difficulties may occasionally be encountered in finding the ovaries. If a tumor obstructs the way, I do not treat it by castration, but by extirpating it directly. If peritonitic layers cover the ovaries, I break through them with the fingers, or cut them through, especially if on ac- count of them coils of intestines are implicated in the operation. If intestinal coils cause the hindrance to finding the ovaries, I take out the intestines through the abdominal wound, as described above, without fear and without bad results, and thus I obtain free access to the organs which have to be removed. With the ovaries I generally seize the tube, in so far as the formation of the pedicle is thereby facilitated. I always, however, am particular to avoid including too much tissue in one ligature, particularly in removing normal ovaries. I perforate the basis in the broad ligament in two or three sections, whicli are tied ofi'. In cutting away, great care is to be taken that not even the smallest rem- nant of ovarian tissue should be left behind. Extra-peritoneal treatment of the pedicle has been given up as generally for castration as for ovariotomy. In treating of the latter I ^T,2 PATHOLOGY AND THERAPEUTICS have hereinbefore described the tacts concerning prophylactic drainage, which are also true for castration. Battev, and after him other ojjerators, particularly Americans, have attempted to perforin the operation from the vault of the vagina. In Germany this method has few supporters. If the ovaries are easily movable and not too voluminous they can, to be sure, l)e seized, drawn down, and, after ligation of the pedicle, removed with comparative facility, through an incision in the floor of Douglas' space. But also largei ovarian tumors, solid masses as large as hen's eggs, and cystomata with bloody and serous contents, even those \vhose surfaces were adherent ovei a greater or less extent, have been removed by me through an incision iu the posterior vaginal vault, especially after vaginal extirpation of the uterus, through the opening in the floor of the pelvis which is caused thereby. On the strength of this experience I would warn against the employment of this method without very great practice in operating iu this narrow entrance to the lesser pelvis. Even the search for normal ovaries may encounter great difficulties, especially if coils of intestine come pressing downward. The i^edicle of the ovary must be drawn down rather strongly, and therefore tears easily, or is easily cut through by the ligature ; and if it slip back after the ovary has been removed, there is very great difficulty in tying it afterwards, so that occasionally, in order to control the hemorrhage at all, laparotomy has had to be performed im- mediately. In my own operations, which, moreover, are not to be designated as castrations, but as ovarian operations on account of disease of the ovaries, I succeeded without any complication worth mentioning, and have, to be sure, observed a Aery easy convalescence in all of them. We obtain this also, however, by the abdominal incision. If the symptoms of the climacteric are very violent, sufficient relief is usually obtained by appropriate arrangement of diet, with especial avoid- ance of alcoholic drinks, and by active derivation toward the intestinal canal. In other cases local abstractions of blood from the genitals, either scarifications or more general ones by leeches and cups, usually bring permanent alleviation to the patients, especially if they are repeated at in- tei"vals corresponding to the occurrence of such rushes of lilood and con- gestions, which are frequently periodical. In the following table I have arranged my own cases of castration. In these are brought together, according to the abov^ definition of castra- tion, only those cases in which normal ovaries were removed. Moreover, the cases are not contained in this talkie in which I have removed the normal ovaries, in addition to further operation on the genital apparatus, such as, in particular, the enucleation of niyomata, by the method which I have published, and salpingotomies. OF THE DISEASES OF WOMEN. 533 > S bo o rt a, (C 1) bo £X 5 w i ,X1 -C °T5 ■z. ^ ^ ^ -z. .^ic O.S > ^ -J c 2 E Q W M _0 c « cSDii wJbcbCciTi _ jj 5 P-.3.S S ill < c75 i o u ° -5 <" (DC ^ •— ' ^ 5 ^1 ii iS cZ o cbJO 3i fij a. W 5i< > ^ r: ~ ° w se br ° ^ oj -1. r -^ — w S' > S JH ^ > (U *J — ,. « !" --^ = P .22 .r , cj re .H t« >- a, -Sort K- 3 1) c . o o - ^ O ^ "^ t3 C E - OS r- > E S o 2 o — "t:. < ^ > 3 .3 J" CN LC iz; ;^ —1 << — , — , ^ i^ ■^ -=^ •uajpiiqa j N : C •sSy -0 i- i- APPENDIX Ernest W. Gushing, M.D^ APPENDIX. In explaining the plates which have been added to this addition- of Mr. Martin's work, the text has been reproduced as far as possible by which they were accompanied in the '■'■ Annals of Gyniecology," from which all of them have been taken. Some observations have been added from my own experience relating to matters kindred to the subjects of the illustrations. The reasons for the introduction of this large number of illustrations from the journal mentioned above are stated in the preface to this second American edition. Plate 1., p. 54. Annals of Gyn.ecologv, November, 18SS. DOUBLE VAGINA AND UTERUS. In the illustration of this case the external genitals are shown, with the labia separated so as to view the hymen and introitus vaginae. The labia are perfectly normal, and the parts, until closely observed, seem to be in a perfectly natural condition. If exposed to view two openings are seen, and a perfect hymen corresponding to each. A septum is between these two passages. The patient was 39 years of age and unmarried Menses at 15 ; periods regular, and duration of flow five or six days. There \vas pain during the first day of the flow, not sufficient to call for operative inter- ference. Some vaginal discharge was present and pain in the lower abdomen. She entered the hospital service of Dr. Gushing Jan. 6, iSSS. By vaginal examination it was found that the finger passed as is usual, except that it fitted more snugly. The vagina was about the usual depth. but was much narrowed, and at the end was felt a small cervix antl OS uteri, but no cid-de-sac. On inspection of the parts the double con- dition was noted, and the passage of the finger gave evidence of tw'o sides, which were exactly symmetrical. Little information could be gained about the uterus from vaginal examination. A sound could be passed into the uterus on either side,. 5^8 APPENDIX. anl seemed to pass of! toward each side of the body. Through the rectum the true condition could be made out. The uterus was not developed, the two parts being joined up to the point of the internal os, then sepa- rating and passing off Y shaped to right and left. The patient was contemplating marriage, and, knowing that she was not perfectly natural, she desired an operation if she could be better fitted for married life. The operation was performed after she w^as thoroughly ir.formcd as to the likelihood of a disastrous result provided she should become impregnated in cither horn. The information that most women with this malformation were able to have intercourse without operation did not satisfy patient that her condition did not require surgical help. The operation was performed, by cutting through the septum through its whole length, and suturing the two edges of mucous membrane with gut both above and below, thus transforming the two passages into one. The septum was about one-tenth inch in thickness externally, but grew considerably thicker as it reached the cen-ix. This made it quite difficult to suture the upper portion, as it was deep in, and there was very little space. There was perfect healing, and the patient left the hospital in twelve days. A second case of double vagina and uterus, similar in all respects to the first, has come under mv observation, being brought to me bv Dr. Cilley, of Boston. There was no occasion for operation, as the person had no difficulty whatever in sexual intercourse by either of the two vaginaj. She had never become pregnant. The following case, with the illustrations, is taken from an old and rare work in Latin, for the use of which I am indebted to the courtesy of Dr. Chadwick, of Boston. The evident care with which the autops)' was made, as well as the exactitude of the drawing, makes the obser\ation of permanent value. APPENDIX. 539 OBSERVATIO DE VTERO HVMANO BIFIDO ET BICORXI CUM VAGINA DVPLICr. BY PKOF. BOEEMER, OF HALLE, A.D. iV'^a. / With Plates A. and B. History. — The patient was a woman of 56 years of age, who had married in her twentieth year, shortly after her first menstruation. During her married life sexual relations could never be consummated, but mean- time, through thirty years and more, both husband and wife endured this condition contently. In the beginning the wife could not be known bv her husband on account of narrowness. When coitus was attempted, it was so distressing that partly she was not able to bear it on account of the pains, and partly the husband was not able to copulate with his wife on account of laceration of his own genitals, and the very severe pains de- pendent on it. The extreme poverty of the couple had prevented an in- quiry into the special cause of this incapacity for coition, particularly since the wife, whose menstrual flow had been obstructed since the early years of her marriage, began to suffer from ill-health, and lived misei^ably in this condition, afflicted with various calamities. From this ill-health, and from a dyscrasia ensuing in her blood, and from the corruption of her humors, there resulted an ulcer on her right foot, which, creeping further, became hopeless and foul, and on account of the simultaneous concurrent relaxation of the fibres around the ulcer (xaxOYi'^ec,, hvaanovTii^rov) , by the supervention of gangrene, it ex- cited a fatal inffammation and corruption of the viscera. Post-morte77i Examination. — At the autopsy it was noted that there was a septum by M'hich the vagina was divided into two canals ; we there- fore made a careful inquirv concerning this unaccustomed condition, and made the following observations : That there was a single vulva which was divided into two unequal ostia by a septum which was membranous, thick, hard, callous, and almost cartilaginous in its nature, broader above and tortuous posteriorly, reaching down to the frenulum. This septum, extending upwards from the aforesaid vulva to the middle and upper part of a bicornate uterus, was formed by the contact and union of two proper vaginaj united by fibro-cellular tissue like a mediastinum, although, indeed, this could be separated as far as the uteius ; there, however, it was invested by a more compact fibrous structure, so that it could not be divided further, but became the common septum of each horn of the uterus. [Annals ok Gyn^vColcka , Itoston, UcLcmbcr, ibiiy.J THE EXTERNAL GENITALS, WITH A DOUBLE VAGINA, AND A SYMMETRICALLY BIFID UTERUS, IN THEIR NATURAL CONNECTIONS. a, a — The labia niajora .stparated. /i — Entrance of each vagina. /— Septum between the two vagina, of which the left was a little larger. /./ — Ovaries. », o — The ligaments of the ovaries, y^ ^ — Fallopian tubes, .f, s— Hydatids of the right tube, o — Spermatic cord, dissected at the pampinirorm body, consisting of p, an artery, and y, spermatic veins distended with mercury, and running to the left ovary, as well as the tube, the ala vespertilionuin, the broad ligament, and the upper part of the vagina. ':54o) (Annals of Gvn^cologv, Boston, Dcccmljcr, 1SS9.] B FIG. I. — A bifid and bicornate uterus laid open, with the Fallopian tubes and a portion of the vagina. FIG. II. — Bicornate uterus, from which the tubes and ligaments have been cut away; each portion of the double vagina laid open, showing the formation of the septum. (.540 542 APPENDIX. There was, therefore, a double vagina, rugous, papillary, and thrown into folds internally, studded with follicles, especially in the upper part,, which surrounded the oval orifices belonging to a uterus bicornis. The uterus divided by a common septum, as in animals, was bicornis^ or seemed formed by the union of two horns united in the middle part ; nevertheless each horn had its own orifice, and in the internal surface of each, at that part which in a normal uterus is called the cervix, there were various folds and cells indicating the ovarium of Naboth. Each horn was quite thick, dense, of a spongy, fibrous structure, invested internally with a very thin villous membrane, which was contin- uous with the lining of the double vagina ; terminating laterally the double fundus it opened into the Fallopian tube by an orifice at its side so patu- lous and straight that it easily admitted a hog's bristle ; the substance of the horns, which was thick where it w^as continuous with the tubes, became thinner and more membranous in investing the latter. Above the pervious and elongated tubes an ovary was attached to each horn by means of the ovarian ligament (ligamentum teres), oval in figure, not indurated, but naturally constituted, and connected with the tube of its own side by the intervention of the ala vespertilionum. The uterus bicornis itself was attached to the side of the pelvis both by means of the broad ligaments and by an extension of the peritonaeum, and to the pubic bone by the round ligaments, which were fringed and fibrous at their* extremities. For studying the direction of the spermatic vessels, which were divided into two branches around the pampiniform body, we filled them with quicksilver, on one side the right spermatic artery separately, and on the other the left one together with the vein ; we have not, however, thought it necessary to delineate the origin of the arteries from the aofta above the inferior mesenteric artery, and the insertion of the left sper- matic vein into the left renal vein, because observation vi. shows exactly the system of spermatic veins and arteries. These vessels first passing through the pampiniform plexus penetrate into the ovaries, the ala vespertilionum, the horns of the uterus, the upper part of the vagina, the tubes even to the fimbriae, and the broad liga" ments, with tortuous branches, of which the most and the largest are venous, the fewer and narrower being arterial. APPENDIX. 543 Plate II., p. 54. Annals »)k Gyn>ecology, July, 18S8. FEMALE MONSTRUM. Represents a very remarkable freak of nature, which is described as follows in the contribution which was sent with the photograph. BY DR. J. BECHTINGER, PARA, BRAZIL. This person is 25 years of age, a native of Martinique (French West Indies), her father a Frenchman, her mother a quadroon. Both healthy, never remembering any deformity in their family or kindred, no consti- tutional disease, syphilis, scrofula, or allied maladies. The third leg is attached to a continuation of the processus cocygeus of the os sacrum, such as I have noticed among some Malay tribes in the interior of Sumatra (Dutch East Indies) ; however, not in such proportion, even approxima- tively. She is still living, but left her native country for France, where this photograph was taken in Paris about a year ago. Besides the two well-developed mamma in their natural position, a third one, which is double, is seen above the os pubis. The hair suf- rounding the lower segments of the abnormal mammge covers the two vaginae with well-developed vulvce (major and minor). Both vaginae are properly supplied with nerves, and normal sexual connection, with correspondingly natural sensations, is possible in either vagina. The sexual appetite is very markedly developed. Every other function appeared normal, as well as the function of the vital organs. Being informed of the existence of a man in France with two genital apparatus, with two penes, four testicles, and three movable legs, she expressed the desire and determination to make his acquaintance. A photograph of the latter individual is enclosed. The interest excited by the publication of the above extraordinary case led to the following editorial remarks : — TERATOLOGY.* It is with great pleasure that we observe among our subscribers and correspondents a deep interest in the subject of teratology. Let it never again be said that the profession in America is not interested in purely > Aiin.ils of Gynaecology, November, iSSS. 544 APPENDIX. scientific subjects. Possibly this branch of special study is in general, and as a whole, somewhat abstruse, but concretely j^resented in the form of a comely diplo-teratologicul female, it has aroused an amount of interest which we had never anticipated. Many correspondents have written in a somewhat sceptical vein, requesting information about, and especially a pictui'e of, the corresponding three-legged and doubly endowed man, a photograph of whom was enclosed by Dr. Bechtinger when he sent the communication conceining the woman above mentioned, which was pub- lished in the July number. In correspondence with our greatest authority on teratology. Dr. Geo. J. Fisher, of Yonkers, N.Y., it became evident that the male indi- vidual in question is identical with the one first described as an infant by Acton, and afterwai'ds by Dr. Fisher, in his exhaustive monograph on diplo-teratology, embodied in the Transactions of the New York vState Medical Society. Dr. Gihon has also had the cointesy to send us from California photo- graphs of the same individual, and we have been informed b}- Dr. Gray, of the Army Medical Museum, that there is a cast of the same person extant in Washington. As it is evident that the subject is new to many of our subscribers and exchanges, and in order to answer at once and in full the numerous letters which we receive on the subject, we publish in this number the plates and an abstract of the description of Dr. Fisher mentioned above {vide infra). As far as can be ascertained the two cases are each unique of their kind, certainly so as a pair. IscHio Pagus Dipygus " (Plates C-D). — [Acton. — Medico- Chirurg. Trans. ^ London., 184.6., vol. xxix., p. 102, pi. iv., figs. /, 2.'\ The Lancet {T^07tdo7i). vol. ii., p. 124., figs. 1-4., 1865 (Am. ed., Jan., jS66, p. 7/). " The subject of the present monstrosity is a male child, name John Baptist Dos Santos, of Portugal, six months old. The father and mother are both healthy, of short stature and dark complexion ; no jDeculiarity of any kind has been observed in their family. The mother has had two well-formed children. She remarked nothing unusual during her preg- nancy ; the child was hovn at full term, and the labor was an easy one. " The child is exhibited lying on its back in a little cot ; is lively and good-looking, and well-proportioned both in the upper and lower extrem- ities, the peculiarities being confined to the parts below the umbilicus. A 1 Transactions of N.Y. Slate Med. Soc, iSoo, p 356, Case 41 . APPENDIX. 545 truss is worn on account of an umbilical rupture. Below the umbilicus, and to the right and left of the mesial line, are two distinct penes, each as laro-c as the penis of a child six months old ; their dh-ection is normal. Water passes from both organs at the same moment. Each penis is pro- vided with a scrotum, the outer half of each scrotum containing one testicle ; the inner half of the scrotum is far removed from the outer, and the two inner halves appear like another scrotum between the two penes. " Between and behind the legs of the child we see another limb, or, rather, two lower extremities uniting together in their whole length. The ■upper part of this compound limb is attached to the rami of the pubes by a short, narrow stem, half an inch in length and as large as the little finger, apparently consisting of separate bones or cartilage, for, upon moving the compound limb at the same moment that the finger is kept on the stem, crepitation is felt, but I could not detect any pulsation. Imme- diately behind this stem, and concealing it, the compound limb assumes a size as large as the combined natural thighs of the child, and within the upper part irregular portions of bone may be felt (probably a portion of a pelvis and the heads of the thigh-bones), which maybe traced down, united together in one mass, to a leg of comparatively small size, though still larger than either of the healthy legs, and terminated by a double foot in the position of talipes, with the sole turned forward, and furnished with ten toes, the two great toes being in the centre of the others ; the two outer toes on each side are webbed. (See Plate C.) " When the child is placed on the belly, the spine and back present a perfectly normal appearance ; the anus is in its usual situation ; the functions of the bowels are duly performed. Viewed in this position, the compound assumes a roundness and fulness equal to the buttocks of a young child, and a slight depression is observed, as if for the anus. Tracing the limb downwards, we find only one patella, which is on the same aspect of the limb as the anus; the joint bends freely and the compound extremity terminates as above described. This compound limb is quite motionless; the upper portion above appears endowed with sensibility : its vitality seems low, as the toes have a bluish appearance ; the upper portion, how- ever, is of the same temperature as the body of the child." A further description of this monstrosity is given in " The Lancet" (London, vol. ii. p. 124, Aug., 1S65), when this subject was 19 years old. It coincides very closely with the above. (Plate D.) Speaking of the extra leo- it says: " He remembers to have been told that wlien he was a year old the third limb projected more stiffly than it does now, and a Portuguese chemist, officiating as surgeon, broke the limb at some part so as to make it less cumbrous. • He believes that it was at the junction of the [Annals of Gynaecology, Boston, November, iSSS.] c <'XCO Male, 3 legs, double genitals. See page 544. (546) LAnnals oi- Gyn-'Ecolooy. Bostoi), November, jSSS.J D '^^'~ '^ ^^^^/^i^'"^^^^^^ Same case as on Plate C (547) 54S APPENDIX. lower leg with the thigh that this was eflected, and that the leg was then bent upward and forward in the position in which it now is. Examina- tion renders this probable, since it is certainly dislocated into an nnnatural position, and has only a false joint. But it is possible that at this time the neck of the thigh-bone was broken away from the body, and that the upper bone is that neck, remaining attached to the arch of the pubes b^• a ball-and-socket joint. . . . Pie is very active, and runs very swiftly, and is a good horseman. He usually disposes of his third limb by strapping it with webbing to the side and front of his right thigh. As he walks, when dressed, no external deformity is observable. His virile powers are unusually good, and he uses the left penis in sexual intercourse, sometimes finishiug with the right. Plate III., p. 56. AN^fAI,s ok Gyn-'ecolocy, Dereinlier, 18S8. CONGENITAL ATRESIA OF VAGINA. Mrs. D. entered my hospital service in June, i8S8, at the recom- mendation of her physician. Dr. Forest, of Rockland. She stated that, although married for over a year, her husband has never been able to consummate the marriage by sexual intercourse, and that he was about to apply for a divorce. Examination shows the external parts normal ; the entrance to the vagina occluded by a fleshy mass, in the lower part of which w^as an opening, which, with difficulty, admitted a sound. Through this men- struation took place. The parts were sensitive, and irritated by fruitless attempts at intercourse. Rectal examination showed the presence of a uterus and of ovaries. Under ether the obstruction was divided, and found to be about half an inch thick, and very tough and resistant ; beyond this was a narrow vagina. The whole of the obstruction was removed, and the mucous membrane within united to that without by continuous catgut suture. The parts healed well ; the vagina was dilated by packing with iodoform wool until it seemed normal ; and the jxitient returned (o her home and husband in time to assist in celebrating the Fourth of July. She afterwards bore a child, and the labor was normal. A case of complete congenital occlusion of the vagina, with retention of the menstrual secretions was brought to me by Dr. Pike of South Dan- vers. The patient, who was iS years old, had been accused of pregnancy. The hymen was very thick, and pressed outward by the fluid which had distended the vagina and the uterus until the latter was as large as a man's head. Tiie tough hymen was excised, antl the uterus emptied and well APPENDIX. 54tr washed out with a weak suhlimatc solution, which was, in turn, (hsphiccd by boiled water. The outer and inner edges of the seat of the hymen were united with catgut. The patient made a good recovery. Later ex- amination showed a diverticulum in the vagina which appeared to lead to a rudimentary horn of tlie uterus. A case of complete occlusion of the vagina, with absence of the uterus and ovaries, was brought to me by Dr. Norris, of Cambridge. The person was engaged to be married ; and tlie inquietude of her mother over the fact that her daughter had never menstruated led to an examination and consultation. The external parts were well formed, and the breasts were foirly well developed. T!ie hymen appeared to be imperforate, but a rectal exami- nation showed that there was neither vagina, uterus, nor ovaries. A sound in the bladder could be felt close to the wall of the rectum. Higher up a mere cord could be felt stretching across from side to side of the pelvis occupying more or less the position of the tubes, and slightly thicker where the uterus should have been. The general health of the person was excellent, and although it might have been surgically possible to form some sort of a vagina, yet the only advice which could be given to the unfortunate individual was that marriage, under the circumstances, would be not only a misfortune but a fraud, which no court would hold binding, and tliat all thouo-hts of matrimony should be abandoned. VARIETIES OF THE HYMEN. In this connection the next plate [E] is interesting, in whicii Dr. E. S. MacKee, of Cincinnati, has depicted the varieties of the liymen, as follows : — I. The hymen semilunaris, or normal hymen. II. The hymen circularis, with small central opening. III. The hymen cribriformis, sieve-like, containing man\' holes like a water- pot. IV. Tlie hymen fimbriatus, similar to tlic fringe-like appendages of the ostium abdominale of the tubiv Fallopiaine. This form is the most important in a forensic point of view, as it may be taken for the normal hymen which has been torn. V. The hymen imperforatus. This is a frequent cause for surgical treatment, on account of the retensio-mensium tlependent upon it. It may prevent coj^ulation. lAsNAi.s OK GvN.etoLoiiv. Utisloii, J.muaiv. 1SS9J 1 W^r'i ■"■^ ix: w VARIETIES OF THE HYMEN. (550) APPENDIX. 551 VI. In rare instances the opening of the hymen is found divided into two parts by a perpencHcuhir bridge from the concave border of the hvmen to the meatus urinarius, where it becomes fast. VII. In some instances there is a variety in which there exists an upper or anterior and lower or posterior opening, with simply a band lying transversely across the vagina. In rare cases we also find a second hymen existing above the first. VIII. The horseshoe hymen. IX. The bi-lobate hymen. HYPOSPADIASIS AND HERMAPHRODITISM. Although a hypospadiac is a male, yet in some cases the diagnosis is difficult or even impossible. Usually, however, due care at the first examination would give a proper diagnosis of a question wdiich is of the greatest importance for the whole future of the individual. It, therefore, is properh- considered in a work on gynaecology. Sometimes, moreover, very difficult legal and social questions arise as to the real sex of a person. The cases and illustrations of hypospadiasis presented herewith represent a condition, rare, it is true, and yet of sufficient frequency to make the first examination of an infant, with a view to determine the sex, a very important matter. It is not easy to distinguish between a hypos- padiac male and a female infant ; the little cleft penis may easily pass for a large clitoris, the position of the urethra, the appearance of the labia, minora and majora, are identical, as the testicles in hypospadiacs usually do not descend into the split scrotum until later in life. In these cases, also, there may be an oj^ening simulating a vagina, although precisely liere is where the chief point of difference may be found between hypospadiacs and females. It must not be forgotten, however, that the vagina may be absent in females. In short, there are cases where the diagnosis can only be made post mortem. Practically, all doubtful cases are classed as girls, and educated and clothed as girls, and a diagnosis is made, if at all, after puberty. The cases here published show the social and moral difficulties likely to arise from such a mistake. It is easily seen how difficult it is to change not only the dress, but the whole social environment and mode of earning a living, if the original error of diagnosis is ever recognized. H\'pospadiac males, educated as women, therefore, have every motive for concealing their condition, even if the\- understand it, and it is probable that there are a considerable number of such, persons living as women in the com- 552 APPENDIX. munlty. This condition lias always jijivcn rise to strange and marvellous stories from the ancient '■^ Jtivenis quondam n^tnc fccmina Ccenis Rnrsiis et in vctercm fato revolu/a figurcm^^^ lo the celebrated Hohman,' who is apparently female on one side and male on the other, and who, after living in sexual relations as a woman for some twenty years, on the cessation of menstruation, at about forty, found out that he was a man, married a woman, and is still living, while the pathologists are w^aiting, and we might almost say hoping, for a post- mortem examination. It is probable that some scandalous occurrences which occasionally disturb social purity, and furnish food for sensational gossip, or material for prurient fiction to the discredit of womanhood, might, if the truth were known, be traced to the actions of hypospadiacs. By a careful examination of the sexual organs at birth, repeated at and after puberty in doubtful cases, or in sucii as seem to show an abnormal and masculine type of development after puberty, the physicians can usually prevent these unfortunate persons from being educated as women, — a mistake which, while unimportant and even convenient during child- hood, is almost certain to lead to much mental suffering, and often to serious social trouble, after the age of puberty. ' American System of Gynaecology, vol. i. APPENDIX. 553-. A CASE OF COMPLETE HYPOSPADIASIS. BY PROF. MAIN-SALIN, Assistant Lecturer Gynecology and Obstetrics, Caroliniseji Institutet, Stockhohn, Sweden. Translated by Dr. J. G. Tapper, Elgin, III. The person under consideration was reared as a girl among her sis- ters without any knowledge of abnormality of her body until her twenty- third year. It is true she was informed by a physician, at the age of fifteen, that although her organs of generation closely resembled those of the female, yet they were defective in the absence of a uterus, but without this naturally leading to the discovery of her sex. At the time I first saw her, she was attired as a lady, moving in the very best of society, and her demeanor was of such a character as to place her in this rank. She complained of amenorrhoea, with other symptoms, which induced me to insist upon an examination, which gave the following results: — The patient was five and one-half feet in height, slender in form ; features of the face were coarse. Upon both cheeks and chin were marked evidence of a beard. The growth was so pronounced, that he must have shaved every day to avoid attraction. The heavy, braided hair reached to the middle of the waist. The voice was properly masculine ; yet, in consequence of the fact that it was very disagreeable to himself, being known as a woman, to converse in a deep voice, he had accustomed himself to use a kind of falsetto, which gave the voice a peculiar clano-. With the exception of this it was very pleasant. Trained as a female voice, it had, through its naturally deep, and acquired falsetto, tones, a wonderful compass. The entire body was masculine. The chest was strongly developed, and, with the abdomen, was thickly covered with hair. No development of mammae. To cause these parts to appear with womanly giace he had a pair of pads introduced beneath the underwaist. The pelvis was small. The distance between the spinie ilii ant- TAnnai.^ oi- <;> v.kcoi.ogv, BosIoii, March, .SSS.