w m 'f^WmfMn '^SIwiHIIt'lIf SWW^ (tnlumbia Itniwrraity in thr (City of Nruj ^ork CEnllrgr uf JlbiiBiriauB an^ ^urgrauH "N^xxx.^., .C^..^v.&a^^ Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/treatiseondiseas1888sken TREATISE ON THE DISEASES OF WOMEN FOR THE USE OF STUDENTS AND PEACTITIONERS BY ALEXANDEE J. C. SKENE. M. D. PROFESSOR OF GYNECOLOGY IN THE LONG ISLAND COLLEGE HOSPITAL, BROOKLYN, NEW YORK FORMERLY PROFESSOR OF GYNECOLOGY IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL GYNECOLOGIST TO THE LONG ISLAND COLLEGE HOSPITAL PRESIDENT OP THE AMERICAN GYNECOLOGICAL SOCIETY, 188T CORRESPONDING MEMBER OF THE BRITISH, BOSTON, AND DETROIT GYNECOLOGICAL SOCIETIES FELLOW OF THE NEW YORK ACADEMY OF MEDICINE EX-PRESIDENT OF THE MEDICAL SOCIETY OF THE COUNTY OP KINGS EX-PRESIDENT OF THE NEW YORK OBSTETRICAL SOCIETY WITH 251 ENGRA VINGS AND 9 CHR0M0-LITH0GRAPH8 NEW YORK D. APPLETON AND COMPANY 1888 COPYEIGHT, 1888, Br D. APPLETON AND COMPANY. TO THOMAS KEITH, M. D., LL. D., F. R. C. S. E., THIS WORK IS DEDICATED AS A TRIBUTE TO HIS ACHIEVEMENTS IN SURGERY, HIS JUSTICE AND COURTESY TO THE MEDICAL PROFESSION OF AMERICA, AND AS AN ACKNOWLEDGMENT OF HIS KINDNESS TO THE AUTHOR. PEEFACE. This book was written for the purpose of bringing together the fully matured and essential facts in the science and art of gyne- cology, so arranged as to meet the requirements of the student of medicine, and be convenient to the practitioner for reference. In the plan adopted, the diseases peculiar to women are, as far as possible, divided into three classes. The first class comprises those which occur between birth and puberty ; the second, those between puberty and the menopause ; and the third, those which come after the menopause. Each subject is briefly described, and histories of cases, typical and complicated, are given as illustrative of the disease or injury under consideration, together with the author's method of treat- ment. The number of ilkistrative cases given depends upon the practical importance of the subject and the ability to make it more plain by the use of illustrations. In carrying out this plan, the history of gynecology and the discussion of all unsettled questions have been omitted, as being at variance with the plan adopted. Credit has been given as far as possible to those who have made original discoveries, but a vast number of original workers have been passed unnoticed for want of time and space even to name them. To the medical student, history has no value until he has mastered the rudiments of the science and the art, and the prac- titioner can find in the works of reference all the historical facts which he may seek. yi PREFACE. The author has ventured to give his own views and methods pertaining to practical matters, believing that while thej may differ to some extent from the general literature of the day, they will be found reliable in practice and may be of interest to the spe- cialist. Marginal references have not been made, because all selections from the literature that have been incorporated in this work are those already well established and familiar to the gynecologist, and foot-notes only embarrass the reader who is seeking for the facts alone. Acknowledgments are due to my associates — Dr. J. H. Ray- mond, who has rendered valuable aid in the preparation of the work, and Dr. E. L. Dickinson, who has made the drawings for the original illustrations. The Author. TABLE OF COT^TENTS. CHAPTER I.- II.- III.- -Methods op Observation . . -Development of the Sexual Organs .... ■Arrest of Development and Entire Absence of Functional Activity — Arrest of Development and Growth in the Later Stages of Evolution, and Consequent Imperfection OF Function . . . . • IV. — Flexions of the Uterus . . . • Y, — Diseases of the External Organs of Generation VI. — Diseases of the Vagina .... VIL— Injuries to the Pelvic Floor from Parturition and Causes ...... VIII.— Fistula in Ano and Coccyodynia IX. — Inflammatory Affections of the Uterus X. — Corporeal Endometritis .... XL — Subinvolution ..... Xll. — Sclerosis of the Uterus .... XIII. — Membranous Dysmenorrhcea XIV.— Lacerations of the Cervix Uteri from Parturition XV. — Cicatrices of the Cervix Uteri and Vagina . XVI. — Inversion of the Uterus .... XVII. — Dislocations of the Uterus XVIII. — Retroversion of the Uterus XIX. — Abuse of Pessaries .... XX. — Hypertrophy of the Cervix Uteri XXI. — Fibroma of the Uterus .... XXII. — Malignant Disease of the Uterus XXIII.— The Menopause ..... XXIV. — Diseases of the Ovaries .... XXV.— Diseases of the Ovaries (continued) XXVI. — Neoplasms of the Ovary XXVIL— Cystic Tumors of the Ovaries— Symptomatology and Physi- cal Signs . . . . • XXVIII.— Ovariotomy XXIX.— Illustrative Cases of Ovarian Neoplasms XXX.— Diseases of the Fallopian Tubes XXXI.— Pelvic Cellulitis ..... XXXII. — Pelvic Peritonitis .... PAGE 1 22 30 54 76 99 112 162 171 203 214 220 229 242 259 266 279 304 334 343 348 398 422 438 454 473 488 509 530 547 555 579 viii TAIJLE OF CONTENTS. CHAPTER PAGE XXXIII.— Pelvic II^matocele ...... ."596 XXXIV. — Diseases of the Uki.vary Groans .... (J09 XXXV. — Malkormatio.vs of the Bladder anu I'uktiira . . 022 XXXVI. — Function of the Hlauder ..... 647 XXXVII. — Functional Diseases of the Hladuer .... 653 .XXXVIII.— Functional Diseases of the Bladder (continued) . . 674 XXXIX.-tMethods of Exploration of the Bladder and Urethra . 694 XL. — Organic Diseases of the Bladder .... 703 ,XLI. — Organic Diseases of the Bladder (co.vtinued) — Treatment of Cystitis — Croupous and Diphtheritic Cystitis — Cystitis with Epidermoid Concretions ..... 736 XLII. — Xon-Inflammatory Diseases of the Bladder . . . 760 XLIII. — Non-Inflammatory Diseases of the Bladder (co.vtinued) . 777 XLIV. — Xon-Inflammatory Diseases of the Bladder (continued) . 793 XLV. — Non-Inflammatory Diseases of the Bladder (continued) . 804 XLVI. — Diseases of the Urethra and Urethral Glands . . 818 XLVIl. — Organic Diseases of the Urethra (continued) . . 849 XLVI 1 1. — Organic Diseases of the Urethra (continued) . . 868 XLIX. — Diseases of the Glands of the Female Urethra . . 879 L. — Vesicle and Urethral Fistula .... 892 LI. — Gynecology as related to Insanity in Women . . 929 INDEX TO ILLUSTEATIOI^S. FIG. PAGE 1. Examining table ........ 8 2. Bimanual examination . 9 3. Sims's speculum . 11 4. Cusco's bivalve speculum . 11 5. Sims's position, seen from above 12 6. Nurse holding Sims's speculum . 12 7. The movements of the speculum — first movement . . 13 8. " " — second movement . 13 9, " " — third movement . 14 10. Simpson's probe ..... . 14 11. Sims's probe 15 12. Whalebone sound . 15 13. Jenks's sound 15 14. Skene's curette . 16 15. Hanks's dilator . . 17 16. Palmer's dilator . 17 17. Sponge tents . 18 18. Tupelo tents . 18 18a. Ether inhaler . . 21 19. Mailer's duets . . 22 20. Coalescence of ducts . 22 21. Disappearance of septum , 22 22. Appearance of fundus and cervix 22 23. Infantile uterus (Winckel) 23 24. Palma plicata . 23 25. Infantile uterus, antero-posterior section, scant invaginatioi 1 23 26. Virgin uterus (Sappey) — anterior view 24 27. " " — median section 24 28. " " — transverse section . 24 29. Double uterus and vagina (Eisenmann) 25 30. Uterus unicornis (Pole) .... 26 31. Uterus bicornis unicollis (Winckel) . 26 32. Uterus bifundalis unicollis (Courty) . . 27 33. Uterus duplex (Cruveilhier) . 27 34. Anteflexion of cervix — first variety , 57 35. Anteflexion of body of uterus — second variety 58 36. Anteflexion of body anc . cervix — thirc variety 58 INDEX TO ILLUSTRATIONS. PIO. 40. Thomas's anteversion pessary .... 41. " " " — in vagina, in position 42. " " " — on removal . 43. Graily Hewitt's anteversion pessary . 44. Thomas's stem pessary .... 45. Extreme anteflexion .... 46. Skene's soiMul and scarificator , 47. External genitals of a parous woman . 48. The superficial veins of the perinaeum (Savage) 49. External genitals of a virgin . 50. Cribriform hymen .... 51. Annular hymen .... 52. Fimbriate hymen .... 53. Rectum continuous with allantois (bladder) and duct of Miiller (Schroeder) ..... 54. The depression has extended inward (Schroeder) 55. The cloaca is dividing (Schroeder) 56. The perineal body is completely formed (Schroeder) 57. The upper part has contracted (Schroeder) 58. Spurious hermaphroditism (Simpson) . 59. Length of vaginal walls 60. Triangular shape of the perineal body 61. Sims's vaginal dilator .... 62. The levator ani (after Luschka) 63. The muscles of the pelvic floor (after Hart and Savage) 64. Diagrammatic sagittal section of the female pelvis 65. Complete laceration of the perina3um . 66. Sagging of the pelvic floor 67. Diagram of the sweep of the suture . 68-69. Sutures properly and improperly introduced 70. Peaslee's needle .... 71. Skene's tissue forceps .... 72. Emmet's curved scissors 73. Emmet's scissors .... 74. First step of perineorraphy, denudation begun 75. Second step, continuing the strip 76. Vivifying complete .... 77. Skene's needle-forceps .... 78. Stitch in place ..... 79. The stitches in place .... 80. Laceration with rectocele 81. Perineal body restored (profile view) . 82. Scissors for removing sutures . 83. Complete laceration of perinajum 84. do. operation ; denudation complete 85. do. " rectal sutures 86. do. " the remaining sutures placed 87. Hajmorrhoid clamp .... 88. Hard-rubber rectal tube 89. The operatic m for fistula in ano 90. Mold of uterine cavity in the virgin (Guyon) . 91. " " " " multipara (Guyon) vagina) Plate I Plate I Plate 11 Plate U 151 153 166 171 171 INDEX TO ILLUSTRATIONS. XI Plate III Plate III Plate III FIG. 92. Section of mucous membrane of uterus 93. " through corpus uteri of an infant 94. " " " " of a woman aged eighty-three 95. One of the median columns in the cervical canal (Courty) 96. Section through the mucous membrane of cervix shov/ing cystic degen- eration ... 97. Elongation of the cervix (Winckel) . 98. Hypertrophy of body of uterus (Winckel) 99. General enlargement of uterus (Winckel) 100. Skene's instillation tube 101. Curette .... 103. Dysmenorrhoeal membrane (Simpson) 103. Membrane of membranous dysmenorrhoea (Barnes) 104. The decidual membrane expelled in abortion 105. Bilateral laceration ; unequal division of the cervix 106. Bilateral laceration, with thickening of the everted lips 107. Extensive multiple laceration 108. Multiple incomplete laceration 109. Incomplete bilateral laceration 110. " " " in section 111. Crescentie laceration 113. Skene's hawk-bill scissors 113. Denudation of cervix . 114. Skene's triangular needles 115. Counter-pressure instrument . 116. Sutures in place 117. Sutures tied .... 118. Removal of crescentie-shaped piece (seen in section) 119-120. Method of bringing the sides of the section together 121-122. Another method of closing the gap 123. Partial inversion (Thomas) 124. Complete inversion (Thomas) . 125. Polypus simulating partial inversion (Thomas) 126. Polypus simulating complete inversion (Thomas) 137. Byrne's method of reduction of inversion 128. Cup pessary to exercise gradual pressure (Thomas) 129. Replacement of uterus by dilatation through abdomen (Thomas) . 130. Section of pelvis, showing its inclination and the axis of the inlet 131. The normal range of the uterine axis (Van der Warker) . 132. Diagi'ara of the uterine ligaments ...... 133. Section of pelvis, with the slings of the uterus . . . . 134. Diagram of the uterus slung between the broad ligaments 135. The normal inclination of the pelvis and the transmission of force from above ..... 136. The three degrees of prolapsus 137. Prolapsus uteri with cystocele 138. The shallow pelvis with lessened inclination of brim 139. Increased inclination of inlet 140. Uterus replaced, with pessary in position 141. Stem pessary, modification of Cutter's 142. The three degrees of retroversion 143. Retroversion of the second degree PAGE 172 173 174 175 181 182 182 182 189 198 232 232 233 244 244 245 245 346 246 247 250 250 251 354 254 254 266 266 269 269 276 276 378 280 281 282 384 384 285 287 291 292 293 298 300 305 306 xu INDEX TO ILLUSTRATIONS. FIO. 144. Retroversion witli iuii)i'rfeot invagination of cervix 145. Apparent imperfect invagination . . 146. Tlie same uterus witii its lips drawn back into place 147. The three steps in replacing the retroverted uterus by means of holders ...... 148. Albert Smith pessary ..... 149. Method of measuring tlie lengtli of the pessary 150. Diagram of pessary in situ on looking througli Sims's speculum 151. Slight invagination of cervix posteriorly with suital)]e pessary 153. Decided invagination of cervix posteriorly fitted with a suitable 153. What the pessary does not do . . . 154. How the pessary acts ..... 155. Second step ; the uterus falls into the pessary 156. The knee-chest position .... 157. Fibroid on posterior wall of uterus simulating retroflexioi 158. Trolapsed and adherent ovary simulating retrovei'sion 159. Extreme retroflexion (Barnes) 160. Uterus with defective walls ; the supra- vaginal portion of elongated (after Winckel) .... 161. Stem of pessary ulcerating through cervix . 163. Stem cutting through body of uterus 163. High rectocele due to improper pessary 164. Displacement caused by a badly adjusted pessary . 165. Hypertrophy of the cervix .... 166. The first step ; splitting the cervix . 167. The double flaps of the amputation . 168. Diagram of the pieces removed 169. The sutures in place ..... 170. The sutures tied ..... 171-173. Interstitial fibromata (Winckel) . 173. Subperitoneal and submucous fibromata (Winckel) . 174. Pedunculated submucous fibroid (Simpson) . 175-176. Enlargement due to subinvolution compared with that from of a fibroma (after "Winckel) 177. Ecraseur ...... 178. Wall of uterus caught in ecraseur-wire and removed 179. Electrical action in a single cell 180. Law cell ...... 181. Milliamperemeter ..... 183. Rheostat ...... 183. Uterine electrode ..... 184. Cancer of both lips (Winckel) 185. The fundus uteri and ovaries seen through the pelvic brim 186. The ovary and its ligaments (Henle) . 187. The ovarian, uterine, and vaginal arteries (Hyrtl) . 188. Section of the ovai-y of a bitch (Waldeyer) . 189. Ovary displaced and bound down by adhesions 190. Left ovary, one large cyst (Farre) 191. Compoimd and proliferating cyst (Farre) 193. Multiloeular cyst (Hooper) .... 193. Papillary cystoma of ovary (Winckel) 194. Dermoid cyst of ovary (Winckel) sponge- pessary the cervix is (His) growth INDEX TO ILLUSTRATIONS. xui FIG. PAGE 195. Fibroma affecting both ovaries (Winckel) ..... 478 196-197. Area of dullness in ovarian tumor and in ascites (Barnes) . . 495 198. Cautery clamp ......... 513 199. Keith's short compression-forceps ...... 519 200. Keith's long compression-forceps ...... 519 201. Keith's needle ......... 520 202. Keith's ligature-forceps ....... 520 203. Baker- Brown clamp ........ 520 204. Position of operator, assistants, and accessories in ovariotomy .' . 521 205. Diagrammatic transverse section of the pelvis (Lusehka) . . . 555 206. Pelvic abscess opening obliquely downward . . . . . 557 207. Pelvic abscess opening obliquely upward ..... 557 208. The pelvic peritonfeum (Hodge) ...... 579 209. The reflections and pouches of the pelvic peritonaeum (Hodge) . . 580 210. Retroverted uterus bound back by peritonitic adhesions (Winckel) . 582 211. Subperitoneal pelvic hematocele ...... 596 212. Intra-peritoneal pelvic hEBmatocele ...... 597 213. Diagram of the bladder to show corpus and fundus . . . 610 214. Base and neck of the bladder (Savage) ..... 612 215. Urethra laid open with probes distending the glands (posterior wall di- vided) ......... 614 216. Urethra laid open with probes in Skene's glands (anterior wall divided) . 614 217. Transverse section of urethra with gland on either side . . . 615 218. Longitudinal section of urethral glands ..... 616 219. The meatus everted showing the mouths of the glands . . . 617 220. The relations of the ureters (Garrigues) ..... 620 221. Extroversion of the bladder . . . , . . . . 638 222. Linear cicatrix ........ 639 223. Bladder covered by deep flaps ...... 640 224. Diagram of the result of the operation ..... 641 225-227. Skene's endoscope . . . . . , .695 227a. Principal of the Nitze-Leiter cystoscope ..... 697 227&. " " « "..... 698 227c. Leiter cystoscope ........ 698 328. Skene's bivalve urethral speculum ...... 700 229. Fountain-syringe for washing bladder ..... 740 230. Skene's instillation-tube . . . . . . .743 231. Skene's urinal cup-pessary ....... 747 232. Holt's catheter, with its modifications ..... 749 233. Skene's modifieatiou of Goodman self-retaining catheter . . . 749 234. Retroversion of the gravid uterus (Schatz) ..... 762 235. Skene's pessary for prolapsus of the bladder .... 767 236. Pessary holding up the bladder . . . . . .768 237. Modification of the retroversion pessary, used in prolapsus of the bladder 768 238. Forward transposition of the uterus ...... 773 239. Retrocession of the uterus ....... 774 240. Skene's reflux catheter . . . . . . .822 241. Skene's fissure probe and knife ...... 833 242. Skene's urethral speculum ....... 844 243. Skene's modification of Folsom's nasal speculum .... 844 244. Allen's polypus forceps ....... 845 245. Blake's polypus snare ........ 846 XIV INDEX TO ILLUiSTKATlONS. FIO. 24(5. Dilatation of middle third of the urethra 247. Skene's button-liole scissors . 248. Dislocation of upper third of urethra 249. Complete dislocation with dilatation 249a. Operation for prolapse and dilatation 249b. Growths at the mouths of the glands 250. Siras's tenaculum 251. Operation for vesico-vaginal fistula; paring the edges 252. Sims's sponge-holder .... 253. Emmet's needles ..... 254. Curved track of the needle .... 255. Operation for vesico-vaginal fistula ; the sutures in place 256. Two sutures tied ..... PAGE 852 8G0 801 802 Plate IV Plate IV 897 898 898 899 899 900 900 Plate I, Fig. 83. Complete laceration of perinieum. I, Fig. 84. do. operation ; denudation. n, Fig. 85. do. " rectal sutures. II, Fig. 86. do. " remaining sutures. Ill, Fig. 113. Bilateral laceration of cervix; denudation. Ill, Fig. 116. do. sutures in place, III, Fig. 117. do. sutures tied. IV, Fig. 249«. Prolapse of urethra; operation. IV, Fig. 2496. Growths at mouths of Skene's glands. Note. — All illustrations not credited are from original di'awings by Robert L. Dickinson, M. D., excepting instruments, and Figs. 92, 93, 94, 96, 217, and 218, by J. M. Van Cott, jr., M. D., and Figs. 215 and 216, by A. H. P. Leuf, M. D. DISEASES OF WOMEN. CHAPTER I. METHODS OF OBSERVATION. A THOROUGH familiarity witli the means and methods of investi- gation is the first requisite in acquiring knowledge. The art of ob- servation, which is simply the systematic use of the mental and phys- ical faculties to obtain facts, should be made an essential part of the preliminary ti'aining of every student of medicine. From this point of view, the subject which we have to consider resolves itself into two divisions: first, the ways and means of investigation; and, sec- ond, the objects to be studied. Before approaching the study of gynecology, it is taken for granted that much experience and practice have been attained by the student in the art of investigation. The experience of every- day life, from infancy onward, and the ordinary school education obtained before beginning the study of medicine, tend to develop and cultivate the perceptive faculties. Still, the physician and sur- geon require special training in the art of observation. Accurately noting stracture, form, color, general proportions, and expressions of the human body in health, is the first lesson which every student of medicine should learn. This is the most important step towai'd the attainment of a practical knowledge regarding the functions of the human body, and its deformities, diseases, and injuries. The cor- rect, rapid, and thorough observer has from the outset great advan- tages. Important and necessary as this branch of education is, it is almost wholly neglected in schools and colleges. The chief occupa- tion of teachers appears to be to impart knowledge already in exist- ence, rather than to qualify the student to observe and think for himself. Special attention should be given to this art of observation, be- cause it is the key to science and the first exercise in practice. The 2 2 DISEASES OF WUMEN. systematic way in which kiunvledge is presented in books and by oral instruction enables the student to acquire facts in all brandies of learning, and to classify them. The mental training ol)tained in the study of mathematics and logic prepares men to make reasonable deductions from the facts obtained ; but in institutions of learning, thorour>:h trainino; in the art of observation is seldom given. This lack of preliminary education adds greatly to the labors of the student, because he is obliged to acquire knowledge while he is not in possession of the means of obtaining it, and it is mainly be- cause of this defect that practitioners of medicine are led into error in making diagnoses. They fail to observe all the facts, and hence their deductions are liable to be incorrect. Acute, clear perception is a gift which all do not possess in a high degree, but it can be cultivated in those of ordinary intelli- gence, and it should be by those who intend to practice medicine. The practical study of the elements of natural science, which should constitute a large share of the early education of tliose destined for the profession of medicine, aids much in cultivating the faculties concerned in obsei*vation. So also the arts, especially drawing, painting, and sculpture, help to qualify for the actual in professional life. The trained eye and hand of the artist are most valuable in acquiring the art of medicine and surgery, and a share of the days of youth spent at an art-scliool will save much time and perplexity in the medical school as well as in subsequent professional life. The tirst lesson is to obtain a familiarity with the general appear- ance of the body in health, its structure and the uses of the various organs, the process of development, the slight deviations from the ideal or highest type which occur within the range of health, and finally the relations of the being to his enviromnents or conditions of life. A portion of this subject will be fully discussed in the chapter on the development and structure of the se.xual organs of woman, and the conditions of life which are suitable to her develop- ment, gro^vth, and maintenance. Subsequently the derangements of the body from disease and injury will come in for the greater portion of time and attention. Here it is that the highest per- ceptive power is needed, and the most jiainstaking attention to ob- servation. The fact should be kept clearly in mind that a knowledge of the science of medicine does not give skill in the art of practice, how- ever much it may help in accjuiring that art. Men profoundly versed in the science of medicine may be poor practitioners ; and others, whose knowledge of the science is very limited, may attain METHODS OF OBSERVATION. 3 some reputation in ])ractice ; but the Lest qualified physician is he who knows most of both the science and the art. The subject for present consideration is the method of investi- gation to be adopted in practicing the art of gynecology. Before beginning the actual work of examining patients, it is necessary to know how to do so. There are several methods of investigating the sick and injured given in text-books and taught in the medical schools, but most of these are better adapted to general practice than to special depart- ments of medicine. The methods which I desire to present here are circumscribed, and perhaps less complicated, because they are limited to the diseases peculiar to women. In examining patients it is well to first settle definitely in the mind the object to be attained and how to attain it. Some rational system of investigation should be mastered in all its details before undertaking actual practice. To engage in clinical study ^vithout such preparation is like trying to read a language without knowing its alphabet. The system advised is — first, obtain all the facts regarding the case in hand ; second, arrange the facts in their natural relation to one another ; and, finally, make deductions from the data thus ob- tained. These will be easily remembered in the following order and association: observation, classification of things observed, and conditions indicated by the sum of the information obtained. The examination of a patient should begin by a general inspec- tion ; and, in order to make that inquiry complete and profitable, certain questions should be raised in the mind of the examiner; such, for example, as what is the general appearance of the patient under observation ? What size ? Regular or defective in general outline? Lean or corpulent? What temperament? Is the face pale or flushed? Languid or vigorous? Sad or cheerful? Calm or excited ? Intelligent or stupid ? What diathesis is indicated, if any? In short, does the genei'al physigonomy indicate health or disease ? All these interrogations are made by lookiug critically at the patient. There are so many questions to be answered in this con- nection, that one may find some difficulty in promptly remembering them ; but by patient practice the mind and eye can be trained to take advantage of a rule of obseiwation employed by critical investi- gators in other arts, which is this : having a type of noraial organi- zation in mind, the observer is able to scan a given case, and detect any deviation from that standard of liealthy formation and appear- 4 DISEASES OF WOMEN. ance. Tlie artist, in looking at a picture or statue, does not neces- sarily question every line of the drawing or form by itself, but his trained eye catches any defects that there may be in the work before him. The classification of facts is simply putting together those which are similar in character. The arrangement of material things in groups is familiar to all. A well-arranged library, in which all books pertaining to a given subject are placed side by side, is a fair illustration of this kind of classification. Facts and ideas can be arranged in the mind upon precisely the same principle. The ad- vantage of classification is that it aids comprehension and memory. By recalling one group of facts which have been associated in the mind, the rest will follow in easy and natural order. There are two methods of classifying the information contained in the clinical his- tory of a patient. One is to obtain all the facts possible, and then to arrange them in order. The other is to classify them at each step of the examination. The former method requires a mental grasp and tenacity which few possess, and therefore I would advise the latter. The information obtained by inspection may be classed under four heads : 1. The original character of the organization, whether perfect or imperfect in structure and function. 2. If im])erfect, whether from imperfect development, causing lesions of form or lesions of structure, or from inherited or acquired disease, and inher- ited tendencies to disease, known as diathesis. 3. Evidences of dis- ease, expressed in the face, either acute or chronic. 4. The tem- perament ; which simply means the preponderance of a certain portion or poi'tions of the organization. To illustrate the value of this process of general inspection of patients, the partial history of a case seen in private practice will suffice. A lady called to consult me regarding her son, a little fel- low seven years of age. After a very brief survey of the patient, I saw enough to satisfy me that he had recently had scarlatina, and that when a child he had suffered from sore eyes, and that his father had been subject to rheumatic pains in years gone by. The mother acknowledged that T was right in every ]iai'ticular. A glance at the boy showed that exfoliation of the cuticle, which occui-s after scar- latina, Avas still going on ; the face was pale and puffy, indicating commencing dropsy from acute nephritis, a sequel of the eruptive fever. I also noticed that he had a scar upon the cornea of each eye, the result of a former keratitis. The form of his nose and the character of his teeth indicated an inherited syphilis ; and from the METHODS OF OBSERVATION. 5 appearance of his mother and other facts known to me, I presumed that the father was the one who had transmitted the specific disease. The age of the patient should be ascertained, because that sug- gests the possible existence of the diseases which are likely to occur at certain periods of life. Care should be taken to compare the real and apparent age, in order to ascertain if the patient is prematurely old, or well jjreserved. This interrogation will also serve to keep in mind the fact that, in early life, acute diseases prevail, while degen- erations are usually limited to advanced life. It is important to know the social relations of a patient — that is, whether she is married or single. If married, she is liable to the diseases and accidents attendant upon child-bearing. If she has never been pregnant, her sterility may have resulted either from choice, or because of some defect in her organization. Women who are single are, by reason of that fact, limited in the range of diseases of their sexual organs, and this may be taken for granted unless evi- dence to the contrary is obtained. Having made a general inspection of a given case, and ascer- tained the age and social relations, an examination of the various portions of the body should next be made in systematic order. To do this conveniently, one group of organs or one system should be examined at a time. The various systems are classified as follows : THE NERVOUS, NUTRITIVE, MUSCULAR, AND SEXUAL SYSTEMS. The first three are subdivided as follows : The nervous has two grand divisions, the cerebro-spinal and organic. The nutritive has four subdivisions, the digestive, circulatory, lymphatic, and excre- tory ; and the third has the osseous and muscular. The present purpose is to outline the methods of investigating the sexual system, but, in order to do that successfully, it is necessary to be able to examine the whole body. Xo one can be a trustworthy specialist without having a thorough knowledge of the whole organi- zation. All the parts of the body are so bound together by mutual relations that one can not accurately diagnosticate the diseases of one portion without knowing the condition of all the others. On account of that fact I must refer to the principles upon which the examination is made of parts other than the sexual system. Briefiy, it may be stated that the two principal subjects of in- quiry are the condition of the function and stiiicture of the organs under examination. Perverted function of the cerebro-spinal divis- 6 DISEASES OF AVOMEN. ion of the nervous system is nianifested through derangemeuts of sensation aud motion, and abnormal states of tlie organic nerves is indicated where nutrition is deranged, wliile the organs of nutrition are free from organic disease. The condition of the circulatory system is indicated by the color of the skin and mucous membranes, the chai'acter of the j)ulse, and the heart-sounds. The general nutrition nuiy be estimated by the appetite for foot), the excretions, and the state of the tissues generally. These are meager hints, but, if kept iii mind while examining cases in the de- partment of gynecology, will guard against the mistake of overhjok- ing affections of the general sj'stem, which might modify or cause diseases of the sexual system. In applying the principles already hinted at in the investigations of special diseases of the sexual organs, we lind that morbid action is manifested by symptoms aud i)hysical signs. The symptoms may ])e classed under three heads : First, deranged nei"ve-action ; sec- ond, deranged functions of the organs affected ; and, third, modified locomotion. First Class (nerve-symptoms). — Pelvic pains not specially local- ized ; sacral pain ; pain of certain pelvic organs ; pains beginning in the [)elvis and radiating to other parts of the body. Second Class. — Derangements of function, such as deranged men- struation ; sterility ; abnormal discharges ; deranged function of the bladder and rectum. Third Class. — Aggravation of any or all of the above-named symptoms, by standing, walking, or other muscular exercise. Keeping this classification in mind, (questions will suggest them- selves, the answers to which will determine the presence or absence of these symptoms. One should know the symptoms which belong to a given disease, and then ascertain if they are present by asking questions of the patient. Cori-ect testimony will more surely be ob- tained in this way than by depending upon the voluntary statements of the person examined. Tlie following plan will be of service in obtaining the symp- toms referred to in the three classes given above : First, ask if the patient has pain and where it is located. Ascertain also if this pain is connected with any of the functions of the pelvic organs. Then obtain the history of the functions of the sexual organs, in the past and j^resent. These facts can be obtained from the patient herself, aided perhaps by some one who knows her well. Some l)ractice is necessary to acquire skill in taking testimony, the value of which depends largely upon the physician's ability to make the METHODS OF OBSERVATION. f patient answer his questions correctly. Such questions as tlie fol- lowing regarding tlie menstrual function should be asked : At what age was tlie menstrual function Urst established i At what periods of time has it recurred ? How long does it continue each time ? What are the quantity and character of the flow ? Is it attended with pain, and if so, where is the pain located, and at what time does it occur in relation to the menstrual flow ? Has menstruation always been attended with pain, or only for a limited period in the history of that function ? And, Anally, is menstruation attended with de- rangements of any of the other functions of the body ? From the answers to these questions two points can be decided : First, whether menstruation has been performed normally during the whole or part of the patient's menstrual period of life ; and, sec- ond, if any derangement of that function exists, whether it be in character, recurrence, duration, or quantity. Next in order comes the history of reproduction. Has the pa- tient had children, and if so, how many, and when i Has she mis- carried ? K she has, at what period of gestation, and at what time in relation to birth of living children if she has had any i Was there anything abnormal in her pregnancies, confinement, or recov- ery from labor ; if so, what ? The answers to these questions will determine whether the present conditions date back to some of the diseases or accidents of pregnancy or parturition. H the history so far obtained indicates any disease or functional derangement of the sexual organs, and there is any accompanying affection of the general system, the question arises, regarding the relations which they sus- tain to one another. That question can frequently be settled by ascertaining which of the two affections, the local or general, ap- peared first. The one which precedes is frequently the cause of that which follows. Thus far we have been dealing with symptoms which, as a rule, reveal only derangements of function. They are but expressions of disease, and do not in all cases indicate the conditions of the organization which cause the derangement of function. This brings us to the final division of our subject, viz., the phys- ical signs of disease. These are the physical evidences of change of structure. There are exceptions to the general rule that these physical evidences are always present, but they ai'e few in number, and therefore may be omitted in our general consideration of the subject. The changes of structure and organization in the sexual organs, which are expressed by physical signs, are as follows ; 8 DISEASES OF AVOJrfEN. Changes of position, form, size, consistence, composition, color or appearance, and degree of sensitiveness. The means of obtaining })hysical signs are tlie touch — single or bimanual — jxUpation, percussion, speculum, sound, probe, curette, exploring-needle, uterine dilator, and microscope. The art of employing these means next claims attention. EXAMINATION BY THE TOUCH. This examination is most conveniently practiced when the pa- tient is ])laced upon a suitable table. One that is thirty-three inches higli. forty-three inches long, and twenty -three inches wide, having a projection on the right-hand coraer upon which to rest the feet, answers better than anv table or chair that I have ever seen. Fk;. 1. — Examining table. (The upper part of the foot-rest folds down as the dotted lines show, and the support can be pushed in.) The patient should be placed upon the back, with the pelvis as near the end of the table as possible, permitting the heels to rest upon the table also, while the thiglis are iiexed upon the body and the legs upon the thighs. A sheet held by the edge in both hands is drawn over the limbs from the feet upward, at the same time that the skirts are pushed up ont of the way. This protects the patient from exposure. In this examination the index-fincrer of the rio-ht hand is gener- ally employed, but both right and left should be educated, because it is sometimes difficult to examine that side of the pelvis which faces the back of the hand used. In critical cases, therefore, it may METHODS OF OBSERVATION. be necessary to employ both Lands, first one and then the other, in order to complete the examination. In the majority of cases it is requisite to employ the bimanual metliod, as it is termed — that is introduced , while one finger is into the vagina, the fingers of the other hand are placed upon the abdo- men at the pelvic in- let, and by pressure the parts are brought down to within near reach of the finger in the vagina. Fig. 2 illustrates the mode of making this exam- FiG. 2. — Bimanual examination. ination. This method is quite satisfactory in spare patients with lax abdominal muscles ; but when the muscles are tense, and when the walls of the abdomen contain a thick layer of adipose tissue, the examiner will find great difficulty in practicing it. In sneh unfavorable conditions, when the diagnosis is obscure, much will be gained by using an anaesthetic. Examination of the pelvic organs through the rectum is of great value. In this method the touch is practiced in the same way as in that already described. There are other methods practiced, such as introducing two fin- gers into the vagina, the index and the middle ; and the introduction of the whole hand into the vagina or into the rectum. Simon's o method is to first dilate the sphincter-ani muscle, and then pass the whole hand into the rectum as far up as need be. Extraordinary advantages have been claimed for this method, which brings all the pelvic organs within the grasp of the examiner ; but it has proved to be dangerous, and, owing to the fact that pressure benumbs the hand, it is more difficult than it appears to be theoretically. It should not be practiced, except in rare cases in which it is of vital impor- tance to make an accurate diagnosis that can not otherwise be made. These methods are not without danger, and always do less or more violence to the parts, and are only practiced in rare and obscure cases, mostly those of tumors. Dilatation of the urethra sufficient to admit the finger has been practice 1 and advised for the purpose of 10 DISEASES OF Wo.MKN. aiding in the exploration of tlie pelvic organs, but tlie information gained in this way does not compensate for the suffering and danger ; liOTice tlic j)ractici" is rarely called for, and still more rarely admissible. Digital Touch by the Eectum. — This method is generally restarted to when some obscure, abnormal condition has been discovered by the vaginal touch. Much satisfactory information can be obtained in this way, especially regarding the posterior wall of the uterus, the ovaries, and the sac of Douglas. The bimanual method of practicing the rectal touch is the same as the vaginal. Pressure upon the hypogastrium with the external hand gives the ei>njoiiied aid, as in examining by the vagina. Vesico-Vaginal Examination. — In this method a sound is ])assed into the bludder wliile the finger is in the vagina. By this means certain states of the vagina, urethra, and bladder are investigated. Vesico-Rectal Examination. — This is the same as the vesico-vagiual except that the finger is introduced into the rectum. It is the more valuable of the two in exploring all that lies between the bladder and rectinn. Palpation. — Whenever the touch discovers anything abnormal^ as a tumor, an enlargement of the uterus, or products of inflamma- tion, additional information can be obtained by abdominal palpation. This is accomplished by manipulating the abdomen so as to outline the part in question, and to test its sensitiveness, mobility, and density. Both hands are usually emjiloyed in this examination. Percussion. — It is unnecessary to describe the manner of practicing percussion. Suffice it to say that percussion is practiced in exactly the same way in exploring the abdomen as it is in exploring the thorax, the object being to test the density of the abnormal part and outline its relations to the alxloniinal organs. Palpation and Percussion Conjoined. — This consists in resting the lingers of one hand at one j)oint on the al)domiual walls and making percussion at another point. Its chief object is to ascertain if there is fluid present ; this is shown by fluctuation. There are three ways of accomplishing this: The first is to select points on the distended al)domen directly opposite one another, resting the fingers lightly at one ]mrt, and ])ercussing at the other. This is known as the dia- metrical method. The second, the peripheral method, is to take ])oints on a section of the al)domen and manipulate in the same way. The third consists in resting the fingers at one point and making pressure at the other, to see if the part is wholly movable or partially so. This differs from the others essentially in substituting inter- rupted pressure for percussion. METHODS OF OBSERVATION. 11 Fig. 3. — Sims's speculum The Speculum. — This instrument is twofold in its use. It is one of the most important aids in tlie investigation of disease, and at the same time a necessary instru- ment in treat- ment. A great variety of spec- uhi are used, but two answer all requirements. Sims's speculum and Cusco's bi- valve, slightly modified, answer ever}' indication. In fact, Sims's speculum is all that is needed, ex- cept when an assistant or nurse can not be obtained to hold the specu- lum, then Cusco's may be employed with advantage in examining the cer vix uteri, and for the purpose of making applications thereto. In using Sims's speculum it is ne- cessary to have the patient upon the table already de- scribed, which should be near a window giving a good light. Oc- casionally it may be necessary to examine a patient upon the bed, but this is difficult, and should not be undertaken until the ex- aminer has acquired by practice great facility in the use of the instrument, and only then, when it is impracticable to place the pa- tient upon the table. The position of the patient should be on the left side, semi-prone, \rith the left arm behind the back, the head upon a low pillow, and near the right-hand side of the table, the limbs di'awn up, the right limb above and in front of the left, and the pelvis at tlie end of the table on the left-hand side. Fig. 5 illustrates this position. In order to place the patient in this position, she should stand upon an ottoman or low chair, with her left side toward the end of the table. The skirts on the left side are then raised, and she is directed Fig. 4. — Cusco's Tiivalve speculum. 12 DISEASES OF WOMEN. to sit down oii the tablu ; lier left luuid is ])hiced beliind the hack, and she is made to lie down on the left side, inclining forward. Tlie Fig. 5. — Sims'p position, seen from above. I'k;. Ci. — Nurse liolding Sinis's spccuiuni. limbs are at the same time drawn up and placed in pr(>j)er position. The skirts are then pushed uj) on the right side, and at the same METHODS OF OBSERVATION. ly time a sheet is di'awii over the limbs and arranged so as to expose the labia only. The speculimi is introduced by separating the la])ia "with the fingers of the left hand, holding the instrument in the right hand by the handle ; the point of the blade is placed upon the posteri- or commissure, and, while backward pressure is made, the speculum is passed into the vagina. Care should be taken not to touch the meatus urinarius. The free blade is then grasped with the right hand by the nurse or assistant, while with the left she raises and supports the natis and labium on the upper or right side. The position of the one who holds the speculum should be with the left side toward the patient, the lingers of the right liand surrounding the blade, while the thumb rests in the inside of the blade. The elbow should rest against the side, as a point of purchase to give ability to make steady traction. The left arm should rest upon the right hip of the patient, while the hand supports the labium and natis to keep them out of the way (Fig. 6). Careful training is required to enable one to hold the speculum properly. The chief and essential requirement is to maintain the instrument for any desired length of time in the position in which the operator may choose to place it. The objects to be at- tained by the use of the speculum are, to distend the vulva by making traction upon the posterior commissure, and at the same time to draw the whole floor of the pelvis or perinseum backward toward the sacrum, away from the pelvic organs above, which, from the position of the patient, gravitate toward the abdomi- nal cavity. By these means the vagina is distended by atmospheric pressure, which gives space for the admission of light, and room for inspection or manipulation in operating. These facilities can be extend- ed by changing the position of the specu- lum in the following manner: The as- sistant who holds the instrument can, by rotating the hand, cause the point of the blade in the vagina to describe the arc of a circle (Fig. Y). Bj moving the hand forward, the blade is made to point backward Fig. 7. — The raovcmcnts of the speculum. First movement. Second movement. 14 DISEASES OF WOMEN. toward the rectum; and l)j moving the liand Imckward, the blade is caused to point forward (Fig. 8) ; and, finally, l>y raising or lower- ing the hand, the speculum is made to reflect tlie light upward or down- ward to either the u])perorlower side of the vagina, according to the re- quirements of the examiner ( Fig. 9 j. At the same time that all these changes of position are being made, the re(iuire(J traction upon the pe- rinseum can be maintained. In using the Cusco speculum, the position of the patient is the same as for examination by the touch. The Labia are separated with the left hand, and the instru- ment introduced with the blades closed, the dii-ection of introduction being downward and inward. When the speculum is in position the blades are separated. ' There is quite often difficulty in bringing the cervix into view through this instrument. This can usually be avoid- ed by getting the point of the posterior blade well under the cervix before separating the blades. This speculum is principally used in the treatment of the simpler diseases of the cervix uteri, when an as- sistant can not be procured to hold a Sims's speculum. As a means of investigation it is quite limited in its use. Fig. 9. — The third movement. THE UTERINE SOUND AND PROBE. There are three kinds of sounds : Simpson's, which is made of hard metal, and maintains an unchangeable shape ; Sims's, which is of soft metal, and can be bent or molded to any curve ; and a third, which is elastic and bends on the slightest pressure, Init by its elas- ticity regains its original shape. There are two varieties of the lat- ter : that made of elastic material like whalebone or rubber, and a metallic one, rendered elastic by a spiral arrangement in its mechan- ism, known as Jenks's. The stiff, unyielding sound of Simpson is ten inches long, being smallest at the end, and having a bulb two and sc - "• I ■ !■ i'' QfoTIEMANNScCo. Fig. 10. — Simpson's probe. a half inches from the point. It is graduated in quarter-inches up to six inches (Fig. 10). It is seldom used now, except in a modified METHODS OF OBSERVATION. 15 form. It is difficult to use because its shape can not be adapted to diiierent eases ; and it is dangerous, from the fact that it -svill not bend to light pressure. Fig. 11. — Sims's probe. Sims's probe is made of soft copper or pure silver, both of which metals have the quality of being easily molded. It is like the ordi- nary probe used in general surgery, only longer and a httle thicker, and is provided with a handle (Fig, 11). The ]3robe which is most generally used, and the one which I prefer for ordinary use, is the same as Sims's, only thicker. It is stiff enough to sustain all requisite pressure, and yet can be easily G.T\eW\NUU8KGQ. Fig. 12. — Whalebone sound. molded to any curve. In practice it is well to be provided with this one as well as that of Sims. The elastic probe is the same in form as Sims's, but is made of rubber, gum-elastic, or whalebone (Fig. 12). The sound of E. W. Jenks is hollow and spiral for a distance of two thirds from the pointed end. This spiral arrangement gives it flexibility. It is also graduated and provided with a sliding sheath which is very convenient in measuring the depth of the uterus, the Fig. 13. — Jenks's sound. arrangement being such that the examiner can run the sheath to- ward and away from him, the figures at the end of the sheath near- est the handle giving the measurement of the distance from the point to the distal end of the sheath (Fig. 13). The sound or probe should only be used after the position of the uterus has been ascertained l)y a digital examination, and its sensi- tiveness tested as far as that can be by the touch. It is very impor- tant to know the position of the uteras and its relations to the other organs, in order that the sound may be curved to suit the direction 16 DISEASES OF WOMEN. of the canal of the uterus, and to suggest the direction in wliicli the instiinnent .should he guided. There are two ways of probing the uterus : In the one, the patient is placed upon the back, and the fin- ger of the examiner is carried up to the os uteri ; the sound is then guided along the linger until it enters the canal, when it is passed to the fundus, the handle being depressed to make the sound correspond to the direction of the canal of the uterus. The other way is to expose the uterus with Sims's speculum, and to pass the sound with the aid of the eye. This latter method is the easiest and safest, and gives at least as much information as the one first described. The vaginal walls being distended b}^ the speculum, the instrument is free to accommodate itself to the direction of the canal of the uterus, and, aided by sight, the os uteri can be found at once. Safety in using the sound does not depend so much upon the touch which guides the instrument to the uterus as upon the hand that holds and passes it into that organ. There are few who acquire the perfection of touch to guide the sound into the unseen uterus without using force, which, though very slight, may cause mischief. In sounding or probing the uterus in any way, force should not be used. Tliis rule should never be violated. The Sound and Palpation Combined. — In this method of examina- tion the sound is passed by touch, with the patient upon the back, and, while it is in the uterus, it is held with one hand; the other hand is placed upon the abdomen, and downwarrl pressure made until the uterus is felt. The uterus is then moved by the sound, and the movements are detected by the hand upon the abdomen. The in- formation obtained in this way will be noted farther on. The Curette. — This instrument is used to explore the cavity of the uterus in order to detect any abnormal growths which may be there, and also to remove portions of such growth for inspection, in order to determine their character. The instrument best adapted to this purpose is made upon the pi-inciple of the Recamier curette. It is simply a scoop of small size with a stem of flexible copjier or sil- ver, the object of this flexibility being to enable the investigator to bend or curve it to suit the position of the uterine canal, and also Fig. 14. — Skene's curette. G TIEMANN &C0. that it may bend before doing any damage to the endometrium if undue force is inadvertently used (Fig. 14). The curette is introduced through a Sims's speculum in the same METHODS OF OBSERVATION. 17 manner as the sound, and when once witJiin the cavity of the uterus it is passed over the surfaces of the endometrium, and if any pro- jections are detected a portion can be scraped oli" and removed for inspection. The further use of the curette will be again described, in connection with the treatment of diseases of the uterus. The Aspirator. — This instrument is employed to investigate the contents or composition of tumors formed in the pelvis. When the question arises whetlier tbe tumor present is solid or fluid, and if fluid what the character of the fluid is, the use of the aspirator will determine. The aspirator used in general surgery answers well ; still, a hypodermic syringe, larger than tlie usual size, and armed with a long, slightly curved needle, thick enough at the end nearest the syringe to give it strength to bear pressure, is more convenient. The method of using the exploring aspirator is as follows : The patient is placed upon the back, and the point of the needle is guided to the part to be examined, and is then thrust into the mass or tu- mor; tbe piston is tlien drawn out, and the fluid, if any be pres- ent, is examined. Uterine Dilators. — When it is necessary, as occasionally hapjjens, to dilate the cervical canal in order to explore tlie cavity of tlie Fig. 15. — Hanks's dilator. uterus, resort must be had to some of the dilators. These are of two kinds : The first consists of graduated dilators, which can be 16. — Palmer's dilator. passed in rapid succession, such as the dilators of Hanks (Fig. 15), and the instruments with expanding blades (Fig. 16). These are in- tended to produce rapid divulsion to the required extent. The other kind acts by the swelling of the material of which they are made. Of these tents the compressed sponge (Fig. 17), sea-tangle, and tupelo (Fig. 18) are in general use. It is seldom that tents are required for purposes of examination 3 18 DISEASES OF WOMEN. only ; the dilators mentioned answer, as a rule. Tliev act more promjjtly, and are less likely to cause after-trouble if dilatation is not carried to an extent wliicli is seldom necessary for purposes of ex- amination. Tents are to be avoided if possible, because of the suffer- FiG. 17.— Sponge tents. Fig. 18.— Tupelo tents ing they cause, and the danger of inflammation and blood-poisoning, both of which misfortunes have followed their use. They expand slowly, and cause irritation and pain, which must be endured for hours before they accomjjlish their work. Acting thus like foreign bodies and powerful irritants, they are not without danger. The dilators act more promptl}^ and are less likely to induce inflamma- tion, and, although they cause pain and irritation, these are of short duration. The Concave Mirror. — This is commonly known as the head-mirror, and is used in the practice of laryngoscopy. It is also of much use in speculum examinations when a good light can not be obtained. In emergencies occurring at night, the mirror enables the surgeon to use artificial light with perfect satisfaction. Placing a lamp by the side of the ])atient in front of tlie examiner, the light can be reflected into the vagina so as to expose the parts in a very perfect way. Facility in the use of tin's mirror should be ncquircd, as it is at times indispensable. The Microscope. — A careful scrutiny of the minute structure of pathological specimens is always necessary to complete diagnosis, hence the microscope should be placed high in the list of means for exact observation and investigation. All that need be done in this connection is to remind the reader of the fact. A knowledge of the microscope and its use must be obtained elsewhere. The prog- ress in microscopic investigation has been go great that many men in active practice have neither the time nor the ability to make their own microscopic investigations. When such is the case, the duty of the gynecologist clearly is to seek the aid of the microscopist that he may obtain through him the required information. METHODS OF OBSERVATION. 19 Anaesthesia. — There are certain cases that can not be examined without being ansBsthetized. When there is great tenderness of tlie pelvic organs, and the abdominal muscles are in a condition of spasm, which render the examination wholly impossible or suffi- ciently unsatisfactory to leave a doubt in the mind, then ether should be given to the extent of complete anaesthesia. The relaxation wliich this aifurds simpliiies all investigations in a very marked degree. In the investigation of the pelvic organs of insane women and in vir- gins who certainly require examination yet can not submit, the nitrous-oxide gas is of great value. It acts quickly and pleasantly, and has none of the effects during or after its administration which are so distressing to those of sound mind and horrifying to the insane. The mode of administering it is with the apparatus used by den- tal surgeons to whom we are indebted for perfecting the apparatus for giving this anaesthetic. The gas is condensed in a strong cylin- der which holds one hundred gallons. By a valve arrangement it is permitted to escape into a rubber bag, from which it is inhaled. The inhaler is an ingenious arrangement by which the act of inspi- ration opens a valve that permits the gas to be drawn from the bag, while the act of expiration closes the valve in the supply-tube, and opens another valve for the escape of the impure air. There is still another valve under the control of the operator, which admits air with the gas, so that when the patient is fully ansesthetized the gas can be diluted with air in sufficient quantity to keep up the anaesthesia. The cylinder of condensed gas and the inhaler are put U]3 in a case convenient to carry. The mechanism of this apparatus can be more easily comprehended by examination than by descrip- tion, and a little practice will enable any one to use it. To be able to recognize the normal and pathological conditions which are revealed by the means described requires much practice. It greatly aids in obtaining that practice — in fact, it is quite neces- sary — to keep clearly in mind what to look for. In order to facilitate the memorizing of the objects to I)e investigated, I have arranged the signs under each of the various means of obtaining them as follows : Vaginal Touch. — Position, size, shape, and density of the uterus. Size and shape of the os externum. Presence or absence of discharge from cervix. Condition of vaginal walls, perineal body, and recto-uterine space. State of the rectum and lower portion of sac of Douglas. Position of the bladder and urethra as indicated through the an- terior vaginal wall. 20 DISEASES OF WOMEN. Presence or absence of lixation of pelvic organs ; swelling or tu- mors in the sac of Douglas or broad ligaments. Ti'iidenic'ss at any })art. Bimanual Touch, — Size, form, and position of the body of the uterus. Tenderness and mobility of tlie uterus and other organs and tissues. Position and state of the Fallopian tubes and ovaries. Condition of the bladder. Presence of neoplasms and their relation to the pelvic organs. Products of inflammation, their location and character. Rectal Touch. — Condition of the rectum, posterior surface of the uterus, broad ligaments. Fallopian tubes, and ovaries ; conlirmation or correction of signs obtained by bimanual examination, Vesico-rectal Touch. — AbscTice of the uterus from its normal position in inversion of the uterus, entire absence of the uterus; aid to diagnosis in women who are too fat to permit tlie bimanual examination. Vesico-vaginal Touch. — Changes in the position of the bladder and urethra. Results of disease in the vesico-vaginal septum. Palpation. — Form, size, and density of tumors or products of in- tiammation felt tlirough the abdominal walls. Percussion. — Density of morbid parts, ^Normal resonance. Relations of the above. Palpation and Percussion Conjoined. — Fluctuation, density, or elasticity of morbid parts. Speculum. — Apj)earance of mucous membrane of cervix uteri and vagina. Signs of inflammation of mucous membrane. Relations of the cervix to the vagina. Form of os externum. Character of secretions. Signs of injuries to the cervix and vagina. Nature of new growths suggested by their appearance, Sound and Probe. — Direction of the canal of the cervix and cav- ity of the body of the uterus, in relation to their normal position in the pelvis. Relation of the canal of the cervix and cavity of the body to each other. Straight, deflected, or tortuous state of the cavity of the uterus. Long and transverse diameters of the ca-snty of the uterus. METHODS OF OBSERVATIOK 21 Ciiliber of tlie cervical canal, os cxternutn, and os internum. Degree of sensitiveness of the different portions of the cavity of the uterus. Sound and Palpation Combined. — Displaced uterus may be raised up to meet the touch of the hand upon the abdomen for examina- tion. Mobility of the uterus with or without moving abnormal growths in the pelvis or lower portion of the abdomen. Curette. — Presence or absence of growths or tumors in the uteras. Removal of portions of growths from the cavity of the uterus for inspection. Aspiration. — Abstraction of fluid (encysted or otherwise) for in- spection. Dilators, tents, anaesthetics and head-mirror as aids with other means of exploration. Fig. 18a. — Ether-inhaler. Its principle is the same as that of the nitrous-oxide appara- tus. The reservoir, n, in which the ether is vaporized, is separated from the mouth- piece, A, by the long rubber tube. The valves, e, of the mouth-piece permit the expired air to escape without coming in contact with the ether-vapor. The valve, D, enables the an, os internum; 10, anterior li]) of os externum ; 11, posterior lip. 28. 1, cavity of body; 4, 4, cornua ; .5, os internum; 6, cavity of cervix; 7, arbor vitaring Figs. 23 and 25, which illustrate the infantile uterus, with Figs. 26 and 27, the difference between the results of primary and secondary develop- ment will be fully comprehended. DEVELOPMENT OF THE SEXUAL ORGANS. 25 MALFORMATIONS OF THE UTERUS. The malformations of the uterus are naturally divisible into two classes : those that occur during embryonic life, and those that occur at puberty, the period when secondary development takes place. The lirst class embraces the greatest variety. Nearly all of these malformations are due to arrest of development at different stages of that process. The malformations most frequently seen are the uterus a Fig. 29. — Double uterus and vagina from a girl aged nineteen (Eisenmann) : a, double vagi- nal orifice with double hymen. bipartis, uterus duplex, uterus unicornis, uterus bicornis, uterus bi- fundalis unicollis, and rudimentary uterus, generally known as ab- sence of the uterus. A very rare condition has been described as hypertrophy of the uterus, and classed with the malformations. It is really not a malformation, but a complete development of the 2U DISEASES OF WOMEN. uterus during infantile life. When the first evolution in the process of development — i. e., the union or coalescence of Miiller's ducts — Fig. 30. — Uterus unicorai? from a young child, posterior aspect (Pole): 6, right Fallopian tube; c, left Fallopian tube exceptionally present ; d J, ovaries ; c, bladder (Courty). is arrested, and each duct grows bv itself, the result is the uterus bipartis (Fig. 33). The uterus duplex is formed by the coalescence of the ducts, with arrest of absorption of the central wall. The development goes on, so that in time the whole organ is larger than the n(jrmal uterus, but it is divided into two by the central wall (Fig. 29). Uterus unicornis is produced by a complete arrest of development of one of the ducts at the part which should form one half of the body and fundus of the uterus (Fig. 30). The uterus bicornis occurs as the result of non-union of that part of the ducts which forms the TuSa Fransen Fig. :>]. — Uterus bicornis unicollis (Winckel). body and fundus (Fig. 31). The uterus bif undalis unicollis is formed by the same error of development as that which produces the uterus bicornis and double uterus with the following diiference : In the DEVELOPMENT OF THE SEXUAL ORGANS. 27 uterus bifuudalis (Fig. 32) the liorDS, though not united, are well de- veloped and present outlines more nearly like the normal body of the uterus and the septum formed by the union of the ducts at the part which forms the cervix. In this it differs from the uterus duplex (Fig. 33). Entire absence of tlie uterus is perhaps unknown, unless in monstrosities in whom the lower part of the trunk is wanting. Rudiment- ary uterus is seen occasionally. As most frequently found, there is a very small cervix slightly, if at all, invaginated, and in place of the body of the uterus one or two small solid masses are Fig. 32. — Uterus bifundalis unicollis. Fig. 33. — Uterus duplex (Cruvcilliicr). Left walls developed in consequence of pregnancy. found from a quarter to half an inch in thickness and about the same in length. The effect of these malformations as manifested during func- 28 DISEASES OF WOMEN. tioiial life is (juite remarkable. lu some there is not tlie slightest deviation from health in the function of the sexual organs. In othere the results are verv disastrous. This practicallv gives two classes of uiaU'ormations according to the elfect they have ui)on the healtli and usefulness of the subject. In the one class the malfor- mation does not materially aifect the function of the uterus, while in the other, the functional action is always imperfect — sometimes im- possible. The cases of simple deformity, in which there are suffi- cient development and growth of one or both elements of the uterus to make the organ functionally competent, have no ill etfect uj)on the general usefulness and welfare of the individual. The follow- ing case will illustrate this : Double Uterus and Vagina. — A married lady, thirty-two years of age, who had borne three children and nursed them, called upon me for advice regarding a leucorrhoea which had troubled her since the birth of her last child. Iler general health had always been ex- cellent. Upon making a digital examination, I found the vagina normal and also the cervix, excepting tliat one side of the cervix was closely united to the vaginal wall throughout its entire length. On the left side of the vagina high up I found a hard mass which was also noticed on making bimanual exploration. The first im- pression was that she had suffered from a pelvic cellulitis, and that the mass on the left side was the remains of its products. This idea was given up at once on finding that the patient gave no history of any pelvic infiammation. I then susj)ected that there might be a fibroid in the left side of the uterus, which, by extending the entire length of the cervix, had pushed the vaginal wall before it. A speculum examination revealed a ca- tarrh of the cervical canal. The uterus had the usual appearance of one that had borne children, and the cervix was nonnal in shape and position, except for the peculiar relations of the cervix and vagina on the left side, which were noticed during the examination with the touch. Just \\'ithin the labium minus on the left side, a pe- culiar fold of the vaginal wall was noticed runnine: transverselv. On raising this fold with the point of the sound it w^as found to be a septum, and there was also discovered another vagina to the left of it. Using a smaller Sinis's speculum to distend this vagina, I found the other cervix which had all the characteristics pertaining to a nul- lipara. The passage of a sound showed that the canal of the uterus on the left side was not quite so long as the one on the right. It was then clearly evident that the patient had a double utenis and vagina, and that the right uterus had borne three children, while DEVELOPMEx\T OF THE SEXUAL ORGANS. 2i) the left uterus was a virgin one. She was attended in her conliue- ments by tliree different physicians, none of whom made any refer- ence to this malformation, and it is fair to suppose that none of them discovered it. This case is of interest as showing the fact that some of the mal- formations do not in any way affect the function of the uterus nor the general health of the subject. When there is malformation, and the growth of the utenis falls so far short of the normal type that functional activity is impos- sible, the results are often very unfortunate. The nature of this class of eases bears such close resemblance to those in which there is arrest of secondary development at puberty, that they may be con- sidered together in the following chapter. CHAPTEK III. ARREST OF DEVELOPMENT, AND ENTIRE ABSENCE OF FUNCTIONAL ACTIV- ITY — ARREST OF DEVELOPMENT AND GROWTH IN THE LATER STAGES OF EVOLUTION, AND THE CONSEQUENT IMPERFECTION OF FUNCTION. If absence of the uterus or a rudimentarj state of its develop- ment is associated with absence or a rudimentary state of the ova- ries, there is no tendency to functional action, and the individual may not suifer in consequence. She simply remains an imperfect and undeveloped being. But when the ovaries are present and functionally active, there is generally a tendency to menstruate ; and this tendency, unrelieved by a menstrual flow, is often attended wnth great derangement of the general health and much suiiering. The first evidence of this malfoi-mation from arrest of develop- ment that comes to the notice of the physician is derangement of the menstrual function in some form, or its non-appearance at the proper age. On this account it will be Avell to discuss in a general way the nature and characteristics of menstruation before giving the history of its derangements, which arise from lesions of structure resulting from imperfections of development and growth. Menstruation has been the subject of so many speculations re- garding its physiology, that it would be unprofitable to enumerate them. Suffice it for our present purpose to state that when the utenis attains its normal development in a healthy subject it becomes j:)os- sessed of all the requisites necessary to the development of an ovum ; but when impregnation does not follow, the mucous membrane of the cavity of the body of the uterus undergoes degeneration, either wholly or in part, and is exfoliated in a granular state. This degen- eration and exfoliation, according to some obsen'crs, involve the whole membrane down to the muscular walls, while others claim that they only affect the epithelial layer. Be this as it may, there ap- pears to be a general agreement among the authorities of the ]^resent time that de-reneration and exfoliation occur to an extent sufficient ARREST OF DEVELOPMENT. 31 to expose the smaller blood-vessels of the endometrium, and to so weaken their walls that they give way and haemorrhage follows. This menstrual flow is composed of blood from the vessels, with at least the debris of the degenerated and exfoliated epithelium. The flow, which lasts for days, subsides, the mucous membrane is renewed, and the same high state of anatomical completeness and functional capability is restored, when another menstruation takes place, and so this function is repeated over and over again, except when suspended during pregnancy or lactation, until the end of functional activity at forty-five years of age or thereabout. During the period of functional activity of the sexual organs, from puberty to the menopause, menstruation is an evidence of health, and is also essential to health. It is an index of the state of the sexual system and also of the general health of mature women. Hence its derangements constitute most valuable evidence of the presence of disease, while its normal recurrence is an evidence of health. In practice it -is best to study this function by its character- istics, rather than by theories regarding its cause or the reasons for its existence. It is on this account necessary to comprehend its nat- ural history ; therefore, I propose to give here a synopsis of the con- ditions of menstmation. The laws which govern this function of menstruation, as given in our text-books, are so varied by climate, personal peculiarities, and the conditions of life, that a general average pertaining to these laws is about all that can be obtained, and this can be used to very little advantage in practice. Fortunately, there are certain rales which apply to menstruation with great uniformity, and these should be clearly understood. The most important of these are the fol- lowing : 1. Menstruation should begin at puberty — i. e., when the woman is maturely developed, no matter what the age may be. Increase of size may take place by growth after puberty, but all the organs of the body should be completely defined, so far as form and structure are concerned, before the function of menstruation is taken up. 2. It should recur at regular intervals ; about every twenty-eight days is the average time. A regular periodicity is normal, but the duration of the periods often differs in different persons. 3. The discharge should always be fluid in consistence and san- guineous in color. 4. The flow should continue a definite length of time, the dura- tion depending upon the habit of each case ; at least there should not be any great deviation from this rule. 32 DISEASES OF WOMEN. 5. The quantity should be about the same each time. There should be no deviation from the tirst rule. If the menses appear before development is complete, both in the sexual organs and the general system, it is an error which is either the result of 5) ; jiiid, third, lorwurd flexion of both body and cervix < I^'ig. 36). Pdtholotjy. — Flexion of any form neces.sitates some defect in the structure of the uteru.s, Tiiis consititutes one of the essential differ- ences between flexion and version, which latter is sim- ply an error of location without, necessarily, any change of structure of the uterus. The flexion is usu- ally at the junction of the body and cervix, the point corresponding to the inter- nal OS. Flexion at any point in the body or cervix oc- curs only as an exception, which need not be noticed here. At the point of flexion the tissues of the uterine walls are deficient. On the side to which the organ is bent the wall is compressed and attenuated. On the other side the loss of tissue is not so marked, the thickness being but slight- ly diminished by the stretch- ing. The sub-mucous, fibrous stratum of tissue, whieli is said to give firmness and sup- port to the organ, is absent or deficient on the side to which the uterus is l)ent. The effect of flexion on the uterine canal is to produce constriction or occlusion of the internal os. The external OS is sometimes more open than in health, owing to trac- tion being made on tlie pos- terior lip. The stricture thus formed gives rise to accumu- lation of the secretions of the uterine eavit}', and to partial retention of the menstrual ])roducts. The circulation in the uterus, as will be Fio. 36. Third variety ; anteflexion of body and cervix. FLEXIONS OF THE UTERUS. 59 readily understood, is interfered with. The ol)stniction tends to keep up congestion, and tliis may eventually lead to (jedema and a predis- position to endometritis and pelvic peritonitis. From all these causes derangement of function follows. The men- strual Huid, in place of escaping passively, is expelled, perhaps, by spasmodic contractions, attended with colicky pain. In other words, there is dysmenorrhoea. Sterility also exists in the majority of cases. These pathological conditions increase with time. The pressure at the point of flexion produces anaemia and atrophy of that part, and the intrinsic support of the uterus l)eing thus diminished the flexion increases. Hence, the flexion of the first variety often progresses to the second and third. The anatomical appearances in flexion are well described in Nie- meyer's " Text-Book of Practical Medicine." I quote that portion which applies to anteflexion of the body of the uterus : " On autopsy, flexion of the utenis may be readily recognized, as part of the pos- terior wall of the body, instead of the fundus, forms the highest part of the uterus. Generally, we may restore the sunken fundus to its position, but it sinks back again to its former place when we let go of it. If we cut the uterus out of tlie body, and hold it erect by the vaginal portion, the fundus sinks down anteriorly ; if it be held hoi-izontally, it not infrequently holds its weight if the flexed side be upward, but it bends together if we reverse it." To this I would add that in tbe first variety the cervix projects into the vagina much farther on the posterior wall than on the anterior ; indeed, in marked cases, the anterior lip of the cervix uteri is very little below a line corresponding to the point of union between the cervix and the an- terior vaginal wall. Natural History of Anteflexion. — Sym2)tomatology. — Derangement of uterine function constitutes the principal point in the natural his- tory of flexion. Menstruation, from its first establishment, is often painful — there is dysmenorrhoea. The severity of the pain bears some relation to the extent of flexion. The greater the deformity the more marked is the pain, thougb there are exceptions to this rule. The character of the pain is of the greatest importance. It is inter- mittent, and always precedes the flow, \yhen the flow begins, the pain either subsides or becomes much less. The pain closely resem- bles that which occurs in abortion in the early months of pregnancy. The reason, I presume, is tliat while the fluid is accumulating in the uterine cavity, })ain is excited by distention ; but the flow when once started, continues with less expulsive eflbrt. Painful men- struation often occurs without flexion, but in such cases the pain 60 DISEASES OF WOMEN. continues throughout the whole periud, or during the early part of it, and is not relieved by dilatation of the cervix; while in tiexion it precedes the flow, and is relieved temporarily by dilatation. This pain, at the coniniencement of menstruation, is the most prominent symptom in the history of flexion as it occurs in the young girl. The trouble tends to increase gradually. If the patient gets married, all the symptoms usually increase. Should she become pregnant, there is great liability to miscarriage during the early months. The effect of the pregnancy, however, in part at least, is to remove the deform- ity, even when miscarriage occurs, so that pregnancy is likely to occur again, and go on to full time, and the deformity is cured completely. Checking the menses by exposure to cold, or any cause which will produce liypertemia of the uterus, or endometritis, promptly increases the dysmenorrhoea, and gives rise to new symptoms. Leucorrhoea, backache, local tenderness, deranged digestion, and nervous disturb- ances, are all added to the original symptoms. Sometimes in ante- flexion frequent micturition is a marked symptom. There are all varieties and degrees of prominence of the synn> toms in the natural history of flexion. The dysmenorrhiea which begins at puberty may continue, and increase but little through life. This is most likely to be the case if the individual remains unmai*- ried, and can avoid all the conditions which tend to aggravate uter- ine disease. On the other hand, the dysmenorrhoea mav increase in severity during each succeeding menstruation, and after marriage become intolerable. In the intervals between the menstrual periods the patient in her early life is free from trouble, but eventually symptoms of uterine and vaginal inflammation are manifested. Constitutional derangements, especially of the nervous system, fol- low, and in time we have the broken-down, miserable patients, famil iar to all practitioners. Such patients often seek relief in the use of stimulants and opium, which only soothe for a time, but eventually aid in undermining the health and strength of the unfortunate suf- ferers. The subjects of flexion are very liable to pelvic peritonitis and diseases of the ovaries and Fallopian tubes, with all the suffering which these affections give rise to. Physical Signs. — Although the history alojie might lead one with a toleral)le degree of certainty to suspect the presence of flex- ion, the physical signs must be depended upon for an accurate diag- nosis. The physical signs of flexion arise from the changed relations of the body and cervix to each other. These signs are detected by the touch and the uterine probe. The touch may indicate that the FLEXIONS OF THE UTERUS. 