| F ':-^^M<^^w^ • ' ' ■ ' ^ CM •^j '■^fei^SljS T^^^^*^ (D J^cirv?^£3«5: ■■*■ '#: ro ^v a ^^-^m-r ^^- recA'i [Annals ok Gynecology, Boston, March, iS8S.] 5^ 2. O :j » re si °' ^ O' f' ^ .V % o n 3 i s 2 l-H 'J Photographs of a few of the cases which have come under my obser- vation are given licrewith (Plates iv., viii.), in all of which perfect cure resulted from operative measures. The histories are as follows : — Case I. — Mrs. X. was sent to the hospital May 25, iSSS, by Dr. Fraser, of Weymouth. Her operation was on June 7, «'>'i(l her discharge July 39. Menses at 15. Has had nine children. Climacteric twenty- seven years ago, and she is now 70 years of age. Examination showed tiiat the prolapsed uterus, vagina, and bladder protruded in a mass the size of a child's head at birth. On the right side on the extruded vaginal wall was an ulcer suggesting epithelioma about the size of the palm. ^See Fig. i.) She suffered less pain than was to be expected from it, and called herself perfectly well in other respects. Nevertheless she was hopelessly bedridden, and the ulcer continually grew larger and deeper in spite of the most judicious and persevering treatment by her physician. The object of the operation was to remove the ulcer and the subjacent tissue, and to replace the parts. The whole mass was encircled by an elastic ligature ; under sublimate irrigation all the diseased tissue and a wide margin around it was then dissected away, including the hypertrophied cer\ix uteri and a large piece of the left vaginal wall corresponding to that removed on the right. The pouch of Douglas hung down as seen in the figure, as a fold of peritonaeum containing intestines. It was not opened. Above, the bladder was carefidly dissected out and pushed away. The ureter appeared in the wound, and was freed carefully for about two inches. It is seen in the plate, hooked over the finger of an assistant. Then the vessels were taken up, both separately, and by passing a strong ligature through the vaginal wall around the mass of vessels in the broad ligament and out agaiii through tlie vaginal wall on the other side of the wound ; this was also done on the left side. The elastic ligature was then loosened and the pouch of peritoiiicum with the intestine, as well as the bladder and ureter, were tucked up into the pchic cavity. The clastic band was now tight- ened again, and the operation continued without loss of blood. The vaginal tissues were sutured with interrupted silk and continuous fine cat- gut. The elastic ligature was then removed, and the whole mass was returned to its normal position anil retained b\- an ioiloform tampon. There was little shock and no febrile reaction until the eighth day, June 14th. Restless, weak, temp. 99. S°' -^ rather hard mass was discovered in the lower abdomen. Ixid odor present. Vagina irrigated. Speculum introduced and a free discharge of foul pus followed. Much more was expressed, and the cavitv of the abscess which had formed the tumor just mentioned was fully irrigated with ..y^y- sublimate and phenyl solution. e;6o APPENDIX. A few clavs later, after doinj^ well, she had a sudden attack with chill; temp. io^°, and irrational. .She appeared very ill. Irrigation and the removal of a slough improved her condition at once. No more trouble followed. She gained till her discharge, felt very well, and as the parts were held in place, probably by adhesions, the perinaium was not restored. Case II. — Mrs. X. entered the hospital June 7, 188S. Age, 31 ; one child, 5 years. Menses at 12. Regular at present. Menstrual pains some- times. There is considerable vaginal discharge constantly. Complains of local uterine troubles, but in other respects she feels in good health. Diagnosis: Prolapse of hypertrophied lower lip (see Fig. 4), lacerated cervix, endometritis, and subinvolution. The uterine measurement was four and one-half inches in depth. The endometrium was curetted, which, besides curing its disease, tended to stimulate involution. The cervix was amputated, thus getting rid of the hypertrophied lips and the pendulous mass, and curing the laceration and preventing further prolapse bv removing its cause. Operation was performed by the Martin method on June 12. Discharged July i, well. Case III. — Mrs. Y., age, 40, entered hospital Feb. 6, 1888. She has had four children, followed by five or six miscarriages. She was taking opium, tobacco, etc., in large quantities. Withal she was in rather a loathsome condition. Examination was made and led to the following diagnosis: Hypertrophied cervix with large erosion and laceration, rup- tured perinaeum, prolapse with cvstocele and rectocele. (See Figs. 5 and 6.) The mass was replaced, and the vagina was tamponnetl with wool pre- vious to operation. Opium and all stimulation was stopped entirely within three days, much to the satisfaction both of attendants and patient. Operation was performed Feb. 16, 1SS8. A rubber ligature was placed around the cervix to prevent haemor- rhage. Martin's operation was performed for amputation of the cervix, and silk ligatures were used. No blood was lost during operation, and only slight venous oozing afterward from the needle tracks. Sutures were removed February 28, in part; tlie rest, three days later. There was perfect union of the i)arts. and a very happy result. Later, March 5, she underwent another operation, which was not performed at the first sitting, on accoiuit of the extent of the erosion, and magnitude of the cervix operation. A wide strip of the anterior vaginal wall was removed, and the parts approximated and united by catgut continuous suture, and by three silk sutures. The perinaeum was also restored at the same time by the flap operation, with buried catgut sutures in layers. The result was perfectly satisfactor\ , and the patient was discharged March 31, cured. APPENDIX. 561 Case IV. (Plates VII.-VIII.) — Mrs. M., aged 48 years, was sidmitted to my hospital service in January, 1S90, with a prolapse as large as a cocoanut, which entirely disabled her from any occupation. There were three angry ulcers on the surface of the extruded pos- terior wall of the vagina. The uterus was replaced in the pelvis with much difficulty, and retained by a packing of wool, which was changed every day, when disinfecting and astringent douches were administered. After ten days of this treatment, with rest in bed. the foul ulcers had as- sumed a healthier appearance, and the foetor arising from them had diminished to such an extent that operation seemed opportune. The patient being in the dorsal position and the uterus drawn down, the protruding mass was about half as large in each dimension as it had been on entrance, and therefore occupied one-eighth of its former bulk ; the three ulcers were also somewhat smaller, but still deep and with an unhealthy appearance. (Fig. 7.) The uterine cavity measured five and one-half inches. The perinaeum was ruptured and greatly relaxed and stretched. The cervix was seized on each side, with pressure forceps, about two inches from the extremity, and the whole mass was encircled with a rub- ber ligature. The bladder was next carefully dissected away from the anterior surface of the cervix. (Fig. S.) Then the posterior flap was dissected away, carrying with it the ulcers. The peritoneal cavity was opened at one point, but immediately closed with fine catgut. The posterior incisions joined the previous anterior one at each side of the uterus. (Fig. 9.) By careful work about two inches of the hypertrophied cervix was freed, and then this part was amputated and the stump attached to the anterior and posterior vaginal walls bv Martin's method (Fig. 10.) The whole operation was, of course, performed under irrigation, and disinfectant douches were used afterwards. Some two weeks later the stitches were removed, and a very thorough perineal operation was per- formed. The patient left the hospital entirely cured. In operations for rupture of the perinaeum, I am accustomed to use a combination of the flap-splitting method and the suture in lavers with cat- gut, which I described at the meeting of the American Medical Asso- ciation in June, 1SS7, as follows : — "In his operation for restoration of the perinceum,! the lamented Schroder lately used two or even three layers of continuous catgut suture, superimposed one on the other and running from 1)efore backward, and 1 Journal of the Am. Med. Assoc, Oct. 2i, 1SS7. 562 APPENDIX. tlien in tlie reverse direction, thus building up a perinaium before he united llie vaginal mucous membrane. ''Jenks' operation for ruptured pcrinxnim proceeds, as vou remember, bv splittuig the septum between the rectum and the vagina, dissecting it in both ways until the adhesions are freed, and then, by bringing the lateral surfaces together, the incision, previously horizontal, is made verti- cal. Jenks remove^ the flap of vaginal tissue thus freed. Dr. Marcy has modified the operation by retaining this flap, uniting its edges in a straight line, continuous with the new perineal raphe. To hold the parts better in apposition he inserts pins in each side, which are united in the vagina and outside of the body by projections with hooks or eyelets on them. " Now, in moderate cases of rupture of the perinseum, the buried con- tinuous suture of Schrceder may be adapted to the operation, and I have used it in this manner. Commencing at the very bottom of the wound made by splitting the septum, as already described, one end of a piece of tendon or catgut is attached in the median line, and then the sides are brouf>-ht together by stitches taken with a large curved needle, each titchs taking up more tissue on alternate sides until three or four on each, side have been inserted, then the stitches are taken deeper so as to reach the ends of the sundered transverse muscles of the perinaum, and draw these tocrether. These switches may be taken deeply with safety, because there are no vessels to be injured except the pubic arteries which lie close undci the rami of the pubic bone. The rectum is, of course, carefully guarded from injury bv one or preferably two fingers in it, and the whole operation can he convenientlv performed under irrigation with a sublimate solution 1 1000' " Each stitch thus reinforcing the previous one. the continuous suture brings all the tissues into close apposition, leaving no pockets, and I am now content to dispense with the use of pins, as by the above method there is no dragging of the tissues out of their normal position by any bag-string action of threads or wire. " The end of the long continuous suture should be cut off, after secur- ing it, and afterw^ard buried by bringing together, in the median line, the edf-es of the vaginal mucous membrane in the usual manner. B\ thus burying the end of the suture there is less chance of septic matter creeping into the wound at the point of emergence of the catgut. " I am using this method, with excellent results, even in cases where the rupture extends into the rectum. Here the lower edge of the split septum is doubled on itself, and becomes the two edges of the reiit in the rectum, to be united from the anterior or raw surface with the finest silk continuous suture. APPENDIX. 565 " I turn down the point of the ilnp of vaginal mucous membrane so that the anterior end of the union of the parts is Y shaped." Much subsequent experience with this method has confirmed me in the belief in its efficacy, and it is seldom that I find it necessary to carry the denudation up the vagina on each side of the columna ru it. and remains there for two or three days. The patient keeps the bed for a week, and then the stem is removed with antiseptic precautions. In a few days more she may get up, and the suffering and trouble are usually found to be cured ; the erosions, naturally, are gone. Seldom is after-treatment necessary. Such a case with such a result is represented by the photograph Fig. 2, and I could report a series of similar cases with equally satisfactory results, operated on by Dr. Marcy and myself. I suppose that it is hardly necessary to insist here on the fact that neither this nor anv other operation on the cervix is to be undertaken while there are acute inflammatory processes going on in the uterus or the parametrium. Emmet has sufficiently pointed out the necessity of re- moving all inflammation by rest, hot douches, tampons, etc. With our present knowledge of the frequency of salpingitis, and of the bacterial exciters of inflammation, we can understand better than formerly the reasons why these precautions are necessary, and how often the whole focus of inflammation can be removed in the form of a diseased fallopian tube. For cases of stenosis with elongation of the ceixix, ero- sions, and endometritis, mere dilatation is often not sufficient, and it is desirable to remove a portion of the hypertrophic tissue, and at the same time to restore the proper shape to the cervical canal and os externum. It is not my j^resent purpose to enter into the question of the choice of operations ; the habit and skill of each surgeon may accomplish a good result in various ways. The next class of cases is where, after parturition, although there is little laceration of the cenix. the uterus remains subinvoluted, with en- dometritis and erosions. I believe that in these cases the subinvolution is caused by the en- dometritis and not vice versd^ /.e., they are the results of a mild sepsis, or bacterial infection ; and precisely these cases, when not too inveterate, are susceptible of cure by antiseptics, such as nitrate of silver, tincture of iodine, or strong carbolic acid ; of these the latter applied thoroughly, on a cotton-holder, is the most effective. Of course, hot douches, and ergot, strychnia, etc., are also indicated, with vaginal tampons of glycerine 14, alum 1, boroglyccride i, as recommended by Wylie. Even in old cases, where the uterus is enlarged and hardened, much good can be accomplished by this sort of treatment, but the results are not usually very satisfactory ; and in the next class of cases, where there is cer\'ical laceration, the indications for surgical interference are even more imperative. APPENDIX. 575 Nevertheless, where want of courage, or opportunity, on the part of the patient, or a want of faitli in surgical measures on the part of the physician, exclude operative interference, the patient can be made com- fortable, and with patience, sometimes, apparently cured without operation. vSome women have such a horror of a knife that they will go about all their lives with a lacerated cei"vix and ruptured perineum, never being quite well, and requiring more or less perpetual treatment, rather than undergo an operation. This state of mind is not confined to women ; in fact I think they are braver than men, who, when they have haemorrhoids, or hernia, hydrocele, or spermatocele, are notoriously unwilling to undergo any radical operation, but find that their " business" requires it to be perpet- ually postponed to a more convenient season. For such women much can be accomplished, even in cases of ectro- pium, by puncturing the cysts, scraping off' as much of the glandular structure as is possible under the influence of cocaine, and applying at intervals strong carbolic acid to the diseased mucous membrane. The dry treatment as used by Dr. Engelman is very effective in heal- ing the erosions, and promoting involution of the everted lips. He dusts the parts with iodoform, and packs against the erosions balls of iodoform-cotton wool, about an inch in diameter, each of which balls is enclosed in a thin layer of styptic iron-cotton. This remains in place for tvvo or three days, when it is removed and a new dressing applied. Under this treatment, without douches or glycerine tampons, the erosions heal, the glands diminish, and the everted lips come together. Dr. Engelman was kind enough to show me several such cases in St. Louis, and it struck me as a very nice, clean, and effective treatment. Apostoli, of Paris, who has been kind enough to send me his pam- phlet, uses a constant current of electricity, with one pole in the uterus, and with a large pad of fuller's earth for the other pole on the abdomen ; bv this means a ciirre77t of high tensile strengtJi can be used zvithoiit much pain., which effectuallv arrests the glandular development in the endometrium, causing an eschar, and thus in Apostoli's opinion, answers the purpose of a curetting. Where there is not much laceration of the cervix, nor rupture of the perineum, these various measures answer verv well for patients who have a fear of operative measures, and ha\e a skillful and persevering phvsician. Nevertheless, it seems to me more scientific and satisfactory to give the patient ether, scrape out the uterus after thorough disinfection, remove the glandular hypertrophy at once, repair the lacerations, make a good OS, covered with flat epithelium, and thus cure the patient. ^•j6 APPENDIX. At the same time, if, as is very frequently the case, there is a rupture of the perineum, possibly complicated with cystocele or rectocele, the jierineum can be repaired, and the appropriate colporraphy performed, to remedy the other lesion. With little pain, and no fever, the patient thus gets in an hour a benefit which she can seldom receive in years of local medical treat- ment. How much more, then, in cases where there is any symptom of malig- nant degeneration of the erosions, is it the plain duty of the attendant physician to recommend thorough removal of the suspected tissues? The consensus of authority all over the world asserts that inveterate cervical erosions are peculiarl}' liable to cancerous degeneration. I hope that the foregoing figures have made it clear that these so-called erosions are not in any sense losses of substance, caused by mechanical irritation, etc., but that they are an active new formation of glands, prone to recur, even when removed, readily invading the portio vaginalis, where it should be covered by flat epithelium, and thus, by all analogy of pathology, they are to be viewed with suspicion, and removed with thoroughness. Every one who is in a jDOsition to see many cases of cancer of the cervix knows that it is the saddest part of his mournful duty to tell the patient that it is "too late to remove it all," and in no one thing is a greater advance in practice to be hoped for than in the early recognition and removal of whatever seems either malignant, or doubtful, or so inveterate as to be likely to be an early stage of that most dreaded of all the ills to which the sex is subject, viz., a cancer of the womb. APPENDIX. 577 Plate X\'. Annals of Gyn.ecologv and P.kdiatry, March, 1890. FIBROCYSTIC TUMOR OF UTERUS. A MYOMA of the uterus, bes'ide the pain and haemorrhages to which it gives rise, the mechanical difficulties and obstructions which it may occasion, and the inflammatory atfections in the uterine appendages and in the peritonasum which it may excite, may become a source of grave danger, and an immediate cause of death through various processes of degeneration to which it is liable. In large centres of population, and particularly in hospitals devoted to the treatment of diseases of women, such neglected and desperate cases of myoma are by no means of infre- quent occurrence. I present herewith the specimens and histories of two cases upon which I have operated within a period of one month at the Woman's Charity Club Hospital in Boston. Each of these cases, if not relieved by speedy operation, would soon have demonstrated the falsity of the dictum that " no one dies of a fibroid tumor." Plate XV. — Mrs. C, aged 48, was sent to the hospital by Dr. C. C. Perry, of Bethel, Vt. Mother of seven children, the youngest 9 years old. First noticed tumor two years ago ; it was called a dropsy ; first noticed umbilical hernia two and a quarter years ago. Abdominal enlargement and hernial protrusion have steadily increased. Lately strength has failed very rapidly, with shortness of breath ; has spent nearly all of the last three months in bed. She stated that seven physi- cians had advised her not to seek surgical relief, as she would die if operated on, or because she was supposed to have dropsy ; but Dr. Perry said it was a tumor, and could be removed. On examination, the abdo- men was tensely distended by a cyst which appeared to be ovarian, with some harder portions in the left epigastric region. There was an exten- sive umbilical hernia which could not be I'educed. The ring was large enough to admit the finger. Examination by the vagina revealed an immense cystocele protruding from the vulva. The cen"ix was high up, and the pelvis filled by a fluctuating mass, through which more solid por- tions could be distinctly felt. The patient seemed better nourished than is usual in cases of large ovarian cyst, but was very weak, and had the greatest difficulty in respiration. At the operation, which was performed January 9, 1S90, it was found to be very difficult to give ether, owing to the pressure on the diaphragm occasioned by the cyst. On rapidly m.aking the customary incision a loop of intestine presented, and on trying to get at the side of it with the finger, the thin cyst wall gave way, and a fountain of voluminous chocolate-colored fluid spurted from the opening. Of this three pailfuls in all were evacuated, or about twenty quarts. The incision 578 APPENDIX. was now rapidly enlarjycd, revealing what appeared to be a multilociilar ovarian cyst with extremely thin walls, which did not present the white and glistening appearance which is usual in ovarian cystomata. One mass after another was broken up with the fingers and removed through the incision, while the adhesions, which were very extensive, were separated from the intestines and omentum. \\'ith the last part of the mass the uterus itself was lifted through the incision, when it was seen that the pedicle, about an inch in diameter, sprang from the cornu of the uterus, but did not involve the ovary or Fallopian tube. At first I under- took to sew ofi' the pedicle and treat it extra-pcritoneallv, but the fact thiit there was another fibroid in the uterus lower down, which might degenerate later ; the suspicion that the tumor was a myxo-sarcoma ; the evident necessity of drainage after the operation ; and the need of saving every moment of time in view of the subsequent steps of the operation for the relief of the ventral hernia, — made me decide to remove the body of the uterus. I therefore encircled the cervix rapidly with two turns of rubber tubing, ran the hysterectomy pins through it above and below the ligature,, and cut away the mass herewith represented. (Plate xv.) I now passed my hand up within the abdominal wall to the site of the ven- tral hernia, and finding where the knuckle of intestine entered it, I was able, by gentle traction from within, aided by some taxis from outside, to unreeve through the opening the entire portion of the intestine which had passed into it; the omentum was then easily extracted. I next, with the scissors, cut away rapidly a portion of the anterior abdominal wall, includ- ing the whole sac of the hernia with its various pockets, and at once united the long abdominal incision, except at the lower part, with inter- rupted silk sutures. The abdominal cavitv was now carefully washed out with hot distilled water, and the abdominal waHs united around the stump, a long glass drainage-tube being left in the wound, with two sutures intervening between the drain and the stump. Except for an attack of the grippe and some bronchitis, perhaps due to the ether, the patient made an uninterrupted recovery ; the stump came away on the twentieth day, and is represented in the figure, showing the pins and rubber tube in situ. (Plate xv.) The treatment of the stump consisted merely in searing the cut end with a Paquelin cautery, drawing the peritoneal sur- faces over it as far as possible after the patient was in bed, and burying the stump in powdered boracic acid, and then letting it dry and shrivel l)y exposure to the air ; there was never any discharge of pus or bad odor, and the pocket left on removal of the stump was simply treated with filling it up with boracic acid. The patient left tlie hospital well on Marcli lo; the cystocele was cured by the traction upward of the vagina. APPENDIX. 579 On examining the specimen it was found that not onlv was the cyst wall a mere membraneous sac, entirely ditVerent from that of an ovarian cystoma, but that the secondary cysts, which were observed during the operation, had also no proper walls, but were merely cavities formed bv distention of the interstices of the tumor with fluid. The consequence was that the fluid by degrees drained out of the smaller cavities, so that, whereas during the operation cystic masses as large as cocoanuts, and others of smaller size, were removed, the tumor in alcohol had shrunk to the most innocent proportions. Plate XVI. Annals of Ovn-Ecologv and P.ediatky, March, 1S90. MYOMA OF UTERUS. Miss Mary X, aged 50, was urgently recommended for admission to the hospital for operation by her physician, Dr. Sawin, of Charlestown. Her history showed that she had a tumor for over twenty-five years. It had increased steadily, and its growth had not been arrested by the meno- pause. Some three years ago such difiiculty of respiration supervened that the patient became unable to lie down. The legs have become enor- mously swollen during the last year. On examination, the patient was found breathing with great difticultv -from a sort of asthmatic attack ; the abdomen was occupied by a large, hard mass ; the upper part of the body was emaciated ; the legs hugely swollen. The examination by the vagina showed the cervix high up and small, while the pelvic cavity was occupied by a smooth, rounded mass of bony hardness. The urine contained a very large amount of albumen. The operation was undertaken only on the express declaration of the pa- tient that she would accept death on the table as a welcome relief from utterly intolerable suflering. The operation also was urgently requested by the patient's physician and family. Apart from the danger of giving ether and the shock of the operation, I could see no reason whv the patient could not survive and be comparatively comfortable, while there was some chance that if the albuminuria was caused by pressure it might disappear on the removal of the latter. Accordingly, I performed the operation the next day, Jan. 9, 1S90, ether being administered with the patient sitting on the operating table crosswise, supported on the breast of one of the physicians present, with her head on his shoulder. \Vhen she was under ether an efibrt was made to put her in a recumbent position, but it was quite im- possible, owing to tlie difficulty of respiration which ensued. I, therefore, 5So APPENDIX. standing opposite the patient, whose legs hung over the edge of the table, made an incision through the peritonasum, and, introducing two fingers, rapidly slit the thin abdominal walls with the scissors downward and up- ward, and introducing the hand rolled out the tumor. The intestines followed, which were quickly caught in hot, wet, sublimated towels, and replaced in the abdominal cavity. Now was the critical moment, for as the veins, relieved from pressure, began to be distended, syncope was greatly to be apprehended. We therefore laid the patient down, and were greatlv relieved to find that she was able to breathe in a recumbent pos- ture, while the pulse, after fluttering a little, came up again. The long abdominal wound was rapidly united nearly down to the tumor. A stout rubber cord was then passed twice around the massive pedicle, includ- ing the immensely enlarged tubes and ovaries. I divided the peritoneal covering and capsule of the tumor, as is my custom, several inches away from the ligature, especiallv at the sides and over the bladder, in order to avoid wounding the latter, and to allow for the great retraction of the broad ligaments which takes place under an elastic ligature, but is im- jjossible when the wire loop is used. The capsule was then stripped down from the more solid masses and the tumor cut across over a broad surface. The appendix vermiformis was firmly adherent to a portion of a tube which was included in the ligature, and had to be carefully sepa- rated. Hysterectomv pins were now put through the stump, and as it was found on examination that a portion of the bladder was constricted by the ligature, the anterior part of the stump was pushed and pressed down under the latter until the bladder was free. Thorough irrigation, as before, with the use of a glass drainage-tube and a dry treatment of the stump and boracic acid, were employed. A large amount of serum was drawn from the tube during the next two days, w^hile the patient insisted on sitting bolt upright in bed during the first two nights. An India- rubber tube was then substituted for the glass tube, and some four days later an immense discharge of serum occurred, comprising at least several quarts, which soaked the bed and ran down on the floor. A long piece of tubing was attached to the one in the ^vound and carried over the edge of the bed, and through this the fluid escaped profusely for some two days, when it ceased entirely, and the tube was removed. Tiie patient w^as more or less insane every night for about ten days. Nevertheless, her convalescence was otherwise undisturbed. She learned to lie quietly on her back for the first time in three years. The oedema departed from the legs, and the urine became nearly free from albumen. The appetite was ravenous. The stump was removed on the seventeenth day, still encir- cled bv the rubber ligature. Whether this patient will ultimately APPENDIX. 58r recover from her albuiiiinuii;i or not, the relief aHorded by the operation is very marked, so that the latter appears entirely justified.' The large multinodular growth weighing fourteen pounds shows at its large portion a calcareous mass of stony hardness. As the latter mass occupied the pelvic cavity, its pressiu-e on the ureters was probably largely instrumental in excitinir and maintaininti- tiie all)uminuria. In considering the choice of the methods of treating myomata, I shall confine myself chiefly to interstitial and sub-serous tumors, which do not present any opportunity for removal from the interior of the uterus. I will briefly refer to the fact, however, that very recently a new means has been obtained by the method of Vulliet for widely dilating the cervical and uterine cavities. This consists in the introduction into the uterus ot strips of iodoform gauze, with which it is wholly filled. These are re- moved in from twelve to twenty-four hours, and the uterine cavity irrigated with sublimate solution and again packed with a larger quantity of gauze. By repetition of this pi^ocedure the uterus may be so dilated that two or three fingers may be carried to the fundus, and the internal surface of the latter has even been photographed. The methods and indications for re- moval of fibrous polypi by the vagina are now^ well established and need not claim further attention here. In regard to the treatment of intra-mural or subserous tumors, however, a great controversy rages at present. I am not now referring to the treatment by ergot or by injections of ergotine. This treatment is now so thoroughly understood and so generally adopted that it is safe to say that no myoma becomes troublesome hereabouts until after ergot has been very thoroughly employed. The burning question at present is between those who use surgery and the followers of Apostoli, who undertake to relieve or cure all myomata by galvanic treatment. I will here quote from the latest work of Tait on "Diseases of Women and Abdominal vSurgerv : " — " Havmg diagnosed a case of uterine myoma, what is to be done with it? The answer to this question will depend upon the age and position of the patient and the severity of symptoms. If the patient is under 30, removal of the uterine appendages may be at once accepted as the proper course, for whether the symptoms be severe or not, increase of growth is certain, and operative interference will be necessary sooner or later. " The mortality of this operation at an early period is a mere bagatelle, and the certainty of cure is 95 per cent. After 40, if the hiemorrhage is Mime 10. Five ini-vnths aftir diitiMtinn. I'atitnt iloing- well and can walk about. Some albumen in urine, but no casts. A gooil tical of free fluid in the abdominal cavit}'. 