01 cervix occupies its normal position, or it may be found to be retro- verted, ■which is its most frequent position in anteflexion. The os points toward the introitus in the same vs^ay that we find it in retro- version. The vaginal portion of the anterior wall of the cervix is much shorter than the posterior. Carrying the finger along the an- terior vaginal wall, the body of the uterus can usually be felt bend- ing forward. The bimanual examination reveals the deformed condition of the uterus in lean patients, whose abdominal parietes are yielding ; but in fleshy subjects with rigid abdominal muscles, very little can be learned by this mode of exploration. When rigidity of the parts is the obstacle to exploration, an angesthetic may be used with great advantage, as practiced by Sir J. Y. Simpson. When the signs thus obtained point to flexion, the diagnosis should be confirmed by using the sound. Much trouble is often experienced in introducing this instrument. Indeed, it is impos- sible in extreme flexion to carry the sound into the uterus without first straightening the bend at the junction of tlie body and cervix. To do this, the cervix should be seized by a tenaculum, and gently drawn downward, while at the same time the fundus is pressed up- ward and backward. In this way the canal is partially straightened, and the sound can be introduced. There are cases where it is only necessary to curve the sound properly and manipulate with, care, and the point of flexion can readily be passed. When the sound passes into the body of the uterus in the direction indicated by the touch, the diagnosis is complete. While there are many conditions which might present the signs of flexion as obtained by tbe touch, the combined testimony of the touch and sound are sufficient to make the diagnosis sure. Causation. — There are several causes of flexion, which may ac- count for the different opinions held by authors on this subject. The errors, I presume, come from investigators accepting the cause found in a limited number of instances as applying to all cases of flexion. Some of the more important causes assigned may be briefly noticed. Rokitansky considered that the peculiar density and arrange- ment of the mucous membrane of the cervix and lower part of the corpus uteri, formed one of the chief supports of the organ, and gave it its slight anterior inclination ; consequently, he looked upon the pathological state of this layer as the basis in the development of uterine flexions. He thought the uterus bent upon itself, from cir- cumscribed atrophy of one of its walls, arising from inflanmiation. He claimed that the glands of the mucous membrane, becoming dis- er2 DISEASES OF WOMEN. tended from iiuj)ri8oned secretions, so pressed upon the other tissues as to cause atrophy at that part. When the distended glands rupt- ured and collapsed, the part rendered thus defective permitted the uterus to bend upon itself. Several eminent writers on this subject, Dr. Ludwio; Joseph beinf^ the most recent, after careful observa- tions, have been unable to discover this peculiar condition of the mucous membrane and its submucous layer to which Rokitansky alludes. If they are correct, further discussion of this supposed cause is useless. Should Rokitansky be riglit, the cause he favors would chieri}' affect cases of acquired flexion ; while the majority of cases occur before we have any evidence that inflammation pre- ceded it. Vircliow attributes the primary cause of flexion to congenital shortness of the anterior uterine ligaments, which drag the body of the utenis forward, or flex it. The uterus being held in this posi- tion, pressure results, wdiich leads to atrophy of the tissues, and thus all the conditions of flexion are present. Klob, who is one of the best authorities on uterine pathology, doubts the views expressed by Virchow, and states that wnth the nor- mal firmness of the tissues the uterus is not likely to be deflected by the cause in question. He also calls attention, as a reason against the theorv of Vircliow, to the fact that false membranes or short li^a- ments, which would incline and fix the fundus forward, would ne. cessarily cause ]:)ressure on the fundus of the bladder. This would cause the bladder to distend more in its lowest portion, which would press the lower part of the cervix uteri backward, and in place of producing flexion would cause anteversion. Kloli admits that the cause assigned by Yirchow may produce or maintain flexion, but only when there is defect of tissue in the uterus itself, arising from some anterior cause. The relation of the bladder to the uterus is looked on by some writers, including Yirchow and Ludwig Joseph, as of some impor- tance in the etiology of flexion. The uterus is known to make a descent corresponding to the variations in the shape of the bladder, which in foetal and infant life changes from the elongated fusiform to the short ovoid shape, and its fundus, thus approaching the floor of the pelvis, draws the attached uterus with it. As the cervix uteri is closely attached to the posterior surface of the bladder, it will be readily understood that perverted development in the con- nections of the two organs might lead to flexion. The only causes which I consider worthy of discussion in con- nection with anteflexion, when it occurs as a primary or uncorapli- FLEXIONS OF THE UTERUS. 63 cated disease, are : 1. Malformation resulting from arrested or im- perfect development. Flexion arising from this cause may be classed among the congenital deformities. 2. Deformities arising from in- flammation and degeneration of the uterine walls on one side. This will include atrophy of the anterior uterine wall at the os internum from inflammation and distention of the cervical glands ; also fatty degeneration in advanced life, and excessive involution after parturi- tion, by which one of the uterine walls is weakened at the junction of the cervix and body. These may be called acquired flexions. I purposely omit a number of conditions usually given as causes of flexions, such as metritis, enlargement of the corpus uteri, preg- nancy, uterine tumors, abdominal tumors, accumulations of fluid in iitero, ascites, fecal accumulations, and adhesions from inflanmiatory exudations. Several of these causes, such as pregnancy, produce flexion so very seldom that they may be treated as exceptions to the ordinary laws of pathology, and are of no practical importance. The others named are more important than the flexions which they pro- duce, and I should prefer to discuss flexion occurring under such circumstances as a complication of the primary affection. It is, to say the least of it, objectionable classification, to discuss the primary and most important disease as the cause of a consecutive affection, and one which does not always follow. Regarding the first cause — impei'fect development — I can readily see how flexion might occur therefrom. During the time when in- vagination of the lower portion of the cervix and upper part of the vagina takes place, the process is liable to progress farther on one side tlian on the other. Should the posterior vaginal wall become reflected much higher than the anterior, the attachment of the vagi- na, being lower on the anterior surface of the cervix, would naturally pull it forward. From the fact that this malformation at the junc- tion of the uterus and vagina is present in the vast majority of cases of anteflexion of the cervix, I have looked ujjon it as one important cause. If this arrangement should tend, as it probably does, to bring the cervix forward so as to flex the uterus to a slight degree previ- ous to its complete, development, the ]:)ressure at the point of flex- ion would arrest the growth at that point, and then the wall would become more attenuated still, and flexion of the body would be produced. Imperfect development may cause flexion in another way. The infantile uterus, having little strength of tissue to support itself, might readily become flexed, and so remain during the period of secondary development. I am aware that good authorities, such as G4 DISEASES OF WOMEX. Klub, .statu that previous to puberty the uterus is neither l)ent baek- ward nor forward ; but other observers have found tlie infantile utenis antetlexed in many cases, and one can readily understand wliy the organ might remain so. The position in sitting at school and in sewing so often maintained by girls, constipation, and improper cloth- ing, all tend to retard development and hence j)roduce flexion. The uterus might readily increase in size at all parts except the portion compressed at the point of flexion. Flexion occurs also from excessive develo])ment of the cervix. The unnaturally long cervix pressing upon the posterior wall of the vagina is inclined forward, while the body of the uteinis remains in its normal axis. This produces slight flexion, which in time becomes greater, on the principle that the deformity, once established, tends to increase. When flexion is caused by inflammation, the explanation given by Rokitansky and already referred to, applies in some cases of ac- quired flexion. Irregular involution is doubtless one of the causes of flexion when it occurs after confinement or miscarriage. If press- ure was brought to bear on the cervix, fundus, or both, so as to favor flexion, involution might go on beyond the normal limits at the point of pressure. Treatment. — A brief review of the various plans of treatment will, I believe, show that while they are of great value, and capable of giving relief in many cases, still it will be found that they do not fully equal all demands. The use of extra-uterine pessaries will re- lieve some of the prominent symptoms, but will not overcome the deformity. Intra-utenne pessaries, while they sustain the uterus in its normal shape, are objectionable in some respects ; they are often difficult to introduce, are not easily held in position, and are liable in some cases to cause so much irritation as to make their prolonged use dangerous to life. The surgical methods which have for their object only to relieve the symptoms or evil consequences of flexion, are chiefly dilatation and division of one wall of the cervix. Dilatation is certainly of much value, but the improvement is often, indeed generally, only temporary. Division of one of the cervical walls answers the same purpose as dilatation, and the effect is not more lasting. lUit neither of these modes of treatment overcomes the deformity altogether, and seldom permanently cures the troublesome sym]>toms. Tlie ment of dividing the cervical wall appears to me to be, that it may correct the conditions of the flexion which cause sterility, and when that is accomplished, and pregnancy follows, the development of the uteras FLEXIONS OF THE UTERUS. 65 (luring gestation permanently cures the malformation as a rule. If pregnancy does n<^t follow, the patient is not always improved, ex- cept tem])orarily, by the treatment. The objects to be attained in the treatment of flexions of the uterus are, to straighten the organ and to keep it so until the defect- ive portions of its walls become developed sufficiently to render it self-sustaining. Shonld the means used fail to overcome the de- formity, the next aim should be to relieve the patient from the con- secpiences of the flexion by other means, such as dilating the canal of the uterus, or dividing the posterior wall of the cervix after the manner of Sims. The means to be used in the management of flexion must be adapted to each case, and hence the subject resolves itself into, flrst, the treatment of flexion of the cervix ; second, flexion of the body of the uterus ; and, third, flexion of both. It follows, naturally, that the treatment of flexion of both the body and cervix — i. e., the third form mentioned — should include the treatment of the first and second forms. The treatment of flexion is as follows: When the vaginal por- tion of the cervix is unusually long and conical, amputation may be called for, and is often followed by very satisfactory results. In the majority of cases a less important operation will answer. By clip- ping out a Y-shaped piece in each lateral edge of the os, and extend- ing upward from an eighth to a fourth of an inch, a few of the circular fibers are divided. This permits the longitudinal fibers to contract, and thus shortens the vaginal portion of the cervix. By far the most frequent and important lesion that occurs in the connection of the uterus and vagina is the imperfect invagination of the anterior wall of the cervix, which has been described under the head of pathology. To overcome this deformity, I have adopted tlie following plan of treatment : The patient is placed on her left side, and Sims's speculum is introduced. The posterior lip of tlie cervix uteri is seized with a tenaculum, and the cervix drawn back- ward toward the hollow of the sacrum. This puts the anterior column of the vagina on the stretch, at the point where it is reflected on the cervix. The vaginal wall is then divided transversely with the scissors, about three fourths of an inch from the os uteri, the incision being from a quarter to three eighths of an inch deep (Fig. 3T). The vaginal wall is dissected up, so that when the incised jxjrtion is put upon the stretch the sides will come together. In other words, the upper and lower edges of the incised central por- tion of the vaginal wall are drawn apart, and the sides brought together to fiil the space, so that the transverse incision now ap- 6Q DISEASES OF WOMEN. peal's as a longitudinal one. Three or four sutures are introduced, to keep the parts together till they unite (Fig. 38). Uperatiou lor imijcrlcct invagination. The incision. If the uterus is slightly below its normal level, and inclined to retroversion (a condition not uncommon in antetiexion ), much benefit will be obtained by introducing a double-lever pessary, largest at its posterior extremity. This will hold up the uterus, and, by making ^ Fig. 38. — Operation for imperfect invagination. Sutures in position. pressure in the posterior vaginal cul-de-sa<\ draw the cervix back- ward, and thus hold the edges of the wound together and favor union. The etfect of this simple and safe ojKMtition is to bring the anterior wall of the cervix farther down into the vagina, and permit it to extend backward more toward the axis of the pel- vis, where it ought to be. This plan of treatment I have found to be sufficient for the relief of tlexion of the cervix uteri in many cases. FLEXIONS OF THE UTERUS. 67 The treatment of flexion of the body of tlie ntenis requires flrst that the organ should be made straight, and then that it should be kept straight, as already stated. The first ob- ject can be accomplished most easily by the use U of Elliott's uterine adjuster (Fig. 39). I am in- ; j debted to Dr. T. G. Thomas for the knowledge \ of the method of using this instrument. It ' looks like a uterine bougie, with a round metallic disk at its end. By turning this disk, the point of the instrument can be bent forward or back- ward at the will of the operator. In using it to straighten the flexed uterus the instrument is canied forward and passed into the uterus ; the disk at the end is then tui'ned in the reverse di- rection, and the instrument, carrying the body of the uterus with it, is bent in the opposite dii-ection until the body and cervix uteri are brought into line with each other. There are certain precautions necessary in using this instru- ment to straighten a flexed uterus, but these will be brought out in the history of cases which fol- low. In straightening the uterus with Elliott's ad- juster it is useful to bend the uterine body back- ward bej^ond the line of the cervix when this can be done without causing much pain. The stretch- ing of the wall of the uterus at the point of flex- ion stimulates nutrition and gives strength to the weak part. By repeating this treatment many times, much relief is given, and much progress made toward finally overcoming the deformity. To keep the uterus straight in anteflexion of the body, two of the many methods commended I have found useful — the first being the use of an anteflexion pessary, those of Thomas (Figs. 40, 41, and 42) and Hewitt (Fig. 43) being preferable. These mechan- ical supports will sometimes answer where the vagina is large and relaxed, conditions not often found in flexion. The other means is the intra-uterine stem with a vaginal pessary to keep it in position — the glass or hard-rubber stem and vaginal pessary, with a cup devised by Thomas, being my choice (Fig. 44). In using the intra-uterine stem the greatest possible care should Fig. 39.— Elliott's ine adjuster. uter- 08 DISEASES OB^ WOMEN. be employed because of the great danger of exciting inflammation. Before resorting to the use of this instrument all congestion and Fig. 40. Fig. 41. Fig. 12. Figs. 40-42. — Thomas's anteflexion pessary; in vagina, in position ; on removal. irritabilitj sliould be subdued, as far as possible, and the uterus should be trained to tolerate a foreign body in its cavity. The lat- ter can be accomplished by the careful use of Elliott's adjuster, which should be em- ployed to straight- en the uterus many times before using the stem. The de- tails of this part of the treatment will be given in the his- tory of cases. De- fects of the canal of the uterus are fre- quently associated with flexion. Some- times the whole ca- nal of the cervix is too narrow, and again thei-e is a stric- ture at the internal OS. To overcome these defects, and to aid in correcting the flexion, several methods have been employed, the chief among them being incision and dilatation. When the constriction is at the internal or external Fig. 43. — Graily Hewitt's antcversion pessary. FLEXIONS OF THE UTERUS. 69 Fig. 44. — Stem pessary of Thomas. Incision and dilatation are OS, or botli, I prefer incision followed by the use of the intra-nterine stern, or the frequent passing of the uterine sounds of different sizes. Where the whole canal is contracted, I ]>refer dilatation. This may be easy and gradual, or forcible. The first consists in passing graduated sounds, the other in using the nterine dilator (see Fig. 16). I prefer the forcible dilatation when there are no contra-indications, such as extreme sensitiveness ; bnt I do not approve of carrying the dila- tation beyond that which is snfficient to admit a No. 10 or 12 English sound. The extreme dilatation prac- ticed by some, which is carried to a point sufficient to admit the index- iinger, is dangerous and unnecessary, necessary when the canal is undersized, and should be employed only when that condition exists. Little permanent good will come of this treatment except as preparatory to the use of the stem. In cases of flexion of the body and cervix it follows, as a matter of course, that all the means given above for the treatment of each must be em- ployed. Finally, it may be noted that success in the treatment of flexions depends upon the careful use of the means suggested, avoiding, as far as possible, the ever-present danger of exciting inflammation, which may make matters far worse. And much depends upon the age of the patient. It is always more easy to correct deformities in the young than in those of more advanced life. It should also be borne in mind that there is a tendency for the flexion and all con- sequent symptoms to return unless utero-gestation foUows. On this account I have classifled the results of my treatment in married women under two heads, viz., relieved, and cured. The former em- braces those who have been relieved from dysmenorrhoea, but have remained sterile, and the latter those who have been relieved and have borne children. ILLUSTRATIVE CASES. Anteflexion of the Cervix Uteri, Sims's Operation. (Relieved.) — This patient was a strong, healthy lady, who began to menstruate at the age of fourteen years. She continued in good health, and the menses were normal, except that she had more discomfort than be- 70 DISEASES OF WOMEN. longs to perfect liealtli. About the age of eighteen, menstruation became more painful, and she had some backache and occassional leucorrlia?a. These symptoms increased but little until she was married, at twenty-two years of age. Then she began to have dvsmenorrluta, and occasional menorrhagia. The leucorrha^a and backache became more persistent and her strength failed. The pain at the menstrual period was not very severe ; in fact, it was not at all like the violent pain often present in flexion of the body of the uferus, but it made her life quite miserable at that time. About eighteen months after her marriage she tirst applied for treatment, when the above symptoms were related. The OS externum pointed toward the vulva, and the vaginal por- tion of the cervix was slightly flattened from below upward. The invagination of the cervix anteriorly was nearly normal, but not in proportion to that of the posterior wall, which appeared to be ex- cessive. The body of the uterus was in its normal position ; the sound could not be passed until the cervix was dragged backward and brought in a line with the body. She was treated for a time to relieve her congestion and cervical endometritis, and then the posterior wall of the cervix was divided according to Sims's method. When the edges of the wound healed, there was considerable inversion of the mucous membrane, showing that it was redundant. The protruding portions were trimmed off, and then the results of the operation were quite satisfactory in ap- pearance. She was relieved of all her symptoms, for a time at least, but remained sterile, although the canal was large enough, and the sound could be passed. Three years afterward she was seen, and then she was complaining of leucorrhrea and occasional pelvic pains. This case was treated eight years ago, and is the last one in which 1 have performed Sims's operation for flexion. Extreme Anteflexion of the Cervix Uteri; DysmenorrhcEa. (Re- covery.) — The patient was first seen at the age of twenty-five. Her past history was tliat of good health. Menstruation occurred first at fifteen, and from that time onward was normal, except that it was accompanied with pain. During the first few years after puberty the pain was slight, but it gradually increased until it was suffi- ciently severe to unfit her for everything during the menstrual period. Her general health began to fail ; she lost flesh, and became very nervous and irritable, and it was on this account that she sought relief. I found that the anterior wall of the cervix uteri was on a line FLEXIONS OF THE UTERUS. Yl with the anterior wall of the vagina, and the os pointed toward the pubes. The posterior wall of the cervix projected into the va- gina far more than nornial ; in fact, the cervix was hooked upward. The body and fundus were in the normal position. Fig, 45 \^nll give an idea of this form of flex- ion. It gave the impression that in the descent of the uterus the antenor wall of the cervix had been arrested in its progress by the vaginal wall, while the posterior wall of the uterus descended beyond ^^^^I'g^^-^^^^'^^ the normal extent. It was very difficult to pass the sound; to do so, the uterus had to be raised up in the pelvis and partially retro verted. Drawing the cervix forcibly backward toward the sacrum developed a band of the anterior wall, which ran from the extreme end of the cervix upward and forward about an inch and a half, and there blended \vith the vaginal wall. It was easily seen that this abnormal attachment of the vagina was the cause of the flexion of the cervix. Preparatory treatment was employed for a short time, to reduce congestion, and then the operation, already described, to correct the invagination of the cervix, was performed. The ridge of anterior vaginal wall was divided a little less than an inch from the cervix, and then very gentle traction was suflicient to draw the cervix back into its proper relations with the body of the uterus. The wound, which was made at right angles to the axis of the vagina, became parallel to it, when the cervix was carried back into its normal po- sition. It was closed with silk sutures, carried deep down into the wall of the vagina, to make sure that the deeper portions of the wound were coaptated. When the sutures were tied, the invagina- tion was seen to be complete, and the cervix was carried well back, quite as far as it should be ; there was also a noticeable traction on the sutures, because the cervix inclined to flex forward again. To correct this, a stem-pessary was introduced, which extended al)Out half-way up the cavity of the body of the uterus. This was held in position at first with a marine lint tampon, and when the wound healed the stem was held in j)lac?e by the retaining pessary. The operation was done without ether, and the patient did not com- plain of pain, except when the stem was introduced into the uterus. Ten days after the operation the sutures were removed and the union M'as complete ; the stem was still left in place. After another week had gone, there was considerable congestion in the canal, indi- cated by a free discharge. The stem was removed, and an applica- 72 DISEASES OF WOMEN. tion of t:inuin and ijlycurin made. After the sutures were removed, the douche of l)ora\' and warm water was used daily, and once a week the stem was removed and the canal jxiinted with tannin and glycerin. The next menstrual period was without the severe piiin which she suffered l)efore the treatment. Still there were backache and pelvic tenesmus. The stem was left in place during menstrua- tion and for three weeks after, but during that time it was removed every week, and the application of tannin made. The second menstruation after the operation, the first after the removal of the stem, was painless. Subsequently there was no re- currence of the flexion, and her menstruation has continued regu- lar and ^^'ithout pain. It is now three years since she was treated, and she remains well and free from dysmenorrhoea. I may add here, that in all cases of anteflexion of the cervix, due to imperfect vagination, the treatment given above has been suc- cessful. Anteflexion of the Body and Cervix Uteri with Prolapsus. (Recov- ery.) — This patient was a little below the medium size, but was strong and active. She began to menstruate at thirteen, and con- tinued to do so rather irregularly. She generally went over time a varying number of days. From the first, menstruation was painful, the pain gradually increasing from month to month and year to year. This pain was chai*acteristic of flexion ; it began before the flow was relieved, diminished when the flow was well established, and subsided entirely on the second day. The pain was referred to the uterus, and was intermittent. From puberty to al)Out twenty-one years of age her health was j^erfect between the menstnial periods. She then began to sufter from backache, leucorrhopa, occasional ova- rian pain, and gradually her digestion became impaired, and the nervous system fretted. She was first seen at the age of twenty-four, when the above history was obtained. It was evident that all her symptoms were increasing in severity ; general congestion and tenderness of the vagina, uterus, and ovaries, were found at the examination. The OS externum pointed toward the vulva, and the fundus could be felt through the anterior wall of the vagina. The cervix was normal in size, and projected into the vagina in due proportions, anteriorly and posteriorly. The uterus rested low down in the pelvis, and the cer- vix appeared to be bent forward by the pressure u]>on the pelvic floor. These signs, obtained by touch, were all confirmed by the sound and speculum. The sound was passed through the os internum with difficulty at first. There was no change in the stnictures of the FLEXIONS OF THE UTERUS. Y3 litems except tlie flexion ; tlie con2;estion was well marked, and there was slight leucorrhd^a, indicating that cervical endometritis was being developed. The treatment of this patient consisted in remedies to improve digestion. Bromide of sodium was given to qniet her nervous sys- tem. Locally, the hot- water douche was em]:)loyed ; the os exter- num was dilated, and tincture of iodine applied to the cervical canal ; the uterus was raised to its proper elevation, and held there at tirst with a tampon, and afterward with a small Peaslee's pessary. The following week the internal os was dilated, until it admitted a No. 10 sound, and the iodine was also repeated. This caused much pain, and compelled the patient to rest in bed a few days, during which time the hot douche was continued. After this, the uterus was made straight by using Elliott's adjuster once a week. The douche and iodine were continued, and this completed the plan of treatment. For six months this course of local treatment was followed out, the constitutional treatment being varied as the symptoms changed. The tenderness and congestion first disappeared, and the pain dur- ing menstruation gradually became less and less, and finally ceased entirely. The patient remained under observation tw^o months longer, and then married, and seven months later her physician reported to me that she was four months pregnant. Anteflexion of the Body of the Uterus ; Stenosis at the Os Inter- num, treated with Stem-Pessary. (Recovery.) — This patient had good health, but was of a highly nervous temperament, a condition which had been increased by a severe and prolonged education. She be- gan to menstruate at fifteen, and had dysmenorrhea from the beginning. She managed to get along by resting at the menstrual periods, and bearing her suffering as best she could, but at the age of twenty-eight gave up, and sought advice. Her general health at that time was impaired, and she was quite despondent. When first examined, the usual signs of anteflexion of the body of the uterus were found. The cervix was also slightly bent forward. The canal of the uterus was of full size, except, at the internal os; a small probe only could be passed at that point. The uterus was quite tender, and there was some catarrh of the cervical mucous membrane. Tonic and sedative treatment was begun, and the strict- ure was incised on two sides, with the hysterotome. After this, a sound was passed twice a week for a time. The pa- tient was much relieved by this treatment, but still suffered pain at DISEASES OF WOMEN. the niL'Uijtraul periuds. The i)ain returned tu a certain extent, at each menstruation, and at the end of a year treatment had to be re- Fio. 46 — Skene's sound and scarificator. newed. At that time the patient appeared to l)e as badly off as when first seen. Dilatation of the canal and straightening the uterus with Elliott's adjuster gave some relief. More tliorough treatment was advised, but she would not consent to give her whole time to it. Four years later the patient returned in nmch worse condition than when first treated. The tissues of the uterus were much liard- er, and there was more tenderness. Great pain was experienced upon passing the sound, and any effort to straighten the uterus was un- bearable. Sleeplessness was now a prominent symptom, and she was obliged to take morphine at the menstrual periods. I prescribed the rest-treatment, Avith tonics, bromides, massage, and the hot-water douclie, and the application of tincture of iodine to the cervix uteri and the upper part of the vagina. When the general health had been improved 'by two months of this treatment, the cervical canal was dilated, under the use of cocaine, until it ad- mitted a No. 12 sound. The uterus was then straightened with the Elliott adjuster, and a glass stem-pessary introduced. Although she was kept quiet after the introduction of the stem, the suffering was so great that at the end of two hours it had to be removed. The general treatment was resumed for about four days, and the stem was again used ; this time it was worn for five days, but had to be again removed, owing to the pain it caused. The irritation was again subdued by the hot douche and cocaine applied to the canal of the cervix, and occasionally an application of iodine and carbolic acid was made. A week later the stem was used again ; it then caused less pain, but she had to remain in bed, and there was still consid- erable distress. There was also a marked leucorrh(i?al discharge. It was necessary to remove the instrument about every five days, and treat the cervical endometritis. Three weeks passed before the patient could be trusted to walk around, and it was two months longer before she could walk out and FLEXIONS OF THE UTERUS. 75 ride without causing pain. Tlie dysnuinon-lifjea was less severe each mouth, and finally subsided entirely. The stem was worn altogether about four months ; during all that time the case had to be watched and treated for a recnrring endometritis, but finally the recovery was complete. Two years have passed since the treatment was completed, and the patient remains well. The chances are, however, that the flexion will recur. It will be noticed that the stem caused much irritation, and re- quired constant watching. This I find is the case very often. There are few patients who will tolerate the stem unless great care is tak- en, and they are treated the moment that symptoms appear. The longer the trouble has existed, the more difficult it is to use the stem. The uterus becomes more dense in structure and more sensi- tive in old cases, and the results of treatment are not very satisfac- tory. This is the rule, and there are not many exceptions to it. The patient whose case I have jnst described is one of the oldest that I have ever successfully treated for flexion. All the cases here given are intended to show the different forms of flexion, and the various methods of treatment employed. It will be seen that my object is not to use one method of treatment in all forms, but to adapt the treatment to the peculiar requirements of each case. Finally, I may add that I have succeeded in relieving all cases of flexion, of whatever form or degree, temporarily at least, by the treatment described, excepting when there were complications, such as ovarian disease, or the results of old inflammations. A consider- able number have entirely recovered, and borne childi'eUo CHAPTEE Y. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. ANATOMY. The Pudendum. — The pudeudum comprises all those parts that are situated at the outer and lower portion of the pelvis. It is hounded above by the lower part of the abdomen, on either side by the thigh*, and below by the perin?eum. In general outline it is wedge-shaped, the edge being do\\Tiward. The several parts are the mons veneris, the labia majora and minora, the clitoris, and the hymen. The mons veneris is a mass of tissue which covers the sym- physis pubis, and occupies the triangular space formed by the junc- tion of the abdomen and thighs ; it is composed of fatty tissue and rather thick integument, which, after puberty, is covered with hair. At its lower border it is divided into two folds by the upper por- tion of the urogenital fissure. The labia majora are two j^rominent rounded folds of integument, continuous above with the mons vene- ris, which extend downward to the perinreum. They are fonned by integument covered with hair on the outer side ; the inner sur- face is more like mucous membrane in general appearance, but it contains sebaceous glands instead of mucous folliclcp. The tissues of the lal)ia beneath the skin are, connective tissue, elastic elements, and fatty lobules with undei-lying adipose structure. The vascular supply is abundant, forming a venous plexus. The labia minora, also called the nymphn?, are two small folds of mucous membrane, situated upon the inner sides of the labia majora, and extending downward until they meet posteriorly, and form the thin circular band, the fourchette or fnenulum vulva\ which extends across at the posterior part of the opening of the vagina outside of the hymen. The outer surfaces of the labia minora are continuous with the labia majora, and tlie inner surfaces with the mucous mem- brane of the vestibule. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 77 The clitoris is analogous to the penis, but possesses neither cor])U8 siiono-iosum nor urethra ; it is erectile in structure, and is described as having three i)ai'ts— the crura, corpus, and glans. The crura are '<•'« ■F;,cR.cr V.,-: Fig. 47. — Tlie external genitals of a «oiiiau who has lioiiie children. oblong, spindle-shaped processes, formed by the bifurcation of the corpus ; they are attached to the rami of the ischium and pubes. The corpus is located in the median line beneath the pubic arch, and terminates anteriorly in a rounded extremity, the glans. The relations of the clitoris and the labia minora are as follows : Each labium divides anteriorly into two folds, which surround the glans clitoridis, the superior folds meeting to form the preputium clitoridis ; the inferior folds' being attached to the glans, and forming the fnenum. The vestibule is the triangular, smooth surface, bounded above by the clitoris, on either side by the nymphae, and below by the an- 78 DISEASES OF WOMEN. terior vaginal wall. Just above tlu; junction of the vestibule and vagina the meatus urinarius is situated. It is distinguished by its prujectirtn beyond the general surface of tlie vestibule. The hymen is a thin semi-lunar fold covered on both external and internal sur- faces with mucous membrane, and stretches across the posterior part of the orifice of the vagina. It is a continuation of the vagina (Budin). In fact, the h}Tiien covers the orifice of the vagina, closing it completely, except a small, crescentic opening just behjw the mea- tus urinarius. It varies in different subjects in regard to its shape, hence the above description can only be taken as that of the typical form — the deviations from this type will be referred to in connec- tion with the pathological conditions of the hymen. The meatus urinarius is situated in the median line, at the June, tion of the lower margin of .the vestibule and the margin of the an- terior wall, about three quarters of an inch below the clitoris. It is kept closed by the muscular tissue of tlie urethra, and presents a puckered appearance and projects slightly beyond the general plane of the vestibule. The line of junction between skin and mucous membrane runs along the base of the inner aspect of the labium majus, passes down beside the base of the outer aspect of the hymen, and through the fossa navicularis. The deeper structures of the external parts of generation are mostly glands and blood-vessels with connective tissue — the arrange- ment of the two latter giving the characteristics of erectile tissue. The glands are of two kinds, the sebaceous and nuicous. The sebaceous glands are abundant in the tissues of the nymphiv ; they furnish a yellowish-white secretion, which has a ]ieculiar odor. In those who are not quite cleanly in their habits this secretion accumu- lates beneath the upper folds of the nymphie, around the glans cli- toridis. The mucous glands are of two varieties — the glandulte vestibu- lares majores and the glandule vestibulares minorcs. The glandulte vestibulares ininores are about six in number, and are situated about the meatus urinarius ; they are of the com}X)und racemose variety, and have short ducts with large orifices. Some- times one or more of these ducts is found, much eidarged, and look- ing like a cul-de-sac, large enough to admit the point of a small catheter. The glandulpe vestibulares majores are two in number and al>out the size of a pea, and are of a reddish-yellow color. They are situ- ated at the ])Osterior extremity of the bulbi vestibuli, and are jiar- DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 79 tially included in the bnlbi, or, more properly speaking, the glands and the biilbi overlap each other. They, like the glandultie minores, are of the compound racemose variety, and their acini open into a duct, more than half an inch in length, which is wide where it leaves the gland, but b(3Comes nar- I'lG. 4P.— The superticiiil veins of the pcrinanim (Savage) : /<,.r/, crura clitoriclis ; c, cor- pus clitoridis; 1, 2, 3, corpus cavernosum urcthrte ; 5, superior perineal and obtura- tor veins ; 6, veins of communication with superior epigastric veins; 8, 9, 10, pudic vein and primary branches ; d, tuberosity of ischium ; o, coccyx ; 6', vulvo-vairinal gland; «, anterior border of gluteus maximus muscle; B, superficial sphincter'and muscle ; (j, erector clitoridis muscle ; h, left crus clitoridis. rower toward its orifice. These ducts, in their com-se, ran along the nnier side of the vaginal bulbs, and terminate in front of the hymen, about midway from the base of the vestibule and the posterior border of the hymen, or its remains. 80 DISEASES OF WuMEN. Tlie remaining deeper structures of the pudendum of special in- terest are cellular tissue and two masses of i)loi>d-ve.-sels, known as the hull)i vestihuli vagina*. These bulbs of the vaginal vestibule are, when distended with blood, about an inch long; they are located on each side between the vestibule and the pubic arch. They are composed of reticulated veins and erectile tissue. The upper ends of these bulbs are pointed, and communicate, by an intervening small plexus, the pars inteiTQcdia, with the vessels of the glans cli- toridis (^Fig. 48). The oriUcium vaginae differs greatly in size and general appear- if:St£t^.a&2^^4^'?^^r>^ii;'::'^ ^^"^frrin biG. 4'.t. — Kxtcriial L^uniiais ol vir^'iii. ance in the virgin, in those accustomed to sexual intercourse, and in those who have borne children (see Figs. 49 and 47j. DISEASES OF THE EXTERNAL ORGANS OF GENERATION. 81 In virgins the hymen is present, as a rule, and its upper crescen- tic border, with its concavity looking toward the urethral opening, forms the vaginal orifice. There is a considerable variation in the shape of the hymen, and, though there are deviations from the nor- mal type, they are not of necessity morbid states, but rather jk-cuI- iarities of formation. The most common of these are the liymen cribriformis (Fig. 50), which has a nmnber of small openings ; the Fig. 5n.-Cribriform hymen. Fig. 51.-Annular hymen (j). Fig. 52.-Fimbriate hymen hymen annularis (Fig. 51), which has one small central opening ; the hymen fimbriatus (Fig. 52), so called because it is fringed some- what like the extremity of a Fallopian tube. ^ The hymen is usually lacerated in several places during the first coitus, but of some instances this does not take place. Cases have been seen in mar-ried women in whom the hymen is very elastic and distensible. Hyrtl mentions one specimen, in the museum at Halle, where the hymen is perfect, though the woman had given birth to a seven monthb' child. The cai-uncuhB myrtiformes are a number of isolated elevations of mucous tissue about the orifice of the vagina, whicli most authors claim to be the remains of the lacerated hymen. Schroeder has a: ])onited out that these elevations or canmculfe Fig. 53. — R, rteetum, are ])roduced by child-bearing, and not bv simjDle laceration of the hymen. Clinical observations coidirm tlie view^s of Schroeder. Development and Malformations of the Vulva. —During the second month of fetal life the rec- tum, allantois, and Miiller's ducts communicate, but there is as yet no openmg of these to the exterior (Fig. 53). continuous with All, allantois (bladder) and M duct of Miiller (va- gina) ; z, depression of skin which grows inward and forms the vulva (Schroeder). 82 DISEASES OF WOMEN. Fig. 54. — Tlie depression has extended inward and become continuous with the rectum and allantois forming the cloaca {CI). Fig. Tjo. — The cloaca is dividing into urogen- ital sinus (Su) and anus by downward growtli of perineal septum. Later on, about the tenth week, the genital cleft forms; this is a depression in the skin which gradually e.xtends deeper and deeper until it connnunicates with the allantois and the rectum, and becomes the cloaca (Fig. 54). The structure which lies between the rectum and the allantois grows in a down- ward direction, dividing the cloaca into two parts ; that which is situated anteriorly is the urogenital sinus into which Miiller's ducts open ; the posterior part becomes the anus, while the lower end of this downward growth forms the perinaeum (Fig. 55). The upper portion of the urogenital sinus, becoming more and more coutractel, forms tlie urethra, the lower part remaining as the vestil)ule (Figs. 56 and 57). As has elsewhere been stated, the ducts of Miiller unite to form the vagi- na. The clitoris is formed from the genital eminence, and the labia minora from the edg^es of the .s, made into a roll of suitable size, and moistened with carbolized w;'.ter. This DISEASES OF THE VAGINA. 105 Fig. 61. — Sims's vaginal dilator. was removed daily, and, as it expanded after being introduced, it answered in that case very well. Tiie tendency in all these eases is to contraction and return of the atresia ; in fact, I have never seen a case of complete atre- sia j)ermanently cur- ed. In view of all these, I have been guided in practice by the valuable sug- gestions of West. The following is from his work on "Diseases of Women," page 34 : " The operation .for atresia is performed by the bistoury or guarded bistoury, or Pouteau's trocar. The bistoury is to be gener- ally preferred. Pouteau's trocar is resorted to when a considerable part of the lower vagina is absent, and the sac is punctured some- times pretty high up per rectum. This operation is in such cases preferable to vain, painful, a.nd dangerous attempts to bore the thin tissues between the urethra and rectum to make and maintain a new vagina. Such a proceeding results only in vexation. It is far better for the malformed woman to discourage all hopes of n:iatemity. The artificial passage into the rectum is easily kept open, and the men- strual fluid runs off through it." INFLAMMATORY AFFECTIONS OF THE VAGINA. Vaginitis. — The vagina is seldom if ever affected witli idiopathic inflammation ; vaginitis, therefore, always occurs as the result of some specific cause, or is secondary to some contiguous infiammation, such as endometritis. There are several varieties of vaginitis. Clas- sified according to the intensity and duration of the affection, there are the acute and chronic forms ; when classified according to the causation, there is a number of forms, the most important of which are gonorrhreal, erythematous, sometimes called erysipelatous, and diphtheritic. As a rule, the inflammation is general, involving the whole canal ; occasionally it is circumscribed, and then it is found just within the vulva, or else at the upper part. Pathology. — Owing to the anatomical peculiarities of the vagina it is not susceptible of the catarrhal form of inflammation, so com- mon to mucous membranes elsewhere. From the fact that the vag- inal mucous membrane resembles in structure the skin, and that 100 DIbEASEb OF WOMEN. there are few raucous follicles found in it, vaginitis, in its pathology, is more like dermatitis than like tlie ordinary intlainmations of mu- cous membranes. Congestion, transudation of serum, premature ex- foliation of the epithelium, and, in well-defined cases, the formation of pus, are the characteristic results of acute vaginitis. In the subacute form there is less congestion and less pus, other- wise the inflammatory lesions are the same. This may all be more briefly stated in aufjther form, as follows : Vaginitis occurs either as erythematous, purulent, or exudative — never as purely catarrhal. The morbid appearances in these forms differ. Erythematous vaginitis is characterized by great capillary congestion, which gives the intense redness of this form of inflammation in tiie first stage. Then, as the disease advances, there is exfoliation of the epithelium. Sometimes the epithelium comes off in thin flakes, resembling in this respect the exfoliation of the cuticle in dermatitis. This leaves the mucous membrane denuded of its epithelium, and gives a glazed appearance to the whole canal. During this time there may be a free serous secretion and some pus found, but these are not profuse in all cases. In purulent vaginitis the lesions are the same as already described. In the exudative forms the characteristic lesions are present ; the diphtheritic naembrane as in diphtheria, the croupous in that form of inflammation. There are other forms of vaginitis mentioned by some autliors, but they are peculiar in regard to causation, while in their pathol- ogy they do not differ materially from those described. Symptomatology. — The syuiptoms in the acute form are a feeling of internal heat and fullness. These increase in inten&ity, and pain in the vaijina and utenis come on. Vesical and rectal tenesmus are present in severe cases, and urination and defecation ai-e painful. The urine causes violent smarting of the inflamed parts about the vulva with which it comes in contact. So severe is the pain in some cases during and after mination, that the patient resists the inclina- tion until the power of evacuation is lost, and there is retention. There are constitutional disturbances also. At first there is fever, and following that loss of apjietite and debility. The discharge is profuse, and sero-pumlent in character ; it causes excoriation of the external parts, which often extends to the limbs. If great cleanli- ness is not observed, the discharge decomposes and causes a very dis- agreeable odor. In the subacute and chronic fonns of vaginitis the symptoms are the same in character, but less in degree ; in fact, the annoy- DISEASES OF THE VAGINA. 107 iiig discharge is the only symptom observed in many of these mild cases. riiysical /S/fjiis. — By inspection of the jiarts when the labia are separated the characteristic discharge can be seen and recognized. It differs from that of vulvitis in being less tenacious. The. nmcous glands about the vulva give to the discharge of vulvitis a cohesive- ness which is not foimd in that of vaginitis. The use of Siras's speculum will show the inllamecl ajipearance of the membrane and the discharge which is present. The anterior and lateral portions only of the walls of the vagina are seen through the Sims speculum, but by watching the folding together of the posterior and anterior walls, as the speculum is with- drawn, the whole canal can be thoroughly inspected. The difference between the signs of acute and sub-acute inflam- mation is simply in the intensity of the congestion, the extent of the canal involved, and the quantity and character of the discharge. To distinguish gonorrhoeal vaginitis from the non-specific fonns the microscope alone is suflBcient. When there is a question regard- ing the nature or the cause, specimens of the discharge should be examined for the gonococci. Causation. — There is a predisposition to vaginitis in those of delicate health and strumous diathesis, but it is not marked. Judging from my own observations, the common causes of vagi- nitis are gonorrhoeal virus, metritis, especially puerperal, and ery- thematous affections. This applies to the acute foi'm of the affec- tion. Sub-acute and clironic vaginitis may be caused by any inflam- mation in the neighborhood of the canal. Dysentery, for example, causes vaginitis not infrequently. Different fungi have been credited with causing vaginitis, but this is not well settled. When it occurs in connecti(ju with the eruptive diseases the cause is, of course, the specific morbid material which produces the constitutional disease. Prognosis. — With proper care vaginitis can be arrested and re- covery secured without any permanent lesions. It is liable to re- cur if caused by gonorrhoea. Sometimes permanent damage is done to the canal when the vaginitis is due to any of the eruptive diseases or diplitheria. Treatment. — In the past, treatment of vaginitis has consisted mainly of the frequent use of medicinal douches. The agents used, and the means and ways of using them, have varied greatly with different practitioners. Yery recently a new method of treatment has been brought to the notice of the professi(m by Dr. Engelmann, lOS DISEASES OF WoMKX. of St. Louis. His nietliod he terms the (h-y treatment, which consists in the use of medicinal jxnvders and medicated tampoiiB. A number of veal's ago I ti-ied this method, in an imperi'cct aiid limited way, in the treatment of vaginitis among the insane, and obtained ex- perience, enough to know that it is of great value. 1 lind even now, however, that while using certain agents in powdered form, and also the tam))on, the discharge from the inflammation and the powder used lodge in the folds of the mucous membrane, and that it is necessary to use a vaginal douche occasionally in order to make the treatment effective. In acute vaginitis T employ what may be called a mixed treat- ment, using the medicinal agents and j)owder with tampim, and oc- casionally employing the douche in the following way : After cleans- ing the mucous membrane thoroughly with a douche of wann water and borax, a drachm to the quart, 1 then thoroughly apply sub- nitrate of bismuth and prepared chalk, equal parts, and introduce a tampon of borated cotton, the tampon l)eing so arranged as to thor- oughly keep the vaginal walls apart; at the end of twenty-four houi-s the tampon is removed, and any accumulation of the discharge and powder is thoroughly removed and the tampon replaced. At the end of the next twenty-four hours the tampon is removed and the douche of borax and water employed, and the dry treatment i-e- peated. In acute cases where there is much pain, and especially if due to specific cause, I employ iodoform in place of the bismuth. If the trouble does not yield promptly to this treatment I give up the dry dressing, and every third day apply to the entire canal, by means of the atomizer with strong pressure, a solution of nitrate of silver, one grain to the ounce, or sulphate of zinc, one half grain to the ounce. I find that such mild solutions, applied with considerable force with the atomizer, diffuse the application very thoroughly, and l^roduce a far more marked effect than much stronger solutions used as a douche. The method of application or sprapng the canal is as follows : A Sims's speculum is introduced, and when the canal is distended by pressure, the spray is thoroughly a]>j)lied to the upper portion of the canal and to the anterior and lateral walls, and the posterior wall is sprayed as the speculum is gradually withdraMni. In the inter- vening days between these ap})lications I employ daily, or t\\'ice a day, a vaginal douche of a solution of sulphate of zinc, sixty grains to the quart of warm water. In cases that can not be so cai-efully watched and treated, I rely DISEASES OF THE VAGINA. 109 almost wholly upon the sulphate-of-zinc solution, used as a vaginal douche twice a day at first, and subsequently once a day. This an- swers remarkably well in a great majority of cases, but there is a constant liability to miss a portion of the canal, especially the u})per and posterior fornix. To overcome this, an application of the nitrate of silver or sulphate of zinc is to be made to these neglected parts once or twice a week through the speculum. This simple treatment is usually sufficient in all ordinary cases, but whenever the disease is specihc in its origin, and is complicated with urethritis and endometritis, then these affections should be treated simultaneously in the ordinary way. If treatment is neglected or discontinued too soon, the vaginitis will recur in a very short time. Vaginismus. — Since the time when Sims first described this affec- tion and its treatment, it has been considered by most writers as a distinct affection, and is usually classed as a neurosis of the vagina or hymen. In all the cases which have come under my observation the trouble has been due either to some affection of the muscles of the pelvic floor, or to a hyperaesthesia of the mucous membrane of the vagina. The foniier has already been spoken of in connection with injuries of the pelvic floor. Ilypergesthesia due to affections of the other pelvic organs, I have always looked upon as a symptom of the preceding disease of the utei-us, rectum, or bladder. Yiewing the subject from this stand- point, httle need be said about it in this connection. The removal of the affections which give rise to it is the chief indication, and is generally sufficient in the way of treatment. Occasionally, it is necessary to give relief while the treatment is being employed to remove the cause ; and, in those cases in which the cause can not be removed, efforts should be made to reheve the hyperiesthesia. This can usually be done by the judicious use of cocaine. Neoplasms of the Vagina. — Many of the neoplasms of the vagina are the same in character as those found elsewhere ; as, for example, sarcoma, carcinoma, fibroma, and lipoma. All these ai'e very rare. The diagnosis and treatment of these neoplasms are based upon the same principles as those w^hich guide the jiractitioner in dealing with such affections when located in other parts of the body. I will, however, give a brief account of some of the more com- mon neoplasms of the vagina : Cysts of the Vagixa. — These vary in size from that of a buck- shot to that of a child's head — one case, at least, being on record. 110 DISEASES OK WOMEN. ill which the tiiiuor was of the latter size, and so seriousl}'^ interfered witli labor as to necessitate the evacuation of its contents before the labor could proceed. The contents of these cysts are fluid, of a color which may be yellowish, reddish, or greenish. Nelaton reported a case in which, on analysis, the cyst contents were found to be made up of water, eighteen parts ; albumen, one part and a half ; and salts, a half-part. Microscopical examination has shown the presence of epitlielium, pus, cholesterine, nucleated and lymphoid cells in these cysts. AVinckel, who has examined these cysts with great care, states that their walls are made up as follows : The external surface is covered with the ordinary pavement epithelium of the vagina ; the thickness of the walls varies between one twenty-fifth and two tifths of an inch — the thinnest portion being formed of connective tissue alone, the thicker with the addition of smooth nmscular libers. The internal surface is usually perfectly smooth, but may show papillae covered with epitlielium, which in the majority of cases is cylindri- cal, more rarely simple, or stratified pavement epithelium, or still more rarely, stratihed pavement and cylindrical epithelium in the same cyst. These cysts of the vagina are caused in some cases by a closing and subsequent distention of the vaginal glands. They may also be due to dilated lymph-vessels, to oedema, and to the accumulation of blood after an injury. Cysts may also have their origin in AVolff's or Gartner's canals and in Miiller's ducts. It is probable that cysts of the vagina are more common than is generally supposed. Their recognition is not difficult, provided that a careful inspection is made of the vaginal canal. Their treatment is exceedingly simple. It consists in emptying them by an incision through their walls. To prevent their refilling, a portion of the wall may be cut out, and the interior of the cyst painted with the tincture of iodine. Fibroma, Myo:ma, and Fibkomyoma. — These growths occur but rarely. Like the cysts of which I have already spoken, they vary very much in size ; some being so small as only to be recognized by the most careful examination, while others mav be so lare:e as to in- terfere seriously with micturition or defecation, or even to so dimin- ish the caliber of the pelvic canal in pregnant women as to prevent the deliveiy of the child through the natural passage, and to necessi- tate laparotomy. These tumors are readily recognized by their den- sity. If there is any doubt in the mind of the practitioner, an aspi- rating needle will at once exclude a cyst or an abscess. If the tumor attains any considerable size so as to interfere with any of the func- DISEASES OF THE VAGINA. HI tions it should be removed, or if, though small, it is increasing in size, this would constitute sufficient indication for its removal. This may be done by Paquelin's cautery, if the tumor is sufficiently pedun- culated, or if not, it may be enucleated. Sarcoma. — This is so rare as to need but the simple mention. Its treatment would, of course, be prompt removal as soon as recog- nized. Carcinoma. — All that I think it necessary to say on this subject has been said in the chapter on cancer of the uterus, to which the reader is referred. CHAPTER VI r. INJUKIES TO THE PELVIC FLOOR FROM PARTURITION' CAUSES. A XI) othp:r In order to comprehend fully the nature of the injui-ies to the pelvic floor and then* varied and important pathological relations, it is necessary to review hriefly the anatomy and physiology of this structure. The pelvic floor, which is also known by the somewhat indefinite name of perina?um, comprises the tissues which together occupy the space between the bones of the pelvic outlet. It is composed of muscles, fascia, areolar and elastic tissues. The muscles, which are the chief element in the stnicture and perform its function, have their origin from the iischium, the pubes, and the coccyx. From these points they extend down- ward, inward, and backward to the median line, and are united to the terminal ends of the rectum and va- gina and to each other from the op- posite sides. The levator-ani muscle arises from the posterior surface of the os j)ubis, the pelvic fascia, and the s])ine of the ischium. It passes downward, backward, and inward, to be inserted at the following points : in the me- dian line, the walls of the vagina and rectum, its fellow of the opposite side, and the end of the coccyx. Fig. 62 shows the ])osition and attachment of this muscle. The transversus-perinnei muscle arises fi'om the spine of the ischium, and passes across to the median Fig. 62. — The levator ani, seen from witliout after removal of part of the liip-hone (after Luschka). a, anal oj)cninrj, with sphincter ; v, va"iiia. INJURIES TO THE PELVIC FLOOR. 113 line, wlicre it joins its fellow of the opposite side. This muscle fills u]) part of the space left uncovered by the levator ani. The coccj- geiis arises from the spine of the ischimn, and is inserted into the side of the lower part of the sacrum and side and front of the coc- cyx. It is understood, of course, that there are two of each of the nmscles thus far described, one on each side — although the two parts of the levator ani may be considered as one because they act as one muscle. The same may be said of the transversus-perinsei muscle. The buibo-caverno- sus muscle can be most easily traced by taking as its origin the space between the sphincter ani and the orifice of the vagina. From this point its two halves pass upward, one on each side of the vagi- na. The upper an- terior end of each slip of muscle di- vides into three parts, which are inserted as follows : One into the lower surface of the corpus cavernosum of the clitoris, a second into the posterior por- tion of the bulb, and the third unites with its fellow of the op- posite side in the mucous membrane of the vestibule ; and all of them are, through the medium of tendon and fascia, connected to the pubic bones. If this muscle is traced from above downward to the center of the pelvic floor, it will be seen to have an origin and insertion like that of the anterior fibers of the levator ani ; hence the bulbo-cavernosus and levator ani may be considered as one muscle. This view is justifiable from the fact that they also contract together, having a similar function. All of these muscles have one feature in common, and that is, the blending of their fibers from the opposite sides of the pelvic 9 Fig. 63. — The muscles of the pelvic floor (after Hart and Savage). 114: DISEASES OF WOMEN'. outlet, and their attacliment to the terminal ends of the rectum and vagina. The Kphiiicter-uni muscle, which liius a function peculiarly its own, is closely united to all the other muscles of the pelvic floor by an interlacintj of the muscular fibers and by tendinous and fascial attachments. This muscle arises from the end of the coccyx, and surrounds the end of the rectum in conjunction with its circular fibers, while some of its deeper fibers are attached to the tissues in the median line between the rectum and vagina. The superficial fibers of this muscle are circular, and attached to the integument like all tnie sphincteric muscles. Taking the muscles of the pelvic floor in the aggregate, they form one complete diaphragm of muscular tissue which fills the pel- vic outlet. By this arrangement the rectum and vagina are held in position, and their tenninal ends controlled in the performance of their functions. The muscular attachment of the muscles and va- gina is in part shown by the preceding Figures 02 and 63. The normal elevation of the pelvic floor is illustrated by Fig. 64. This position of the pelvic floor and the relations of the rectum and vagina should be noted because they become changed in most of the injui-ies of this structure. The muscles of the pelvic floor are surrounded by the deep and superficial fascia, which in some parts become ligamentous in char- acter ; for example, the ischio-perineal ligament — that dense portion of the fascia which stretches from one side to the other through the space between the rectum and vagina. This fascial structure accom- panying the muscles is characteristic of all muscular structures which have to afford continuous sustaining power, like the muscles of the back, of the neck, abdomen, and thigh. jF\mction.—^These anatomical facts regarding the floor of the pel- vis suggest that its functions are to sustain the rectum and vagina, and to aid in their functions. The arrangement of the muscles is such that they clos3 by sphincteric action the terminal ends of the rectum and vagina, 3'et also permit the distention of their orifices during the acts of parturition and evacuation of the rectum. When pressure is made downward by any body in the rectum or vagina, the perineal muscles act to draw the orifices of these canals upward, and hence supply a resisting force to the downward pressm'e which effects dilatation of the vagina and rectum. This action of the mus- cles in resisting downward pressure is well demonstrated during par- turition. When the child's head presses upon the floor of the pel- INJURIES TO THE PELVIC FLOOR. 115 vis, the muscles, by retraction, distend tlie sphincter ani to a great extent. The dilatation of the vagina is produced by a more passive Fig. 64. — Diagrammatic sagittal section of the female pelvis, u, uterus ; r, rectum ; s, symphysis; p, perineal body ; b, is beneath bladder. This is the position of the uterus when the bladder is almost empty. giving way to the forces above, and yet the muscles exert a well- defined power in retracting that portion of the pelvic floor. This function of the muscles should be noted because it enters into the mechanism of most of the injuries to be discussed. This brief statement regarding the function of the pelvic floor embodies the essential points in its chief offices. There remains something to be said regarding its relations to the pelvic organs. Up to the present time the attention given to this subject by gynecologists has been almost wholly confined to laceration of the so-called perineal body — an injury frequently seen, but not by any means the only one that occurs to these parts. This concentration of attention on one portion of the subject has given rise to great 110 DISEASES OF WOMEN. diversity of opinions regarding the function of tlio perinaeum and its relations to the displacements of the pelvic organs, one party to the controversy believing that the perineal body has much to do with sustaining the pelvic organs in position, the other holding that it has very little power in this respect. AVithout summing up at great length the arguments on both sides, the facts bearing on the practical side of the subject may be briefly stated. In all injuries of the pelvic floor which impair its supporting function to any extent, prolapsus of the pelvic organs will follow in time, except in three conditions : 1. When the injury is compensated for by the muscles (which still maintain their attachment to the vagina and rectumj drawing the remaining portion of the pelvic floor upward, forward, and toward the pubes, thereby closing the vaginal orifice and supporting the pelvic organs. 2. Wliere by reason of some intra-pelvic inflammation the organs have become flxed by adhesions ; and, 3. Where the patient is abundantly supplied \vith adipose tissue, and takes very little active exercise. Excepting under the circumstances liere named, prolapsus of the pelvic organs invariably occurs after important injuries of the pelvic floor. The displacement does not follow the injury immediately, but, as a rule, comes on slowly. This conclusion has been arrived at from a large number of clinical observations, and it helps to definite- ly settle the question regarding the value of tlie pelvic floor as a means of support for the ])elvic organs. From these facts one may obtain the key to the differences of opinion which have been held by gynecologists regarding the functions of the pelvic floor. Those who believe that it plays a secondary part in maintaining the pelvic organs in position argue that there are anatomical structures which sustain the pelvic organs in place without aid from the pel- vic floor, and, in proof of this, point to the fact that the removal of the pelvic floor is not followed by displacement of the pelvic or- gans. This is often seen in cases in which lacerations sufficient to largely impair the function of the pelvic floor have existed for • years in women in active life without the occurrence of prolapsus of the pelvic organs. And, more than all this, it is said, prolapsus of the peine organs occui's where there is no apparent injury of the pelvic floor — i. e., no laceration of the perinanim. The falla- cies of this argument are that, although the pelvic organs are held in position by supports that are sutflcient to resist ordinary taxation for a given time, they are not able to do so under ex- INJURIES TO THE PELVIC FLOOR. 117 traordinary pressure for any length of time unaided by the pelvic floor. Again, the cases cited in which prolapsus does not occur while the periuiieum is lacerated belong to one or another of the three ex- ceptional states which I have already given. And, finally, the cases in which there is prolapsus while the pelvic floor appears to be uninjured are, as a rule, cases of mistaken diag- nosis, the floor of the j^elvis being really imperfect, although not apparently so on examination by the sense of sight alone. Some observers look for a laceration of the perinseum by inspection of its mucous and tegumentary surfaces, and, if injury to these surfaces is not found, they pronounce the pelvic floor perfect, while the fact is that laceration of the periuseum in the median line is only one of many injuries of the pelvic floor which render it functionally imper- fect. But granting that the pelvic floor takes no part in supporting the pelvic organs under ordinary taxation, it certainly aids in doing so in case there is extraordinary downward pressure from lifting heavy weights, violent coughing, and the like. Again, when the pelvic floor is injured — say by laceration — and loses the power to support itself and the vagina and rectum, prolapsus, especially of the vagina, occurs. This causes a dragging upon the pelvic organs which in due time will cause them to descend. In view of these well-- known facts, the most enthusiastic advocate of the independent sup- ports of the pelvic organs must admit that the pelvic floor is at least indirectly concerned in supporting the structures above it. Varieties. — The injuries of the pelvic floor usually seen in prac- tice are : 1. The various degrees of laceration of the peringeum, i. e., in the median line of the pelvic floor. 2. Subcutaneous separation of the muscles of the pelvic floor at their junction in the median line, or so-called perineal body; 3. Laceration in the median line, and temporary loss of power in the remaining muscles from overdistention. 4. Laceration of the levator-ani muscle, occurring alone or accom- panied by the lesions already given. 5. Atrophy and permanent paralysis from injuries during partu- rition and other causes. 6. Loss of muscular motion caused by the products of foi'mer inflammation. The first of these, laceration in the median line of the pelvic floor, is the injury most frequently sustained during parturition. Several degrees of this injury are described by authors, but in re- lis DISEASES OF WOMEN. gai'il to the pathology and treatment there are only two which, in this connection, require attention : the one which extends through the muscles of the anterior portion of the pelvic floor — that is, from the vulva to the sphincterani muscle, and the other which extends through the sphincter-ani muscle and into the rectum. The former of these is the injury which is most frequently recognized, and is therefure presumed to occur most frequently, although this point is not yet settled. Certainly it is the least grave in its consequences if j)roperly cared fci', because it is the most easily remedied hy surgical treatment. In its simplest form the laceration extends through the mucous memlmane of the vagina, the integument, and the junction or union of the bulbo-cavernosus with the transversus-periuii^i muscle, a few fibers of the levator aul anrl the fascia, elastic and areolar tissues which constitute the perineal bf)dy. When this injury is uncomplicated with laceration of the muscles of the pelvic floor elsewhere than at the median line, the separated ends of the muscles involved in the rupture still retain their union with the divided side of the perineal l)ody and with each other. This is very clearly shown by the fact that the bulbo-cavernosus, trans- versus perintei, and anterior flbers of the levator-ani muscles hold the separated sides of the perineal body and the posterior, uninjured portion of the pelvic floor upward. At the same time that the pos- terior portion of the pelvic floor is maintained at its normal eleva- tion, it is often brought forward to compensate for the loss of sup- port caused by the laceration (Fig. 65). This compensation does not occur in all cases, but usually does so unless there is damage done to the muscles other than at the median rupture alone. I have observed in some cases sufiicient drawing forward to lessen the dis- tance between the meatus nrinarius and anus very perceptibly. This is familiar to all who have studied the subject with a view to operat- ing, from the fact tliat, in order to estimate the depth of the lacera- tion, to determine how extensive the vi-s-ifying of tissue need be, it is necessary to retract the posterior portion of the pelvic floor with the finger or sound in order to press the rectum or aims backward into its place. This compensation ]>revents prolapsus of the pelvic organs for a long time, in some cases for many years, and is one rea- son why rupture of the perineal body is not always followed by pro- lapsus uteri. In this condition the vidva is not enlarged from dis- tention by the partially inverted vaginal walls, nor is the uterus necessarily displaced. Many such eases axe seen among patients who seek relief for other affections, but have no symptoms which INJURIES TO THE PELVIC FLOOR. 119 can be traced to the laceration, except occasional paiii in the scar tissue in the injured part. Case. — Mrs. H., aged forty, had had six children. During her first labor she says she was " torn," the child weighing thirteen Fig. 65. — Complete laceration of the periuEeum; anus drawn i'orwaid ; no rectoeele. pounds. Of the perineal body a part of the anal sphincter alone re- mains ; but a little way up the posterior vaginal wall a thick, strong, muscular band crosses, which tightens about the examining finger and draws the anus forward. The uterus is in place, and there is no rectoeele ; nor sagging of the pelvic floor ; nor are thei'e symptoms. (See Fig. 65.) Rupture through the sphincter ani is the most unfortunate of all injuries of the pelvic floor, owing to the incontinence which follows. The unhappy subjects of this accident are debarred from taking 120 DISEASES OF WOMEN. imicli active exercise, and usually avoid society. Strange afi it may appear, they do not all suffer from |)rolapsus of the pelvic organs; in fact, 1 think that prolapsus following this injury, to any great degree at least, is the exception. This is, no doubt, due to the fact that such patients are unable to do much walking or standing, and therefore the pelvic organs are not submitted to much downward pressure. It might be supposed that relief from this distressing con- dition would be sought before sufficient time had elai)sed for prolai> sus to occur, but this is not always the ca.se, for I have seen several such injuries of many years' standing, and yet there was very little displacement. There is indeed very little falling of the pelvic floor or of its divided sides. This is accounted for by the fact that the laceration extends through the greater portion of the pelvic tioor, leaving little remaining to settle dowTiward. In most cases the two halves of the floor are held well up in position by the muscles which are attaclied to them. When the laceration is through the sphinc- ter-ani muscle only, and does not extend upward into the anterior wall of the rectum and the posterior wall of the vagina, there is a little control of the rectum still retained. This retaining power is sometimes favored by a band of scar tis- sue, which lies between the upper fibers of the divided sjihincter, and gives a fixed point toward which the muscle can contract in an imperfect way. There is usually prolapsus of the raucous metiibrane of the rectum in cases of long standing, and the prolapsus is almost alwavs greater if the wall of the vasriua and rectum are also lacer- ated to any great extent. The second form of injury mentioned in the classification is sub- cutaneous separation of the muscles of the pelvic floor at their junc- tion in the median line, or perineal body. The mucous membrane of the vagina and the skin covering the perina?um remain normal, but tlie transversus-perinaei muscles are torn apart in the median line. The bulbo-cavernosus muscles are separated from their inser- tion at the center of the perinfcum, and possibly some of the fibers of the levator-ani muscle are also lacerated. There is, in short, a complete laceration of the deeper structures of the perinjcum, the skin and mucous membrane alone remaining uninjured. The result of this injury is falling of the pelvic floor, and usually jirulapsus of the pelvic organs. The function of the pelvic floor is destroyed as completely as in the injury first described. I beheve that this condition has frequently been mistaken for functional imperfection of the perinaeum, or relaxation, as it has been called. The fact is, that it is a well-defined anatomical lesion, INJURIES TO THE PELVIC FLOOR. 121 which can be demonstrated quite easily by passing the finger into the vagina and pressing downward and outward. In this way the absence of the muscles, fascia, and connective tissue is discovered. It is found also by this examination that all muscular resistance is lost in the parts. Again, while the index-linger is in the vagina the parts anterior to the sphincter-ani muscle can be grasped between the linger and thumb, which will show that where the perineal body should be there is only skin and posterior vaginal wall. There is still another method of examination, and, perhaps the most critical one — that is, to pass one index-finger into the vagina and the other into the rectum, when it will be found that tlie onlj- resisting mus- cular tissue felt betw^een the two fingers is the sphincter ani. These examinations by the touch are quite sufficient ; but, if fur- ther evidence is desired, it may be obtained by trying to excite con- traction of the muscles which act as a sphincter vaginae. This can be done by the interrupted electric current, or by irritating the labia. In making a vaginal examination, every one has noticed how actively the muscles of the pelvic floor contract and close the introitus vagi- nae in the normal state ; but in this injury no such contraction oc- curs, nor can it be produced by pricking the labia with a needle, or any such means used to excite reflex action. In case the levator-ani muscle remains intact, the posterior por- tion of the pelvic floor remains in its normal position, except that the end of the rectum may be displaced backward, whicb it often is, because the vagina and uterus are prolapsed. The counterpart of this lesion is often seen in cases that have been operated upon with the intention of restoring the pelvic floor or perinpeum, the operation having failed in its object. Union of the skin and mucous membrane is obtained, but the muscles are not united, and hence, although upon removing tbe sutures tbe result is pronounced to be perfect, and to the superficial observer appears to be so, the muscular function of the pelvic floor has not been restored, and the operation is, in fact, a complete failure. The third form of injury given in the classification presents tbe same lesions as have been given in describing the two preceding forms. There is a laceration in the median line down to the sphinc- ter ani, and also an overstretching of the muscles, which give rise to sagging of the whole pelvic fioor and backward displacement of tbe rectum. In some cases, in place of overstretching there is retraction of the ends of the torn muscles, so that they have no further connec- tion with the di^-ided sides of the perineal body or with the sphinc- ter ani, and hence they can no longer sustain the pelvic fioor even in 122 DISEASES OF WOMEN. ail imperfect way, as is observed iu cases of (simple laceration already described, in Avliich eoiiipensati(jii is made l)y tlie muscles drawing the posterior portion of the pelvic floor upward and forward. Evi- dence of this subcutaneous overdistention or retraction of the nius- eles and temporary i)aralysis is seen in a great many cases of partu- rition. Every obstetrician has observed the complete relaxation of the pelvic floor that so frequently follows delivery, even when there is no laceration of the integument. There is not only loss of mus- cular motion, but also loss of sensation in some cases. That this re- laxation is due in many cases to overdistention of the muscles with- out solution of continuity is probable from the fact that recovery is so rapid and complete. Still, in many cases the injury done to the muscles is sufficient to defy the natural recuperative ])Owers, and remains permanent, if not relieved by surgical treatment. In many of the cases of this kind seen in practice the muscular insufficiency is doubtless caused by overdistention produced by pro- lapsus of the pelvic organs. As soon as the pelvic organs descend so as to make continuous pressure upon the pelvic floor, the muscles (impaired by the laceration in the median line) gradually give way, and finally lose their contractile power, either temporarily or perma- nently, according to the length of time that the prolapsus has ex- isted. It follows, then, that it is only when sagging of the pelvic floor is seen before any prolapsus of the pelvic organs has taken place that we can reasonably infer that the muscles were impaired at the time that the laceration occurred, and that the injury was more ex- tensive than the mere separation at the median line. The fourth injury is laceration of the levator-ani nniscle with or without being accompanied with the injuries which have been de- scribed already. This is the most extensive injury which occurs, and is one of the most disastrous of all in its consequences ; and what gives it greater importance is the fact that it is not, so far as I know, conmionly men- tioned in our literature. I am satisfied that this injury to the pelvic floor occurs frequently, but, fortunately, recovery occurs many times unaided by any special treatment. Still, there are many cases in which the injury is permanent, and can not be relieved by any treatment known at the present time. This condition may be associated with complete laceration in the median line, but usually is not. I pre- sume that the subcutaneous laceration of the muscles saves the super- ficial structures of the perineal body. When there is no laceration in the median line the tissues between the rectum and vagina appear to be normal ; at least the distance from the anus to the posterior INJURIES TO THE PELVIC FLOOR, 12? comuiissnre of the vuii^ina is nonual, bat tliere is loss of contractile power in the parts. The whole pelvic iioor, including the rectinn, vagina, and lower part of the labia, projects downward below its normal elevation. This suggests the thought that subcutaneous lacer- ation of the transversus perinsei generally takes place also when the levator ani is injured. Fig. (>(*) shows the downward displacement resulting from the injury to the muscles. This displacement can be demonstrated upon the subject by placing one linger upon the pubes and the other on the tip of the coccyx, and observing the extent to which the pelvic Hoor projects below these two points. Again, by placing the pa- tient upon the side and flexing the thiohs at right angles with the trunk, the downward displacement becomes apparent. In the most ])ronounced cases the parts project downward almost on a line with the nates. The physical signs of this condition will be referred to again in connection with atrophy of the muscles, and the differential points will be noted. Atrophy, and the consequent paralysis from injuries during par- turition and other causes, occurs only in cases of long standing, and is, in fact, a secondary state re- sulting from laceration of the mus- cles or overdistention. It may follow any of the injuries already mentioned that have been long Fig. 66.- — Sagging of the pelvic floor. The sweep from a to b denotes the sagging portion of the pelvic floor. The bulging posterior vaginal wall (rectocele) shows white between the labia. neglected, or in which unsuccessful efforts have been made to over- come the original injury. The muscles, having been torn or sepa- rated from their liganrentous attachments during parturition, become functionally inactive, and remain so until they undergo fatty degen- eration and are Anally lost. These are usually neglected cases, but the same condition is seen when a surgical effort at restoration has been made which has resulted in union of the skin and mucous membrane without restoring the muscles. The same thing is pro- duced in another way. The pelvic floor sustains an injury, slight 124 DISEASES OF WOMEN. in itself, wliicli is perinitted to reimiin until jirolapsus of the pel- vic organs i)r()(hices overdistention of the muscles, and maintains it so long that atrophy of the muecles takes j)lace and permanent loss of the function of the pelvic floor follows. Other and rarer cases are seen in which atroi)hy of the muscles occurs as the result of long-continued overdistention. This I have seen in cases of paralysis caused by hypertrophic elongation of the cervix uteri and small tibroids in the uterus. In these cases there was no evi- dence that the floor had sustained any injury other than that pro- duced by the prolapsus. I am also personally convinced that pro- lapsus of the pelvic organs may be due to injuries of the uterine ligaments 'and upper pelvic fascia while the jielvic floor sustained no injury whatever until the prohq^sed organ caused its overdistention. Again, habitual constipation will cause ])aralysis of the muscular tissues of the rectum, and also (to some extent, if not wholly) of the levator ani, and, if this continues long enough, atropliy and jierma- nent paralysis will follov/. If to this constipation prc»lapsus of the pelvic organs is added, and they both continue for a long time, per- manent insufficiency of tlie j^elvic floor will occur from nuiscular atrophy. Finally, I presume (though I can not prove) that atrophy of the muscles occurs in very old won'ien from no other cause than senile malnutrition. In this state of the parts other anatomical le- sions occm' in nearly all cases. The fascia and elastic tissue are wanting, and the blood-vessels — notably the veins — become over- distended, giving a well-marked passive hyjjeraemia. The vast ditfer- ence in the vascularity noticed in operating in different cases is accounted for in this way. The extent of prolapsus which occurs in tliis form of muscular insufficiency differs. In the most marked case that I have seen it was so great that the anus was nearly on a line with the nates while the patient was in Sims's position. The physical appearance of this affection has been already illustrated in connection with recent lacer- ations — the fourth injury described (see Fig. 60). The informa- tion obtained by inspection is usually sufficient for a diagnosis, but still further evidence can be obtained by the touch ; this shows the lax, non-resistant state of the muscles, which, as already stated, can not be excited to contraction by irritation or the electric current. In the diagnosis of all these injuries, the all-important question is to determine whether the paralysis is due to overdistention of the muscles and is temporary only, or due to atrophy, and hence perma- nent. This can not always be settled at once and positively. If the tissues of the pelvic floor appear to the touch to be lacking muscular INJURIES TO THE PELVIC FLOOR. 125 fiber, and no muscular contraction can be induced by stimnlation, it is ])resuni})tive evidence of muscular atrophy ; and yet it may be only a temporary loss of muscular power. It is necessary, then, to sup- port the pelvic floor and let the patient rest in the recumbent posi- tion to remove all downward pressure from the parts, and, by the use of astringents and electricity, endeavor to restore the muscular function sufficiently to prove that there is still nmscular tissue pres- ent. If by such means, the muscular function is even partially re- stored, the diagnosis is completed, and the indications for further treatment are established. It is then and only then that surgical treatment may be employed with the hope of obtaining complete recovery. Should all well-directed efforts fail to give evidence that the muscles still retain their true anatomical characteristics, it is use- less to hope for success in operating. Symptomatology. — The symptoms which are developed by injuries to the pelvic floor are not sufficiently diagnostic, or else they have not yet been sufficiently studied, to make them of decided value to the diagnostician. Patients express a feeling of want of support of the pelvic organs, or, as they express it, a dragging-down feeling, and some derangement of the fmictions of the rectum and bladder, but, as these symptoms occur in all the forms of injury named, and as tliey also in like manner occur in displacement of the pelvic organs, but little reliance can be placed upon them. When the function of the levator-ani muscle is lost from injury or atrophy, there is usually much difficulty in evacuating the rectum. This is, of course, most marked when the patient is constipated, but it is noticed also when the bowels are free, though to a less extent. When there has been a laceration in the median line the scar tissue is often tender to the touch, and occasionally causes some general nervous disturbance. The sensitiveness of this scar tissue is sometimes so great as to pro- duce reflex muscular contraction when touched while the patient is anaesthetized. The admission and expulsion of air from the vagina (flatus vaginalis) is said to occur frequently in these injuries, and it is no doubt one of the most reliable symptoms of injuries of the pelvic floor, as it rarely occurs in any other condition. The last of the pathological states of this structure to be described is muscular rigidity produced by a previous inflammation, the prod- ucts of which have impaired the muscular tissue. This affection has been classed by authors under the head of rigid perineeum, vaginismus, and spasmodic muscular contraction, but it belongs to a different pathological order of things. There are cases of rigidity or spasmodic contraction of the muscles due, perhaps, to 120 DISEASES OF WOMEN. liypenesthesia, Imt tlie condition under consideration is simply a riiiid state of the muscles caused by the produftK of a former inllam- mutioii which have impaired the ela>ticity and motion of the muscles. The cases of that kind that I have seen have given a history of pel- vic inflammatii)n— in two followinf^ scarlatina, in one from an injury sustained by falling u})on the rail of a fence, and in another from a perirectal abscess. No difficulty was experienced in either case until after marriage, when it was found that coition was impossible. An ex- amination showed that the vagina Wcis rigidly closed and the nmscles of the pelvic floor could not be distended. All efforts to move them caused severe pain. In short, there was muscular anchylosis. The treatment for this affection commended in the books is to incise the pelvic floor from the vaginal orifice down to the sphincter-ani muscle, an operation entirely uncalled for and unsatisfactory in its results, as will be seen when we discuss the treatment. Causation. — The causes of these injuries are traumatic (excepting the last one described), that is, overdistention or stretching of the parts during parturition. The exceptions to tiiis have already been mentioned, viz., long-continued overdistention from prolapsus of the ]Delvic organs, extreme constipation, and malnutrition in old age. There are, no doubt, certain states which j)redis})ose to these in- juries. Phlegmatic women who have failed to take exercise sufficient to develop these muscles are liable to lacerations during parturition. In such cases the muscles of the pelvic floor are poor in quality, and rupture easily under extreme pressure. The very opposite of this ap- parently predisposes to the same accidents. In vigorous muscular women the pelvic floor is often unyielding because of the great strength of its muscles. They resist the pressure of the child as it is forced against the pelvic floor by a powerful uterus, and, seemingly, rather than relax and stretch, their union at the median line gives way ; it is in such cases that complete laceration in the first degree is most likely to occur. Again, in those in whom the pelvis is shal- low and wide in the straits, the child passes easily through the pelvic canal, when rather sudden, unrestrained pressure comes upon the parts and they are very liable to give way. In others still, either from habits of life or the position of the uterus in relation to the pelvis, the return circulation is retarded, the vessels become overdisteuded, and a deranged nutrition, \y\t\\ softening of the tissues of the pelvic floor, renders them easily torn. The immediate cause of lacerations — whcthci- subcutaneous or complete— is distention during delivery. The tissues in the median lin e give way in the great majority of cases because the greatest INJURIES TO THE PELVIC FLOOR. 127 pressure is brought to bear at that point. That the laceration ex- tends to, but not through, the sphincter-ani muscle, as a rule, is no doubt due to the strength of this muscle. In fact, it is a matter of surprise that the sphincter is ever lacerated when its position is con- sidered in rehition to the force brought to bear ujjon it. The only rational explanation of the laceration which I have been able to ob- tain from a careful clinical study of the matter is as follows : The trausvcrsus-perinfei, levator-ani, and bulbo-cavernosus muscles are so strongly attached to the sphincter-ani muscles that, during de- livery, when the head distends the pelvic floor they hold the sphinc- ter ani upward and forward. If the size of the head is out of pro- portion to the distensibility of the pelvic floor, one of two injuries must occur : either the muscles attached to the sphincter must give way and permit the sphincter to recede downward and escape injury, or else the sphincter must be torn through. This effect of the other muscles upon the sphincter ani during delivery of the child's head can be seen by the way in which the sphincter ani is drawn upward until the anus is distended an inch or two. While the fetal head was unusually distending the pelvic floor, and while the hand was placed upon the parts to " support the perinseum," I have felt, or fancied that I could feel, the muscles attached to the sphincter ani give way and permit the rectum to recede and escape injury. Regarding the causes of injuries to the levator-ani muscle, one has but to recall the phenomena of labor as related to it to under- stand how it may be freely lacerated in ordinary labor. It certainly is as freely exposed to injury as some of the other muscles which we .know are frequently lacerated subcutaneously. In delivery with forceps, the levator-ani muscle is frequently injured, I believe. While the child's head is in the grasp of the forceps and during traction, I have noticed, by passing the finger into the rectum, that the levator ani was drawn so tightly over the edges of the blades of the forceps that it appeared as if it must be torn, and I feel sure that it often is, I am the more fully convinced of the tnith of this by having carefully watched patients that I had delivered with for- ceps, and have found in some of them evidence of injury of the levator ani above its lower attachment. That evidence was obtained by finding, on subsequent vaginal examination, that the resistance of the levator muscle usually found was wanting, and also that there was prolapsus of the pelvic floor, and loss of contractility upon irri- tating the parts. Treatment. — The object in treating these injuries should be to restore the lacerated muscles by securing union of their severed 12S DISEASES OF WOMEN. fibers. In the ordinary or most commonly recognized injury, lacera- tion in tliu median line down to, but not through, the Kphincter, the iiinnediate treatment usually employed is to close the wound with sutures at once, or to cleanse the wound from blood-clots and coapt the parts, carefully bind the patient's limbs together, and trust that union may follow. The treatment by the innnediate use of the suture will be made plain by the following : Pi'imanj Operation. — The wound, if seen wlien it occurs, is tri- angular, the base running parallel to the rectum and the apex being at the posterior part of the vulva. The sides of the wound come to- gether quite easily, and only require well-adjusted sutures to keep them in position. IMuch care is necessary in using the sutures. If they are imperfectly introduced they do harm by preventing the union which often takes place without surgical aid. If one is not accus- tomed to this simple operation of closing the wound with sutures, it would be infinitely better for the patient to trust to nature than to have the surgeon employ sutures in a bungling way. The sutures should be introduced as follows: The needle, held in the groove at right angles to the forceps, should be entered in the skin exactly at the edge of the wound, and as far down as the deepest part ; it is then carried into the tissues and made to describe the arc of a circle and emerge at tlie margin of the mucous membrane of the vagina. The needle is again introduced on the opposite side and carried through as before, and brouglit out at the point in the skin opposite where it was first introduced. If this is properly done, the position of the suture in the tissue will be as represented in Fig. 67. The center lines repre- sent the sides of the wound and the dotted THemI)r^np- ^^^® shows the suture, which describes a circle, the point at which the suture is I tied and the opposite point of its cir- ' skin cumference being at the ujiper and lower angles of the wound. There are three advantages in using the suture in this way : First, the ends of the suture com- FiG. eV.-Diagratn of the sweep of - ^^^^ ^^ ^^^^ ^^ ^f ^^^^ ^^o\m^ hold the suture. ^ '^ the parts exactly together without the aid of superficial sutures ; second, the cui-ve which the suture takes deep under the tissues brings the central ]>ortions of the wound to- gether, whereas, if the suture is passed straight tlu'ough the tissues, the edges of tlie wound would curve inward, while the central parts would not meet. Fig. 08 shows the ])arts adjusted by a proper su- ture, while Fig. 69 show^s the effect of the imperfect one. Again, INJURIES TO THE PELVIC FLOOR. 129 the suture running deep into tlie tissues gives additional surety of catching the ends of the muscles so as to reunite them, which is the chief object of tlie operation. In the pri- mary operation — i. e., the introduction of su- tures immediately after the injury occurs — Peaslee's needle is easier to use than the or- dinary perineal needle. Fig. TO shows the instrument. This needle, with a handle, and an eye near the point, is armed with a thread fi«s- «?- 69.— Sutures proper- •^ 1T11 • ttV i"'^ improperly mtroauced. and passed through the tissues as already ilescribed, and the end of the suture is passed under the thread in the needle ; this is then witlidrawn and brings one end of the suture into the tissues. The operation is repeated on the other side, wliich ~n^ Fig. 70. — Peaslee's needle. completes the introduction of the suture. The only advantage of this needle is that it is easier to manage than the ordinary one It can only be used, however, in the primary operation. The silk suture properly prepared is by far the best for the immediate opera- tion. Silver wire, which at one time was the only suture which could be relied upon, has been superseded by others that are vastly superior for this purpose. It is impossible to keep the parts clean after confinement without causing pain while the ends of silver-wire sutures are projecting from the parts. The silk sutures save the patient much discomfort, and are not in the way of the means neces- sary to be used to keep the parts clean. This constitutes the whole primary treatment of injuries of the pelvic floor, as given in our text-books — a kind of management gen- erally sufficient in central lacerations, but that can have little influ- ence in restoring the other forms of injury. To secure the reunion of the muscles that have been lacerated subcutaneously, especially the levator ani, the parts should be well supported and kept at rest. If the pelvic floor is permitted to remain in its relaxed and displaced position there is but little chance of the lacei-ated muscles uniting, nor, in case they are simply overtaxed by distention, will they regain their tonicity promptly if left unaided by support. Especially is restoration likely to be prevented if the patient is permitted to as- sume the erect position too soon, and if, to increase the injurious effects of this unwise liberty, the uterus is crowded down into the 10 130 DISEASES OF WOMEN. pelvis by a compress and tires6 and bandage fastened to the aljdoniinal binder. V>y these means the severed ends of the muscular fibers are brought nearer together, so that they have a better chance to unite. An objection would natu- rally be raised to this treatment on the ground that it would obstruct the free flow of the lochia. This can be overcome bv makiiiir the compress of absorbent cotton, antiseptic gauze, or marine lint, and draining the vagina with a drainage-tube or a strip of gauze oi- lint. I believe that in this way the vagina can be drained and kei)t as clean as it can be by occasional douching. In fact, I am inclined to think that the very frequent use of vaginal injections so generally employed in this age of antisei:)tic obstetrical practice often tends to retard the restoration of injuries of the pelvic floor. It is well, also, to let the patient rest upon either side after the first twelve or twenty-four hours. This position takes off all pressure from above, and favors the upward inclination of the pelvic floor. Great care should be taken to avoid distention of the bladder and rectum. Con- stipation after coniinement is almost sure to prevent or, at least, retard recovery. By attending to these simple means nmch can be done toward preventing that incurable condition, permanent paraly- sis from atrophy. After convalescence from confinement, in case it is found that, although there is no complete loss of muscular action in any ])art of the pelvic floor, there is a muscular weakness shown by the inijiaired power of resistance to pressure, the supporting treatment, with judi- cious rest and exercise well regulated, should be kept uj) until strength is restored. The restoration of the function of the muscles, as already stated in speaking of general treatment, is the great object of all surgical operations for the relief of these injuries of the pelvic floor. It matters not how much tissue may be gathered together and united in the region of the perineal body, it will have no functional action if destitute of muscular tissue. The success of all surgical ]u-oced- ures depends upon the restoration of the muscles, elastic tissue, and fascia, and not the mere uniting of the tegumentary and areolar tissue. In this plastic operation, known as pcrincorrhaph}', or I'cstoration of the perinaeum, much surgical skill is necessary in order to succeed. This is true of all operative surgery, and yet special care is necessary in this operation, because union by first intention must be secured INJURIES TO THE PELVIC FLOOR. 131 or else the operation will fail. In many operations in surgery, if the wound does not heal by first intention, union may be secured l>y granulation and a perfect result obtained ; but in the operation under consideration, if the whole or any part fails to unite promptly, partial or complete failure is the result. This calls for the employ- ment of all known surgical means most favorable to prompt healing. On this account, then, some general considerations regarding plastic operations in gynecology will be in place before describing the methods of operating. What will follow on this subject will apply equally to all operations about the pelvic floor and pelvic organs, especially lacerations of the cervix uteri. The following may be given as the conditions necessary for the healing of the wounds in question : 1. A condition of the wound and of the general system favorable to the repair of injuries. 2. Perfect coaptation and retention of the parts to be united, and protection of the parts from extrinsic and offending agents during and after coaptation. If these conditions are all secured, success must of necessity fol- low. The management of wounds is not a matter of blind chance. The process of repair in living tissues is governed by definite laws which are always the same under identical circumstances. To ob- tain the conditions necessary to the fulfillment of these laws is often difiicult and sometimes impossible; still, the nearer we come to all the requirements the more surely will the desired ends be accom- plished. The first of these conditions, viz., good general health, may be found wanting in many ways and degrees which are too familiar to require notice, but there are some of these which may be mentioned because they are very often overlooked — preoccupation of the sys- tem by some highly taxing function, like lactation, for example, and certain deranged states of the nervous system. These certainly have an important bearing upon the healing of wounds, although little if anything is said in our works on surgery regarding them. In fact, there is good reason for believing that enfeebled states of the nerv- ous system have much to do with retarding the healing of wounds, even when the general nutrition appears to be normal. We fre- quently hear surgeons say that patients recover from injuries much more promptly when they have courage and hope without fear; but exhausted and irritable states of the nervous system retard the pro- cess of repair, although the patient may be indifferent or perfectly satisfied in regard to recovery. 132 DISEASES OK WOMEN. Regarding the imfavorable conditions of tlie tissues generally met with, the following are the most ini])ortant : Contusions. — Contusions accompanying wounds caused by par- turition.. Lacerated wounds of the pelvic organs often heal promptly I if well coaptated immediately after they occur, but no such union should be expected in case the tissues are greatly contused. AVhile this is true of the immediate treatment of wounds sustained during laboi', it is pretty definitely settled that operation wounds made dur- ing the process of involution — that is, within four or six weeks after continement — often fail to unite. From this we learn that while tissues are undergoing involution they are not in the best condition to heal ; and also that, when involution is delayed beyond the usual time, treatment should be employed to complete the process before undertaking plastic operations. Scrupulous care is also required in preparing the tissues by mak- ing clean, accurate incisions which will give smooth surfaces to the parts to be united. Old scar tissue should also be removed from all wounds where union by first intention is desired. These are rules in surgery which are well known, but they are sometimes overlooked in practice. HcmiorrTiage. — Haemorrhage in tliese operations is often a source of diflSculty and delay to the operator, but, worse than that, it is sometimes the cause of failure. In the vast majority of s^urgicai operations all that is required of the surgeon is to arrest the hremor- rhage, by any of the ordinary means, in order to secure a good re- sult ; but in the operations in question, if some kinds of styptics are used, they prevent union. Cases differ so very much in regard to haemorrhage that I have given much thought to the predisposing causes of this bleeding tendency, so marked in some patients. The hfemorrhagie diathesis in its most typical form is generally found in men, but a less marked haemorrhagic tendency is common to many women, and these are very unpleasant subjects to operate upon. During the past few years it has been my misfortune to meet with quite a number of cases in which the bleeding tendency was noticeable. The cause of this in most of them, I think, was im- paired general health, due to exhausting conditions of life rather than to any congenital imperfection of the blood itself. Another very important element I have found to be mechanical intei-ruptioi of the circulation, the pelvic organs becoming congested from re tardation of the portal circulation, induced by hepatic disordei sedentary habits, tight lacing, and so forth. The products of formei pelvic inflammations, such as pelvic cellulitis, also tend to maintain! INJURIES TO THE PELVIC FLOOR. 133 a hypersemic state of tlie pelvic organs ; this we often find long after all evidence of active iiiHaunnation lias subsided. The condition at the time also is often favorable for bleeding ; the well-defined vas- cularity which exists in conditions such as imperfect involution in- sures hirmorrhage in all operations undertaken during such unfavor- able states. The possible haemorrhage from such causes can be avoided by the proper selection and preparation of cases before oper- ating. The rule which should be followed in this matter is to secure the best possible state of the general health of the patient, and to reduce all hyperremic states of the pelvic organs as far as possible. This is generally possible to a great extent, because the object of plastic operations is to restore the organs to their original form and stract- ure, differing in this regard from many other operations in surgery which have for their object the removal of diseased parts. In carrying oat this plan of treatment, however, there is one difficulty encountered in practice ; when patients are ill and suffer- ing they will gladly accept any operation which promises them relief, but, when they are free from pain and have gained in health, they hesitate about undergoing any surgical treatment which is designed to keep them from suffering in the future. This, however, does not prevent the surgeon from advising that which is best. There are patients — fortunately very few — who have the hsemorrhagic diathesis sufficiently marked to debar them from operations, and it is doubtful if any preparatory treatment will change this constitutional pecul- iarit3^ Such subjects should be let alone ; to operate in these cases is dangerous, and almost always ends in failure. I have had three such cases in the past five years; two of them were operated upon before discovering their peculiarity, the result being depletion of the patients without any benefit from the operation, and the devel- opment of extreme caution on the part of the operator in selecting cases in future. The third case was diagnosticated earlier, and I declined to operate. The management of bleeding vessels in these operation wounds is of great importance. All haemorrhage should be arrested before bringing the parts together, because a slight oozing, which would do no harm in a wound to be treated by open dressing, may jDrevent union in wounds in which drainage should not be employed, or, at least, should not necessarily be required. This often requires an amount of time which the surgeon reluctantly bestows, but success in treating this class of wounds depends largely upon attention to this matter. Still more, the means used to arrest hiemorrhage should 134 DISEASES OF WOMEN. be sncb tis will not interfere with the process of healing. Hitherto the means ein])l()VLd have been ligation or torsion of the large vessels, and for minor bleeding the use of ice or cold water. More recent experience lias pointed out objections to these means. Chilling the tissues by cold is injurious, it is said, and no doulit the statement is true. It has, fortunately, been found that hot water is more efficient in controlling hsemorrhage, and its effects upon the tissues are not unfavorable — hence its use as a styj)tic in these operation wounds is strongly commended. Torsion is objectionable, because it is less certain to control bleeding than the hgature, and quite as liable to give rise to suppuration. In view of this fact, it may be said without doubt that the antiseptic ligature is the best means of controlling the vessels in these wounds. Regarding the material to be used as a ligature, it may be said that that which can be inclosed in the wound without giving subsequent trouble is the thing required. The prop- erly-prepared catgut ligature fulfills the indications. Some recent experience indicates that the Japanese ligature, made of whale-sinew, is the best, owing to its being absorbed with gi-eat facility. Occa- sionally, in deep lacerations, a small artery on each side may require to be ligated ; the chief arterial bleeding, however, comes from the upper portion, the small vessels coming apparently from above down- ward in the areolar tissue, between the rectum and vagina. These sometimes bleed quite freely, and they are not controlled by tighten- ing the sutures, which arrest the haemorrhage at points lower down. Such vessels I control by passing a needle through the vaginal mu- cous membrane above the denuded surfaces, and thus carry a ligature under the bleeding vessels, tying it over the free surface, chec;kiug the bleeding on the principle of acupressure. The sutures can b^. left in position until tlie perinreum has completely healed ; they can then be removed with the aid of the speculum. Occasionally it be- comes necessary to ligate some of these vessels which bleed persist- ently and can not be controlled in the way I have previously de- scribed ; it is then well to ligate them with a line catgut ligature, the ends being cut off short and inclosed in the wound. In spite, however, of all precautions, secondary luiMnorrhage will occasionally occur after this operation. I have met with four such cases in my j^ractice ; in one of them it occurred on the seventh day after the operation. In all of them the bleeding took place from the upper or vaginal portion of the wound, the blood flowing into and widely di-stending the vagina before appearing externally. In my first case I was obliged to remove the sutures, empty the vagina of blood-clots, and ligate the bleeding vessels. This resulted INJURIES TO THE PELVIC FLOOR. 135 fii spoiling my operation, for, although I reintroduced tlie sutures, union did not take place. This haemorrhage occurred on the sec- ond day. In my three subsequent eases I secured much better results. In- troducing a Sinjs's specuhnn on the (interior side of the vagina, I removed the clots and blood by sponging, and then, throwing light into the vagina by means of a concave reflector, I was able to see that the blood welled up from the upper portion of the wound. In place of i)ulling the edges of the wound apart and searching for the bleeding vessels, I passed a curved needle and ligature down and around the ])lace where the bleeding came from, and was al)le, by tightening \nj ligature moderately, to control the bleeding entirely. These cases subsequently did well, and the result of the operation was good. Sutu/vs. — The coaptation of the tissues by means of sutures re- quires more than a passing notice. The success which J. Marion-Sims obtained with the silver-wire suture led at once to its general use in gynecological operations. There is, however, good reason for believing that the results obtained by that great surgeon depended as much upon his skill in using sut- ures as upon the material which he used. To-day we know that it matters little whether silver-wire or pre- pared silk sutures are used, provided they are properly introduced. The silk selected should be braided, and not the twisted variety, for the reason that the braided silk retains wax much better, and does not unravel on being handled. The wax in the twisted silk breaks and separates from the silk, and the silk thereby becomes porous and will absorb blood-serum which readily decomposes. The reason why surgeons formerly failed in the operation for vesico-vaginal flstula, when they used silk, was because the organic matter, ab- sorbed by the unprepared silk, decomposed and caused septic inflam- mation. The braided silk, properly saturated with wax, overcomes this completely. The parts to be united should be brought together and held there without any straining upon the sutures. It is equally important to introduce the sutures so that they will prevent the in- curving of the undenuded edges of the parts to be united, and, finally, a sufficient number of sutures should be employed to secure uniform retaining pressure at all parts of the wound. These are facts which every one is supposed to know before en- gaging in surgery, but in practice a large number of failures are seen because of neglect in regard to them. The management of these wounds during the healing process 13G DISEASES ur WUMLN. dilfers somewhat from the modern treatment of womids in gen- eral. Dressings. — The antiseptic dressings which surgeons use in some form or other are difficult of application in the ojjerations for restor- ing the cervix uteri and perina*um. So fully is this the case that some of our highest authorities on gynecology make no pretensions to using antiseptic treatment in such wounds, unless frequent bath- ing of the parts with water and carbolic acid may be called such. No doubt some of our best operators get good results with this kind of after-treatment, but it is more than probable that still better re- sults can be obtained by treatment more in accordance witli the rules of antiseptic surgery. Viewed in the light of modern investigation, it appears that the frequent douching of wounds with carbolized water is a practice at least ten years behind the surgery of to-day. In treating wounds of the perina;nm there are many perplexing difficulties in the way of obtaining a proper antiseptic dressing. Here, also, the vaginal douche has been freely used, for the purpose, it is said, of remo^dng vaginal secretions which might irritate the wound and prevent its healing. Such treatment is generally un- necessary, if not injurious. In all operations for repairing old injuries of the perinteum it is better to first cure all uterine and vaginal dis- eases which give rise to abnormal discharges. That is the only sure way of protecting the operation wound from that soui'ce of disturb- ance. This, of course, can not be accomplished in the treatment of lacerations immediately after confinement. Then it becomes a very- important question how to protect the perineal wound from the lochia. Various means have been suggested for this pui-j)Ose, such as coating the vaginal surface of the wound with collodion, placing carbolized lint or borated cotton upon the inner portion of the wound, and, the most common of all, the frequent use of vaginal injections. It is hardly possible to say, at the present time, which is best. The collodion has not l)een tried often enough to speak positively rcganl- ing it. In using the lint or cotton tliere is danger of separating the edges of the wound, the very thing of all others to be avoided. Perhaps the best treatment, after carefully cleansing the parts and bringing them accurately together, is to let the wound alone for about two days, trusting that during this time it may become sufficiently protected, by a coating of fresh lymph, to resist the subsequent dis- charges. After the lochia l)egin to decompose, the frequent use oi the vaginal douche is advisable, and should be continued until the union is completed. In the secondary operation for restonug the perinteum, the vag- INJUEIES TO THE PELVIC FLOOR. 137 iiijil j)()rtion of the wound may generally be left alone. It is pro- tected from the air l)y the anterior vaginal wall, which makes a suit- able dressing provided the uterus and vagina are in a normal condition, as thev should be, before the operation is done. If suppuration takes i)lace and ])iis is discharged into the vagina, it should be disposed of l)v injections. The outer portion of the wound may also be left without dressing, but it is better to apply lint or cotton upon each side of the sutures ; if silver wire is used, or if silk is employed, the lint can be placed over the wound and retained in place by keeping the limbs together. The advantage of this kind of dressing is that it absorbs any discharge that there may be. Perhaps the most important point of all in the management of such cases is to keep from dropping urine upon the wound. The most scrupulous care should be taken to close the end of the catheter in withdrawing it. If this is neglected, a few di'ops of urine will escape from the eye of the instrument, and, falling upon the wound, will cause trouble. The nurse should be carefully instructed to use the catheter in this way, and, to make doubly sure of cleanliness, a little absor])eut cotton should be placed between the meatus urinarius and the wound every time the instrument is used. Notwithstanding all this care, suppuration "will sometimes occur, and then the question arises how to manage this complication. If the suppuration is limited to the track of one suture, that one may be removed and the remaining ones tnisted to keep the parts to- gether. It sometimes happens that a cellulitis which begins in the region of the sutures extends outward and ends in suppuration. This should be treated by a free incision and drainage, which may save the operation. On the other hand, if suppuration takes place between tlie surfaces to be united, there is very little hope of obtain- ing union at all by any kind of treatment. A partial or even com- ])]ete success may be obtained in such cases if the suppurative process is detected early, and drainage from the lower edge of the wound is established. This can be effected by loosening one or more of the sutures, and then introducing carbolized silk thread or catgut to secure the free escape of the inflammatory products. DESCRIPTION OF THE OPERATION FOR RUPTURE IN THE FIRST DEGREE. Yelpeau, of Paris, was the surgeon who first operated for the restoration of the pcriuieum. The first part of the operation consists in denuding the surfaces 138 DISEASES OF WOMEN. tf> be united. The extent to which this should he carried depends U])<»n the character of the injury. If tliere is no i)r()la])sus of the pelvic tioor or of the posterior vaginal wall (see Fig. int ha.s been introduced, the supply is cut off and the evacuation tube opened. If the contents of the rectum do not flow out, the bulb is pressed and relaxed after the manner of using a Davidson's syringe. This process is repeated until the bowels are freely evacuated. The bow- els were moved in this way until the twelfth day (the sutures were removed on the ninth) ; after that the bowels were moved daily by the senna and salts. At the end of three weeks the restoration of the muscle was as perfect as could be, and the patient was dismissed with complete retaining power. This case illustrates tlie danger there is of the ends of the sphinc- ter muscle being torn apart when the bowels are moved. A skilled nurse, well used to the management of such cases, can do much to avoid this unfortunate accident, and yet when all care is exercised it will often happen. In order to avoid this, several ways have been tried. Keeping the bowels contined for ten or twelve days was the fashion for a long time. More recently some operators have kept the bow^els free by laxatives that rendered the contents fluid and pro- cured an evacuation every day after the second day from the opera- tion. I have tried both, and now prefer the reflux-catheter evacuator when a nurse can be obtained who knows how to use it. "When this is net possible, I prefer to keep the contents of the bowels solu- ble and to move them every second day — beginning on the third day after the oj^eration. When union is obtained, excepting of the sphincter muscle, as in the case just related, and a second operation is performed, some op- erators prefer to begin de novo^ dividing the united ])oi'tion and then proceeding as in the primary operation. I much jirefer to keej> all that has been gained and to restore the sphincter in the way already described. I was flrst induced to adopt this method in a case that had been twice operated upon before it came to me with the result of restoring all but the sphincter. So much tissue had been removed that I dared not risk a possible complete failure, hence I attempted to restore the sphincter in the way just described, and with success. My second case of this kind was one in which complete laceration occurred during labor ; primary union, without sutures, of the peri- neal body took place, but not of the sphincter. Since then I have repeatedly operated successfully in such cases of paitial failure in my own practice and that of others, INJURIES TO THE PELVIC FLOOR. 155 OPERATION FOR RESTORATION OF THE PELVIC FLOOR IN SUBCUTANEOUS LACERATION BETWEEN THE VAGINA AND RECTUM. This operation is the same as when the laceration involv^es the skin and mucous membrane also, excepting that the whole of the skin and mucous membrane occupying the position of the perineal body is removed. Before beginning the denudation the tissues in front of the sphincter should be seized between the thnmb and finger. This will indicate the extent to which they should be removed^ "While the parts are thus held in the finger and thumb, or with a tissue forceps, the whole mass should be removed with one sweep of the curved scissors. After this is done, if there is still some loose tissue lying over the muscular structures below and on either side, it should be removed. The sutures are introduced as in the ordinary operation, special care being taken to pass the sutures deep into the muscular tissues, and to use plenty of them. At the present time I see accounts in the journals of restoring the perinseum with one su- ture. I have seen some of these so-called restorations, and found the results utterly useless, A Typical Case of Subcutaneous Laceration, belonging to the Sec- ond Class described in the Classification. — This patient was the wife of a physician ; 1 give the history as I obtained it from her hu,s- band. The patient was thirty-three years of age, the mother of two chil- dren ; the first born on March 29, 1880, and lived eleven hours; sec- ond born September 9, 1881, now living; and one miscarriage since the operation in February, 1884. The first labor was tedious, lasting from Friday at S a. m. till Monday at 2 p. m. — seventy-eight hours, but accompanied with no after ill-effects of any note. In the second labor, though it was normal in duration, from its inception until the completion of the first stage it was observed that the presenting head was very low in tlie pelvis, resting upon the posterior wall of the vagina, while the cervix was directed toward the hollow of the sacrum, and was un- evenly dilated, the anterior lip being much thicker than the posteri- or. As the head descended toward the vulva the recto- vaginal tis- sues were pushed before it and extended beyond the vulva on the periucieum. The anterior segment of the cervix, descending in front of the head and tightly grasping it, had to be pushed upward in the interval between tlie expulsive pains and held until complete exten- sion occurred and the delivery was com])leted. Nothing of note 156 DISEASES OF WOMEN. transpired during the Ijing-in period of sixteen days, excepting great difficulty in moving the bowels. Tpon taking an upriglit position, it was found that the protni.sion or prohii)se wliich was noticed at tlie time of deHvery was still pres- ent, and complaint was made of the feeling that " everything was falling out '' ; from this time onward defecation could (>n]\ be accom- plished by pushing the protruding mass well back into the vagina. Her subsequent health was bad ; rapid loss of flesh and strength fol- lowed ; nervous prostration, impaired digestion, and loss of appetite su- pervened, totally incapacitating her for her usual duties. ( )ue month after confinement she had a very painful attack of mastitis, which, however, did not go on to the stage of suppuration, but further pros- trated her, accompanied as it was by aphtlue, ulceration of the cornea, facial neuralgia, etc. These sequelae, together with over-lactation, car- ried on for fourteen months, naturally first retarded and then pre- vented the proper involution of the pelvic organs ; and the prolapse of the recto-vaginal wall, dragging do"wn the heavy utenis, caused constant distress, pain, and suffering, both physical and mental. Constipation of the most intractalde kind now existed, and the bowels could only be evacuated by liquefying their contents with purgatives aided by enemas. Examination made twelve months after confinement revealed a slight prolapse of the anterior vaginal wall, bladder, and urethra, and extensive prolapse of the posterior wall, which caused the rectum to be drawn forward through the ostium, forming a sacculus. The uterus was three and one fourth inches in depth and retroverted. The mucous membrane of the vaccina and the inteo:ument of the pelvic floor presented no appearance of having been ru]itured at any time, but there was not a sign of any muscle or fascia in the center of the space between the vagina and rectum. J/«y 10, 1883. — (The operation was performed in the way de- scribed above. The following is added to the doctor's report by the author.) After rallying from the anaesthetic, great pain at the seat of the upper stitch was comi)lained of, necessitating the free use of opium to allay it. For eight days the urine was drawn by catheter, the patient being unable to void it at any time when lying in the dorsal position. Twenty-four hours after tiie ojieration the Ix^wels were readily moved by a single enema, and for several days acted without resort to any provocative. Two of the sutures were removed on the eighth day and the others on the tenth day. Perfect union existed throughout, and three weeks fi-om the day of the operation the jia- tient was up and around the room. INJURIES TO THE PELVIC FLOOR. 157 From this time on tue im])rovemc'ut in every particular has been rapid and uuinterrnpted, with an entire disap])earanee of tlie pro- lapse, though the uterus remains considerably retrovei-ted, which position it had occupied for years before the marriage of the patient. At this time, fourteen months after the operation, there has been no return of the former ti'ouble, though she performs all her domestic duties and can exercise without fatigue or distress. At the time of making this report she weighs over twenty pounds heavier than she (lid one year ago, and to every appearance is in perfect health. Median Laceration down to the Sphincter Ani, complicated with Temporary Relaxation of all the Muscles of the Pelvic Floor, and Pro- lapsus of the Recto-Vaginal Walls. — The patient was twenty -seven years old, well developed, and in good general health. She had been married four years. She had had two children, the first sixteen months old and the second five months. Her second labor was tedious and difiicult ; the cause unknown. Two weeks after her last confinement she entered actively upon her household duties, and very soon afterward began to suffer from pelvic tenesmus, which was much aggravated by the erect position. Being of an active dispo- sition, she persisted in attending to her duties until her discomfort became so great that she was obliged to seek relief. "When first ex- amined, she said that in standing and walking she was tormented with a feeling of dragging downward in the pelvis, and lately had felt "something protmding from the vagina while in the erect po- sition." Her bowels had usually been regular, but lately she noticed that they moved with difliculty, as if there was some loss of expelling power, and when voluntary efforts were made to evacuate the recturu. the recto- vaginal walls protruded. All these symptoms were much reKeved upon lying down. She weaned her child when it was three months old, because she had not much milk, and her friends made her believe that her suffering was due to nursing. At the fourth month she menstmated, but, not being any better, she sought advice. The laceration Avas found to be as ah'eady stated. The transversus-perinsei muscles were still attached to the sides of the laceration, and by drawing the parts out- ward the vagina was distended laterally as well as antero-posteriorly. The distance from the vestibule to the anus was increased by the downward and backward displacement of the posterior portion of the pelvic floor. The posterior rectal wall and the anterior vaginal wall were found lying upon the sphincter-ani muscle, and when the patient coughed or strained they protruded a little beyond the liue of the anus. There was also commencing prolapsus of the base 15S DISEASES OF WOMEN. of the bladder and anterior vaginal wall. By passing a large sound into the rectum it was found that the recto-vaginal walls, imme- diately above the sphincter-ani muscle, were very tliin, indicating that the muscular coat of the vagina had been torn hjngitudinally, or else that its attachment to the muscles of the pelvic floor had been severed ; perhaps both injuries had occurred. The patient was prepared for the operation in the same way as in the case just related. The denudation was made in the usual man- ner, but was carried upward on each side nearly half an inch above the outline of the scar of the original laceration and about three quarters of an inch broad from without inward. The nuicous mem- brane was also removed upon the vaginal wall up to the point where it came in contact with the anterior vaginal wall ; that was made the apex or most prominent point of the \avifying. This was much be- yond the limits of the laceration. The object in vivifying the tis- sues so high up on either side was to secure the ends of the bulbo- cavernosus muscle in the wound in order to reunite them, and for a like reason the vivifying was made high up on the vaginal wall in the hope of uniting its muscular coat to the muscles of the pelvic floor. When the parts to be united were vivified it was found that all that remained of the vaginal wall at that point had been removed, leaving nothing but the rectal wall. This was not owing to liaving removed too mucli tissue, but because ths muscular coat of the vagina had been destroyed by the original injuiy. There was free haemorrhage, especially from the veins in the deep portion of the wound, but the sutures controlled it. The first suture was passed around wholly within the tissues, but the next ones were passed deep in on one side, then out and across in front of the rectum, and finally througli the other side, the object being to bring the sides of the wound to- gether in front of the rectum. The fifth and sixth sutures were passed through each side and through the middle coat of the vagina, and the seventh through the sides only. After tying the sutures and placing marine lint over the wound, an abdominal bandage was applied, and a narrow perineal bandage attached to it and fastened rather firmly. When the patient recov- ered from the ether she had vomiting, which lasted into tlie night ; she also had sharp pain, which, toward the moraing of the follo^nng day, was accompanied with severe rectal tenesmus. This prevented lier from sleeping, and made her quite weary. The pain and tenes- mus were caused, I am sure, by the fact that one or more of the sutures was passed through a portion of the rectal wall. I took pains to avoid the rectum, but must have failed to do so altogether. INJURIES TO TIIK PELVIC FLOOR. 159 A suppository of niorph. Kiilpli. and ext. belladonnae, each a fifth of a grain, was nsed night and morning to relieve the pain, M^hich did not subside wholly until tlie m-orning of the fourtli day. She took very little nonrishuicnt— nothing solid until the fifth day. On the evening of the fonrth day she had a dose of pnlv. glycyrrhizse comp., and at noon on the fifth day an enema ; this moved the how- els, and from that time they were kept regular by the same means. After the second day the perineal bandage was removed altogether and the lint-dressing continued. On the fifth day after the bowels moved there was a slight discharge from the vagina containing traces of pus. She was then ordered a vaginal injection of sid- phate of zinc, sixty grains to a quart of warm water, given with the fountain syringe at low pressure, so as not to distend the vagina too much. This was continued once a day until the eighth day, and after that twice a day for another week. She was unable to urinate, and hence the catheter had to be used until the tenth day after the operation. This gave rise to a slight cystitis ; it was treated by a teaspoonful of sweet spirits of niter in a small glass of flaxseed-tea every five hours, continued for three days. The sutures were re- moved on the tenth day, and union appeared to be complete. She was not permitted to leave the bed until the eighteenth day. The vaginal douche of zinc solution was continued up to the next men- strual period, and then discontinued. After the flow ceased, the douching was resumed, and continued for two weeks longer. She was examined two months after the operation, and the re- sult was found to be perfectly good. Laceration of the Levator-ani Muscle and Laceration in the First Degree in the Median Line of the Pelvic Floor. — The patient was thirty-four years old, and had three children — the eldest ten and the youngest three years of age. The la^t child was delivered with for- ceps, and she dates her trouble from that time. She gave the symp- toms of displacement of the pelvic organs in a marked degree. Standing and walking caused great distress. She was constipated, and had great difficulty in evacuating the bowels. She felt that the rectum had lost its expelling power, and, when she made voluntary efforts during defecation, the vaginal walls protruded. The laceration in the median line was not more than half-way down to the sphincter-ani muscle, but the parts were relaxed, and both vaginal walls prolapsed. The uterus was also retroverted and low down. There was complete separation of the transversus-peri- niei muscle, and the bulbo-cavernosus muscle was either lacerated or else overstretched, so that it was functionally imperfect. The IGO DISEASES OF WOMEN. posterior half of the pelvic Hoor was displaced downwani, and the levator-ani niuscle did not contract on beint^ stimulated. The touch also showed that the levator had ai)])arently become atrophied. Rest in the recumbent position for two weeks, and support of the pelvic floor and uterus by a tampon in the vagina and a )>erineal bandage, did not restore the tonicity of the pelvic floor sufficiently to encour- age a continuation of that treatment. It was now evident that the levator ani could not be restored. I then decided to operate with the hope of restoring the bulbo-caveruosus and trans versus- perinaei muscles and indirectly uniting them to the sphincter ani, to com- pensate, as far as possible, for the loss of the levator. The operation was the same as that performed for subcutaneous laceration in the median line, excepting tliat all the tissues were re- moved down to the sphincter ani, and the denudation was carried high up in the posterior vaginal walls and on each side. Care was taken to support the pelvic floor during the healing process, and the nurse protected the parts with counter-pressure when the bowels moved. Good union was obtained, and at the end of a month it was e^ddent that the muscles had been restored, excepting the levator ani. The loss of this muscle was, to a considerable extent, compen- sated for by the restoration of the other muscles, but there was still sagging of the posterior part of the pelvic floor. The patient was not permitted to walk or stand much for a month, and the retro- verted uterus was kept in place with a pessary. She was greatly re- lieved, but, at the end of a year, she was still unable to take her full share of active exercise without supporting the ])arts with a perineal bandage. With the aid of this support her usefulness was nearly restored, but she was not cured completely. Atrophy and Permanent Paralysis of the Muscles of the Pelvic Floor. — Tlie patient was forty-three years old when first treated ; she had borne two children, the youngest being fifteen years old, and had had a large number of miscarriages. Her first labor was tedious and instrumental, but she made a fair recovery. When first seen there was a general sagging of the pelvic floor, great distention of the -snilva, rectocele and cystocele, and prolapsus of the uterus. There had been a very slight median laceration of the skin and rau- cous membrane, and evidently complete subcutaneous laceration of the muscles at the median line. At that time, fourteen years ago, I did not understand the nature of such cases, hence I followed the authorities and treated her in the usual way. She was placed in bed and the pelvic organs kept in position, and, when the parts had ap- parently improved in nutrition sufficiently to give pros})ects of heal- INJURIES TO THE PELVIC FLOOR. 161 \n(r, the usual operati(.)n was pert'onned. The result was ajipareutly ali that could be desired when the sutures were removed. So far as the shape and quantity of tissue was concerned, the perineal body was restored, but it proved to be functionally useless. As soon as the patient returned to her usual liabits of life the vaginal walls and uterus began to descend and put the central portion of the floor upon the stretch, which caused pain in the scar tissue, so that she suifered more than before the operation. The perineal body became thinned by distention until it was only a band not more than a quar- ter of an inch thick, stretching across from one side of the distended vulva to the other. Traction upon this band, of scar tissue mostly, caused by the protruding vaginal walls, gave such acute pain upon standing or walking that it was necessary to incise the parts. It is needless to say that she was not improved by the treatment. She passed from under my observation, but I learned that about a year afterward she was again operated upon by another surgeon with no better results. Nearly live years after my treatment she was found among the incurables. Rigidity of the Muscles of the Pelvic Floor from Inflammatory Sclerosis. — The patient was a delicate blonde, twenty-five years old. She had measles at twelve years of age, and at that time had some inflammation in the region of the pelvic floor which terminated in a discharge of pus from the vagina. Ever since then she has had leucorrhoea. At puberty the menses appeared, and have continued normal. She was married six months before I first saw her. Coitus was found to be impossible, and all efforts to accomplish it caused her great pain. An examination revealed the fact that she had catarrh of the cervix and a vaginitis such as occm's in the strumous diathesis. The muscles of the pelvic floor were rigid and tender to the touch. It was presumed that, when the inflammatory disease of the cervix and vagina was relieved, she might be capable of fulfilling her social functions, but such was not the case. Nitrous-oxide gas was used to produce anaesthesia, and, with a Sims's speculum, the vulva was distended sutiiciently to temporarily paralyze the muscles. Seine laceration of the mucous membrane at the vulva also occurred, but when this healed the rigidity and tenderness of the pelvic floor were sufiiciently relieved to permit the sexual function. About two months afterward the tenderness and rigidity of the muscles returned to a slight extent, but were promptly and permanently relieved by a repetition of the forcible distention with the speculum. Several years have passed since this treatment was employed, but there has been no return of the trouble. 12 CHAPTER YIII. FISTULA IN ANO AND COCCYODVNIA. FISTULA IN ANO. Fistula in ano in women differs in no wise from the same affec- tion in men, so far as its pathology, symptoms, and physical signs are concerned ; and, as these are fully described in treatises on surgery, I shall treat of them here only incidentally. But the treatment of tistula in women has some important peculiarities connected with it, and I propose, therefore, in this chapter to deal with the subject of treat- ment alone, giving special attention to those points of difference as I have observed them in the two sexes. Having had several very unsatisfactory results in treating fistula in ano according to the usual methods of surgery, I determined some years ago to seek other means better adapted to the relief of that affection of the rectum. The history of my own failures, and those which I have seen after treatment by other surgeons, may be the best introduction to what I have to say on this subject. ]\Iy fii*st case, treated in hospital, was a dissipated woman, who did nut know her age, but appeared to be about sixty. She had a very severe purulent vaginitis, presumed to be a neglected gonorrha'a, and also a fistulous opening extending from the side of the perinanim, about three quarters of an inch from the mesial line, into the rectum above the sphincter muscle. AVhen the vaginitis was relieved, I treated the fistula by laying it open in the usual way and placing some lint in the wound so as to make it heal by granulation from the bottom ; in this I was disappointed. The divided surfaces slowly healed over, but did not unite by intervening granulations or by new tissue. The result was that the divided ends of the sphincter muscle were never united, and the patient lost the retaining power of her rectum. During the healing process applications were made to the parts, in the hope of exciting proliferations to fill in the space, but without avail. The patient, a disgusting creature to begin with, became much worse after the operation. FISTULA IN ANO AND COOOYODYNIA. 163 While I was thinking of some way to restore Lcr sphincter, she was granted leave of absence from the hospital one afternoon, and, promjitly getting drunk, was arrested and sent to jail next morning by tlie police justice, who remembered her of old. What her sul> sequent history was I do not know, but I do know that I felt relieved when I heard of the disposition made of her by the judge. The next case of fistula occurred in private practice ; it was that of a young lady who broke down from over-taxation and dysmenor- rhoaa. She had a pelvic abscess and finally a fistula, which I was called upon to treat after her physician had partially restored her health. The external opening of the fistula was situated in the an- terior and lateral portion of the perinseum. Owing to my experience with my hospital patient I was unmlling to opei'ate in the same way, but gladly decided to employ the elastic ligature, strongly rec- ommended at that time in the treatment of fistula. Accordingly, I passed the ligature through the canal, and, bringing the end out through the anus, tied it rather tightly. Considerable pain, which caused my patient great suffering, followed, and lighted up many of the old nervous symptoms from which she had just recovered. The ligature cut its way outward rather too rapidly, perhaps, and in six days all the tissues were divided except a very small portion of the skin, which I snipped with scissors. The parts healed over, but the ends of the sphincter muscle did not unite. In fact, the result was about the same as in my hospital case. For a long time the retain- ing power of the rectum was completely lost. Two years after the operation I examined her, and found that the contraction of the scar tissue had brought the ends of the muscle nearer together, but still the function of the sphincter was imperfect. The patient was un- able to retain fluid faeces or gas, although when slightly constipated she experienced very little trouble. Two other cases have come under my observation, in which the conditions presented were very much like those described in my own cases. The first one was a lady, thirty-two years of age, married for ten years, and sterile. For three years she had suffered from a painful growth at the meatus urinarius ; this gave rise to so great tenderness as to prevent coitus and to cause distress during micturition. The tumor was removed and the parts healed well after the operation, but still she had symptoms of vaginismus which compelled her to return for further treatment. A careful examination revealed the following condition : The perinaeum was shorter than normal, and was drawn upward by the action of the sphincter-vagin-ae muscle lOi DISEASES OF WOMEN. until it nearly closed the introitus va<^iniB. The rectum appeared tn be also drawn forward, bo that the distance from tliu po.steriur wall of the rectum to the meatus uriuarius wa.s altogether shorter than is usually found. A scar was formed on the right margin of the anus. The function of the sphincter ani was imj)aired, U})on inquiry, 1 learned that seven years before she had been operated on for listula. and had never since had complete control of the rectum. The other case referred to so closely resembled in history those just given that it need not be related in full. The only point of diHerence was that this patient sought advice regarding her want of control of the rectum. It will be observed that in all four of these cases the fistuloe were situated either upon the anterior c»r lateral margins of the anus. A question here arises, whether the operation for listula situated more toward the ]iosterior margin of the rectum would terminate iu the same unfavorable way. This 1 can not an- swer, as I have never seen a case ; I can not, however, see an}- reasoQ why it should not do so. I am not disposed to believe that the re- sults obtained in the operation for tistula in ano are always so unfort- unate as in the cases recorded here. If that had proved to be the case, the attention of surgeons would have been given to the subject long ago. That the power of the s})hiueter-ani muscle is lost in a large number of cases aftei" the operation is, I believe, a fact. I might go further than this and say that, in all cases in which the listula is lo- cated completely outside of the muscle, and it is therefore necessary to divide the sphincter in operating, there is great danger that it will not be fully restored. The divided muscle retracts, and the space between its ends is filled in very slowly with new tissue; as a result, there is usually a large amount of scar tissue necessary to connect the two ends. This must impair its functions, if it does not entirely destroy it. In a healthy subject in whom the termination of the fist\da does not extend far outward, and the induration of the tissues around the canal is not extensive, the healing process may go on ra})idly, thus coimecting the ends of the muscle by means of intervening new tissue. Under such circumstances, the function of the muscle may l)e re- tained ; on the other hand, if the fistula extends from high up in the rectum to a point some distance outside of the nmscle, the operation is almost sure to be a failure. Of course, the greater the amount of tissue between the rectum and the fistula, the farther will the ends of the muscle be separated by retraction, and the longer will the parts be in healing. In such cases the fimction of the sphincter is FISTULA IN ANO AND COCCYODYNIA. 165 very liable to be impaired. When the fistula is located beneath the mucous menibraue only, then a j)erfect result can always be obtained. Mr. John Gray ("Lancet," December 11, 1S80) states that operative treatment should be deferred until the walls of the abscess, as well as the consequent fistulous tract, have assumed a condition of health and a disposition to take on a healing process. This is certainly a good rale in surgery, because it secures, as far as possible, the con- dition necessary to prevent fecal incontinence. In order to avoid such unfavorable results, it was evidently necessary to operate with- out dividing the sphincter muscle, or, if that were impracticable, to secure union of the divided ends of the muscle with the least possi- ble quantity of intervening new tissue. In the hope of curing the fistula without dividing the sphincter, the following method was adopted : An incision was made through the skin and lower part of the sinus large enough to admit two lin- gers below and one at the upper end of the wound. The edges of the wound were held apart with retractors, and the opening in the rectum was found and brought into view by passing the linger into the rectum and everting the rectal wall through the wound. The edges of the opening in the rectal wall were then pared with the scissors, and two or more catgut sutures were introduced and tied. The external edges of the wound were kept apart by a pledget of carbolized lint, which was changed every day until the wound healed. The idea was to first convert a complete fistula into a blind external one, and then finish the cure by compelling the external sinus to heal from below outward. To prevent any strain upon the sutures by distention of the rectum, I paralyzed the sphincter by overdistention, and kept the bowels free by saline laxatives. Of two cases treated in this way one was a success and the other only partially so, as the opening into the rectum closed, but a blind external fistula re- mained. Regarding this method of treating fi^stula, I can only say that the danger of losing the sphincter muscle is avoided, which is very im- portant, hut there are objections to it. The operation is dilficult to perform — at least the closing of the opening in the rectum with sut- ures is not easy — and, then, my impression is that it will fail to cure some cases. AVhile thinking of some other method of treatment more satis- factory than that given above, I noticed a suggestion in the " Chicago Medical Review," by Dr. Dudley, to lay open the Ustula, trim oH the indurated tissues along its track, and treat as a lacerated perinfeum, with sutures. It occurred to me that this method was deserving of 10)6 DISEASES OF WOMEX. II trial, and I detorniined to ])iit it to the test of practice as soon as Ii could get an opportunity. It was, of course, impossible to tell what the results would be, but I thought that it promised as much as the meth«»ds which I had used. Such an oj)portunity presented itself to me, and the result will be seen in the followinf!; history: Fistula in Ano successfully treated by the New Method. — The ]xi- tient was a married lady, wIkj had antetlexion of the uterus, which caused sterility. On two occasions she had dysentery, which left a tender condition of the rectum and hfumorrhoids. While under treatment for the flexion of the uterus, she had an abscess on the right side of the anus, which terminated in the formation of a com- plete fistula. The external opening was about an inch from the anus on the right side, and the internal open- ing was immedi- ately above the sphincter-ani mus- cle. There was the usual exudation around the fistu- lous tract, but it was not so exten- sive as in many of these cases. The rectum having Iteen thorougldy washed out with disinfectants, after a free evacuation of the bowels, a bivalve rectal spec- ulum was intro- duced and the fis- tula laid open. The scar tissue was care- fully dissected out. and special care was taken to vivify the mucous membrane around the upper opening of the fistula. The ends of the sphincter muscle I Fig. 89. — The operation for lisluhi ; the trait laiil open and the sutures in place, a, anus ; r, outer end of fistula. FISTULA IN ANO AND COOOYODYNIA. 1G7 retracted, so that it was necessary to remove a considerable portion of the mucons membrane and cellular tissue in order to expose the ends of the muscle in the edges of the wound. Fine silk sutures were then introduced into the nmcous membrane of the rectum, the lower ones being made to include the sphincter-ani muscle. Deep sutures were then introduced from the outside upward in the same manner as in the operation for restoring the perinseum. Fig. 89 shows the sutures in place. The deep sutures were tied first, and the slight traction upon them drew the tissues downward and shortened the length of the wound very much. This brought the sutures in the mucous membrane very near together. I should have stated that before the fistula was laid open the sphincter-ani muscle was stretched until paralyzed ; this prevented any tension upon the sutures for the first few days. The bowels were moved daily, and after each evacuation the rec- tum was washed out with carbolized water. There was a little sup- puration in the track of one deep suture, but union was complete in ten days. The deep sutures were removed on the ninth day, and the sutures in the mucous membrane were removed at the end of two weeks. The recovery w^as perfect, the function of the sphincter muscle being fully restored. COCCYODYNIA. This affection was first described as a neuralgia of the coccyx by Dr. ISTott in the " jSTorth American Medical Journal," May, 1884, but it attracted little attention until 1861, when Sir James Y. Simp- son revived the subject and gave it the name which it now bears. Pathology. — Pain upon moving the coccyx and contracting the muscles attached to it is the chief characteristic of this disorder. The morbid conditions found are variable. Fracture and dislocation of long standing and caries of the coccyx have been discovered in some cases ; in others, no appreciable lesions can be detected. It is presumed that, in the absence of structural changes of the bone and muscles, the pain may be due to rheumatism of the tendons of the muscles or neuralgia of the nerves distributed to them. Symptomatology. — There is little or no suffering while the pa- tient is at rest, but upon rising, sitting down, or evacuating the bow- els, pain over the coccyx is experienced. Sitting is painful in some cases, owing to pressure upon the bone. Any sudden movement is attended with suffering. Some patients are unable to rise from a low seat without assistance. 108 DISEASES UF WOMEN. Physical Signs. — Tenderness upon pressinc; and moving tlie cor- cyx is tlie cliief diagnostic si<^n. Painful liu-niorriioids. fissure <>f the anus, and spasm of the adjacent nuisclcs caused by ascaricJes in the rectum, may be mistaken for tliis affection, but they can be ex- i chided by physical examination. J*j'o tic origin, and usually involves the entire uterus, so that changes of structure are found in the mucous and muscular coats of the organ. Tliis also (when it terminates in recovery) tends to chronic inflam- mation of the mucous membrane. The process of involution is ar- rested by this inflammation, and when the tissues are changed by INFLAMMATORY AFFECTIONS OF THE UTERUS. 177 iiiflaniinatory action the uterus is not only larger than it should l)e hilt is changed in structure. This will be referred to again under the head of subinvolution. Endometritis due to gonorrhoeal virus will also claim a separate notice, and with these few observations I shall for the present dis- miss all the varieties except acute and chronic endometritis, which will be discussed in this chapter. Acute Endometritis. — Acute endometritis is exceedingly rare if puerperal, gonorrhoeal, and septic inflammations are excluded. I am aware that acute cervical or corporeal endometritis is described in books, and Thomas claims that the affection occurs frequently. My own observations lead me to the conclusion that the acute metritis does not progress beyond the stage of acute congestion, and fre- quently passes off without causing the slightest permanent change of structure. Occasionally the acute stage subsides, and a chronic or subacute endometritis follows. When one follows the other in this way they stand to each other in the relation of cause and effect. The disease may affect the cervix or the body or both at the same time. Acute cervical endometritis is more properly an acute congestion, which does not cause any very marked disturbance either of the pelvic organs oi* the general system. The symptoms are not pro- nounced. Pelvic tenesmus of a slight nature, a sense of aching in the pelvic region, with or without backache, is the evidence ob- tained at first, and then leucorrhoea soon follows. This discharge is usually catarrhal and non-purulent. In some cases there is also a vaginitis and a vaginal leucorrhoea which contains some pus-cells, but when there is a free purulent discharge there is room for a suspicion that the cause may be specific. This form of cervical endometritis frequently ends in recovery, but may become chronic. All else that needs to be said on this sub- ject will be given in the consideration of corporeal endometritis. Acute Corporeal Endometritis. — While I have stated that acute corporeal endometritis may occur alone, I have always found it ac- companied by more or less cervical endometritis. The pathology of acute non-specific endometritis I consider to be a hyperremia, with such derangement of function as may come from it. This congestion may lead to swelling of the mucous mem- brane, destruction of its epithelium to some extent, and the forma- tion of pus, but these changes are not so marked as they are in me- tritis due to specific causes There is derangement of the menstrual function ; the flow may be retarded, anticipated, profuse, or scanty. A free menstruation is usually very beneficial. Symptoms often 13 178 DISEASES OF WOMEN. subside as soon as a free flow is establishtd, and if this flow con- tinues the usual time or longer the patient promptly recovers. Free menstruation luis always a[)peared to me to be a natural means of relief in this affection. The symptoms and physical signs of general acute endometritis are similar to those found in the chronic form of the affection, and to save repetition these points will be taken up Under the head of chronic endometritis. Prognosis. — This is favorable. The great majority of cases re- cover, and the worst tliat may happen is that the disease may linger and assume the chronic form. Causation. — The causes wliich give rise to ordinary inflammation of mucous membranes generally will produce acute endometritis, especially if operative at f»r near the menstrual period. Extreme sexual excitation or over-indulgence, exposure to cold, over-fatigue, and injuries from careless examinations with the touch or instru- ments, are fair examples. Treatment. — Complete rest is the first and most important ele- ment in the management. To quiet the nervous system, full doses of bromide of sodium should be given. This may also relieve pain. Should, the suffering still persist, opium should be used, but not if it can be avoided with justice to the sufferer. Hot applications should be made over the hypogastrium. Lin- seed-meal poultices, covered M-itli oil-silk, should be preferred, but if the patient complains of the weight flannels wrung out of hot water may be used in the same manner. The hot-water douche should be used twice or three times a day if it gives relief. The bowels should be kept free with saline laxatives ; should these cause flatulence and pain, a laxative pill of colocynth or rhubarb and belladonna will answer better. This simple treatment is generally sufficient. More heroic meas- ures are often resorted to, but usually with the result of prolonging the disease. Chronic Endometritis. — r)ne would naturally suppose that in en- dometritis the inflammatory process, when once begun at any part of the mucous membrane, would extend to the whole endometrium, but such is not the case. Clinical observations show that cervical endometritis frequently occurs without corporeal. They occur to- gether also, but cervical endometritis occurs most frequently. This law in the pathology of uterine disease, which appears peculiar, is explained possibly by the fact that the mucous membrane in its ana- tomical structure, and more especially in its function, differs very INFLAMMATORY AFFECTIONS OF THE UTERUS. 