5S2 APPENDIX. not very severe, and even if it is, a fair trial may be made of tlic use of salts of potash and large doses of ergot, together with stringent confine- ment to the bed during eacli period, and during the wliole of its duration. This is of more use than anything else, and it is the reason why we are obliged to operate on poor women when we do not on rich ones, for the greatest kindness to a hospital patient, especially a woman, is to cure her speedily by removal of the uterine appendages." Under no circumstances does Tait sanction " uterine tinkering with injections of astringents or electrical currents. These things are dangerous, irksome, tedious, ami ex- pensive, and, whatever good results, it is not permanent." The mortality of the operation in his hands is one and one-half per cent. He gives a list of 262 cases operated on since December iS, 1881, with four deaths. Of course, it is understood that in neglected cases of degenerated fibroids, and in those ^\ hich continue to grow after the menopause, Tait, like most other surgeons, approves of and performs supra-vaginal hysterec- tomy. The German authors and surgeons, as well as the American, ap- pear to be even more ready to perform hysterectomy, or less disposed to trust to the removal of the ovaries, than Tait himself, and the ingenuitv and skill of some of the most eminent laparotomists of New York and Berlin are devoted to improving the technique of the operation in such a wav that the whole of the uterus may be removed, so that the abdomen may be closed, leaving an opening into the vagina with drainage from below, as after vaginal hysterectomy.' While the thunders of the Philadelphia school of abdominal surgeons are directed against the practice of electrolysis as a pernicious heresv, Schroder, Martin, and other German authors have de- voted great attention to finishing the operation by dropping the stump into the abdominal cavity after securing it well from hasmorrh.agcs by sutures and ligatures. This procedure is not well adapted for operators who do not have the dexterity and rapidity of Martin, and the resources of care- fully drilled assistants and of a thoroughly organized and aseptic hospital. At the best, it takes a good deal of time, and in abdominal surgery time is of the utmost importance. Most men require half an hour to safelv finish a stump so that it may be dropped into the abdomen, where, if the liga- tures are too tight, it will slough, and if they are not tight enough it will bleed. On the other hand, in an uncomplicated case, by the use of the rubber ligature and extraperitoneal treatment of the stump, the whole opera- tion need not require that the abdon^.en be open more than fifteen minutes, and the most successful English and American operators seem to be quite unanimous in treating the stump extraperitoneally as a rule. ' In the introduction to the 2d American edition of his worl; (see p. 30), Dr. Martin describes the procedure which he has recently adopted for removing the whole of the cervix in supra-vaginal hysterec- tomy. APPENDIX. 5S3 In regard to the use of the constrictor, I am personally quite con- vinced that the rubber tube is greatly sujjerior to the wire loop or serre noeud, for the following weighty reasons : Most of the accidents attending hysterectomy are caused by the implication of the bladder or ureters in the loop of the wire constrictor, or by obstruction of the ureters or intestine through too great traction on the broad ligaments. These difficulties can be entirely avoided by the use of an elastic constrictor and by incising the capsule of the tumor at a great distance ai)ove the ligature, so as to permit of a sliding of the broad ligaments and bladder out from under the con- strictor, wdiile the stump of the uterus itself is still held by its connection to the tumor or by holding it with forceps. There is absolutely no danger that the elastic ligature will break, as all hcemorrhage is controlled wnth a relatively slight tension of the constricting tube, whereas it is well known that in applying the wire loop it frequently does break at the most inoppor- tune moment. Moreover, as the slump shrinks the elastic ligature follows it down without care or supervision, while with the wire loop it is neces- sary to have some one continually watching and ready to tighten the loop .as the stump shrinks, As against the united and nearly unanimous opinion and practice of the principal surgeons of the world in favor of the surgical treatment of those mvomata, which are causing serious trouble, stand Apostoli raid his followers, who practically deny the necessit\' of such treatment, and main- tain the use of galvanic electricity for the relief of the dangers and sufler- ings occasioned by myomata. As is frequently the case in such matters, the disciples make more sweeping claims than does the master, and the respect with which the treatment has been received and accepted rests largely on the authority of Keith, who, as is well known, in his younger days gained great distinction by his wonderful success and skill in remov- ing these tumors by hysterectomy. Keith has recently pulolished the his- tories of over one hundred cases of myoma, or what he diagnosticates as such, which were treated by himself with electricity ; and he expressly states that since beginning the use of electricity he has not had to perform hysterectomy, intimating pretty strongly that there is no necessity for this operation for the relief of mvoma, and bemoaning the fact that he had formerly performed it so often. In fact, in his book and elsewhere, he has used very strong language on the subject, stating in effect in one of his articles that it is little less than criminal to perfoi-m hysterectomy for this purpose ; at least until after a very thorough trial of galvanism has been made. Stat mag)ii nomnn's umbra . It is an ungracious task to analvze the reasons which have led this great surgeon to take such an extraordinary position, but it is evident either that such cases as are herewith presented no longer come uniler his observation, or tlie Keith of to-tla\- is not the 584 APPENDIX. master whose courage and skill once elicited the admiration of the pro- fession. An analysis of his cases conlirms this impression — one at least died from the effects of the treatment. Many others were not particularly relieved by it. In others, again, there is very little evidence to show that there was really a myoma jDresent, or anything more than a subinvoluted uterus with metrorrhagia. The time elapsed is so short in most cases- that there is no certainty that the results are permanent. While constrained, therefore, to combat the proposition that elec- tricity will relieve all cases of myoma, and to point out the great fre- quency of cases which can only be saved by speedy hysterectomy, I by no means deny that electricity, when cautiously employed, is an efficient agent, although not entirelv devoid of danger, in combating the haemor- rhage and more particularly the nervous symptoms and suflerings de- pendent on myomata. In this respect some of the good results partake of the nature of the '' faith cure." The claims of Apostoli himself are far less' sweeping than are those of some of his followers. In a recent publication he says : " For the hundredth time I will repeat that my treatment has nothing to do with the unvarying radical cure of fibromata ; and if such result is sometimes observed, it is the exception, and electrotherapy up to the present time has for its sole ambition the symptomatic cure of the patient, and the parallel but limited retrogression of the fibroma."' On the one hand. Apostoli claims that whatever be the nature of tlie fibroid tumor, the electrical treatment, if carried out for a sufficiently long time, will produce absolute effects, always symptomatic and generally anatomical. On the other hand, he admits having seen the method fail in cases of fibro-cystic tumor complicated with ascites. He also warns against the danger of failing to recognize suppurating tubes, and states, that intra-uterine galvano-caustic is contra-indicated in all cases of collec- tion of pus in tlie female pelvis. If the collection of pus is beyond the reach of vaginal interference, Apostoli expj-essly states that laparotomy is demanded. He admits that very serious results may ensue where the necessity of rest after the use of electricity has not been enforced. -I cannot better sum up this question than by quoting from what I have recently written (Annals of Gyn., Feb., 1S90) : — '' It is evident, therefore, that the electrical treatment of myoma, like any other application of a powerful agent, is something which requires- knowledge, skill, and judgment; it presupposes the possession of a diag- nostic knowledge and acumen which verv few men have, and the want of which is liable to be followed by fatal results. If Apostoli could always make an accurate differential diagnosis without opening the abdomen, he could do more than the most accomplished experts of our acquaintance APPENDIX. 585 cliiim to iic able to accomplish. I'hcrc is no doubt that he is a particu- larly able diagnostician and has had an uin"ivalled experience ; l)ut he does not make his diagnosis solely by touch or from the history, but partly ex Juvantibjts et noccntibus ; that is, he begins his treatment prudently, warily, and watching how it is supported by the patient. Great intoler- ance or a rise of temperature after treatment warns him of the presence of inflammatory complications, and the treatment is modified accordingly. His would-be imitators should imitate his caution as well as the rest of his treatment. " Now the practical question which we have to consider is, not what can be accomplished by one individual of extreme skill, caution, and experience, but what results can be obtained by other men of fair ability and moderate skill, who are willing to conscientiously attempt this treat- ment of myomata. The question is extremely difficult, as the cases which are reported are apt to be the successful ones, and particularly those which occur during the early part of the experience of each author with this subtle agent. Possibly a fairer deduction can be drawn from the average experience of various well-known men, both as mentioned here and there in debate, and as communicated in private conversation, and this is to the eflect that on the whole they are disappointed in the results obtained by electricity, and for the following reasons : The fibroid tumors, which occasion the most suflering and the most danger to the patient, are those which are either fibrocystic in character, and which continue to grow in spite of electricity, or those which are complicated with inflammatory affections of the tubes, of such a nature as to make the application of the latter agent both painful and dangerous. Electricity, therefore, fails, or cannot be used, in just those cases where it is most needed ; and those cases where its action is most satisfactory are the ones which would do reasonably well under simpler forms of treatment or without treatment. Hysterectomies, therefore, must continue to be per- formed, especially in the poor, who are obliged to labor, or who live where they cannot get the benefit of skilled medical attendance. " On the other hand, however, I know from published anil unpub- lished cases, from the testimonv of friends and from abundant personal experience, that there is no doubt that many cases can be greatly relieved of suflering and haemorrhage by a judicious and carct'ul use of galvanisiu. To be sure, the hemorrhage can also be relieved by curetting ; but, con- sidering everything, it must be admitted that in many cases it can be relieved quickly, safely, and pleasantly by intra-uterine galvanism. Tlie suflerings, too, which are thus relieved are not those of an intense order, due to inflammatory tlisease, but rather the morbid susceptibility, the 5S6 APPEXDIX. nervous apprehension, the fear and horror of the very idea of a tumor, which make the women thus afflicted wretched, nervous, and miseral)le. " The same gentlemen, wlio, as above stated, assert tliat they are disappointed in the use of electricity on the whole, yet say that they aie not doing so many hysterectomies as formerly, and that they have repeatedly observed the cessation of haemorrhages, amelioration of sufferings, and a moderate shrinking and greater mobility of the tumor under the use of clectricitv ; so that the patients who sought their advice in misery and despair, and readv to submit to any operation, are able to be about and to enjov their lives, and wait w^th resignation for the menopause, which, as is well known, usually terminates their sufferings. To get these results, very strong currents do not seem necessary, and, in short, the prudent and cautious use of an intra-uterine application of a moderate dose of galvanic electricity is something which mav jDroperly be tried, and which will often yield the most gratifying results ; while, if this agent is used in a reck- less, bungling, careless, or uncleanly way, electrical treatment is able and apt to do serious mischief, and even to cause fatal results. " With I'egard to the use of galvano-puncture for myomata, I must speak v.'ith much more limitation. Those who have seen much of pelvic surgery, and know how complicated may be the conditions in Douglas' cul-de-sac, and who know how the intestines, ovaries, and tubes \my be bound together and dislocated in the most extraordinary w^ay ; those who realize how unstable and prone to decomposition are many myomata when once the capsule is penetrated ; those who are in a position to know the sad history of various isolated and unpublished cases, and to receive the confidences of those who are using, or have used, punctures, — will hesi- tate long before emploving the latter. I cannot speak here from personal experience, never having employed galvano-punctures for myomata, and not intending to do so. For me, the woman who requires galvano-punc- ture for a myoma requires abdominal section ; and until more convincing proofs of the utility of galvano-puncture are furnished. I would advise that it be avoided, or at least be left in the hands of a very few men, who, like A2:>ostoli, may be able, by exceptional care, and skill, and experience, to give this treatment a standing in surgery which at present it does not possess. " That it is often effectual cannot be gainsaid ; that it is safe cannot justly be affirmed. Every man must be the judge, according to his own skill and his own conscience, whether it is safer to open the peritoneal cavity by electro-puncture from the vagina or by an abdominal incision. For me, the latter is the safer way, and I believe that anything like a general introduction of the use of galvano-puncture will be a deplorable ' progress backward,' and will in the end necessitate more abdominal sections than it will avoid." APPENDIX. 587 Plates XV'II.-XXV'IIl., p. jrxi. Annals ok CJyn.'ecology, April, 1S88. INCIPIENT CANCER OF THE CERVIX UTERI. Read before the Section for GyncEcology of the Ninth International Medical Con- gress^ by E. W. Cashing, M.D., of Boston, Secretary of the Section. At the meeting of the American MecHcal Association in i8S6, and later and more fully before the Connecticut State Medical Society, I have ■called attention to the views of Ruge and Veit concerning the true nature ■of " erosions" of the portio vaginalis cervicis. It is now generall}' conceded that these eminent observers are quite right in attributing the greatest importance to the glandular hvperplasia, Avhich is really the most important anatomical change underlying the con- dition of erosion, or ulceration, so called. In investigating the subject of cancerous affections of the cen'ix, however, Ruge and Veit have described a condition or change of the glands, which they consider to be in itself of the nature of cancer, a transition from innocent to malignant new formation. This explanation of pathological changes, which certainly do occur as they describe them, seems to me to be much less clearly demonstrable than the view which they maintain concerning the nature of erosions. Briefly, they attribute the greatest importance to a certain filling up •of the lumina of the glands with epithelial cells, eitlier columnar, corre- •sponding to the natural lining of the glands, or flat, with one or more nuclei. They give figures showing how solid processes of epithelium, un- doubtedly cancerous, are found side by side with glands more or less com- pletely occluded by the proliferation of the epithelia, and thev draw the inference that the undoubted cancer originated directly in the solidified glands, and that the latter represent an early stage in the de\elopment of the cancer transition. This fascinating theory agrees so well with the views and theories of Thiersch and Waldeyer, and their followers, that it has been very widely accepted, and a plate showing the transition is given in Dr. A. Martin's admirable hand-book of Gvnitcologv. Nevertheless. I think it probable that greater importance has been attached to this condition of the glands than is warranted bv an\- facts thus far demonstrated. In the first place, as Ruge and \^eit expresslv declare, in the vast majority of the cases examined b\' them, the carcinoma did not originate in the new-formed glands, but infiltrated the cervix as a "■ carcino-sar- coma," an aggregation of small cells, lying in masses, more or less com- SSS APPENDIX. pletelv separated by partitions of connective tissue. In such cases there was no evident connection with the epithelium of the surface, nor with the glands. In four out of twenty-two cases of incipient cancer of the cervix, however, they found appearance of solidification of the glands, and filling up of their lumina with epithelium, which they describe and figure as a transitional stage in the development of the cancer which was adjacent. Of course it is permissible, while accepting the strict accuracy of the description and drawings of these obsei'vers, to explain the phe- nomena described by them in another manner ; and, with much diffidence, I venture to suggest that my studies of the changes in question have led me to different conclusions from those of Ruge and Veit. As it is my custom in cases of lacerated and eroded cervices to remove the diseased tissue pretty thoroughly, and to examine the specimen microscopically, I have found a number of incipient cancers. I have prepared photo-micrographs of two of these and of one doubtful case, all showing the condition of the new glands described by Ruge and Veit. But I have also found in various cases, where there was no suspicion of cancer, a precisely similar filling up of the glands with epithelial elements^ so that I have been led to conclude that this is not characteristic of cancer, but that it is merely a reaction of the glandular tissues to what we in ignorance call an irritation, — a sort of pen^erted growth of the glands which undoubtedly occurs in the neighborhood of cancers ; undoubtedly is an early symptom of cancerous affection, but in itself is not necessarily cancerous at all. The question is of practical importance in regard to the microscopic diagnosis of suspicious affections of the cervix ; for as it is admitted that the diagnosis cannot be made securely by the unaided eye, nor by the touch, and as vaginal hysterectomy is now advocated, and at any rate free amputation of the portio vaginalis is indicated, in all c^ses of undoubted cancer, even in an incipient stage, a great responsibility is thrown on the microscopic examination. It is not a mere abstruse point of pathology ; it comes home to every conscientious gynsecologist, for on the decision of the microscope rests his advice and his action. Case N. H. shows how difficult the decision mav be, — diagrnosti- cated as cancer by the eye and touch, 49 years old, glands filled up, small cell infiltration, broken line of epithelium, papillary projections. Is it a cancer? We can only say that it was likely to become so, not that it is so already, by any safe microscopic landmarks. And here it is right to call attention to the difficulty of stating in any given case that the lumen of a gland is filled up with flat epithelial cells. APPENDIX. 589 The plates of Ruge and Veit are not conclusive on this point. If a ghind is lined with large cylindrical cells, with well-stained long nuclei, and then a section is made which cuts these cells crosswise, or lays hare their free ends, we get a picture of flat epithelium, which is very deceptive, and, with less experienced observers than Ruge and Veit, liable to lead to great error. Even when a whole series of glands lying adjacent to each other show oc- cluded lumina on section, I cannot feel that the diagnosis of carcinoma is justified, but only that of adenoma, — an adenoma which may become destructive, but is not carcinomatous until changes occur in the connective tissues between the glands ; until the boundaries of the glands are broken through by the growing cells, and the proliferation and collection in alveoli occurs free in the stroma of the organ apart from the glands. Even when the new glands are thus manifestly involved in the carcino- matous growth, it has seemed to me that they are invaded from without by the growth of cells in the surrounding tissue. I have not found any evidence that after filling up the lumen of a gland the proliferating co- lumnar epithelium changes to the flat variety, and breaking through the boundary of the gland invades the surrounding tissue. Moreover, in attributing so much importance to the fact that they found the lumina of some of the new glands occluded, Ruge and Veit have not noticed the explanation that precisely these solid acini orbi-anches may b)e the first stage of their existence previous to the formation of the lumen. Such a mode of growth is seen in the formation of new glands in the Avails of a multilocular cystoma of the ovary. These little solid sprouts lined with columnar epithelium afterwards become hollow, and then dilate, forming cysts, A similar mode of growth is seen in the female breast when rapidly enlarging preparatory to the secretion of milk. Shall we, then, say that a case is not cancerous vvhicii shows no dis- tinct structure of carcinoma on microscopic section ; only a glandular hypertrophy, with some of the glands filled with epithelia, and the stroma infiltrated with small cells, the surface irregular and denuded of its epithe- lial layer.? It is not safe so to say. For these are the very cases which, occurring in cervices amputated from women of fifty or over, with old lacerations and erosions of the os uteri, are precisely similar to others which, neglected, become eventually cancerous. Just here we find that the Thiersch-Waldeyer theory of the epithelial origin of carcinoma fails entirely. In just these cases is it impossible to find the transition from the hypertrophic glands to the cancer. The glands are there ; if the case has gone far enough the carcinoma may be just beyond ; but I cannot find a case where the latter arises from the solidified glands bv a transition or a development and spread of the process of solidification. Neither does 590 APPENDIX. it arise by an inward grovvfli of the epithelial pockets which project down between the sprouting papillie. (As seen in Fig. lo, Annals of Gyne- cology, No. I.) On the contrary, the carcinoma develops among a cloud of infiltrated small cells. They collect in masses, while the connective tissue is pushed apart or arranges itself in bands or alveolar boundaries. The connective tissue is manifestly " irritated ; " it is full of small cells ; it takes the stain strongly. Then the carcinomatous process spreads inward and outward, involv- ing and invading the new-formed glands, eating up first a part, and then the whole, of each by an infiltrating cloud of cells, which are small, round, and by no means of the flat, epithelial type, which can be seen where the carcinomatous development has proceeded further. What have we here.^ The mind reverts at once to the " miasmatic infection " of the older writers, to the unknown impulse of Ruge and Veit, who have so clearly described the difficulties in the way of the acceptance of the epithelial theory in cases of carcino-sarcoma of the cervix. May we not reconcile the long contest between the two theories, which assign the origin of cancer, respectively, to the connective tissue and to the epithelial layer of the glands of the organ involved, by suppos- ing that the anatomical arrangement of cells which, clinically and micro- scopically, we call cancer is only the outward and visible sign of a morbific agent, at present hidden from us. Whether there is a mass of small cells, and we speak of sarcoma ; or whether there are sprouting processes of large epithelial cells, which we call carcinoma; whether the cells are alike or varied, large or small, — neither of these facts constitutes the real nature of the cancer. Its preva- lence in certain families, its malignity, its tendency to necrosis, its power of metastasis, its infection of neighboring parts, its rapid sapping of the vital powers, its vile and peculiar smell when exposed to the surface and decomposing, — all these and various other properties point to a class and nature of malady which our present knowledge and mode of regarding disease will not permit us to explain by dislocated fragments of epiblast accidentally included in tlic foetal tissues, or by any of the other hypoth- eses by which the ardent supporters of Thiersch and Waldeyer have attempted to fortify their assertion that every epithelial cell must be derived from some previous epithelial cell. In studying these and many other specimens of carcinoma of the cervix I cannot avoid recalling the time when, sixteen years ago, I was making sections of tissues showing the lesions of tubercle, syphilis, and lepra, and wondering ^vhy they were all so similar, and so like sarcoma, APPENDIX. 591 viz., a clciid of small cells with some large " epithcliod" cells. Now we understand better the morbific agent in the first three of the above mala- dies ; shall we not learn to separate the anatomical evidence of disease from the disease itself.^ If we see a charred and splintered tree, we infer the action of the lightning ; if we see a lung solidified by pneumonia or tubercle, we infer the presence of the causative agent of those diseases. Shall we continue in cancer to suppose that we have only some exaggerated or depraved action of the normal tissues, or shall we infer that this, also, is a disease of infection, a germ disease, like leprosy or rhino-scleroma? In 1878 Ruge and Veit wrote : — "• If we sum up in a few words the result of histological investigation concerning cancer of the portio vag., we have here, precisely in the spot where cancroid most commonly occurs, most frequently observed the origin of the latter from connective tissue. Cancer of the uterus can grow graduallv in an altered portio, or it arises in and from a cauliflower ex- crescence. " A second possibility of its origin is from epithelium, from the epithelium of the glands ; this is the glandular form. The epithelial origin, in the narrower sense, the development of cancer from the surface epithelium with its epithelial cells, we could never observe with certainty. " As is especially evident in glandular cancers, carcinoma owes its real origin to an irritation, to an impulse, the nature of which is unknown to us. " It is possible that cancer., like tuberczilosis^ ivill sotfie day be at- tributed to germs. " Epithelial processes are not the beginnings of cancer." I do not, of course, claim that this can be demonstrated at present;, perhaps no specific bacterium can be found with our present appliances. Nevertheless, we must have some way of regarding this important ques- tion, and I think that we are too much under the influence of a cellular pathology, which regards the changes in the tissues so closely that it is in danger of ignoring the fact that the result of disease is not the disease itself. The practical deductions which depend on our speculative opinions- as to the nature of cancer are of the greatest importance. In the first place, if the disease comes from within, if it is a perverted growth of a part of the tissues, dependent on some original error of development, it is necessarily absurd to try to find, empirically, any medicine which should cure it. Nevertheless, new methods and new medicines are continually coming up, futile, as a rule, it is true. If, however, the disease is an in- fection of some kind from without, we are justified in trying, empirically. 592 APPENDIX. if as yet vainlv. for some remedy which may overcome it. Of more prac- tical importance is the question of the utility of cauterizing the stump (jr cavity from which a cancer has been removed. There is a very considerable amount of evidence going to show that surgical interference with a cancer is sometimes followed by a recrudes- cence of the disease, more rapid and violent than the original disorder. If we consider that the operation opens veins and lymphatics, which some- times become infected with the morbific agent of cancer, just as acute tuberculosis sometimes comes on after operations around a tuberculous joint, we can better understand why a thorough cautery of the tissues left bare by the removal of a cancer of the cervix should be apparently so useful in lessening the chances of the return of the disease. Did time suffice I could trace out many other points in which the theory of an infection fits better with the clinical history of cancer than any other. At present I can only say, limiting myself to the cancerous degeneration of hypertrophic glands of the os uteri, that I cannot find that the glands pass by direct transition into a cancerous degeneration ; that the glandular hypertrophy precedes and accomj^anies the inception of cancer of cervix, and in such cases every gland seems to be a focus of in- tense local excitement, with infiltration of small cells in the neighborhood ; that cancer of the cen'ix occurs almost exclusively in women who have borne children, and, as far as observations go, very largely in those who have long suftered from glandular degeneration of the portio vaginalis cersucis ; that we are, therefore, justified in considering the newly-formed glands as tJie roao? through which the cancerous infection usually enters the tissues, and we are required and obliged to attempt the cure or removal of glandular degeneration of the portio ; that all suspicious cases of erosions of the cenix should be early submitted to microscoj^ical examination, bv excision of a small wedge of tissue, — a proceeding which under cocoaine is neither painful nor difficult ; that where the microscojDe shows glandular degeneration, the surface bare of epithelium, the tissues densely infiltrated with small cells, especially if the woman be fifty or over, we should not say that the microscope only shows chronic inflammation, but that, -uoJiile cancer is ?iot proved., it is not excluded ; and we should recommend a free removal or destruction of the suspected tissue. APPENDIX. 