179 widely in the body and cervix uteri. Ceri-ain it is that the pathology and syniptouiatology, as well as the physical signs, show that corporeal and cervical endometritis are two very distinct affections, demand- ing different consideration and treatment. At the same time I nmst admit that they have many features in common, and that they also occur together occasionally, hence I shall give some general remarks which will apply to both. There has been much discussion regarding the pathology of en- dometritis, both cervical and corporeal. Much of this difference of opinion I think arises from the use of the terms. Some claim that the only lesion in this affection is congestion, othei-s claim that there is true inflammation ; the difference apparently arising from the fact that one defines inflammation as one thing, while another believes it to be something else. If endometritis, as we usually see it in practice, is compared with the process of acute inflamma- tion in other mucous membranes when it runs its entire course, then it will be found that endometritis is exceptional. It is known that in ordinary inflammation of the mucous membranes there is tirst congestion, then hypersecretion, then suppuration or purulent secretion, occasionally ulceration, and rarely, if ever, except in spe- cific inflammation, an exudation of plastic lymph ; then recovery follows. The damage done to the membranes depends upon whether the process enlls in suppuration, ulceration, or exudation. If this is taken as the typical result of inflammation of mucous membranes, then it is a fact that inflammation of the mucous membrane of the uterus is extremely rare ; but the fact is, that the process of inflam- mation in mucous membranes begins in some cases and progresses only to congestion and hypersecretion, and if these are long continued certain changes in the mucous glands, epithelium, and cellular tissue take place, but suppuration or ulceration does not occur as a rule in endometritis. The inflammatory process does not begin, nm through all its stages, and then end, but it begins and progresses to a given stage, and is continuous instead of ending at a definite time. Cervical EEdometritis. — Pailiology. — In cervical endometritis, which is now usually called uterine catarrh, there is very decided congestion and hypersecretion of the glands of the cervix. This secretion differs very little in its physical properties from that which is normal, except that it is excessive in quantity. If this congestion is long continued, the exfoliation of epithelium progresses faster than its replacement by the development of new cells, so that the membrane 18 covered \vith young epithelium which gives it a reddish color. 180 DISEASES OF WOMEN. Tliis disturbance of the balance batween the process of exfoliation and reproduction not only involves the mucous membrane of the canal, but extends outward from the os externum about half the thickness of the walls of the cervix. This <^ives rise to the cred color of the mucous membrane around them. To the touch they feel like shot, imbedded in the membrane ; these have long been known as the "ovulfe Nabothi "- -more recently this condition has been called INFLAMMATORY AFFECTIONS OF THE UTERUS. 181 " cystic degeneration of the cervix " (Fig. 9G). Sometimes one or more of them become very large, and by pressure cause alisor])tion of the middle wall of the uterus around them. The hypenemia sometimes extends to the middle coat of the cer- Fig. 96. — Section through the mucous membrane of the vaginal portion of the cervix showing cystic degeneration. vix, and then for a time the tissues are softened and (pdematous. With this condition there is usually free leucorrhoea and menor- rhagia, especially when the body of the uterus is affected. Occasion- ally, though rarely, the menstrual function is suspended or dimin- ished. In some cases of long standing, especially when there is laceration of the cervix, the areolar hyperplasia extends to all the tissues ^f the cervix, giving rise to that iudm'ation known as scle- rDsis. 182 DISEASES OF WoMliIN. These are the principal pathological conditions observed in the oi'diiKirv forms of cervical endoiucti'itis. Occasioiuillv the di.scharp- Fig. 98. — Hypertrophy of body of uterus fol- lowing corporeal endo- metritis (Winckel). Fig. 99. — General enlaip- ment of uterus, contrast in;; with the two preceding fi;;- ures (Winckel). Fig. 97. — Thickening and elongation of the cervix, as a result ofcervical endome- tritis (Winckel). may be miico - purulent, at times it is sero-nmco-purulent ; but this occurs only in extreme cases, and usually is due to some specific cause, and hence need not be considered in this con- nection. The ordinary form of cervical endometritis, described above, occurs in jjarous and imparous alike. There is another form of cer- vical endometritis which occurs only in the imparous, and has some peculiar characteristics which should be noticed here. In these cases the changes in the vessels already noted may or may not be present; usually they are not. The discharge from the cervical canla('e of the clear, translucent secretion we find a very thick and exceedingly tenacious material of the consistency of thick glue, and of a darkish color not unlike ])neumonic sputum, though more solid and dense, and not usu- ally so bright-red in color. Associated with this peculiar dischaige INFLAMMATORY AFFECTIONS OF THE UTERUS. 183 there are usually luarkecl tenderness and djsuienorrlKea, whicli are not accounted for by any other condition of the uterus than the state of the cervical mucous membrane. I am inclined to think that this form of cervical disease is due to some malformation or arrest of de- velopment of the glands of the mucous membrane. I have been led to believe this because it occurs in those in whom the uterus is im- perfectl}^ developed generally, and also the same peculiar secretion is observed in some women after the menopause, when the uterus and its mucous membrane have undergone tinal involution. In other cases of this class the mucous membrane of the cervix becomes prola])sed, causing dilatation and inversion of the lips of the external os, so that the cervix appears as if it had sustained superficial, bilateral laceration. In such cases the appearance is such as to lead to the belief that the patient has borne children, or had a miscarriage ; but I have found it associated with unruptured hymen, showing that it could not have come from injuries during parturition. Dr. Emmet describes cases of laceration that he has seen follow- ing criminal abortion in those who have not borne children. In the cases to which I refer the anatomical appearances are the same as he describes, but I am satisfied that in those that have come under my observation the laceration was apparent, not real. As soon as the membrane is reduced to its normal dimensions by exsection of a portion of it, and relief of the inflammation by treatment is accom- plished, the external os contracts, and the cervix resumes its original virgin form, showing that no iujury to the muscular coats of the utenis has ever occurred. Symptomatology. — Cervical • endometritis does not necessarily give rise to marked constitutional disturbance ; when it does so the symptoms usually appear in the form of general debility, especially of the nervous system. The patient may become easily fatigued and somewhat changed in disposition, and less inclined to mental activity. Sometimes there is considerable mental disturbance, but nmch of all this is usually due to the fact that the patient is annoyed by the presence of a more or less profuse leucorrhosa, which gives her discomfort, and leads her to suppose that she is suffering from a serious affection. The constitutional effects of this local affection depend very much upon the sensitiveness of the patient. The menstnial function is not necessarily affected. In cases of long standing there may be irregular menstruation, and the flow may be inclined to diminish, but this is not the rule. The character of the leucorrlioeal discharge is diagnostic. It is dense, thick, opaque, and tenacious, while the vaginal leucorrhoea is 184 DISEASES OF WOMEN. serous, non-tenacious, and usually purulent. If the disease is long c'oiitiinu'd hackat'be comes on, the pn'ni bfiiif^ located in the sacral ivgiou, which distinguishes it from the lumbar pain characteristic of general delnlity and some of the acute diseases. Theru is often, also, some pelvic tenesmus. All these symptonjs are usually very much aggravated by muscular exercise; the sym])toms alone, how- ever, are not sufficient to enable one to make a diagnosis. All that can be learned from them is sim})ly rhat there is some uterine affec- tion which, if it does not yield i)romptly to constitutional treatment, demands further investigation in order to settle definitely its char- acter. Physical Signs. — These, as obtained by the touch, are usually rather unsatisfactory. Upon making pressure upon the cervix there is sometimes tenderness, but not always: in some cases a roughened condition of the nmcous membrane around the os externum can be detected by the touch. Not infrequently there is a little relaxation of the vagina, and the uterus rests lower in the pelvis. Speculum examination affords the best means of ascertaining the lesions. We can usually see enough of the mucous membrane within the OS externum to determine the presence of the inflammati(^n. This is rendered more positive when the redness and ei'osiiju of the membrane extend outward upon the vaginal surface of the cervix, and also when there is eversion of the membrane. There is usually a free leucorrhoeal discharge from the cervical canal. Sometimes tliis hypersecretion is the only evidence of the disease present. Passing the sound into the cer^^cal canal shows that it is more sensitive than in health, and the membrane bleeds more easily on touch than it should. It will be seen that the physical signs, as well as the symptoms, are not by any means marked in cervical endometritis, yet they are sufficient for diagnostic purposes. Whenever the con- stitutional disturbance and the local symptoms are severe, it may at least be suspected that the mcml)rane of the cavity of the body of the utenis is also involved. This will be more fully discussed under the head of corporeal endometritis. In the form of cervical endometritis referred to, in which the secretion of the glands is opaque, dark in color, and exceedingly te- nacious, the discharge is not at all times very jjrofuse, but enough can be obtained by using a small curette to show its character. This in itself will be sutiicient to deterujine the diagnosis. Causation. — The predisposing causes of endometritis are imi)er- fections in the general organization, and in the develo-pment and growth of the sexual organs. Scrofulous and tuberculai" diatheses INFLAMMATUKY AFFECTIONS OF THE UTERUS. 185 incline to clirouic intlaininatioii of the mucous nieinbranes generally, md the nieiulji-aiie of the uterus is no exception. When the uterus is under size or malfonned in a slight degree, 30 that menstruation is imperfectly ]:)erformed, an inflammation of its mucous membrane is very likely to come on sooner or later. Sed- entary habits and unsuitable clothing, over-fatigue in standing or walking, or anything which interrupts the return circulation from the pelvis, predispose to this affection. So, also, deranged nutrition, from insufficient nutriment or over-taxation, mental or physical, which leads to impoverishment of the blood. Frequent child-ljearing and prolonged lactation also predispose to the same trouble. All these causes act to produce derangement of innervation and circulation, and so favor the develoi3ment of inflammation. The exciting cause which plays the most important part in endo- metritis is imperfect involution after confinement or menstruation. The great majority of cases take their origin from this imperfection of the menstrual or parturient involution. Other exciting causes which may be mentioned are injuries to the uterus from displacements, the use of ill-fitting pessaries, injuries during confinement, causing puerperal inflammations; abortion, es- pecially if produced, intemperate coition, and efforts to prevent con- ception, and finally gonorrhoeal virus. This specific cause of endo- metritis no doubt produces a form of inflammation which differs from the non- specific forms, and hence we will refer to it at another time. So far as I know the same causes produce both cervical and corporeal endometritis, so that in the present state of our knowledge I am not prepared to state any difference in the causes of the two affections, if any such exists. I am inclined to think, however, that as cervical endometritis is beyond doubt much more common than corporeal, it may be inferred that the one tends to the development of the other. Prognosis. — Of the uncomplicated cases of cervical endometritis the great majority yield to the proper treatment. There is in some a tendency to a recurrence of the disease, even after recovery has apparently been perfect. In those cases of imperfect development there is not the same certainty <^f giving complete relief. Treatment, — The constitutional treatment of inflammatory affec- tions of the uterus should be based upon the principles of the gen- eral management of local inflammations. To correct any defect in the general health, to imjDrove menstruation, and to calm any excite- ment of the nervous system, comprehends the whole subject. The sexual organs being dependent upon the nutritive and nervous sys- 186 DISEASES OF WOMEN. terns for support, general thrriipiutic agents can only alFcct the one by action through the otlier. There are a few medicines whicli act especially upon the sexual organs, through the circulatory or nerv displaced, it should be replaced, and sustained in its normal position by the sui)port of a well-fitting pessaiw, if need be. INFLAMMATORY AFFECTIONS OF THE UTERUS. 187 To reliev^u ])alii and quiet the irritation a vaginal this only occurred a few times it was soon possible to remove the secretions without difficulty, and a ]ireparation of equal parts of tincture of iodine and carbolic acid was applied thoroughly to tlie entire canal with the glass pipette (Fig. lOO). A few drops of this mixture was drawn up into the tube by compressing and releasing the bulb. The pipette was carried up to the internal os, and while it was being slowly withdi-awn pressure was made upon the rublter bulb, which gently cxjielled this mixture and thoroughly applied it to the entire mucous membrane. This local treatment was repeated every five days during the next two succeeding inter-menstrual pe- liods, and the general tonic and sustaining treatment continued, varying the chalybeate tonics from time to time. From this time onward local applications were made after each menstrual peiiod. INFLAMMATORY AFFECTIONS OF THE UTERUS. 191 and a^ain in alxmt two weeks, making two local treatments l)etween each menstrual period. Her general condition greatly improved; the cervix diminished in size by a marked contraction of the cali- ber of the canal; the Icucorrlireal discharge almost entirely disap- peared, and at the end of five months from the titne that the treat- ment was first begnn she was dismissed qnite well. She was di- rected, howevei", to return after the menstrual period for two or three months, to ascertain if there was any disposition to a recurrence of the cervical endometritis. It was found that she remained well, and hence recovery was considered to be complete. Cervical Endometritis, with Hyperplasia of the Mucous Membrane. — This patient was twenty- eight years of age, rather small and deli- cate-looking, but had enjoyed good health up to her last confinement. She had been married eight years and had three children, the last one being ten months old at the time when I saw her first ; she had nursed all her children, the first two for about a year, but tlie last one she weaned when it was eight months old, because she did not feel well, and had not sufficient milk for it. When her baby was about four months old she began to suffer from leucorrhoea, back- ache, and pelvic tenesmus — the latter symptoms being very much aggravated by active exercise. She had also lost considerable flesh, was easily fatigued, and somewhat nervous and depressed ; her gen- eral nutrition appeared to be fair, and her appetite was good ; her bowels were regular, and, although her pulse was not strong, she had a good, clear, healthy complexion. Digital examination revealed slight relaxation of the vagina, especially of the upper portion ; the uterus was rather low in the pelvis, and, while the body was normal in size, the cervix was considerably enlarged. The cervical canal was dilated, and the lips of the external os everted. Around the os, and extending outward to about half the thickness of the cervical walls, the mucous membrane was quite granular and rough to the touch. Throiigh the speculum a very free leucorrhoeal discharge from the cervix was observed, and the first impression was that there was superficial bilateral laceration of the cervix, but on more careful investigation it was found that the mus- cular wall of the uterus was very little, if at all, injured, and that the enlargement of the os externum and the eversion of its lips were line to the enlargement of the mucous membrane. The corrugations of the thickened mucons membrane were so marked as to give a papillomatous ajipearance, and the congestion was such that the parts bled freely on being touched with a sponge. The patient was put upon a systematic course of rest and exercise, 192 DISEASES OI- WOMEN. simple but nonrisliing foixl, and the citrate of iron and quinine an a tonic. Locally, she was ordered a vaginal douche of two quarts of water, two drachms of borax, and a half drachm of tannic acid to be used twice daily. A number of the more prominent ])oint8 of the mucouri membrane, which j)rojected from the o.s externum, were removed with the scissors. A borated tampon was introduced and removed on the following day, and two days afterward the iodine and carbolic acid niixture was applied to the whole length of the cer- vical canal with the pipette. ( )ne week afterward that portion of the cervical mucous niemljrane which could be seen was smooth, less re- dundant and less vascular ; the canal was still dilated, and the rugosi- ties of the mucous membrane were abnormally prominent. The more prominent portions of the mucous membrane of the canal were touched with a tifty-per-cent solution of chloride of zinc applied with a camel's-hair brush. Considerable pain followed this a|)plica- tion, and continued until late in the evening. From this onward the vaginal douche was employed once a day, borax and water only being used, the tannic acid being omitted. The carbolic acid and iodine were applied to the canal of the cervix with the pipette, the secretion being carefully removed with the curette before the appli- cation. This local treatment was employed once a week during the inter-menstrual periods for about five months, after that one appli- cation after each menstrual period for three months longer. At this time her general health had been considerably restored, the canal of the cervix had returned to its normal size, the leucorrhceal discharge had entirely disappeared, and the mucous membrane around the oe externum was perfectly normal. She had nf) further trouble from backache or pelvic tenesmus, and she was dismissed perfectly well, locally and generally. Cervical Endometritis, Stenosis of the External Os, and Cystic De- generation of the Mucous Membrane. — ^Tliis patient was an KnglisL lady, thirty-nine years of age. She had two children, the youngest one being: five vears old. She had an excellent constitution, and her health had always been quite perfect. After her second confinement her convalescence wa^ interrupted for a short time by some local trouble, the nature of which I could not exactly determine. She recovered from this, but afterward suffered from uterine leucorrhoea This gave her very little trouble, and as she hoped that it might dis- ap])ear she did not seek medical advice until two years afterwai*d, when she called upon a physician, wlio told her that "she had ulcer- ation of the womb." He treated her for about six months by apply- ing nitrate of silver, making the applications with a swab through a INFLAMMATORY AFFECTIONS OF THE UTERUS. 193 cyliinlrical speculum. This I learned from the patient herself, who I stated that the doctor told her he was using nitrate of silver. The treatment diminished the leucorrhoeal discharge, but she : bef the next twenty-four hours. This tampon, while it j)re- vented the contraction of the os, interfered at the same time with the process of healing, so it was given up. At the end of a week after the tirst treatment there was found still a number of cysts, some of them within the cervical canal. These were all opened and the leucorrhoeal secretion remcjved from the canal with the curette, and the mixture of iodine and carbolic acid applied ; and tincture of iodine alone applied to the vaginal portion of the cervix. These applications were repeated once a week, and the warm- water douche continued for four months. During this time aU the local symptoms disappeared except the leucorrhceal discharge, and this diminished in quantity and became less opaque in character, but it did not wholly disappear. The size of the external os remained ample, while the canal con- tracted very decidedly, so that it was almost of its normal caliber. The scar tissue became less dense, and all tenderness disap])eared. After the first four months' treatment the patient was seen for an- other three months, just after the menstrual period, when the iodine and carbolic acid were applied to the cervical canal, and the iodine to the vaginal portion of the cervix. Seven months from the time that she first came under my observation she Avas found to be preg- nant, and hence was dismissed as recovered. I subsequently learned that she passed safely through her confinement, but 1 have had no opportunity of examining her since, although I believe that she re- mains quite well, and hence it can be inferred that the cure was quite permanent. Cervical Endometritis treated by Caustic, which produced Con- traction of the lower two thirds of the Cervical Canal. — This lady was twenty-eight years of age, of remarkably strong orgauization, and had always enjoyed good health until the birth of her tliird child. At that time she had some ditiiculty in her labor, and sus- tained a slight laceration of the perin.neum ; after this she had pelvic tenesmus and leucorrlnea. When she first came under my observa- tion she had slight prolapsus of the uterus, with rctrovei'sion in the first degree ; there was cervical endometritis, indicated by the deep- red color of the mucous membrane and free leucorrluea, but there was no other jjathological change in the mucous membrane. An INFLAMMATORY AFFECTIONS OF THE UTERUS. 195 application of tannin and glycerin was made to the cervical canal, the uterus was replaced, and she was told that it would be necessary to restore the perinaeum in order to give complete relief. The thought of an operation somewhat disturbed her mind, and a friend advised her to place herself under the care of her physician, a liomre- opathist. This she did, and at the second visit he told her that he had introduced a pencil of nitrate of silver into the womb, and had applied some cotton to keep it there, and desired her to return to his office the next day so that he might remove the cotton. On the way home she suffered severe pain, and was obliged to go to bed as soon as she reached the house. She suffered considerably during the night, and the following day sent for the physician, who removed the cotton, and told her that she would be all right. She continued, however, to have a good deal of pain and pelvic tenesmus, especially when she tried to stand or walk. For the next two or three days she had a discharge which differed from the former leucorrhoea ; it was less tenacious, yellow in color, and at times quite offensive in odor. She returned to the physician for further treatment as soon as she was able. The discharge became very much less, and finally disappeared entirely. She was encouraged to hope that she would get well without any further treatment. In this, however, she was misled. Her backache and pelvic tenesmus increased in severity, especially when standing or walking, and she began to have painful menstruation. About a year from the time she had the caustic ap- plied she returned to me. I found the displacement about the same ; there was no leucorrhoeal discharge whatever, and no external evidence of the former endometritis. The os externum was con- tracted, and its lips curved inward ; the tissues around the os were extremely hard, and to the touch and inspection appeared to be mostly scar tissue. The cervical canal was contracted in its lower two thirds, so that ' a small uterine sound could be passed with difficulty ; there was none of the elasticity of the normal canal left, but a hard, almost cartilaginous condition existed. The passing of the sound caused considerable pain, and some haemorrhage. The patient was then sent to my private hospital, and an effort was made to dilate the cervix by the use of graduated sounds. This gave pain, and was not effectual. Then the whole length of the contracted portion of the cervical canal was incised on the two sides, the incisions being made with my hysterotome (Fig. 46) through the scar tissue, and the canal was then dilated sufficiently to admit a No. 23 sound ; a tent made of marine lint and dipped in carbolic acid and glycerin. 196 DISEASES OF WOMEN. ODe part of the former to three of the latter, was passed up into the canal and retained there by a vaginal tampon ; this was left in jjo- sition for twenty-four hours, when it was removed. A short, hard- rubber stem-pessary, which reached beyond the line of contracti(»n, but not up to the internal os, was introduced and worn for nearly three weeks. During that time it was repeatedly removed and tinct- ure of iodine applied to the cervical canal, and a vaginal douche of borax and warm water was used. The treatment was continued throughout with all antiseptic i)recautions. After the operation on the cervix the uterus was kept in place, first by means of a tan)j»on, and subsequently by means of the pessary, which answered the purpose while the patient remained in a recumbent position. The pei'ini^um was then restored, and the patient disnussed after two months of treatment in the institution. She subsequently returned to me once a month, when I passed the uterine sound and applied the tincture of iodine, in order to prevent any recurrence of the con- traction. Six months from the time that she was operated upon she became pregnant, and, although some trouble was anticipated in the dilatation of the cervix during her labor, there was none. Prof. Charles Jewett attended her in her confinement, and all went well, and she has remained free from uterine trouble ever since. Cervical Endometritis in an Imparous Woman. — This was a cul- tivated lady, with an excellent constitution, who began to menstruate at fourteen, while she was a school-girl, and continued to do so nor- mally until she had been teaching several years in a high school She taught many hours daily, and being strong and very ener- getic she preferred to stand, as a rule, while drilling her class. This overtaxation brought on dysmenorrhc^a, backache, and leucorrh«ea. These symptoms were not marked at first, but as she kept on at her work they gradually increased. When she was twenty-eight years of age she came under my care. She had then been married about one year, and although her symptoms had not increased — in fact, she had enjoyed better health after being relieved from her arduous duties as a teacher — still she had backache and leucorrhrea, especially on taking active exercise ; and she was sterile. I found the men- strual function perfectly normal, except that she had backache and some pelvic tenesmus during the flow, but these were relieved to some extent if she kept quiet. Her chief symptom at that time was a rather free leucorrhoea. A digital examination found the pelvic organs well developed. There was no tenderness nor any evidence of disease that could be obtained by the touch, except that the os externum appeared to be larger than is usually found in the virgin INFLAMMATORY AFFECTIONS OF TOE UTERUS. 197 cervix. On speciilmn examination quite a free leucorrliocal dis- cbarge was observed, and there was a ring of deep-red color in the raucous membrane around the os externum. The cervix was rather large in proportion to the body of the uterus, and was of a deeper color than normal, and the upper portion of the vagina also was congested. The canal of the cervix, including the internal os, was normal in size, so that the uterine sound could be passed to the fundus without difficulty or causing much pain. As her health was quite good, no constitutional treatment was necessary. During the succeeding two months six applications of iodine and carbolic acid were made to the cervical canal. The next month three applications were made of iodine alone, and the next month after that glycerin and tannic acid were applied. At the end of that time the leucorrhoeal discharge had entirely subsided, the patient suffered much less from backache, and had no pain or discomfort at lier menstrual periods. She was then dismissed, and nothing more was heard of her until four years afterward, when she returned to inform me that she was two months pregnant. I have not seen her since, but have heard through her family that she was delivered of a healthy child after a somewhat tedious labor. Cervical Endometritis in an Imperfectly Developed Uterus. — This lady appeared to be rather frail, but had always enjoyed good health. She began to menstruate first at thirteen, and for the first year was rather irregular, and always had some pain the first day. The flow lasted only from two to three days, and the dysmenorrhoea increased somewhat from month to month ; and she began to have backache before and after menstruation, with occasional leucorrhoea. When she was twenty-four years old she was married, but from that time onward her dysmenorrhoea increased ; she had almost continuous backache, and a good deal of tenesmus, with occasional attacks of frequent urination. One year after her marriage she came under my observa- tion, and I found the uterus rather below the normal size ; there was slight anteflexion of the cervix, but the body of the uterus was in its normal position. The uterus was tender to the touch, and there was also some hyperesthesia of the vagina. A speculum examination revealed a general conarestion of the cervix and va2:ina, the cervix being smaller than it ought to be ; the os externum was small, and while there was a slight vaginal leucorrhcea there was no discharge from the cervix. The canal of the cervix was quite large in propor- tion to the size of the external os, and the os internum was so small that an ordinary-sized uterine sound was passed with difiiculty, and caused pain. The canal of the cervix contained a plug of very thick, dai'k- 19S DISEASES OF WOMEN. colored, and very tenacious secretion. This was removed with the curette, but with fi^reat ditiiculty, ami (juite a free hiL'inorrlia<;e oc- curred during its removal. After removing this secretion very care- fully, and waiting until all haemorrhage had subsided, a mixture of carbolic acid, glycerin, and water was carefully applied to the entire canal fur the purpose of neutralizing any septic material which might exist there. A small V-shaped piece was removed from each side of the cervix at the os externum, and four very su])erficial incis- ions were made at the os internum. The uterine dilator was then introduced, and the os internum and externum dilated until a No. 9 sound could be easily introduced. The patient was kept quiet in bed for several days, and as tliere was no constitutional or local disturbance at the end of that time she was allowed to get up and go about again. From this time onward for about three months the uterine sound was passed once a week to prevent contraction of the cervical cauaL At the same time the secretion was carefully removed from the car nal, and carbolic acid and tincture of iodine — one part of the fcjrmer to two of the latter — were thoroughly applied. A vaginal injection was ordered of one quart of warm water and forty grains of sulphate of zinc, to be used once a day. The effect of this treatment was to relieve the dysraenorrhoea, backache, and general feeling of discom- fort in the pelvis. The leucorrhreal discharge became more free, somewhat lighter in color, and less tenacious. The application of iodine and carbolic acid was continued for two months longer, when all treatment was sob- pended for three months. At the end of that time she returned, and stated that her leucorrlia?a remained the same, although others wuse she felt tolerably well. In passing the sound the canal of the cervix was found to be ample, but the character of the secretion had returned to what it was when she lirst came under my observation. I made applications of the tincture of iodine to the cervical canal for about two months, without ai")parently improving the condition; I then tried a 10-per-cent solution of chloride of zinc, applying it once a week, but without improving the case. I then decided to remove a longitudinal strip from each side of the mucous membrane of the cervical canal ; this was accomplished by seizing the cervix with a tenaculum, and then passing a small-sized Sims's curette &S\tN\KV\H«»W. I Fir. 1(11. ^ (Fig. 101) up to tlie internal os, and under strong pressure draw- ing it down and cutting out a deep strip of the mucous membrane. INFLAMMATORY AFFECTIONS OF TUE UTERUS. 199 This was repeated on the opposite side. The idea of removing the two sections rather than removing the entire membrane, as recom- mended by Sims, Thomas, and others, was to leave a portion of the membrane, which would expand as healing took place, and in that way compensate for the loss of tissue, and thereby prevent the oc- i currence of stricture of the canal by contraction. During the heal- in"" process the uterine sound was cautiously passed about every tliird day. This at first caused some haemorrhage and pain, but soon it could be done without trouble of either kind resulting from it. The applications of iodine were again begun and continued for about two months, six applications in all being made. The final effect of this was to control the leucorrhoea, and the little discharge that remained became more transparent and less tenacious — more like the normal secretion of the Nabothian glands. She was then dis- missed apparently well, and she remained so, but continued to be sterile. I have treated a large number of cases of this class in the same way, except that I have not lost time in trying different applications, 1 but have removed the sections of the mucous membrane at the out- set. Two of my patients have subsequently borne children ; several of them have had some contraction of the canal, which had to be relieved by dilatation. In quite a number of them the leucorrhoea has returned, and while I have been able to keep them comfortable by occasional treatment, they have never completely recovered. Cervical Endometritis in a Young Girl, with Marked Thickening of the Mucous Membrane of the Cervix, Dilatation of the External Os, and Eversion of the Mucous Membrane. — This girl was rather small, delicate, of marked nervous temperament, and highly cultivated. Her circumstances were such that she had been able to obtain an I excellent education and every advantage and accomplishment that she could desire. She was precocious, and began to menstruate when she was eleven and a half years old. She had always suffered slight pain during her menses, and also had leucorrhoea, which was trivial at first. She had suffered much from backache, headache, and general debility, but was able to attend to her education until she was sixteen years old. Her leucorrhcea at that time became quite profuse, and her backache and pelvic tenesmus so severe that she was obliged to give up muscular exercise almost altogether. During this time she had been treated with tonics, and change of air. At the age of eighteen she was placed under the care of a physician m New York, wiio said that she had some falling of the womb, and treated her by tamponing the vagina with cotton, after the method 200 DISEASES OF WOMEN. of Boseman, who, I believe, calls tliis metliod of treatment "column- inli- cated, will usually yield to appropriate treatment. There is a decided tendency in many cases for it to return, but even then it can be re- lieved by removing the cause. The most obstinate cases, and also those that are neglected, recover at the menopause. The affection is not in itself self-limited, but is limited by the period of functional activity of the uterus. There is a prevaihng opinion that endometritis, when it continues up to the menopause, complicates " the change of life," and favors the development of malignant disease. The former opinion is true, the latter doubtful. The results vary with the different kinds of treatment used. I have never seen a case cured by certain methods, which have been commended to the exclusion of all others ; for example, hot- water douching, and the application of the tincture of iodine to the vagina. Neither does endometritis yield to treatment so long as there % a displacement of the uterus, or a laceration of the cervix ; but, when all the conditions necessary to recovery are secured, then endometritis will yield to local treatment in the vast majority of cases. Causation. — The causes of corporeal endometritis have been re- ferred to in discussing cervical endometntis ; hence, to save repe- tition, it will suffice to say that there are certain conditions of the general system which predispose to the affection. The strumous diathesis, imperfect general nutrition from either gross living and sedentary habits, or exhaustion from overtaxation, are tlje chief pre- disposing conditions. The direct or exciting causes are complicated labors, miscarriages, derangement of menstruation, and sepsis. The vast majority of cases of corporeal endometritis, which have come under my observation, were clearly due to the causes given above. In fact, if those caused by gonorrhea are excluded, nearly all the others can be ascribed to lesions of parturition and derange- ment of menstruation, which arrest the post-partum and post-men- strual involution. Treatment. — The constitutional treatment of inflammatory dis- eases of the uterus was briefly referred to while discussing the treat- ment of cervical endometritis, so that it is only necessary to repeat the general statement, that every means should be employed to re- store the general health. The treatment must, as a matter of course, k CORPOREAL ENDOMETRITIS. 207 be adapted to tlie nature and degree of the impaired state of the a-eneral organization in the given case. The local treatment, such as the hot-water douche, already de- scribed, applies in part to cervical endometritis, and therefore need not be repeated here. It will suffice to give directions regarding topical applications to the corporeal mucous membrane. I will first consider the indications for intra-uterine medication, the remedies to be used, and the means of employing them. This question is still with many an unsettled one, both as regards the I curability of corporeal endometritis, and the value and safety of I intra-uterine medication. The literature on the subject of intra- I uterine treatment is not very definite, hence I shall confine myself I to a few points, which I regard as fairly well established, and likely to be of service in the treatment of this disease. The important questions which come up for consideration on this subject are, first, is it safe and advantageous to make intra-uterine applications ? Second, if so, what curative agents shall be employed ; and, third, how shall they be applied ? Turning to the text-books or the current literature on the sub- ject in search of an answer to the first question, I find the greatest diversity of opinions. The pioneer gynecologists of Europe, such as M. Gendriri, M. Jobert de Lamballe, Bennet, and Simpson, rarely, if ever, made ap- plications beyond the os internum, believing that endometritis could be cured by treating the cervix and the cervical canaL On the other I hand, we find that Aran, Scanzoni, and Gantillon, and Dr. Henry • Miller (who, by the way, was the first to employ intra-uterine medi- cation in this country), Kammerer, Nott, Peaslee, and many others, relied to a very great extent on intra-uterine applications for the relief of corporeal endometritis. Many more names might be mentioned to show the want of har- mony among physicians on this point, but no useful knowledge would be gained thereby. All that can be learned from a review of the literature is that intra-uterine medication is more extensively employed now than formerly. Believing that time tends to drift the profession to the side of correct therapeutics, it may be inferred that local applications to a part or to the whole of the lining mem- brane of the uterine cavity are sometimes necessary, if not indispen- sable, in treating endometritis. In seeking an answer to the second question, one encounters a 'variety of medicinal agents, ranging from the actual cautery to the blandest anodynes. 208 DISEASES OF WOMEN. liearing in mind, however, tlie second object to be gained, name- ly, to restore the organ to health, and leave it uninjured, it is evident that all destructive agents should be avoided. This has already been stated in discussing the treatment of cer- vical endometritis, and all that was then said ap])lies with greater force in regard to corporeal endometritis, because that portion of tlie mucous membrane is more delicate in structure. In my own practice I employ either bichloride of mercurv, one grain to an ounce of water ; tincture of iodine ; tincture of iodine, two parts, and carbolic acid, one part ; or suppositories of iodoform and cocoa-butter. There is so much risk in treating the mucous membrane of the cavity of the body of the uterus that there are certain precautions which should be kept in mind. These may be formulated as follows : That intra-uterine applications exciting to the cervical canal should not be used until other means have been thoroughly tried and have failed. The uterus should be in or near its normal position. The cervix uteri should be sufficiently dilated to allow any excess of the fluid to escape from the cavity of the body. After having carefully freed the cervical canal from the secretion, the easiest and most effectual way of making applications is to use the glass pipette, already described. The solution to be employed is drawn up into the glass tube by the rubber bulb ; the instrument is then passed up to the os inter- num or to the fundus uteri, if desired, and, as it is withdrawn, press- ure is to be made upon the bulb whieli forces out the solution and brings it in contact ^^ith the entire lining of the canal. The method generally in use of dipping a probe wrapped with cotton into the solution, and passing that u]) into the canal, is very unsatisfactory. The cotton on the probe injures the mucous mem- brane, and the solution is deposited about the os externum — very little, if any, getting into the canal. The injections by means of a syringe and a reflux catheter, com- mended by many, I have tried, but I have abandoned the method because it is dangerous and unnecessary. It is well to use some bland fluid, such as warm water and salt, to test the toleration of the uterus before using the more potential agents. A small quantity of the agent used is all that is necessary. Six to ten drops is sufticient to cover the surface to be treated, and more than that is useless. When from long-continued congestion the mucous membrane of the cavity of the uterus has become h}i)ertrophied, giving rise to CORPOREAL ENDOMETRITIS. 209 tliat eoiulition now known as endometritis poljposa, the use of the I curette "-ives the most prompt relief. The blunt instrument should I always be used, because it is perfectly effective and free from dan- i rt-er. Dilatation of the cervix with tents, as a preliminary to the use I of the curette, should be avoided. No such dilatation is needed, as a rule. When the mucous membrane is hypertrophied, the canal of I the cervix is usually sufficiently dilated to admit a curette large [ enough to do the work. By carefully adhering to this rule of prac- tice the pain and danger from the use of tents are avoided, which are great advantages to the patient. In the great majority of cases of corporeal endometritis with thickening of the mucous membrane, the use of the curette gives prompt and permanent rehef ; still, there are some which may re- quire to be followed up with other local treatment, such as has been described. ILLUSTRATIVE CASES. This patient w^as thirty-two years of age, had been manied ten years, and had two children. After the birth of the iirst child she was quite well for two years, and then she again became pregnant, and miscarried at three and a half months. After this she had a slight leucorrhoea for a time, with other evidence of uterine disease, but she appeared to have recovered from this, and gave birth to an- other child. She made a good recovery from her confinement, and nursed her child for about six months. Her health then began to fail, and she weaned the child. Two months after this the menses returned, and at the time were quite scanty, and only lasted for a day or two. She attributed this to over-exercise during a journey which she had taken, not expecting to be unwell. After this she suffered from backache, pelvic tenesmus, and irritable bladder, with free leucorrhoea, at first like an ordinary cervical secretion in character. Her general condition also became largely disordered. The appetite was capricious ; the bowels con- stipated and distended from flatulence ; she also had occasional at- tacks of nausea, and at times headache ; she became quite nervous, and her sleep was broken and disturbed ; the backache and peh-ic pain and tenesmus were such that she could only stand or walk for a short time. She also had pain in the pelvis, which radiated through the abdomen ; her menstruation became irregular, generally coming on at the end of two or three weeks and continuing longer than normal, and was too free, and during the year pre^^ous to my seeing her had at times been offensive ; between the menstrual periods the 15 210 DISEASES OF WOMEN". discharge was of a mixed cliaracter, composed of cervical leucorrlioea stained with blood and mixed with serum, and oecasionallv traces oj pus, which was then slightly offensive. She complained at time also of pruritus of tlie vulva. Wiien first examined I found tli uterus larger tlian normal, the increase in size being mostly of tin body and fundus. Bimanual pressure being made upon the body 0 in the minute. She was thin, feeble, and anemic in appearance. The mammae were shrunk and flat. For some time before admission she had suffered niucli from occiusional headaches and giddiness; frequent nausea and vom- iting ; palpitation and occasional rigors. "■ On making a vaginal examination, I found the uterus small and mobile. The cervix uteri was much atrophied, and the vaginal por- tion of it scarcely made any projection into the canal of the vagina. The OS nteri was so much contracted as to admit a surgeon's probe with ditiiculty. It was dilated by a slender bougie being left in for two or three days ; and, when the uterine sound was subsequently used, the uterine cavity was found to be only one and a half inch in length, or about an inch less than normal. " A variety of means was employed with the view of beneliting the general health of the patient, and of exciting action in the uterine system, but with little or no effect. '' Diarrhoea repeatedl}'- occurred during the three or four weeks she remained under my care, requiring the free use of opiates for its restraint ; and as the uterine symptoms did not at the time seem to admit of special attention and treatment, the patient was transferred to one of the general wards of the hospital, where she was placed under the care of my colleague, Dr. Bennett. " Durinsr the foUowincj month the diarrhoea recurred from time to time very severely. At last anasarca in the lower extremities and albuminuria supervened ; ascites followed ; and shortly afterward her face and arms became oedematous. About a month after these symjv toms appeared delirium at last came on, , the fa3Ces passed involun- tarily, and ultimately she died in a state of prolonged coma. " On post-mortem inspection some crude tubercles were found iu both lungs, especially in the left. The liver was enlarged, and showed some fatty transformation. The kidneys presented also some stearoid degeneration, and in the right there was in addition a small tubercu- lar abscess. The large intestines were very much thickened in their parietes, and contracted in their caliber, while their mucous mem- brane was ulcerated in various parts. Along the lower end of the ileum several large ulcerations were seen running circumferentinlly around the interior of the bowel. One or two ulcerations were also found in the stomach. The uterus was very small, and atrophied in its length and breadth, its size being diminished about a third below SUBINVOLUTION. 219 the natural standard in all its incasiircnients, and its parietcs were correspondingly thin and reduced. The whole length of the uterine cavity from the os to the fundus was not more than one inch and a half, while the normal uterus usually measures in this direction two inches and a half. When a section was made of the posterior wall of the organ, the thickness of its parietes at their deepest or most developed point was not above three lines, instead of the normal measurement of live or six lines. Tlie tissue of the uterus a^^peared dense and fibrous, and the section of it presented the orifices of nu- merous small vessels. The ovaries seemed also much atrophied, and smaller than natural. Their tissue was dense and fibrous, and pre- sented no appearance of Graafian vesicles. There was no inflamma- tory deposit on the peritoneal surface of the uterus or its appendages ; but some thick pus, or tubercular matter, existed in the distended cavity of the right Fallopian tube." CHAPTEK XII. SCLEROSIS OF THE UTERUS. Fifteen years ago I employed tliis term to designate an aflfection of the uterus, which up to that time had been known by a variety of names — such as chronic interstitial metritis, hypertrophy, chronic inflammatory hypertroj^hy, and areolar hyperplasia. Subsequently Gallard used the same term in the same way. This affection of the uterus is a change of structure produced by a pre-existing inflammation or derangement of nutrition, and may be more properly considered as the product of morbid action, rather than active disease. The term which I have selected, therefore, more clearly indicates the tnie nature of the affection than the names of the affections or processes which produce it, and by which it has heretofore been designated. Pathology. — This comprises certain changes of stnicture, mostly of the middle coat of the uterus, which, as already stated, have been caused by preceding morbid processes. This chancre of structure consists in an excess of connective tissue, the result of an areolar hyperplasia. This element in the structure of the uterine walls rapidly increases, encroaching upon the mus- cular element, and more especially upon the blood-vessels in the connective tissue. The result is marked increase in the density of the tissue?, and an?eraia from pressure upon the vessels. Thore is frequently an increase in the size of the whole organ, but in some cases the uterus is not enlarged. In fact, the utenis may notably dimini?;h in size, when the hyperplasia is sufficient to cause atrophy of the other tissues of the uterus. The histological composition of the tissues differs in different cases, and in different stages of the development of the affection. In those cases which have their genesis in puerperal metritis there is generally at first, in addition to hyperplasia of connective tissue, a fatty degeneration of the muscular tissue, which has not SCLEROSIS OF THE UTERUS. 221 been disposed of by the process of involution. There are, also, in some cases, some of the products of the intlammation in the form of exudation into the tissues. All these give the uterus its increase in size, which to sonic extent is permanent, although the organ may diminish very much in time. The hyperplasia of the connective tissue causes atrophy of the other tissues, and to that extent the uterus is reduced in size. When the sclerosis follows non-puerperal metritis the uterus, which dur- ing the stage of inflammatory engorgement was larger than normal, may become reduced to, or even below, its normal size. This is more likely to occur when the hyperplasia is extensive, and involves all the tissues of the uterus and their blood-vessels. Sclerosis may be general or local. When due to puerperal or chronic metritis, or to deranged nutrition from long-continued con- gestion, the whole organ shares in the morbid process. AMien it is due to some injury and inflammation, or deranged nutrition of the cervix, the body may remain normal. Circumscribed patches of sclerosis in the body or cervix have not been found. Finally, this is a permanent affection. When once the changes of structure have taken place they remain, to a certain extent at least. There is no tendency to complete restoration of the normal tissue. There may be a slight diminution of the size of the uterus. I am inclined to think that even at the menopause, the period at which almost all uterine affections subside, this lingers, and possibly remains always. I have had an opportunity of observing several cases some time after the change of life, and the utems in all of them was larger than it should be. Dr. Xoeggerath claimed that sclerosis, or chronic me- tritis, as he called it, predisposed to cancer of the uterus. This may be so. There is in this affection a change of structure, and, accord- ing to the rule in pathology, a consequent lowering of the vitality of the part, and a predisposition to further degeneration. Symptomatology. — The clinical history of this affection differs in many points from that of other forms of uterine disease, but there are no symptoms that are diagnostic. There is more marked constitutional disturbance in the pro- nounced cases than is found in the average inflammatory affections. This may be due largely to the exhausting effect of the disease which preceded the sclerosis — this being quite suflicient to keep up the general ill-health. There is derangement of menstruation, usuallv amenorrhoea. In well-marked cases neuralgic pains in the uterus are frequently pres- 222 DISEASES OF WOMEN. ent, wliicli arc imicli worse at the menstrual period. The pain at this time often begins before the flow and continues throughout the whole period, and sometimes a day or so after. In some ea^es the pain is acute and irregular, in others of a dull, aching character, and in a few both varieties of pain coexist. The form of suffering may be likened to a very great aggravation of all the disagreeable feelingi- of an ordinarj' menstruation. The clinical history (so far as symptoms are concerned) in the inter-menstrual period closely resembles that of corporeal tndcjme- tritis. Physical Signs. — These are briefly as follows: Aniemia of the uterus, indicated by the pale appearance of the cervix, as seen through the speculum, and suggested by amenorrhosa ; enlargement and in- duration of the uterine walls, as detected by touch and sound ; in- creased length of the cavity of the utenis without increase of the lateral and autero-posterior diameters ; slight retraction of the lips of the 08 externum, and the small size of the cervical canal compai-ed with the size of the walls of the cervix. The hardness of the uterus is a most valuable sign, but one that is not easily detected. To the touch, the uterus does not in all cases appear to be more dense than the virgin uterus, but where it is en- larged it is softer in consistency, except in sclerosis ; hence, when there is an increase in size and induration, not due to fibroma, the evidence is in favor of sclerosis. In the great majority of cases the uterus is more tender than iu any other affection, except acute metritis, and endometritis with flex- ion. The touch excites this sensitiveness, and the passage of the sound causes marked pain. Prognosis. — Sclerosis being a permanent change of structure, recovery with or without treatment is the exception. By relieving any comphcation which may be present, such as displacement, the patient may be made sufiiciently comfortable to reach the menopause, and then recovery may take place. Sclerosis of the cervix may be relieved to a great extent, some- times completely, by trachelorrhaphy, if the cervix has been lacer- ated. In case the cervix has not been injured its size can be I'educed, and the tissues may become softened and the nutrition im]iroved by taking out a V-shaped piece on each side, and bringing the parts to- gether, as in the operation for laceration. Causation . — The causes of this affection, given in the Hteyature f>f medicine, are che same as those of almost all other inflammatory SCLEROSIS OF THE UTERUS. 223 diseases of the uterus. In the cases wliich liave come under my own observation, tliey were either acute metritis following; child-bearing, or miscarriage or long-continued general endometritis, and injuries to the cervix during kbor. This leads me to believe that these are the only causes of this affection. In fact, as sclerosis is the result of a deranged nutrition of an inflammatory nature, it follows that the cause must be a pre- ceding metritis, partial or general. Treaty// enf.— Sclerosis is, of course, a preventable disease in the majority of cases. If the inflammatory affections which lead to it are carefully managed the structural changes will be avoided, except- ing in severe puerperal metritis. When once the changes in the tissues which constitute true scle- rosis have occurred, it is still a question w^hether any known treat- ment can entirely relieve it. As already stated in the prognosis, benefit may be obtained by removing complications, such as lacera- tion of the cervix. In ihe hope of causing absorption of the areolar tissue, mercury, iodine, copper, and belladonna have all been em- ployed ; and, it is needless to say, that the hot- water douche has also been frequently tried. Dr. Noeggerath, of New York, recommends amputation of the cervix, permitting the stump to heal by granulation instead of cover- ing it over with vao;inal mucous membrane. This he deems advisa- ble, not only in the hope of relieving the sclerosis and to counteract the effect of the operation, but also to prevent the development of malignant disease. So far as my own personal observation goes, I am obliged to say that I have not seen much benefit from any such treatment, and have come to look upon the disease as an incurable one. There is one remedy which promises to be useful, and that is electricity ; but I have not had experience enough in its use to enable me to speak definitely regarding it. I may say, however, that it promises more than anything else that I am familiar with, but more extensive observation is necessary to determine its true value. HISTORY OF CASES. Sclerosis of the Cervix Uteri. — This case is one of the very few that I have seen of sclerosis of the cervix, not accompanied with laceration. It is possible that the cervix had been lacerated during one of the patient's confinements, and that the wound had healed, but I could not find any trace of such injury. The patient was thirty-one years old, and had borne four chil- 224 DISEASES OF WOMEN. I dren ; the last one three yeare before the time when this history was taken. She did not recover from this continement as well as she had in previous ones, but I could not get any hist arated from the uterus, but becomes broken up either during ex- pulsion or in handling it afterward. It is iimch more probable that it is completely exfoliated and broken up subsequently than that it is separated in circumscribed patches. All these facts lead to the conclusion that the affection is a perversion of nutrition and func- tion rather than an organic disease, inflammatory or otherwise, which gives rise to this peculiar condition of the mucous membrane at menstruation. It is clearly evident that there is nothing pathoh»gi- cal in the condition of the mucous membrane itself, but that the whole morbid process consists in the separation of the membrane in mass, in place of disintegration, which is the normal character of the mucous membrane in menstiniation. There are other views regarding the pathology of this affection : one, that it is the result of gestation, which is arrested at a very early stage, and that the membrane thrown off is really a decidua vera. That this theory is fallacious will be seen when the physical signs of this affection are discussed. The idea that it is an inflammatory affection is not well sustained. No such product or result of inflammation is found elsewhere in the mucous membranes of the body, nor is it necessary that inflammation MEMBRANOUS DYSMENORRIICEA. 231 of any part of the uteiTis should be present in order to produce membranous dysmenorrlicea. Associated with this membranous dysmenorrhcea we occasionally find iniiammatory conditions, but not of the mucous membrane of the cavity of the body. There may be, and often is, a general hy- perajmia of the uteras and vagina, but usually it is not greater than that which is seen in normal menstruation. There is occasionally, in cases of long standing, cervical endome- tritis, but this does not extend to the body of the uterus. In fact, I believe that a well defined endometritis can not occur at the same time as membranous dysmenorrhcea. This affection, then, is cer- tainly siii yeneris, and is not the result of inflammation in any form or in any stage of the inflammatory process ; neither is it a utero-ges- tation ending in abortion at a very early stage of pregnancy, as some have maintained ; neither does the membrane partake of the nature of any of the morbid neoplasms which occur in mucous membranes elsewhere in the body. The mucous membrane in this affection is developed in the nat- ural manner after each menstmation, and the gross appearances and histological composition of this structure show that it is normal, and differs in no way from the mucous membrane of the uterus up to the time when the menstrual flow is about to begin. Perhaps there, is, in some cases, an increase in the quantity of the membrane, but only to a very limited extent, if at all. In short, the only pathol- ogy connected with this affection is in the manner in which the membrane is thrown off. Symptomatology. — This affection occurs in single and married women — about as often in one class as the other, perhaps. It also occurs in those who have bome children, but in most of the cases that I have seen in married women the patients have been sterile. The recurrence of the menstruation is generally regular ; sometimes it is delayed, and sometimes there is a sense of pelvic discomfort before the menstrual flow, but not always. The chief symptom is the pain which comes on usually during the first day, sometimes later, and increases in severity, and is somewhat intermittent in character until the membrane is expelled, when it rather abruptly subsides. The flow sometimes is scanty previous to the expulsion of the membrane, and after that it is generally quite free ; at times abnor- mally so, and occasionally small clots are passed. Sometimes there is a leucorrhceal discharge succeeding the men- strual flow, the discharge being occasionally tinged with blood. In 232 DISEASES OF AVOMEX. other cases the meiistnial flow subsides after the expulsion of the memljrane, and no leueorrli(ea of any account occurs afterward. There is really nothiufj; in the clinical history of this affection by which it can be positively distinguished from dysnienorrhcea due to „^^^, other causes. Hence 5S«i& Fig 102. — Sketch of a dysmenorrhceal membrane, as seen under water (Simpson). the diagnosis nuist always depend upon the j)hysical signs. ' — In order to make a diagnosis, it is ab- solutely necessary that the men»brane expelled should be preserved and ex- amined. The gross ajipearances of the specimen are usual- ly all that is neces- sary to satisfy the diagnostician re- garding the nature of the affection, but in cases where there is a doubt the microscope must be called in to aid in the diagnosis. The morbid materials expelled from the uteriLs whicli simulate the membrane produced in this affection are the.decidua expelled in abortion in the earliest stages of pregnancy ; the masses of filjrin which have formed in the uterus in menorrhagia ; very dense masses of secretion from the cervix ; and the membranous-looking shreds ex- pelled from the cervix and vagina after astringent or caustic applica- tions. The decidiia in early abortion is most difficult to distinguish from the menstrual membrane. In the early abortion the membrane ex- pelled is usually larger and more 103. — Membrane of membranous dvsmenorrhoea (Barnes). MEMBRANOUS DYSMENORRIICEA. 233 ,trl >''i,?»Vv, ovoid or round, and not so markedly triangular as the decidua of menstruation, and is also thicker, and usually is accompanied with villi of the chorion. If there is still a doubt, the microscope re- veals the fact that the menstrual membrane possesses only small cells, while those of the decidua- vera menibrane are so great as to be easily distinguislied. There is a decided microscopic difference in the epithelium, the tubes, and the inter-glandular tissue. This difference between the two membranes is not only in the decidua of early abortion, but also in the decidua of extra-uter- ine pregnancy. In being tlnis able to distinguish be- tween the decidua of preg- nancy and the membrane of menstruation, the only great difficulty in the diagnosis is overcome. The shreds of fibrin ex- pelled from the uterus some- times look membranous in form, but have none of the structure ol the mucous membrane, and hence can be detected on cursory ex- amination. The same may be said of the masses of unusually dense secretion of the cervix. The membra- nous shreds that come from tbe cervix and the vagina as the result of astringent and caustic applications resemble at first sight the menstrual mem- brane. The most perfect of these exfoliations from the vagina I have seen after the use of the persulphate of iron ; these speci- mens, however, are much thinner and differ entirely in structure, being made up mostly of epithelium, and therefore need not be mis- taken for the menstrual membrane. With due attention to the membrane expelled, the diagnosis can be made with great certainty. Causation. — Discarding the current views regarding membranous dysmenorrhoea — that is, that it is due to infiammation, or else the re- sult of gestation — one is left without any very rational view to offer Fig. 104. — The decidual membrane expelled in abortion. The serotinal attachment is drawn out to a pedicle. 23-1 DISEASES OF WOMEN. regarding its causation. While it is not, perhaps, the part of wisdom to discredit the accepted views on any question in medicine until one has something more reliable to otTer, still, if the causes assigned can be readily shown to be incorrect, it is intinitely better and safer to be entirely in ignorance of the causes of things than to attribute them to the wrong causes. Fortunately, however, while I find my- self at variance with most of the recent authorities regarding the cause of this affection, I am in perfect harmony with the views of Dr. Oldham, who was the first to discover " dysmenorrhtjea mem- branacea.'' Dr. Oldham distinctly pointed out the characteristics of this affec- tion, and stated that the membrane is formed under abnormal ovarian stimulus ; and I am fully satisfied that he was not only the discoverer of the disease, but also conceived the true idea regarding the cause of it — viz., some undue ovarian intiuence or sexual excitation. In other words, it would appear to be some derangement of innervation and nutrition. Taking this view of the causation, I expect to find myself in har- mony with the neurologists at least. This class of specialists mani- fests a willingness to trace many diseases originally to some derange- ment of the nervous system, when they find anything like good reasons for so doing. Hence. I expect their support in choosing, as 1 do, to believe that the starting-point in the pathology of this affec- tion must be some derangement of innervation produced by disease or functional derangement of the ov^aries. Confirmation of this view regarding the cause of membranous dysmenorrhnea may be found in studving the agencies which give rise to other morbid states of the uterus, like the fibroid growth, for example, which in its anatomical elements does not differ especially from the tissues of the uterus from which it springs; and, if we could find the cause of this devi- ation from healthy nutrition, it might be applicable to the disease under discussion. But, unfortunately, the causes of fibroid tumors given in our literature are unsatisfactory, and by no means well sus- tained. From the fact that uterine fibroids are more common in sterile women than in others, it would appear that sterility predisposes to their development, and perhaps no better explanation of the cause of these growths has ever been given than that of my somewhat hu- morous friend, who said that "the uterus, being prepared for normal work and not finding it to do, took up the development of fibroids as a sort of occupation for its formative powers."" May it not, then, l)e that a well-defined predisposition to reproduction, uncalled for by MEMBRANOUS DYSMENORRHOEA. 235 gestation, excites this morbid action on the part of the uterus which leads to this abnormal exfoliation of its mucous membrane ? This view might at least be entertained, because in other cases, when we are unable to detect the cause of a disease in something that is tan- gible, we usually attril)uto it to deranged innervation and conse- quent malnutrition. This view of the causation is, to some extent, sustained by the etfect of medicines upon the lesions. This aifec- tio!i has always been recognized as one that is often difficult to cure, many times incurable, in the hands of the most competent phy- sicians and surgeons. This possibly may have been due to misap- prehension of the nature and cause of the disease, and hence falla- cious therapeutics, rather than to the incurable character of the disease. In favor of this line of thought I may state that the patients whom I have treated in years past, on the theory that the cause was indammatory, have derived little benefit, while those who were treated foi* deranged innervation, malnutrition, and undue ovarian excitation, have made very much better progress. I am inclined to attribute most of the trouble to ovarian influence, the condition of the ovaries being that of an undue nerve excitation and possible congestion. I have been led to this belief by two facts : that the majority of the patients that I have seen have been subjects of a highly nervous organization, and in most of them there has been tenderness of the ovaries, and pain at times, without there being any evidence of ovaritis. The rheumatic diathesis is said to favor this affection, and it is possible that this may be so, although I am unable to recall any of my patients as being rheumatic ; neither have I been able to trace it to the tubercular or strumous diathesis, nor to syphilis. It is certain, however, that, if either of these conditions existed, it would have its influence in helping to keep up the uterine trouble, and every effort should therefore be made to relieve it by treatment. Treatment. — The treatment of this affection is necessarily both palliative and curative. While the patient is suffering during the expulsion of the membrane, it is very necessary to relieve the j)ain as far as possible. This, of course, can be most promptly done by the use of opium, which should be avoided if possible, however, be- cause of its after-effects. Chloral hydrate answers fairly well in some cases. I was induced to try this agent by the accounts given of its effects in reheving the pains of the first stage of labor. I am not sure that it has any ad- vantages over chloroform, camphor, and belladonna, or conium and 236 DISEASES OF WOMEN. cannabis Indica ; in fact, in the majority of cases, one has an oi> portunity to try several agents, and, of course, tlie patient will decide which gives most relief. Indications for general treatment are to quiet all nervous disturbance and to improve the general nutrition of the mucous membrane. It so happens that when the first part is attended to the latter will follow in due order. To quiet the nervous irritation and disturbance there is nothing that equals the bromide of sodium. This should be given in twenty- or thirty-grain doses three times a day for ten days or two weeks before the menstrual period. And, if the pain is not severe enough to require the addition of some of the remedies already named to re- lieve it, the bromide may be continued throughout the menstrual period and several days after. From this it would appear that the bromide is to be used continuously ; but one or two weeks in each month it can be omitted. When the l)romide has been employed for some time, and it seems desirable to give it up, conium may be administered in moderate doses combined with camphor, if the pa- tient is weak. If there is any evidence of the rheumatic diathesis, the bromide of lithium should be given. Next to quieting the nerv- ous system, any debility that may exist should be overcome by nerve tonics. Undue nervous excitation so often goes liand in hand with nervous depression that in many cases it is necessary to combine the tonic and sedative treatment. All the remedies which may be used need not be here mentioned. In regard to the modification of nu- trition, it need only be said that any accompanying derangements of the digestive organs that may be found should receive careful atten- tion ; but this hardly need be mentioned in this connection. My rule of treatment has been, after subduing all nervous dis- turbances, to put the patient upon the iodide of sodium in case she is in fair strength and inclined to flesh. If there is amemia, I prefer the iodide of iron. If these do not aecomplLsh the object, I employ mercury, giving it in small doses, never continuing it long enough to produce sahvation, carefully watching to avoid this. In cases of anaemia, where I have feared the debilitating effect of this alterative, I have given the bichloride of mercury with iron. After keeping them upon this treatment until I could see some evidence of its effects, I have then put them upon iodine and arsenic. In regard to local treatment, I have been entirely guided by the views of the pathology as expressed above, and have therefore em- ployed alteratives and sedatives almost exclusively. Of these I have found iodoform most effectual. I have also used iodine and mer- cury with advantage. In cases where I have found any complications MEMBRANOUS DYSMENORRHGEA. 237 I have carefully attended to them, restoring displacements and cor- recting flexions, and so on. Wlien the canal of the cervix lias been at all constricted 1 have enlarged it by incision and dilatation. When the congestion which occurs at the menstrual period has not subsided in a few days, I have eini)loyed the warm-water douche. After this, I have applied to the cavity of the uterus small bougies of cocoa-butter with as much iodoform as they would take up. Three or four grains of iodoform mixed with vaseline that has l>een lique- fied by heat, and introduced through the pipette, is j^erhaps the Ijest method of applying it. This has been introduced once a week or once every five days. When there has been much tenderness, and the use of the pencils has caused pain, I formerly used aconite and opium and iodine ; this I have introduced into the cavity of the uterus. I am now trjdng cocaine to subdue the tenderness as a pre- paratory means to the use of the iodoform. But so far this new remedy has not been a perfect success. In cases where this has failed and the uterus was not especially sensitive to intra-uterine medication, I have instilled mto the uterine cavity a few drops of a 5-per-cent solution of carbolic acid, making one application a few days after the menstrual flow and not repeat- ing it until the next period. In the interval I have used the iodo- form. I have also. used the fluid extract of conium and hydrastis Canadensis ; but this I have found gives more pain than any of the other applications that I have used; and so of late I have used an infusion of the hydrastis alone, which ajjpears to answer as well and gives less pain. HISTORY OF CASES. Case I. Membranous Dysmenorrhcea in a Married Lady who was never Pregnant. — This patient was forty-one years of age, of good constitution, and had been married eight years. She began to men- struate at thirteen, and continued to do so regularly and normally until she was twenty-one ; then she began to have occasional pain, about the menstrual period, in the region of the ovaries. About a year after this she began to have severe uterine pains during the menses, and states that she occasionally passed masses that looked like membrane from the uterus ; they were small, however, and did not appear at each period. After her marriage the pain at the menstrual periods became worse, and almost every month she passed a membranous cast of the uterus. The usual history of each menstruation is that the flow be- gins not very free, and, after continuing for about five hours, the pain becomes very intense and lasts from three to eight hours, when 238 DISEASES OF WOMEN. she expels tlio membrane :inmia. Even where this does not occur the injury interrupts, more or less, the process of involution and produces all the troubles Avhich usu- ally follow therefrom. There is more or less inflammatory action set up in the jiarts, and the efforts at healing the laceration develop mucii scar tissue and not unfrequently enlargement and hardening of the parts from areolar hyperplasia. The scar tissue thus formed and the sclerosed tissues beneath and around the scars are often tender and painful. All this proves to he a source of local irritation, and sometimes causes much general disturbance throng] i reflex action. The inflam- LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 243 inatory action wliicli immediately follows the injury does not entirely subside when cicatrization is complete. The iiitlammation in the cervical mucous membrane lingers there, and hence old lacerations are generally accompanied with marked catarrh of the cervical mem- brane. This is kept up and often aggravated by the eversion or rolling outward of the divided walls of the cervix, which exjjoses the cervical mucous membrane to friction and the acid secretions of the vagina. Therefore, the cervical endometritis accompanying lacerations has no natural tendency to disappear. It is also rebel- lious to treatment, and finally, if it is subdued, it soon returns unless the original injury is repaired. In lacerations of long standing, and especially those that have been treated by caustics, the mucous folli- cles become closed and distended, assuming the form of small cysts. The presence of these distended cysts increases the size of the cer- vix and gives an irregular outline to the surfaces under which they are situated. By pressure they cause absorption of the tissues of the cervix, so that when they are punctured or ruptured and their con- tents are evacuated the cervix becomes diminished below the original size. The several forms of laceration of the cervix uteri most fre- quently seen in practice are : 1. Lateral lacerations of one or both its walls. 2. Antero-posterior laceration ; usually found in the posterior wall, but occasionally involving both. 3. Multiple lacerations, usually three in number, but occasionally more. 4. Incomplete lacerations, in which the solution of continuity extends from within outward through the mucous membrane and muscular walls of the cervix, but not through the mucous membrane of the vagina. This form of injury is generally bilateral, but occa- sionally the lacerations are multiple, involving the two walls laterally and the posterior and anterior walls also. Sometimes two of these forms of injury are found together, as, for example, a complete bilateral laceration and an incomplete lacer- ation of the anterior wall of the cervix. The first, and by far the most common of these injuries, lateral laceration, presents several varieties. The bilateral laceration, in its typical form, divides the cervix into two equal parts, and extends up to the vaginal junction. As seen at times, the laceration is superficial, extending not more than half way up to the vaginal junction ; again, the laceration may extend on one side up above the vaginal junction, while on the other 244 DISEASES OF WOMEN. it is much less exteusive. In other cases the liilatcnil laceration divides the cervix into two nnc<|ual parts, the anterior portion usu- ally being the larger (Fiir. 10.')). The morbid states of the cervix uteri which accom])any this form of injury and are caused by it vary i^reatly. In the simi)lest forms the cervix, in the aggre- «j:ate, is not much en- larged ; the divided halves rest nearly to- gether, and protect the mucous mem- brane of the cervi- cal canal. Under these circumstances a slight hyperaemia of the cervical mu- cous membrane and a slight leucorrhoea are all the lesions present in many cases. Even these are not always found. In other cases the halves of the cervix are widely separated. The mucous membrane of the canal is everted, and is generally de- nuded of its epithelium, markedly congested, often thickened and irreo;u]ar, and covered ^vith a profuse leucorrhoeal discharge. In still other cases there is, in addition to the above eversion, a marked liy- perplasia of all the tis- sues, especially on the inner surfaces. The new tissue fills in the space between the halves of the cervix, so that the opposite sides of the laceration can not be brought togeth- er (Fig 100). This superabund- FiG. 105. — Bilateral laceration ; unequal division of the cervix. i Fig. 106.- -Bilateral laceration, with thickening of the everted lips. LACERATIONS OF THE CERVIX UTERI FROM PARTURITION. 245 Fig. lt)7. — Extensive multiple lacerations. ant tissue is produced by arrest of involution and areolar hyperplasia. The tissue is denser than norinal, and, in fact, presents a true sclerosis. Lacerations of the an- tero - posterior walls, while they are said by Emmet to occur frequently, are comparatively less often seen, because they generally heal promptly and com- ])letely of their own accord. Where they are found, they are generally complicated ■svith all the lesions de- scribed in connection with lateral injuries. Multiple lacerations vary greatly in number and ex- tent. A trilateral laceration is most frequently met with. The cervix is usually di- vided into three unequal parts, as seen in Fig. 107. This may be called a complete multiple laceration, because all the tissues of the cervix are divided. There is another form of this injury in which there are a number of lacer- ations which extend from within outward, but do not involve the vaginal mucous membrane (Fig. 108). The lateral incomplete lac- eration may be unilateral or bilateral. Generally, both walls are divided from within outward to the outer mucous coat. This injury is over- looked quite often by gynecol- ogists. At least, I infer this from the fact that Dr. Em- met is the only writer of all those whose works I have consulted M'ho mentions it. Fm. lOS.— Multiple incomplete lacerations g m. w^% I^^Bh^,;. lo 1 24G DISEASES OF WOMEN. Fig. 109. — Incomplete bilateral laceration. It is usually described as a patulous or dilated eoudition of the cervix, and to the touch aud iuspection it appears to be so, but a careful exaniiuation shows that the cervix is divided into two parts that are he]hysician told me that the child was large in proportion to the mother, and that he was obliged to deliver with forceps while the head was high in the pelvis. In the delivery, much damage was done to the cervix and vagina, but the pelvic floor was not torn. She recovered slowly from her labor, and continued to have a dis- charge and pain, mostly of a neuralgic character. I found a semicircular band of scar tissue running from the ramus of the pubes, high up and around the vagina to the opposite side. The scar was unyielding, so that the finger Qould be intro- duced with some difficulty into the vagina. It extended deep down below the mucous membrane of the vagina, and at tlie upper ends was fixed to the pubic bones. It appeared to me that in the original injury the whole of the vaginal wall, together with the bulbo-caver- nosus muscles and the anterior fibers of the levator-ani muscle had been torn away from its attachments to the floor of the pelvis. I have never before nor since seen an injury exactly like this, and hence I do not know positively how it was produced, but pre- sume it occurred as I have stated. About half an inch from the median line of the posterior wall of the vagina the scar tissue was divided on each side. Traction backward was then made with a narrow-bladed Sims's speculum which distended the vulva and at the same time brought the ends of the incisions, which were made parallel to the axis of the vagina, together. The sides of the incis- ions were held together with sutures. The immediate effect of this operation was to relieve, in a marked degree, the pains from which the patient had suffered. It also restored the dilatability of the vulva, so that the patient could resume her sexual duties when the incisions had healed. She still has pain and tenderness, and I pre- sume that there will be contraction again which will require further treatment. The case being a recent one, its future history has yet to be de- veloped. CHAPTER XVI. ESr\'ERSION OF THE UTERUS. Intersion may be defined as a turning inside out of the uterus, in which its walls descend into its cavity. The external surface l>e- coraes the internal, and the fundus uteri, which should be highest in the pelvis, becomes lowest. There are several de- grees of inversion, varying from a mere depression of a portion of the uterus, to a complete inversion. In practice two degrees can be made out, and these can be easily comprehended by a reference to Figs. 123 and 124. In tiie first form there is a depression of one side or partial inversion ; the second form is a com- plete inversion. When the vagina is also inverted, the condition is known as inversion and prolapsus. This complication occurs as a rule in the puer- peral state only. In all cases of inversion, at least at the time when this accident occurs, enlargement and relaxation of tlie tissues of the uterus are found. This is particularly so in the puerperal state, when inversion oc- curs most frequently. Sym])toinatolo(j]i. — The severity of the symptoms depends ujjon the extent of the inversion and the sudden- ness with which it occurs. Partial inversion, brought about gradually, may not cause suffi- cient disturbance to attract attention. The symptoms of shock are present when the in- version occurs suddenly, as it does in the puer- peral state. The shock and pain are more marked, as a rule, when the inversion is accom- panied with prolapsus. In a few recorded cases, the shock alone proved fatal. Fig. 123.— Partial inversion (Thom- as). If there is great Fig. 124. — f'omplcte version (Thomas). INVERSION OF THE UTERUS. 267 hsemorrliage as well as shock, the patient is more likely to suc- cumb. Haemorrhage occurs when the inversion is incomplete as well as when complete, especially at the time when the accident takes place. The presence of the uterus in tlie vagina causes disturbance of the bladder and rectum, by pressure. These are the symptoms which occur in acute inversion, and if the patient passes safely through this stage then the symptoms of chronic inversion appear. In complete inversion after the uterus has fully contracted, the haemorrhage is not profuse, except at the menstrual periods, when there may be menorrhagia. This is generally a sero-sanguinolent discharge for the first week or even later, then the irritation may cause congestion, ulceration, and general inflammation of the vagina and mucous membrane of the uterus, and a consequent leucorrhoea and pumlent discharge. If the uterus remain outside of the vagina it usually becomes dry from exposure to the air, but it also becomes abraded in places and finally ulceration occurs. Whether the uterus remain in the vagina or becomes completely prolapsed, the inflammation, ulcera- tion, h8emorrhage, and the purulent discharge which arise there- from may break down the general health of the patient and the case terminate fatally. Throughout all this there is pelvic pain and tenesmus. Physical Signs. — The diagnosis (which is not by any means easy in all cases) depends largely upon the physical signs. These differ somewhat in recent cases and in those of long standing. When the inversion occurs after labor, the bimanual touch wdll reveal two very important facts. The uterus is not found in its position behind the pubes, but occupies the pelvic cavity, and can be outlined in the vagina. By moving the uterus between the two hands, the fundus and body will be found below in the true pelvis, while in place of the fundus being found above, a depres- sion in the uterus can be felt at the superior strait. If the vagi- nal touch alone is relied upon, the condition will be taken for the coming placenta. The placenta being attached to the uterus, as it usually is at this time, obscures the uterus, but upon trying to re- move it from the vagina by hooking down one of its edges with the finger, the solid uterus will be found above the placenta, the two being united, but easily separated. While this exploration and re- moval of the placenta — if it is present — are going on, the left hand is placed upon the abdomen, and the absence of the uterus above is 268 DISEASES OF WOMEN. observed, as already stated. Passing; the tincjer above the nuu^s in the vagina, in search of the walls of the cervix and the us uteri, a furrow is felt which shows that the walls of the vagina and uterus are continuous, and that there is no opening into the cavity of the uterus. These signs will suffice for any one who is familiar with the normal condition of the parts in labor, to make a diagnosis. In fact, there are only two things which could easily be mistaken for inversion, a fibrous tmnor and the presenting membranes in a case of twins. The latter could be made out by palpating the abdomen and finding the large uterus with the child, and the other, though less easily, could be detected by the presence of the uterus behind the pubes and the presence of the uterine canal which could be fol- lowed by the touch beyond the tumor. These physical signs should be sufficient to suggest the diagnosis, which can be confirmed by restoring the inversion. " This is easily accomplished by any one familiar with obstetric manipulations. When there is complete prolapsus, as well as inver- sion, the diagnosis can be made by inspection. The form of the tumor, the appearance of its mucous membrane, the presence of the placenta, or, in case that it has been detached, the irregular appearance of the placental site compared with the rest of the membrane, and the contractions of the uterus, which can be noticed while handling the parts, are quite sufficient to settle the diagnosis. In old cases, in which the uterus has become reduced to its origi- nal size by involution, the diagnosis is not so easy as in recent cases, and yet, by the aid of the sound and the bimanual touch, the diag- nosis can be made with certainty in the great majority of cases. By the touch the round tumor is found projecting into the va- gina, aud the lips of the os externum can be distinguished surround- ing the tumor. The fornices can sometimes be made out also. In most of the cases that I have seen the cervix was thinned out so that its walls felt as if continuous with the vagina, and the fornices were also obliterated. In either condition the evidence is in favor of inversion, but when the cervix can be found the evidence is more valuable, especially if the finger can be passed up into the cervix between its walls and the body of the uterus. There the mucous membrane of the cervix can be felt refiected upon the tumor to the same extent all around. These signs can be made out by the vaginal touch. The biman- ual touch is still more satisfactory. By that method the uterus can be raised up in the pelvis by the finger or fingers of one hand in the INVERSION OF THE UTERUS. 269 vao"ina, while with the other liand a body with a depression in its center can be felt through the wall oi the abdomen. In spare pa- tients with relaxed abdominal nmscles the bimanual touch will usu- ally suffice to make the diagnosis quite positive. In doubtful cases the uterus may be drawn down with a tenacu- lum or pressed dowm by a hand upon the abdomen, while a rectal examination with the index-finger of the other hand is made. In this way the fingers of the two hands may be made to meet above the uterus, and at the same time the finger in the rectum may detect the cup-shaj^ed end of the uterus above. In case the bimanual touch is not practicable, owing to the patient being very stout, or the abdominal muscles unyielding, the same signs can be obtained by passing a sound into the bladder and turning it backward until it meets the finger in the rectum above the uterus. To facilitate either or both of these methods of examination by the touch, the uterus may be drawn downward by a noose made of tape or rubber passed aronnd the cervix, as recommended by Barnes. Chronic inversion is likely to be mistaken for fibrous polypus of the uterus. A number of mis- takes of this kind are on record, but most of them occurred before the time when the uterine sound and the bimanual touch were employed for diag- nostic purposes. The differentiation can usually be made by the methods of examination already de- scribed. In polypus, the uterine sound can be passed be- yond the tumor into the uterus above, whereas, in inversion, the progress of the sound is arrested at the neck of the uterus. The bimanual touch, rec- tal touch, and vesico-rectal examination, reveal the uterus above the tumor. The inverted uterus is tender, the polypus is not. This sign is of much value. By seizing the tumor and turning it around it will move in the cervix if it is a polypus. The Fig. 126— Polypus i^^q surfaces will glide backward and forward ui^on simulating com- i t i . . plete inversion each other, but m inversion no such motion can be (Thomas). produced. Incomplete inversion is not easily diag- nosticated under the most favorable circumstances. To distinguish partial inversion from an intra-uterine fibroid of small size is next to Fig. 125. — Polj-pus simulating partial inversion (Thom- as). /::m^-., \ 270 DISEASES OF WOMEN. impossible. Fortunately, sueli a diagnosis is not imperative, because active treatment is not often called for in these incomplete and doubtful cases. Prognosis. — Inversion is always a grave condition. Tf it does not prove fatal at tirst from shock and luemorrhage, it becomes a continuous ti-ouble, which either gradually undermines the general health, and thereby shortens life, or else keeps the subject in a state of impaired usefulness and ill health. There is no certain tendency to natural recovery, and although quite a number of cases have been recorded in which spontaneous rej>lacement of the uterus was said to have taken place, such an occurrence must be very rare. From the fact that most of these cases are recorded by the older authors, it is possible that in some of them the diagnosis was incorrect. One thing is certain, no such fortunate termination should be expected or relied upon. Without treatment the condition will probably continue. The ])rognosis is rendered more grave by the fact that the treatment is not without danger. There are several methods of treating inversion, but neither of them is wholly safe. This statement applies to chronic inversion. When the inversion occurs during labor, immediate replacement is easy and not attended with any great risk. The dangers in restor- ing an old inversion are from inflammation and septicaemia, pro- duced by the injm'ies to the uterus, vagina, and adjoining parts during the violent efforts necessary to accomplish the object. These dangers are greatly increased by unskillful operating, still unfortunate results have occurred in the practice of the most skillful surgeons. Causation. — The conditions which predispose to inversion are enlargement of the uterus and relaxation of its tissues. These are best illustrated in the puerperal state. Inversion can not take place in a normal non-puerperal uterus. The condition of the uterus im- mediately after the delivery of the child is most favorable to the accident, and it is at this time and under these circumstances that inversion most frequently occurs. Predisposing causes, other than pregnancy or parturition, are known, but they are operative in bringing about a condition of en- largement of the uterus and relaxation of its tissues. These are distention of the uterus from tumors or fluids. The relaxation of tissues which is found in imperfect involution and prolapsus is also given as a predisposing cause, but I have not seen the record of any case which could be clearly traced to this cause. To briefly restate this matter, the tendencies to inversion depend upon enlargement, distention, and relaxation. The exciting causes INVERSION OF THE UTERUS. 271 are traction or pressure upon the fundus uteri when it is in a con- dition favorable to inversion. The direct causes are traction upon the umbilical cord or pressure upon the fundus uteri at the moment when the child is expelled, or sudden delivery of the child, either by traction or the natural muscular efforts. Muscular eJfforts, when there is relaxation of the uterus, are meutioned as a cause, and cases are recorded in which inversion is said to have occurred in that way, but that cause must be seldom operative. Prolapsus uteri is also credited with having some causative relation to inversion, but I have no knowledge on this subject. Next to parturition come intra- uterine tumors in the causation of inversion. All the cases which have come directly under my own observation, or that have come to my knowledge indirectly through competent contemporary authori- ties, have been clearly traceable to parturition or hbrous polypi. The conditions are alike in pregnancy and intra-uterine tumors, so far as the uterus is concerned in the predisposition to inversion. There is enlargement of the uterus with relaxation followed by muscular contraction. During the growth of the tumor the uterus increases in size, and finally endeavors to expel the growth, and when the muscular contractions are going on the fundus uteri is dragged downward by the pedicle of the tumor. In this way all the predisposing and mechanical conditions are jjresent which are most competent to cause inversion. Treatment. — There are several methods of managing inversion. Of course the indications are to restore the uterus to its proper rela- tions. This is often difficult in chronic inversion, and sometimes impossible, hence other means must be employed to give all relief possible. In case replacement can not be accomplished, the most promi- nent symptoms should be relieved by treatment ; haemorrhage should be controlled by astringents and inflammation should be reduced by appropriate care. Inversion can be successfully treated if seen im- mediately after it occurs. The method of operating is to grasp the uterus in the right hand, and carry it upward until the cervix can be felt with the left hand through the abdominal wall ; counter- pressure is then made while the fundus uteri is being forced upward with the right hand in the vagina. The abdominal walls being thor- oughly relaxed, as they are immediately after confinement, the bi- manual manipulations are comparatively easy. The os uteri can be felt with the left hand, and by pressing the abdominal wall down into it with the fingers it is dilated, and when the fundus is restored far enough to engage in the os, the lips of the cervix can be pushed 272 DISEASES OF WOMEN, over the fuiidus, in tljc same way that they are pushed over the head of the child in dehverv. Cases of Recent Inversion. — I have seen four cases of inversion soon after they occurred, one in my own practice and three in con- sultation. Two of these were inversion with complete prolapsus, and the otlier two were uncomi)licated. My own ease was that of a strong young woman in her second confinement. The pelvic outlet was rather narrow, and the perinseuin rigid, so that the pains which ex- pelled the head were most powerful, especially the last one. The moment that the head passed the perinseum the whole child was expelled with extraordinary force. While the nurse rested her hand upon the abdomen I tied the cord, and then I found the placenta presenting at the vulva, I passed my linger up to bring the edge down and then deliver it, but I found a hai'd body above to which it was attached. I then passed my left hand over the abdomen, and found that the uterus was not there. Inversion was suspected, and I at once sepai'ated and removed the placenta, which was very easily done in this case, and then witli bimanual manipulation restored the uterus with the greatest facility. The removal of the placenta and the reduction of the uterus occupied but a moment. The patient did not apparently suffer, but I think that there was slight shock and consequent anaesthesia, so that the reduction was painless and finished before she reacted. I found I could grasp the fundus easily, and by making firm ]->ress- m'e upon one comer with my thumb and upon the other with the middle finger, and thus raising the whole uterus up until I could feel the OS with the fingers of the left hand, the pressure and counter- pressure effected the reduction with ease and rapidity. I found that the reduction of one horn first, as recommended by Dr. Noeggerath, answered well, first because the horn was more easily brought under pressure, and also because it appeared to yield most readily. In grasping the uterus the thumb naturally rests upon one horn, and by making firm pressure at that ]iart, which is more convenient than to press upon the center of the fundus, it appears to be the natural way of effecting reduction by the unaided hand. The hand was made to follow up the reduction, so that when it was completed the hand was fully within the utenis, and it was left there, and pressure upon the utenis with the left hand upon the abdomen was made until the uterus contracted and the hand was expelled. This was the part of the procedure which required the most time, owing to the uterus being slow to contract. INVERSION (;F the UTERUS. 273 The three other cases were seen in the practice of others. One that I saw with Dr. A. R. Matheson, was a complete prolapsus as well as inversion. I saw the patient in about half an hour after the inversion occurred. There was considerable shock, and the doctor was obliged to hold the uterus with the placenta attached in the firm grasp of both hands to prevent haemorrhage. The prolapsus was reduced first and then the inversion, in the same way and in about the same time as the case just described. I saw another case of in- version and prolapsus with Di-. Bliss. It was of three days' stand- ing. The doctor did not attend in confinement, but was called to see the patient because of the inversion. When I saw her she was exceedingly weak. The pulse 140, and feeble. She was anasmic, and the abdomen greatly distended and tender to the touch. The uterus was resting between the limbs, and parts of the mucous mem- brane here and there were in a sloughing condition, and other por- tions were dry and glazed looking. Yasehne was applied over the whole surface, and the uterus first pushed up into the vagina and then grasped with the hand, and the inversion reduced. The opera- tion in this case was more difficult and prolonged. Owing to the tympanitic state of the abdomen it was difficult to make proper pressure upon the lips of the cervix, and that was a cause of delay. The extreme depression of the patient (while it raised a doubt as to her being able to stand the operation of reduction) gave that com- plete relaxation and general anaesthesia which was favorable. No anaesthetic was given. In about ten minutes the reduction was effected. The patient recovered. One other case I saw with Dr. Bodkin. The inversion occurred at two o'clock, and three hours later it was reduced. There was some excitement of the pulse, and the patient had pelvic pain. There was very little haemorrhage, but there had been considerable at the confinement. Chloroform was administered, and the reduc- tion was accomplished by the same method. More time was required than in either of the other cases, because there was more contraction of the uterus, but by means of upward pressure and counter-pressure upon the lips of the cervix the reduction was accomplished in a short time. Chronic inversion is far more difficult to manage than recent in- version. In fact, when the inversion has existed long enough to permit the uterus to regain its original size, or nearly so, by involu- tion, and has contracted firmly, its reduction is always difficult, and sometimes impossible. This has led surgeons to devise several methods of reducing this inversion under these circumstances. 19 274 DISEASES OK AVOMEX. Dr. Thomas has elassiiied tliese methods as follows : ^Methods of effecting gradual reduction and methods of effecting rapid reduc- tion. The method of reduction by taxis is the oldest and most re- liable, and should be tried first in all cases, because, if it fails, the gradual reduction may be tried subsequently, ])rovidiiig that the taxis is not so violent and prolonged as to cause fatal inflammation. Tiiere are several ways of applying taxis, but only two ways of attaining the desired end. The pi'inci])le of tiie one is to reduce first that portion which was last inverted, and the other is to reduce the fundus first and dilate the cervix at the same time, so that the portion first inverted is first reduced. To some extent both objects may be attained at the same time by so manii)ulating that both changes of position may go on together. The method of oj)erating is as follows : The patient should be placed upon the operating table in the dorsal position, and the surge'on's liand carefully in- troduced into the vagina. It is necessary to dilate the vagina, in the great majority of cases, in order to admit the hand. Some- times the dilatation is difhcult to accomplish with the hand without mpturing the vagina. When this is the case, dilatation as a pre- liminary measure should be accomplished by stretching witii the speculum and the inflatable rubber bag. The right hand is introduced into the vagina and the uteras grasped with the thumb and fingers. The uterus is compressed and at the same time carried u])ward, and held against the left hand, which makes the counter-pressure. The manipulations with the right hand should be so directed that one or both horns should be reduced first. The cervix should be dilated, and reduction begun at that point at the same time that reduction of the horn is effected. Fortunately, the efforts to accomplish the one favor the other. This method of Noeggerath's, which has already been discussed, is that which I prefer, but there are certain modifications which are of value in certain cases, and should be employed when failure of the one method makes the trial of the modified methods necessary. For example, Dr. Thomas has employed a cone of wood in place of the left hand for dilating the cervix. In thin patients this can be inserted into the ring of the cervix, which can be felt through the abdominal walls, and gradually forced into the cervix until sufficient dilatation is obtained. Barren placed the fingers around the body of the uterus and the thumb upon the fundus, and forced the cervix against the sacrum to secure counter-pressure. Courty's method consists in using the index and middle fingers of the left hand in the rectum, to dilate the cervix and make couu- INVERSION OF THE UTERUS. 2Y5 ter-pressure. This method of using the left liand combined with the method of Dr. Noeggerath is higlily commended by Dr. T. G. Thomas. Dr. Emmet describes his method as follows : " In 18C5 I succeeded in eifectiiig a reduction by passing my hand into the va- gina, and, with the fingers and thumb encircling the })ortioii of the body close to the seat of inversion, the fundus was allowed to rest in the palm of the hand. This portion of the body was firmly grasped, pu8hed upward, and the fingers were then immediately separated to their utmost ; at the same time the other hand, was em- ployed over the abdomen in the attempt to roll out the part form- ing the ring, by sliding the abdominal parietes over its edge. This raanoBUvre was repeated and .continued. At length, as the trans- verse diameter of the uterine cervix and os was increased, by lateral dilatation with the outspread fingers, the long diameter of the body became shortened, and. the degree of inversion proportionately less- ened. After the body had advanced w^ell within the cervix, steady upward pressure upon the fundus was applied by the tips of all the fingers brought together." This method, which appears to me like Yandel's, is natural in theory, but in trying it I have found that I could not separate the fingers to any extent, owing to the fact that the extensor muscles are feeble in their action, and not capable of doing more than resisting the pressure of the vagina. Dr. Emmet also commends the closure of the cervix with silver sutures in cases where the reduction can not be completed. He gives a diagram representing the cervix as being about three times as long as the body, and drawn over the fundus and held there by sutures. I have never practiced this treatment for the reason that in all the cases in which I have been able to get the body and fun- dus reduced wholly within the cervix, the complete reduction has been easily and speedily accomplished. Again, I can not see how sutures of any kind would resist the pressure of a partially inverted uterus, with a strong tendency, which there always is, to become further inverted. Repositors have been used to aid in the taxis by De Paul, Avel- ing. White, and others. The most useful of these, and one that fulfills the requirements is that invented by Dr. John Byrne, of Brooklyn. It consists of a cup and stem with a movable plug or button in its center. The button forms the bottom of the cup when it is placed over the uterus, and while the cup is in place the plug is pushed forward by the screw in the handle against the fundus, and in that way makes the required upward pressure. 276 DISEASES OF WOMEN. Fig. 127. — Byrne's method of reduction. Fig. 127 shows Dr. Byrne's repositor as used, and its cup or bell-shaped instrument with the plug and screw adjustment for making counter - pressure and dilatation of the cervix. A piston in the lower cup pushes the fundus up. There are a numljer of ad- justable cups which can be adapted to the require- ments of different cases. Cases are sometimes met M'hich can not be restored by taxis. Kesort must then be had to such means as gradual reduction by con- tinuous pressure. Thiti is effected by a cup and stem (Fig. 128) which are held in place by a perineal band of i-ubber or elastic fastened to a bandage applied around the pc^lvis. When using this instrument care must be taken to keep the uterus in the line of press- ure. When the va- gina is relaxed the uterus may fall backward or for- ward out of the line of pressure ; this can be avoided by using a tampon around the uterus, which may be worn for two days if no great distress is caused by it. It should be examined from time to time, and if there is much Fig. 128. — Cup pessary to exercise gradual pressure (Thomas) INVERSION OF THE UTERUS. 277 irritation the instrument should be removed and vaginal injections used until relief is obtained, and the use of the instrument may be aeain resumed. The rubber bag tilled with water answers a very good purpose. To apply this, the patient should be placed in Sims's position, and through the speculum, the upper portion of tlie space between the uterus and vagina should be tilled with prepared wool ; then the bag should be introduced between the fundus uteri and the pelvic floor, and distended with water. A firm perineal band is then used to support the pelvic tioor. Dr. Thomas recommends a strip of adhe- sive plaster for the perineal band, one end being fastened to the sacrum and the other to the abdomen, with two ojDenings, one for the tube of the bag, and the other opposite the urethra to permit urination. I prefer the ordinary muslin or elastic band, because it is more easily removed and readjusted. The degree of pressure and the time which it should be continued must depend upon the re- sults. If there is much pain or irritation the treatment must be sus- pended. The combination of elastic pressure and taxis has been employed with advantage. After the pressure has been used for a time taxis should be tried, and in case this fails the elastic pressm'e should be again attempted. Care must be exercised in the use of taxis — it should not be too violent or long-continued ; this must be de- cided by the operator in each case. Dr. Charles Martin, of France, succeeded by using a stream of cold water projected against the fundus uteri, through the speculum. This he employed twice a day. The stream was thrown with con- siderable force ; he also filled the speculum with cold water, and kept the uterus in it three or four minutes. Dr. T. G. Thomas, from whose work I take the above statement, approves of this method. Dr. Thomas has devised another method, which I understand he employs or advises where other methods fail. The following is taken from his work on diseases of women : " Thomas's method consists in abdominal section over the cervical ring, dilatation with a steel instrum.ent, made like a glove-stretcher, and reposition of the inverted uterus by any one of the methods mentioned, by the hand in the vagina. Fig. 129 will render this clear. " This procedure, let it be remembered, is not offered as a method of treating inversion of the uterus, but as a substitute for amputa- tion. Few cases will, I think, resist elastic pressure and judicious taxis ; but that some will do so can not be questioned. It is to 278 DISEASES OF ^'OMEN. save these few cases from amputation that I suggest abdominal section. " One of the cases operated on in this way has proved fatal. Let it not be forgotten that a certain number of these cases treated by elastic pressure and by taxis likewise do so, for, as in my second case, these operations are often performed upon exsanguinated women whose blood is impoverished. One instance of death after reduction by elastic pressure is recorded by Dr. Tait in the eleventh volume of the ' London Obstetrical Transactions,' while one of the earliest cases on record reduced by taxis — that of Dr. White, of Buffalo, likewise ended fatally." One other method is worthy of mention, name- ly, that of Dr. Brown, of Baltimore. He makes a free incision in the fun- dus uteri, and through the opening thus made he Gtretehes the cervix and then reduces by taxis. In case of failure of all ef- forts, hysterectomy may be performed. This, I consider advisable, if the patient is near to or past the menopause, but it should not be un- dertaken until all other methods have failed. There are several methods of amputating the inverted uterus. Dr. McClintock applied a string ligature around the highest portion which strangulated the uterus, and in two or three days when de- composition of the tissues began, he amputated. Hegar accom- plished the same object by passing strong sutures through the cer- vix, and after drawing them tight enough to close the vessels and close the peritoneal cavity, the body was amputated. It will suffice to simply mention amputation without giving elab- orate details. It was frequently practiced in the past, but is sel- dom heard of now. Other methods succeed, and with the method of Thomas in reserve — in case pressure and taxis fail — amputation will seldom, if ever be called for. Cases might be quoted to illus- trate the treatment of chronic inversion, but they would add noth- ing of value to the methods of operating given above. Fig. 129. — ^Tieplacement of uterus by dilatation throuErh abdomen. CHAPTER XVIL . DISLOCATIONS OF THE UTEKUS. The uterus is peculiarly subject to physiological changes of position. The bladder in front causes the uterus to move forward and backward according to its dilatations and contractions. In a similar but much less extensive way, distention of the rectum acts to push the uterus forward. The abdominal pressure from above is constantly changing, and is, therefore, constantly affecting the posi- tion of the uterus less or more. The movements of the uterus under the influence of the ever varying degrees of abdominal press- ure are easily observed by watching the anterior vaginal wall and uterus through a Sims's speculum in the living subject. There is an up and down motion, very limited but constant, caused by ordi- nary respiration, and under extra exertion, such as coughing, the displacement becomes very marked. Below there is the pelvic floor, which has least of all to do with changing the position of the uterus, and yet much to do in counter- acting the inclinations to displacement produced by other influ- ences. These changes of position, when limited in degree, are physio- logical, the organ promptl}^ returning to its original position as soon as the displacing influence is removed. It is only when the uterus remains displaced permanently or is carried far beyond the physio- logical limits that the dislocation is to be regarded as pathological. When this occurs, the malposition gives rise to suffering from de- ranged menstruation, circulation, and innervation, and in some cases to sterility. Usually, the functions of the bladder and rectum are disturbed and the general system suffers from reflex influences. It is only when such symptoms as these are present that displacements of the uterus claim the attention of the gynecologist. In order to fully comprehend displacements of the uterus it is very necessary that the normal position of the uterus should be 280 DISEASES UF WUMEN. flearly understood, and this can only he attained by a knowledge of the aiKitoniy of the pelvic organs. Anatomy. — In discussing this subject attention will be chiefly (lirecteil to the jiosition of the uterus in the pelvis, its relations to neighboring organs, and the position and character of the structures which keep it in position. One would naturally turn to the cadaver in the hope that by careful dissection the exact position of the uterus could be deter- mined, but after life is extinct the uterine supports hjse their tirra- ness, and changes of position usu- ady take place. Moreover, it fre- quently happens that the pelvic or- gans are less or more dis])laced toward the end of life, so that a normal state of the parts is not often found in the cadaver. Dis- section also tends to displacement, no matter how carefully it may be performed. To obviate this, sec- tions of the frozen subject have been made, and much valuable in- formation obtained from them. Still, the greater part of useful in- formation on this subject must be obtained from careful and oft-repeated examinations of the living subject. With information obtained from all these sources there are still differences of opinion among authors on certain points. Under the circumstances, in place of giving a number of conflict- ing opinions, it will be better to give the views which I have adopted as the result of my own observations on the living subject, and after a careful investigation of the views of others. In the first place, it may be said that the uterus is wholly within the true pelvis. The line on the diagram running between the symphysis pubis and the promontory of the sacrum divides the true pelvis from the abdomen, and all the pelvic organs, the uterus included, are below this plane, the superior strait, as the obstetricians call it (Fig. 64). The long diameter of the uterus in the pelvis corresponds very nearly to the axis of this plane, as represented by the line (Fig. 13(»), and it is equidistant from the sides of the pelvis. The position of the uterus vai'ies from time to time, as already Fig. 130. — Section of pelvis, showing its inclination and the axis of the inlet. DISLOCATIONS OF THE UTERUS. 281 stated, but in all its changes it returns to the axis of the inlet of the pelvis, slightly behind the center of the true conjugate. This is not iiiathematicallv correct, but is sufficiently so to foi-m a basis from which further studies, both anatomical and clinical, may be con- ducted. In order to obtain some idea of the position of the uterus and the influences which the other pelvic organs have in changing this posi- tion, reference should be made to Fig. 64, which shows a section of the normal pelvis. Fig. 131 shows the changes in the position of Fig. 131. — The normal range of the uterine axis, varying according to the distention of the bladder; a, with bladder empty ; d, with bladder full (Van der Warker). the nterus during the several degrees of distention of the bladder. These physiological changes should be noted and the causes which give rise to them, in order that they may be recognized clinically. Next in the order of inquiry are the anatomical structures by which the uterus is held in position. This requires a consideration of the 282 DISEASES OF WUME.V. struetui-al a.sPo('i;itioiis of tlie uteriiH and all the other pelvic ortfans and tissues. The position of the several pelvic organs may he given in a general way as follows : The uterus in the center, Fallo- pian tuhes and ovaries on either side, the bladder in front, rectum behind, and the vagina below. Covering all of these, except the vagina, is the peritonaium, which is the chief bond of nnit)n be- tween the upper jxtrtions of the pelvic organs, and ont of which are formed the ligaments which have much to do in keeping the nterus in place. The peritonaeum, while it covei-s the pelvic organs, is attached to the bony walls of the pelvis through the medium of the periosteum and areolar tissue, so that one end of each liga- ment may be said to have an attachment to the inner side of the pelvic bones. The round ligaments are anatomically an excejition to this rule. They contain nmscidar tissue in considerable quan- tity, and are really outgrowths from the uterus in the form of round cords, whicli start from the uterus near the proximate ends of the Fallopian tubes, and sweeping round the outside of the pelvis, pass out through the inguinal rings into the labia majora. These ligaments, as well as all the others, can be seen by looking down upon the pelvic organs in situ. The uterus is seen in the middle of the pelvis, and extending across on either side of it are the two broad ligaments made up of the two folds of peritona?um, which unite after covering the uterus, Running backward from the uterus to the sacrum are those peritoneal folds known as the utero-sacral liga- ments. Between the uterus and the bladder, on the sides of the latter, the folds of peritonteum form the utero- vesical ligaments. These ligaments Fig. 132.— Diagram of the uterine liga- are SO Called, not because they are ments as seen on lookinjr into the brim. j x t j. , „ j.' \ ..*. ° composed oi hgamentous tissue, Imt rather because they perform a function similar to that of ligaments. With the exception of the round ligaments which are composed of muscular tissue covered with peritonaeum, the others are made up of double folds of peritonaeum containing between these folds are- olar tissue and some fibers of the pelvic fiuscia. An idea of the position of these ligaments and their relations to the uterus may be obtained from Fig. 132. I have noticed that, in the dissecting-room, gentlemen are not able at all times to find the utero-sacral and utero-vesical ligaments ; the broad and round ligaments they easily note. The others can be DISLOCATIONS OF THE UTERUS. 283 brought into view in the following manner : If the uterus be drawn well forward by a tenacuhini, two tense bands will be seen, the utero- sacral ligaments, extending from the side of the uterus back to the sacrum, and as they are thus raised up a pouch of peritonfeum ap- pears between them. This is the sac of Douglas. By reversing this manipulation, and drawing the uterus backward, the utero- vesical ligaments will be seen running forward on either side of the bladder. The utero-vesical ligaments, in addition to their attachments to the uterus and bony walls of the pelvis, are also connected indirect- ly to the anterior vaginal wall by intervening areolar tissue. The utero-sacral are connected in the same indirect way with the upper portion of the posterior vaginal wall, and also to the rectum, on the left side at least. At the junction of the supra-vaginal portion of the cervix and body of the utenis all the ligaments, except the round ones, are attached. Here also the anterior and posterior vaginal wall and a portion of the bladder join these other structures. The union of these structures at this point is not direct, but is through the intervention of areolar tissue which is found in con- siderable quantity in this region. From this it will be seen that these ligaments are continuous from side to side, and also from be- fore backward. The chief function of these ligaments, aided by the anterior vaginal wall, is to keep the uterus and bladder in position. This is clearly evident from the mechanical principle apparent in the anatomical arrangement of the parts in question, and from the fact that the uterus remains in place for a considerable time when the pehnc floor is defective, and the abdominal pressure more marked than normal. In short, many cases have been seen clinically in which all the other means that could possibly contribute to supporting the uterus were removed by disease and injuries, and yet the uterus was main- tained in position under ordinary circumstances. The most rational idea of the means and ways by which the uterus is maintained in the pelvis I obtained from the following statement by Dr. Frank P. Foster. Speald«g of the supports of the uterus, he says : " Ordi- narily, they consist wholly of the anterior wall of the vagina in front, and the utero-sacral lio-aments behind, which tosfether con- stitute Avhat may be called a beam traversing the pelvis antero- posteriorly on which the uterus rests, being interposed between them, firmly attached to the one anteriorly and to the other poste- 284 DISEASES OF \YOMEy. riorly, making them, so far as mei-haiiical effect is coiicenied, one structure." This is a cleai* and cumpreliensive statement of the prin- ciples upon which the utero-sacral ligaments and the anterior vagi- nal wall act in supporting the uterus. I would go one step further than Dr. Foster, however, and claim a like function for the other uterine ligaments. The broad ligaments, firmly attached to the bony walls of the pelvis, and holding the uterus in their folds, make a continuous structure extend- ing across the pelvis in its transverse diameter. These structures, taken to- gether, act like " beams" or (to be more mechanically accurate) cables of a suspension-bridge, which support to a large ex- tent the uterus in its center. The utero - vesical ligaments also supplement the anterior vaginal wall as a supporting medium. According to this view of the subject, the chief supports of the uterus are the anterior vaginal wall, utero-sacral, vesico-uterine, and broad liga- ments. Fig. 133 shows a section of the pelvis with these ligaments and the anterior vaginal wall with the uterus resting upon them. Fig. 13-i shows a transverse section of the pelvis just in front of the uterus and broad ligaments, and represents these structures and the manner in which they support the uterus. A similar function may be claimed for the round liga- ments, at least so far as their effect in preventing the back- ward displacement of the uter- us. Some have claimed that the round ligaments have but little supporting power to sustain the uterus in place, while oth- ers give it tinich credit in this direction. Those who believe in Fig. 133. — Section of pelvis ^th the slings of the uterus ; behind, the utero-sacral liga- ments ; in front, the anterior vaginal wall (after a section by Hart). Fig. 134. — Diagram of the uterus slung between the broad lijiaments. DISLOCATIONS OF THE UTERUS. 285 Alexander's operation of shortening the round ligaments for the relief of retroversion of tlie nterns certainly claim great 8ui)porting power for these ligaments, and with good reason, I think. Finally, I may add, that I believe that the ligaments, the vagina, and the other pelvic organs all aid in keeping the uterus in position, and are sufficient to do so under ordinary circumstances. Still, when extraordinary sti-ain is brought to bear upon the pelvic organs, the pelvic floor supplements these supporting structures. Moreover, the relation of the trunk to the pelvis has much to do, if not in keeping the pelvic organs in place, certainly in freeing them from pressure from above. The pelvis is so placed that, in the erect posture, its cavity is be- hind rather than beneath the abdomen, and the abdominal muscles partially divide the greater cavity from the lesser. This is shown in the accompanying diagram, where the arrow indicates the direction of the force transmitted to the pelvis through pressure from above (Fig. 135)." There is very little direct ab- dominal pressure upon the pelvic organs in the erect posture. The axis of the pelvis is backward and downward, while that of the ab- domen is perpendicular, so that the pressure is indirect from above. Some claim that a suction power is exerted upon the pelvic contents by the diaphragm. It is said to act like a piston in the cylinder of a pump. There is reason to be- lieve there is something in this, from the fact that, on examination through a Sims's sp)eculum, the uterus is seen to rise and fall wdth respiration. This motion is to a large extent arrested when the pa- tient is in the erect posture. If it is a fact, as it appears to be, that the abdominal organs are fixed by suspension in their normal position, and that in their descent during this limited motion the pressure upon the pelvic organs is indirect, then this relationship contributes to maintain the position of the pelvic organs as surely as if there were some traction or suc- FiG. 135 The normal inclination of the pelvis and the transmission of force from above. 286 DISEASES OF WOMEN. tion action of the diaplirat the return circulation. Whether that is a fact as regards the causation or not, there is usually a passive hyperemia of the parts in these displacements. These changes of the position DISLOCATIONS OF THE UTERUS. 289 and relations of these parts are gradually developed. In case the prolapsus proceeds to the third degree, the pelvic floor gives way under the influence of the conthiued pressure. The perineal mus- cles become overdistended and the vulva enlarged, until the uterus is permitted to protrude without resistance. In the second order of the development of prolapsus — that is, where the loss of the pelvic floor is the starting-point of the mal- position, the flrst lesions appear in the vagina. The walls of the vagina at the introitus begin to protrude and their descent is gener- ally attended with increase of tissue. Usually both walls prolapse together, but in many cases one or the other takes precedence. As the prolapsus progresses the bladder and anterior wall of the rectum descend, producing rectocele and cystocele. In due time the uterus follows with all the changes in its supports already described above. There are cases in which the prolapsus begins at the lower part of the vagina, while there is no apparent injury of the pelvic floor. This has been accounted for by imperfect involution of the vagina after child-bearing. The large, heavy, and lax walls of the vagina make undue pressure upon the pelvic floor and it gives way before them. A similar state of things occurs, so far as appearances are concerned, where there has been subcutaneous laceration of the mus- cles of the pelvic floor which impairs its function. Prolapsus of long standing changes the structure of all the tissues. Atrophy of the muscular tissue of the vagina and pelvic floor occurs, and the ligaments of the uterus lose their character- istics so that they can not be restored to their original state by any means. There is a prolapsus which occurs as the result of degeneration of the supports of the uterus. It occurs in feeble old women in whom general nutrition is greatly impaired. The perinseum and vagina lose their elasticity, the adipose and areolar tissue disappear, and the vaginal walls, bladder, and atrophied uterus descend. Such patients are also subject to prolapsus of the rectum and sometimes prolapsus of the mucous membrane of the urethra. I have called this senile prolapsus to distinguish it from the ordinary descent of the uterus which usually occurs in middle life. I believe it to be due to the general atrophy of the pelvic viscera because of the time of life when it occurs, and the fact that I have seen it in those who have not borne children. The first case that I carefully studied was in an old maiden of seventy years of age. Symptomatology. — The natural history of prolapsus uteri as manifested by symptoms and physical signs, difliers to some extent 20 290 DISEASES OF WOMEN. ill different cases, thoiirolapsus uteri, caused no doubt from their want of care after confinement and in carrying heavy burdens. General weakness, induced by exhausting diseases and extreme old age, affects the pelvic organs very decidedly. This, no doubt, is the cause of prolapsus uteri in women with consump- tion and in the very aged. The most important, certainly the most fre(pient, causes of uter- ine displacement are the injuries and improper management incident to child-bearing. The condition of the uterine snpjiorts after partu- I'ition is that they are all greatly enlarged through the growth of gestation, and, while they are competent to maintain the large uterus which rests in the abdominal cavity, they must undergo involution in conjunction with the diminution of the uterus. If this involu- tion fails in the uterine ligaments and vagina while it goes on in the uterus the supports fail, l)ecause they are too long and relaxed. Im- perfect involution, not only of the uterus but of all the other tissues and organs of the pelvis, is seen to give rise to displacement. This imperfect involution may be due to post-partum inflammation or to the j)atient resuming the active duties of life before involution is completed. In regard to the injuries of the pelvic floor and their effect on the position of the uterus the reader is referred to the chapter on that subject. , Finally, enlargement of the uterus, whether from imperfect in- volution, inflammation, or the presence of neoplasms, will cause prolapsus. This will occur although all the supports may be nor- mal ; the balance between the supports and the organs to l)e su|v ported being disturbed by the increased weight of the uterus, de- scent will occur. DISLOCATIONS OF THE UTERUS. 295 It should also be borne iu uiiiid that the abnormally large uterus will prolapse in spite of the normal supports, while, on the other hand, defective supports which permit a normal uterus to descend will ii'ive rise to enlargement of the uterus by congestion, swelling, and, finally, hyperplasia, and by this increase of weight will incline it to remain displaced. TREATMENT OF PROLAPSUS UTERI. There are four important objects to be attained in the treatment of prolapsus uteri : to restore the displaced organ, to keep it in place, to restore the supports of the uterus, and to remove complications and accompanying affections if any such exist. The restoration of the uterus to its proper place is performed as follows : The patient is placed in Sims's position, and, if the pro- lapsus is complete, the uterus is grasped in the lingers, and, while compression is made, it is pushed upward in the axis of the pelvic cavity. By these means the displacement is reduced from the third degree to the second ; then the perinseum should be retracted with Sims's speculum, and with two sponges in holdei*s the uterus should be raised to its normal elevation. Difficulty in accompHshing this is sometimes caused by the fundus uteri turning backward while the upward pressure is being made, so that, in place of overcoming the displacement, the prolapsus is changed to a retroversion. This can be guarded against by making the pressm-e mostly on the posterior side of the cervix. l*assing the sound and making it guide the uterus in the riglit direction while upward pressure is being made is anotlier way of managing difficult cases. "While these manipulations are being made the patient should relax the abdominal muscles by avoiding all straining. Many patients fail to obey orders in this respect ; they continue to hold the breath, and strain as if preparing to resist the pain of some injury about to be inflicted npon them. I have overcome tliis annoyance by causing the patient to take long regular respirations while being treated. In rai'e cases, in which much difficulty is met in replacing the fallen uterus, the patient should be placed in the knee-chest position, and then the chances are that the uterus will slip back to its position without much help. If any aid is needed it can be given by the sponges in holders, or what is quite as good, if not better, in manipulating with the patient in this position, is to use one or two fingers in place of the sponges. With a very limited experience and a knowledge of the methods described any one can manage this portion of the treatment. To 296 DISEASES OF WOMEN. keep the uterus in place is tlie question wliicli is not easily settled. The object of all the mechanical means which may be employed is, lirst, to keep the organ in position and thereby give relief. At the same time through the agency of the artificial support, and other means, to restore the natural supports. If the prolapse is not beyond the second degree, and is due to relaxation only of the uterine supports, and not associated with any injury that destroys the integrity of the pelvic lloor, the uterus may be retained by means of a pessary or tampon until the supports recover their original strength. In connection with these mechani- cal means, rest in the recumbent position is one of the most im- portant factors in bringing about the desired result. The material used for the tampon should be absorbent cotton or marine lint. To simply keej) the uterus in place the cotton is no doubt the best. It is soft and most agreeable to the tissues. When there is any vaginitis or endometritis causing a free discharge, ma- rine lint does better. It takes up the discharge, disinfects it, and prevents decomposition. This it does better than the cotton. In some cases the lint is irritating to the tissues and can not be long continued. Sometimes I have alternated the use of the cotton and lint with much satisfaction. Since the introduction of antiseptic material for dressings, the tampon has been far more useful in surgery. In the past when sponges, not well prepared, were used, they could be retained in place but a few hours ^vithout causing decomposition. Now the marine lint or borated cotton can be worn twenty-four or forty-eight hours without being offensive. For those who have vaginitis or any inflammation of the uteinis I direct that the tampon be applied in the morning after having used the douche of hot water, plain or medicated. At night the tampon is removed and the douche again used and afterward the tampon re- placed, if the uterus will not stay in place without it, but omitting it for the night if the recumbent position will overcome the tend- ency to displacement. When there is no inflammatory complication the tampon may be left in place two days and a night. At the end of the second day it should be removed at bed-time and replaced next morning, the douche being used after removal and before intro- ducing it again. Astringents of various kinds have been employed with the t;mi- pon, the cotton being saturated with the solution to be used, or the agent may be employed in powder. The latter is much the prefer- able way when the milder astringents are selected. As a rule I pre- DISLOCATIONS OF THE UTERUS. 297 fer the borated cotton or marine lint alone, using sucli astringents as may be required in the douche. In many cases there is some loss of the pelvic floor from pre- vious injury. This structure should be restored as soon as the tis sues are in a condition to warrant surgical treatment. As a rule, in those cases of prolapsus which have existed for some time, the nu- trition of the tissues is impaired and needs treatment preparatory to operating. For a more complete discussion of this subject the reader is referred to the chapter on injuries of the pelvic floor. Keeping the uterus in its position by the tampon and other means of support has the effect of not merely relieving the prolapsus, but also of giving the uterine ligaments every chance to regain their normal condition. Artificial support is palliative and curative as well. The mechanical supports used in the treatment of prolapsus include a variety of devices. The pessaries used are of two kinds — those that are placed in the vagina and are held in position by the pelvic floor, and those that are held in place by being attached to a strap round the waist. The former are applicable in the first and second degrees of prolapsus while the pelvic floor remains normal or nearly so. The latter are used in complete prolapsus, and in those cases where there is so much loss of the pelvic floor that it will not keep the pessary in position. Whan the perinseum is sufiicient to support the vagina and the prolapsus is limited to the flrst or second degree, the instrument known as Peaslee's pessary answers very well. It is a simple ring made of whalebone and covered with soft rubber (see figure). When in position it rests upon the pelvic floor. It should admit the cervix without making pressure upon it, and should fit the upper portion of the vagina without distending it to any ap- preciable extent. It acts by carrying the upper portion of the vagina and the cervix backward into the normal position, and at the same time raises the uterus to a very slight, but sufiicient extent. If well adapted it takes off the pressure from the lower part of the vagina and permits it to contract and regain its tonicity. Fig. 137 represents prolapsus in the second degree. Fig. 140 shows the pes- sary in position after the uterus has been replaced. When there is relaxation of the pelvic fioor due to the prolapsus it is necessary to keep the patient at rest much of the time during the first week or two that the pessary is worn. If this is not prac- ticable a perineal band should be worn to support the pelvic floor while the patient is exercising. In the progress of the treatment the vagina should contract when the uterus is supported by the pessary. This, in time, requires that a smaller instrument should be 298 DISEASES OF WOMEN. used. The rule is tlmt the smallest instrument should l)e em])loyed that will keep the uterus in plaee. If too lar«:e a pessary is used it Fig. 140. — Uterus replaced, uith pessary in position. will keep the uterus in place, but will overdistend the vagina and weaken the supports of the uterus in place of restoring them. One great advantao:e which the ring pessary has is in being easily introduced or withdrawn, and that it does not become displaced except to settle downward, and this can be easily corrected by the patient assuming the knee-chest position from time to time. AVhen the uterus inclines to retrovert after having been elevated, a common occurrence, a retroversion pessary will act better than the ring, but the use of that instrument will be more fully discussed under the head of retroversion. Prolapsus occurring after the menopause when the uterus has undergone final involution, may be relieved in some cases by the old glass-globe pessary. It certainly is the best instrument that I have DISLOCATIONS OF THE UTERUS. 299 found for old patients having prolapsus of the vaginal walls, bladder, and the remains of the atrophied uterus, if the pelvic floor remains sufficient to support tlie pessary. It simply keeps the uterus and bladder up in the pelvis by distending the vaginal walls. The ute- rus may be anteverted or retroverted, but is so small that it makes no difference wliat position it occupies so long as it is kept high enough up. The globe is easily used. In fact no mistake can be made with it except to use one that is too large. This must be avoided, be- cause one that is too large will cause vaginitis and ulceration. It is a fact also that the pessary which answers when first used will be too large when the parts regain some of their original tonicity. For a time the patient should be kept under observation and the in- strument changed to suit. This globe pessary is the most trouble- some instrument to remove. I have usually succeeded by using a small Sims's speculum and a Sims's vaginal depressor, and seizing the instrument between the two and making traction. When this fails, a pair of miniature obstetric forceps should be made out of strong copper-wire, by doubling it to form loops and twisting the ends to make the handles. With this the globe is very easily grasped and removed. The intra- vaginal pessaries, such as the ring and globe already mentioned, and all others that rest wholly within the vagina are liable to slip down and give the patient great dis- comfort, and sometimes they come away entirely. This is especially the case when first introduced. To obviate this, a perineal band should be worn until the peringeum, upon which the pessary de- pends for support, regains its tonicity. By this arrangement the same results are obtained as by the use of the cup and stem j^essary, to be noticed hereafter — in fact, better results so far as the comfort of the patient and the final effects are concerned ; therefore, I have always endeavored to relieve prolapsus when possible by the intra- vaginal pessary. Several uterine supporters have been devised to meet the require- ments of cases in which the pelvic floor is relaxed from long disten- tion, so that it has not power to sustain a pessary in position, and the patient's circumstances will not permit long rest in the recum- bent position and the use of the tampon. They are all constructed on similar principles of mechanism and action — namelj^ cup and ring to receive the cervix uteri, and a stem attached which projects from the vagina and is fastened to apei'ineal band, which in turn is attached to a waistband. The advantages claimed for this kind of uterine supporter are that if properly ad- 300 DISEASES OF WOMEN. jn^ited it will certuinly keej) the uterus in place, and the j)atient can remove and readjust it when desirable. These are valuable features no doubt, and may be fairly claimed for the instrument as a rule, but not without many exceptions. There are cases where this form of instrument, while it will keep the uterus at its proper elevation, will not keep it in its proper axis without very great care in its ad- justment. Under such circumstances the patient can not remove and replace the pessary with any satisfactory results. While pushing up the uterus, during the introduction of the pessary, a retroversion takes place, and wearing the instrument only aggravates that form of displacement. The further objections which may be placed over against the advantages of this kind of pessary are that it can not be worn for any great length of time without doing harm and caus- ing great discomfort, and where in a given case the patient can not adjust it properly herself it will do more harm than good, and should not be employed on any account under these conditions. Again, in the most favoralile cases, it is a constant source of irritation, less or more. The vulva is irritated by its presence and usually becomes inflamed in time ; the pressure of the cup against the cervix and upper end of the vagina causes inflammation and ulceration, if the patient takes much active exercise. The reason for this is that the pessary is firmly fixed by its support outside of the body and the movements of the pelvic organs against this fixed instrument cause great friction. The intra-vaginal pessary moves with the pelvic organs, but the stem pessary does not accom- modate itself to the requirements, and hence its power to do harm. From the little that has been said, it will appear that the use of the vaginal stem pes- sary for the relief of prolapsus is most misat- isfactory. All that can be said of such means of support is, that in some cases they may be used for a time in the hope of helping to restore the natural uterine supports. Dr. Paul F. Munde has truly said, " The ideal pessary for complete prolapsus uteri is yet undiscovered." The instrument which I have found to answer best of the stem pessaries is a modification of Cutter's (Fig. 141). These pessaries should he fitted with care, and just here another difiiculty is encountered in the fact that they are- all made of one size and shape, so that it is diflicult to change them to suit special Fig. 141. — Stem pessary. Modification of Cutter's. DISLOCATIONS OF THE UTERUS. 301 cases. This I have tried to overcome by making the stem flexible, or rather so that it can be molded, and capable of being shortened, so that it can be made to suit each case. Fortunately, stem pessaries are rarely needed, and, I may say, that every year I iind less need for them. By a careful and judicious use of the ring and the tampon, aided by the T-bandage to support the pelvic floor, one can accomplish nearly all that can be done by these artiflcial supports. The important facts in connection with pessaries already men- tioned, may be recapitulated here, and they should be borne in mind. They are as follows : First, these means of relief for prolapsus most- ly are temporary and palliative, and can only keep the uterus in place until the tissues are prepared for the operation of perineor- raphy when the pelvic floor has been injured ; second, they keep the uterus in place till the normal supports are restored ; and, third, they reduce a complete prolapsus to an incomplete, when an intra- vaginal pessary will answer the purpose. While these artiflcial means of support are being employed, ef- forts should be made to strengthen the parts and to remove all com- plications which tend to keep up the prolapsus, astringent injections should be continued, standing and walking should be limited to an amount which is sufticient for exercise, and lifting heavy weights and wearing tight and heavy clothing should be avoided. The bow- els should be kept free, so that straining at stool may be unneces- sary. This last point should be carefully attended to. Constipation is a potent cause in producing and keeping up prolapsus. The gen- eral health should be cared for, and if there is any debility it should be met by the proper tonic treatment. In some of the most favorable cases complete relief will be ob- tained by the means described, so that all mechanical supports can be given up. Care should be taken not to remove the pessary too soon. I have found in cases of prolapsus that it is best to reduce the size of the pessary by changing from time to time to a smaller one. Martin, of Berlin, has reported one hundred and ninety-two cases in which he has operated for the cure of prolapsus. In all but six he was obliged to perform an operation upon the cervix ; in three instances it was necessary to extirpate the entire uterus. In one hundred and seventy-one cases silk sutures were used, in seventeen the continuous catgut, the latter being highly commended, al- though it is noted that it is not safe to depend entirely upon these, as secondary haemorrhage may occur if they are not re-enforced with 302 DISEASES OF WoMEN. silk. Relapses occurred only eleven times, and those, too. in old subjects. The operations i)erforraed were anterior and pusteriur kolporrliaphy, Avith perineorrhaphy. In conn)arint( my own results with the above, 1 find that I have succeeded as well by the combined use of mechanical supports and surgical operations. That in the treatment of prolapsus, where o\y erating upon the cer^^x uteri and pelvic floor has failed, kolpor- rliaphy has also been useless. I have, therefore, abandoned that op- eration. TREATMENT OF PROLAPSUS BY GALVANO-CAUTERY. Dr. John Byrne, of Brooklyn, has treated successfully nine c;L like a cul English sound. At the same time I used Elliott's ad- juster to straighten the uterus, and cariied tlie fundus backward. This was accomplished with unusual facility, the uterus making no resistance to bending in any dii-oction. The instrument was with- drawn, and the patient placed in bed to rest ; there was no pain or inflammation following this treatment. Three days afterward I made a digital examination, and found the uterus retroflexed. By using again tlie Elliott adjuster I was able to change the retroflex- ion back to the original anteflexion, which remained so for several days. It being necessary to pass the sound every third day to pre- vent the recurrence of the stricture at the internal os, 1 took advan- tage of the opportunity, by changing the flexion a number of times, and found that whatever position I placed the body of the uterus in, it would remain there. The dilatation of the os externum gave the patient great relief from the dysmenorrhosa. The usual treatment for congestion and hyperaesthesia was continued, and the canal kept dilated by the use of the sounds. A stem pessary was tried, but she could not tolerate it except by keeping in bed. She improved so much in two months that she left the hospital, and only returned occasionally as an out- patient. For two years I kept her under observation and, although she was not entirely free from pain, she was able to make her living. In this case I feel sure that the trouble originated in an imper- fect growth at the time of secondary development. In one other case of which 1 have full notes, the flexion came after the patient's second confinement, and, perhaps, was due to a derangement of involution. CHAPTER XIX. ABUSE OF PESSARIES. Injuries to the Pelvic Organs Caused by the Improper Use of Pessaries. — The dangers of stem pessaries have ah'eady beeu referred to in the chapter on flexions, so far as their hability to cause acute inflammations of the uterus, pelvic ceUular tissue, and peritonaeum. There are still other injuries whicli they may give rise to. When the stem is small and badly adjusted with reference to the character of the flexion, the point of the instrument may become imbedded in the wall of the uterus, or the lower part of the stem may divide the posterior wall of the cervix. Both of these injuries I have seen in practice. In one case, an anteflexion of the cervix, a small stem of steel with a hard-rul)ber disk at its end was introduced by a general practi- tioner, and left in place for three months. The patient soon began to suffer from a inirulent discharge, which gradually in- creased, and there was much pain, greatly aggravated by walking. AVhcn I saw her the relations of the stem and uterus were as shown in Fig. 161. After the removal of the stem, the cervix presented exactly the same appearance as that seen after Sims's operation for flexion, except that there was more thickening of the edges of the wound and more inflammation than I have ever before seen after discision of tlie cervix by the surgeon. The inflammation subsided under ordinary treatment, and she was at least none the worse for having worn the stem. Another patient came under iny observation while wearing a stem pessary, which had been introduced six weeks before by her medical Fig. 161. — Stem of pessary ul ccratinff through cervix. ABUSE OF PESSARIES. }35 attendant. She had suffered pain and tenderness from the time that the stem was introduced, and for a week before she came under my care the suifering was so great that she was obliged to stay in bed and take opium freely ; she had also a purulent discharge, and at times bleeding. The stem was about the thickness of a No. 9 catheter. It was made of hard rubber, and was held in place by a cup pessary in the vagina. While the stem was still in place (the vaginal pessary having been removed) the body of the uterus was found to be markedly anteflexed, and its anterior wall near the fundus was unusually prominent, as if it contained a small fibroid tumor. The Hexed shape of the uterus led me to suppose that the stem must be curved, but on removal it proved to be straight. I then passed with some difficulty, owing to the tenderness of the uterus, a much-curved sound into the cavity of the uterus, and then after straightening the sound, it was passed into the groove made in the posterior wall by the stem. One might suj^pose that the cavity of the uterus was simply dilated so that the sound could be curved forward and then straightened and passed along the posterior wall, but I am confident that such was not the case. The posterior wall of the body was flexed forward and rested upon the anterior wall on either side, and the sul- cus made, by the stem was in the center. Fig. 162 shows the conditions as they ap- peared to me during my examination. There was considerable bleeding after the removal of the stem, and the uterus be- came more flexed apparently as soon as the support was withdrawn. There was relief from the acute symptoms and inflammation caused by the instru- ment, but the dysmenorrhoea was worse than before. Atropliy of the muscular tissue of the vaginal walls from over- distention by pessaries that are too large is quite frequently seen. Practitioners who are not skilled in the use of pessaries, yet never- theless use them, produce this injury of the structures of the vagina. The same unfortunate results are effected by those who believe in the theory that in order to keep the uterus in place, in retroversion, for example, it is necessary to use a pessary large enough and suf- ficiently curved to force the posterior wall of the vagina far up in the pelvis above its normal elevation. Fig. 162.— Stem cutting- through body of uterus. 336 DISEASES OF WOMEN. The followinf]^ case will illustrate this : The ])atient had children, and wiuj said to have had a displacement ; jjrubably n troversion. She was treated with a variety of pessaries, so she told me, but did not get well ; when she came to me, she had much backache, ])elvic pain, and vaginal leucorrlui'a ; she was then wearing a pessary nearly large enough to fill the pelvis, and much curved both in front and behind. The uterus was in about its proper place in the pelvis, but the vagina was greatly overdistended and its walls were thin, especiall\ the posterior wall behind the cervix. On removing the pessary, a difficult task owing to its size, the vaginal wall, and the rectal wall also, I think, fell downward and f(jrmed a rectocele high up. Fig. 163 will give an idea of the state of the parts as they appeared to the touch, after the pessary was removed. The part of the thin wall of the vagina bulijed down- ward, and felt to the touch exactly like the ordinary rectocele, except that the protniding mass was at the upper part of the vagina in- stead of the lower ; when seen through the speculum introduced about an inch and a half, this was confirmed by the eye. The first impression obtained by the touch was that of a portion of intestine distended with gas lying behind and below the cervix uteri. The patient felt a little more distress, strange to say, after the pessary was removed ; when slie tried to walk without it, she suffered from pain and tenesmus very severely. This I have found to be the case in all instances of overdistention of the vagina; patients suffer with tlie support, and for a few days suffer more without it. This is much the same experience as ladies have who can not go without corsets, and the tighter they lace them and the more damage they do, the more they miss them when they discontinue their use. This patient was kept rather quiet for a time, and astringent in- jections were used, which, after a long time, restored the vagina more -High rectocele due to improper pes- sary. ABUSE OF PESSARIES. 