593 INCIPIENT CANCER OF THE CERVIX UTERI. To explain the above paper I have selected a few of the figures used to illustrate it by projection on a screen, and have added other and better ones. These figures I have made by photographing some of my sections of a specimen of cancer of the cervix discovered in its first stages at an autopsy. The specimen was given to me by Prof. Kundrat, of Vienna. The patient had not complained of any such symptoms during life as to lead to an examination or warrant a diagnosis. The gross appearance of the specimen was that of a small ulcer, rather ragged, in a lacerated ixnd " eroded " cervix. Fig. I shows at a the normal epithelial covering of the mucous mem- brane ; at (5, this is broken through rather abruptlv, and the rest of the surface is not covered bv any mucous membrane, nor is it divided from the subjacent tissues by any -regular layer of cells, as is the case in the " erosions " caused by papillary thickening or glandular hypertrophv ; at c is seen a tortuous blood-vessel running up into the cancerous nodule, of Avhich the processes or pegs are seen in cross section. The rapid increase of the cells raises the cancerous surface at d ; above the level of the sur- rounding parts at e the mucous membrane reappears. On each side of the cancerous nodule is seen a gland. In that on the left the duct is preserved, Avhile in that on the right it is known from other sections that a duct existed leading up to surface. These glands are seen enlarged in Figs 2, 3, and 4. Enveloping the glands, and reaching beyond them in every direction, is seen a dark stain covering about half the field. This repre- sents a very active proliferation or immigration of small round cells. For want of any accurate knowledge this is called " an inrtannnat()r\- reaction of the tissues ; " its resemblance toother "• inflammator\' " accumulations of cells around points of bacterial infection is %'erv striking. Fig. 3, Above is one of the glands seen in Fig. i. At a and b the gland is normal and lined with cylindrical epithelium. To the left of h the contour of the gland is lost, and at c it is seen again, but it now is represented by a solid epithelial process. This, however, I do not con- sider to be a transition to a cancerous peg, but a process of rapid growth of the gland in which a lumen w\\\ afterwards ap[)ear ; d siiows the duct 594 APPENDIX. of the gland; r, f., /, cross sections of cancer-pegs; ^, //, a longitudinal section. The centre of the field is occupied by a cancerous mass, whicli, by shrinking in alcohol, lias left a narrow open space. Between this and the gland above the tissue is packed with small cells entirely obscuring the proper muscular uterine cells; /■ is a shadow^, caused by im2:)roper adjust- ment of the ray of light in photographing. Fig. 3 shows the larger gland shown in Fig. i ; towards a the cylin- drical epithelium lining the gland is still to be seen intact; everywhere else it has disappeared, and is replaced b}" a thick layer of large cells, forming a ring around the lumen of the gland, seen in the figure, about half an inch wide. At b and c were apparently processes of the gland, already now destroyed ; at . In most of the sprouts, however, no lumen is visible; and this may be explained in two ways, either by the section running in one wall of a hollow sprout, or by the fact that the sprout buds out into the tissues as a solid mass of cells, and becomes hollow as it gets older and larger. I am convinced that although the first explanation may account for the appearances in some sections, as in the gland opposite C, and in Fig. 15, 3'^et the second exj^lanation is true as concerning the mode of growth of rapidly-forming new glands, as seen at Z>, -£", F^ and in Fig. 16. The subjacent uterine tissue of the vaginal portion is seen in the upper part of the picture to be darker and infiltrated with round-cell nuclei, while in the lower part of the field it is normal. Fig. 15 (450 x) shows the glandular branch seen at C, in Fig. 14. Below the open lumen the ciliated columnar lining is shown very clearly. Over A., B can be seen the dark nuclei occupying the lower half of each cell. To the right, as far as the space over C, the nuclei are shorter and more irregular, corresponding to an infiltration of cells of another and rounder form, apparently due to a rapid proliferation of the cylindrical epithelium, or to a change similar to that seen in Fig. S. Higher up, opposite Z>, the section runs obliquely through the cylin- drical epithelium lining tlie wall of the gland, which here makes a turn, and correspondingly the cross sections of the cells are seen in various degrees of foreshortening. In the middle, on the level of D and above />', the cells have an appearance like pavement epithelium, which they clearly APPENDIX. 599 are not ; and it is also of importance not to confound tlicm with cancer cells, nor to attribute to tlieni any particular significance which they do not possess. The border of this gland on the right is darker, from intense staining of the cell nuclei. By comparing the difierent parts of this figure with the corresponding places in Figs. 14 and 13, a correct idea may be formed of the significance of the dark lines and patches in the latter figures, which represent, in general, dense aggregations of highly stained nuclei of newly formed cells. Fig. 16, (300 x), from another section of the same specimen, shows the above-mentioned mode of growth of the glandular sprouts as solid pro- cesses, at A and B ., less clearly at C and D. The clubbed end of tlie large gland opposite E shows divisions, and ni these an apparent filling up with cells, which I understand, however, as a stage of the process of becoming hollow in sprouts previously solid, and not the reverse. The uterine tissue in which these sprouts lie is normal. Nowhere, then, in this most interesting specnnen is there any micro- scopical evidence of cancer, and yet the case had been pronounced to be such by very able and competent men, and certainly coincided clinically in every respect with other cases which finally develop into undoubted cancer. The microscopical appearance to which I attach the greatest impor- tance is the complete loss of every kind of epithelial covering and the infiltration with small cells. Certainly in such cases of bleeding erosions in women of fiftv or over a free exxision of the diseased parts is indicated as soon as the disease is discovered. Weeks are precious. If we may ever speak of a pre-cancer- ous stage, this is it ; or, rather let us say the disease is now purelv local and superficial and may easily be wholly removed. The operation is a trifle ; the danger of delay is terrible. Plnte XXIX., p. 336. Annals of Gvn.ecologv, August, iSSS. VESICO-CERVICAL FISTULA. Case IV. — Vesico-cervical fistula. — Mrs. Z., age 33, was sent to me by Dr. McGregor, of Littleton, N.H. She has eight children ; the first six were delivered easily, and the last two after difficult instrumental labors. With the last child, two years ago, the labor was verv much pro- longed, and also difficult. Laceration took place at this time. This was previous to the attendance of her present physician. She entered the hospital Dec. 16, 1SS7. Her condition was as follows: Considerably 6oo APPENDIX. emaciated, rupture of periiia-um tlirough sphincter, cicatricial adhesions about cervix, which was deeply torn on each side, and through the an- terior lip was a vesical fistula passing into tlie vagina. The cervical tissue could be felt better than seen, owing to retraction. Bladder was small, and urine flowed away constantly. She was operated for the fistula five times, — Dec. 19, Feb. 9, March i, March 27, and July 5, — each. except the last, being a failure ; the sutures holding properly, and the urine passing naturally for from ten days to two weeks, when it would each time reopen. The parts were refreshed, the amount difiering somewhat at diflerent sittings, and the surfaces at different times were united with silk, silk-worm gut, wire, besides animal ligature. The last operation was performed Julv 5, similarly to the others, except that silk was used which had been soaked in a solution of iodoform and ether. A permanent catheter was inserted in the urethra. Sutures were re- moved July 12, and then it looked as though it would again open : but at the time of her discharge, July 23, it was found perfectly united, and she had recovered. During her stay in the hospital she had gained thirty- five pounds. The perina-um was restored later. Plates XXX. -XXXII., p. 3S4. Annals of Gvn.ecology, January, 1889. Annals of Gvn.ecology AND P.EDIATRY, June, 1S9O. UTERI REMOVED BY VAGINAL HYSTERECTOMY. My experience in vaginal hysterectomy now consists of thirteen cases- all of which were performed for cancer or malignant adenoma of the uterus. The youngest patient was 26, the oldest 66 years of age. All the patients recovered from the immediate effects of the operation. One who was operated on in another State, and who was not seen by me after the operation, died at the end of a week with symptoms of peritonitis, after a historv of verv obstinate vomiting. The operation had been a particularly easy one. Another patient, one of the early cases, in whom the disease had in- vaded the left broad ligament, so that the clamps had to be applied in unhealthy tissue, did very well for ten days, so that she was considered out of all danger. She felt so well that, without permission, she sat up in bed to take her supper. The same night the patient in the next bed heard her make a strange sountl, antl saw lier make a convulsive move- ment ; the night-nurse, who quickly went to her bedside, found her dead. No autopsy was made, but it was thought probable that the death was attributable to embolus, frcjm the detachment of a clot in the stump. All ihe other cases recovered, having a remarkably easy convalescence. APPENDIX. 60 1 Of the cloven cases which recovered, two have since died from re- currence of the disease, — one at tlie end of n year, the other lived over a year. Both these cases are reported and figured here, — Plates xxx.-xxxi. One other is said to have died. I am credibly informed that another has- a mass in the vicinity of the liver, apparently of a malignant nature, al- though thei'e is no local recurrence. All of the others, seven in number, are in excellent health. In all the cases in whom there was recurrence, the disease reappeared within six months of the time of the operation. In performing vaginal hvsterectomy I depart from the method of Martin by using clamps on the broad ligaments, instead of ligatures. I did this from necessity in my first case, not being able to control the haemorrhage satisfactorily with ligatures. The use of the clamps was so' satisfoctory that I have used them in all subsequent cases, making no at- tempt to apply ligatures. A great advantage resulting from this method is that the clamps depress the perinaeum and secure perfect drainage. The operation is shortened by their employment, and after their removal there are no ligatures remaining in the vagina to cause the secretions to be foul, and to require subsequent removal. In applying clamps it is not often possible to put one clamp on the whole of each broad ligament, as Greig Smith recommends; and if this were done, there would be considerable danger of slipping of the clamp. It is simpler, both in application and removal, to use clamps similar to those used in ovariotomy, the lighter varieties which are made for that operation being well adapted for vaginal hysterectomy. I have also devised a clamp which can be applied, one branch at a time, like an obstetric forceps. The vagina being freed from the cervix, both in front and behind, and the pouch of Douglas being opened as described by Martin, a strong clamp is applied to the lower thick part of the broad ligament on eacli side, and the tissues cut away between it and the uterus with blunt- pointed scissors. The uterus can now be drawn down somewhat forther, so that the finger which is passed in front of the uterus, after separating the bladder from that organ, can be made to meet the finger of the other hand in the pouch of Douglas, either above the broad ligament, or, in my experience, more often by perforating the latter close to the uterus but below the level of the tube, where the broad ligament is thin and free from blood-vessels. A clamp can now be applied, first on one side and then on the other, keeping close to the uterus to avoid the ureters ; the tissues which are compressed are severed with scissors on the side of the clamp next the uterus. Then the latter can be everted as Martin de- scribes, and the upper part of each broad ligament, preferably outside of the <^02 APPENDIX. attachment of the tube and ovary, can be secured with a light pair of chimps, making three pairs used altogether, although sometimes catgut ligatures may be used instead of the last pair. These clamps remain in place for forty-eight hours, or even for some hours longer, when they are to be removed. There is no need of using a drainage-tube, as the clamps act as drains ; neither is it well to pack the vagina with iodoform gauze or anything else, as any form of packing obstructs drainage. The operation with clamps is now practically the only method em- ployed in this country, and at present the operation of vaginal hysterec- tomy is fully established as the natural and proper remedy for uterine cancer. I fully agree with Martin that it should be performed in all cases as soon as a diagnosis can be made, and I shall never cease to regret the loss of one valuable life which was due to recurrence of the disease after I had amputated the cervix only, when I might have removed the whole organ. I am persuaded that it is impossible to say m any given case of cancer of the cervix that the body of the uterus is free from disease, and this fact was shown in the case represented by Plate xxxi., where the mucous membrane of the fundus was affected, although until the uterus was removed it appeared as though only the cervix was diseased. Likewise I am sure that the operation of Baker, consisting in high amputation of the cervix, and cauterization of the cavity and wall of the body and fundus, if attempted with anything like the thoroughness repre- sented in the illustrations of that operation, is more difficult and dangerous than vaginal hysterectomy ; moreover, owing to the uncertainty as to the thickness of the uterine wall, it is quite impossible to perform the operation with that completeness which it is easy to represent in a diagram. At the last meeting of the American Medical Association, at Nash- ville, attention was called by Dr. Franklin Maitin to the importance of an early diagnosis of uterine cancer and the advantage of prompt performance of vaginal hysterectomy. Although the same objection was made to the operation which was offered at the last International Medical Congress at Washington, viz., that it is too dangerous, yet it is certain that in competent hands and in properly selected cases the operation is not more dangerous than any other abdominal operation, while the indications for radical extirpation are more urgent than are those for surgical inter- ference in many cases which admittedly require abdominal section. The reasons for the high mortality in the early history of the operation in America are, first, that it has often been performed by surgeons who had never had or sought previous opportunity of seeing it done ; and, secondly, because very many operations were performed in cases where it was impossible to remove the whole of the disease, so that often enough APPENDIX. 603 what should be a surgical triumph has ended in a sanguinary catastrophe. With the more frequent performance of the operation, and with greater care in rejecting cases which are obviously unfit for it, there is no doubt that the results will improve, so that vaginal hysterectomy will be sought and advised more readily and earlier, and will be undertaken and per- formed more dexterously and successfully, with the happy result of saving a multitude of women from protracted pain and dismal death. Plate XXX. —Mrs. H. entered the hospital Nov. 7, 1888. Age, 43 ; three children, aged 31, 19, 14; menses at iG\ no menstrual difficulty. Last period August i, for three days. For several years there had been a vaginal discharge, but until quite recently she had considered herself per- fectly healthy. About the time for her next menstruation, September i, she had a hsemorrhage, which condition has continued ever since. There was a two weeks' confinement in bed on account of great weakness. She was a patient of Dr. Tower, of East Weymouth, by whom she was brought to the hospital. Examination showed disease of cervix uteri, with cer- vix infiltrated and some adhesions in the neighborhood of the left broad ligament. The diagnosis of carcinoma was considered probable from macroscopic appearances, and was verified by a microscopic section. Ether was administered November 9, and as much of the growth as possible was removed by the curette. Hysterectomy was recommended to the patient. This was accepted, and the operation performed November 15. The method was that usually described, except that the uterus was pulled down entirely by the cervix, and there was no turning. Ovaries and tubes were removed. Sutures were of silk. The broad ligaments were not ligatured, but were compressed by four straight clamps, two of the Wells' variety and two smaller sizes. The hcEmorrhage was very little, indeed, and the reaction good. The clamps were removed on the third day and a g-yVo sublimate douche given. The recovery was only delayed a little by a retention of discharges ; and as these were removed without difliculty, the case progressed satisfactorily, and she was discharged Dec. 34, 1SS8. Plate XXXI. — Mrs. X., aged 66^ was a patient of Dr. Hunt, of Newton, and was brought by him to this hospital. She has seven children, and gives no history of any trouble during labors, or any difficulties of men- struation. She had always been healthy till about fifteen months ago, when she began to have a vaginal discharge, usually watery, but some- times of bloody matter. Suffers from weakness because of the discharges. No pain. She learned in September last that she had cancer, and she en- tered here December 9, and had a vaginal hysterectomy performed on the following day. Examination showed carcinoma, apparently confined to 6o4 APPENDIX. the cervix. No operation was thought a(lvisaV)le short of hysterectomy. It was performed as in the foregoing, but without any sutures; chimps were used, and some iodoform gauze packed into vagina. The chimps were removed on the third day. The iodoform gauze w-as inserted for the purpose of antisepsis, and to prevent possible haemorrhage. When the gauze was removed it had be- come rather foul, was saturated with the discharge, and probably caused it to be pent up to such an extent as to favor absorption of septic matter. There was a rise of temperature, and considerable pain. The use of gauze was not a success, as it did not allow drainage, and did aid in a temporarv septic trouble. Gauze is not to be recommended, and will not be used again. The febrile symptoms kept up till the vagina was opened by a speculum and the collected pus was removed. Following this the wound healed perfectly, and she was discharged Jan. lo, 1S89. Examination of specimen showed that the disease had invaded the mucous membrane of the body. Although these patients both died, after the lapse of about a year in each case, yet I have reported them here, to show that no promise can be given that the disease may not recur. In the great majority of cases., however, it does not return, so that good liopes of permanent relief may be given. To show how complete the recovery may be, I add a letter from Dr. Hurd, of Newburyport, who sent me a patient who was miserably wasting- away in the almshouse, having a cancer of the cervix. The operation was performed on March 12, 1SS9. ^lore than a year afterwards she was in the condition described below. Newbl'rvport, Mass.. April 19, 1S90. Dear Dr. Gushing: — The woman to whom allusion is made is not only alive, but in perfect healtli. I see her frequently as she goes back and forth to her place of work. It was a successful operation. There has been no sign of any return of the cancerous aflection. I envy the man that has such unequivocal assurance that he has snatched one human being from the jaws of tleath. The last time that I saw her, to converse with her, she said that she did not remember any- time in her life when she was more free from ailments of every kind, or felt more vigorous. Therefore, you cannot be too much congratulated on the success of this case. Yours truly, (Signed) E. P. HURD. APPENDIX. 605 Plate XXXII. shows a uterus affected with cancer of the cer\-ix, which was removed by vaginal hvsterectomy in January, 1890. The patient, who had been confined to her bed by pain and haemorrhages for three months, made a very satisfactory recovery, except for the occurrence of a vesico-vaginal fistula, which was closed under cocaine two weeks after the first operation. She is now in excellent health, six months after the operation. Plates XXXIII. and XXXn'., p. 3S4. Annals of Gvn.'ecology, December, 1SS9. SARCOMA OF FUNDUS AND-BODY. — CANCER OF BODY AND FUNDUS. REMOVED BY VAGINAL HYSTERECTOMY BY J. G. PINKHAM, M.D., LYNX, MASS. Plate XXXIII. Sarcoma of Fzindus and Body. — The patient was a widow, ^^ years of age. She had been married twice, and had had eleven children and two miscarriages. At the age of 51 she passed the menopause without disturbance of health. Family history excellent. Personal history that of uninterrupted good health until February, 1SS7, at which time, after a hard day's work at washing, a vaginal discharge, similar in apjoearance and amount to the catamenia, came on and lasted three or four days. It was not accompanied with pain. Thereafter the flow recurred once in twenty-eight days, like regular menstruation, with no noticeable discharge from the vagina in the intervals, until June 16, iSSS. At this time, during the flow, she experienced for two days pains like those of labor, in consequence of which a firm, dark-colored, globular mass, as large as a good-sized orange, was extruded from the vagina. After this the vasfinal discharge became oflensive. In August and September of the same year, smaller masses of similar character were passed. 6o6 APPENDIX. On October 1 1 she was admitted to the Lynn Hospital. She was then somewhat pale, l>ut liad a good appetite, and was fairly strong. There was a continuous, bloody, and foul-smelling vaginal discharge, with an occasional passage of masses like those before mentioned. On examination the os uteri was found to be widely dilated, and protruding therefrom was a soft, brittle mass as large as a man's fist. Continuous with this and occupying the whole uterine cavity was a tumor somewhat polypoid in shape, attached to the uterus high up anteriorly and to the right, by a broad base. Under ether the growth was removed with the wire ecraseur, the uterine cavity well washed out. and a mixture of pure carbolic acid with strong tincture of iodine, in equal parts, applied to the stump of the tumor. The basic portion of the growth was quite firm in consistence and of a grayish-white color. The central portion was softer, and resembled brain tissue in appearance. The outer or lower segment, including that part which protruded through the os, was darker in color, and seemed to be composed of blood-clot intermixed with sloughing por- tions of the growth. After this the vaginal discharge ceased, and the patient improved. On December 12 she was discharged from the hospital, feeling tolerably well, but having a hard lump of uncertain character deeply situated in the abdominal wall, just above the umbilicus. Later an abscess formed. This was opened and a drainage-tube inserted. The discharge of pus was profuse, and continued for a long time, the patient being thereby much reduced in strength. Sometime in January, 18S9. the vaginal flow began again. On Jan- uary 31 the curette was used and a large amount of matter like that pre- viously described was scraped away ; after which the discharge lessened, but did not cease entirely. On February 23 and on March 22 the curet- ting process was repeated, each time without ether, the patient meantime losing flesh and strength and becoming quite anaemic in appearance. The curette failed to remove the more solid basic portions of the growth. It was now decided that extirpation of the uterus offered the only rational hope of a cure or even a marked relief of the patient. She was accordingly readmitted to the hospital, and having been duly prepared, the operation was performed on the loth of April, in the presence of Dr. Wm. G. Wheeler, of Chelsea, Dr. S. W. Torrey, of Beverly, and the hospital staff. In making the operation I followetl very nearly the method which I had seen employed by Dr. E. W. Cushing, of Boston. The patient was placed upon her back with the hips well out over the end of the table, and the legs suspended by means of broad straps and APPENDIX. 607 rings to a bar overhead. Irrigation was kept up nearly all the time (luring the operation with su1>Hniate solution, i to 4,000, and carVjolic solution, I to 100, used in alternation. The uterus was first curetted, it being found pretty well filled with the growth. Then it was plugged with iodoform gauze, and the os closed with several stitches in order to prevent the discharge from coming in contact with the wound. As a means of making traction upon the uterus, a long piece of stout silk thread was passed through both lij^s of the cervix. The posterior incision was first made, and the cul-de-sac of Douglas opened. It having been found by exploration through this opening that the parametria were free from disease, and the uterus not too large to allow of removal by the vagina, the circular incision was com- pleted, the uterus separated from the bladder, and the first pair of clamp forceps applied. As an aid in the application the finger carried up behind the uterus was thrust through a thin place in the broad ligament^ and the end brought forward to be used as a guide. The included por- tion of the broad ligament was divided with curved scissors, the point being kept turned towards the uterus. A second pair of forceps having been applied, and the included tissues cut as before, the uterus was so far released from its attachments that it was easily drawn down, retroverted,. and the fundus brought out at the vulval opening. The ujDper part of the broad ligaments, with the tubes, was then clamped and severed, no attempt being made to remove the atrophied ovaries. The record show^s gradual improvement of the patient, with no serious symptoms at any time. On the 21st, eleven days after the opera- tion, some shreddy sloughs, comjDOsed without doubt of the tissues which had been compressed by the clamps, came away from the vagina. In three weeks after the operation the patient was able to sit up, and shortly afterwards left for her home. She is now ni good health. The clinical history of this case, and the gross appearances of the tumor, would seem to leave no doubt as to the nature of the disease. That the question might be definitely settled, a portion of the growth was sent to Dr. W. F. Whitney, of Harvard Medical School, for examination with the microscope. The following statement was received from him : — '• I have examined the specimen received from you, and find that it is a soft, rather homogeneous growth, witli relatively large Ivmph spaces. It is composed of large round and spindle cells, with little granular, intercellular substance. The diagnosis is spindle-cell sarcoma." This' case mav be regarded as a typical one of the class demanding vaginal extirpation of the uterus. Plate XXXLV. Cancer of Body anJ Fundus. — Mrs. S., aged 54, 6oS APPENDIX. American. At the age of 44, having previously enjoyed good liealth, she began to have irregular, excessive, and painful menstruation. A physician was consulted, but the patient obtained no relief, the symp- toms being, as is usual under such circumstances, attributed to the change of life. In iSSi she came under the care of Di". William (i. Wheeler, by whose advice curetting and other thorough measures of treatment were resorted to. The curette was used on four difiereni occasions, the relief obtained being only temporary. For the past two years the flowing and pain have been almost constant. Discharge offensive. Until recently she has declined to listen to any proposals looking towards extirpation of the uterus. But in September, 18S9, having been strongly urged to this course by Dr. Wheeler, she consented to enter the Lynn Hospital, and to submit to the operation. On admission, she was pale, emaciated, and weak. Digital examination showed the vagina and cervix uteri to be in a state of senile atrophy, while the body and fundus were much enlarged and very hard. The difficulties in the way of removal seemed so great that I was inclined to abandon the j^roposed operation. Dr. Wheeler, however, took the ground that removal was possible, and that, as no other rational course of treatment was open to us, it was our duty in so desperate a case to give the patient her one last chance of relief. Yield- ing to his judgment, I operated on the 6th of September, finding my anticipations of difficulty fully met. The uterus could not be drawn down to any extent, and nearly all the work had to be done by the touch without the aid of the sight. Long and patient manipulation was re- quired to separate the uterus from its vesical and rectal attachments, to apply the clamps, and sever the broad ligaments. Division of the peri- naeum down to the sphincter ani was necessary before extraction could be effected. The patient was under ether about two and a half hours. During the operation she was greatly prostrated, repeated subcutaneous injections of brandy being required to keep lier alive. After the opera- tion she rallied slowly, remaining weak for a long time. Several sloughs of skin and cellular tissue formed at the sites of the hypodermic injections employed during the operation. The ulcers thus produced were slow in healing. There was consider- able disturbance of digestion and a moderate fever, lasting two weeks; but at no time Avere there any alarming symptoms. Convalescence was jDrotracted ; but on October 22 the patient left the hosi:>ital, being then in a fair condition of health. The illustration shows the ulcerated interior and thickened walls of the uterus full size after two months' immersion in alcohol. APPENDIX. 609 Plates XXXV.-Xr.lI., p. 304. Annals ov Gvn.wcologv, June and July, 1.589. .SECTIONS OY NORMAL AND DISEASED FALLOPIAN TUBES. The diseases of these organs have assumed such a preeminent im- portance in gynaecological literature and jDractice that a study of the normal and morbid histology is both interesting and useful. As a slight contribution towards a better comprehension of this sub- ject, I offer some plates made from micro-photographs which I took from preparations of some of my specimens. The first three plates are from sections of a normal tube, the others from a severe case of catarrhal sal- pingitis which entirely disabled the patient, and required removal of the uterine appendages. The condition of tl^^ portion of the Fallopian tube which is represented, with a low power, in Plate xxxviii. is shown very plainly by the sub- sequent figures. The resemblance between the lesions here shown and those of chronic endometritis is very striking, consisting of an infiltration of the mucous membrane, with small cells, and the formation of glandular pockets lined with cylindrical epithelium ; although in the wall of the uterus such pockets, or glandular tubes, appear to be merelv a multiplication or pei"verse growth of the glands normally found there, >'et in the tube thev are wholly abnormal, as the walls of the tube normally contain no glands, while the figures which resemble them on cross section are merelv the outlines of the longitudinal fold of mucous membrane {vide Plates XXXVI. and xxxvir.). In the accompanying illustrations it will be seen that in cases of catarrhal salpingitis the thickening of these folds of mucous membrane (Plate XLi.) produces recesses, or pockets, whicli appear on cross section to be closed sacs (Plate xLii.), although they are not to be con- sidered as really closed unless there is evidence of distention, with secre- tion. This condition is noticctl by Martin, and aptlv compai'eil to the condition of the vaginal portion in cases of erosion. The resemblance to the lattei condition becomes much more striking \\\ studying the condition represented by Plates xxxix-xl., representing glands quite similar to those of uterine mucous membrane, which have been formeil in the wall 6io APPENDIX. / of the tube under the influence of chronic salpingitis. It will be remem- bered that in Plates ix.-xiv. a series of photographs is given, showing how, in cases of endometritis with erosion, these glandular growths may spread beyond the physiological limit of cylindrical epithelium, and pass- nig over on to the vaginal portion may replace the flat epithelium by a series of glands and follicles which commonly and clinically are called "erosions," or '^ ulcerations." Qiiitc similarly such glands bore their way into the muscular wall of the tube, where, physiologically, there arc no glands at all ; the tube thus becomes thickened and capable of exuding a large amount of catarrhal secretion, which, if retained, gives rise to the well-known forms of distention of the tube. A study of this condition, moreover, gives rise to some important considerations. In the first place, it is easily conceivable that in such a condition, where glandular pockets are burrowing in the muscular wall of the tube, and approaching very near to the peritoneal surface, an adhesive inflammation should be excited in the walls of the latter, gluing the tube to the surrounding parts. It is, there- fore, unnecessary to refer the adhesions and attacks of adhesive pelvic peri- tonitis to escape of secretion from the abdominal end of the tube, although this mode of origin undoubtedly may occur during the early stages. If the analogy between erosion of the portio vaginalis and chronic salpingitis is admitted, it is of interest to recall the fact that, in the former condition, such glandular proliferations may pass entirely through the whole wall of the collum, and, originating in the mucous membrane of the cer- vical canal, may appear on the outside near the junction of the vaginal portion with the vagina. If the similar glandular growths in the muscu- lar wall of the tube here represented (Plates xxxix.