337 nearly to its normal caliber. There remained for over a year, when I last saw her, and perhaps ever since, a sagging of the upper part of the posterior vaginal wall. Another case, somewhat of the same character, came to me from the West. She was forty, and single ; her health and strength had been good until she was thirty-six years of age, when she began to have a variety of nervous symptoms clearly due to general debility. She was treated by several reputable physicians, but not recovering as fast as she desired, she consulted still another, who told her that she had falling of the womb, which caused all her troubles. There was not a symptom that pointed to any disease or displacement of the sexual organs, but a Cutter pessary was introduced and the patient wore it about two years. Her general health improved very little, and the pessary soon caused her trouble ; still she persisted in wearing it because the doctor said she must do so ; her condition be- came so wretched that she came East, in the hope of gaining relief. When she came to me she had some vaginitis and vulvitis caused by the pessary, but the uterus was perfectly normal in every way. The Cutter pessary had pushed up the posterior vaginal wall fai- beyond the cervix, which lay on one side of the instrument, i:iot between the bars as it should have done. The condition of the posterior vaginal wall at the upper part was about the same as in the case just related. The lower part of the vagina was normal, excepting the inflammation caused by the pes- sary. The vulva was also inflamed, and she sufl'ered greatly from this, especially in taking exercise. This patient also felt the want of the pessary when it was removed, but only for a short time. She was examined seven months after the removal of the instrument and was found to be perfectly well. Injury of the Posterior Vaginal Wall by the use of Pessaries in Cases of Incurable Retroversion. — This case illustrates a class which, thouffh not larffe, deserves notice. In retroversion with fixation of the uterus, either from a cono;enital state or because of adhesions or shortening of the post-uterine ligaments, there is sometimes a slight mobility of the uterus which admits of its being partly restored. This leads the practitioner to hope that, by the use of the pessary, the displacement can be corrected. The result is that the posterior portion of the pessary makes too great pressure upon the vaginal wall and produces inflammation and abrasion. This usually causes a free vaginal discharge and pain enough to make the patient seek relief before much permanent injury is done. In all such cases pes- saries should not be used at all, but if one is employed in the hope 23 338 DISEASES OF WOMEN. of doing good, it should be abandoned as soon as it causes anv irri- tation. In these incurable cases, a slight relief may sometimes be given by using a Peaslee's ring, or a Smith's pcfssary very little if at all curved posteriorly. Either of these instruments will hold the uterus a tritle higher in the pelvis, and this will, in some cases, give a sense of su}>j»<'rt and relief To tlie ])atient. Overdistention and Atrophy of the Anterior Vaginal Wall from the use of Anteversion Pessaries. — This condition is rarely seen ex- cept among the patients of those who look upon anteversion as a morbid state of importance whenever it occurs. In order to raise the body of tlie uterus up when it is anteverted, it is necessary to elevate the anterior vaginal wall far beyond its normal position. In order to do this, the instrument must make well-marked pressure upon the parts, and, if this is continued, the muscular wall becomes atrophied and overdistended, and this can be carried on to a very great degree, the whole length of the vagi- nal wall becoming double that which it originally was. "When the pessary is removed in such a condition, there is at once observed a well-defined and large prolapsus of the vaginal wall, and if the instrument is left out, cystocele will soon follow. This is the rule, but the final results depend to some extent upon the length of time that the pessary has been worn. The stretching of the vaginal walls caused by pessaries can Ix* overcome by removing the instrument, and prescribing rest and astringent injections. But if the overdistention has been kept up long enough to cause atrophy of the muscular tissue, the injury is permanent and can be very little improved by treatment. There is also danerer to the bladder and urethra from the ante- version pessary. The following case will show how this comes about : Frequent "Urination associated with Slight Anteversion of the Blad- der. — The lady was about thiity. and had a child seven years old. Slie gradually developed a pelvic tenesmus and some irritability of the bladder. She consulted her physician, who diagnosticated ante- version of the uterus, and stated that the disturbed function of the bladder was due to the malposition of the uterus. Thomas's ante- version pessary was introduced by the physician in charge ; this gave the patient a sense of support which was agreeable, but more disturbance of the bladder was caused. The physician urged the patient to wear the pessary, telling her that she would get used to it, and the unfavorable effects would pass off ; but this proved not to be the fact. The patient then came under my care, having woni ABUSE OF PESSARIES. J39 the pessary for two weeks ; I at once removed it, witli the result of giving some relief, but there was still more impatience of the blad- der than before the instrument was used at all. The tnie state of affairs proved to be that the patient had a slight catarrh at the neck of the bladder, not due to the malposition of tlie uterus at all, and the pessary only increased the original affection. In proof of this, the symptoms all disappeared when the disease of the bladder was removed, and without changing the position of the uterus in the least. Cup Pessary with an Extra-Vaginal Support, causing Vulvitis and Ulceration of the Vagina. — All the pessaries having a stem attached to a band around the body have given trouble when worn for any length of time. The evil caused by the one used in this case, is typical of most of them. The patient lived in the country, and, while suffering from pel- vic tenesmus, called in a physician who adjusted a Babcock's uterine supporter for " falling of the womb." She was directed to remove it at night and introduce it in tlie morning. For a short time she felt some relief, but soon began to suffer from a profuse vaginal dis- charge and great tenderness about the vulva. The suf- fering increased until she was unable to walk, and the introduction of the support- er gave great pain. When I examined her I found the relations of the uterus and supporter as rep- resented in Fig. 164. The uterus was retroverted and the cup and stem were situ- ated in front of the cervix and held the anterior vaginal wall high above its normal position. There was some ulceration of the vaginal wall and general vaginitis and vulvitis. The apparatus was removed, vaginal injections of borax and water employed, and in a short time the inflammation was relieved. The uterus was then restored to its normal position, and retained there with a pessary such as I u6e in such cases, and she did very Fig. 164. — Displacement caused by a badly adjusted pessary. 340 DISEASES OF WOMEN. well. But for several inoiitlis there was a tendency to prolapsus of the anterior vaginal wall, owing to the overstretching oi it In her former sui)])orter. The Upper Rim of a Cup Pessary partially imbedded in the Vagina, around the Cervix Uteri. — 'I'his ])atient had a prulap.sii> uteri, and the physician who had her in care used a cup and stem of soft rub- ber ; the cup was quite a large one and its edges were rather sharp. I think it was called the liarrington supporter. She was much re- lieved by this instrument, being aljle to do her duty as a laundress, but she began to have a vaginal discharge and occassional bleeding, with pain and tenderness. I saw her with the doctor and found a ring of raw tissue in the vagina, around the cervix uteri, correspond- ing to the size and shape of the cup. The uterus was large, measuring nearly five inches. Evidently the pressure uijon the instrument was more than the tissues of the vagina could stand. The patient rested for a time and used vagi- nal injections ; the parts healed promptly, but the scar tissue re- mained tender, and gave way under the pressure of the insti-ument, whenever she wore it for anj length of time. I think that this patient could have been cured by rest in the recumbent position until the enlargement of the uterus and relax- ation of the vagina had been overcome, and then the pehnic lioor restored. But she could not give the time to this, being poor, and obliged to work to live. She was directed to wear a perineal pad fastened to a wai.st-l)elt, and she got along fairly well in that way. A Pessary imbedded in the Posterior Vaginal Wall. — In the cur- rent literature there have been many extraordinary cases recorded of pessaries having passed through the vaginal walls into the rectum and bladder. Some of these cases have been very remarkable, and have been recorded as matters of curiosity. Little has been said about the causes of such accidents or how to manage them. The following case illustrates the most common forms of this ac- cident : The patient was a widow who had borne several children, and had been well until the menopause, vchen she became insane. At the outset of her mental derangement, her physician suspected that she had some uterine disease, and, on investigating the case, found the uterus larger than it ought to be and rctroverted. H( restored the organ to its normal position and introduced a pessarv which held it there ; the instrument was well adapted and answered the purpose well. After this his attention was wholly directed h her mental condition, and she recovered her mind in about one year. The pessary was forgotten by her physician, who introduced il ABUSE OF PESSARIES. 341 while she was in the asylum. When she came home, or soon after, she began to have a discharge from the vagina and occasional bleed- ing. I then was called to examine her, and found all that portion of the pessary which rested behind the cervix uteri, iudjedded in the vaginal wall. The tissues to the extent of nearly a (juarter of an inch had united in front of the pessary bar. Traction was made upon the pessary until the tissues inclosing it were made tense, and they were then divided down to the instru- ment ; there was much bleeding, but the parts healed well, leaving a large scar in the posterior vaginal wall. This case is one the like of which is not infrequently seen ; they differ from most of those already mentioned, in the important fact that tliey occur in cases in which the instrument is well adjusted and answers its purpose for a time, causing no trouble until the vagina begins to contract during the final involution at the menopause. The vagina contracts so much that the pessary, which, at the time of its introduction was small enough and had plenty of room, becomes altogether too large and must imbed itself in the vaginal walls. I have seen a sufficient number of these cases to satisfy my- self that they occur in the practice of the most competent gyne- cologists, sometimes, perhaps, from neglect in giving specific direc- tions to the patient to report from time to time, so that the behavior of the pessary may be watched, but more often from the fact that the patient having been relieved of all her symptoms, either forgets the pessary, or else feels secure and safe, so long as there is no suf- fering which she can not, in her own opinion, attribute to tbe meno- pause, the time when there is the greatest danger of the accident in question. Pessary entirely imbedded in the Vaginal Walls, except about three quarters of an inch. — This patient came to me v/hen she was forty-six years old ; she vv^as still menstruating, but irregularly, and on one or more occasions had menorrhagia. She was suffering from a prolapsus of the uterus which caused her much trouble when she was on her feet. I restored the uterus, and used an instrument to keep it in place. This gave her relief at once, and she was able to take up her duties as in times past. She came to see me several times and I made some applications to the uterus which caused a slight endometritis. I directed ber to continue her visits from time to time, in order that I might see how the pessary was acting ; this she did not do, for feeling perfectly' well, she concluded that there was no need of further treatment, and she acted accordingly. Ten years passed, and though she began to have a purulent discharge 342 DISEASES OF WOMEN. and occasional bleedin^ from the vagina, still she neglected hep. self. After a time she eulied a physician, who made a suj>erticial examination, and told her that he suspected that she might have cait cer; he advised her to place herself again under my care; this she did, and 1 found the vagina almost completely closed. On tbo right side anteriorly, I found a small portion of the pessary exposed, but the rest was imbedded in the vaginal walls and covered over by considerable tissue. The granular and highly- vascular character of the tissues sug- gested that the doctors suspicion of cancer might be correct. The pessary could be felt through the wall of the rectum which appeared to be quite thin at that point. Passing a sound into the Ijladder, a part of the pessary appeared to be encroaching uj)on it. With difficulty the finger could be passed between the free portion of the pessary and the vaginal wall until it reached the cervix uteri, which was normal. The pessary had to be removed, yet the task appeared to be a difficult one. There was so much haemorrhage caused by the examination that I dared not divide the tissues which enclosed the pessary, neither did I feel that I could with safety rapidly and forcibly tear the instrument out of its place, fearing that I might do damage to the rectum and blad- der. I finally adopted the following method with success : Using a Sims's speculum, I seized the part that was exposed in the anterior part of the vagina with a very strong forceps, and ^^"ith a small finger-saw cut out the section within reach. I then laid hold of an end and by traction caused the pessary to revolve until another por- tion came into the place of the one removed ; this was sawed off, and piece after piece was taken out in this way until the whole was removed. The sinus was washed out for the j^urpose of cleaning it and stopping hfemorrhage, but there was so nmch bleeding that 1 had to use a tampon to control it. The patient did quite well, and beyond a marked thickening of the vaginal walls, has now no trace of the injury. Since my experience with this case, I have seen quite a number of cases of imbedded pessaries, and have removed them in the way described. Two cases I have in mind now in which the pessaries were imbedded in the posterior vaginal wall, were treated by sawing out the anterior half or third of the pessary, and then by turning the remaining portion around it was destroyed and removed without breaking down or dividing the tissues surrounding it. CHAPTER XX. HYPERTROPHY OF THE CERVIX UTERI. This is a peculiar and rather rare affection. It differs from the enlargement of the entire nterus, which occurs in pregnancy and in some of the inflammatory affections. The hypertrophy is confined to the vaginal portion of the cervix, and is distinct from the enlarge- ment of the supra-vaginal portion, which occurs in connection with metritis, subinvolution, and pregnancy. Pathology. — The only change in structure of the cervix is in quantity. The length of the cervix is increased, which is the main point in -the pathology. Sometimes it is thickened, but not in pro- portion to the elongation. It is characterized by great increase in length without increase in the diameter of the cervix, and no changes occur in the composition of the tissues. This is a true hypertrophy, which occurs from causes wholly different from the ordinary conditions which produce hypertrophy. The extent of hypertrophy differs in different cases ; this is due, to some extent, to the stage of progress when the first examination is made. In some cases the cervix projects from the vulva one or more inches, while in others the cervix rests just behind the hymen or in the vulva (Fig. 165). The cervix is generally conical and the os externum is generally small, as it should be in the virgin cervix. It occurs in the unmarried most frequently, but occasionally in those' who are married but sterile. Symptomatology. — The symptoms are exactly the same as those due to prolapsus. In the first stage there is pelvic tenesmus, and a sense of overdistention of the vagina. The presence of this large cervix causes irritation of the vagina and consequent leucorrhoea. Owing to the great increase in the length of the uterus, it becomes doubled up in the pelvis, and this often affects the menstrual func- tion, giving rise to dysmenorrhoea. In the last stage of the affec- I 344 DISEASES OF WOMEN. tion, in which the cervix protrudes from the vulva, there is much discomfort ; and the feehng of distention causes great irritabihtj of Fig. 165. — Hypertrophy of the cervix. {^.) the general nervous system. Excoriations and ulcerations of the mucous membrane are produced. Pliysical Signs. — The bimanual touch reveals the fact that while the fundus uteri is at its normal elevation, the cervix is either down at the vulva or protruding beyond it. At the same time the firmness of the vaginal walls, occupying their normal position, shows the great length of the extra-vaginal part of the cervix. This sign is diagnostic when the cervix is still within the vulva, but when the cervix has escaped through the vulva there is prolapsus of the vagina which obscures the signs to some extent. Emmet claims that elon- gation from prolapsus of the uterus has been mistaken for hyper- trophic elongation. This does not seem possible for one who knows anything about the nidiments of gynecology. By restoring the pro- lapsed uterus, any little elongation M-liich may have come from stretching will disappear, while no change of position will make any difference of length in hypertrophy. The use of the sound also HYPERTROPHY OF THE CERVIX UTERI. 345 helps greatly in determining the extent of the hypertrophic elon- gation. Causation. — The fact that this affection is limited to the virgin cervix makes it appear as if the hypertrophy might be due to neg- lected functions, but the fact is that its cause is not known. Prognosis. — The hyj)ertrophy yields to surgical treatment very promptly. All the cases that I have treated, five altogeth- er, have been com- pletely relieved by amputation of the cervix. Treatment. — The removal of the super- abundant intra-vagi- nal portion of the cervix by amputa- tion, is the only meth- od of treatment which gives satisfaction. Several methods of operating have been employed, such as the circular method, made with the knife or scissors, the ecraseur, and the galvano-cautery wire. Originally, in all of these methods the stump was left to heal by granula- tion. J. Marion Sims greatly improved the operation by covering the stump with mu- cous membrane. Simon and Marckwald made a double- flap operation, and I have adopted a modification of this method. The details of the operation, as I perform it, are Fig. \ as follows : A rubber cord is passed around the cervix and drawn tight enough to control the hgemorrhage ; the ends of this cord are then seized with a fixation- forceps, which keeps them from slipping, and also holds the cervix in the desired position. The cervix is divided from the canal outward on either side as Fig. 166. — The first step; splitting the cervix. Fig. 167.—The double flaps of the amputation. . — Dia- gram of the pieces removed. 346 DISEASES OF WOMEN. high up as the amputation is to be made (Fig. 106). The double flaps are then made with the scalpel in such a way that the two short flaps are on the in- side (I'igs. 167 and 168). The portions removed are wedge-shaped. Two middle sutures are then introduced from the cervical mucous mem- brane, or short flaps, to the outer mucous mem- brane, and the lateral sut- ures are used in the same way as in restoring a bilat- eral laceration. Fig. 169 sbows the sutures a.s intro- duced, and Fig. 170 shows them when tied. Before tying the sut- ures tlie rubber cord should be loosened, and if there are any vessels that bleed freely they should be controlled. Slight ooz- ing is controlled complete- ly by tying the sutures. There are two things M'hich have been brought out by experi- ence, and these should be kept in mind. The tirst is, that the cer- vix after amputation retracts or shrinks, so til at it should not be amputated too high up, but left a quarter or three eighths of an inch longer than it should apparently be. It will he found short enough two or three months after the op- eration. The next point is, that the middle and outer layers retract after the operation far more than the mucous membrane of the cervix ; especially is this the case when there is a cervical endometritis present. In several of my cases, I found several months after the operation that the mucous membrane protruded from the os externum, and had to be clij)ped Fig. 169. — The sutures in place. Fig. 170. — The sutures tied. HYPERTROPHY OF THE CERVIX UTERI. 347 oflF. This is a simj)le thing to do, Imt by observing the directions this item of after-treatment will not be recj^uired. The after-treatment is the same as that employed in the op- eration for restoring a lacerated cervix uteri, and need not be de- scribed here. In a certain number of cases I have noticed that the outer walls of the cervix retract more than the mucous membrane after this operation. Immediately after the parts have healed, the cervix is quite perfect, but in a few months the mucous membrane protrudes beyond the muscular wall. This is more likely to occur, I think, in case there is a cervical endometritis accompanying the hyper- trophic elongation. When this condition of protrusion or prolapsus of the cervical nmcous membrane is found subsequent to amputa- tion, the easiest and quickest way is to draw the superabundant tis- sue and clip it off. Just here I may mention that hypertrophic elongation of the anterior half of the cervix occasionally occurs in bilateral laceration. When this elongation is very great, I have found it best to amputate the redundant part as a preliminary to the operation for the lacera- tion. This is done in the same way as taking off a finger by the flap operation. CHAPTER XXL riBEOMA OF THE UTERUS. These new growths of the uterus belong to the middle period of life, occurring during functional activity of the uterus, and are the most benign, both in composition and behavioi-, of all the neoplasms of the uterus. They partake far more of the nature of a hyper- plasia than a degeneration. Fibromata originate in the middle coat of the uterus and in histological composition are the same as the tissues which produce them. Efforts have been made to lind some difference between the structure of these growths and that of the wall of the uterus, and several names have been employed whicli would convey some idea of their structure. Filjroid, fibrous myoma, fibro-myoma, and hysteroma are the names that have been used to designate these tumors. I prefer the term fibroma, believing that it is as comprehensive and indicative of the chai'acter of the growth as any. By comparing a section of the uterine wall with a section of fibroma, it will at once appear that they are very much alike. Both are composed of muscular fibro-cells, fibro-plastic elements, and cellu- lar tissue. There is also a similitude in their function or, more prop- erly speaking, both the tissues of the middle coat of the uterus and those composing a fibroma are similar in their behavior in this re- spect ; they are both given to great increase by growth and decrease by atrophy. While it is a fact that the same histological elements are found in the wall of the uterus and in fibromata, the construction and ar- rangement of these tissues differ sufficiently to cause a difference in the physical characters of the two. Compared with the wall of the uterus the fibroma is more pearly white in color, less vascular, usual- ly more dense to the touch, and cuts more like cartilage. Fibromata grow usually in the body and fundus of the uterus, but in rare cases they have been found in the cervix. All of these growths nmst of necessity begin in the muscular tissue of the wall of FIBROMA OF THE UTERUS. 349 Fig 171. Fin. 172. Figs. 171, 172. — Interstitial fibro- mata (Winckel). the uterus, but the direction in which they grow varies in different cases, and this has led to a very clear and useful classiiication of fibromata. When the tumor remains im- bedded in the middle coat of the wall of the uterus it is called interstitial (Figs. 171 and 172), when it grows toward the outside, subperitoneal, and when it grows toward the cavity of the uterus, submu- cous. Figs. 171 to 173 will show the three forms classed according to location. The subperitoneal variety might well be divided into two classes, those that are situated outside of the broad ligament and those that are within its folds. Though very little has been said in books about the fibromata which grow within the folds of the broad ligament, the history of such differs so much from the ordinary subperitoneal variety that a special notice is quite necessary. Fibromata situated in this position, instead of becoming pedunculated, extend out- ward between the folds of the broad ligament and di'op down deep into the pelvis. It is not until they become quite large that they extend up out of the pelvis. Being surrounded by the folds of the broad ligament they are more firm- ly fixed in the pelvis than other subperitoneal tumors, and consequently cause more displace- ment of the pelvic organs. The uterus and the Fig. 173.— Subperitoneal bladder are usually pushed far over to the oppo- and submucous fibro- •, • i j! ,i t • i jsu ,„ mata (Winckel;. ^^^^ ^1^6 ^^ ^ti® pelvis, and the pressure upon the ovaries and pelvic nerves made by such a tumor causes much pain. Fibromata in this position cause the most suffering of any of this class of tumors, and they are more likely to cause cellulitis than when located elsewhere. In some cases the tu- mor drops down very lew in the pelvis behind all the pelvic organs. One case of an unusually large fibroma which came under my care had a large mass behind the rectum which extended down to the peritonaeum. It appeared to be a part of the tumor, but I presumed that it must be something else. Dr. Thomas Keith saw the case, and pointed out that the tumor had split up the broad Hgament in its growth, and extending downward beneath the peritonaeum neces- sarily got behind the rectum. The location of the tumor has a marked influence upon its his- 350 DISEASES OF WOMEN. tory .itkI treatment ; tlie classification should be clearly understood and kept in mind on this account. Those that grow toward the in- side of the uterus may remain l^road- ly attached to the uterine wall or they may become pe- dunculated. Fig. 174 shows this lat- ter condition. They may be single, conglomer- ate, or multiple. The single tumor consists of one mass, the multi])le of several masses situated apart and at different places in the uterus, and the conglomerate consists of a num- ber of masses growing close to- gether and sur- rounded by one capsule. These growths occur, as a rule, in the body and fun- dus of the uterus, rarely in the cervix. They vary greatly in shape. "When ver\' small they are usually round, but as they grow the}- sometimes l)e- come irregular, especially is this true of the conglomerate variety. In all cases the tumor is in a sense distinct from the wall of the uterus. The tumor is in the uterine wall, but not a part of it. There is in almost all cases a clear line of demarkation between the tumor and the tissues of the wall of the uterus. The tissues which surround the tumor and separate it from the neighboring tissues are chiefly cellular, and are called the capsule. This, after all, is only a separation in the ari-angement of the tissues of the uterine wall and tumor which shows the difference between the two. Were it not Fir.. 174. — Pedunculated submucous fibroid (Simpson). FIBROMA OF THE UTERUS. 351 for this the morbid growtli would be very mucli like circumscribed hypertrophy of the uterus. As it is, the development, growtli, and decay of fibroids are influenced by the uterus, from which they take their origin and nutrition, and are governed by the same laws. Fibroids occur only during the active functional life of the uterus. They increase in size during pregnancy, and generally diminish in size after confinement, and after the menopause they often disappear with the final atrophy of the uterus. Even in the absence of pregnancy the growth of a fibroma resembles the normal growth of a jiregnaut uterus, in the respect that there is simply an increase of tissue without change of structure. The rule is that fibroids are never seen bsfore puberty, and they usually disappear after the menopause, but not always immediately after the cessation of the menstrual function. Usually, the menopause is postponed in cases of fibroma, the patient continuing to menstruate until fifty years and over. Neither does the decrease in the the tumor begin as soon as the menses stop in all cases. On the contrary, the organic forces which maintained the menstrual function being no longer called for are devoted to the growth of the fibroma, and this growth may go on for some time after the menopause, but the rule is that in time the process of atrophy begins and the tumor diminishes, and finally disappears, or nearly so. During the growth of these tumors they frequently change their position and relations to the uterus. The submucous tumor extends more and more into the cavity of the uterus. This change in posi- tion diminishes the area of connection between the tumor and uterus. It becomes pedunculated, and in this condition is sometimes de- scribed as a fibrous polypus of the uterus. This process of expulsion of the tumor fi'om the uterus may go on until separation is com- plete, the tumor being expelled as is an ovum in miscarriage. Fig. 174 shows this. The same changes occur in the reverse direction in subperitoneal fibromata. They frequently become pedunculated, and it has happened that they have become detached from the uterus altogether. When this has occurred (which has not been often) there are usually found adhesions of the tumor to the ab- dominal viscera, and a vascular communication between the tumor and the parts to which it has become attached has been established. Sometimes such adhesions occur in tumors which are not peduncu- lated, but it is a notable fact that fibrom.ata are the least liable to form adhesions of all the neoplasms. There are certain facts in the clinical history of fibromata regard- ing their growth and decay, which should be noticed. It has al- 352 DISEASES OF WOMEN. ready been stated that we should expect that these fibromata, ]>einp; like the uteriKs in structure and depending u])i>n it for nutrition, would liave many features in ccular changes are to be expected in subperitoneal tumors. It was found that, where glandular endometritis wa.s alone present, no hiiMiior- rhages had gone before. In the case of interstitial tumors associated with glandular endometritis exclusively, tliere was likewise no j»re- cediug luLMnorrhage. It was present only with interstitial en- dometritis. Therefore, haemorrhage will not take place where the interglandular tissue is quite intact ; Init it will occur where both structures proliferate equally (endometritis fungosa), or where one or the other form develops predominantly, or where glandular en- dometritis exists on one side and interstitial endometritis on the otber. Compression of the numerous vessels causes venous con- gestion ; haemorrhage will set in, especially when glands and tissue have proliferated equally. The glands exert no influence on the under surface ; their cliuracter is usually benign. The border-line between mucosa and muscle is intact. Endometritis glandularis is of a benign nature." These pathological changes in the mucous membrane and the increase in its extent by the great enlargement of the uterus, cause a marked increase in the vascularity. To this state is due the menor- rliagia and hciemorrhage which are so generally present in cases of fibromata. Deformity of the uterus is produced in many cases, but in some even large tumors tlie uterus presents the form of that of pregnancy. It is simply enlarged but not changed in form. There is often displacement of the utenis, especially in the interstitial and subperitoneal varieties. The tumor either drags the uterus toward the side upon which it is located, if it is small, or pushes the uterus in the other direction, if the growth is large. The cervix uteri may be disturbed in many ways. It is some- times greatly elongated and far out of its normal position. Many times it is spread out on the tumor so that it appears to be a part of it. The canal of the cervix is often tortuous and its caliber lessened. The effects of fibroma of the uterus upon surrounding organs are due to pressure which may cause derangement of function. These effects depend upon the size and location of the tumor, with refer- ence to the degree of the derangement. "When the tumor is still small enough to remain in the pelvic cavity and make pressure to a limited extent only, the symptoms j^roduced resemble those caused by uterine displacements and small ovarian cj^sts. The rectum may be pressed upon and its function perverted. The bladder may suf- FIBROMA OF THE UTERUS. 355 fer from pressure winch may prevent it from distending, or it may be rendered irritable and tender from pressure. In some cases the pressure may become so great that the function of the bladder and rectum may suffer, and even the ureters themselves may be affected in the same way. I have seen several cases, three, in all, I think, where the ureters were obstructed from the pressure of fibromata, and the kidneys were affected in consequence. The pressure may become so great that the function of the rectum or bladder becomes arrested, and inflammation of the cellular tissue or peritonaeum may occur and prove fatal. I have repeatedly seen slight attacks of pel- vic inflammation caused by pressure of fibromata ; one case proved fatal from pelvic inflammation and rectal obstruction. I saw the patient first when she began to have inflammation, and I found the tumor impacted in the pelvis and it could not be dislodged by any means. The inflammation progressed, and the obstruction of the rectum became complete by the addition to the tumor of the prod- ucts of the inflammation. In most cases the tumor can be raised up out of the pelvis when it becomes large enough to give much trouble by pressure. The pressure may be directed upon the pelvic nerves so as to cause very great pain. When fibromata escape from the pelvic to the abdominal cavity, they do not cause so much trouble unless they become very large. They may cause peritonitis and intestinal obstruction, but that is rare. They were supposed to cause ascites, because fluid in the peritoneal cavity was found in a certain proportion of cases. Keith believes that this fluid is a trans- udation from the tumor rather than from the peritonfeum, as in or- dinary ascites. The quantity of the fluid is seldom sufficient to cause much trouble. Symptomatology. — The symptoms of uterine fibromata are natu- rally of three kinds : First, those manifested by the general system, which are also called constitutional or remote ; second, those which originate in the uterus itself ; and, third, those that are produced by the pressure of the tumor upon neighboring organs. The severity of tlie remote symptoms depends upon the size and location of the tu- mor. There are a great many patients who do not suffer in general health from fibromata of the uterus until the growth has advanced to a considerable size. Sooner or later, according to the extent of disturbance which the growth causes, the general health becomes impaired. The patient becomes anaemic and is generally debilitated, because of either the loss of blood or deranged nutrition, or both. These symptoms are not by any means diagnostic, but may come from a variety of affections. In the most marked cases, when the 356 DISEASES OF WOMEN. patient is extrciiiely aninnic, the skin becomes slii^litly bronzed, and gives to tlic patient tlie appearance of having malignant disease. The symptoms which are manifested by the uterus are pain and htemorrhage. Tlie pain is not always pronounced, in some cases it is not at all ])crsistent. It is irregular, spasmodic in character, and is most marked when the tumor is submucous, and least so in the interstitial variety. The haemorrhage is the most prominent symj)- toni of all. It usually comes on periodically, and is, therefore, in some cases a monorrhagia. ^Menstruation is too free, and lasts too long, and recurs too often. Bleeding may come at any time, there being no regularity whatever in some ca.ses. This symptom is so constantly present, that Dr. J. Mathews Duncan called fibroma the bleeding disease of the uterus. This nanie is w^ell deserved, for certainly no other affection gives rise to so much haemorrhage of the uterus as does this. The size of the tumor does not influence the severity of the l)leediiig. In some small tumors the bleeding is greater than in others of mon- strous size. It is the location of the tumor which determines the baemorrhagic symptoms. It is greatest in the submucous, less in the interstitial, and least in the subperitoneal as a general rule. The submucous pedunculated variety is the worst of all for causing bleeding. A very small tumor of this kind may cause the most persistent and exhausting haemorrhage. The symptoms caused Ijy the effect of the tumor upon neighbormg organs are generally most marked when the tumor occupies the pelvic cavity. Then the press- ure upon the bladder and rectum causes irritation and functional ol> struction of these organs ; less or more pelvic tenesmus of a general character is sometimes very severe. The effect upon the bladder is to render urination very frequent and sometimes difficult or impossi- ble. I have seen three cases in which there was retention of urine. The tumor was pear-shaped in all of them, and large enough to ex- tend above the brim of the pelvis. The urethra and bladder were carried upward, so that the urethra was caught between the tumor and pelvis, and compressed. Urination in these cases was, for a time difficult, and then retention came. All voluntai'y efforts to evacuate the bladder only made matters worse, by forcing the tumor downward and wedging it into the su])erior strait. Relief was given first by the catheter, and then by ])ushing the tumor upward, the pa- tient being placed in the knee-chest position. Pressure upon the pel- vic nerves and ovaries often causes much pam. Pain in the back and limbs, which is often present, no doubt comes from the same cause. Pressure upon the ureters may cause obstruction and hydro- FIBROMA OF THE UTERUS. 357 neplirosis, and all the unfortunate results to the kidney which must follow. In such cases there is at first pain in the region of the ureters, and subsequently the symptoms of renal disease appear. Fibromata large enough to occupy the cavity of the abdomen give very little trouble, as a rule. So far as affecting the neighboring organs, very large tumors interfere with free respiration, and the action of the stomach and bowels to some extent. The ascites which sometimes accompanies fibromata of the uterus was supposed to be due to irritation of the peritonaeum. It is more likely that it is a transudation from the tumor itself, as already stated. This is sug- gested by the fact that hydro-peritonaeum is usually found in connec- tion with oedematous tumors. Physical Signs. — The positive signs of fibroma are the increase in size, change in form, and consistence of the uterus, and the dis- placement or distention of the canal, as related to the body of the uterus. The touch discovers the fact that the uterus is enlarged, apparently, and by the bimanual touch it usually can be proved to bo really so. The shape of the uterus is changed in nearly all cases. It is irregular in outline, one side being much larger than the other. In the subj^eritoneal variety, this deformity is quite marked. The tumor projects from the surface of the uterus so boldly that it can be instantly detected. In some of the cases of submucous fibroma, and occasionally in the interstitial, the uterus is uniform in shape, and appears like a uterus enlarged by gestation, and even when there is some irregularity of form it is not unlike that which is often found in pregnancy, but the uterus is very hard in the one case, while in the other it is very soft. The hard character of the tumor and uterus is a very reliable sign of fibroma. In all conditions which cause enlargement, the uterus is softened except in fibroma and in very rare cases of cancer. Whenever the uterus is enlarged and in- durated, fibroma may be strongly suspected. Deflection of the canal of the uterus from the center is a very important sign of fibroma. The relations of the canal of the uterus to the axis of the pelvis, as shown by the sound, are changed in all forms of displacement, but the canal is still in the center of the uterus. In fibroma the canal is excentric and very often tortuous. The use of the sound, by which this displacement of the uterine canal can be detected, gives this most valuable evidence of the ex- istence of a fibroma. Figs. 175 and 176 will show this point very plainly. The one shows a uterus large, owing to subinvolution, the other about the same size from enlargement due to a fibroid. In not a few cases the canal is so deflected, displaced, or com- 358 DISEASES OF WOMEN. i Fig. 175. Fig. 176. Figs. 175, 176. — Enlargement due to subinvo- lution compared with tliat from growth of a fibroma (after Wincliei). ))ressed, that the sound can not be passed. A flexible l)ou^ie may be used, under these cireunistances, and altliough it will not posi. tively show the position of the canal it gives valuable indica- tions of it. When the sound can not be used at all, this valu- able sign is not obtainable, but the fact that the canal in a hirjie uterus will not admit the sound is evidence of fibroma. There is no other condition of enlarge- ment of the uterus in which the sound can not be passed, as a rule. Small fibromata, which oc- cupy the pelvic cavity, present some physical signs which resemble displacements of the uterus, ovarian tumors, tubal pregnancy, the products of former inflamma- tions and diseases of the Fallopian tubes. The differentiation between flexions and versions of the utenis and fibromata is based upon the following facts : In flexion and version the uterus is not much enlarged, and, as a rule, can be re- stored to the proper position when all signs suggestive of liljroina disappear, and then, too, the sound shows that the cavity of the uterus is not displaced nor enlarged. Ovarian tumors are distin- guished from fil)romata by being less dense and not usually fixed to the utenis ; one can be moved without the other. Early pregnancy is usually distinguished from a fibroma by the history and synij)- toms, but the physical signs dift'er. The uterus is soft in pregnancy, while it is unduly hard in fibroma. The enlargement and softening extend to the cervix in pregnancy, bat not in flbroma. Should a doubt exist, the differential diagnosis can easily be made in a short time by watching the progress of the case. The signs of pregnancy will soon become sufficiently jjronounced to settle the question. The most difficult cases to deal M'ith arc those in which preg- nancy takes place while there is a fibroma present ; I have seen sev- eral cases of this kind. Two of these were pregnant when first seen, and^in both the diagnosis of fibroma was made and in only one did I suspect pregnancy at my first examination. In the others I was aware of there being a fibroma present, but I did not detect the pregnane}' until several months had elap.sed. Fibromata situated within the folds of the broad ligament are not FIBROMA OF THE UTERUS. 359 easily distinguished from the products of a pelvic cellulitis, extra- uterine pregnancy, and diseases of the Fallopian tubes. The history of the case, taken in connection with the physical signs, will usually suffice to enable one to make the diagucjsis. Large fibromata which occupy the abdominal cavity have to be differentiated from fibro-cysts of the uterus and ovarian tumors. In regard to the distinctive signs by which the diagnosis between ovarian tumors and fibromata is made the reader is referred to the section relating to the diagnosis of ovarian tumors. The solid hard iibroma is easily distinguished from a fibro-cyst of the uterus by its density, as recognized by the touch, but a soft fibroid may be so elastic as to give the signs of an imperfect fluctua- tion, and simulate a cyst with a thick wall. In such cases of doubt the chances are in favor of the tumor being a soft fibroma, but if it is very necessary to make a diagnosis it may be done by aspiration. The accumulation of fluid in the upper part of the cavity of the uterus, occurring as a complication of a uterine fibroma, gives the physical signs of a fibro-cyst so perfectly that one must certainly be led to make a false diagnosis. I have seen two such cases, one was a very large intra-uterine fibroma which closed the canal of the uterus below by pressure in the latter stages of its growth. The secretions of the mucous membrane accumulated at the fundus and gave distinct fluctuation. One of the most distinguished gyne- cologists of this age saw the patient with me and thought as I did that it was a fibro-cyst, but it was not. The histories of these eases, especially one which is given further on, will show more fully the peculiar character of the pathology and the difficulties of diagnosis. Causation. — Yery little, if anything, is known about the true pathogenesis of uterine fibroma ; certain facts in regard to age, race, and social relations have been ascertained which favor the occur- rence of these neoplasms. The age when women are most liable to these growths is between thirty and thirty-five years. There are many exceptions to this, however, but it is rare to have these growths come before puberty or after the menopause. It may be more cor- rect to say that they never occur before puberty and rarely after the menopause. In regard to race, the negro is more liable to fibromata than the white, although no good reason has been discovered why this is the case. The influence of the social relations is stated by Thomas Addis Emmet as follows : " The development of these growths is retarded by child-bearing, and even by marriage, for the sterile woman is less liable than the 360 DISEASES OF WOMEN. old iiuiid, but ill turn she is more t^o than the woman who has borne cliildren." These facts are deductions from large tabulated observa- tions of ca^es by Dr. Emmet, and are therefore reliable. He also gives his views regarding these social states as related to the causor tion of these neoplasms, in the following : " Uetween the ages of thirty and forty yeai-s the unmarried woman is fully twice as subject to fibrous tumors as tlie sterile or the fruitful. I have already referred to this subject, when treating of the causes of disease, and pointed out that this Ls one of the tributes which an unmarried woman pays for lier celibacy. It seems as if it were the purpose of Nature that the uterus should undergo the changes dependent upon pregnancy and lactation about once in three yeai-s throughout the child-bearing period, and that if the uterus is not physiologically occupied in child-bearing there is greater lial)ility to the development of fibrous tumors as the woman advances in life. This will also be the case with the married woman who has taken means to prevent conception, as well as with her who has been sterile from some cause beyond her control, but to a less degree in the latter case. I think I have had occasion to note that the sterile woman who has earnestly wished for children does not have her liability to fibrous tumor increased by the fact of her sterility, an instance, probably, of the remarkable effect of mind upon the body. Finally, the woman who may have been fruitful in early life, but remained sterile long afterward, from some accidental cause, may have a tumor developed, but is less liable thereto from having once borne a child." Prognosis. — Fibromata of the uterus, while the most fre(piently seen of all the neoplasms of the sexiial organs, are the most harmless so far as their tendency to destroy life. They occasionally prove fatal, but many cases progress until the menopause, when the growths disappear altogether or become reduced during the tinal involution of the uterus, so that they are harmless. The dangers are, first, haemorrhage, which recui*s so often in many cases that it endangers life. Very few patients bleed to death directly, l)ut some become so reduced by the long-continued loss of blood, which impairs nutrition, that death conies as the result of some secondary affection which would not have occurred except for the exhausted state of the patient. Peritonitis and cellulitis are liable to be set up by fibromata, and of the fatal cases peritonitis is a not infrequent cause. Softening of the tumor and decomposition may cause a fatal septicaemia. Blood-poisoning sometimes occurs during the expulsion of extra-uterine fibroma. Tlie tumor being in part FIBROMA OF THE UTERUS. 361 cut off from the circulation undergoes necrosis before its expulsion is coniplcted, and causes septiciemia, and death takes place when rehef and recovery appear to be witliin the immediate reach of the sufferer. Pressure upon the pelvic organs may cause death by arrest- ino- the functions of these organs. This is most likely to take place when the tumor grows in the In-oad ligament and is therefore fixed in the pelvis. 1 have also seen death occur from pressure upon the ureters causing obstruction to the lluw of urine, renal disease, and finally urcemia. Although there are dangers from all of the com- plications named above, a very small percentage proves fatal even when left without treatment ; and by judicious management a large nuinber can be relieved entirely or helped sufficiently to be able to pass through life in comparative comfort. Within the past few years such means as ovariotomy, hysterectomy, and electrolysis have been employed in the treatment of uterine fibroma, with re- sults which raise the hope that the great majority of these neo- plasms will be controlled, and the death-rate from this cause re- duced to a minimum. Treatment. — The size and location of uterine filDromata, and the conditions and complications produced by them differ very greatly, and hence the treatment must vary with each case. The ways and means may be said to vary from the simplest medication to the most daring surgery, and each method, if judiciously adapted to the re- quirements of cases as they come, gives satisfactory results. Medicinal agents have been employed in great variety, but ergot alone has been found of real value. The action of ergot upon fibromata may accomplish beneficial effects in two ways. By excit- ing uterine contractions it may produce expulsion of the tumor if its relations to the uterine wall are such that it can be expelled. On this account ergot does its best work in the submucous variety of uterine fibromata. In the same way the ergot, by causing con- traction of the uterine walls, may lessen the area of attachment of a subj)eritoneal fibroma, and arrest or retard its growth by lessening its blood-supply. This view of the beneficial effects of ergot upon the progress of subperitoneal fibromata, is based upon the fact that when such tumors are pedunculated, they do not, as a rule, grow so fast as wlien they are attached to the uterus by a broad base. In this respect, the action of ergot is simply to aid in the natural method of disposing of these growths, viz., by expulsion, which in the submucous or intra-uterine variety is often complete, the growth being wholly exiK^lled from the uterus. Ergot also acts in another way to arrest the growth of such tu- 302 DISEASES OF WOMEN. mors. Dy kcepiu:^ the utcriLs in a conditiuu of pennanunt contrac- tion, and by contracting the blood-vessels, the size of the tumor is diminished, and atrophy takes place. In order to obtain the good ed'ects of ergot in tliis way, it must be given in liberal doses, suffi- cient at least to produce all the contractions of the uterus that the patient can endure the pains of, and it must l)e continued for a long time. It sonietimes happens that the ])atient can not take ergot for any length of time without having indigestion and loss of appetite ; occasionally, also, the uterus fails to contract in res])onsc to full doses of this drug. In either case it is useless, and should not be con- tinued. In some cases the use of ergot, while it does not diminisli the size of the tumor nor aid in its expulsion, appears to retard its growth, and it also controls the bleeding which is a great gain. When the patient can be guarded against the great loss of blood, she may be enabled to live in comparative comfort and usefulness until the menopause. The menorrhagia can sometimes be helped by treating the endo metrium. The endometritis is often attended with fungous growths which greatly increase the tendency to hosmorrhage. The removal of such fungosities with the curette will often give relief, and the subse- quent application of tincture of iodine to the uterine mucous mem- brane at regular intervals, is of service. In order to use the cu- rette and apply the iodine, it is necessary that the cervical canal should be sufficiently large to permit an entrance to the uterine cavity. In some cases the cervical canal is so narrow and the cavity of the uterus so deflected that such treatment is impossible. When expulsion, with or without the use of ergot, has advanced far enough to j^edunciilate an intra-uterine tumor and dilate the cer- vix utei-i, the tumor can be separated from the uterine wall and re- moved by dividing the pedicle. When the dilatation of the cervix is complete, and the tumor is expelled from the uterus and is lodged in the vagina (the pedicle still remaining attached to the uterus) the separation and removal of the tumor are quite easy. There are several methods of dividing the pedicle. I prefer to use the wire ecraseur. The galvano-cautery ecraseur has been used but it is difficult to apply, and it is impossible to avoid burning the uterus and vagina, and has no advantages over the wire or chain. The ecrasenr which I use is modified to suit the wire. The por- tion to which the wire is attached is so arranged, that each end of the wire is held fast by a pinching screw, so that the loop of wire FIBROMA OF THE UTERUS. 363 can be Icngtlieiied or shortened in a moment (Fig. 177). I employ the steel wire used for piano or zither strings, the thickness of the wire being adapted to the size of the pedicle. The wire has one very great advantage over the chain in being easily applied. It is elastic, and yet stift" enough to be easily made to slip over the tumor to be snared. Objections to the wire or chain ecraseur have been raised. There is danger, it has been claimed, of the uterine wall being drawn into the grasp of the chain and a part of it removed, and an opening made directly into the perito- neal cavity. The fact is, that as the wire is tightened around the pedicle, the tissues are forced out of its grasp equally on both sides. There is no drawing of the tissues into the grasp of the wire. If there is inversion of the uterus at the point of the attachment of the pedicle, the wall of the uterus might be included in the ecrasevr-whe and removed. This happened once in my own practice, and I believe the same thing has been done by other operators. Fig. 178 shows the condition referred to as it occurred in my own patient. The inversion of the part of the uterus was not detected before the operation was com- pleted, but an examination of the tumor showed that the inverted portion of the uter- ine wall was completely removed. Ko harm came from it. The patient did well, but the greatest anxiety was felt for some time. Sometimes it happens that the tumor, while it protrudes into the vagina to a slight extent, is grasped by the cervix so firmly, that the wire of the ecraseur can not be applied. The same difficidty has been encountered when the tumor — the size of a fetal head — is lodged in the vagina. Under such circumstances, the tumor should be re- duced by rapidly taking sections of it away with a strong scissoi"s, and then the ecraseur can be used, or if the great the base of the tumor can be enucleated. The removal of the base of a tumor is easily accomplished by seizing the mass in the center with a tenaculum forceps and separat- FiG. 177. — Ecraseur. litemorrhage is not 364 DISEASES OF WOMKN. injj^ it first from tlic mucous membrane which forms the capsule and finally from the muscular wall. Much care and ^jjentle handling of the enucleating instrument should "^ X be employed, because tiie muscular wall of the uterus at the point of at- tachment of the tumor may be ab- sorbed, and the base of the tumor rest upon the peritonseum. Thi< .state of affairs I have found in two cases which I treated by enucleation, the histories of which will be given. Intra-uterine fil)romataliave been treated by dilatation, or division of tlie cervix uteri and enucleation be- fore they became pedunculated. At one time this treatment was quite in vogue in this country. The operation is difficult and dangerous. The dangers are from shock, htem- orrhage, and septicaemia, and so far as I can learn the results have been in many cases unsatisfactory. Some years ago I abandoned this method for other methods of treatment whicli I believe to be less dangerous and more effective in such conditions. Removal of the ovaries for the relief of small fibromata which cause exhausting haemorrhage has given very satisfactory results. This plan of treatment was suggested by the fact that these neo- plasms disappear, as a rule, after the menopause. Reasoning from this it was presumed that by removing the ovaries, and thereby in- ducing the cessation of the menstrual function prematurely, the same effect upon the fibromata would be obtained. Practically, it was found to be so, and hence in properly selected cases the re- moval of the ovaries is the best treatment. In some cases, although the removal of the ovaries appears to be the best means of giving re- lief, it is found impractical. When the ovaries can not be reached with sufficient ease to make their removal possible, or when they are so closely adherent to the uterus, as they sometimes are, that they would require to Ije dissected from their attachments it is unsafe to try to remove them. Under such circumstances it is better to per- form hysterectomy. Fig. 1 7S. — Wall of uterus caujjht in ecraseur-wire and removed. FIBROMA OF THE UTERUS. 365 It is well in view of these facts, to be prepared to remove the uterus, when ovariotomy is undertaken for the relief of uterine fibromata, for should the one operation prove to be impossible the other could be resorted to. Beyond tli/^ fact that the ovaries ai'c sometimes more difficult to get at in these cases, there is nothing in the operation which differs from ovariotomy generally, hence noth- iner need be said about it in this connection. It should be understood that the exact value of this method of treatment is still under consideration, and more time and cases are needed to settle the question definitely. All who have practiced this method of treatment often enough to obtain valuable experience report favorably of it. Wildow states, that in seventy-six cases the menopause occurred immediately in sixty-one. In four cases, the effect upon the haemorrhage was temporary. In sixty-three cases the fibromata diminished. In three cases there was a primary diminution and a subsequent increment of the tumor. More recently Wildow has given the statistics of one hundred and forty-nine cases, of which fifteen died. I presume that the death-rate has been less than this with some operators. Shonld it prove to be so great as ten per cent it would become a questionable procedure, notwithstanding that the results in the successful cases should prove to be satisfactory. Hysterectomy for the relief of uterine fibromata has now been performed a sufficient number of times to enable one to discuss its relative merits with some degree of certainty. In the first place it is adapted to large, rapidly-growing tumors, which do not yield to less heroic treatment, but i-ender the patient useless and threaten her life. Dr. Thomas Keith, who, up to this time, is by far the most suc- cessful operator, in speaking of this subject, says : " I often ask myself the question : Does a mortality of eiglit per cent justify an operation for a disease that, as a rule, has only a limited active life, that torments simply, and that only for a time, though of itself it rarely kills ? The mortality of an ordinary uter- ine fibroid, if left alone, is nothing approaching a death-rate of eiglit per cent. I doubt even if the mortality of the extreme cases exceed this. And, after all, the great difficulty is, not in doing even the worst of these operations, but in knowing what are the cases in which it is right to advise those who trust themselves to us, to run the risk of a dangerous operation, with all its attendant miseries. Could we get the mortality down to five per cent in the bad cases, and these only are the fit subjects, tlien one might advise interfer- 300 DISEASES OF WOMEN". ence with a more easy luiiul. I do not think that we can so advisu. if the mortality can not be kept under ten per cent." It appears at the present time that by the judicious use of other means of treatment the number of cases wliich will require liyster- ectomv in the future will be diminished, but still there may always be some that will demand it. Dr. Keith says that all his operations were done on account of repeated haemorrhages and ruined health. He also states that the time chosen for the operation was a day or two before menstruation was expected, because the patients had then regained more or less force from the loss of the previous period. Electrohjsis.—Thh method takes the highest rank among the means of treating fibroma of the uterus. In order to fully compre- hend this subject, some knowledge of the elements of electro-physics should be obtained. The following treatment of this matter was prepared for me by my friend Prof. Charles Jewett : Some knowledge of electro-physics is essential to the intelligent use of electric- ity as a therapeutic agent. The limits of this cliapter, however, will not permit more than a brief mention of such ele- mentary facts as are necessary to a proper understanding of the teiTninology and technique of electrical treatment in gyn- ecology and a few words of advice with reference to the selection of apparatus. For a more extended knowledge of the subject tlie reader must be referred to the many standard works on electrical science. The physical forces are no longer re- garded as having a distinct and inde- pendent existence and manifesting them- selves by their effects ujion matter, but rather as affections or conditions of mat- ter itself. In short, the diffei'ont physi- cal forces are different modes of motion in the molecules of bodies. The phenom- ena of electricity, then, are due to a mode of molecular motion. It is an important practical fact that the molecular forces are mutually convertible. Any one may be trans- fonned into any other force. Familiar examples of the conversion of force are the transformation of heat into light when a bit of wire -Electrical action in a sinfrle cell. FIBROMA OF THE UTERUS. 367 is brought to incandesccnco in a gas-tluiiio, the generation of heat by friction or impact, the production of ligiit by electricity, and so on. Ill ])ractice, electricity is derived from a variety of sources. The electricity of a frietional machine is the product of tlie mass motion of the glass plate, or rather of the muscular force expended in turn- ing the phite. Magneto-electricity is obtained from nuignetisra. The electrical energy of a galvanic battery is the result of the chem- ical action of its elements. In accordance with the law of the cor- relation of forces, the amount of electrical energy, by whatever method developed, is the mathematical equivalent of the force ex- pended in producing it. Galvanism, faradism, and static electricity are the kinds of elec- tricity commonly used for therapeutic purposes. Galvanism, for use in medicine, is generally obtained from chemical sources, A simple example of a galvanic cell may be constructed by immersing, at a short distance apart, a plate of gas carbon and one of zinc in dilute hydrochloric acid in a common glass tumbler (Fig. 179). A moment- ary chemical action takes place in the cell. The chlorine of the acid enters into combination with the zinc, forming the chloride of zinc, which goes into solution in the fluid of the cell. Bubbles of free hydrogen collect upon the surface of the carbon plate. It can now be shown, by methods familiar to electricians, that the free ends of both plates are charged with electricity. If the free ends of the plates be conjoined by means of a copper wire the plates imme- diately deliver their charges through the wire. But since the chemi- cal action now becomes continuous the charge is continuously re- newed, and thus a constant flow of electrical disturbance is main- tained. If the wire be disconnected, the chemical action ceases in the cell, and the flow of electricity is arrested. Both are renewed on again connecting the plates. The active metal, zinc, is called the yodtive element of the cell, the carbon the negative element. The conjunctive wire, the plates, and the intervening cohinm of fluid constitute the electrical circuit. The continuous propagation of the molecular disturbance in the circuit gives rise to the teim current. For convenience, the current through the wire is said to flow from the carbon to the zinc plate, though in fact we have two currents, one of positive electricity flowing from carbon to zinc, and one of negative electricity from zinc to carbon. The free end of the carbon, from, which electricity flows through the wire, is termed the positive j)ole., the corresponding end of the zinc is the negative pole of the cell. If the conjunctive wire be cut, the free ends of the wire now become the poles of the circuit, one the positive, the other 368 DISEASES OF WOMEN. the negative j)ole. For ordinary therapeutic uses metallic ])late8 variously covered with moist sponge, chamois, or otherwise, are at- tached to the free ends of the wire, and are commonly termed electrodes (from eXeKrpov and 0809, the electrical pathway). The positive electrode, sometimes called the anode {ava and oBo^, the way up), the negative electrode, the cathode (Kara and 0809, the way down). A combination of several galvanic cells in a common cir- cuit is a galvanic hath nj. Bodies which, like the conjunctive wire, are capable of transmit- ting electricity, arc called conductors. Others which lack this prop- erty are termed non-conductors. These terms, however, are merely relative. Different substances differ widely in their conducting power, and, strictly speaking, no body is so good a conductor as to oppose no resistance to the passage of the current, none so poor a conductor that its resistance may not be overcome in some measure by power- ful currents. The metals are examples of good conductors, silver and copper being the best. Glass, vulcanite, ivory or bone, and dry wood ai*e good non-conductors. Such substances, when used for the purpose of preventing leakage of the current, as in the handles of electrical instruments, are termed insulators. The capacity of a galvanic cell for generating electricity is de- nominated its electro-motive force. It depends upon the energy of the chemical action in the cell, and therefore varies with the ma- terials which enter into its construction. In a battery of similar cells arranged in series (the zinc of one cell being connected with the carbon of its neighbor), the electro- motive force will be increased in proportion to the number of cells. The term current is not only applied to the flow of electricity in the circuit but is also used in a quantitative sense. It is employed ill the sense of current strength, and represents the quantity of elec- tricity flowing through the circuit. The term resistance is used to denote the degree of obstruction opposed by the circuit to the pas- sage of electricity through it. As may be inferred from what has already been said ^A\\\ reference to the conducting power of bodies, resistance varies with the materials of which the circuit is conq)osed. In case of wire, or other conductor of given material, the resistance varies directly as its length, and inversely as its sectional area. Not only the conjunctive wire, but the exciting fluid as well, and the plates of the cell offer a greater or less amount of resistance. The total resistance within the cell is designated the internal, in distinction from that without, which is called the external resistance of the circuit. The electro-motive force of a battery corresponds approximately FIBROMA. OF THE UTEFvUS. 369 to the liorse-power of a steam-engine, the current to the motion of tlie machinery. The vahic of the current in a given circuit will depend not only on the electro-motive force of the battery, but also upon the resistance in the circuit. It will vary directly as the electro-motive force, and inversely as the resistance. In other words, the current will he equal to the electro-motive force divided by the resistance. This is the law of currents, and is known as Ohm's law, so named from its discoverer. Letting C stand for current, E for electro-motive force, and R for resistance, the law may be conveniently expressed by the E R following formula, C = .^ . Putting R' for the internal resistance, E and W for the external, we have C = ^^j-, ^f^, . By application of sim- Iv + iw pie algebraic rules, any three of these quantities being known, the other may be found. A knowledge of this law and its uses is of the utmost importance in all practical applications of electricity. By its aid many of the perplexing problems encountered by the beginner in electrical practice may be readily solved. For quantitative determinations we must have units of quantity. The adopted unit of electro motive force is the volt, that of resist- ance the o/wi, and that of current the amjpere. A volt is the amount of electro-motive force necessary to yield one ampere of current through one ohm of resistance. An ohm represents approximately the resistance offered by 230 feet of pure copper wire of No. 16 American wire gauge. A volt is very nearly the electro-motive force of a single Daniell's cell. To illustrate the application of Ohm's law in practice, suppose the electro-motive force of a given galvanic cell to be 1*5 volts. Let the internal resistance be one ohm, and that of the connecting wire E 1'5 •5 ohm. We have C = -or-r^oA^ = 7-^=1- One ampere is then I\ -[- K I'o the strength of current that flows in such a circuit. If, now, we have a battery of fifty such cells, connected in series, the total elec- tro-motive force of the battery will be 75 volts, and the total internal resistance will be 50 ohms. Suppose that a portion of the human body and the necessary instruments for regulating, measuring, and applying the current be introduced into the external portion of the circuit. If the tissues of the body in the circuit offer a resistance of 1,000 ohms and the instruments and conducting wire a total of 4.50 ohms, the entire external resistance will be 1,450 ohms. From T5 Ohm's formula we have - — , , ,^ = "050. The current in this 25 50 + 1,450 370 DISEASES OF WOMEN. case will therefore be fifty tliouRandtliR of an ampere, or, as it is ex- pressed, 50 milliamperes, tlie milliaiiipere being one thousandth of ;ni ampere. From C = ^, f ^.„ we get R'+ R" = ? and R" = ? - R'. Tlie required data being given, we may by means of this formula find the total external resistance or any component part of it. Sup- pose a portion of the body be connected in circuit with the same battery, instniments and conducting wires as in the case last cited. Suppose the current is now found to be 50 milliamperes. The resistance, exclusive of that offered by the tissues interposed, being known, we may readily compute the resistance of the portion of the body through which the current is passed. We have frt»m the last formula, R" = 5 - R', R" = ^^J" - 50 = 1,450. Deducting the vy *U0' ' known resistance of the wire and instruments, we have 1,450 — 450 = 1,000. The resistance offered, then, by the portion of the body placed between the electrodes is 1,000 ohms. From the formula C = - ^, -^„ we also have R' = — - — 11' K -|- K C and E = C (R' -f- K"). The application of these formulas in practice is obvious from the illustrations already given. When enormous resistances like those of the human body are con- cerned, such elements in the computation as the internal resistance of the battery, if it be low, and that of the conducting wires may be disre- garded. The results will be sufficiently exact for practical purposes. The resistance offered by the human body is by no means a con- stant quantity. It varies by hundreds of ohms not only with the amount of tissues interposed in the circuit, but also \\dth the varying character of the tissues in different parts of the body, the area of the electrodes and their firmness of contact, with the degree of moisture of the part to which they are applied, and other causes. It is well known that the conducting power of the electrodes and the com- pleteness of the electrical contact may be increased by moistening the electrodes with a saline or acid solution, instead of plain water, a fact often useful in practice. The accumulation of hydrogen bubbles which takes place ujion, the surface of the carbon plate when the battery is in action weakens the current in proportion to the extent of surface so covered. This phenomenon is known as polarization. Various means are provided in the construction of different batteries for overcoming this diflR- culty, or, as the expression is, for depolarizing. For example, di FIBROMA OF THE UTERUS. 371 polarization is accomplished in certain cautery batteries by occasion- ally agitating the fluid and thus removing the hydrogen from the plate. In ordinary batteries the effects of polarization are partially or wholly obviated by various chemical provisions. Ey electrolysis [eXe/crpov and \vai<;) is meant electro-decompo- sition, or the resolution of the chemical compound into two con- stituent parts by the action of the current. For a simple illustration of electrolysis, place in a beaker-glass a solution of iodide of potas- sium. Selecting for the electrodes some non-corrodible metal, plat- inum-wire for example, innnerse them at a short distance apart in the solution. Iodine will be liberated at the positive pole and potas- sium at the negative. A few drops of starch- water dropped into the solution will demonstrate the presence of free iodine at the positive electrode, and, since the potassium enters into combination with oxygen and hydrogen, forming the hydrate of potassium, an alkali, its presence may be shown at the negative pole by a few drops of red-litmus sohition. The body thus decomposed is termed an electro- lyte. Since bodies which are — in an electrical sense — unlike, attract one another, and like bodies repel, chemical elements attracted to the positive pole are called electro-negative elements, those which go to the negative pole electro-positive elements. In general, substances liberated at the negative pole are termed anions^ those set fi'ee at the positive pole, cations. Galvanic currents, with which we have thus far dealt, are con- tinuous currents. The current of a faradic machine is an interrupted current, consisting of a series of more or less rapidly recurring im- pulses. Moreover, it is an alternating current — that is to say, each alteraate impulse traverses the circuit in opposite directions. Since the polarity is reversed with each impulse there is no difference in the therapeutic action of the electrodes. The electricity of a static machine is also characterized by instantaneous discharges. Another important difference between faradic, or especially static and gal- vanic electricity, is one of tension. By tension or potential is un- derstood power to overcome resistance in the circuit. Faradic, and especially static electricity, are characterized by high tension. The value of the electric current, other things being equal, depends upon the difference of potential between the point from which and that to which the current flows, just as the force of a waterfall de- pends upon the difference of water-level above and below the fall. Space will not permit a description or even an enumeration of the various forms of the galvanic cell, which are more or less suited to therapeutic requirements. For portability the latest forms of 372 DISEASES OF WOMEN. the chloride of silver hattery leave little or nothing to he desired. Their principal disadvantage is a high and varying internal resist- ance. They answer well, however, the ordinary requirements of galvanization. For a stationary battery for office use the Leclanche battery, or more especially some one of its nioditications, is deservedly becoming ])opular. Any amount of electro-motive force required by the physician for galvanization or electrolysis may be obtained by the use of a large number of cells, and for cleanliness, con- venience, and durability they are thus far unexcelled. A battery of forty to 'Sixty such cells, though somewhat cumbersome, can easily be disposed of in a closet or in the cellar. With proper use it is always ready for work, and requires little or no attention for long periods. The best modification of the Leclanche battery that has been brought to our notice is the Law bat- tery (Fig. ISO). Its mechan- ical construction is of the ; highest order. It is subject to absolutely no deterioi-ation when not in use — which can not be said of most batteries, even of the Leclanche par- tern. The carbon plate is jirepared by a sjiecial process, and, with projier care, lasts indefinitely. The only part> that require renewal are the zinc and the exciting fluid, ! and these Imt once in two or • This is an inqiortant advantage over other forms of the Leclanche cell in which the carbons as well as the other elements require renewal, from time to time, at an ex- pense little short of the first cost of the cell. For cautery purposes, it is not unlikely that a small ])ortable bat- tery of storage cells will be found most suitable. They can be readily recharged during the intervals of use by means of a few gravity cells. The well-known cautery batteries of Pilfard, Daw- son, and Byrne are extensively employed, but are inferior to a good j storage battery in reliability and in convenience of use. There is a common misapprehension in regard to the effect of the size of cells upon the current. The electro-motive force of o Fig. 180. — Law cell. three years in ordinary office use. FIBROMA OF THE UTERUS. 373 cell of given elements renitains the same whether the size be large or small. The internal resistance of the large cell is less than that of the small one since the resistance of the column of fluid between the plates varies inversely as its sectional area. Through a low ex- ternal resistance large cells will give more current than small ones. If the external resistance be very great the current will be practically the same whatever the size of the cells. This may be shown by Ohm's law. With a battery of fifty cells, each having an electro- motive force of 1'5 volt and an internal resistance of 1 ohm, let the E 75 external resistance be 10 ohms. We have C = -f^Tn^UT/ = ^~r — \~^rr^ it -(-XV 50 -f- 10 = 1*25. A battery cell with plates five times as large will have one fifth the internal resistance, or '2 ohm. The current from fifty such 75 cells through the same resistance will be = 3'75. Thus there is a great gain in the use of large cells when the external re- sistance is small, as is the case in cautery batteries. Not so in case the current is passed through great resistances like those of the human body. Suppose, for example, the external resistance is 1,450 ohms. 75 With the battery of fifty small cells we have C = — — ; — ^ .