-xl., and Plate XXXVIII., opposite c, above d) ever develop any such activity of growth, they must inevitably cause just such attacks of inflammation of the sur- rounding peritonaeum as, in fact, are known to occur. The second consideration of importance in regard to these changes in the wall of the tube is, that by thus approximating tlic structure of the latter to that of the uterus, they make it possible for an ovum to take root in the tube, and furnish a soil fit for the development of a placenta. It has been pointed out by Profess(M- Tait that so many cases of tubal preg- nancy occur in women who have been sterile for years, or who have had symptoms of chronic salpingitis, that he attributes great importance to the latter condition as a cause of ectopic gestation. It will readily be seen of how great importance these glandular pockets would be in retaining and nourishing an ovum in cases where the acute stage has passed away, leaving, however, the alterations in the character of the mucous membrane of the tube. APPENDIX. 6ii Plate XLIII., p. 3cX). Annals ok (Jyn^«cologv, March, 1889, THE PATHOLOGY AND DIAGNOSIS OF SO-CALLED PELVIC CELLULITIS, WITH SPECIMENS OF SALPIN- GITIS.^ BY E. W. GUSHING, M.D. Few diseases present a more constant and well-defined group of symptoms, both objective and subjective, than the inflammatory aflfection of the pelvic contents, which is so well knov^n under various names. In few diseases has the proper comprehension of the pathology, as derived from autopsies, been so long obscured by notions supposed to be founded on physical examination ; in none has a just realization of the essential nature of the disease been followed by so brilliant and successful surgical measures. Curiously enough, from early times there have not been wanting accurate descriptions of the diseases of the Fallopian tubes, as found at autopsies ; but these were supposed to be affected as a consequence of pel- vic inflammation, rather than as being the essential and causative factor of the latter. It required the surgical genius and success of Tait and Hegar to bring the profession- to realize that the diseased and swollen tubes involved in a mass with ovaries, lymph, and perhaps pus, as described so accurately by Bernutz and Goupil in 1857, ^^'^ verily the same lumps and " efiiisions " we are all continually encountering in pelvic inflammations, and which, under the teachings of eminent authority, have been supposed to be outside of the cavity of the peritonaeum, between the folds of the broad ligament, a supposed inflammation of cellular tissue, forming a so- called " pelvic cellulitis." Verily a case oi lucus a non htcefido. Perhaps it will be worth while to pause here a moment and enjoy the pleasure which delighted the pedantic Wagner, — that of transporting ourselves into the spirit of other times, and observing how wise men have thought, in order to mark our own progress : — " Es ist ein gross Ergetzen Sich in den Geist der Zeiten zu versetzen Zu schauen wie vor uns ein weiser Mann gedacht Und wie wir's dann zuletzt so herrlich weit gebracht." In the first place, it is often supposed that the ancients knew little or 1 Read before the Section for Clinical Medicine, Pathology, and Hygiene of the Massachusetts Medical Society, Dec. 12, 18SS. 6i2 APPENDIX. nothing of uterine diseases, had no works on the subject, and left all treat- ment of such aficctions to ignorant niidwives. Nothing can be further from the truth. The most important uterine diseases have always been, and always will be, clinically the same, although the treatment has improved with the knowledge of pathology, and with the advance of surgery due to the introduction of anaesthesia, and the enforcement of cleanliness. How graphic and true is the clinical description of pelvic inflamma- tion by the father of medicine : ' " If the uterus is inflamed, the menses are suppressed, and the vagina is mottled with many fine veins like a spider's web, the fever is acute and causes delirium, and the menses, when they reappear, are scanty and unhealthy ; if the patient eats anything she vomits, and pain invades the lower part of the abdomen and the loins, :and the patient faints and shivers through her whole body ; but the belly is sometimes hard and sometimes soft, and is inflamed and swollen." Then comes the description of the symptoms of subacute general peritonitis, which sometimes ensues, and the severe course of which is described. To this let me add the description of the results of local examination from Mercatus, the court physician of Philip II., of Spain : " " If the posterior and superior part of the uterus is inflamed, there is pain in the parts around the navel, and sometimes we see them raised in a swelling ; but there is worse pain in the loins, and the excrements are passed from the bowel with difficulty," etc. " If the fundus is inflamed, there is acute pain in the lowest part of the abdomen, so that the latter seems unable to bear any touch, even externally ; and the uterus is usually drawn toward the inflamed place ; and this accounts for its os and collum being turned the other way. It differs from an hysterical attack in the ardent fever and intense heat of the part. If the anterior part of the uterus is affected, a difficulty of urination or a stillicidium ensues, and there is severe pain in the umbilicus and the parts near and below the latter ; and if the finger is placed against the os uteri it feels to the touch hard, close, hot, and retracted, especially if the inflammation is in the uterus itself or in its neck; and by the pain, hardness, and heat you will distinguish this condition from pregnancy. " But if the sides of the womb are inflamed, the groins are tense, and the thighs are moved with difficulty and pain, and in some cases the leg on that side limps in walking," etc. Then follow the symptoms of suppuration, with a graphic descrip- 1 De morb. mulierum., lib. li. 8 De virg. et vid. affect, et dc uteri niorbis, lib. ii., p. 600. APPKNDJX. 613 tion of the severe cases, and a description of the various ways in which the abscess breaks ; the relief afforded thereby ; the treatment with poultices/ sitz-baths, narcotics, vaginal injections and vaginal supposi- tories, cotton tampons medicated with emollient and discutient decoc- tions, cupping and venesections, the latter only when the inflammation does not arise from abortion, nor from severe labor, or if the patient has not lost much blood. " Universa etenim curandi phlegmones ratio in prohibitione ejus quod fit et ablatione ejus quod factum est constitit." (" For the universal method of treating phlegmons consists in preventing whatever is forming, and removing whatever has been formed.") If resolution does not come on, suppuration is encouraged by appro- priate treatment until it comes within reach, when it is to be opened after the surgical method of ^Etius, which consists in cutting the integument with a knife and opening the abscess with a hot iron, placing the woman in a position favorable for drainage, and washing the cut three times daily. I have brought here several of my books, in which the curious will find how various wise men have considered this subject before us. To understand them it is only necessary to remember that the uterus in gen- eral included the os externum or vulva, the vagina or sinus or cervix uteri, the OS internum (now called externum), the collum or vaginal portion, as well as the tubes or cornua uteri, so called from the fancied resemblance to the horns of animals, situated on the uterus as the head. Of course the tubes were well known before the description of Fallopius, from whom they now take their name. The question naturally arises as to how much better off is a woman with pelvic inflammation now than was one similarly aflected in the time of Philip II. Probably, in acute cases, not much better oft', as far as medical treatment is concerned. The disease is the same, the therapeutics are the same, except that the surgical treatment is now bolder, surer, and better, under favorable cir- cimistances and in the hands of experts. But it may be said that these ancient authors knew nothing of pelvic cellulitis ; they laid all the trouble to inflammation of tht uterus and its- appendages ; they did not know about the '• areolar tissue." That is where they were in the right, and where in modern times the greatest error has arisen, it is only within the last few years that really accurate views have again prevailed as to the nature of pelvic inflamma- tion. That the Fallopian tubes could be diseased and adhere to the ovaries and to other parts has long been known. 1 " Make and apply to the lower abdomen a poultice of foenugrecum, linseed, wheat flour,'boiIed figs, and turpentine." 6i4 API'ENDIX. In his classical work, which I have here, Fallopius says distinctly that the tubes are never adherent to the ovaries unless as the result of severe disease of the uterus : — " Nunquam observare potui meatus istos seminaries conjunctos cum testibus, nisi uterus male aBectus fuerit. Nam si in uno latere adfuit tumor aut cancer, ejusdem etiam lateris testis ita contractus ct colligatus cum dicto meatu apparuit ut connati simul viderentur, at oppositi lateris sani scilicet testis non ita se habere semper visus est. Sin autem utrum- que latus erat affectum, uterque meatus pariter conjunctus cum teste a me reperiebatur, hocque bis aut tcr ad summum vidi." (" I have never been able to find those seminal passages (tubes) joined with the testes (o\'aries) unless the uterus was diseased ; for if on one side there was a swelling or cancer, the ovarv of the same side appeared so contracted and adherent to the said passage (tube) that they seemed congenitally united. But the ovary of the opposite healthv side never seemed to be in such a condition. But if both sides were affected, each passage was found by me equally joined to the ovarv ; and this I have seen twice or at the most three times.") De Graaf,^ in his celebrated work, which I show here, figures Fal- lopian tubes deformed and occluded at their extremities. After De Graaf, and quoting his work and that of Fallopius, comes Ruysch, of Amsterdam, who in 1725 published at immense expense his treasury or catalogue of his wonderful museum. Fortunately I am in possession of a copy, which I have here. He correctlv explains- and figures the occlusion and dilatation of the Fallopian tubes and their adhesion to the ovaries, due to inflammatory processes usuallv following difficult labors, and insists on the consequent sterility. He relates cases of puerperal fever with autopsies where the pelvis was full of foul matter apparently regurgitated or forced through the tubes from the uterus. He insists on the frequency of inflammatory aflections, and conse- quent great distention of the tubes, which he says he never would have believed if he had not made autopsies on so many women. I will not take up any more time by quoting these old authors at length ; but as they are overlooked in the modern references to tlie subject, I have thought it well to present their books to-night. It must be remem- bered that these works were in their time great authority, and were con- tinually studied and quoted ; the successors of these authors in Europe • A plate in the same work (De Graaf, " Opera Omnia," 167S), showing a tubal pregnancy copied from V'assalius, and properly interpreted, is interesting at this time. Ann. of Gyn., December, 18S8. ' Anatomical Observations, 43, 84, and 85, " Adv. Dec," i., p. 6, th. ix., 15. APPENDIX. 615 have therefore always preserved a just comprehension of the nature of pelvic disease, and descriptions of the various forms of salpingitis are scattered through the works of the pathologists and gynaecologists of more recent times. A very full bibliography of the subject is given by Professor Wylie at the end of his admirable article on salpingitis in the recent " American System of GyucEcology," edited by Professor Mann. It is needless for me to repeat it here. It is sufticient to say that about 1884, by the writings of Marchal de Calvi, followed later by Nonat (1849), and yet later by West, wSimpson, and others, the seat of pelvic inflammation was located in the areolar connective tissue which surrounds the cervix and fills out the broad ligament. On the other hand, Aran insisted that the masses felt during life and found after death were connected with the uterus and tubes. In 1857 and later, and more fully in 1863, Bernutz and Goupil described and explained the real nature of pelvic inflammation with precision and ac- curacy ; by the courtesy of Dr. Sinclair 1 present their work to-night. It now seems difficult to understand why their observations did not have more effect on the profession, especially as the discriminating mind of Thomas ^ very early supported their views with the weight of his authority, while Emmett has always upheld the doctrine of "■ pelvic cellu- litis," and T believe was, until very recently, still unshaken in his opinions. * The popularity of the works of the latter author, the authority of his personal teaching, and the inffuence of the men who have studied under him, combined with the fact that the doctrine as taught seemed founded on the plain evidence of the sense of touch, — all these causes conspired in this country to smother the truth as taught by Bernutz, until the results of the autopsies described by the latter were supported and emphasized by the results of hundreds, ay, thousands, of operations for salpingitis, where the evident "cellulitis" could be felt to disappear from the " broad liga- ment," as the operator shelled out a pus-tul)c and ovarv trom behind the uterus. It is not always easy to understand what is meant by pelvic cellulitis ; but as far as I comprehend the various authors, and as I previouslv under- stood the subject myself, it is as follows : — The disposition of the cellular tissue in the pelvis is prettv well known. Something like a year ago I read before the society, in connection with the subject of tubal pregnancy, a translation from Bandl " of the instructive 1 Diseases of Women, 2(i ed., 1S69, pp. 3S0, 381 et seq. • Ann. of Gyn., February, 1SS8, p. 324 et seq. 6i6 APPENDIX. work of Schlesinger, who, by injections of air and of liquid glue between the folds of the broad ligaments, near the tubes, showed that areolar tissue, loosely connected, ran between the folds of the ala vespertilionis up along the psoas muscle, inwards around the cervix, and between it and the bladder, outward to the inguinal ring, and downward between the rectum and vagina. Now this is precisely the course taken by the pelvic collections of pus in seeking for an outlet ; and when on examination of a patient a mass is found laterally and posteriorly to the uterus, nothing is more natural than to suppose that the hard mass is in the thickness of the broad ligament, and thus entirely outside of the abdominal cavity, below the peritonaeum. If the mass enlarges, it would be held that the peritonaeum lining the cul-de-sac of Douglas is lifted up, still leaving the " effusion of lymph " extra-peritoneal ; if after death the ovaries and tubes are found diseased in many cases, it was urged that these were bad cases, and there- fore fatal ; that here the tubes or ovaries were aftected because they also were between the folds of the broad ligament, and more or less connected, on one side at least, with this areolar tissue. That, however, most cases which are not fatal, and which recover without suppuration, get well be- cause the lymph in the areolar tissue is absorbed. If the pelvic peritonaeum is inflamed, it is held to be by extension of the disease from its point of origin between the folds of the broad ligament around the blood-vessels and lymphatics. This, as I understand it, is the doctrine of pelvic cellulitis or para- metritis. It is plausible, fascinating, but. as I believe, entirely false, except perhaps in certain puerperal cases, where a rent, extending at the side of the cervix right into this areolar tissue, may become septic like any other wound. How, then, shall we explain the symptoms.'' If the mass or masses which we feel are not in the broad ligament, where are they ": If not effusions in the areolar or cellular tissue, where are they.- In answering this I will premise that I am well aware that in one sense the tubes and ovaries are between the folds of the broad ligament ; but when speaking here of the broad ligament, I mean that part of it which comes up to the limit of the side of the tube, or to the hilum of the ovary — regarding these organs as practically in the general cavity of the abdomen, like the fundus of the uterus itself. I answer, then, that the mass as felt is in the pouch of Douglas, behind the broad ligament, or laterally at the side of the fundus uteri, or even sometimes on one side posterior and on one side anterior to the latter. What is the mass? It is a distended tube, or tube and ovary, which mav or mav not be imbedded in a mass of lymph more or less recent. la APPENDIX. 617 bad cases, there may be pockets of serum or of pus outside the tubes, but yet within the cavity of the peritonaeum, above the latter, and roofed in by coils of intestine matted together and lined with lymph, which may form a strong and smooth membrane — a sort of sac for the abscess. (See Fig. I.) If the areolar tissue is entered, it is secondarily, while the abscess is finding its way out along the lines above described. The diagnosis is to be made between this condition, with its various subdivisions, and the tumors proper and cysts which are found in the same locality. These comprise : — 1. Distended tube and its complications: Hydrosalpinx ; hematosalpinx ; pyosalpinx ; tubercular salpingitis ; tubal pregnancy ; abscess between tube and ovary surrounded by sac ; serous collection in pouch of Douglas, adjacent to tube and roofed in by adherent intestines ; pus-pockets in the same locality as the last, but usually more thoroughly enclosed by a wall of lymph. 2. Tumors or other possible conditions : Parovarian simple cyst ; parovarian papillomata ; small cystic tumor of ovary ; small dermoid cyst ; fibroid tumors of uterus ; faecal collections ; haematocele (intra-peritoneal). 3. Cellulitis proper : Periproctitis and perityphlitis ; psoas abscess, descending ; abscess around vermiform appendix, descending ; infected wound of cervix and vagina. Inflammation of haematocele (extra-peritoneal), or of tubal pregnancy (after rupture between the folds of the broad ligament). The differential diagnosis of the above affections is often difficult and sometimes impossible without an exploratory incision. Very frequently two or more of them are combined ; e.g.^ the chief cause of suffering in a case of fibroid (myoma) of the uterus may be, and often is, a complication with pyosalpinx. So also a tube in a state of moderate catarrhal salpingitis may, when nearly healed, become the abode of a tubal pregnancy, and this in turn may by rupture lead to a pelvic haematocele, and to severe attacks of pelvic peritonitis. It would unduly prolong this paper to discuss elaborately the subject of differential diagnosis ; but -there is one point in the symptoms or history of the case which always leads us to suspect tubal disease, and that is the occurrence o^jfever. The patient usually can give a very definite answer to the questions, Did vou ever have inflammation of the bowels? How long were you confined to bed by it? Did any matter form and break? Then there will be a history of repeated attacks of pelvic pain with fever.. 6i« APPENDIX. of severe and repeated suffering during the menstrual periods, of lameness, backache, etc. Usually, or always in old cases, there is a history of re- peated and fruitless attempts at mechanical assistance : the patient cannot wear any j^essary ; Drs. A, B, C and X, Y, Z have trieil to fit pessaries, but they all hurt her, and often she has been very ill after the womb was " raised up with an instrument." The patient is said to have an adherent retroversion : "her womb is grown on to the back passage," or there is an anteversion or lateral version. In many cases there is a recent history of suppuration. The patient is found in bed, with the symptoms described by the ancient authors above mentioned, who, be it said, also describe at great length the hard masses which remain unless the " peccant" matters are properly "concocted" and eliminated. Or there is a fistula, continually or occa- sionally discharging pus ; in the latter case there is usually an account of attacks of pain and fever whenever the fistula closes. It is very difficult to describe exactly the feeling on bimanual examination ; by repeated practice a certain familiarity with the pelvic organs and their relations is acquired which cannot easily be adequately conveyed in language. The first thing observed is that the examination is painful to the patient. The uterus appears displaced ; at first it seems retroverted, but by careful examination it is usually found that the fundus is ante- verted and often drawn to one side, showing that the tender mass be- hind and lateral to the uterus must be something which does not belong there. Now. small ovarian tumors, dermoid cysts, and cysts of the broad ligament do not give rise to fev-er, and are not usually painful to the touch, unless owing to some complication ; the same may be said of fibroid tumors when small and subperitoneal ; tubal pregnancy can usually be excluded, especially in chronic cases; the tumors of simple hydrosalpinx are not fixed, but movable ; " pelvic cellulitis," i.e.., inflammatory effusion between the folds of the broad ligament, is practically a myth ; pelvic haematocele has a characteristic history and course. Therefore, by exclu- sion we arrive at a pretty clear diagnosis of salpingitis and consequent localized peritonitis. Especially is this opinion confirmed when another mass is found on the other side of the uterus, also tender, fixed, and chronic. The only double tumors likely to be found en Ijotli sides, except distended tubes, are ■double papillomata of the broad ligaments and double dermoids, both of which, bv their lack of fever and tenderness, and bv their steady growth. APPENDIX. 619 soon dirterentiate themselves from tubes, and require an operation which settles the diagnosis. It is often desirable, especially before deciding on an operation for removal of diseased tubes, to examine the patient under anaesthesia ; the relaxation of the abdominal walls, and of the muscular floor of the pelvis, and the consequent relief of the pelvic organs from pressure, wonderfully facilitate the examination, which is completed by a rectal examination, W'ith two fingers in the rectum, the thumb in the vagina, and the other hand on the abdomen. I may here observe that great care must be taken not to rupture the pus-tubes nor to squeeze out pus from imperfectly occluded fimbriated exti'emities. Such an occurrence might easily be, and in fact has frequently been, followed by a severe or even fatal peritonitis. In such an examination, the first landmark to be sought for is the fun- dus of the uterus ; just as in the corresponding operation for removal of the tubes, we start out from the fundus to determine their position, size, and attachment. In normal cases, especially under anaesthesia, the tubes can usually be felt at either cornu, forming, with the round ligaments, bodies which feel about as large as lead-pencils, which can be rolled under the fingers, and moved freely about. After an attack of gonorrhosa, their increase in size and hardness can often be observed long before acute perimetritic symptoms develop. In catarrhal salpingitis, where the fimbriated extremities are occluded and the tubes are distended, they can be traced as soft, sausage-shaped bodies at the sides of and behind the uterus, sometimes quite large, but usually freely movable and not very tender to the touch. In pyosalpinx, however, they are more apt to be fixed bv repeated attacks of pelvic peritonitis ; the tubes fall down behind the ovaries, as described so well by Wylie, and are glued to them ; the left tube gener- ally gets first into Douglas' pouch and keeps the other out ; tube, ovary, and effused lymph form a mass of a size widely varying from that of an egg to that of the two fists, or larger ; on one side this blocks up the pouch of Douglas and presses on the rectum, and bulges down behind the uterus; on the other it may lie further forward, even at the brim of the pelvis, where it is rejidily felt as a liunp in the iliac region. If the tubes and the neighboring adhesions contain mucli pus, fluctuation may be distinctly felt, with the well-known symptoms of pelvic abscess ; more frequently the mass is hard or doughy ; often it varies from week to week, as pus and serum distend the tube and the surrounding pockets, and then are gradually absorbed again. That is the real nature of pelvic cellulitis ; and nothing is more sur- prising and convincing than to feel from the vagina the disappearance of 620 APPENDIX. n mass, supposed to be in the areolar tissue of the broad ligament, as the operator unrolls and shells out a pair of pus-tubes. It may be said that there is nothing new in all this. Such affections of the tubes are described by Bernutz and Aran, by Kiwisch and Ed. Martin and Klob, and by many others. That is true; but what is com- paratively new is the realizing sense, on the part of the profession, that the tubal affections are the origin and not the consequence of the pelvic peritonitis ; that the former come directly from the passage of infection from the uterus into the tubes. From this last fact results a growing appreciation of the danger of infection from gonorrhoea, and from sounds and instruments. The pithy remark of Crede, "that he who does not examine a woman does not infect her," is well worthy of remembrance, both in regard to obstetrical and gynaecological work. I purposely say little as to the causes and symptoms of the disease ; are they not written in all the books? It is all an infection from one cause or another. The immense importance of gonorrhoeal infection in causing tubal disease is becoming more and more appreciated both by the profession and the public ; and the erring husband who hereafter infects his wife will receive the execration he deserves. An important duty rests on the rnem- bers of the profession in duly impressing on men the danger of infecting their wives, even after they themselves seem to be cured. But it will be said that this explanation may suffice for old, chronic cases, which are operated on either for severe inflammatory attacks or for unendurable pain and loss of health. But how about the cases which are "resolved" and get well? How about a woman who "catches cold" after " local treatment " and runs through a course of cellulitis, where there is a mass in the pelvis as big as a child's head at term, the uterus fixed, the roof of the vagina hard? This cannot be a tube, neither is it an abscess, for it does not suppurate, but under expectant and soothing treatment it all goes away. Now these cases are frequent, and in the first place very many or most of them do not get well entirely, but have a mass of adhesions and a disease of the tubes left, which cause sterility and future trouble. Some do get well, however, and bear children. What 'S such a mass? Is it not in the areolar tissue? No, the mass is inside the cavity of the peri- tomeum. It is chiefly one or more serous cysts, bounded by the perito- naeum below, and above by adhesions and by coils of intestines. The hardness is caused by involuntar)' contraction of the muscles, and by tenseness of the cyst ; possibly to some extent by an infiltration of the adjacent "areolar" tissue with a gelatinous substance ; the origin is in the tube and the cause is the " treatment." APPENDIX. 621 Another group of cases, too important to be more than mentioned to-night, are the cases classed as cellulitis which followed labor or abortion. Here again every one, in discussing the subject, admits a puerperal •■ cel- lulitis " of the " areolar tissue ; " but how many such are seen post-mortem ? Beside the cases of acute septicaemia, thrombosis, etc., when there is peritonitis, what is found at autopsy.' Just what Ruysch found (Obs. 43, 84, 85), — a collection of foul matter_/>ee in the pelvis^ the tubes diseased, .and similar matter in the tubes and uterus. Most- of these patients die; although in some the matters are shut out from the general abdominal ■cavity, a pelvic abscess results wliich is not between the folds of the broad ligament; if this matter is evacuated, the diseased tubes remain, and may -give rise to continual trouble afterward. In some cases a condition of comparative comfort results ; but the diseased tubes can be detected long afterwards in very, very many cases in women who never recover their health perfectly. Very lately, Tait has operated on a series of these puerperal cases. He reported eight in June last,^ with two deaths. J. Price (and per- haps others) has followed him in this country, having operated, as he writes me, on seven puerperal cases up to the present time, with two deaths. In all the cases there was no sign of disease between the folds of the broad ligament ; salpingitis and pelvic peritonitis were what was foimd. I saw myself one of M. Price's operations on a woman with pelvic inflammation after abortion, and I shall never forget the hugely distended pus-tubes, large as Bologna sausages, which were shelled out, while the pelvis was full of stinking pus in pockets running up between ti e intes- tines in all directions; it was, as Ruysch said, "coUuvies humorum non sine magno foetore." Here is a great field in the future for the snatching of women from almost certain death by an operation which, if not de- ferred until too late, offers a good prospect of relief. In illustration of the foregoing, I present to the society a series of pathological specimens removed from my cases, the histories of which have been condensed into the followino- table : — I Ann. of Gyn., June, i8 622 APPENDIX. • m >. •= 1 "7 ;> 5~-^ <£5 ^ fct = ^ 4J c i BOW •cES C S'c— «< ' "> (5 X u 3 X O.C 5^5 c c c k. ."" u iJ?-= :- . ^_, TJ.E X •:2 ■c X X X X X X e of on aftc ructi of nth wo \ died « 1) u III v v u H >• r u V v c 3 rt u c — 5 =•0 HX "• U) h X c X rt 0) > c X > c X X « > c X « > X X rt XX u — X c u C Z-^rt < < <: < <; < < w 2 " « '^ " >> >< > >> >< ti. >| > X x" ^ X X x x' X ■ijjoq JO 3UO c c c c ■^ e K « S5 « n CC n c C £ 73 c X !2 It- •r. > ■- 3 X c rt 'St X c rt rt « X nd pelvic th hstula id vagina ; verywhere Tin "former tonitis. uS. •S.!;^ cii c c •3O 1-s o_ _£.- >< ^ rt X E 't ^ c- tmc X " c c c _ ^ r^ yosalpin abscess, to rectu intestini adheren general c >1 1"? 1: "5 c c. d rt rt m •f 3 5 u X 'c X 3 3 X So c K Bh U CL, Oh Ch b U U< cu •aSESStQ !» m M £ 2 S2 lit JO UOIJEjnQ >-» >-■ ?^ >> >< >^ >. >y ■ " ■^ - ■* rO -^ •>f f»3 •U3jp rO t. -HMO JO ■OX •3]^u!S JO paujfj^ S ^ en % is' S S s S s 9Sv S ft- «> •8 ft «" wj ft a »i f? ^ ;■« ?fi ffi ^ ^ a S 1 .c S" .;; Ji ■§ •A N .; 00 uT Q ^ c 3 >— > c •— > <—t ■— > ^. 3 <; 6 ^ « rO •«- VO « r» 00 o> Z APPENDIX. c in 3 c T3 >, • c *- c a "a c — T8 t3 « tj JC 3 = ^ Si a3 ioo c.« ■5 c o ■o c he c 1/ c c bJlC ES i> or 5 u c 0/ P •o a •c •c •c i L. k. o % ^ ^ -:3 o x; > 2 >■ > 01 11 > i! o ID p. "3 C 1 u 2 c n x: ■M > o. o o u Pi K A w » « V, K « d di PC « pi « K « ■ K - — - W ffi E ai !ii E ffi XI 3 x> 3 X) -^ii ox 3 4) J. ^x 01 uT 11 X Ul 11 c . c ^5; ^5 u in-C ^1 "5 , es una Ul 11 X X 3 uT ^x CJ O 3 o o O h O T) ?-, .- j: V 3 i V u c 3 *•* s .». bo X .*. I •« 01 c u O-X 3 a, CJ X o rt 5 X m c Sf t> > 01 *r ^ hn Ul X (D > > > > 3 u > o o o 3 O ^ X -C i« «i (« X in Ul « 3 X X 3h r y. < p. FE K c o u E ,; X c o X) e >> s c E 3 X "3 > o S 3 Ij V b V. n. E g tC U E .i;«j:j= Mao ^* 41 v to > b b > >< > >■ J3 X X x' x' X O o P3 n PQ o; « c PQ ■" 1/1 „ • c • ~u , < ^ c ¥ u 3 5; . c S", i^ o u i: C Ul X3« 3 .. <— 3 O _ C I/- s c •a c ■ X ?, ^• c y rt '2.0 E fS ?^ « X c 1 T3 C n •a c "S. ■a 1, x' c c !§■ .Ec > >,0 c i> c o X E 3 3 >< c 6 c 'a. o cu Hi Dh Oh cu 0, C^ ^ o E E (/■ >% >^ >, •^ r< t^ N « rO "1 N re o N " o O o s i ^ s s § ^' s s > o > 1 > 01 c c n ■— > ;." s ::> ■«• i:^ >o »^ 00 ? 634 APPENDIX. J3 n = — 3-3^2 j: W) - i 3 .. ^22 2 H S C u ti« =1: > ■jCi3A033>{ JO qicaci JO jviidsoH cuS ."Si C8 O 3 5" 5 P"^ c = 5 icle 3 3 c« •0 •a & V a. >. 0. ? 3 —* tof JC" S :« ii-tj 3 3 ^ r^ w 1^.^ 3 E ■« a u V a a-o _• a !>ii « 1. S: L. ^ a 3 3.5 ^ a a 5r, rt be a 3 < < < < " X aJT^a a i; -2 = S S = C = K 5 J3 - ^ p. - I > S°=.2-|£ O - -o -a '.c — 1. u. t: a. < •q^oq JO auQ ■s c c 1 n n 03 n n CQ "^ a. -.0 C 3 >.E 5 a a:? 0.0 U C-T3 •£•?.= •-ai - 3 ^.Ef^ S-5 2 C ^ ? 5 y ^ 3^ kjjg •" « C »-.- " ■0 = t iS — 3-S ° Ct) b S «3«U, o '-'— « C W5« u « u C/3 •Bog 3 U S .• •T3 C p a^ 4) •I se . u . 3.2 ^ > -"3 „ i 5) ?>a = .= 3 a< •aseasfa JO uopBjnQ u >% • ^ 'U3jp -HMO JO -OM - " - - « . •3l3uis JO pSIJJE}^ 73 s s s s s s •32v 8, "4 ? 5 ^ :^ :^ :^ -if :^ .^ ^ . Q .0 J3 a I— > a a a 1— I (I. 01 d. d „ ^ 8 Z ■^ " n " M APPENDIX. 625 Case XXVI. (Platk XLIII.)— This patient had a difficult labor fourteen years ago, followed by inflammation of the bowels, and she has never been well since. At various intervals she has had discharges of pus through the vagina or rectum. For some six months she has been a great sufferer ; and, vs'hile waiting at the hosjoital for some two weeks before the operation, she was not able to leave her bed, having pain, fever, and haemorrhage. In the pelvis, to the left of the uterus, was a large mass, showing indistinct fluctuation ; to the right, and higher, another smaller mass could be felt. Latterly she has been under the care of Dr. J. P. Bush, who was present at the operation. On section, the left tube was found as large as the small intestine, and so closely resembling the latter that by the eye it could not easily be distinguished therefrom. As one end however, was clearly connected with the cornu of the uterus, while the other was attached to a fluctuating sac, I proceeded to shell out the latter, and finally removed the tube and the abscess sac, as seen in the specimen and in the photograph. During removal, however, the sac burst and deluged the pelvis with foul pus. This was well washed out with hot water, everything was cleaned and disinfected, and then the pedicle was secured, the other pus-tube and ovary were removed, the abdomen again thoroughly washed out, a glass tube inserted, and the wound closed. There was never any fever nor trouble of anv kind during con- valescence. These twenty-six cases, occurring within a period of eight months, comprise all the operations for salpingitis which I have performed up to February 7, 1S89. A great many other cases which undoubtedly would be benefited by operation have been declined, postponed, or put under observation, because the symptoms did not seem sufficiently severe to warrant an operation. The cases of pyosalpinx proper, where there are collections of pus in the tubes or in encapsulated cavities between the tubes and neighboring organs, are the most satisfactory cases for operation, as the indications are clear and urgent, and the danger of carrying such tubes in the body is not inconsiderable. Moreover, it seems as if, by the protracted presence of pus in the tubes, a sort of toleration is acquired, which enables the women to better resist the danger of infection during operation. Otherwise, it would hardly seem possible for cases to recover, even by the aid of the most thorough wash- ing out, when the pelvis has been flooded with foul pus, owing to the bursting of a pus-sac during removal. 626 APPENDIX. Platfs XI-lV.-XLVl., p. iof). Annai.s ok Gvn.t.coi.ogv, N'ovembcr iind December, 1887. SALPINGITIS. These plates are taken from the article by Dr. W. Gill Wylie, of New York, in the " Annals of Gynaecology," in which he reported sixty consecutive successful operations for salpingitis. The plates show very well the various conditions of the diseased organs, according to the amount of pus present, and the nature of the disease. To no one is the profession in this country more indebted than to Professor Wylie for the introduction of the operative treatment of salpingitis, and its recognition as a reasonably safe and entirely legitimate procedure. PlateXLVII., p. 400. Annals of Gyn.kcologv and P-ediatky, June, iSgo. HYDROSALPINX. Plate XLVII. represents an unusually fine specimen of hydrosalpinx which was found in removing an ovarian cystoma. There had been no symptoms to indicate the existence of the former, and it was quite free from adhesions. The uterine end was impermeable, and could onl}- be found and opened by careful dissection. The specimen is of interest because various suggestions have recently been published with reference to saving and restoring tubes which are apparently simply dropsical ; that is, occluded at the uterine extremity and distended with clear serous fluid, as was the one represented by this plate. A. Martin, in particular, in his article on diseases of the tubes, pub- lished in Eulenburg's " Encyclopaedia of Medicine," gives figures showing how the distal extremity of the occluded tube can be excised and hemmed with a continuous catgut suture. The women thus operated on menstruated afterwards without pain, but none of them conceived. Of course it seems a pity to remove the tube when the ovary is healthy and there is no sign of suppuration or active disease in the tube, but yet it is difficult to sup- pose that after long-continued distention the mucous membrane of the tube can return to a condition nearly enough normal to permit of the occurrence of conception, nor yet is it probable, even if the occlusion at the uterine end is opened by a probe at the time of operation, that it will remain open and will permit the passage of an ovum. On the other hand, it is certain that by opening the uterine extronity and leaving the distal extremity, which is no longer fimbriated, patulous, there is grave dancrer of establishing a direct channel for infection of the abdominal cavity as a consequence of the operation. — a danger which seems to more than overbalance any advantage to be derived from the possibility of con- APPENDIX. 627 ception, which, if it occurs, may lead to a tubal rather than a normal preg- nancy. A simple hydrosalpinx will rarely call for abdominal section ; if found when the abdomen has been opened, the cases will be rare where anything better can be done than to remove it. Plates XLVIII.-LV., p. 40S. Annals of Gyn.«cologv, February, 1888, May, 1890. EXTRA-UTERINE PREGNANCY. Of all the grievous ills which may imperil the life of a woman, or the credit of her physician, there is, perhaps, nothing connected with gynae- cology worse than an extra-uterine gestation. Many men inactive prac- tice have never met with a case, and many more have only recognized it when too late. Nevertheless such occurrences are much commoner than is generally supposed, for usually only the fatal cases are recognized. The symptoms, when well marked, are definite enough, and easy to under- stand, especially afterwards. Whoever has been in attendance where a pregnant tube has ruptured will never forget it, — the patient pallid, collapsed, fainting, yet conscious and with unclouded intellect, writhing with pain and prescient of impending death, taking leave of the astounded husband and the weeping children ; the physician troubled, embarrassed, helpless, in the presence of a great misfortune, evolving with difficulty a diagnosis, and uncertain which this may be of divers kinds of death — crudelis ubique Luctus ubique pavor et plurima mortis imago. By the skill of Dr. M. G. Parker, and through the courteous permis- sion of Dr. W. F. Whitney, the curator of the pathological museum of Harvard Medical School, I am able to present photographs of six most interesting specimens of tubal and interstitial pregnancy, besides the unique specimen furnished by Dr. Bernays, and that of Dr. Engelmann. In nothing is the contrast between the old gynaecology and the new more marked than in considering this subject. The records of the late Dr. J. B. S. Jackson, who prepared and put away in the museimi, wdiich is his monument, the specimens which we study to-day, seem really Hippo- cratic in their brevity, accuracy, and in the simple way which the inevi- table death is announced. No thought of interference, no suggestion that these women might easily have been saved by prompt operation, or by an eai'ly diagnosis and arrest of foetal development. How changed is the sentiment to-day may be seen in the papers, whicli are now published in rapid succession, relating the histories of women snatched from impending death by prompt surgical interference. 62S APPENDIX. The illustrations which are here presented may well serve to impress upon the readers the importance of this condition, and to emphasize its gravity, its frequency, and its curability by surgical treatment. But lately regarded as an event of extreme rarity, as an almost un- heard-of freak of nature, extra-uterine pregnancy now confronts the pro- fession as an accident to be at all times watched for, and as an explanation of many calamities which liavc hitherto been misinterpreted and misunder- stood, until the patient was peacefully buried with a false diagnosis, or triumphantly treated for a ha;matocele or pelvic eflusion. Just in pro- portion to the increase of accuracy in diagnosis, of courage in operating on such cases, and of care in making and recording autopsies in cases of sudden death, grows the conviction that extra-uterine pregnancy is rela- tively a frequent occurrence, and one urgently calling for immediate sur- gical interference. Rare are the cases where it can be diagnosticated with any approach to certainty before the occurrence of rupture. If, happily, such a diag- nosis is made, the case related by Dr. Engelmann, and illustrated by Plate I.V., should convince others, as it has convinced him, that the only proper treatment consists in immediate removal of the ectopic gestation, which may at any moment burst and destroy the life of the patient, even before skilled aid can be summoned. That operative interference is required when rupture has occurred into the abdominal cavity is at present disputed bv none; when, however, the rupture has happily occurred between the folds of the broad ligament, the ovum usually dies, and the case should be, and usually is, treated as one of pelvic haematocele without operation, except in the rare cases where the fcrtus lives and goes on developing, or where secondary complications occur, wliich may require surgical inter- ference. The cases lately reported \\\ the Transactions of the Obstetrical Society of Philadelphia, in the "Annals," following the large number previously reported as coming under operation in Philadelphia within the last three years, serve to emphasize the fact that there I's no reason to suppose that extra-uterine pregnancy is relatively more frequent in that city than in others, and the conclusion is obvious that, as comparatively few such oper- ations are reported elsewhere, a great many women must be dying all over the country who might be saved by accurate diagnosis, prompt de- cision, and skilful operation. APPENDIX. 629 HISI^ORY OF A CASE OF EXTRA-UTERINE PREGNANCY. Plate XLVIII. BY PROF. AUliUSTUS C. BERNAYS, A.M., M.D., OF ST. LOUIS, MO. Mrs. J. N. was married when 19 years of age. vShe became preg- nant soon afterwards, and was prematurely delivered of a living child of about six and one-half months' gestation. About one year afterwards she again became impregnated, and again miscarried at about six or seven months, the child living only a short time. In 1876 her husband, being in affluent circumstances, took her to Germany, where several of the great gynascologists were consulted. These gentlemen made careful examina- tions and gave advice, but could not make a satisfactory diagnosis. x\fter her return to St. Louis she remained barren, but was always more or less a gynaecological patient. Some of her physicians said that she had retro- flexion ; some thought there was a chronic metritis with enlargement of the uterus. The winter of the year 1S85 and 1SS6 Mrs. N. enjoyed unusually good health ; but in the beginning of April, 1S86, she began to com- plain of the usual molimina of an incipient pregnancy. She had head- ache, toothache, morning vomiting, and some hysterical manifestations of temper. Dr. H. Wichmann, the family physician, an experienced and careful practitioner, was called in. The patient told him that she was pregnant- but that she wanted him to do something for her vomiting. The doctor treated her, making daily visits from April 13 to May i. Her vomiting, however, grew worse and worse, and the doctor was often called twice per day in the beginning of May, when the patient had faint- ing spells, bordering on complete collapse. These fainting spells were always ushered in by a peculiar colicky pain in the lower part of the ab- domen. They grew more frequent and more alarming day by day ; the vomiting also was incessant, and the patient grew very weak. A slight muco-sanguineous discharge became noticeable ; and, in fact, there was some little bleeding from the womb about May 15. The patient now in- sisted that she must have permanent relief; and although she, as well as her husband, was extremely desirous of offspring, she demanded of Dr. Wichmann that he produce an abortion on her. The doctor thought this operation clearly indicated, and on May 17 he introduced a Sims' specu- lum, and through it a uterine probe, and much to his surprise found the womb empty, and the cavity only about half an inch longer than normal. As a matter of course he told his patient that she was not pregnant. On May iS she had three fainting attacks, and was constantly vomiting. 630 APPENDIX. On May 20 she insisted on another examination, which was made with the same result as before. On May 21, in tlie morning, she again had an attack of syncope, which was very severe. During all this time the patient was able to walk about her room and take light exercise. On the morn- ing of May 22, before daybreak, Dr. Wichmann was called to his patient, and found her collapsed. He succeeded in reviving her, but was soon enabled to diagnose a severe intra-abdominal Inemorrhage, and was com- pelled to admit to the perfectly conscious patient that she would die in a few hours, if not sooner. The lady, with remarkable fortitude, then told the doctor that she desired to have a careful autopsy held on her remains, for she felt certain that none of her doctors had ever thoroughly understood her case, and she thought that an examination might be of benefit to the science of medicine. On Sunday morning, May 23, at the request of Dr. Wichmann, I per- formed the post-mortem with the assistance of Drs. Bremer and W. H. Heidorn. It was one of the most interesting post-mortem examinations I ever performed, and it brought to light a unique specimen, which is beau- tifully illustrated by the photograph, Plate xlviii. The incision in the median line from the jugular fossa to the symphy- sis pubis laid bare the cavity of the abdomen, and the visible organs were seen to be pale, bloodless, totally exsanguine. After the omentum was laid back, the abdominal cavity was nearly filled by a firmly contracted cake of blood, which was continuous and a perfect mould of the intestines. It was lifted out, and weighed, perhaps, ten pounds. All the organs were normal in structure, as were also the organs in the chest. The source of the haemorrhage was discovered to be the ruptured sac of a tubo-abdomi- nal pregnancy of about three and one-half or four months' gestation. The rent in the sac was about one and one-half inches in length. The ovum had developed in the fimbriated extremity of the left Fallopian tube. The sac had grown towards the left into the abdominal cavity. The blood had poured forth from the torn margin of the placenta. The uterus proved to be bipartitus et unicollis. The two uterine bodies were so nearly alike that it is impossible to state in which of the two the former preg- nancies had taken place. There was a well-developed decidua in both of the uteri. There is nothing about the os uteri to indicate, in the least particular, that there are two distinct corpora above. Eacli uterus has one Fallopian tube, and there are two well-developed normal ovaries. A study of the photograph will enlighten the reader concerning the relative shape and size of the anatomical structures concerned in the specimen. A search of the literature of extra-uterine pregnancy has failed to show a similar case. The case is unique in the particular that -jjc find APPENDIX. 631 ■a uterus hipartitus et unicoUis^ complicated -with a tubo-abdotninal pregnancy. The history of the case is peculiarly instructive, and the lessons which are to be learned from it are numerous. I will leave them for elu- cidation to some more experienced hand, and to one who is so situated that he can devote more time to the theoretical part of our science than I, who am a slave to its practice. SIX CASES OF TUBAL PREGNANCY. From the Pathological Museum of HarvarJ University. Plate XLIX. — The uterus is seen cut open, with the tube and the corpus luteum. The woman was 27 years of age, and about ten weeks pregnant. Four or five weeks before death a discharge came on, supposed to be catamenial ; this ceased after continuing for three weeks, but re- appeared a day or two before death. Attacked in the morning with agonizing pain, she died in six hours, with the symptoms of internal hasmorrhage ; the nature of the case having been recognized by Dr. Storer. On examination three pints of blood were found in the peritoneal cavity. The ovum was in the outer half of the right tube, one and one-half inches in length, and no part of it had escaped from the tube ; the rent in the last being irregular and one-third of an inch in length. Uterus thx-ee and one-half inches in length, and without a trace of decidua. Corpus luteum in the right ovary and finely marked. Reported by Dr. H. R. Storer, i860. No. 3910. For a collection, by Dr. G. H. Lyman, of eleven cases of tubal preg- nancy that have occurred in this State, and mostly in this city, including the above, see " Bost. Med. & Surg. Journal," Vol. LXL, p. 464. Plate L. — Uterus, decidua, corpus luteum, and foetus connected by cord with the tube, are shown. From a patient, aged 24, married two and a half years ; miscarried twice, at six and eight weeks. Had always suffered from dysmenorrhoca. Ten weeks pregnant. Slight pains and uneasiness in pelvic region duriiio- that time. No previous hemorrhage. Ten days before death had a verv severe attack of pain in the pubic region, like strangury, which was relieved by an opiate. Fatal attack came on with sudden diffused pain in hypogastric region, spasmodic in its character, with distressing rather than painful intervals. The rapid collapse led to a correct diagnosis before 633 APPENDIX. death. Lived three and a half hours. Two quarts of blood in abdomen Right Fallopian tube dilated from its uterine termination, outward, into a sac two inches in diameter, the sulcus separating it from uterus being strongly marked, though shallow. From sac to fimbriated extremity three and a half inches. Rent in upper anterior portion of sac, one and a half inches long. Foetus, three inches in length, lay in pelvic cavity ; length from vertex to umbilicus, two inches. Cord unbroken. Uterus much softened, length three and five-eighths inches ; breadth at widest part, two and one-quarter inches. Vascularity increased ; vascularity of sac very marked ; decidua perfect. Fine corpus luteum in right ovary three- quarters of an inch in diameter. Cyst, size of a pea, upon the left ovary, and, within, traces of an old corpus luteum. Case reported by Dr. G. H. Lyman, as above. Plate LL — The uterus measured three inches and one-fourth in length, and was changed in structure as is usual in gestation ; inner surface softened^ but wMthout any well-marked decidua. The outer half of the right Fallopian tube was enlarged to about the size of the last joint of the thumb, and, having been cut open, the membranes of the ovum are shown with a well-developed foetus three-fourths of an inch in length. The lady from whom this specimen was taken w^as a patient of Dr. John D. Fisher, 18 years of age, and had been married only ten weeks. The catamenia appeared on the day of her marriage ; at the end of three weeks it appeared again, as she thought, and in two weeks more it appeared for a third time; discharge unusually profuse, of a bright red color, and continued for a week without much intermission. After the last period it frequently recurred, and, on any considerable exertion, became so profuse as to cause faintness. On the morning of the last day she was unusually cheerful, and had been exercising freely, so as to become somewhat fatigued. At II o'clock A.M. profuse flooding came on, and she became excessively faint ; at i o'clock Dr. F. found her with symptoms of com- plete collapse as from haemorrhage. Under the use of stimulants she revived somewhat, but remained in a fluctuating state until 9 in the even- ing, when reaction became pretty fully established ; soon after this she fell asleep and slept until about half-past 3, when she awoke quite faint, and so continued until 7 in the morning, when she died, twenty hours from the time of the attack. There had been a slight pain with tenderness just above the right groin, a sense of fulness in the abdomen, and an unusual degree of fulness over the lower part, on examination by the hand. On dissection there were found three quarts or more of blood in the peritoneal cavity, the right Fallopian tube having ruptured at the point APPENDIX. 635 which is marked in the preparation by a reddish-brown coaguliim. In several other cases of tubal pregnancy which have occurred in this city there has been observed a tendency to haemorrhage, as in the above case, though not to the same degree, the patients generally regarding the dis- charge as an irregular flow of catamenia, and as an evidence that preg- nancy did not exist. Dr. J. B. S. Jackson. No. 711. Plate LII. — The uterus measures 3^ inches by 2^ inches, and in thickness ^ of an inch. Decidua strongly marked. The ovum is in the right tube, measured 2 inches by \% inches, and the foetus is plainly seen, about as large as at two and a half to three months. The tube is ex- tensively lacerated, but the fimbriated extremity, through which the mem- branes protrude, is not involved. Both ovaries were very carefully examined, but no corpus luteum was found. The peritoneal cavity was, as usual, filled with blood. The case occurred at the State Almshouse at Monson. An Irish- woman, aged 25 years, had passed two menstrual periods, and on the ist of February, 18S7, complained of constipation and pain through the pelvis, during defecation. This she had for four or five weeks, but was otherwise quite well. On the morning of the 13th she had a very severe attack of pain after a dejection, and this continued; but at 2 P.M., having got relief she arose,, dressed herself, and went downstairs. There she became faint, and vomited, and the pain returned with increased severity and symptoms of collapse. She rested quietly, however, through the night, but the next morning fainted on going to stool, and died at 10 A.M. Dr. S. D. Brooks, Supt. of the Almshouse at Monson. No. 2909. Plate LITI. — No history of the specimen has been obtained, except that death occurred from rupture of the cyst. The embryo was found in the abdominal cavity. In the region of the right Fallopian tube, 4^^ cm. distant from the ovary, is an ovoid swelling 7x5 cm. The wall of the tumor is covered with a thin membrane; the substance of the wall appears, in great measure, to be composed of clotted blood. The interior of the sac was covered by a smooth, thin membrane, from one portion of which hangs a small cord, apparently composed of vessels ; these pass into a slightly raised, honeycombed-looking expansion of tissue which lies beneath the above-mentioned membrane, and is closely adherent to the wall of the sac. 634 ArrF.NDIX. This lias a diameter of alioiit 3 cm., and is tlie placenta. Numerous small round fibres (vessels?) pass from the membrane into the walls of the sac. Ovary on rii^bt side not surely found. Case of Dr. A. R. Holmes, of Canton, Mass. No. 703. INTERSTITIAL PREGNANCY. Plate LIV. — Healthy woman ; aged 36. In April, 1873, became preg- nant. Pain which she had had in right iliac region for two years continued, and there was a menstrual show in April and May. June 15 Dr. Davison found her with excruciating pain in uterus, os not dilated ; relieved for a time by opiates ; collapse and death in twenty-seven hours from attack. .Specimen examined and described by Dr. R. H. Fitz, with two figures, in " American Journal Medical Sciences," for January, 1S75. The uterus generally was considerably enlarged ; but a most striking feature of the external appearance was a very great prominence of the fundus upon the left side and a jagged opening there, with thin edges, nearly half-inch in diameter, through which the foetus was seen. Through this opening a very copious haemorrhage had occurred into the peritoneal cavity. Left Fallopian tube very much higher than right. Corpus luteum in left ovary. Ovum two and half inches long ; fcEtus as at ten weeks, uterine wall about it being less than two lines thick. Left Fallopian tube open from its free extremity to the foetal sac, and to the extent of an inch from its uterine extremity, the intermediate por- tion being reduced to an impervious cord ; inner sin-face very much swollen, pale and soft. No decidua in foetal sac nor Fallopian tube. Dr. F. refers to other published cases, remarks upon, this one, and upon the anomaly in genei'al, and raises the question whether the present case mav not have been one of impregnation in a rudimentary horn of the uterus. Case of Dr. A. T. Davison, vSouth Boston. No. 4299. OPERATION IN THE EARLY STAGES OF EXTRA- UTERINE GESTATION. I'l.ATK LV. I?Y GEORGE J. ENGEI.MANN, M.D., ST. I.OlflS. I HAVE been quoted as favoring electricity, at least in the hands of the general practitioner, in the very early period of extra-uterine fcEtation ; and such, indeed, has been my repeatedly expressed opinion. Increased experience has caused me to waver, and a case recently APPENDIX. 635 recorded by Dr. Mooney, of this city, althougli a single case, has appeared to me so convincing' an argument in favor of tm?nediate operation at ivhatever period Qyi\x^-\iX.e.v\nc pregnancy may be detected, that I am now an earnest advocate of surgical interference in all such cases, although I would still urge electricity to be used until the diagnosis is fairly estab- lished, or until dangerous symptoms appear, when the abdomen should, of course, be opened, whether or not the diagnosis be assured. By the kind permission of Dr. Mooney I was enabled to examine and photograph the specimen here presented, which is, I believe, a far more convincing argument for early operation than the most able appeal by any partisan of the knife. In this case the rupture occurred at so early a stage that no diagnosis could have been made with certainty ; not a menstrual period had been missed, pregnancj'^ was not even suspected, and, if suspected, this soft little mass could never have been diagnosed £fs an ovum by the most ■expert examiner ; in fact, it was so small that I, at first, had my doubts if it were not merely a menstrual haemorrhage, — an extravasation of blood distending the tube. Not until microscopic examination revealed the not-to-be-mistaken villosities of the chorion and embryonic tissue, did I feel assured that it was really a case of tubal pregnancy. How instructive a specimen it is ! We see how clearly the operation is indicated, how readily it can be performed, how distinctly the course to be pursued is outlined. Moreover, we see that rupture may take place at any moment, at any and the earliest period. Whilst so early a rupture inay be unusual, it is enough to know that it does occur, and hence it is self-evident, I may say, that any other but surgical treatment in a case of ectopic gestation endangers the life of the patient, as each day of delay must appear to be the loss of a golden opportunity, unless primary rupture has ali'eady taken place and pregnancy is well advanced ; then we may deliberate as to the proper course to pursue. The history of the case likewise shows how impossible it is to recog- nize these early stages until dangerous symptoms appear, so that I should be inclined to urge operation, exploratory incision, if merely a suspicion of such a condition be entertained after careful examination, tluring nar- cosis, by an experienced gyniecologist. From the report of Dr. Mooney, I take the tbllowing : Patient, aged 31 ; mother of one child ; had not missed a single period ; had menstruated as usual, but the flow had continued live or six days longer than was her habit, when on the afternoon of October 3 she complained of cramps, but not of sufficient severity to send for a physician ; her sufferings increased, however, and the doctor was called at midnight, v^dien he found all the evidences of abdominal collapse, death occurring soon after his arrival. 636 APPENDIX. At the post-mortem examination the abdominal cavity was found filled with blood, cstimatctl at aljout one gallon ; the small embryo, which had escaped into the cavity, was not found. Uterus and ovaries were re- moved, and are shown in the accompanying cut, from a photograph taken from the fresh specimen. The uterus was somewhat enlarged, its walls slightly thickened ; cavity, length normal, 65-^ cm. ; the endometrium pale, somewhat hy- pertrophied, as it would be toward the close of the menstrual period. The tubes were perfectly healthy, but unusually thin, especially the left; fim- briated extremities free ; no evidence of inflammation. The uterine ex- tremity of the pregnant right tube is somewhat thicker than that of the left tube; 33^ cm. from its uterine terminus it expands into an egg- shaped ovisac, 434^ to 314 cm., with its larger end toward the uterus. The walls of the ovisac are thicker than those of the tube in other parts. Upon the free upper border of the sac is a round opening y^, cm. in diameter, from which a clot protrudes. The uterine extremity of the pregnant right tube contained fluid blood ; not so the left, in which only the normal secretion Avas found. I could detect no distinct cavit}' within the dilated portion of the right tube, but the character of the distention was proven by the delicate tissues of amnion and chorion, and the microscopically recognizable villos- ities which, mixed with clotted blood, formed the mass within the sac. Unmistakably a tubal pregnancy, which points clearly to ligation and removal as the only treatment, and, moreover, to operation in early stages, as it tells us that fatal rupture may take place at any time, and that we have no warning. It is on the evidence aflbrded by the history of this case, and the specimen presented, that I have abandoned the teaching that electricity should be tested in the early stages of extra-uterine foptation, and would now urge immediate operatioji. — Atnials of Gyncvcology and Pcediatry, May^ i8go. Plates H and I. Annals ok Gyn,ecolo<,y, M.irch, 1S89. REMARKS ON ECTOPIC GESTATION, WITH REPORT OF T\VO RECENT CASES. JOSKPII PRICE, M.n., PHILADEIJMIIA, I'ENN. It is not my purpose to make a formal discussion of this subject — merely to emphasize certain points of treatment, and to enter protest against defining electrical foeticide as the "American method," as has re- APPENDIX. . 637 cently been done by a reviewer wbo was so poorly qualified for his posi- tion as to make the following statement : " We know of but one native gynecologist who advises the universal resort to laparotomy in every stage of ectopic pregnancy ; and he had what we may call the misfortune to have had a successful case of recovery after laparotomy." There are a number of abdominal surgeons in this country, who, with keen apprecia- tion of their profession as life-savers, are unwilling to toy with a dan- gerous and unsatisfactory force, but who believe the best interests of their patients are served by the speedy and absolute removal of the offending condition. The results obtained by this class of men are not only equal to those claimed by men who practise the so-called •' American method," but much better, inasmuch as the errors of diagnosis are eliminated. Ectopic gestation, its diagnosis and treatment, has of late been the burning question of abdominal surgery. As material accumulates, and intelligent discussion progresses, we are gradually approaching unanimity •of opinion as to the nature, location, and complication of this dreadful accident. Lawson Tait, in his recently published *■' Lectures on Ectopic Pregnancy and Pelvic Ilaematocele," has given us the most scientific and logical discussion of the subject that has ever been presented. A careful study of this work, supplemented by that of a remarkable editorial review of it published in the " Buffalo Medical and Surgical Journal," for March, 1S89, will amply repay all who are interested in the subject. My own experience leads me to accept Mr. Tait's views, and I wish to emphasize •one or two points. First, is the frequency of occurrence. I have myself operated upon twelve cases in the last two and a half years, and the fol- lowing communication from Dr. H. F. Formad, coroner's physician, of Philadelphia, bears directlv on the subject : — " Dr. Joseph Price : — • " Dear Doctor, — In answer to your Inquiry, I state that during five years of continuous service as coroner's physician of Philadelphia, con- ducting all the autopsy work, I obsei'ved nineteen cases of extra-uterine pregnancy. I have reason, however, to believe that more cases occurred, but escaped notice. I am sorry not to be able to give detailed descriptions ■of these cases at this time ; moreover, they were all cases of sudden death, mostly with histories unknow^n. Yet, the specimens being preserved, I propose to give them a close study, and to give you at some future time a full anatomical description. The next volume of the Pathological Society will contain a tabulated record of all my cases. The majority of specimens I exhibited from time to time before that society. " I may state that the cases were all of the same kind and nature, and [A.NNAI..S OF GvN.