^^ '^ -^ 50 -j- IjioO = -050. With the battery of fifty large cells of the same material C = 75 :; = -051-1-. There is practically no gain in the strength 10 4- 1,450 ^ F .; & & of cun'ent. The only advantage of the large cells for the purpose of electrolysis or galvanization is the greater amount of materials and consequently greater durability. In cautery batteries, however, the resistances are comparatively small, and here large cells are used. Moreover, only a small num- ber of cells is required. If it were possible to construct a circuit having no external resistance one cell would give as much current as a thousand. With a cell having an electro-motive force of 1*5 1'5 volt and an internal resistance of '2 we have C = = 7*5 ; with a thousand such cells we have C = ' = 7"5. It will be ^00 — (— readily seen that where very low external resistances are concerned very little gain in cuiTent will be effected by multiplying the num- ber of cells. As the external resistance increases a larger number of cells will be required, hence the large number of cells needed when the enormous resistances of the human body are to be overcome. Exact dosage is no less important in electricity than in the use of 374 DISEASES OF WOMEN. Fig. 181. — Milliamp^remeter. other reined iiil agents. The old metliod of meusuriiig the current hy tlie niuuber of cells employed was entirely wanting in precision. Owing to the gradual ex- haustion of the hattery-Huid by use, the varying resistance of the conducting- cords, the electrodes, and the diifeivnt portions of the body, there can Ix; no constant relation between the number of cells in circuit and the current strength. A convenient and reliable galvanc^meter is, therefore, to the electro-therapeutist what the apothecary's balance or graduate is to the dispenser of drugs. The vertical galvanometer will be found the best for the purpose, and it should cover a range of from one to five hundred milliamperes. The milliamperemeter of Barrett and Perret has proved a satisfacto- ry galvanometer in our use (Fig. 181). For the purpose of regulating the current strength a current se- lector or switch-board, by means of which a large or small number of cells can be switched into circuit, has been commonly employed. This device is open to the objection that it uses different portions of the bat- tery unequally ; that it does not permit a sufficiently gradual in- crease or decrease of the current ; and that, as the switch jumps from one stud to the next, at the instant when it touches both, one cell is short-circuited and its force thus wasted. Instead of the switch-board I have used, for some time, a rheostat or cuiTent - regulator, in- vented l)y Mr. II. S. Bailey, elec- trician of the Law Telephone Com- pany, of New York (Fig. 182). Fiq. 182.— Rheostat. FIBROMA OF THE UTERUS. 375 This instrument consists of a hundlc of carbon plates insulated from one another, placed in vertical j)osition, and attached to a vertical me- tallic rod, by means of which it can be racked up and down in a col- uam of water. "When connected in circuit, the strength of current is regulated by the depth of immersion as in the common water- rheostat, but with the advantage over that instrument of much greater precision and greater facility of manipulation. By means of this rheostat a resistance of from twenty to two million ohms can be thrown into circuit. The current can thus be gauged at will from an imperceptible strength of one or two milliamperes to the full force of the battery. The current may be increased, diminished, or turned oft" altogether, without the slightest shock to the j^atient, an important advantage over the switch-board. This method of regu- lating the current has the advantage, too, of using the entire battery at once, whether the current applied be one or a thousand milliam- peres. Since each cell does the same amount of work as its neighbor all parts of the battery constantl^^ maintain an equable strength. Moreover, the comparatively trifling cost of the regulator is a by no means unimportant item. The introduction of the Bailey regulator and the railliamperemeter marks an important advance in electro- therapy. The Method of applying the Electric Current in the Treatment of Fibroid Tumors. — The method of using the current which I have adopted, is to pass an electrode into the cavity of the uterus, and in- sulate that portion of the instrument which rests in the vagina. The other electrode — a broad one — is applied over the abdominal surface where the tumor is located. The electrode in the uterus is connected with the negative pole of the battery, and the other with the positive. The current then is gradually turned on, until it is as strong as the patient can tolerate it, and is continued for eight or ten minutes. This is repeated every third or fourth day. The electrode which is introduced into the uterus is shaped like a uterine sound. The por- tion of it which occupies the cavity of the uterus is made of plati- num. The rest is copper covered with hard rubber, and over this there is a sheath of rubber, which can be moved forward or back- ward to regulate the length of the portion to be insulated, which varies, according to the depth of the canal of the uterus in different cases. Fig. 183 shows this instrument. The electrode which Apostoli uses for the outside of the tumor is composed of sculptor's clay, rolled, cut to a size sufficient to cover the prominent part of the tumor, and about half or three quarters of an inch thick. The chy 37G DISEASES OF WOMEN. is covered with some tliiu fabric like cLeese-clotli, to keep it to- getlier. This is applied over the abdomen, and then a broad me- ^ Fig. 183. — Uteriiiu flcctiudL-. tallic plate applied over the clay. This answers very well so far as fitting the rounded abdominal surface, and by its own weight it keeps its place with and also protects the skin from irritation. It is not very convenient, however. The clay has to be kept wet all the time, in order to be ready for use when required. It also requires to be made warm in cold weather, and is not very clean to handle. Owing to these inconveniences of the clay, other materials have been used. I employ a sheet of absorbent cotton about balf an inch thick when wet, and gently compressed, and over that an electrode made of a number of small metallic plates fastened together with Avire. In this way the electrode fits the irregular curves of the ab- dominal walls. Even this is not exactly what I desire. AVhile it is free from the objections of the clay it does not adapt itself to the body as well as the clay. This leads me to believe that something more convenient than anything now in use may be yet devised. This gives the method of using electrolysis in the way which appears to me to be most acceptable, but there are modifications as practiced by some which should be noticed. Some prefer to ansesthetize the patient and use a current stronger than the patient could otherwise bear. This may insure more rapid progress in the treatment, but it is perhaps more dangerous and disagreeable to the patient. I prefer a current which the patient can tolerate, and continue it longer at a time and repeat the treat- ment more times. Sometimes it happens that the cervix uteri is displaced, so that the electrode can not be introduced into the uterine cavity. In such cases, a needle-pointed electrode should be thrust into the tumor, and the curi'ent passed in the usual way. Apostoli speaks of this as making an artificial canal in place of the normal one of the uterus. In order to maintain this canal made by the first puncture, the current used must be strong enough to destroy the tissues in imme- diate contact with the instrument. Should the opening close another puncture can be made at the next treatment. In cases where there is severe monorrhagia Apostoli recommends the introduction of the positive electrode into the uterus, and using a current strong enough to slightly char or dry the mucous mem- FIBROMA OF THE DTERCS. 377 brane, and in that way arrest tlie bleeding. This is no doubt good practice when the l^leeding can not be arrested by other means such as curetting or the application of astringents. (illustrative oases.) Fibroma of the Uterus ; Recovery without Treatment. — This case illustrates a class, not by any means large, in which the disease runs its course without causing much discomfort or impaii'ing the health to any great extent, and without being influenced by treat- ment. The patient was highly nervous and very active, had a good constitution, and enjoyed good health. When she was about thirty years old her menstrual flow became more free than formerly. She had up to that time been quite regular and normal in regard to men- struation. This slight menorrhagia continued, and occasionally was quite profuse. She also had backache and pelvic tenesmus, which rendered her less active and enduring than in her earlier life, I first saw her professionally when she was thirty-one years of age. She was then single and enjoying fair health. I supposed that she might have a fibroma of the uterus from the history, and suggested that I should find out by examination the exact condition. This she objected to. From this onward she continued about the same. The menor- rhagia continued, and she had at times dysmenorrhoea and leucor- rhoea, but all of these did not impair her health or usefulness suf- ficiently to make her willing to submit to treatment. At forty years of age she married, and then her symptoms increased consid- erably, but in the intermenstrual periods she was fairly well. Four years after her marriage she had an attack of malarial fever of a mild order, and then the menorrhagia and dysmenorrhoea became worse, and I then had an opportunity to examine her, and found that there was a fibroma in the posterior wall of the uterus, probably inter- stitial. She soon recovered from the malaria and its effects, and then her uterine troubles became as they had been formerly. About this time I made an application of iodine to the cavity of the uterus, but as she improved she did not return for further treatment. I saw her occasionally while visiting other members of her family, and heard that she was about the same as formerly. According to her own statement, she was not at any time quite well, but not ill enough to be willing to be treated. When she was forty-nine she again consulted me, and I then found that the men- strual flow had been diminished for over one year, and had been ab- sent altogether for three months. She was quite nervous and rest- 378 DISEASES OF WOMEN. less, just as many are at tlie int'ii- and vigorous lady wlio liad always enjoyed gcjod health until after she was twenty-five years old, Avas fii'st seen when she was thirty-one. She M'as married at twenty-six, and soon thereafter began to menstruate too freely ; she never was pregnant. AYhen first seen she was prostrated with a severe menorrhagia. 1 then ob- tained tlie facts given above, and also learned that she had suffered from pelvic pain, leucorrhcea, backache, and a gradually increasing menstrual flow until the time I saw her, when she was quite ex- hausted. Tbe uterus and tumor extended upward to half-way be- tween the pubes and umbilicus. Stimulants and ergot were given, but the How continued, and then the tampon was used, which stopped it. She improved from this time, quite perceptibly, but was pulled down at the next period, thougli not to so low a point as before. She was then put under treatment for the endometritis. The hot- water douche was tried, and the whole endometrium touched with tincture of iodine. In order to do this it was necessary to dilate the os exter- num, and then by using the pipette, the application could be made very thoroughly. There was at first considerable catarrh of the cer- vix, and for that a few applications of tincture of iodine and carbolic acid, equal parts, were made. Under this treatment the menstrual flow became less free, althougli the tumor increased slightly in size. After remaining under treatment intermittently for about two years, she was induced to place herself under the care of a physician who made the acquaintance of her husband. Tiiis gentleman treated her twice a week with a mild continuous current of electricity, which he passed through the tumor by placing one electrode upon the ab- domen and the other upon the back. Three quarters of a year were occupied in this way, but without any improvement ; she neither gained nor lost, except that her flow was more free. She returned to my care again, and I resumed the treatment of the endometritis with iodine; I also continued the elec- tricity, but did so by procuring a battery for the patient, and having one of my assistants teach her how to use it. In place of applying FIBROMA OF THE UTERUS. 379 it twice a week, as the doctor had done, she used it every day, and I am satisfied that she nsed it as effectually as the doctor. This treatment was kept up for two years. Whenever her menses became very free, or if the lencorrhfca returned, she came for treat- ment, otherwise she used the electricity alone. The tumor had diminished perceptibly, but her general improvement was out of proportion to local changes, excepting that the endometritis was re- lieved. After this she went to live in the country, and was not seen again until she was forty-six years old. I then found that the menses were normal, and that the tumor was very much reduced. When first seen, I could with ease introduce the sound into the uterus seven and a half inches, while at the age of forty-six the cavity of the uterus measured less than four inches. Interstitial Fibroma of the Uterus treated with Ergot ; Recovery. — This patient was thirty-four years old, married, and had one child when she was twenty-three years old. After its birth she suffered from leucorrhoea and backache, but did not have any treatment until she was twenty-seven years of age. She then began to menstruate too freely, and was treated by her physician, but without effect. The menorrhagia, while it depressed her, did not disable her alto- gether, so she went about her duties nntil she noticed a tumor in tlie abdomen ; she then came to me for advice. I found the uterus en- larged, extending upward to within two inches of the umbilicus. The cavity of the uterus was deflected to the right and backward, and the sound passed to the depth of seven inches. The fibroma occupied the left anterior wall and projected considerably to the left, giving to the whole mass (uterus and tumor) an irregular out- line. There was some endometritis, and the patient was slightly ange- mic, but otherwise her health was good. Half a drachm of fluid extract of ergot was given before meals, for about a month, in the hope that it might incline the tumor toward the cavity of the uterus, and by partially expelling it bring it within reach for the operation of enucleation. At the end of a month there was no change in the position of the tumor ; ergot was then used hypoder- mically about twenty minims every third day. This excited strong uterine contractions, which lasted for about an hour or more each time. This treatment was continued for three weeks, but without changing the position of the tumor, though it diminished in size. The hypodermic use of the ergot was then given up, because the patient became tired of the pain it caused. She continued to take the quantity first given by the mouth for seven or eight weeks, and 380 DISEASES OF WOMEN. the tumor continued to decrestse in size. TIjc liypoderniic use of the ergot was tried alood from above the tumor. The pedicle was easily di- vided, and the remains of the tumor were further reduced, so that it could be brought through the vulva without laceration. The re- moval of the mass was followed by a gush of dark blood, at least a pint in all, and there were several clots which remained in the vagina. These were rapidly removed, and then I could see the distended and empty uterus. The blood had accumulated in the uterus above the tumor, and given rise to the fluctuation and rapid increase in the size of the uterus which I had observed. With the light reflected from the head-mirror I was able to ex- amine the entire cavity of the uterus most thoroughly. By holding the lips of the os externum apart with an elevator and sponge-holder, the view of the interior of the uterus was complete. The site of the attachment of the tumor could be clearly seen, and the gradual contraction of the uterus was also noted. There was nothing of interest in the after-history of the case. The patient made a good recovery, and gradually regained her health and strength. It is now four years since the operation, and she has continued in perfect health. Uterine Fibroma, supposed to be a Uterine Fibro-Cyst ; Death from Septicaemia during the Process of Expulsion. — An unmarried lady of somewhat delicate organization came under my observation when she was thirty years of age ; she said that five years previously she began to suffer from menorrhagia, and soon afterward began to ob- serve a gradual increase in the size of the abdomen. When fii^st seen, the tumor was about the size of the uterus at the seventh month of gestation; all the physical signs of a submucous fibroma were obtained. Her general health was somewhat impaired, she was anaemic, owing to the menorrhagia, which was not excessive; otherwise she was in fairly good health, and, as her circumstances in life were good, she was able to be around and enjoy life. She was placed upon a general tonic treatment, with the use of ergot and cannabis Indica, which were given at the menstrual period. She continued for three years to do fairly well, occasionally having an attack of menorrhagia, which pulled her down a little, but she readily recovered from this, and went about in her usual way. FIBROMA OF THE UTERUS. 383 Slie was seen only occasionally, and the general plan of treatment was not changed. About the fonrth year after she came under my observation, she had an attack of monorrhagia which was rather more severe than usual, and she took larger doses of ergot, and continued the remedy longer than was her habit. This controlled the menorrhagia but produced severe uterine pain, for which I was called to prescribe. I then carefully examined the tumor and found that it had increased in size considerably from the time 1 had seen her before — about four or five months. I found that the upper portion of the tumor was quite elastic, and that there was distinct fluctuation extending through an area of about five inches. I then suspected a fibro- cyst. Soon after this she was seen by my distinguished friend, Dr. T. G. Thomas, who, without knowing of the patient's histoiy or my own opinion, made the diagnosis of fibro-cyst. During the remainder of that winter and the next spring she had more menorrhagia, and was kept more continually under the influence of ergot ; when summer came she had regained some of her former strength, and went to the country, where she remained for several months. She returned in the autumn slightly improved, but about a month afterward began to suffer from severe pains, due to uterine contractions. These pains increased in severity and frequency, until she was unable to leave her room. She then sent for me, when to my surprise I found the cervix uteri fully dilated and the tumor partially expelled from the uterus, occupying and completely filHng the vagina. The ergot was suspended, and she was relieved from her severe pain by the use of opium, but the pressure upon the pelvic organs became so great that it was necessary to try and relieve her. The lower por- tion or capsule of the tumor began to slough, and I then determined to remove all of the tumor, or as much of it as possible. In the mean time the uterus as examined through the abdominal wall had not diminished very much in size, and the fluctuation was more marked and more extensive. She was at this time very anaemic, and so weak that I dared not anaesthetize her. So I proceeded without doing so, with the patient in Sims's position, and with the aid of Sims's speculum I rapidly removed all that portion of the tumor which occupied the vagina, using the tenaculum forceps and haemo- static scissors. There was very little haemorrhage, and the patient derived very great relief from the removal of this portion. She was permitted to rest for a few days and ergot was again given, which produced expulsion of another mass about as large as the one that 384 DISEASES OF WOMEN. had b'jen expelled, this was removed in the same way as the other; while removing a portion whieh extended up into the cervix uteri, about live or six ounces of Huid escaped from the cavity of the uterus. Immediately after tliis it was found that the fluctuation was greatly lessened, and the size of the tumor, as observed through the abdominal walls, had markedly diminished. She had after this con- siderable fever and disturbance of the stomach, and this, along with her marked anaemia, prostrated her so that nothing could be done for nearly a week but to sustain her. At the end of that time her temperature diminished somewhat, she was able to take nourishment and stinmlants, and as considerable more of the tumor had been ex- pelled, a third attempt was made to remove it. I was able to re- move all that portion outside of the cervix ; I then endeavored to remove a portion that was still within the grasp of the cervix ; as soon as I did this, about four ounces of putrid matter were discharged from the uterus. Although there was not much haemorrhage, and the patient did not complain of pain, she was so much exhausted and her pulse was so feeble that I was obliged to desist, feeling confident that if I undertook to remove the remainder of the tumor, the patient would succumb. The cavity of the uterus was carefully washed out with carbolized water, and the patient put to bed and stimulated and nourished as well as possible. Two days afterward, when she had rallied considerably, I found that the lower por- tion of the cervix had contracted around the tumor, and that it was breaking down and decomposing. I thoroughly and repeatedly washed out the inner cavity of the uterus, and hoped by so doing to control the septicaemia from which she was suffering in a most marked degree. I also felt confident that if I could bring her strength up again that I might be able to remove the whole of the tumor. But this proved to be impossible, although the uterus con- tracted again, in fact, sufiiciently expelled the tumor to partially dilate the cervix. She at no time was in any condition to bear so formidable an operation as completing the enucleation of the tumor. The septicaemia still proceeded, and she died about five years from the time that she first came under my observation. On post-mortem examination it was found that a portion of the fibroma as large as a fetal head remained, and was attached at the posterior and right lateral wall of the uterus, and that it closed the cavity very tliorouglily by pressure, and that there was still a little fluid in the fundus uteri. It was clearly evident from this, that this obstruction of the canal below and the distention of the ca\nty of the uterus above, whieh gave rise to the fluctuation obtained at her FIBROMA OF THE UTERCS. 385 examination, explained the resemblance of the physical signs to tliose obtained in the uterine libro-cysts. It is a number of years since this case came under my observa- tion, and I am satisfied that liad I known then as much as I know now about the management of such cases I should probably have been able to save her. As it is, I still think that had she sent for me when she returned from the country, and before her strength became so nnicli exhausted from the efforts at expulsion, I might have been able to remove tlie whole of the tumor ; but it was otherwise. A Case of Submucous Fibroma in which Pregnancy progressed to Full Time, and the Tumor was completely expelled about a Week after Confinement. — This case was seen in consultation with Dr. Bodkin, who, when called to attend her in confinement, found a solid tumor which so completely filled the pelvis that he could not reach the os uteri. The labor-pains continued, tbe membranes ruptured, and the cord became prolapsed. The tumor was recognized as a fibroma which extended down into the cervix and at the same time upward toward the fundus. It was a long, narrow tumor which may have assumed that shape by stretching during the growth of the pregnant uterus. We agreed to try to deliver by version. Accordingly, when the patient was anaesthetized the doctor succeeded in pushing up the tumor out of the pelvis, and passing his hand past the tumor and through the os, which was quite dilatable, be turned and delivered. I then took charge of the placenta, which was retained for some time. To facilitate its delivery and at the same time to investigate the tumor, I passed my hand into the uterus and was able to make out by bimanual touch the size and location of the tumor. It was oblong, as already stated, and situated in the anterior wall a little to the left side, and extended from the cervix nearly to the fundus, and evidently was immediately beneath the mucous membrane. The patient did very well considering all things ; she had con- siderable hsemorrhage at the time, and the discharge afterward was free and at times offensive, and she had long-continued after-pains. About seven or eight days after her confinement she had an at- tack of tenesmus, and in the hope of obtaining relief she got up to the commode, and by vigorous expulsive efforts expelled the tumor. It was much shrunken, no doubt, but even then the doctor estimated that it was about seven inches in length and three inches in diam- eter. She subsequently did well. In this connection it may be stated that uterine fibromata cause sterihty, as a rule, owing perhaps to the endometritis which is usu- 26 , 386 DISEASES OF WOMEN. ally present, and when preu^naney takes place miscarriage generally occurs. Still, 1 have seen at least four cases that went to full time. In all except the one recorded above the tumors were subperitoneal and not laruv. Extreme Dilatation of the Cervix TJteri and Expulsion of a Sub- mucous Fibroma while only Slightly Pedunculated; The Case diag- nosticated as Inversion of the Uterus; Operation and Recovery. — This patient came to my hospital clinic and gave a history of mcuijr- rhagia for years, and for several months past a metrorrhagia and uterine pain. She was quite anaemic, but had always been well and strong until the excessive menstruation came. She also stated that she visited the outdoor department of the Woman's Hospital of New York, and the gentleman who saw her said that her womb was turned inside out, that she should enter the hospital for operation, and that her case was a dangerous one, I presumed that the diagnosis made was inversion of the uterus, and on asking the doctor about the case he told me that he believed it to be so. On my first examination I found a tumor in the va- gina which, in size and shape, was exactly like an inverted uterus. The mass was covered with uterine mucous membrane. Absence of the fundus and body of the uterus in the upper part of the pel- vis was observed by the bimanual touch. That portion of the mass which was uppermost was larger than that which is usually found in inversion of the uterus, but in the center of it there was a slight depression which is generally found in inversion. Passing the sound around the tumor gave evidence that the vagina was at- tached to the upper part of the tumor, but by pressing the tumor to one side and separating the vagina from it, I could see that there was uterine mucous membrane above the vagina, which extended upward, inward, and over the tumor. By seizing the tumor and t^^^sting it round upon its axis, I also observed that the upper ])art of the vagina did not move with it as would have been the case if there had been inversion of the uterus. From these signs I con- cluded that the tumor was a fibroma, with a small but very short pedicle attached to the fundus uteri, and that the cer\dx and lower portion of the uterus were so completely dilated that the vaginal and uterine walls were continuous. I presume, that in time, the tumor would have dragged the fun- dus uteri downward and produced inversion. This has occurred. In fact, it is not an unusual thing to find a partial inversion of the uterus caused by fil)romata during their expulsion. The pedicle was divided with the ecraseur and the tumor re- FIBROMA OF THE UTERUS. 387 moved. The cavity of the uterus then appeared like a cup-shaped dome at the termination of the vagina. A sponge, in a holder, was gently pressed against the fundus uteri, and held there until the uterus conti'acted, which it did quite slowly. This was done to pre- vent a possible inversion from taking place. The patient recov- ered very promptly. Soft Fibroma ; Atrophy of the Muscular Wall of the Uterus at the Point of Attachment of the Tumor ; Enucleation after Dilatation of the Cervix Uteri and Partial Expulsion; Recovery. — The jjatient was forty-nine years old, m.irried, and had had two children, the last one sixteen years before the time when she came under my care. She was a strong, healthy lady, and had been weL until she was about forty-hve years of age. At that time she began to menstruate more freely than at any previous time in her life, but being told that it was due to "change of life" she did nothing for it, until she became so weak that she sought advice of a practitioner who treated her locally for ulcei'ation of the cervix which he said she had. She grew worse, the bleeding was more free and lasted longer at each period, and she had a profuse watery discharge at other times. Then uterine pains came on, which she said were like the first pains of labor. This was the history which I obtained when called to see her the first time. On examination I found the cervix well dilated, and part of a soft fibroma occupying and filling the upper part of the vagina. The pressure gave her much discomfort, and I found that the por- tion in the uterus was quite as large as that which occupied the vagina. Without giving the patient an anaesthetic, I removed all that was outside of the uterus with the ecraseur. There was no pain and very little bleeding caused by the operation. The patient being fatigued by remaining in Sims's position I did nothing more for two days, and at the end of that time the larger part of the mass was expelled from the uterus. It was oblong but not pedun- culated. All that was protruding from the os externum was re- moved with the ecraseur^ and the stump was seized with a double tenaculum forceps and enucleated. Traction being made with the forceps the mass was separated from the capsule with a blunt cu- rette. There was very httle pain caused until the mass was sepa- rated all round and the deepest attachment was reached. Then the patient began to complain. This was fortunate, because it made me very careful. I simply made steady traction and counter-pressure with the curette. When the mass came away I could see the peri- tonaeum very plainly at the bottom of the cavity. My assistant 388 DISEASES OF WOMEN. also observed it, uiul recognizing wliiit it was, he naturally was quite anxious. A space, about t!ie size of a twenty-five cent i)iece was ex- posed. It had not been wounded at all, but appeared as if it had separated from tiie tumor very easily. To make sure that there was no mistake I examined by the touch and found the parts exactly as they aj)peared to be on inspection. Submucous Fibroma of Large Size extending through the Uterine Wall to the Peritoneum ; treated firct by Partial Exsection with the Galvano-Cautery and Several Years after by Enucleation; Recovery. — This was a liospital case which 1 saw with Dr. Cushing. The tumor was large, and extended down into the cervix on one side and could be easily reached. The patient was suffering greatly from bleed- ing. Partial excision was made by passing two large curved needles thi'ough a section of the tumor, and then passing the wire be- low the needles, and cutting it off by heating the \vire. Section after section was removed in this way, until all that portion which could be reached conveniently was removed, about two thirds of the whole, perhaps. The operation was long, and I did not think it prudent to continue the efforts to remove the whole mass. Recov- ery from the operation was without interruption, and the patient was much improved. The menorrliagia subsided, she gained her former strength, and was able to make her living as a laundress. In a few years the tumor had grown again, and all the old symptoms returned and were worse than ever. Dr. Cushing had to see her for several attacks of menorrhagia, which nearly proved fatal. She then came into the hospital. The tumor was nearly as large as it w^as before, and she was extremely feeble and anaemic. There was a cardiac mitral murmur. The officers of the hospital strongly advised that I should not operate, and I would have gladly followed their advice, but the patient begged that I should try again to help her, and I agreed to do so. The tumor was low down in the pelvis and projected beyond the opposite side of the cervix. Ether Avas given, and the pulse improved a little under its influ- ence. The capsule was di\nded with the therm o-cauterv, and sepa- rated from the tumor over its exposed portion. A strong forceps was fixed in the mass, and while strong traction was being made the enucleation was performed with the spoon-saw of Thomas. When I had nearly completed the separation, I noticed that there was very little resistance on the part of the uterine wall at the upper part ; I then made a bimanual examination and found that I had passed through the muscular coat of the uterus entirely. I was fearful that if I made any further effort to complete the FIBROMA OF THE UTERUS. 389 enucleation I might wound the peritoniEum. The detached por- tion was separated from the rest, and the operation stopped. The portion left was about the size of a hen's egg. There was not much bleeding, but I can only say that the patient was living when she was put to bed. The uterus contracted fairly well. There was no further lijemorrhagc, but a free discharge of serum continued for a number of days. I felt sorry that I had not been able to remove the whole of the tumor, but was glad that her life had l)een spared. She improved slowly in strength, and was able to leave the hospital in three weeks. The heart-murmur, which was presumed to be largely due to her extreme anaemia, proved to be due to mitral in- sufficiency, and although she had no more trouble from menorrhagia, she did not fully regain her strength. She took wp her old occu- pation, but it was more than her strength could endure. A little over two years after the operation she died suddenly of heart-fail- ure. The post-mortem revealed the heart lesions which proved fatal. The part of the tumor which was left had not grown, in fact, it probably had diminished. The scar at the point of the deepest enucleation showed that there was no middle coat of the uterus at the side of attachment of the tumor. These facts proved conclusively that in operating I had gone through to the perito- naeum, as I thought I did at the time. The following cases, treated by hysterectomy, are from the work of Dr. Thomas Keith : Large Solid Fibroid, Weight, Forty-two Pounds ; Supra-Vaginal Hysterectomy; Recovery. (Keith).— Mary C, aged twenty-eight, was sent into the Royal Infirmary by Dr. Robertson, of Ardros- san. She had sought relief in many quarters in vain. The tumor was very large, and was first noticed five or six years before. She M'as wasted about the chest and arms, like a case of old ovarian disease. The abdomen measured forty-nine inches at the umbilicus ; the tumor was firm and solid throughout. The ensiform cartilage was turned upward, and the growth extended under the sternum and ribs ; close to the sternum there was a large projection the size of a cliild's head. No trace of the ovaries could be detected. The greater part of the pelvis was occupied by the tumor. There was no dis- tinct cervix, only a small triangular projection drawn to the left side, almost beyond reach of the finger. For several years no great inconvenience had resulted ; menstruation was never in excess, and for the last fifteen months it had entirely ceased ; since then, the increase in the tumor had been rapid, and she could do little or noth- 390 DISEASES OF WOMEN. ing owing to its weiglit. Slie sat all day knitting; at twenty -eight, her life-prospeets were anything bnt bright. For ob^^ous reasons, this patient was not taken down to the large theatre, l)nt was operated on in the ward, on the 18th of April, 1881. Sulphuric ether was given, and the operation was performed under carbolic-acid spray. The sponges, thirty in number, had been lying for a long time in a five-i)er-cent solution of carbolic acid ; they were washed in hot water, and then put into a two-per- cent solution, and wTung almost dry. These were used over and over again, and were not washed in any fresh solution during the operation. Dr. Wilson was present from Glasgow, and there were about twenty visitors and students. The lirst incision measured twelve inches ; it terminated four inches abo\'e the pubes, so as to avoid the bladder, which was to be elevated on the tumor. On the right side, the broad ligament rose as high as the crest of the ilium. The left broad ligament was largely spread over the half of the tumor as high up as the ribs. The opening was then enlarged to twenty-two inches, and, by dint of hard pushing and patience, the huge mass was slowly moved forward as far as its cpnnection on the left side would permit. The right ovary was easily seen. On searching for the left, it was found to be transformed into a long, tense, umbilical-like cord, seven or eight inches in length. Here and there along this tense band were several small cysts. It was so imbedded in the tumor that it never could have been removed. The right, broad ligament was transfixed by soft-iron wires, secured and divided ; all bleeding from the tumor was prevented by a series of strong-locking forceps. The fibroid was now more easily dealt with. It was drawn for- ward, so as to put on the stretch its enormous connection on the left side. About a dozen powerful-locking forceps, ten inches in length, were now applied to the broad ligament l)efore and l)ehind. The whole was then cut downward, and the mass enucleated as low as possible. A strong, soft-iron ligature embraced the base, which was of great thickness. The tumor was then cut away, the stump showing a section of the cervix in the center. The forceps were removed one by one, and all bleeding vessels separately tied. Some of these were large, and one threw blood over the assistant's head. There was much trouble in finding some bleeding points among the loose cellular tissue of the huge gap now left. The hnemorrhage was mostly venous. All present could see that the condition was full of danger, and that secondary htemorrhage FIBROMA OF THE UTERUS. 391 into this loose tissue was not one of the smallest risks of the opera- tion. When all oozing seemed to have ceased, the stump (the thick- ness of the leg) and the end of the right, broad ligament were se- cured, with much tension, outside ; a glass drainage-tube was fixed in above the stump, and the wound closed bj forty silk sutures. The operation lasted one hour and three quarters. After much blood and serum had escaped from the tumor, its weight was forty- two pounds. Ten hours after the operation, five ounces and a half of sirupy blood were removed from the pelvis through the tube. The pulse was 94 ; the temperature 102'2° ; rising two hours afterward to 103*4°. During the night, back-pain was relieved by injections of morphia. The first day was passed fairly well. In the evening the pulse was 120, and the temperature 102*2° ; flatulence was troublesome. She felt weak, and had whisky and water to drink. There were only four ounces of bloody serum from the tube. On the third morning, the pulse was 120, and the temperature 104°. On the fourth day, the pulse was 114 to 125 ; the temperature ranged from 101° to 103*5°. On the fifth day, after a restless night, the temperature had risen to 100° ; it fell to 104°, and again in the afternoon it rose to 105*5.° There was oedema of the labia, and much cellular infiltration in the pelvis. She looked very ill during these days, not caring for food, though taking stimulants freely ; on the sixth day the pulse dropped to 92, and the temperature also fell to 101*0°. The tube was re- moved, there being only a tablespoouful of reddish serum in the pelvis. On the ninth day the wound was found healed throughout. The stump was dry and sweet. The pulse and temperature almost normal. In the third week there was again a rise of pulse, and of tem- perature from 101° to 103.° This continued for ten days, and caused some anxiety. On the eighteenth day, the wires were loose and were removed. The loop was two inches and three quarters in diameter. Seven weeks after the operation she left the hospital. She is now a strong woman, in perfect health, and can do anything. Soft Bleeding Fibroid; Intra-Peritoneal Treatment of Pedicle; Recovery. (Keith). — In 1870, Dr. Kidd, of Alyth, sent me an un- married woman — a domestic servant — with a fibrous tumor, low in the pelvis and extending to the umbilicus. She was no longer able foi* 392 DISEASES OF WOMEN. her situation, partly from j^iiii ;inet\veen cancer and the number of children born ; for it \nll be found that patients with cancer of the uterus will average one third more children than women free from malignant disease of the womb ; indeed every case of carcinoma uteri will average live children, a large family at the present time. Prolonged lactation, anti-hygienic surroundings, poor or improper food, exhausting diseases, grief and anxiety, all are more apt to be accompanied by cancer than an opposite condition of afiairs ; never- theless, seventy-five per cent of cases will give a history of good health up to the development of this neoplasm. It is quite certain that laceration or erosion of the cervix has a causative intluence upon cancroid ; hence in suspected epithelioma the previous history must always be elicited. I do not mean that laceration will cause it ; but with a latent tendency, an erosion or laceration will often determine the precise point of eruption of the disease. Treatment. — This may be divided into constitutional and local ; and the local treatment consists in («), topical applications, and \J)\ operative procedures. Constitutional treatment is always in order, and is always bene- ficial, but operative treatment demands the highest judgment ; used in season, surgical means may eradicate a growth that never reap- pears ; used when any tissue or part other than the uterus has become infected, an operation is useless for cure, and may, indeed, hasten the fatal termination. But, be it understood, there is only one means of actually treat- ing a patient with cancer, and that is to operate surgically, not merely to nurse her. Hgemorrhage demands prompt treatment on account of the ex- haustion it induces. Astringent injections — hot better than cold — plugging of the vagina with small pieces of ice, or, rarely, plugs soaked in perchloride of iron, may be used. Tannic acid, rhatany, catechu, perchloride of iron, or ergot by the mouth or ergotine hypodermically I consider as inefficient, and are only mentioned here to be condemned. They are too frequently employed in practice. Rest, especially dunng menstruation, freedom from mental shock of any sort, and cessation of intercourse should be enjoined to pre- vent haemorrhage. MALIGNANT DISEASE OF THE UTERUS. 409 Pain finally becomes intolerable. What shall be given? The easiest way to quell this symptom is by filling the patient with oi)ium or morphine, the latter given hypodermically. Hydrate of chloral, while producing a more natural sleep than opium, does not seem to control the pain so well. Cannabis Indica and hyoscyamus are highly thought of by the French ; also vaginal pessaries of iodoform (fifteen grains). The hydrochlorate of cocaine is an efficient local and general remedy for pain. The discharge is offensive, and the patients wish its fetor de- stroyed before demanding treatment for almost any other symptom. Condy's fluid, Labarraque's solution, carbolic acid, and its allies (thymol, phenol, etc.), bromine, lead acetate, or iodine — any of these will act antiseptically, and will in part deodorize the discharge. At the same time the amount of the discharge can be diminished by any astringent injection, such as alum, iron, zinc, lead, or copper, but tannic acid seems to have a specially favorable action upon the flux from cauliflower excrescences. The diet should be as simple as possible, yet composed of food in which there is a minimum of volume and a maximum of nutri- ment. A milk-diet is known to be so beneficial that the laity regard it as a " cancer cure." A moderate amount of alcohol should be taken daily with the meals. JSText in importance to diet is the mental condition. The sur- roundings should be as pleasant as possible. The prognosis and diag- nosis need only be known to the immediate friends. Finally, certain symptoms, such as peritonitis, ulcerations, and erosions of the genitals, may call for treatment, which in no respect differs from that in non-cancerous cases. In the local treatment of carcinoma of the cervix the application of caustics is one of the first things tried by the inexperienced ; and it is the use of caustics for cancer anywhere that has become the pre-eminent means in the hands of the unprincipled. Pure nitric acid removes by a slough extensive portions of the diseased tissue, and simultaneously stops hcemorrhage. The cervix should be washed and dried immediately before, and washed again immediately after the operation. Chromic acid, bromine solutions, acetic acid, perchloride of iron, and even gastric juice have been employed as caustics, and of this group I prefer the first named. Among the many remedies from which special benefits are said to accrue in the treatment of cancer is the milk of aveloz. In the 410 DISEASES OF WOMEN. "Xew York Medical Record," of July 11, 1SS7, is a report on this driiir, made bv Dr. James B. Hunter, from which I make the iiA- lowing abstract : " The milk of aveloz is the product of a i)lant growing in IJrazil, one of the Jiuj^/io/'hiarca:, many varieties of which are well known for their irritant and acrid juices. Dr. Hunter had not been able, from any botanical works at his dis]:)osal, to ascertain exactly the position of the plant furnishing the juice known as the milk of aveloz, but it appeared to be closely allied to the Ilura crepitans^ the milk of which is described by the older botanists as possessing extraordinary properties as an irritant. " Boussingault made an examination of some of the juice, and was attacked, he says, with a severe form of erysipelas. The courier who brought the juice, as well as the inhabitants of the house in which he spent the night on his way, were also attacked with severe inflammation of the skin. Another species of the same family grow- ing in Brazil is the Ilippomane mancinella, or manchineel tree, about which there are fabulous accounts, as that it is fatal to life to sleep beneath its shade. It is true, however, that a di'op of the juice of that tree applied to the skin will quickly raise a blister full of serum. It is not surprising, therefore, that the milk of one of the Ei(,j>horhia family should be possessed of very active properties. " Several years ago a small quantity of the milk of aveloz was sent from Brazil to the autborities at Washington, and distributed for trial. Then for a time none could be obtained. Later it was to be purchased of a gentlemen in this city — John T. Kirby, IG Beaver Street. The depot for its sale is in Pernambuco, the juice being collected chiefly in the pro\'ince of that name. The prepara- tion is said to be patented by the Government of Brazil, and its use is indorsed by the Central Board of Health of Eio de Janeiro. "Two preparations are furnished, one of which is recommended for open ulcers, and the other for cases of cancer in its early stages. The principal or only appreciable difference appears to be in the degree of inspissatiou. " The method of using the drug advised is, that the affected sur- face be thoroughly cleaned with a carbolic lotion, and dried. The juice is then applied freely with a soft brush, retained in place by lint or cotton, and covered with light rubber or gutta-perclia tis- sue. The purpose of the application is to produce the effect of a caustic. Special care is necessary to prevent contact with sound tis- sues, as it is extremely irritating. The application is repeated every three or six days, according to the condition. Dr. Hunter's experience MALIGNANT DISEASE OF TOE UTERUS. 411 had been confined to cases of epithelioma of the cervix. He first alhidcd l)rieflj to the experience of others. Its application to dis- ease of the breast is said to be very jDainfuh There is not usually much pain in its use on the cervix uteri." During the past three years Dr. Hunter has applied the milk of aveloz in many cases of epithelioma of the cervix, and, though its effect had often been negative, in a certain number it had produced results that he had not obtained by any other means. In cases of spongy, easily disintegrated crevices, it had left a better surface than nitric or chromic acids, or than the actual cautery. It had also seemed to him that the recurrence was delayed longer than after the ordinary caustics. He had confined its use to cases where the knife was not applicable, or where operation was not allowed. In some cases he had been surprised at the comparatively healthy condition of the surface remaining after the eschar came away, and sui'prised also at the long interval that elapsed before there was fresh breaking down. One of the effects of a free application of the juice to a diseased surface is to promote a copious serous discharge, thus depleting the congested vessels. In some cases a marked difference has been ef- fected in the character of the discharge, which has become and re- mained for a long time almost inoffensive. Cases which the doctor related illustrated the treatment and its results, which he described as follows : " All that could be said was, that they were in some respects better, as to the arrest of the disease and as to the comfort of the patients during its progress, than those afforded by many of the usual methods. As far as he could judge at present, he should not use the aveloz with any expectation of effecting a cure ; but it seems probable that it may do more than some other remedies toward arresting the progress of the disease, and perhaps prolonging the period during which surgical treatment may be employed with some hope or promise of success. " He had not lost sight of the fact that some cases of cancer of the uterus undergo changes in their progress that might erroneously be attributed to the remedies used ; but, after making due allowance for that source of error, there still remains something to be said in favor of the drug in question." I have myself had no experience with aveloz, nor should I men- tion it here did it not have the indorsement of so good an authority as Dr. Hunter. Caustics seem to have a temporary good effect, but I think the activity they excite may produce an extension of the neoplasm itself. 412 DISEASES OF WOMEN. Interstitial injections of solutions — zinc chloride, and carbolic acid, have been tried with varying success. Paquelin's thermo-cautery or tlie hot iron (the parts around being protected) may be substituted for caustics, or they may be used to stop hiiemorrbage with, or aid in closing over, any sound surface after any operation Simon's scoop, tlie sharp spoon, the curette, or even the linger- nail may be used to rapidly and completely remove soft, villous, semi-putrid masses, for then the consistency is such that other means can not be employed, a firm hold with an instrument being impos- sible. The scooping should be thorough, and performed antiseptically. It causes greater haemorrhage than any other operation ; but bleed- ing may be checked by any of the above-named methods. Yet if done rapidly it is possible that powerful cauterization after a thor- ough scooping may completely arrest the progress of tlie disease. Sims's operation consists in scooping out the epithelioma (for it is epithelioma that this method is especially intended to remove) with the sharp spoon or curette, or cutting it down with a scissors or knife, and then scooping every particle of diseased tissue away. After thorough drying of the parts they are plugged with j^ledgets that have been soaked in saturated alum-water to which carbolic acid has been added (1-40), or in persulj^hate of iron, two thirds water, and squeezed dry after such soaking. The plugs are removed in five days and then wadding, soaked in a chloride-of-zinc solution, and squeezed dry, is packed into the cavity. This is very painful. Five days later this plug is removed ; and the slough denudes a granulating surface which will heal, Sims claims, within two weeks. This method is best adapted to cases in which the disease is limited to the cavity of the cervix. A modification of this I have frequently practiced in the class of cases referred to ; I thoroughly and very rapidly remove all the diseased tissue with a curette, and then plug the cavity with cotton and allow this plug to remain twenty-four to forty-eight hours. It is then removed and the surface thoroughly cauterized with Pa- quelin's thermo-cautery or the galvano-cautery. In case the bleed- ing subsides promptly after using the curette, the parts are sponged and pledgets of cotton saturated in zinc chloride are applied, and a dry tampon of absorbent cotton is placed in the vagina to take up any of the zinc solution that may be squeezed out of the cotton by contraction of the parts. This dressing is removed in about forty- eight hours, and then the patient is kept at rest until the slough MALIGNANT DISEASE OF THE UTERUS. 413 separates ; and if any suspicious-looking tissue remains, it may be touched with the cautery. Amputation of the cervix is the chief means at our disposal for the treatment of malignant disease of this portion of the uterus. The contraindications are : When the neighboring glands are involved ; when (the vaginal portion of the cervix being healthy) the vagina is invaded ; and when the cancer closely approaches, or lias reached, the junction of body and cervix. The importance of a thorough physical examination before de- ciding to operate is therefore self-evident. The Scraseur is seldom used for amputation of the cervix. It is very painful, and on the lower sm'face of the cervix we may not reach the limits of the cancer, while above, the chain may include a part of the vagina. Galvano-cautery demands the same preliminaries and cares as re- moval by the ecraseur. I prefer Sims's position to the lithotomy position so often advised for this operation, Thomas's forceps grip the whole cervix and their projections prevent slipping of the wire. When the wire fits the line of demarkation, the operator should make the current and tighten the wire very slowly, gently pulling on the forceps as the wire burns deeper ; by this means the tissues will be made to assume a funnel-shaped appearance as they retract. A careful examination for diseased tissue should now be made, and should such be found it can be removed with the galvano-cautery knife, or the dome cautery may be employed to remove any suspi- cious tissue. The Germans do not regard either of these methods as compara- ble with removal by means of the knife. For, it is claimed, they confine the operator to one cut, whereas the knife can follow the borders of the new tissue however irregular they may be. But I am satisfied that the loss of blood and the uncertainty of manipula- tion from the haemorrhage, render it far more likely that diseased tissue will be missed in this operation than when the galvano-cautery is employed. Schroeder's operation for removal of the vaginal portion of the cervix consists in cutting both sides of the cervix so as to make two lips — anterior and posterior — and then excising a wedge-shaped por- tion from each ; the flaps are then stitched together and the incisions first made are last of all closed by sutures. This operation is only apphcable to those cases seen very early in the disease. 414: DISEASES OF WOMEN. ■ Scliroeder's snpra-vagiiial o])eration consists in cutting through the vairinal raucous membrane at the anterior fornix, the cervix being pulled down and firmly held, 8oj)arating the bladder uj) to the utero-vesical pouch of j)eritonieum, then carrying the cervix forward and cutting the mucous raendjrane of the posterior fornix in a like manner. Some regard injury to Douglas's cul-de-sac as dangerous ; others claim that the pouch can be cut into and some of the peritonfEum removed with the tumor. The next step is to cut with knife or scissors above the lateral fornices, taking care to avoid wounding the branches of the uterine artery. Thus, we see great care must be taken in the preliminary clearing away of the cervix. The operator now cuts through the anterior cervical wall in the healthy tissue above the tumor, opens the cervical cavity, and stitches the anterior vaginal wall to the anterior wall of the cervix. The cei^vix thus being held in place it is amputated when the knife passes through the posterior wall which is to be stitched to the pos- terior vaginal wall. The lateral wounds are closed with deep sutures which are meant to diminish the opening into the pelvic connective tissue, and to ar- rest haemorrhage. Should the vagina be affected it is to be severed at the distance of half an inch from the carcinoma. Baker, of Boston, advocates a " high amputation," which is meant for a substitute for the entire removal of the uterus by Freund's or Schroeder's methods. It is claimed for it that more of the uterus can be removed than by any other amputation ; that it is far more practical for the general practitioner than vaginal hyste- rectomy ; that more recoveries follow and fewer recurrences of the neoplasm have been observed. The patient is placed in Sims's po- sition, the cervix is pulled down to the outlet, and the su]u-a-vaginal cervix is separated from the bladder in front, and the peritonjpum behind, up to the internal os. These two incisions are connected by lateral cuts; and then a funnel-shaped portion of the body is removed by the uterotome. As the incision begins much higher than in Sims's operation, we can remove not only the entire cervix, but almost half the body of the uterus. Actual cautery— red heat — is applied to the whole denuded surface ; and no tampon is em- ployed to control the haemorrhage. One of the most daring advances in gynecology is the introduc- tion of an operation invented and performed by W. A. Freund, hence MALIGNANT DISEASE OF THE UTERUS. 415 called " Freimd's operation"; it is the extirpation of the entire uterus. Excision of tlic uterus is appropriate when cervical malignant growths are extending or threaten to extend upward, or when there is actual disease of the body. Freund's operation — by abdominal incision — is as follows : The incision is made from the umbilicus to the symphysis pubis, and the intestines are held up toward the diaphragm by warm, fine-linen cloths (soaked in some antiseptic solution) from the beginning to the end of the operation. The recti abdominales are separated so that the pelvis can be thoroughly inspected. The parietal peritonaeum is stitched to the abdominal coverings, or a thread is passed through the fundus uteri, and another through the peritonaeum of the anterior part of the pelvis, both threads being held by assistants. The uterus is grasped by forceps — Freund's or any good instru- ment may be used — drawn upward, and three ligatures are then applied to each broad ligament. These ligatures are called the upper, middle, and lower, the two np]3er passing through the broad liga- ment, while the lowest includes the parametrium laterally, and with it the uterine arteries and the vaginal vault. In detail, the first suture — double silk — passes through the ova- rian ligament from behind, and through the broad ligament just below the free margin, in order that the ovarian artery may be in- cluded when this loop is tied. The second ligature passes through the ovarian ligament along- side of the first, and then through the round ligament, so that a second loop is formed, which, tied anteriorly, controls the pampini- form plexus. The third suture is best carried by a special needle designed by Freund, which is guarded by a trocar. So sheathed, it follows the finger of the operator in the vagina, pierces the vaginal wall twice — first through the antero-lateral portion of the vaginal roof into the vagina, and (secondly) back through the postero-lateral part of the vaginal cul-de-sac — behind the base of the lateial ligament, into the pouch of Douglas. The lateral fornix is pierced twice with this needle by grasping the free end of the double thread as soon as the first penetration is made, and holding it while the needle, pulled backward, runs on the thread, and thus can carry the suture a second time through the lat- eral fornix. The thread is cut beyond the eye of the needle after this last manoeuvre, and the end cut is carried through the round ligament completing this ligature, and controlling the uterine ai'tery. 41C DISEASES OF WOMEN. A catheter in the bladder serves partly as a guide to the next step, which commences the excision of the organ. The utero-vesical pouch is cut tlirough, and the peritonaeum resting on the bladder is sewed to the subjacent tissue. The peritonaeum of Douglas's cut-de-sac is cut and treated in a similar manner. Freund separates the cellular tissue with the finger in preference to an instrument. Finally, each broad ligament is cut internal to the three ligatures, and the uterus is removed. The ends of the ligatures are drawn into the vagina, the intestines are replaced, and all subsequent treatment is as after ovariotomy. Only a little over twenty-five per cent of recoveries after this operation have been recorded. Haemorrhage may be particularly severe, and with shock and possible inclusion of the ureter, it is one of the dangerous sequeke of ablation of the uterus by Freund's method. Schroeder has modified and, I think, improved Freund's opera- tion, which, according to the former, is thus performed. "While the uterus is finnly held down in the vagina as close to the vulva as possible, the first cut is made through the utero-vesical pouch, but the peritonaeum is not injured. The next step is to free the cervix behind, and open into the pouch of Douglas. Two fingers are then passed into the last cut, and brought forward over the fundus down into the vesico-uterine pouch, and, while they are in this position, the peritonaeum is di- vided. The fingers, thus hooked over the fundus, retroflex it, unless the utenis is very unyielding or hard, or the vagina is very small, and pull it out through the posterior wound. Sometimes forceps are necessary to do this. Each broad ligament is ligated in two places, and a third ligature encircles the whole. The utenis is now cut free from everything, and the two pedicles are brought into the vaginal wound, each being sutured to both the anterior and posterior fornix. A di-ainage-tube is inserted into the cavity of the pentonjeum between the stumps. The vagina is packed with antiseptic dressing. Finally, the sutures are removed in from ten to twelve days. Schroeder claims the same percentage of recoveries (seventy-five per cent) as Freund's statistics exhibit for deaths. From the frightful mortality of Freund's abdominal method, it has come to be almost abandoned, and vaginal hysterectomy — just described in detail — has taken its place. Statistics regai'ding vaginal hysterectomy are not reliable, nor as MALIGNANT DISEASE OF THE UTERUS. 417 yet very useful, first, because unsuccessful cases arc seldom reported, and secondly, because only a small number of cases at best have been publislied. Scbroeder says if one person out of twenty be cured, this ought to be considered a good result. He also admits that recurrence is frequent after vaginal extirpation. If ablation of the entire organ by Schroeder's method should be performed only when cancer affects the body, or in those cases where it is limited to the cervical mucosa, and, in either case, when the vagina is capacious enough not to oppose difficulties to the operation, then I think it will be a most difficult matter to decide when to perform vaginal hysterectomy, for it is doubtful if the touch can determine infiltration of the lymphatics. At the present day there are no known ante-mortem means of determining with certainty whether the uterus is or is not the sole locus of malignant disease. Again, when cancer is limited to the cervical mucosa, its detection is very rare. It would seem that vaginal hysterectomy, according to Schroed- er's own statements, is destined to become a rare operation. CANCER OF THE BODY OF THE UTERUS. This condition, though rare as compared with carcinoma of the cervix, is by no means a phenomenon. Pathology. — In corporeal epithelioma the epithelium of the uterine glands undergoes hypertrophy, and there is formed a fungat- ing polypoidal mass, which propagates itself over all the organ, or projects into its cavity, perhaps into the cavity of the cervix. The cancerous mass always ulcerates and leaves wide cavities in the hardened uterine wall. The organ is enlarged. Scirrhus or encephaloid may, in rare cases, be found in the body of the womb, although the best authorities state that there is scarcely an unquestionable case of corporeal encephaloid, and that scirrhus has never been met with. These varieties form beneath the mucosa in the substance of the uterine tissue, and extend outward, causing peritonitis and agglutina- tion with neighboring organs and parts. AVhen they extend inward they are certain to ulcerate. Either form of cancer, when accompanying fibroids, does not seem to modify the latter's characteristics. One case is recorded of caulitiower excrescence of the fundus ; this projected out through the cervix down into the vagina. 28 418 DISEASES OF WOMEN. The microscopical appearances in no wise differ from similar neoplasms in the cervix (lain of indigestion. Such symptoms not only appear during the decline of the menstrual function but continue during the post-cessation period. Those who have observed most carefully the resemblance in cer- tain ways between puberty and the nienopause, claim that those who suffer at puberty are liable to do so at the menopause. This is often the case, no doubt, as those who begin wrong are likely to end in a similar manner. Provision is made at puberty for the menstrual function, as has already been pointed out, and it may be briefly stated that a like provision is made in women in health for giving up that function. During involution, and especially after the cessation of menstru- ation, the secretion from the skin is increased ; the urine salts are more abundant ; there is a freer elimination of carbonic acid from the lungs. The skin acts more freely, and there is often a free ac- tion of all the mucous membranes. This shows that the process of elimination is more active in every way and compensates for menstruation. Indeed, the increased activity in elimination, in some cases, appears to be out of proportion to that which is necessary to compensate for menstruation. Should these compensating changes in the nutritive system fail, the subject is sure to suffer more or less. Kegarding the management of patients at the menopause, the reader should recall the facts stated when discussing the care of girls at puberty. The same rules of hygiene which should be observed when the menstrual function is being established, are equally effect- ive when that function is being given up. Bearing in mind that the sexual organs are preserved in health largely through the agency of the nutritive and nervous system, every effort should be made to pre- serve good general health at the menopause. All causes which act unfavorably upon the nervous system should be guarded against. Those who live generously and exercise little, should take less food and do more work, while those who are overtaxed and poorly fed, should have rest and a better diet. Any disease or derangement of the functions of the sexual or- gans which may exist when the patient is drawing near to the time for the cessation of the menses, should be attended to. Much harm has arisen by physicians advising patients who are suffering from THE MENOPAUSE. 425 symptoms referring to the pelvic organs to have patience, and they will be all right after the change comes. The diseases and disorders relating to the " change of life " may be classified as follows : . . ,. 1. Premature menopause, caused first, by certain conditions of the sexual organs, and, second, by diseases of the general system. 2. Prolonged menstruation, caused hrst, by local diseases ; sec- ondly, by constitutional affections. 3. Diseases and derangements of the nervous system, due to the menopause. 4. Derangements of the nutritive system, due to the menopause. 5. Diseases of the sexual organs due to the menopause. Typical cases of each of the above-named classes are frequently met with, but more often the cases are compHcated. Deranged digestion and nervous troubles often go together. Some local affec- tion and a general distm'bance are combined, and in some of the worst cases, the whole organization is upset. There is also a great variety in the character of the diseases and derangements grouped under each head. In the disorders of nutri- tion, there are two leading forms of trouble : In the one, the appetite, digestion, and assimilation are all defective ; while, in the other, dis- inteo-ration and elimination are most at fault. A similar but far greater variety of affections is presented by the nervous system. An almost endless number of differing symptoms is encountered here, which tends to confusion; still, there are two principal divisions which may form the basis of a classification, viz., those which manifest morbid excitation of the nervous system and those which show a depression. There is, of course, a marked distinction between those who suffer from derangement of the organic nervous system and those in whom the cerebro-spinal system is affected. ILLUSTRATIVE CASES. A Case iUustrating the Normal Menopause.— A lady who had a very good constitution, and, with the exception of having had some acute diseases in early life, had enjoyed uniform good health. She had borne five children, and after the birth of the last one she men- struated regularly and perfectly. When she was forty-six years old, the menstrual flow began to diminish in quantity and duration, varying a little in this respect from time to time. Iij^six months from the time that the change began, the duration of the flow was reduced from five days to two. She then missed two periods, and 426 DISEASES OF WOMEN. tbeii the flow returned, and lasted three days, and was a little freer. Then she went for four months, when there was a slight show for part of a day, and that was the end. During the time when the gradual diminution of the flow was taking place, she became somewhat languid and indisposed to her usual mental and physical activity, llcr appetite was not quite as good as formerly. While languid when undisturbed, she was ea.'^ily roused by any excitement. Her face would become flushed, her hands and feet clammy, and she was nervous and irritable. When these feelings passed away, she felt annoyed to think that she could not control herself as in times past, and would become a little de- spondent. All these symptoms were more pronounced at the men- strual periods. When sufliering most she felt that if she couhl have a free menstrual flow it would relieve her. These feelings continued to annoy her until the flow ceased entirely, and for about nine months afterward, but they diminished in severity, and Anally left her alto- gether. After the cessation of the flow, she gained considerable flesh, and her former mental and physical activity returned, and her health has been excellent ever since. When the diminution in the flow began, and her peculiar symp- toms came on, she consulted me about her condition. When told that all could be attributed to the change of life, she pleasantly ac- cepted the situation, and made no change in her mode of life, nor did she take any medicine. This enabled me to obtain the liistory of the case unmodified by treatment. Premature Menopause caused by Deranged Innervation. — The pa- tient was one having a good organization, but a very marked nervous temperament. She had three children, the youngest of whom was five years of age when I first saw her. She was then thirty-six years old. Three years before our first consultation she had many exciting cares thrust upon her, which affected her nervous system very injuri- ously. Though possessed of means sufficient to secure every luxury of life, her cares depressed her greatly, and exhausted her nervous system. Her nutrition was impaired to some extent, but still she had the appearance of one in fair health, although she was restless, sleepless, had headache very often, and snft'ered fi-om wandenng neuralgic pains. Her sufferings in this way had continued for about one year, during whicji time the menstrual flow was at times scanty and less in duration than normal. Then the menses stopped altogether for six months, then returned for several months, though scantily, then THE MENOPAUSE. 42Y ceased for two months, returned once, and then again in four months, and then stopped entirely. Five months after the hist menstruation was the time that I first saw her. She consulted me because she fancied that if her menses would return her health would improve. To describe her symptoms would be tedious and unprofitable ; suffice it to say that she presented typical neurasthenia. There was no organic disease noticeable out- side of the nervous system. Being fully satisfied that if the men- strual function could ever be restored, it must be accomplished by restoring the nervous system first, the treatment was directed to that object. Sleep at night was obtained by giving thirty grains of bro- mide of sodium late in the afternoon, and half an ounce of whisky at bed-time. Aconitia, one two-hundredth of a grain, relieved her at- tacks of neuralgia. Massage and general faradization were employed daily, and tonics were given, consisting, first, of valerianate of zinc, then pyrophosphate of iron and arsenic, and then iodide of iron. Citrate of iron and quinine was also given at times. The form of tonic was changed whenever she becauie used to that which she was taking, and the most appropriate diet was given. Her general health improved gradually, and in the summer she was able to rest and enjoy life in the country by the sea. Sea-bathing was also tried after a time with benefit. About one year of this treatment restored her health, but the menses did not return. In fact, the restoration of that function was despaired of after three months' treatment, when, on examination, it was found that the organs of generation had un- dergone complete involution. Premature Menopause due to Chlorosis. — The following case is taken from Tilt's valuable work on " The Change of Life." The case is given as " Chlorosis mistaken for Cessation," but, from my way of looking at the matter, I think that the chlorosis was the cause of the early cessation of the menstrual function. Chi orotic women are liable to cease menstruating at an early period, and frequently suffer at the change just as they do at puberty. Entertaining, as I do, the views given in a previous chapter on chlorosis, it is not pos- sible for me to believe that chlorosis could be developed at the meno- pause. It is a condition due to imperfect development, not to change in structure : " Case. — Annie W., aged thirty-three, and married, had an ante- mic hue of countenance. The menstrual flow first came at thirteen ; had been regular and without pain until tw^enty-oue, when she mar- ried, and had one child at twenty-four. There had been a gradual diminution of the menstrual flow for the previous year, with intense 428 DISEASES OF WOMEN. debility, epigastric faintness, and drenching perspirations, and a loud hi'ult de souffle in the carotids. Was it a case of chlorosis in a mar- ried woman or chlorosis occurring at cessation ? I inferred the latter from the gradual failing of the menstnial flow, and the pertinacity of the flushes and perspirations. A camphor-mixture, a hclladonna- plaster to the pit of the stomach, and sulphate of iron in pills, cured the patient, and when I saw her again, three years afterward, her health was good, but there had been no return of the menstrual flow." The Menopause delayed by Fimgosities of the Endometrium. — This patient was married, and the mother of Ave children. After the birth of her last child, she suffered from uterine leucorrhoea, proba- bly caused by endometritis. She had fair health in spite of that, and menstruated regularly until she was forty-six years old, and then the menstrual flow became more profuse. This continued intermit- tently for nearly one year, when the menses came more frequently, lasted longer, and the flow was quite profuse. Her heakh failed gradually ; she became anaemic, weak, low-spirited, and nervous. Though her flesh remained (she was rather stout), her strength was greatly reduced. Her family physician gave her the usual remedies — lead and opium, ergot, cannabis Indica, and aromatic sulphuric acid — in the hope of controlling the flow, but without effect. Finally she consented, w^ith some reluctance, to an examination, when a large number of polypoid growths were found in the cavity of the uterus. These were removed with the curette, and the flow- ing stopped for six weeks ; it then returned for a few days, but was not very free. There was a return of the menstrual flow in two months, very scanty, and another in three months, and that was the end of it. She was then forty-eight years old. After the removal of the fungous growths with the curette, her health improved under tonic treatment, and, when last seen, at forty- nine years of age, she was quite well. Derangement of the Ganglionic Nervous System (from Tilt). — Gan- GLioxic HvPER-ESTUESiA. — Miss C. was forty-eight, tall, stout, with dark hair, and a flushed face. The menstrual flow came regularly from thirteen to forty-seven, then irregularly, being often a mere show. This patient had never been nervous or hysterical, and she now complains of pain at the j)it of the stomach, which first appeared when the menstrual flow became irregular, and says that she is never without uneasy sensations at the epigastric region, which do not generally interfere with her occupations ; but paroxysms of acute pain often occur, especially at night, when they suddenly awaken THE MENOPAUSE. 429 her from a sound sleep. The pain tlien experienced is described as a " tearing pain," and, after it has lasted from ten to twenty minutes, ropy mucus comes from the mouth, by expuition, without eructa- tions. When the intensity of the pain has abated, the 2:)atieiit lies for hours conscious, but prostrate. Sometimes she faints after a bad attack ; then she is forced to keep her bed a day or two, and during the last six months flushes and perspirations have been abundant. The tongue was clean, digestion good, and no trace of tumor at the pit of the stomach. I had six ounces of blood taken from the arm, and I gave two tablospoonfuls of a comp. camphor mixture before, and ten grains of carbonate of soda after meals ; two comp. col. pills and ten grains of Dover's powder on alternate nights, and a mustard or a linseed poultice was applied to the pit of the stomach every night. The camphorated mixture that I gave in such cases, before the bromides came into use, was composed of three drachms of tinct- ure of castor, six drachms of tincture of hyoscyamus, and five ounces of camphor julep. After continuing all this for a month, the par- oxysms came only once a week, instead of almost every night ; I then ordered a warm bath to be taken for an hour every night just before going to bed ; belladonna and opium plasters to the pit of the stom- ach alternately every week, and a scruple of sulphur once a day. This was persisted in for six weeks, and was then left off, as there had been no paroxysms for ten days. When the patient left town, I advised her to take the mixture should she feel worse, as well as the pills and the sulphur, and to have six ounces of blood again taken from the arm in three or four months. This case seems to me best accounted for by admitting a neuralgic affection of the ganglionic nervous center ; for the stomach performed all its functions health- ily, there was no sign of cerebral disorder, neither was this affection obscured by other nervous disorders. It caused no hysteria, no pseudo-narcotism, not even headache. The neuralgic character of the case was well marked by the paroxysmal outburst of the pain, its seat in the central ganglia by the exhaustion that followed tlie attacks. The following case from Tilt, illustrates another of the same class of affections. Ganglionic Dyssesthesia. — Sarah B., tall, stout, and healthy-looking, with brown hair and hazel eyes, was forty-seven when she came to the Paddington Dispensary, September 8, 1849. The menstrual flow first appeared at seventeen, w^as always regular, and accompa- nied by pseudo-narcotism. She married at twenty -five, had two children, and the menstrual flow left suddenly, without known cause. 