«.toLot;v, Bosto;i, M;irch, 18S9.] H ife?«>5.'. 5^ > c: — 2 <: "o 2 c ^ •a 5 a, 1 Q J ul i CO 3 D .« h rt ^ iS W c J _rt u PQ — 3. D c M in' Q U c u 6 c CS E C i) B "5 £ E u £ a "O- •71 tP rt u 3 < -^s ^638; [Annals ok GYNyKroi.ocY, Boston, Mdrth, 1&S9.J 00 > r w o z > o iil^' " (639) 640 APPENDIX. have the following featLiies in comnion : Death from sudden profuse hir;monhage in the abdomen, all witliin twelve hours, save one case, in which death ensued five days after the rupture of the sac, while in some cases as early as three hours. All cases w^ere tubal, as many right as left, and all between four and eight weeks of foetal development. In all cases the sac was located near the end of the tube except in one case, where its seat was just at the point of exit of the right Fallo2:>ian tube from the uterus. This was the case in wdiich death was so unusually delayed. The women were mostly young, and a few middle-aged ; all had borne children before ; nearly all had chronic salpingitis, with adhesions and contortions of the tubes. All were from the working-class, and in all the rupture of the sac appeared to have taken place while the women were exerting themselves at work or housekeeping. Women of German extraction were in the majority, and two were colored. The foetuses were found only in half of the cases, it being very difficult, and sometimes impossible, to recover the small embryos in the enormous masses of clotted blood distributed usually throughout the whole abdominal cavity. In no case was there less than a quart of blood coagula. In every case there were formed foetal mem- branes within the sac. The following history of my last case gives the essential clinical features of all the cases. The post-mortem was held November 12, 188S. White; German woman; aet. 26; married; two children ; both living; the youngest three years old ; probability of having aborted once, about a year ago ; menstruation habitually regular as far as could be learned ; absence of last period ; robust health up to November II, when, at 7 A.M., while washing or scrubbing, she was suddenly seized with violent pain in the abdomen and fainted. This was followed by complete collapse, syncope, some convulsions, coma, and death at noon, or within five hours. None of these cases were diagnosed before death, and the physician called in usually regarded the case as one of gastric or intestinal colic, and prescribed remedies accordingly, and after death referred the case to the coroner. Possibly some similar cases were not reported, or not examined, and have escaped record." This communication likewise shows how frequently the accident occurs without giving rise to symptoms enough to allow its diagnosis before rupture. Diagnosis before rupture is the junction where enthusiastic excursion- ists connect with the " American method " (an electrical road) for a self- satisfactory journey to Utopia. I believe thata. />os/i/ve diagnosis of extra- uterine pregnancy before rupture is impossible. It has been made, and operation has verified it. It has been made much oftener, and operation APPENDIX. 641 has demonstrated an utterly dissimilar pathological condition, producing symptoms exactly like those caused by extra-uterine gestation before rup- ture. Moreover, the ablest exponents of the so-called " American method" confess, with Dr. Thomas, that "a positive conclusion is very generally difficult, and often impossible." As to treatment, if from combination of characteristic symptoms, con- firmed by the presence of a mass, extra-uterine pregnancy is considered probable, operate, and remove the sac. If the operation proves the diag- nosis correct, a fearful calamity has been surely and speedily averted. If the diagnosis of extra-uterine pregnancy proves not to be correct, yet the j^atient has been relieved of a condition more or less dangerous, one in itself amply justifying the operation. No one questions the treatment of extra-uterine pregnancy after the rupture of the tube. The operation in the following cases was as simple as possible for abdominal surgery. Every detail was minimized. Short anaesthesia, sliort incision, rapid but clean enucleation, careful tying, free flushing with warm distilled water through an irrigator one-half inch in diameter, — water poured from pitcher to funnel from a height, — and well-placed drainage. Both patients recovered without a bad symptom. Case I. — Double tubal pregnancy. Mrs. M., set. 35, white; four children, the last 18 months old. Delayed menses in November two or three weeks beyond term. Three weeks ago was seized with agonizing pelvic pain and collapse at midnight. This attack was followed by re- curring attacks of collapse and pain, constant uterine haemorrhage, loaded with shreds of decidua. Abdominal section performed December 22, 1S88. Removal of both appendages for double tubal pregnancy. The right tube had ruptured into abdomen, discharging its contents. Abdo- men full of clotted blood and placental debris. The left tube was fouml greatly elongated, and tlistended to the size of an orange by blood-clot, which protruded from pavilion extremity ; the cornual extremity was occupied by placenta and membranes. General peritonitis and adhe- sions of pelvic and abdominal viscera. Irrigation and glass drainage. Microscopic Examination of Specimens. '' 1322 Walnut St., Dec. 22, 1888. "Dear Dr. Price, — The specimen you gave me from the woman upon whom you operated to-day, I took to Dr. Piersol, who found what he says are certainly villi of the chorion, thus establishing bevond pcrad- venture your diagnosis of extra-uterine pregnancy. Further examination 642 APPENDIX. may show more that is of interest, but the proof of the correctness of the diagnosis was, I suppose, what you most wanted. " Very truly yours, ■' Ahi IIUK V. MiEGS." Case II. — Left tubal pregnancy, right hydrosalpinx; Mrs. F., a?t. 34, white ; married twice ; four children by first husband, none by second. Sterile for eleven years ; typical history of tubal pregnancy. Inaptitude to conception ; absence of three menstrual periods ; sudden agonizing pelvic pain and collapse recurring at short intervals. Her physician, Dr. Eugene P. Bernardy, saw her in collapse. Diagnosed ruptured tubal pregnancy, and insisted upon prompt surgical interference. Abdominal section, Decemiier 29, iSSS. Removal of both appendages for left ruptured tubal pregnancy and right hydrosalpinx. The left appendages filled the pelvic basin, the primar}^ rupture having occurred between the folds of the broad ligament, with secondary rupture into the peritoneal cavity. Gen-- eral firm adhesions. The pelvis was emptied of clot, the placenta and membranes coming away in the tube. Irrigation and glass drainage. [Annals of Gynecology, Boston, December, j8S8.J 5 1-1 ? •») to ^. O o^ 7.0 :S' < j3 3. S 3 n 3- 51 3 crq 3 2 Q " 2- P" >*i a. J'' (643) 644 APPENDIX. EDITORIAL. » In connection with the reports of cases of ectopic gestation, and the ■discussion on that subject at the Philadelphia Obstetrical Society, reported in this number, we have thought that it would interest our readers to reproduce the report of two rare cases, with the illustrations, from the beautiful folio of Boehmer, royal professor at Halle, published in Latin, m 1752, for the use of which we are indebted to the kindness of Dr. Chad- wick, of Boston, whose erudition and services to medical literature are well known. The cases are not only valuable from their rarity, but from the extreme care with which they are reported, and of course a fact well observed and accurately described is always valuable. We shall take great pleasure in presenting to our readers, from time to time, the labors of our predecessors who have wrought so faithfully in their day and generation, that now that they rest from their labors, their works may follow them. •' Tantus labor tie sit cassus." Observatio I. De Conceptione Ovario. (K-M — PI. I., II., III.) " A certain woman, 38 years of age, who for twenty years had earned a miserable subsistence by prostitution, and had indulged too frequently and too violently in sexual congress, having become pregnant contrary to expectation, bore a preternatural mass in her abdomen for about four months. " She menstruated regularly before her pregnancy, but sufiered from a suspicious leucorrhcEa ; in doubt whether she had conceived, she endured, however, the symptoms of pregnancy, although complicated with many sufferings. "The menses were suppressed at the first month of conception, toward the end of September, 1749, and she experienced a languor of the whole body, and suffered from nausea, vomiting, attacks of fainting, and a spasmodic rheumatic affection of the joints, which at intervals decreased, but never wholly ceased during the subsequent time. " At the third month of pregnancy she first perceived, from the out- side, a hard swelling in the abdomen, growing by degrees, and extending to the left side of the hypogastric region, with troublesome increase of weight. "Therewith there was increasing difficulty of urinating, which she > " Annals of Gynaecology," November, 1889. APPENDIX. 645 aggravated by strong drastic and acrid emmenagogues. Perhaps she had ahead}' often tried . . . " ' tennellos convellere foetus, Et nonduni natis dira venena dare.' " Thus it happened that not only did an acrid matter, flowing from the genitals, and eroding them, by a continual stimulus excite bearing down, heat and pressure in the vagina, but that severe pains, in the hy- pogastrium especially, and in tiie sacral and left lumbar and iliac regions, ensued, with tormina, as if about to result in labor. '' After almost continuous tortures of this kind, a painful swelling of the abdomen appeared simultaneously. Intense inflammatory fever su- pervened, accompanied w^ith violent symptoms, not remitting in severity. From this, on the ninth day, after the supravention of convulsive move- ments, and of a sudden swelling of the whole abdomen some hours before the end, she perished miserably at the Ides of December of the same year, in the hospital at Halle." The dissection made on the following day, before the class, is re- ported with the precision Which characterizes German autopsies, and which makes a report of one hundred years ago as valuable as one of yesterday. The abdomen was found full of blood and sanies, with foul odor, and signs of general peritonitis. " In the hypogastric cavity, toward the left iliac region, a morbid mass, rounded, prominent obliquely above the margin of the pelvis, joined to the uterus in front, resembled a double uterus.^ On the posterior surface it bore a great sac,^ fleshy and membranaceous to touch and sight» which, completely filling the cavity of the pelvis, cohered^ very firmly with the upper prominent part of the uterus, to which it lay posterior, in- clined somewhat to the right.'' It was thoroughly inflamed, and posteri- orly, where below its middle part a rupture, with incipient sphacelus * was observed, the right foot *^ of the embryo, protruding to the knee, hung down toward the coccyx. " The ligaments' by which the uterus is fostened to the walls of the pelvis and the symphysis pubis are unequally stretched ; the right ovary is triangular, furrowed, and seamed," its ovarian ligament" of natural shape, but that on the left side too thick and abnormally long.'" The fim- briated end of the Fallopian tubes on the right too sinuous, and distended 1 Plate 1., A, B, B, C, and O, O, O. ■ Plate I., M, M, and N, N. Also Plate II., 2 Plate II., M, M, M. B, B., andC, C. 'Plates 1., B, B; II., N, X; III., II, H. "Plate II., F. opiates I., A, and III., A, A. !' Plate 1 1., G. rpiau II., K, R. 10 Plates I., H ; II., L; and III., G. opiate n., S. ; Annai.s 01-' Gv.N.KcuLuc.v, Itostdii, November, iS'Sv.J K— I'l. I. THE UTERUS WITH THE LEFT OVARY IMPREGNATED, And with the other parts in place, together with the Vagina, seen from the anterior surface, in natural situation and connection. A The uterus of double the natural si/,e, inclined above to the ritjht, and reachinu; above the fatal sac, with which it is adherent behind and below. F The upper sinuous part of the right Fallopian tube. Q Part of the right ala vespertilionis, concealing the rest of the tube and the right ovary. H, The left ovarian ligament enlarged and elongated. 1^ The left Fallopian tube laid open towards the uterus, nearly straight, running obliquely to the pregnant ovary. K, Fimbriated extremity united with the ovary. O O O, The impregnated left ovary, forming a large irregular sac, filling the whole pelvic cavity. (646) [Annai.s of GvN.F.cot.oCfV, Boston, November, 1SS9.] PI. II. POSTERIOR VIEW OF CASE SHOWN IN PLATE i. A Upper part of the uterus. D Tlie right Fallopian tube, irregularly distinguished, adherent at E, t" the fa-tal sac. F, Right ovary. Q^ Right ovarian ligament. 1^ Left Fallopian tube. L Left ovarian lig&ment. M M M , Wonderful expansion of the impregnated left ovary. N N N Adhesions with the uterus. Q Tlie tunica exterior communis of tlie ovary separated into two layers, joined to each otlier, and to the subjacent fibrous layer, too, by loose areolar tissue. -R R R, Rupture of the sac, through which the foot of the embryo protrudes. (647) [Annals ui Gvn.«cologv, Boston, Novcmbci, 1S89.] M — PI. III. riG. f CASE SHOWN IN PLATES 1. AND II., Showing the Sac laid open from behind, and containing, the Embryo of nearly four months. A Uterus. B, Thickened and convoluted dc-cid.Kil membrane. C, Rod passed through the uterus, 'd D Opening from the Fallopian tubes into the uterus. E, Right tube which lay upon the rectum. | | |' Points of adhesion of the rectum with the right side of the uterus and the foetal sac. T Fcetus half natural size, owing to the reduction of scale of the whole drawing from the original plate. (648) [Annals ok Gvn.kculuijV, Boston, November, 1889,] N — PI. IV. psaj. JFUG Mi. EARLY TUBAL PREGNANCY, And Calcareous Fibroid of Uterus. Fig. I. uterus laid open on its anterior surface, phowing adherent rounded mass and two swell- ings in the right Fallopian tube. Fig. II. shows the body which was contained in the uterus, exposed by division of its capsule of mucous membrane, forming an irregular spongy, fibrous, and calcareous mass- Fig. V. shows the right Fallopian tube laid open and containing, at o D, an ovum, perfect, with a fcrtus- of about the fifth week ; at m a small fleshy body surrounded by membranes, which the author regards- as an imperfect product of conception ; seen also in Fig. VI. C649) 650 APPENDIX. unequally,' and flexed around tlic upper and anterior surface of the rec- tum;- the left tube, however, descending with an oblique and rather tortuous course,^ coalescing with the gravid ovary '* both tubes open interioidy at the fundus of the uterus ;^ finally a natural structure of the ala. vespertilionis " on the right, although a small part of the other was seen to be conjoined to the left ovary and the tube ' on that side." The lectum was densely adherent to the sac and much compressed by the expansion of the latter. We have not space to follow at length this careful autopsy, nor the experiments as to the vascular supply made bv injections of mercury into the veins and arteries, which showed that the sac was supplied by the left spermatic vessels. Still less the long disserta- tion which follows. Suffice it to sav that the author was satisfied that the pregnancy was ovarian and not tubal, and he gives his reasons for so thinking, based on a careful dissection of the sac, and a separation of its wall into two layers. "The exterior of these was fibrous ;* the interior one similar to the uterus, sinuous and tibroso-vascular, varying in thick- ness, very thick around the site of the placenta, and in its whole circum- ference^ lined with a thin, villous membrane.'" Obser\'ATio II. De coftcremento osseo-lapideo., in riteri cavo reperio^ jiuicta conceptione t7{ba7-ia perfecta et 1771 perfect a. (N — PI. IV.) " A woman, 36 years old, the fruitful mother of several children, had lived in infirm health since her last labor, which occurred some j-ears before her death. " First, however, she complained of a certain tumor, apparent from the outside in the hypogastrium, hard, painful, heavy, troublesome, as large as a small fist, subsiding somewhat between the menstrual periods ; at these times, however, increasing again with dull pain. " In this state, however, she conceived again, but the embryo was clischarged prematurely at about the second month " In the last month before her death (i\.,D. 1745), not suspecting the existence of pregnancy, she was seized with pains on the opposite side, — that is, on the right side ; in the beginning they were severe, sometimes, nevertheless, remitting, but afterwards increasing successively, and ex- tending to the hypogastrium ; finally growing continuous and pungent, ' Plate II., D. 6 Plates II., H, and III., I, F, F. 2 Plate riI.,E. 'Plates II., K, and III., F. 3 Plates I. and II., T. 8 Plate II., q. « Plates I., K,and II., E. o Plate III., X, X. = Plate III., D, D. i" Plate III., O, O, APPENDIX. 65 1 with pertinacious obstruction of the bowels, and suppression of the catamenia. '' Suddenly there supervened spasmodic pains in the right iliac region and around the umbilicus, accompanied with most acute inflammatory fever, from which, after the abdomen had finally swollen, and the pros- tration of strength had increased, the patient died on the sixth day." The autopsy showed that death had been caused by general peritonitis. There is no mention of blood in the abdominal cavity. The uterus con- tained a spherical mass, as seen in Plate IV., loosely adherent everywhere, and continuous with the endometrium posteriorly. On incision of the capsule of mucous membrane, a body was found, which was solid, unequal, rough, hard, spheroidal, with deep depressions in some places ; in others, again, protuberant, weighing about an ounce, slightly connected with its capsule by connective tissue. It was hard enough to be split with difficulty, and had a bony or stony crust, being fibrous and spongy internally. The fragments effervesced in mineral acid ; it was evidently a fibroid with calcareous degeneration. The chief inter- est, however, is connected with the right tube, which, as Plate IV. shows, contained two enlargements separated by a constriction ; it, as well as the right ovary, was also greatly inflamed, and adherent to neighboring organs. The enlargement furthest from the uterus, when opened, contained a little foetus of about the fifth week, complete with cord, rudiments of placenta, and enveloping membranes ; the other a minute mass in lavers, which the author concluded to be a mole or imperfect product of con- ception. It was contained, like the other, in a membraneous vesicle, divisible into two layers, slightly adherent to the wall of the tube bv con- nective tissue. This body was formed of concentric layers, and was of a fleshy, fibrous, and vascular nature. FROZEN SECTIONS. Plates O-C^ Thkre is a great deal of interest attaching to the plates of frozen sections of two bodies which contained ectopic pregnancies. These are quoted by Prof. Lavvson Tait in his lecture on Ectopic Gestation, and in his work on Abdominal Surgery, from the work of Drs. Berr\- Hart and Carter, in the " Edinburgh Medical Journal." We reproduce the fio-ures here, from their interest as a unique contribution to the literature of this important subject. (Annals ok UvNyiitoLuoY, Boston, February, 1889.] a t/l '■ I.--.' \ Ammoiic cavtty Placenta Amnion. Top of Uiit ended broad hganent and tube ■ Jtectum CKorton _ Foetus Y/->J ^Obturator inttrnxtt Levator ani levator an* Paraproetai ti$aue Fig. 1. Sagittal lateral section (right) of pelvis, with cxtra-uterine gestation in right broad ligament. (652) '[Annals of Gyn/kcologv, Boston, February, iSHg.] Hcematoma W' — - Pouch of Dougtaa Cermcal canal Bladder- Rectum Fig. 2. Sagittal mesial section of the same pelvis, showing- uterus and decidua. This section demon- strates, inter alia, that what is termed clinically retro-uterine hajmatocele, may be hematoma. (653) (Annals ok GvN,iic, page 1092. In this case symptoms of pregnancy were observed in 1827 ; but no birth followed them ; the patient died at the age of 82, of pneumonia. At the autopsy the tumor was found to be attached to the walls of the uterus. It was about the size of a man's head, and here and there, over its surface points of calcification could be detected. The uterus, right tube, and ovary were normal ; the left ovary was wanting. The foetus was enveloped in a capsule, and was in a remarkably well-preserved state; the face, internal organs, and even the striae of the muscles being recognizable. The placenta was found, but its position is not stated. Case V. Is reported by Dr. Galli, in La Sperimentale, xxxix. : 2, p. 135. In this case, two children having been borne, pregnancy occurred, for the third time, at the age of thirty. Foetal movements ceased after the eighth month. No birth followed. Subsequently, for a long period, she suffered from severe abdominal pain. Became pregnant again, and was delivered of a healthy male child. The product of the third pregnancy was carried for thirty-seven years. In her sixty- seventh year she fell, and probably disturbed the lithopsedion, as a violent peritonitis intervened, from which she died. The autopsy revealed a well-formed lithopsdion; but nothing further is stated. Case VI. Is reported by Dr. Plexa, Monatschr f. Geburts/t, xxix., 4, p. 242. In this case symptoms were manifes.t which caused the diagnosis of extra-uterine pregnancy to be made. There were repeated attacks of abdominal pain, accompanied by fever. These gradually subsided, and strong hopes were entertained that this case would eventuate in a Lithopjedion. After one and a quarter years, however, a peritonitis ensued, from compression of the intestines between the tumor and the abdominal walls, which caused the patient's death at the age of forty. At the autopsy it was found that the foetus had entered the abdominal cavity by the bursting of the left Fallopian-tube. The right ovary and tube were normal. The color of the foetus- was dark-brown and calcification had begun. Case VII. Is reported by Prof. J. Van Grau and Dr. Schrant in Genees. en Heilkunde tc Amsterdam^ ii., i, pp. 17-96. The patient was married at twenty years of age. Had seven children, and three miscarriages. Twelve years before her death she noticed a gradually increasing swelling of the abdomen. The tumor was distinctly movable, and appeared to be adherent at the umbilicus. A diagnosis of lithopredion was made; and, at her death, at the age of forty-two, in the Amsterdam Hospital, this was confirmed. The tumor was free, except at the front, where it was attached to the abdominal walls. The foetus was developed in a calcified membrane; its head was situated at the um- bilicus, the back toward the lett hypochondrium ; arms and legs drawn toward each 65S APPENDIX. other, and to the right. The uterus was in the lower pelvis, and was normal. The left ovary and tube were also normal. In the place of the right ovary there seemed to be a cyst, filled with a brownish substance, attached to the tube. After the covering was stripped off the foetus was seen with the head, legs, and arms drawn toward each other. The internal organs, muscles, and other structures were easily recognized. Case VIII. Is reported by Dr. Wagner, Arch, des Heilk., vi., No. 2, p. 174. The patient was a widow, sixty-eight years old. At the age of twenty-four she had given birth to five children. In her thirty-seventh year she again became preg- nant, but was never delivered of the child. Labor-pains were not present. For a long period the abdominal enlargement remained constant in size, and Ca;sarean section was advised. Finally, the tumor began to grow smaller; her menses re- turned, and fair health was experienced, the only complaint being of a feeling of weight in the abdomen. At the autopsj'the tumor was found to fill the lower pelvis, and to be attached to the bladder, rectum, and uterus. The tumor weighed three- quarters of a pound, and was about the size of a man's head. It was covered by a yellowish membrane. The left tube and ovary seemed to be growing from the tumor, the uterus being pushed to the right. The foetus was of female sex; the head was much drawn to the right, and bent upon the thorax. The skull was markedly compressed, the bones overlapping; calcification was present, but not uniformly. The various organs and muscles were not distinguishable, being changed to a fatty mass, which contained haematoidin crystals. Case IX. Is reported by Dr. Bossi, Siizineister d. Vereins d. Aertze in Steirinark, xi, page 37. In this case a lithopjedion was diagnosed in 186S. During the years 1869 and 1870 abortion was induced several times. The operation was repeated in 1S72, with a fatal result, peritonitis following. The autopsy revealed a pear-shaped tumor about the size of a man's head, covered with a capsule, which was very thick and hard (calcified). Portions of the foetus were in a natural condition, and portions were changed to adipocere, some of the bones being entirely denuded. The tumor communicated with the rectum by a small opening. The uterus and tubes were normal. Right ovary atrophied, left one adherent to tumor. Case X. "Tiibingen Inaugural-Abhandlung," von Wilhelm Kieser. The lithopredion was found in a woman 90 years of age, in 1720. In 1674 she had all the symptoms of pregnancy, foetal movements being very noticeable. At the expiration of nine months labor-pains started up; the membranes ruptured. Pains continued for two weeks, and then gradually disappeared; the foetus having apparently escaped into the abdominal cavity, after rupture of the uterus. Two children were subsequently born. The autopsy revealed a large tumor, 13.5 cm. in diameter, covered with a capsule so hard that a knife could not cut it. The stroma contained an exudation in which lime-salts were deposited. The skin of the foetus vas well preserved, covered by epidermis more or less calcified. The muscles APPENDIX. 659 could not be recognized, having been clianged to a "soft substance" (adipocere). The brain was a blackish-brown mass, which was pulverulent and easily melted ; the membranes were of a leathery consistence. A citron color was diffused through- out the entire structure. The reports concerning the position of the tumor are not trustworthy. Case XL Is reported by Smellie in his " Collection of Cases and Observations in Midwifery," vol. ii, page 65. The patient was pregnant in 1731, with the usual signs. At the 6th month foetal movements ceased, as the result of a fright. Under treatment she discharged a mass, which was thought to be a part of the placenta, as well as a small amount ■of fluid. There was no decrease in the size of the abdomen. In July, 1733, two years and two months from her first pregnancy, labor-pains returned, with an apparent rupture of membranes. At this time the child was found in the abdomen. In January, 1734, she became pregnant, and was delivered, Oct. 28. She was again delivered, Oct. 22, 1735, also Oct. 9, 1738, and June 17, 1741. She was admitted to Guy's Hospital Oct. 14, 1747. She died Nov. 7, 1747. The autopsy showed the abdominal contents to be nearly in their natural state. In the right pelvis was a child, attached to the ilium and neighboring membranes by the peritonaeum, in which the tube and fimbriae were apparently lost. The foetal integument had become partially calcified. Case XII. In giving the history of this case I hoped to quote irom the recoixi- books of the physician in attendance at the time of the accident, who, as I understand, took extensive notes ; but I am unable to do so, owing to his death a few years ago, and the subsequent destruction of his records. I am fortunate, though, inasmuch as such information as I have of the case comes from a twin sister, who is still a remarkably vigorous woman, both mentally and jDhysicallv, and whose statements, as far as they go, are undoubtedly correct. Mrs. A was married September 24, 1S44. She never had any miscarriages. She was delivered of a perfectly healthy child, January 29, 1S48. Early in January. 1S56, she became, as events proved, pregnant again ; though her condition at the time was merely sur- mised, as menstruation continued to be present, and, in fact, existed, with more or less regularity, throughout her entire pregnancy. It was not until the middle of May that the attending physician made a positive diag- nosis of pregnancy, basing his opinion on fcetal movements, which became manifest at that time. Earlv in March, while visiting friends, she fainted, vomited, and complained of epigastric pain. There was no flowing at this time. The following dav she rode home, a distance of four miles. Directlv after this she had three " inflammatory fevers." characterized bv abdominal pain, excessive tvmpanitis. and uncontrollable 6(>o APPENDIX. nausea and vomiting. Dining one of these attacks an abscess formed just above the pubes, which opened, but did not discharge much, if any. Counting from the middle of May, when foetal movements began, October I would be the probable date of confinement. About that time the physician was summoned, not on account of labor-pains, as she never had them, but on account of excessive and painful movements of the child. These were always very marked, and caused her the utmost inconven- ience. As she expressed it, she felt more life with this child in two hours than during her entire previous pregnancy. October 13 the j^hysician was again summoned for the same reason as before. At this time " something was rubbed on the abdomen," after which the movements grew less and less, and finally ceased. For the following ten years she was an invalid, though nothing very explicit could be obtained as to her condition. She was generally miserable, and had a number of attacks of abdominal pain at irregular intervals, sometimes accompanied by icterus. During this period the tumor very gradually decreased in size, finally remaining sta- tionary, and causing no trouble other than a feeling of weight when standing or walking too long. Her health was fair until 1SS3, when a malignant growth attacked her larynx, which eventuated in her death,. December 24, 1SS6. The autopsy was jDerformed December 26, 1886^ Drs. Bill and Metcalf assisting. The body was very inuch emaciated.. The tumor was apparently situated in the median line, with its most prominent point at the umbilicus, but on palpation it was found to extend downwards and to the left. On making the incision it was found to be adherent to the abdominal walls, and it seemed as though it would have soon made its way through, either from pressure or ulceration, so thinned had the structures become at the point of its adherence. The position of the tumor may be best described by borrowing the obstetric expression,, sacrum, left anterior, though it was entirely out of the pelvic cavity, the base of the skull being on a level with the umbilicus. It was almost lying loose in the abdominal cavity, the only points of attachment being the one just referred to, to the abdominal wall; what was probably the um- bilical cord, and some small adhesions to the intestines. These were ranged round the tumors, none in front of it, and were one mass of adhesions, forming, with the abdominal wall, a cavity, as it were, con- taining the tumor. The umbilical cord (?) passed directly downwards, enclosing the uterus, and then gradually fading out into the peritonaeum. Nothing that would answer for a placenta, or the remains of one even, could be found. Roughly speaking, the parts of the ftiotus were normally disposed, the thighs and arms being flexed on the abdomen and chest respectively. The left leg was rotated slightly outwards, as well as APPENDIX. 66 1 •extended, and the forearms, instead of being crossed, were more or less parallel with the long axis of the body, the hands being placed well up be- side the head, as is shown in Figs. i6& 17. The tumor weighed 3^ lbs., was 83^ in. long, and 121^ in. in circumference. The cross-section showed it to consist of a fcetus and its envelopes, the process of calcification being especially marked in the membranes. The uterus, Fallopian-tubes, and ovaries were also removed, but furnished no points of importance. The autopsy suggested an extra-uterine pregnancy of the abdominal variety ; but the history points rather to one of the tubal variety, pri- marily. To epitomize the various dates : — Mrs. A was married in ... 1S44 1st child . ....... 4 years later. 2d pregnancy . . . . . . . 8 " " Probable rupture of cyst and peritonitis . . at the third month. Death of foetus . . . . . , t' 't ninth " Period of ill health ...... 10 years. " " health 27 " Death from cancer of larynx invading the lung, at the age of 67. 662 APPENDIX. LITHOP^^DION. Plates R and S. With a paper read before the American Association of Obstetricians and Gynaecologists, September, iSSS, and published in the " Annals of Gynaecology,"' December, iSSS, Prof. Franklin Townsend, of Albany, pre- sented the specimens represented by Plates Rand S, which were obtained from the Museum of the Albany Medical College, of Albany, N.Y., with the history, as reported by the late Dr. J. H. Armsby, of Albany. " The specimens were obtained at a post-mortem examination held by Dr. Parkhurst, in the presence of about twenty persons, upon the body of Mrs. Amos Eddy, aged 77, of Frankfort, Herkimer Co.. N.Y. Mrs. Eddy's maiden name was Rebecca Smith. She was born in Fredericks- town, Columbia Co., X.Y., in the year 1775. Her pai"ents were born in England. Her mother, Sarah Smith, gave birth to twenty-four children, of whom four pair were twins, Rebecca being the twelfth child. Mrs. Eddy was married in New Lebanon, Columbia Co., N.Y., in 1795, at the age of 30, and removed with lier husband. Amos Eddy, to Frankfort. Her- kimer Co., N.Y., where they both lived and died, — he at the age of 70, and she at the age of 77 ; she became pregnant in 1802, seven years after her marriage, and died in 1S52, carrying this foetus fifty years. " No unusual symptoms attended her pregnancy ; her catamenia ceased, quickening was felt at the usual time, and the motions of the child increased as would be natural. At the expiration of eight and a half months she had severe labor pains, following a sudden fright from the falling of a vessel into the fire while she was engaged in cooking. Her physician. Dr. Farwell, of Litchfield, was called ; the labor pains con- tinued for several hours with regularity and force, but at length subsided, and she remained comfortable for two or three weeks. '• Her health then began to decline, and the full period of pregnancy having passed by, her friends became extremelv anxious, and availed themselves of the advice of Drs. Guiteau, Hull, Coventry, White, and others. For a considerable time she w^as confined to her bed, and after a year and a half of extreme suffering her health began to improve, andvvas finally restored ; during the remainder of her life she had good general health, but suffered occasionally from severe attacks of pain in the abdo- men, which resembled labor pains. After her health was restored, her catamenia returned, and continued until the age of 45. She travelled much about the country, and consulted various medical men, among others the late Professor Willoughby. of Fairfield Medical College ; her health con- tinued remarkably good up to the time of her death, and at the age of 76 [Annals of Gvn-ecology, Boston, Dcccmbtr, it R mj 664 APPENDIX.. she was accustomed to walk five miles from her residence to the villajje and back again.'' " The siDccimcn, with its covering cyst, weighed eight pounds at the time of its removal. The external surface of the envelope was smooth and Avhite, comjjosed of concentric layers of fibro-cartilage, varying at diHerent points from a line or two to three-fourths of an inch in thickness. It had no connections with the abdominal viscera or walls, but was slightly attached to the Fallopian tubes and omentum. The external surface of the foetus was encrusted with earthy substance, of sufficient thickness to preserve its form when dried. The interior seems to be a substance resembling adipocire." — Annals of Gv nee cologv, Dec.., 1888. Plate I, VII., p. 410. Annals of Gyn.'ecologv, May, iS'^o. MYXO-SARCOMA OF FALLOPIAN TUBE. CASE OF J. E. JA^•^•RI^^ M.D. The result of the microscopic examination of the specimen shows that it is a myxo-sarcoma — a very rare aflection of the Fallopian tube. Coe (American System of Gynaecology, vol. ii.. p. S94) says: "■ There is no authentic case of sarcoma of the Fallopian tube on record." He further says: " Sanger reports a case of so-called primary sarcoma of the tubes (Centr. fiir Gyn. 37, 1SS6), which he (Sanger) affirms is the only one on record." Coe doubts the correctness of the diagnosis. The report of the examination of the specimen made by Dr. Wni. H. Porter, Pathologist of the Post-Gratluate vScliool of Medicine, after ■going into a very careful and detailed description, closes as follows : '' The general histological construction of this newly developed tissue would argue against its being classified as an infiammatory growth, but woidd place it among the mixed connective-tissue growths. Owing to the large variety of histological elements found, it is impossible to give it any single name which will in any adequate manner express the condition. It may well be classed under one of two headings. — either as a composite fibro- sarcoma, or a composite m\ xo-sarcoma, the latter being the more accurate of the two." J Annals of Gyn.«cologv, Boston, December, 1S88.J (665) 666 APPENDIX. Plate LVIll., p. 4,50. Annals of Gyn.ucologv and P.«diatrv, August, 1890. PERIMETRITIC ADHESIONS. Plate lv., vvliich I photographed from a specimen found in a woman who had died from a disease in noway connected with the uterus, sliows very well how the latter is often bound down by adhesions, by which it is attached more or less firmly to the neighboring organs. The picture is in itself a lecture against attempting to use pessaries in cases where they do no good and are not well liorne. Such cases as the one here represented, where the tubes are not particularly afTected, and where the inflammatory process has run its course, leaving only the adhesions as evidence of its former activity, are the cases where some- thing may be accomplished by the stretching manipulations of Schulze, or even by the milder measures now recommended as massage. Unhappily it is very difficult to be certain that the disease of the tubes is extinct, so that there is always danger of making the patient vvorse instead of better by any manipulations which are active enough to be efficacious. Plate LIX., p. 45S. Annals ok Gyn.'ecology, March, iSSS. OVARIAN ABSCESS AND PYOSALPINX. CASE OF JOSEPH PRICE, M.D., PHILADELPHIA. The explanation of this figure is on the plate. It is a marked example of the result which may follow gonorrhoeal salpingitis, an affec- tion the gravity of which has only recently been appreciated. The futility of treating such an affection by so-called "conservative" methods, /.e., by hot douches, iodine, and glycerine tampons, is evident. Plate LX., ]). 45S. Annals ok (ivN-iiCOLOov, April, 1SS9. HEMATOMA OF OVARY. — ABSCESS OF OVARY. case of R. H. MURRAY M.I), N.V. On examination, Nov. i2, iS88, when she consulted me, I found the uterus fixed, somewhat enlarged and tender, and a profuse leucorrhceal discharge of muco-pus, the menses having been one week before, with some clots, but no shreds, and not very painful. At the right side of the uterus, very perceptibly felt on bimanual pal- pation, was found an immovable tumor the size of a mandarin orange, not fluctuating, tender on pressure, and directly connected with the Fallo- pian tube, which was distended larger than a finger; on the left side the APPENDIX. 667 tube and ovary were enlarged, fixed, and not fluctuating. As the case, by the previous history of pregnancy, the appearance of the tumor, the con- stant pain and loss of strength and weight, gave a suspicion of extra-uterine pregnancy, and there was evident pyosalpinx, opinion was given that im- mediate operation was advisable. A consultation was suggested, and the case was seen by Dr. W. R. Gillette, who thought that the pyosalpinx with adhesions, and possibly hasmatoma of right ovary, necessitated operation. Dr. J. Janvrin also saw the case, giving as his opinion a probable extra-uterine pregnancy and pyosalpinx of left tube and abscess of ovary. Two days afterwards, in a thoroughly disinfected room, I did a lapa- rotomy, found the left Fallopian tube distended with pus, and an abscess of the left ovary; on the right side a pyosalpinx and hasmatoma of right ovary with abscess. The adhesions were very extensive, causing much loss of time and considerable haemorrhage in detaching tlie uterus, tubes, and ovary from the intestines. On the left side the ureter ran downwards and backwards through the adhesions, and had to be freed and followed up in about six inches of its- course to distinguish it carefully from the peritoneal adhesions. An abscess in the left ovary ruptured while the ovary was being de- tached, and the separation of the Fallopian tube from uterus and broad ligaments caused such profuse hcemorrhage that only by quilting the broad ligament with catgut sutures and attaching it to the side of the womb could the flow be stopped. On the right side the large mass was with the same difficulty de- tached. The ureter on this side also ran down through the mass of adhesions and through an arch made by them, requiring the most careful handling to avoid its rupture. After the removal the abdomen was carefully cleansed by hot water, sterilized by careful boiling, and the intestines freed from adhesions; a drainage-tube w^as used, and convalescence was uninterrupted. Plate LX. Annals ok Gvn.ecologv, December, 1SS7. CYST OF BROAD LIGAMENT. — CYSTOMA OF OVARY. These figures, taken from the article of Dr. W. Gill Wylie, in the above number of the Annals, are given to show the difference in appear- ance of a cyst of the broad ligament and an ovarium cystoma, and tor comparison with sacs of the tube and ovary containing pus. [Annals of GvN.'ECOLor.Y, Boston, J^miary, 1SS9.] i 2 V p o Z (668) APPENDIX, 669 Plate LX 1 1, p. 496. Annals of Gvn.kcology, September, iSSS. TUBERCULAR SALPINGITIS. The importance and gravity of this disease are so great, and the results of surgical interference are so surprising and so satisfactory, that I take pleasure in presentmg to the readers the accompanying picture of a specimen which is almost unique. During the meeting of the American Medical Association at Cincinnati, In iSSS, I was honored hy Dr. T. A. Reamy with an invitation to be present at his private hospital to witness an operation on the patient from whom he removed this "specimen. The lady had suffered great pain in the pelvis for some years, and physical examination revealed the ovaries and tubes enlarged and very tender. There was no history or symptom of tuberculosis. The operation was performed with the skill and care for which Professor Reamy is well known, and presented no especial difficulties. As seen in the photograph, there was in one ovary a dermoid cyst containing a butter-like substance and a few brown hairs ; the other ovary was swollen and cystic. The chief interest, however, lay in the tubes, which were enlarged, occluded, and filled with a cheesy, purulent mass ; the peritoneal covering of the tubes was studded everywhere with miliary tubercles, as seen in the figure. There were no tubercles on the other peritoneal surfaces. The patient made a good recovery, and is much relieved. Dr. Reamy reports that the patient is now in good health, two years after the operation. The following case is given as reported by Dr. F. L. Burt, in the " Annals of Gynecology," in September, iSSS : — Vomiting associated ■with Tuberculosis of Peritonivzim. — Miss H. F. is a domestic ; single ; age, 23. She was born of Irish parentage, at Sligo, Ireland. Six years ago she became a resident of the United States, and has since resided in Chelsea, Mass. Menses appeared at about six- teen, and there has been regularity of periods ever since. Severe pain has always been associated, beginning two or three days before the flow and continuing throughout. She was a patient of Dr. A. E. McDonald in the summer of 1SS6, and was referred by him to Dr. Cushing, for un- controllable vomiting, apparently of reflex origin. The uterus was found retroverted, and was replaced and supported bv a pessary. This was in vSeptember, 1SS6. Later, Nov. 7, 1SS6, she was admitted to the Murdock Hospital. The special symptom complained of was vomiting, which, she claimed, had been of daily occurrence since she was about fourteen years of age, but was somewhat worse before coming to America. Examination showed a patient somewhat ema- ciated, as would be expected after suflering from such continued vom- iting. Otherwise she would have been considered phthisical, although there was no cough nor any evidence of lung trouble. The family his- tory is unknown, but it is my impression that there was no record of 670 APPENDIX. tuberculosis. It could not be made out that tlicre was any disease of the stomacli, rather that the vomiting was symptomatic of some distant disease. There was soreness and tenderness in the left iliac region, a tenderness about pelvic organs, and considerable endometritis. Nov. ix, 1888, the uterus was dilated and curetted and a plug introduced. Following this shortly, there were irregular changes in temperature, evidently not due to the operation, since this should not be followed by a I'ise of tem- perature unless there be some disease outside the uterus. Then for some weeks the temperature kept above 99°, for which no cause could be given. As to the medical treatment she had received, variety, etc., I cannot state, the condition having lasted several years and been treated by several physicians. Perhaps it will suffice to say that nothing had been of anj- value whatever as directed to the symj^tom of vomiting. A change of food or change in the system of feeding was of only temporary benefit, a result of rest to the stomach or of less irritation to the membrane. However, she lished in the " Boston Medical and Surgical Journal," Aug. 9, iSSS, by Dr. A. T. Cabot, in which he also refers to the other work done in this line. APPENDIX. ^71 Phitc I.Xm., p. 496. Annals of Gyn-v-coloov and P.kdiatrv, 1S90. COLLOID DEGENERATION OF DERMOID CYSr OF OVARY. Mrs. G. was sent me by Dr. Bigelow, of Amherst, Mass., with the following history : The patient is 52 years old, and has had a small tumor for at least twelve years, which was diagnosticated as a uterine fibroid by the late Dr. Warner, of Boston. About two years ago the tumor began to increase in size, and during the last few months the increase has been quite rapid. On examination the abdomen is found to be filled with a fluctuating tumor, apparently ovarian. On operation the cyst wall is found to be very thin, and it must have ruptured during the administration of ether, or at least very recently, as there is a large amount of colloid matter free in the abdomen. The cyst was i^emoved without difficulty, the abdo- men flushed with hot distilled water; glass drainage-tube ; une\entful con- valescence. Examination of the specimen shows that the original part of the tumor is a dermoid cyst, containing hair, fat, etc. Most of the mass, however, is composed of gelatinous or colloid substance, apparently sim- ilar to the tumors which in women of the age of the patient are so apt to become malignant. Plate LXI\'., p. 49S. Annals of Gvn.«cologv and P.kdiatkv, iSgo. FIBROMA OF OVARY. Mrs. p. was sent to me by Dr. Jacobs, of Burnham, Me., with the following history : For several years she has had a hard tumor, about the size of a man's fist, which was supposed to be a uterine myoma. During the last year the tumor has grown rapidly, and on account of pain she was unable to work. Being only 24 years old, and living remote from any possibility of sufficient care and attention, or medical supervision, I ad- vised removal of the uterine appendages. At the operation the left ovary was found to be fiimlv imbedded in the lower surface of the tumor, which was strongly adherent to the posterior surface of the right broad ligament. The tumor was lifted with a great deal of difficulty, and, when its attach- ments on the right were separated, it was foimd that there was no connec- tion between the tumor and the uterus, but that the whole mass was an outgrowth from the left ovar\'. Irrigation ; glass drainage-tube ; uneventful convalescence. The plate shows the position of the ovary on the surface of the fibrous new-growth, which is a rare condition in comparison with the frequency of other tumors of the ovary, or of myomata of the uterus. 672 AFFExWlX. Plates LX\'.-LXVni., p. 500. Annals ok Gyn.«cologv, September-Octoher, 1888. CHRONIC PERITONEAL EFFUSION, SOLID TUMORS OF THE OVARIES. MULTIPLE POINTS OF INFECTION OF THE PERITON.^l^M. Mrs. M., of Cambridge ; 43 years of age; has had six children and one miscarriage, between fourteen to twentv-one years ago ; all dead. Last menstruation five months ago. No menstrual pain. Has had stop- page of water from i^ressure. Bowels very irregular. Has been three weeks at a time without a movement. Now better because of treatment. The last pregnancy resulted in a miscarriage, and she has been sick ever since, with her present condition. Has been under the care of some physf- cian for uterine trouble ever since marriage. Was treated by a ring for prolapsus. At the time of the miscarriage the physician wanted to turn the womb (her statement) , and, whatever was done, the next physician made a diagnosis of lacerated cervix. She was then told she had a fibroid growth on the cervix. A few months later some doctor diagnosed three tumors on the ovary, each about the size of a pea, and said she had medicine that would take them away. For the last five years she has been iMider irregular practitioners, at considerable expense and with no benefit. vShe entered this hospital May 14, iSSS, and her condition at that time as to size, etc., is well seen in the illustration of this number (see Plate Lxv.). The distention of the abdomen was from ascitic fluid. The ribs were very widely separated, especially noticeable after the escape of the fluid. The uterus, with the vagina, were prolapsed in a great mass, fluctuating, but revealing something solid in the pelvis. Laparotomy was performed May 17, 18SS. About fifty pounds of milky fluid escaped. There was a tumor of each ovary (solid) the size of a large clenched fist. These were removed, the pedicles ligatured with catgut by the shoemaker stitch, which stopped a rather free oozing of blood. The l)Owels were seen to be completely covered witli very small portions of the papillomata, impossible to remove. The abdomen was closed as quickly as possible owing to the collapsed condition of the patient. Breathing stopped, and was revived by artificial respiration, and hypodermics of brandy were given. Recovered quite well, without much shock. As there was considerable haemorrhage, a tube was introduced. The dis- charge was removed by suction syringe, about § ss t-i-d. May 19, tube was pulled up somewhat, and a cavity containing considerable scrum found. May 20. tube overflowed considerably. Bowels mo\cd on third APPENDIX. >7.1 •tlay. There was some vomitiiij:^ for three days. Next day the tempera- ture was 103.5°, pulse i5o-|-' A cavity with considerable fluid was found at about the same point of the peritonoeum, and after it was freed and washed out with sublimate she began to pick up strength. .She gained very slowly, however, never at all satisfactorily ; temperature, 100" or 101°. The abdomen partially refilled, because of the constant oozing from the papillomatous deposits, and she gradually became exhausted, sinking away to death on the 9th of June, 18S8. SCATTERED PAPILLOMATA OF THE PERITONEUM. Thk case represented by Plates lxv.-lxviii. is one of a class of much interest in regard to the prognosis to be pronounced when papillomata arc found grafted on the various viscera and peritoneal surfaces. It is well known that in some cases of papilloma of the ovary or broad ligament, after rupture of the cyst from accident, absorption, or tapping, minute particles of epithelial tissue, floating in the peritoneal cavitv like spawn or seed, attach themselves to the various peritoneal surfaces and continue to grow there ; when small, these look like miliary tubercles, but some of them grow much larger than the latter. Man}- cases are recorded where these have been foimd at operation, and probably in man}' more cases they have been found where no record of the fact has been j)ub- lished. Curiously, little has been said in our text-books and other medical literature as to the relative gravity of this complication ; and from con- versation we find that the greatest diflerence of opinion exists among operators as to the prognosis in such cases. It is agreed that patients recover from the immedate eflects of the operation in spite of such miliar}- peritoneal papillomata ; but whether they are likely to live weeks, or months, or years is undecided. More- over, the question of the malignancy of papillomata of the ovaries or broad ligament is in a very unsatisfactory condition. Practically, it is known that solid tumors are bad, and apt to be malignant, but the microscopical distinction is not yet made clear. Without entering on this question here. I have presented this case as a slight contribution to this subject. Especially is it desirable to establish the probable course of such cases after operation, and to ascertain whether there is any chance that such scattered papillomata may wither away after the abdomen has been opened, or after establishment of permanent drainage. INDEX OF AUTHORS. Adam, io8. Amusat, 275, 379. Apostoli, 275. Aran, 429. Arning, 347. Atlee, 275, 467-473. 502. Atthill, 23. Aubenas, 243. Bandl, 334. Bardenheuer, 334. Barnes, 454, 177. Battey, 467, 527, 529, 532. Baum, 366. Baumgartner, 152. Bayer, 275. Beelj, 519. Beigel, 34, 452, 460, 501. Benicke, 31, 336, 346. Berard, 334. Bernutz, 429. Bertram, 42. Billroth, 63, 367. Binswanger, 371. Birch-Hirschfeild, 499. Bird, 503. Bischop, 142. Bitter, 336. Blasius, 471. Blau, 305. Boinet, 493. Boivin, 457. Botticher, 261. Bozemann, 334. Braun, 29, 506. V. Braun-Fernwald, 45, 243. Breisky, 56, 187, 241, 24S, 346. Brennecke, 366. Brose, 164, 330. Brown, 467, 503. Bruckner, 250. Budin, 216. Buhl, 390. Bumm, 42S. Bunge, 52. Burkhardt, 289. Burnier, 397, 477, 471. Busch, 134. V. Campe, 262. Chacot, 464. Chrysmar, 503. Clay, 509. Coblenz, 470. Coe, 498. Cohn, 477, 499. Courty, 106, 414. Cousin, 496. Crede, 63, 241, 334. Cushing, E. W.. 424, 426, 433, 449, 455, 460, 467. Czempin, 206, 290, 347, 354. 400, 409, 437. 464. 4/8. Czerny, 85, 366, 367, 50S. Debout, 216. Delore, 273. Deneux, 454. Dohm, 268. Dohrn, 246. Doran, 409. Duffin, 421. Duncan, 44, 17S, 276. 429, 461. Duplay, 427. Duvelius, 30, 31, 421, 4S6. Eich-\vald, 472. Ellinger, 2;^. Emmett, 177, 17S, 22^. 346, 356, 362. Engelmann, 35, 252. Englisch, 453. Eulenburge, 527. Fasbender, 37. Fehling, 529. Finn, 231. (675) 6^6 INDEX OF AUTHORS. Fischel, 426. Flaischlen, 470, 497. Fontenelle, 473. Forster, 416, 499. Foulis, 473. FrAncke, 337. Franckel, 522. Franckenhauser, 279. Frankel, E., iii. Frerichs, 467. Freund, 146, 167, 178, 206, 334, 336, 411, 421, 429, 473. Friedlander, 470, 496. FriUch, 23, 126, 128, 139, 334, 368, 531. Frommel, 318. Funst, C, 242. Furst, L., 362. Gallard, 429. Gallez, 467. Gervis, 56. Godefroy, 56. Goodell, 455. Gotthardt, 246. Gottschalk, 409. Grawitz, 429. Grisolle, 429.' Grosskopf, 257. Gupil, 429. Gusserow, 271, 275, 405, 426, 427, 466, 499. Hagas, 280. Hahn,334. Hausamann, 192, 400. Heer, 257. Hegar, 18, 23, 106. 134, 137, 157. 165, 179, 236, 241, 276, 279, 281, 331, 353, 357' 367- 390. 405. 441. 452. 460, 463, 466, 467, 474, 481, 483, 501, 504, 506, 508, 513, 520, 521, 525, 528, 529, 530, 531- Heitzmann, 429. Henle, 358, 359, 37S, 389. Hennig. 366, 387, 392, 477. Heppner, 62, 63, 169, 249. Hildebrandt, 170, 191, 216, 259, 272, 273. Ilis, 3, 496. Hodgkin, 467. Hoffmeier, 193, 308, 309, 312, 3C4, 36C, 368, 37 1 ' 474- Hoist, 8. Horn Eleonore, 145, 514, Howitz, 346. Hugier, 20. Huppert, 473. Hutchinson, 503. Imlach, 108. Ingham, 498. Jacubasch, 279. Jager, 272. Jaquet, 56. Jenks, 498. Johanowskv, 241. Johannowski, 241. Kaarsberg, 346. Kaltenbach, 134, 179, 241, 246, 251, 281, 373. 394' 406, 473' 474' 506, 513. S^S- Kehrer, 44. Keith, 426, 504, 512, 526. Kidelin, 63, 387, 391. Kimball, 502. Kisch, 39, 42. Kiwisch, 20, 458. Klebs, 442, 499. Kleeberg, 280. Kleinwachter, 246, 498. Klob, 72, 244, 498, 499, 501. Koberle, 2S0, 467, 468, 477, 500, 504. Kocks, 246. Koester, 368. Kohlrausch, 3. Krassowski, 506. Kristeller, 12. Kroner, 178. Kuester, 50S. Kuhn, 421. Kundrat, t,^. Kuster, 3, 341, 344, 502. Kustner, 3, 106, 194. Labbe, 477. Landau, 318, 334, 409. V. Langenbeck, 165, 169, 279, 315, 366. Langer, 284. Larchcr, 259. Laustein, 153. Lawson Tait, 527. Lee, Th., 498. Lenardt, 256. Leopold, ZS^ 258, 367, 368, 38S, 457, 477, 498, 499, 500, 501 , 506. INDEX OF AUTHORS. ^n Leppmann, 529, 531. Lister, 504. Lizars, 503. Loewenhardt, 34. Lohlein, 11 1, 203, 257, 464. Lomer, 279. Lessen, 139, 333. Lott, 45. Madden, 453. Mannel, 279. March, 503. Marchand, 470, 476, 491. Marckwald, 343. Martin, A., 206, 276, 279, 333, 36S, 447, 477. 529- Martin, E., 74, 86, 94, 119, 341, 390, 429, 431, 467, 503, 512. Ma_yer, 12. Mayer, L. , 39, 243. McDowell, 502. Mehu, 473. Meinert, 405. Mejer, C., 193. Michlsen, 125. Mooren, 416, 437. Moreau, 7. Moricke, 35, 357. Mosler, 459. Muller, 333. Muller, P., 97. Munde, P., in, 453. Nagel, W., 2S0, 293, 309. Nelaton. 508. Neugebauer, 135, 136, 137, 160. Noggerath, 177, 219,428,458. Nonat, 429. Odebrecht, 357. Oertel, 67. V. Oettinger, 4:54. Olshausen, 200, 281, 346, 367, 373, 4^3, 456, 461, 467, 46S, 474, 499, 501, 504. 506, 508, 512, 526, 529. Orthmann, 259, 260, 323, 3S7, 3S8, 390, 395, 396^ 409' 498- Parvin, 39. PauW, 496. Pawlik, 15, 309. Pean, 280, 284, 503, 510. Peaslee, 467, 468, 493, 502, 504, 527. Pfluger, 496. Piogroff, 2, 3, 412. Playfair, 44. Polk, 455- Pott, P., 454. V. Preuschen, 246. Priestley, 23. Prochownick, 241. Puech, 453. V. Rabenau, 79. Raziborsky, 39. Recamier, 200. Reichert, 34. Reinl, 236. Richard, 477. Roderer, 467. Rokitansky, 242, 452, 469, 470, 498. Rose, E., 268, 335. Roser, W. Ruge, C, 371. Ruge, Carl, t^z^, 90, 191, 197, 200, 203, 298, 299, 308, 320. Ruge, Paul, 3, 210, 371. Runge, 477. Rydygier, 375. Sanger, 15, 221, 367, Sauter, 366. I Saxinger, 73, 504. Scanoni, 23, 468. Schatz, 23, SS, 124, 4: Schede, 366. Schlesinger, 421. Schmalfuss, 527, 529 Schorkopf, 502. Schroeder, 3, 26, 31, 168, 177, 194, 206, 243, 247, 256, 261, 287, 288, 291, 294, 307, 308, 309, 312, 357, 35S, 364, 366, 394, 397, 427, 443, 469, 474, 476, 500. 520, 526, 529. Schucking, 273. Schulein, 179. Schiiltze, I, 8, 18, 2}), 456, 481, 483, 4S5. Schwarz, 504. Sigesmund, 34. 409, 427, 483. 7, 517- 530. 47, 48, 52, 73, 209, 2i6, 227, 271, 273, 2S0, 297, 29S, 299, l^Z^ 324, 343- 367, 36S, 371. 444, 459, 467. 504, 506, 512, i50> 229, 2S1, 302, 346, 376, 46S, 517- 27, 74' 94, 212,213, 6^^ INDEX OF AUTHORS. Simon, 14, 16, 100, 13S, 331, 334, 340, 341. 343- Simpson, 20, 22, 79, 216, 339. Sims, M., 20, 62, 79, 216, 331, 339, 355, 356, 504.523- de Sinety, 34, 231, 460. Skene. 246. Slavjansky, 45S, 506. Solger, ic6. Speigelberg, 135, 179, 275, 346, 429, 472 473. 498- Stahl, 527. Staude, 165, 366, 368, 382. Stern, 247, 427. Stilling, 503. Storer, 453. Strahan, 449. Stratz, 86, 224, 308, 318. Tait, Lawson, 165, 177, 405, 449, 467, 502, 531- TaufFer, 527, 529. Thoma, 477. Thomas, G., 100, 178, 455, 499. Thornton, 473, 494. Tilt, 461. Trenholme, 527, 529. Turban, 527. Turner, 508. Urdy, 280. Vedeler, 82. Veifc, G., 246, 247. Veit, J.. 156, 170, 298, 299, 308, 371, 406. 409, 441, 444. Virchow, 56, 244, 257, 412, 427, 443, 456, 467> 498' 501- Waldeyer, 3, 426, 469, 470, 473, 498. Warner, 453, 503. Wegner, 247, 517. Wells, 427, 467, 473, 477, 498, 501, 503, 506. 508, 510, 511. Wernich, 273. Werth, 170, 471, 476. West, Ch., 73, 459, 503. Wiedow, 527. Wilks, 501. Williams, 85. Wilms, 165. Winckel, 15, 22, 27, 80, 90, 103, 135, 157, 186, 191, 243, 245, 246, 252, 271, 337, 389, 409, 442. Wittrock, 499. Wolfler, 366. Wutzinger, 454. Wyder, 260. Wylie, 455. Zeemann, 390. Zeiss, 108. Zweifel, 191, 275, 334, 426. INDEX OF SUBJECTS. of th and uterus Abrasio After-treatment . Anaesthesia Anomalies of development and raodificatio Anteversions and anteflexions Amenorrhoea Authors, Index of Castration ■Cervix, Amputation of the Carcinoma of the Follicular, Hypertrophy of the Operation for laceration of the The annular wedge-shaped incision •Conception .... Corpus, Carcinoma of Complications .... Curettement .... Defective development of the vagina Dilators ..... Drainage, Tube-glass . Dysmenorrhosa .... Examination, Bimanual Examination combined Examination, Importance of the neighbo Fistula, Recto-vaginal Vesico- vaginal . ■Genitals, Inflammation of the mucous Gonorrhoea in women Htematocele, Extra-peritoneal Intra-peritoneal Inspection .... Introduction by author Ligaments, Diseases of the broad New-growths of the broad Menorrhagia Menstruation Derangements of Metritis, Acute . Chronic ns of rmg the form and position brane of the the PAGE 28 47 77 38 535 527 345 345 224 346 343 44 319 518 28 47 23 426, 460 44 8 8 14 335 326 194 219 421 442 12 8 4" 428 41 33 37 226 229 (679) 68o INDEX OF SUBJECTS. PAGB Mucous membrane, Inflammation .......... 194 Polypi of the ............. 224 Myomata, fibromata ............. 252 Os, Discision of the external ........... 339 Ovariotomy 502 Ovary, Carcinoma of the 499 Dermoid tumors of the ........... 495 Diseases of the . . . . . • . . . . . .451 Fibroma of the ............ 495 Inflammation of the ........... 475 New-growths of the ........... 467 Sarcoma of the ............ 501 The solid tumors of the ........... 498. Tuberculosis of the ............ 501 Palpation ............... & Parametritis .............. 41 1 Pathology of the vagina and uterus . .......... 47 Pelvic organs, Situation of the ........... I Perimetritis .............. 428 Perinseum, Laceration of the . . . . . . . . . . .160 Restoration of the ............ 160 Peritonaeum, Disease of the pelvic .......... 428 Physical examination of the patient .......... I Physiology and pathology of menstruation and conception ..... 33 Polypi of the mucous membrane .......... 224 Pregnancy, Tubal ............. 406 Pyosalpinx, Hydrohsemato ............ 386 Retroversions and retroflexions ........... 89 Salpingitis ............... 386 .Sexual organs, Malformation of the .......... 48 Sound, Examination with the . .......... 18 Speculum ............... 12 Sponge, Compressed .............. 23 Sterility 45 Temperature .............. 433 Tents 23 Tubal walls 406 Tubes, Disease of the ............ 386 -New-growths of the . . . . . . . . . 409 Tumors of the vulva and vagina . . . . . . . . . 243, 245 Urethra, Resection of the orifice .......... 337 Uterus, Adenoma of the . . .......... 294 Atrophy of the ............ 63 Carcinoma of the ... ......... 298 Descent and prolapse of the . . . . . . • • .112 Examination of the interior of the ......... 22 Inflammation of parenchyma .......... 226 INDEX OF SUBJECTS. 68 1 I'AOE Uterus, Inversion of the ............ 172 Malignant new-growths of the .......... 294 Sarcoma of the 223 Total extirpation »{ the ........... 366 Tuberculosis of the . Version and flexions of the 325 74 Vagina, Changes of form and position of the uterus ....... 74 Inflammation of the ........... 189 New-growths of the .......,,. 245 Operations in the ............ 326 Tumors of the vulva and inflammation of the . . . . . , .189 Vaginismus . . . . . . . . , . . „ „ ,216 Vulva, Inflammation of the .......... 18=; New-growths of the .......... o 243 ^^ f^,|