430 DISEASES OF WOMEN. at forty-four. Since tlieii she lias been entirely free from lumbo- abdominal pains, but has suffered much from other nervous symp- toms. There has been no headache, but a heavy, stujiid feeling in the head, with drowsiness in the day after sleeping well at night, and forgetfulness of familiar things. She was nervous, desponding and low-spirited ; often shedding tears, and had strange sensations in the throat. Ever since cessation she had been distressed by a flutter- ing at the pit of the stomach, " as if something were perpetually swinging within her." It becomes worse after meals, generally abates when she lies down, is seldom felt when in bed, but begins as soon as she rises. When turning the corner of a street, this sen- sation makes her feel afraid of losing her center of stability and of overbalancing herself ; and when she has it in bed, she feels " as if a tub were rolling to and fro within her," and then " the head goes too," as " if something rose from the pit of the stomach to the head, making it feel giddy and bewildered." Since cessation, she has been troubled by burning flushes, without perspirations ; and there is sometimes a good deal of pudendal irritation. There was no organic disease of the heart, aortic pulsation, or dyspeptic condition to explain these singular symptoms ; several practitioners have told her '' it was all nonsense ; " but it will not do to deny a patient's statement because sensations can not be explained. I ordered the compound camphor mixture before meals and on going to bed ; car- bonate of soda after meals ; a large opium plaster to the pit of the stomach ; and a small teaspoonful of sulphur and carbonate of mag- nesia over night. SejDtember 15th, — She was better ; a lead lotion for the pudendal irritation, and ten grains of Dover's powder every night. October 6th. — Instead of perspirations, a papular eruption has appeared on the shoulders, and she feels rather worse than bet- ter; but the remedies were continued, with the addition of com- pound col. pills, to be taken occasionally. October 20th. — All the cerebral symptoms have vanished, she is much better, and can bus- tle about ; but the swinging sensation in the epigastric region still remains. The improvement coincided with gentle, well-sustained perspirations. I ordered the mixture and soda as before, but dis- continued the sulphur and Dover's powders ; prescribing, instead, sulphur, two ounces ; borax, one ounce ; Dover's powder, one drachm ; two scruples of the powder to be taken in a little milk, at night. A. blister was ordered to the pit of the stomach. Novem- ber 6th. — She looks cool and comfortable, is much stronger, and is less troul)led by the swinging sensation. The blister did no good, so I ordered a rotation of belladonna and opium plasters, each to be THE MENOPAUSE. 431 worn a week on the epigastric region, and the mixture and com- pound sulphur powders to be continued. November 23d. — The patient w^is discharged cured. Excrementitious Plethora, Oppression, and Derangement of the Nervous System from the Menopause. — A strong-looking German lady gave me the following history : She was married and in quite comfortable circumstances. She had six children, the youngest be- ing eleven years old. Fi-om the time of her last confinement her health has been good and she menstruated normally, until she was over forty-six years of age. Her menses came then at the proper time but lasted two weeks and the flow was too free. After a lapse of three months the menses came again in a diminished degree, and again in two months, scantily. From the time of her free menstru- ation, when she was about forty-six years old, her health failed grad- ually. She had always been a generous liver, and continued to take her nourishment well, but she became languid, indisposed to exer- tion of any kind, had headaches, was drowsy and sleepy all the time, but often had restless nights. Her mind was disturbed so that she was depressed in spirits, quite fretful, did and said " queer things " which alarmed her family, and her memory was less reliable than formerly. She had little interest in her former duties and amuse- ments, but occupied her time mostly in thinking and talking about her feelings. There were ilushings of the face at times, which she described as rushing of blood to the head, which she fancied might kill her. There were profuse but brief paroxysms of perspiration, which came at times without any physical exertion. She was quite fleshy, and excepting an anxious expression of the face, had the ap- pearance of good health. The tongue was coated, the bowels con- stipated, the urine was loaded with phosphates ; the pulse fuU but slow, and at times irregular; the appetite was not good, but she took food in abundance and drank wine and beer in the hope of getting strength. She suffered from labored digestion and flatulence and a sense of fullness in the region of the stomach. The sexual organs had undergone complete involution although the vagina was relaxed and showed some venous congestion. The treatment was first, ten grains of blue-mass, three grains of calomel, and one grain of ipecac, given at bed-time, followed in the morning with a dose of sulphate of magnesia. This was repeated twice, at intervals of five days, and after that, the following mixture was given : Bromide of sodium, half an ounce; salicylate of sodium, two drachms ; wine of colchicum-seeds, two drachms ; sirup and water enough to make three ounces, and a teaspoonful to be taken « 432 DISEASES OF WOMEN. before meals. She improved very much on this treatment, and the mixture was contiuaed for about six weeks. After the effects of the mercurial cathartic had passed off, she became constipated, and the following pill was given at bed-time. Sulphate of quinine, one grain ; extract of belladonna, one eighth of a grain ; and rhubarb, two grains. When this was not sufficient to move the bowels freely, a glass of Congress water was given an hour before breakfast. Wine and beer were gradually given up, and her diet simplified and reduced in quantity. Exercise in the open air was prescribed, and light, agreeable mental occupation. The progress of the case was quite satisfactory for about two months, then there was a standstill for a time. The medicine was then changed to a mixture of hydro- chloric acid, one and one half drachm ; tr. nux vomica, one and one half drachm ; tincture of cannabis Indica, two drachms ; tincture of cardamon, one ounce ; and simple sirup, two ounces ; one drachm before meals in water. The pill at bed-time was continued. This last prescription was given for about two months with an interval of three days after each bottle, when she took the pill only, at night. From this time onward, the progress of the case was steady until she Unally recovered her former good health. Such a case as this is infrequently seen in practice. The causes being conditions of life favoring derangement of nutrition and sluggish disintegration, aggravated greatly by the rather abrupt ces- sation of the menses. Impaired Digestion and Assimilation arising from the Cessation of Menstruation. — This lady was married and the mother of a family, of spare habit and a nervous temperament, but her health had been good in the past. When she was forty years of age, her menstrual flow diminished in quantity and duration, and simultaneously her appetite failed, and she lost flesh and strength. Always an active person, she now became restless, nervous, and irritable. Her tongue was clean, but of a deeper color than normal, showing that rapid exfohation of the epithelium was going on. The bowels were constipated, the urine was abundant and of light color usually. Her skin was slightly bronzed and usually dry, although she had occasional outbursts of free perspiration. Her pulse was weak, and at times irregular. Her head ached quite often and she had wandering pains about the chest and abdomen. Her greatest trouble was a feeling of distress in the stomach after eating. Eight months from the time that the menstrual flow began to decline, it stopped altogether, and two months afterward I first saw her. As the physical condition of this patient was almost exactly the THE MENOPAUSE. 433 opposite of the preceding case, the treatment was necessarily very different. She was directed to take nutritious food in small quan- tity, six times a day ; to rest as much as possible and have massage at niglit, which gave better sleep. At first, she was given five grains of oxalate of cerium, half an hour before meals, and a teaspoonful after meals, in warm water, of a mixture of lactic acid, tincture of columbo, and pepsin wine, and she improved so far as to take food, and digest it with less trouble, but her strength did not return as fast as I desired. She was also constipated. A tonic laxative pill was then given before meals consisting of quinine, belladonna, and compound extract of colocynth ; and after meals, she was given a teaspoonful of whis- ky with four drops of tincture of nux vomica and four grains of animal charcoal. This appeared to help her, and this course of tonic treatment was continued very faithfully for three months, when she considered herself sufficiently well without further treat- ment. Two years afterward she was found to be in good health. Circumscribed Infiammation of the Vagina and Cervix Uteri, partly due to the Menopause. — The patient was first seen when she was forty-eight years old. The menses had stopped one year and two months before. Her health was fairly good and always had been, but for some time before the menopause and all the time after, she had been distressed by a discharge from the vagina of sero-purulent but rather tenacious material, which caused some external irritation. There was heat and burning in the pelvis which became more marked on walking. She had put up with her troubles so long, be- lieving that it was due to change of life and would pass off in time. I In fact, she had been told this by her physician. But, instead of disappearing, she found that the trouble increased, if indeed it changed at all. Her general health was below par considerably, but there was no organic disease of the organs of nutrition, and yet ultimate nutrition was a little sluggish. The sexual organs had undergone final involution ; the uterus was small, but the os externum was open, and coming from the canal was a tenacious, darkish-colored discharge, not unlike the leu- corrhosa found in young subjects and heretofore described under the head of " Cervical Endometritis in the Imperfectly Developed Uterus." The mucous membrane about the external os was eroded in patches, and on the anterior lip of the cervix there were some granu- lar spots that looked as if they were the products of epithelial hy- 29 434 DISEASES OF WOMEN. perplasia. The appearance of the vagina was peculiar. In place of the general congestion of a well-marked vaginitis, the mucous mem- brane was studded with small red points or patches, while the inter- vening portions of the membrane were pale. The surface of the membrane was covered with a sero-purulent discharge ; at the vulva there were several patches of congestion larger than those higher up in the vagina. Some of these were of a deep-red. and slightly bhi- ish color. The thought came to me that this might be malignant diseaj^e of the cervix just beginning, but this was put aside, because of the duration of the trouble and the fact that I have several times seen this condition after the menopause. I have also frequently seen the same conditions in young insane women who had amenorrhoea. These facts led me to suppose that the inflammatory action was due to impaired nutrition which is pres- ent at the involution of the sexual organs. This low grade of in- flammatory action is no doubt more likely to occur in those who have had some ordinary cervical endometritis and vaginitis before the menopause. The circumscribed red spots, looked to me like a few live coals here and there in the ashes left after the flres of functional life and inflammation had subsided. The treatment consisted of general tonics and local astringents, citrate of iron and quinine was given interaally, and a teaspoouful of sulphate of zinc in a quart of water for a vaginal douche. The parts about the os externum were touched once with a flfty- per-cent solution of chloride of zinc. The sulphate-of-zinc injec- tions did very well for a time, but the progress was favored by an occasional application of glycerin and tannic acid. The local improvement did not surpass the general regaining of strength, but kept pace with it. The recovery was permanent and perfect. Pelvic pains of a neuralgic character are common about the change of life, and are often due to it. The following two cases from Tilt will illustrate this form of trouble. Ovario-XJterine Neuralgia. — Miss X., was forty-seven when she first consulted me. She is small, but well-proportioned ; has been highly nervous all her life. Menstruation was irregular, and tliere was a muco-purulent discharge, vaginitis, and decided ulceration of the cervix, and a most irksome sensation of heat and irritation in the passage. I cured the vaginitis and ulceration by surgical measures, without relieving the vaginal heat and pruritus, so I sent the patient out of town. When she returned, after many months, the pruritus THE MENOPAUSE. 435 ' was as bad as ever, and would come on after any excitement or fatio-nc, or standing about, and would be relieved by resting with the feet higher than the pelvis. This vulvo-vaginal irritation would sometimes disappear on the coming on of a similar pruritus on the palms of the hands and on the soles of the feet, showing that how- ever much the chief seat of neuralgia might be in the womb or va- gina, the ultimate nervous expansions in other parts of the body mio^ht similarly suffer. When this irritation affects the feet and hands there is nothing to be seen there, and she refrains from scratch- ino- them because it would prolong the irritation for hours. As might have been predicted, the symptoms were worse at night, and led to great exhaustion and despondency. I have watched this state of things for twenty years, and at times could give no relief. She was always better for plenty of food and wine, and for such small quantities of citrate of iron and quinia as she could bear. I tried all sorts of injections ; tar-water did most good, but it has been re- peatedly advisable to leave off all kinds of injection, for they seemed to do more harm than good. I syringed the vagina with a solution of nitrate of silver and touched the passage with the solid caustic, with questionable benefit. A rectal suppository, containing a grain of opium and one of extract of belladonna often gave temporary re- lief, but this remedy could not be relied on. By the sacrifice of her own health many a daughter has well repaid the gift of life ; and when my patient lost her mother, who had been long a cripple, re- quiring anxious and fatiguing nursing, she went out of town and got fat, and now suffers much less, only having a slight return of the old symptoms when she gets weaker and more nervous. Ovario-Xrterine Neuralgia. — A very strongly-constituted lady, aged forty-seven, is said to have had some acute uterine disease twenty years ago, while residing in France, when forty leeches were ap- plied above the pubis. With the exception of not being able to re- tain the urine so well as previously to this attack, health remained so good that every year she was able to take long pedestrian excur- sions with her husband. She never conceived, and menstruation ceased suddenly at forty-four; in the following months the nose bled very frequently, and the bowels became constipated ; for which she went to Homburg and was restored to health. On returning to town, in December, 1868, she took very cold enemata, for constipa- tion, which was so great that a wineglass of Friedrichw^hall water, taken every hour, failed to produce watery motions, and only irri- tated the bladder, apparently causing the strange abdominal sensa- tions which have lasted ever since. The patient feels as if there were 436 DISEASES OF WOMEN. a heavy body in tlio pelvis, bearing down upon the rectum, with a burning sensation, referred Bonietinies to that organ, Kunietinies t(j the vagina, or to the bladder. When in bed and lying down, with the feet up, she feels comfortable ; by the time she has half done dressing the burning sensation begins, and la.sts until the buwels have been moved ; soon after this the burning comes back ; it is ag- gravated by standing or sitting, by indigestion, flatulence, constipa- tion, and repletion of the bladder ; also by worry and bad news. The sensation is relieved by moderate walking, by lying down, and by regularity of the bowels, llomburg was again tried ; it did good, but on her return the lady was as bad as before, and consulted several doctors. One attributed the sufferings to stricture of the rectum, another to irritation of the bladder, a third to displacement of the womb. The following summer llomburg was tried for a third time, but the waters were soon left off, for they aggravated all the symptoms, and after the patient's return to town Dr. ]3eale sent her to me. In addition to the pelvic symptoms already described a strong-minded, sharp, matter-of-fact woman was in a state of mental confusion ; her brain felt muddled, and she would sit for hours doz- ing or doing nothing ; despondency l)eing doubtless increased by finding herself helpless as a child, after having passed all her life in doing everybody else's business as well as her own. She forgot where she put things ; once thought she had taken out a large sum of money in her purse, and that she had lost it, whereas a month afterward she found it in some out-of-the-wa}' place. On examin- ing, I found the rectum perfectly healthy, notwithstanding the j^ain and stricture ascribed to it. I was given to understand that marriage had never been concluded, and the vagina was so narrow that I could with difficulty introduce part of my index-finger ; so I ordered lin- seed tea and laudanum injections, three times a day, and henbane internally. A few days afterward I was able to reach the os uteri ; I found the womb exquisitely sensitive; and on sounding the blad- der there was nothing abnormal, except great pain when the sound passed over the uretlira^ the pain not being caused by inflammation, for the finger in the vagina did not feel the urethra as a hard and round body painful on being pressed. Injections with acetate of lead and laudanum, as well as opium and belladonna rectal siijiposi- tories, enabled me, a little later, to examine the womb without giv- ing pain ; there was no ulceration and there had been little vaginal discharge. The pain was most felt at the o]>ening of the vagina, which looked sore, red, and injected, a condition that accounted for a very unusual hardness of the recto- vaginal tissues, a hardness of THE MENOPAUSE. 437 which the patient was sensible, and complained of as something wrong with " the bridge." This was caused by long-continued con- gestion, although the parts were then without heat or redness. This sore state of the vaginal opening was relieved by the apj^lication twice a day, of zinc-ointment, to each ounce of which was added a di'achm of diluted hydrocyanic acid. Vaginitis becoming worse, I swabbed the vagina once a week with a solution of nitrate of silver, and I ordered alum and zinc injections ; suppositories did harm, whether administered by the vagina or the rectum. After thus treating the patient for a few months, the sensations of burning and weigiit had considerably diminished, but were often troublesome. Digestion was much improved by nitro-muriatic acid and pepsin ; pseudo-narcotism and mental disturbance were not relieved by bro- mide of potassium, but were much reduced by henbane and Indian hemp; and then the patient took, for two months, three times a day, at meals, the twenty-fourth of a grain of arseniate of iron, made into a pill with a fourth of a grain of Indian hemp — a combi- nation suitable alike to the general nervous derangement and to the abdominal neuralgia. This leads me to the question of diagnosis. There was no organic disease of the bladder or rectum, nor of the womb, neither displacement nor ulceration of this organ. The dis- ease originated in vaginitis, kept up by excessive walking and drastic medicines, at the change of life. The vaginitis causing neuralgia of both the sensory and the ganglionic pelvic nerves, the neuralgia causing pseudo-narcotism and the other forms of cerebral disturb- ance that usually attend the menopause ; the neuralgic element of the case being shown by the patient's often feeling the disturbance to ascend, as it were, from the pelvis along the spinal column to the back part of the head, where there was most suffering. There was a gradual recovery of health, and this patient has been able to re- sume her usual very active life. A long list of diseases has been given as occurring at the meno- pause. This list covers nearly all the ills that flesh is heir to. The majority of these have no relations to the menopause excepting that when there is a predisposition to any disease, the disturbances of the system due to the change, would favor the outbreak at that time. No notice need be taken of those affections which are common to all periods of life, the menopause only determining the time of their development. When there exists a predisposition to any of the constitutional diseases, the condition of nutrition at the meno- pause, and the disturbed or unbalanced state of the nervous system, favor the outbreak of these morbid tendencies. CHAPTER XXIY. DISEASES or TnE OVARIES. THE ANATOMY AND PHYSIOLOGY OF THE OVARY. The ovaries are two bodies, in shape somewhat like an almond, situated in the pelvic cavity, one on either side of the utenis, and removed from it about one inch. They are connected with tliat organ by the Fallopian tubes and the ovarian ligaments. Before birth the ovaries are on a level with the iliac fossa, and it is not until the tenth year of life that they reach what may be considered their permanent position — that is, the lateral and posterior part of the true pelvis. Hasse, of Breslau, in a female cadaver frozen in the upright position found that the long axis of both ovaries ran out- ward and forward, form- ing wdth the transverse axis of the uterus an an- gle open to the front, with one half of the or- gan projecting above the plane of the pelvic brim. Schultze, on the contrary, regards the long axis of the ovaries as being in an antero-posterior posi- tion, as shown in Fig. 185. It must be borne in mind, however, that the position of tlie ovaries is not a fixed one ; their relation to the uterus and the other pelvic organs is such that, when any one of these is displaced, a change in the position of the ovaries will of necessity occur ; thus the full or empty bladder or rectum acting upon the uterus will tend to push the ovaries in one direction or another. Fig. 185. — The fundus uteri and ovaries seen through the pelvic brim (His). The cross is in the center of the pelvis and on the fundus ; o, o, ovaries encircled by the J^allopian tubes in their backward sweep. DISEASES OF THE OVARIES. 439 The average dimensions of each ovary are : Length, one inch and a quarter ; width, three quarters of an inch ; and thickness, half an inch. Its weight is about eighty grains. As its position changes, so do also the measurements here given. It is probably in its most perfect condition in the virgin at about the age of puberty. Ac- cording to Ilennig's observations, the ovary increases in length dur- ino" pregnancy, but neither its breadth nor thickness exceeds that found in the virgin. When pregnancy has ceased, the ovaries become smaller, and do not at any time subsequently regain the diinensions possessed by the virgin ovary. Tiie relation of the ovaries to the broad ligament is a matter of great importance and interest. These ligaments consist of two folds or layers of the peritonaeum, with a lining of muscular tissue, be- tween which lie the uterus and its appendages. The ovaries, how- ever, are not situated between these two layers, but are suspended, so to speak, from the posterior surface of the posterior layer, and are, therefore, entirely behind both layers or folds of peritonseum, which form the broad ligament, but attached to the posterior layer by their long axis, this attached portion of the ovary being termed the hilum. In the anterior face of the posterior layer of the broad ligament, on either side, is an opening or slit through which the blood-vessels, nerves, and lymphatics of the ovary pass. The ovarian ligaments which connect the body of the uterus and the ovaries, leaving the former at a point between the Fallopian tubes and the round ligaments, after running for some distance between the two layers of the broad ligament, pass out by these openings in the pos- terior layers to the ovaries. These ovarian ligaments are about one inch in length, and are composed of fibrous tissue, into which some of the uterine muscular tissue is prolonged (Fig. 18G). Each ovary is also connected with the corresponding Fallopian tube by one of its iimbrise, and through this to the pelvis by means of the infundib- ulo-pelvic ligament — a ligament about two thirds of an inch in length, running from the outer end of the Fallopian tube to the wall of the pelvis. Thus the ovary is maintained in its position — subject, however, to considerable alteration — by the broad, the ovarian, and the infundibulo-pelvic ligaments. The supply of blood to the ovaries is by the ovarian artery, a branch of the abdominal aorta, corresponding to the spermatic artery of the male. After this artery enters the pelvis, it passes between the layers of the broad ligament in a direction toward the upper angle of the uterus ; its course is parallel to, though below, the Fallopian tube. 440 DISEASES OF WOMEN. It seuds branches to the ovary, which pass out fi'oin between tlie layers of the broad ligament to the ovary through the opening in Fig. 186. — The ovary and its ligaments (Henle). it, uterus; Od, Fallopian tube ;| lo, ovarian ligament ; ip, infundibulo-pelvic ligament ; io, iufundibulo-ovariau liga ment ; Fo, fimbria ovarica ; Fo, parovarium. the posterior layer already referred to. Other branches supply the Fallopian tube and anastomose with the uterine artery. The venoi blood of the ovary passes into the ovarian plexus, sometimes spoke of as the pampiniform plexus, which is situated between the layers! of the broad ligament, and is thence carried to the inferior vena cava on the right side, and to the renal vein on the left. These veins,] which form a network in the ovary, have, according to Rouget, as-j sociated with them muscular trabeculae, which, in their contraction,] prevent the passage of the blood from the ovary into the large venous] trunks, and thus permit of what may be termed an erection of the] ovary. It is probable that during the act of coition such a condition] takes place in the ovary, increasing its size to a considerable extent,] and causing it to become firmer and more sensitive. liouget de-j scribes the lymphatics of the ovary as united into six or eight trunks,] which accompany the ovarian artery, and discharge into the middle] and superior lumbar lymphatic ganglia. The lymphatic circulation] becomes of special importance in explaning the method by which,] under certain conditions, septic matter is absorl)ed, producing sep-l ticsemia. The ovarian and uterine plexuses comnninicate, as do thoj arteries of the same names. DISEASES OF THE OVARIES. 441 The nerves of the ovaries, as well as those of the ntenis, arise iSL ca^liac plexus, which is in part distributed to the ovaries Fig. 187.- -The ovarian, uterine and vaginal arteries (Hyrtl). and to tl>e spermatic ganglia. According to ^-"-^^^^^^ superior mesenteric plexus supplies these ^f ™^t,c gangl a .h>A Conrty suggests wonld be better called gemtal ganglia. These gan .ha, our fn nnmber, are supplied from the sympathetic through two 442 DISEASES OF WOMEN. large hranclics, and in turn supply the ovaries through a considerable nunil)er of liranciies. Development of the Ovary. — At a very early period in the devel- opment of the f(L'tiis, two bodies are formed in the abdominal cavity, one on each side of the spinal column ; these are the WoltHan bodies, the function of which is undoubtedly similar to that of the adult kidney. According to Coste, they are fully formed at the end of the first month, and, according to Longet, are hardly visible after the second month. While these organs are in a state of activity, the kidneys are formed behind them, and at the same time two other organs appear in front of the Wolfhan bodies, and on their inner side ; these are the internal organs of generation — the testicles in the male and the ovaries in the female. The detailed history of the development of these organs is as follows : At a very early stage of development — in the chick as early as the third day — the cells of the mesoblast form a longitudinal cord in the mesoblast, one on each side of the body, and just external to the ])roto vertebrae, which are also formed from this same layer. These cords are at first solid, but a cavity gradually forms within them, and they become the Wolffian ducts. From this primitive tube diverticula are given off, forming, as it were, blind tubes, into which blood-vessels enter, and with the diverticula form the Wolffian bodies, one upon either side. Another portion of the mesoblast projecting in the form of a ridge, and cov- ered with " germ epithelium " on the inner side of the Wolffian body — that is, toward the median line — becomes the testicle or the ovary, according as the individual is to be of the male or female sex. On the outer wall of the Wolffian body an involution takes place from the pleuro-peritoneal cavity, forming at first a furrow, but later, by the union of its edges, a duct, which is known as Miiller's duct. In the female these ducts form the Fallopian tubes, the uterus, and the vagina, while in the male they have no special function, although the upper part remains as the hydatid of Moi-gagni, and the lower as the prostatic pouch, the uterus masculinus, or sinus jjocularis. While the Wolffian ducts in the male form the body and globus minor of the epididymis, the vas deferens, and the ejaculatory duct, in the female the lower part only remains to form the duct of Gaert- ner. If the broad ligament is examined with transmitted light, a cone, nearly an inch in Ijreadth, of whitish, more or less convoluted tubes are seen, in number about twenty, each of which is lined with ciliated epithelium, and contains a clear fluid (see Fig. 188). This is the parovarium of Kobelt, or the organ of Rosenmuller, and is the remnant of the Wolffian body of fetal life. The path- DISEASES OF TOE OVARIES. 443 olo-ical degeneration of these tubes produces the parovarian cystic tumor. Minute Anatomy of the Ovary. -The fact that the ovary is situ- ated behind both layers of tlie broad hgament, and attached only at the hilum, has already been referred to. From this it follows that the posterior surface of the ovary is not covered by peritoneum. The more thorough and skillful investigations of recent years have satisfactorilv demonstrated that the surface of the ovary ^^ i" ^PP^^];; ance and structure very different from the peritonaeum. ^^ hi e the epithelium which covers the broad ligament is transparent and flat- tened, that which forms the surface of the ovary is granular m ap- pearance and columnar in form. This marked difference has sug- 444 DISEASES OF WOMEN. gested to some tliat the covering of the ovary was a mucous rather tJian a serous membrane. These columnar cells are very similar to those lining the Fallopian tubes, except that the cilia which are ])resent in the latter are wanting in the former. It is an error to regard these supertlcial cells of the ovary, which are arranged in a single layer, as in any sense a covering of the ovary. They are in reality an integral part of the ovary, and, as the name "germ epi- thelium" implies, their function is a most important one, being none less than the formation of the ova by a modification of their structure, as has been so well described by Waldeyer. Beneath this layer of germ epithelium is the tunica albuginea. This is made up of bundles of spindle-shaped cells, an-anged, accord- ing to Ilenle, in three layers, the outer and inner ones being longi- tudinal, and the middle one circular. The albuginea contains no Graafian follicles. The third layer — that is, the one next to the albuginea — is what Schron has described as the cortical layer. This contains the smallest of the Graafian follicles arranged in groups, but separated by the stroma of the ovary, this latter being made up of bundles of spindle-shaped cells, some short and others long, each having an oval nucleus, and being jDrobably young connective-tissue cells. The Graafian follicles of the cortical layer are spherical or shghtly oval bodies, with a diameter of one one thousandth of an inch, and have as their external poition a delicate membrane — the mem- brana propria. Lining this is the membrana granulosa, a layer of flat, transparent, epithelial cells, with oval nuclei. "Within this, and occupying the entire cavity of the follicle, is a spherical cell — the o^'um. The ovum is a collection of granular protoplasm containing a spherical or oval nucleus, the germinal vesicle, and this, in turn, a body knowai as the germinal spot. Below this cortical layer, im- bedded in the stroma, are Graafian follicles of almost every conceiva- ble size. While the older anatomists thought the total number of follicles in an ovary did not exceed twenty, this number being all that could be seen by the unaided eye, some of the more recent authorities have placed the number at six hundred thousand. As follicles rupture and discharge each month for a long series of years, the estimate of the earlier writers is undoubtedly too low — probably as much too low as that of some of the recent ones is too high. All the layers thus far described constitute the parenchyma of the ovary. Between this and the liilum is the vascular zone, which contains no follicles, but is made up of bundles of connective tissue and bundles of non-striped muscular tissue, which are directly continuous with the corresponding tissues of the broad ligament. It is in this vas- DISEASES OF TUE OVARIES. 445 cular zone that the blood-vessels of the ovary are found, and, indeed, give to it the name which characterizes it. The Graafian follicle of medium size is, like that of the cortical layer, made up of a membrana propria and a membrana granulosa, and contains an ovum. The ovum is, however, larger than that of the cortical follicles, and is limited by a thin membrane, the zona pellucida or vitelline membrane. This is believed to be formed by the cells of the membrana granulosa. As the follicle increases in size the ovum does not increase correspondingly, so that, while for a considerable time it completely tilled the cavity, now it does not do so, and the space between it and the membrana graimlosa contains an albuminous iiuid — the liquor folliculi. It should be stated that a Graaiian follicle, while it usually contains but one ovum, does some- times contain two or even three ova. At one part of the membrana granulosa the cells are more abundant than elsewhere, forming a mound which is known as the discus or cumulus proligerus ; in the center of this accumulation of cells the ovum is imbedded. Some of the Graafian follicles reach maturity, so far as can be told from their size and appearance, and undergo degeneration before the age of puberty is attained. Some of the small follicles also degenerate, never reaching maturity. The number of follicles which thus de- generate is by no means inconsiderable, and a knowledge of this fact, and that at each menstrual epoch a follicle ruptures, leads us to be- lieve that the total number of follicles in an ovary must be reckoned by thousands. Development of the Graafian Follicles and Ova. — Having described the minute anatomy of the ovary, we are now prepared to consider the manner in which the follicles and their contained ova are formed. The germ e^jithelium, which forms the superficial layer of the fetal ovary, undergoes rapid multiplication, as a result of which the cells grow in a direction toward the vascular stroma of the ovary ; this likewise increases, and in a direction toward the germ epithelium. The stroma, developing between these masses of cells, which are off- shoots from the germ epithelium^thus isolates them, forming islands or nests. These nests are larger below than above where they are for a considerable time still connected with the superficial germ epi- thelium. Indeed, at birth this connection exists and forms what Pfliiger has denominated the ovarial tubes. The cells composing these nests multiply themselves by the process of karyokinesis, thus increasing the size of the nests, and forming new ones by being con- stricted oif from the old ones. Some of the cells of the germ epi- thelium undergo special development in the cell-body and nucleus, 446 DISEASES OF WOMEN. and become ova, wliicli are spoken of as ])riinitive ova. Tlie germi- nal vesicle is formed before tlie vitellus or tlie zona pellucida ; but whether the formation of the germinal spot precedes that of the gonninal vesicle has not been fully decided in the vertebrates. KoUiker finds this to be the order in the development of the ova of intestinal worms. As the multiplication of the cells of the germ epithelium goes on as already described, there is also a continually increasing differentiation of these cells forming the primitive ova. This production of ova takes place in the nests as well as in the superficial layer, and, as a result, we have each nest containing a number of ova, and ova are also found in the same manner in the ovarian tubes. The membrana granulosa is fonned of the cells of the nests and tubes which do not take part in the formation of the ova. If a nest or an ovarial tube contains several ova, each ovum will form a center, around which will be aggregated a layer of cells, forming a membrana granulosa, and by the ingrowth of the stroma between these collections the Graafian follicles are formed. External to the membrana granulosa is formed the membrana propria, and still more externally the fibrous capsule or theca foUiculi. As already stated, two or even three ova may become envelo])ed in a single layer of cells, and thus a single Graafian follicle be formed contain- ing two or three ova. The ova and the membrana granulosa are consequently formed from the germ epithelium, which, as has been seen, consist of cells from, the mesoblast. The membrana propria, the theca folliculi, the stroma, and the vessels are produced from the fetal stroma, which was also originally an outgrowth of the meso- blast. Some excellent authorities, among whom may be mentioned Pfliiger and Kolliker, believe that Graafian follicles and ova are pro- duced after birth ; others equally reliable, as Bischoff and Waldeyer, deny this. Ovulation. ^ — The function of the ovaries is primary in the process of reproduction. Their physiological activity precedes the uterine functions, and continues, as a rule, until the menopause, and possibly after it. Hence the functions of the other sexual organs appear to be responsive to the influence of the ovaries. There are, however, differences of opinion concerning this matter. Observations have been made which show that ovulation and men- struation occur independently of each other, in exceptional cases at least, and a high degree of importance has been given to that appar- ently independent action ; but such irregularities are the exception, not the rule. There are facts in abundance to prove that, when the ovaries are absent or rudimentary from birth, the function of the DISEASES OF THE OVARIES. 447 litems is never established, and the removal of the ovaries after puberty arrests nieustruation in the majority of cases. All that we know regarding the influence of the ovaries upon development of the individual, and the exercise of the sexual functions tliroughout the reproductive period of life, points to the conclusion that these organs are the prime movers and controlling agencies, to s])eak fig- uratively, in the sexual system. The simple facts that ovulation and menstruation do not follow each other in consecutive order in excep- tional cases, and that the two functions are occasionally performed independently of each other, do not affect the general rule in physi- ology. Because irregularities occur in the harmonious action of the sexual organs, their independence need not be doubted. The same natural order of phenomena is observed in all processes of tlie human economy. The primary action of an organ that stands at the head of a system sets all the subordinate organs in functional motion. Taking food is the first step in the great process of nutrition, and digestion and assimilation follow in natural physiological order. There are occasional irregularities in the succession of the processes of nutrition, as when gastric juice is secreted in the absence of food in the stomach ; but such events are exceptions to the rule. Certain impressions made upon the brain are followed by definite mental phenomena, but the brain sometimes fails to respond to impres- sions ; and, again, it occasionally acts independently of extrinsic excitants. So, also, an action or function which has been be- gun by a given influence may continue after the cause which pro- duced it has been removed. If we accept the idea that the ovaries are essential to the very existence of the sexual system, and that their ofiice is the highest and the first in the order of events which col- lectively make the complete process of production, it is easy to under- stand that their absence would arrest the action of the whole system. They are paramount, not subordinate, in reproduction, and in the maintenance of the relationship between the general and the sexual systems the ovaries are undoubtedly the most potential agents. The uterus and vagina are superadded structures, rendered necessary by a more complex and perfect sj^stem of reproduction in the higher species. The anatomical and physiological value of the ovaries as factors in the reproductive system suggests an equal distinction in their association with the general system, and in their influence upon it. This correlation has been variously estimated by authors. Dr. Henry Maudsley, in his book entitled " Body and Mind," says : " The organic system has most certainly an essential part in the constitution and the functions of the mind. In the great mental 4-48 DISEASES OF WOMEN. revolution, caused by the development of the sexual system at pu- berty, we have the most striking example of tlm intimate and essential sympathy between the bi'ain as a mental organ and other organs of the body. The change of character at this ])eriod is not l>y any means limited to the appearance of the sexual feelings and their sympathetic ideas, but, when traced to its ultimate reach, will be found to extend to the highest feelings of mankind, social, moral, and even religious. In its lowest sphere, as a mere animal instinct, it is clear that the sexual appetite forces the most selfish person out of the little circle of self-feeling into a wider feeling of family sympathy and a rudimentary moral feeling. The consequence is that, when an individual is sexually mutilated at an early age, he is emasculated morally as well as physically. It has been affirmed by some philosophers that there is no essential difference between tlie mind of a woman and that of a man ; and that, if a girl were sul> jected to the same education as a boy, she would resemble him in tastes, feelings, pursuits, and powers. To my mind, it w'ould not be one whit more absurd to affirm that the antlers of the stag, the human beard, and the cock's comb are the effects of education, or that, by putting a girl to the same education as a boy, the female generative organs might be transformed into male organs. The physical and mental differences between the sexes intimate them- selves very early in life, and declare themselves most distinctly at puberty ; they are connected with the influence of the organs of generation." This much being claimed by so high an authority for the influ- ence of the sexual organs upon the development and function of the brain and nervous system, I may inquire how far the ovaries are re- sponsible for such results. Virchow and others have stated that the ovaries give to woman all her characteristics of body and mind, and I accept the proposition without qualification, feeling sustained in doing so by the fact that, when the ovaries are absent or defective from birth, the characteristics of the female sex are never fully de- veloped. The tendency in the development of those in whom the ovaries are congenitally absent is toward the masculine type of the race. I have seen two such cases, decidedly masculine in their phys- ical and mental attributes, and there are many others recorded in our literature. There are some authors, however, who appear to stand in opposition to what is here claimed. In Dr. GoodelKs pa])er presented to the Pennsylvania State Society, he says, that '' The physical and psychological influence of the ovaries upon woman has been greatly overrated." And again he says, " In the i)opular mind DISEASES OF THE OVARIES. 449 a woman without ovaries is no woman." He then gives his own views which are that, " beyond the induction of sterility and the probal)le absence of menstruation, the deprivation of the ovaries after puberty does not change the character of the woman." Bat- tey, Hegar, Wells, and Peaslee, are given as confirming this doc- trine. The views held by these authors are based upon observations of mature women from whom the ovaries have been removed. This alone is not a trustworthy source of information, because the results obtained up to the present time appear to be quite variable. For example, Dr. T. G. Thomas had one patient who was passive in her sexual relations before her ovaries were removed, but became aggressive afterward. On the other hand, Dr. M. A. Fallen, in a paper read before the American Medical Association, in June last, related the history of a girl who was promptly and completely cured of " hystero-epilepsy " and an incantrollable desire for self- pollution by Battey's operation. It is true, no doubt, that an individual who has been fully devel- oped under the influence of the ovaries, will continue to manifest her former attributes of body and mind after these organs are removed, but it does not therefore follow that the ovaries were negative in the ])rocess of developing and maintaining those attributes. One who has become blind in middle life will talk familiarly and understandingly of objects impressed upon the mind through the sense of sight, but one born blind can not comprehend the beauties of a landscape. This abundantly proves that mental peculiarities may continue after the physical influences which caused them have been removed. Obser- vations made from the opposite standpoint give evidence which leads to the same conclusions. We find that, if tlie ovaries are pres- ent in a given individual, she will manifest the physical and psy- chical peculiarities of womanhood, although all the other sexual or- gans may be absent. Women, well developed in all that is pecul- iar to the sex, have been observed in whom the uterus and vagina were defective, but I have neither seen nor heard of any such per- fection of organization occurring when the ovaries were absent. Ferhaps the strongest argument on this point is the fact that other parts of the general system, when modified by the influence of the ovaries, are rendered capable of performing the major functions of the uterus, as is illustrated in a very striking manner by \dcarious menstruation and abdominal gestation. In this connection, a brief reference ma)' be made to the influ- ence of the nervous system in controlling the functions of reproduc- tion. The full discussion of this question involves problems in phys- 30 450 DISEASES OF WOMEN. iology whic'li have not been solved, and are therefore beyond the scope of tliis work. Whether the higlier nerve-ceutei's are devel- oped to serve the demands of the nutritive and reproductive or<;an- izations, and whether the location of the nerve-centers which preside over sexual phenomena is in the cerebelhnn or the lunibo-sacral portion of the spinal cord, are questions which I am not at present able to answer. It is sufficient for the present purpose to keeji in mind that the sexual organs are dependent upon the general nutri- tive system for organic support, and that they stimulate, depress, or modify nutrition through the ganglionic nerves chiefly, and tliat the portion of the brain which presides over the organic functions also dominates the reproductive organs. We should also recognize the fact that the emotions are in part dependent upon the sexual organs for their development, and on the other hand that the sexual organs are largely affected by the emotions. Metaphysicians agree in stat- ing that the sexual appetence, which owes its existence almost en- tirely to the ovaries, leads to more emotions than any other human tendency, and clinical observations afford good evidence to the phy- sician, that the emotions affect the functions of the sexual organs in a marked degree. Grief, fear, anger, and even great joy are capa- ble of arresting menstruation and probably ovulation also. In view of this great potentiality of the ovaries in developing certain ca])a- bilitics of the brain and nervous system and in influencing their functions, it is evident that, in order to maintain harmonious action of the whole organization, it is necessary tliat the ovaries shall exist in full development and functional activity. On the other hand, these organs which are essential to the well-being of the individual must, when diseased, exercise a potent influence in deranging the brain and nervous system. From a somewhat extended consideration of this subject, I am satisfled that a great many affections of the brain and nervous sys- tem are due to disease of the ovaries. The remote effects of ovarian disease have been observed and recorded to some extent, but not so fully, I presume, as they might be. The tendency of observers has been to attribute certain mental derangements and diseases of the nervous system to the sexual organs in general- or the uterus espe- cially. A little attention to some of the known defects and diseases of the ovaries and their relations to diseases of the brain and nerv- ous system w^ill, I think, materially change that phase of the subject. Imperfect development of the ovaries not only inodifles the phys- ical peculiarities of the indi\4dual, but also retards the development of the higher nerve-centers. The demands of the sexual organs (e&- DISEASES OF THE OVARIES. 451 pecially tlio ovaries) stimulate the brain to a higher development. A very large part of the brain and nerve power is devoted to repro- duction, and if that function is never estal)lished because of the ab- sence of the ovaries, the brain and nervous system are never fully developed. When a woman is deprived of the sexual organs the nutritive system may possibly attain a normal development, but the nervous system does not — it remains upon a lower plane. There is usually mental weakness and often derangement of mind among those in whom the ovaries are imperfectly developed. Among six- teen young single women, that came under my observation in the Insane Asylum, I found twelve who had imperfectly developed sex- ual organs. Some of them had never menstruated at all, and others had done so imperfectly. The history of these cases led to the con- clusion that the defective development of the ovaries was an impor- tant element in causing insanity. They no doubt inherited an in- sane neurosis or diathesis, but the absence of ovarian influence, which favors a higher and more complete development of the nerve- centers, acted as the major-cause in producing the insanity. This is not claimed to be a positively correct deduction, but there is cer- tainly strong presumptive evidence that such was the case. The mental derangement appeared in the majority of them at or about the period of puberty. There was nothing in the size or develop- ment of these patients to indicate any marked defect in the nutri- tive system. The nervous and sexual system alone were deficient. They appeared to have passed through girlhood in a normal way (although not manifesting a high order of mental capacity) until the period when the sexual organs should have begun to exercise their influence in completing the higher development of the nerve- centers. When that failed to take place, the brain became deranged, instead of assuming new activities. Still it is possible that the im- perfectly developed sexual organs resulted from inferior general organizations which were from the beginning of a low type, and that the insanity which followed was due to transmitted lesions, and was not dependent upon the sexiial organs at all. However, the facts appear to favor the opposite conclusion. One thing is certain regarding this subject : there is enough in the nature of the cases mentioned to invite further investigation in order to settle, as far as possible, the relation of the ovaries to insanity and other diseases of the nervous system which occur at puberty. As the period of puberty approaches a considerable number of Graafian follicles (from twelve to thirty) enlarge, the largest reach- ing a diameter of half an inch. In the early stage of development, 452 DISEASES OF WOMEN. it will be remem1)ored, the smallest follicles were found in the corti- cal layer, those of medium size in the middle layer, and still deeper, the larger follicles. These follicles increase in size by the produc- tion of an increased amount of liquor folliculi. This so distends the wall of the follicle as to cause it to project from the surface of the ovary, and to become thinner and thinner until finally it bursts, dis- charging the ovum with some of the cells of the membrana granu- losa, especiall}' those forming the cumulus proligerus. The ovum passes into the Fallopian tube, and through it descends to the uterus. This ripening and discharge of ova is the process of ovulation and occurs periodically, in the human female about every four weeks. As the time approaches in each month for the rapture of a follicle there is an abundant formation of vascular loops in connection with increased growth of the membrana propria, which together with the liquor folliculi distends the wall of the follicle. This distention stimulates the ovarian nerves, and as a result there is an increased flow of blood to the ovaries and other organs of generation. The wall of the follicle, in addition to being distended, also becomes fatty at its most projecting part, and when it is no longer able to withstand the internal pressm-e it bursts and the ovum is discharged. AVhen this rupture takes place there is in the human female haemorrhage from the vessels already spoken of as being found in the interior of the follicle. The amount of blood effused is sufficient to fill the cavity of the follicle. It soon coagulates, the serum is reabsorbed, the haemoglobin becomes h^ematoidin, and after a time the coloring-mat- ter disappears. In short, the same changes, take place in the blood here as when a haemorrhage occurs elsewhere in a closed cavity. The wall of the follicle becomes hypertrophied and convoluted, and later on undergoes fatty degeneration, with the formation of lutein, giving to the structure a yellow color, on which account it has been called a corpus luteum. The corpus luteum spurium by which name the corpus luteum of menstruation is known, reaches its maxi- mum of development at the end of the third week after menstrua- tion, at which time it commences to diminish in size until at the end of the eighth week it is reduced to an insignificant yellowish cicatrix about one fourth of an inch in diameter, but it sometimes may be discovered if carefully sought at the end of eight months. If, however, the ovum which escaped from a given Graafian follicle becomes impregnated, then the process becomes modified in that fol- licle. The corpus luteum is then denominated verum instead of spurium. The differences between the two varieties of coi'pora lutea are of degree not of kind. The changes which take place are DISEASES OF THE OVARIES. 453 the same in both up to the end of the tliird week, then, instead of diminishing, the corpus hitenm veruni continues to grow until the end of the fourth montli when it reaches the height of its develojj- ment. It retains this nuixininni until the beginning of the seventh month when it commences to diminish, l)ut may sometimes still be discovered nine months after delivery. The history of the corpus hiteum is admirably described by Dalton to whose work on human physiology the reader is referred for a detailed account of its forma- tion, and the subsequent changes which it undergoes. LESIONS OF FORMATION OF THE OVARIES. Both ovaries may be entirely absent, or, j)erhaps, it would be more correct to say, entirely rudimentary, or one ma}"" exist alone, or there may be a third one present. When a single ovary is absent the condition of uterus unicornis usually exists, although this mal- formation of the uterus is not necessarily accompanied by an absence of either ovary. The absence of an ovary may be accounted for in different ways ; it may not have been developed, it may have been properly formed, and by some dislocation of the uterus have had its circulation and nutrition so interfered "with as to have caused it to shrivel and be- come absorbed, or it may have become attached to some other ab- dominal organ, and then its absence be only apparent and not real. Several cases are on record in which a third ovary has been found. The most interesting of these is one which is described and figured by Winckel in his work on " Diseases of Women." In most of the instances the supernumerary ovary was found near one or the other of the normal ovaries, and either behind or in the broad ligament. In Winckel's case it was situated in front of the uterus and connected with the posterior wall of the bladder. As Winckel has so well pointed out, these cases of supernumer- ary ovaries are always to be borne in mind in making a diagnosis. A cyst forming in the third ovary as found in his case might be de- tected between the bladder and the utenas, and be mistaken for some other form of tumor. In such cases also the removal of two ov'aries may not prevent conception, the third ovary being in all re- spects normal, and consequently able to discharge ova. So also even after two ovaries are removed, should a third exist a cystoma may form, which will require operative interference. CHAPTER XXY. DISEASES OF THE OVARIES. (CONTINUED.) HYPERiEMIA, ACUTE AND CHRONIC OVARITIS AND PRO- LAPSUS OF THE OVARIES. Inflammation of the Ovaries. — There are two forms of inflamma- tion of the ovaries, the acute and the chronic. These are verv dis- tinctly different so far as their clinical history is concerned. There is another affection closely allied to these which is described by some writers as hypememia. All these are, however, but different degrees of the same affection, though each follows a different course and gives a history peculiar to itseK. This latter fact justifies the con- sideration of the acute and chronic forms, at least, of ovaritis as sepa- rate affections. The third form, hypei'oemia, is not so fully under- stood nor does it stand out so distinctly from the chronic form as to make its description easy. Ovarian Hyperaemia. — While many of the characteristics of ova- rian hyperaemia are like those of ovaritis, there is very good reason based upon clinical evidence, to believe that the two are different both in pathology and clinical history. Ovarian hypenemia, as it is generally observed, resembles many of the so-called functional diseases of the ovary, in that there is de- rangement of function, with symptoms of oi'ganic disease which usually disappear, leaving no evidence that there has ever been any charge of stricture or any products of inflammation. All this dem- onstrates that the pathology is, as the name imj^lies, a derangement of circulation in which there is congestion, and the consequent de- rangement of function M'ith the accomjianying or resulting pain and suffering. The hyperivmia usually affects both ovaries, and, as a rule, extends to the other pelvic organs, after a time, at least. The derangement of function also extends to the uterus giving rise to derangement of menstruation. In fact, the congestion and func- DISEASES OF TDE OVARIES. 455 tional derangements of the uterus are secondary to the ovarian liyperannia. There is much in regard to ])athologj of this affection wliich is inferred from the symptoms, and can not be demonstrated by post-mortem investigation. The congestion may be of long or of short duration, its continuance depending upon the persistence of the causes which give rise to it. If it is well-marked and long- continued, it tends to chronic ovaritis, and, perhaps, to degeneration of the ovaries and premature atrophy. Should the causes which pro- duce the congestion continue active and no treatment be employed, the affection may continue indefinitely. The general health be- comes undermined by the derangement of the menstrual function and the exhaustion of the nervous system ; and if the patient is not relieved by treatment or by improved hygienic conditions, she con- tinues a sufferer until the menopause. With so little that is definite regarding the pathology, one might well ask if the fact is yet established that there is a distinct affection to be known as ovarian hypergeniia. In answer to this, it can only be said that the clinical history clearly points to this derangement of the circulation as the only rational explanation of the i)heuomena presented in these cases. It should be stated here that there neces- sarily must be present in this affection a derangement of ovarian in- nervation as well as hypersemia. In fact, it appears that this de- rangement is the starting-point in the morbid condition. This view of the matter is favored by the affection depending for its origin upon perversion of the emotions in those of nervous tempera- ment. Symptomatology. — Hypercemia of the ovaries occurs most fre- quently among those who are unmarried, or among young widows who have never had children. It does not come on abruptly like an attack of acute ovaritis, as a rule, though it occasionally does so, but is developed rather gradu- ally. Those most liable to this affection are the nervous and emo- tional who live in conditions of life favoring excitation without complete functional action of the sexual organs. I have never seen a case of this kind among those who lived under wholesome con- ditions of life or who were married, bearing and nursing children, and who lived quiet, rational lives. At the beginning there are pain and heaviness in the region of the ovai'ies, usually accom- panied by much nervous disturbance of the nature of irritability and weakness, the patient being easily excited and as easily fatigued. Soon after the appearance of these symptoms the menstrual func- tion becomes deranged. There is usually monorrhagia, which is 456 DISEASES OF WOMEN. preceded by increase of the ovanan jiain. Sometimes the pain is relieved and tiie patient feels niucli better during the nienstmal riow, and for a time after it ceases. In some cases the first synij) torn developed is derangement of the menstrual functicjn, gener- ally too frequent, and too free menstruation. In a word, menorrhagia is the most prominent symptom of ovarian hyperaemia. The free flow being due originally to the ovarian excitation is conservative at first, I believe, relieving the congestion which j)roduced it. I have frequently seen young women, who apparently suflFered from ovarian congestion, recover completely after one or more free at- tacks of menorrhagia. When the excessive menstruation does not reheve the congestion, which it certainly will not do if the causes which produced it are continued, then it leads to antemia and neu- rasthenia, and this state of health may continue indefinitely. There are other symptoms which may be mentioned, as backache and general pelvic tenesmus, increased on walking sometimes, but not always. In the less severe forms of hyjjeraemia of not very long standing, active muscular exercise gives relief not for the time only, but is oftentimes permanently beneficial. There is often irri- tability of the bladder, which is purely nervous. Physical Signs. — There is tenderness on deep pressure made in the iliac regions, not acute, but of that dull character which is pecul- iar to the ovaries. As the disease affects both ovaries, as a rule, there is tenderness alike on both sides. Bimanual examination usually shows tenderness better than ab- dominal pressure, but I have found that iu these cases it is very diffi- cult to grasp the ovaries between the two hands, owing to the fact that the abdominal muscles are tense ; while in the majority of cases there is tenderness if pressure is made upon the ovaries, either through the vaginal or abdominal walls, I have seen many cases in which steady but not too heavy pressure in the iliac regions gave re- lief. Perhaps these were cases of the kind that Charcot calls hys- tero-epilepsy, in which the convulsions are relieved by pressure upon the ovaries. I have seen some of Charcot's cases, and believe them to be ovarian hyperaemia. The physical signs obtained are rather negative, but by excluding the evidence of other ovarian affections, and takhig the history into account a presumptive diagnosis can be made, and the diagnosis will be confirmed by the subsequent history. Under treatment and im- proved moral and physical hygiene, recovery will take place much more promptly and completely than in chronic inflammation. In connection with this affection of the ovaries, especially if it DISEASES OF THE OVARIES. 457 has existed for several months, there is usually congestion of the uterus and vagina which yields promptly to treatment. Prognosis. — The great majority of patients recover under appro- priate treatment. In fact, many of them recover after the causes are removed without any treatment whatever. This will be seen in the history of the cases given further on. Causation. — Overstimulation of the emotions in tliose of a nerv- ous temperament is one of the chief causes of ovarian congestion. This is operative among those who are not usefully employed, but are permitted or even encouraged to turn their attention to the procreative function while they are still undergoing development. Stimulating tonics which create an appetite which is not satisfied with food will cause gastric congestion, and all the consequences which arise therefrom. In like manner stimulating tbe sexual appetence of unoccupied emotional young girls by evil influ- ences or improper associations leads to ovarian congestion. Those who have lived in the proper exercise of the sexual function, but have been abruptly cut off from normal gratification, are prone to ovarian congestion. Indulgence beyond normal gratification is also said to have produced the same result. All these causes are, to a great extent, psychical, but ovarian congestion may be produced by purely physical causes. It may be secondary to endometritis, seden- tary habits, and constipation, which may interrupt the free circula- tion in the pelvic organs. It is rare, however, that cases of ovarian congestion can be traced to such causes. Treatment. — The removal of the cause, when that can be accom- plished, is, as I have already said, often sufficient to give relief. The termination of an engagement in marriage has cured the men- orrhagia in many cases, and complete recovery has followed when pregnancy occurred. A like good has been brought about in younger patients by di- recting the attention to something other than self and the feelings and emotions. A change from books and society to the woods and fields, and out-door occupation in the way of amusements should be employed. Bathing is useful — either sea-bathing or the shower-bath — if the patient is strong enough to bear it. Tonics to restore the general strength, nux-vomica being the most efiicient; counter- irritants, ergot and bromides complete the list of therapeutic agents. The tonic and ergot should be given through the day, and the bromide at night to seciu-e rest and sleep. Acute Ovaritis. — This is quite distinct from other ovarian affec- 458 DISEASES OF WOMEN. tioTis, because it is probably always tlie result of some special cause — usually a specitic poison, such an gonorrlKx-al infection, ])uc'rperal septicaemia, or some constitutional condition like that wliieli exists in the erni)tive fevers and in acute rheumatism. It may also be traumatic, though that is rare, except when the ovaries become in- volved in a general pelvic inflammation due to an injury. There has been and still is much confusion of tlioui^dit regarding the pa- thology of ovaritis. Some of the contiicting accounts arise, I presume, from confounding acute and chronic ovaritis and ovarian hypera?mia.% There is, no doubt, so marked a resemblance between these three affections, and they are so often associated that it Ls im- possible to differentiate them in many instances. Still, between the typical causes of each, met occasionally in practice, the distinction can be easily made. The acute affection runs its course rapidly, and terminates either in death or a subsidence of the acute inHaminatory symptoms and a damaged state of the ovaries. There are well-defined symptomatic forms, and the changes of stmcture which result in connection with the clinical history are such as belong to acute inflammatory action. In chronic ovaritis there are, on the con- trary, changes which take place much more slowly, and are not marked by the same definite products of inflammation. In conges- tion of the ovaries there are no tissue changes. It appears to me that acute and chronic ovaritis are as well deflned, both in clinical history and anatomical changes, as acute and chronic nephritis. There is still much need of more observation and careful comparisons of the clinical history and post-mortem aj^peai'ances in order to settle more definitely the pathology of acute ovaritis. Paiholocfy. — When ovaritis occurs in connection with the puer- peral state, only one ovary is affected as a rule, AD the tissues of the ovary take part in the congestion, which is the first morbid change produced. Following the congestion there is swelling from the transudation of serum, which is often of a reddish color. The inflammation involves all the tissues ; the vesicles, stroma, parenchy- ma, and the envelope, and not infrequently the fimbriated extremity of the Fallopian tube is involved, and the peritonjieura around the ovary. Then the ovary becomes surrounded with the exudate, so that from the gross appearances it is not possible to tell whether the ovary or the peritonfeum was first attacked. The changes in the ovar^" are, in addition to general serous effusion, destiniction of the vesicles from effusion or purulent infiltration ; sometimes one large abscess is formed in the ovary which destroys most of the tissues ; in other cases a number of small abscesses are found. In short. DISEASES OF THE OVARIES. 4:59 acute ovaritis is general as a rule, but occasionally partial ovaritis occurs. From what has been said, it will aj^pear that ovarian intiani- iiiation is, in its morbid anatomy, simihir to adenitis generally. The congestion, serous effusion, suppuration, the formation of single or multiple abscess, and plastic exudations on the free surface of the ovary are the usual changes. These changes are manifested in dif- ferent degrees at various parts of the ovary, due in part to the course which the disease follows, but more especially to the different stract- ures or elements which compose the ovary. In addition to these pathological changes, there are others which may or may not occur. There are prolapsus of the ovary and adhesions to neighboring organs. The abscess may open into the rectum or the peritoneal cavity, or find, its way into the lymphatics or veins, w^hich are often dilated ; quite frequently the abscess does not discharge at all, but remains encysted. Symptomatology. — There are both local and. constitutional symp- toms in acute ovaritis. There may be a chill or rigor, followed by fever, nausea, vomiting, and pain more or less acute. The acuteness of the pain appears to be greatest when the peritonseum is affectedo There is marked disturbance of the nervous system, shown by irri- tability and anxiety, but no delirium ; not infrequently, however, hysteria and, in a few cases, mania have been developed. The only difference which I have noticed between the symp- tomatic form of ovaritis and other acute pelvic inflammation is that in the former the nervous symptoms are more marked. In mild forms of this affection the constitutional disturbances are less severe ; still there is an elevation in the temperature, increased frequency of the pulse, and deranged primary nutrition. The appetite is poor, and there are dyspepsia, flatulence, and constipation. The symp- tomatic form subsides to some extent after the first few days, and the formation of pus reawakens the general disturbances. There may be a chiU, followed by perspiration, or irregular rigors may occur, and the pain may return more acutely. The local sjTnptom is pain, w^iich is often circumscribed, the patient being able to point out the exact spot in the iliac fossa where the pain starts, and from which it radiates, and where the tenderness is felt on pressure. There are pelvic tenesmus, and a frequent desire to urinate, and, if the left ovary is the one affected, there is often excruciating pain during defecation. Physical Signs. — There is acute tenderness on pressui-e, more definitely located than in pelvic peritonitis. Sometimes the ovary can be felt through the abdominal walls. This is frequently the case 460 DISEASES OF WOMEN. when the ovary is fjreatly eiilarojed by the products of the infhuu- mation, and is tixed high up by adhesions. By the vaginal touch heat and tenderness are detected, and the size of the intlanied ovary can be ascertained. By very gentle manipulation the uterus and the ovary also, perhaps, are found to be movable to a limited degree. The location of the tumor, its partial mobility, its form, and that it is not connected directly to the uterus all go to aid in making the diagnosis. Sometimes the ovary can not be easily felt ; then the rectal touch w^ill enable the examiner to locate it. The bimanual examination Avill also be of very matenal assistance in forming a cor- rect opinion. Differentiation. — Owing to the fact that, in the present state of science regarding this affection, the diagnosis is not at all times easy to make, it is necessary to mention the conditions which resemble it, and point out the differences which help to define and distinguish acute ovaritis from them. Acute ovaritis is easily distinguislied from chronic ovaritis and hyperaemia by the absence in the latter of symptomatic fever. Much aid is obtained by the history which nearly always presents some of the causes which give rise to acute ovaritis. It may be distinguished from pelvic peritonitis and cellulitis by the physical signs. The fixation of the uterus and the more diffuse distribution of the inflammatory products being most marked in the cellular and peritoneal inflammation. In cases of acute ovaritis that are complicated with cellulitis or peritonitis, the differential diag- nosis can not be made upon the living subject. That these affections have occurred together can be determined, but which was the ]3ri- mary affection can only be surmised from the history. Progno-ns. — When suppuration occurs, and the abscess opens into the peritoneal cavity, a fatal termination should be expected. Death may also occur from septicaemia when the contents of the sac of the abscess find their way into the lymphatics or veins. This, I believe, is more likely to occur when there are a number of small abscesses with thin walls. If the accumulated pus is discharged through the rectum or vagina, or if the abscess becomes encysted, recovery may take place. The ovary is, of course, damaged or de- stroyed, but, if one ovary is left in a normal state, the patient may regain health and bear children. In some cases of chronic suppura- tion, in cases where the pus is discharged through the rectum or vagina, or is walled in by peritoneal adhesions from plastic exuda- tion, relief may be obtained by surgical means to be referred to when discussing the treatment. DISEASES OF THE OVARIES. 461 Causation. — Tlie causes of acute ovaritis iiave already been named. Puerperal septic absorption and gonorrhojal infection are the chief causes. Lawson Tait has called attention to the eruptive fevers and acute rheumatism as giving rise to acute ovaritis, and my own observations agree with his in the main. While I have not seen ovaritis occurring in connection with rheu- matism, I have seen several cases caused apparently by the eruptive fevers. I have never seen ovai'itis due to traumatic causes, still I can believe that such might be the case. Treatment. — In regard to the management of acute ovaritis, I may say, in brief, that the cases that have come under my care have been treated exactly as I have treated pelvic peritonitis or cellulitis. I have not discovered any special line of management as specific medication ; hence, to avoid useless repetition, I must refer the reader to the treatment of the above-named affections. 1 may remark in passing that, knowing that the causes are specific in the majority of cases, care may be taken to prevent the occurrence of ovaritis by judicious treatment of the affections which give rise to it. There is room for doubt, however, if much can be accomplished in this way. Chronic Ovaritis. — This form of inflammation is characterized by the slow progress of the affection. It does not come on abruptly hke an acute attack, but more gradually, and the morbid changes of structure resulting from this process are also developed gi-adually. While hypersemia of the ovaries and acute ovaritis may terminate in chronic ovaritis, and in that way the beginning of the affection may be acute and rather sudden in its onset, yet that is exceptional. Judg- ing from the cases which have come under my own observation, it ap- pears that the affection is subacute from the beginning, and has a clinical history more like the chronic inflammations and degenera- tions of other glandular organs, as for instance the liver and kidneys. Pathology. ^-Th& gross appearance of the ovaries which I have seen affected with chronic ovaritis varies considerably, the variations being due perhaps to the portion of the structure involved, or the stage of the affection at which the examination was made. Three rather distinct general appearances have been noticed. In one the ovary is not very much enlarged, but is matted in appearance as if irregularly hypersemic, and the surface is quite uneven from en- largement of a number of cysts. On section it is found that many of the cysts are enlarged or overdistended and their contents differ in color, some being clear or normal, some dark as if filled with 402 DISEASES OF WOMEN. bloody senim, and others of a dark-grayish color, more like the con- tents of a small abscess. In other ciuses the ovary is enlarged to nearly double its normal size, and is soft and appears oedematous. The surface is as smooth as normal, but here and there distended follicles are seen and patches which might be either imperfect scars, or scars after rupture of a follicle in which there have been minute ti-ansudatiuns of blood. In the third form the ovary is smaller than normal, and is irregular on the surface and alto- gether indurated. The diminution appears to be the result of a scirrhosis. In either of the three conditions the peritonaeum around the ovary may be thickened, and exuded lymph may l>e found on the surface of the ovary and the fimbriated extremity of the tube. When such exudates are found there is generally a history of an acute attack which took place in the early part of the ati'ection. This also leads me to believe that mixed cases are not uncommon, that is, cases of chronic ovaritis with circumscribed pelvic peritonitis, the peritonitis preceding or being intercurrent in the progress of the ovaritis. The pathological changes in the histological structures of the ovaries have led to the conclusion that there are two forms of chronic inflammation of the ovaries, the division being based upon the structures first affected. Slavjonsky states that there are two prin- cipal forms, the parencliymatous and the interstitial. In the paren- chymatous form tlie gland tissue is the site of the inflan)matory action. The gross appearance of the ovary corresponds to that form first described above. The ovary is not enlarged at first, microscop- ical examination shows hypersemia and destruction of the blood- vessels around the follicles. The liquor folliculi is usually turbid and at times appears purulent. The young and imperfoctly devel- oped follicles are first attacked as a rule ; and their ei)ithelial cells are changed, becoming in some binucleated, in others undergoing granular degeneration. In the more marked inflammation of these immature follicles germinal vesicles can not be found. The inflam- mation appears to begin at a given point in the gland tissue, but as the process continues the other follicles are involved, and finally the tissues around the follicles become congested and thickened from hyperplasia of its elements. Interstitial inflammation begins in the stroma of the ovary. This form of ovaritis causes the large ovary already mentioned. The tissues are soft and oedematous from the ti-ansudation of serum which becomes turbid. The blood-vessels are distended showing hypersemia which must have existed a long time. In addition to DISEASES OF THE OVARIES. 463 the oedema and congestion, and following in tlie order of develop- ment of the products of the inflammation, the connective-tissue cells are increased in number and diminished in size, and a number of cells like white blood-corpuscles and occasionally pus are seen, the latter in small quantit}' and irregularly distributed. I am indebted to my colleague Prof. Frank Ferguson, for these microscopical ap- pearances and the pathology here given, obtained by the examina- tion of inflamed ovaries which I have removed. It appears that no matter what part of the ovary becomes affected first the inflammation will in time extend to the rest of the organ, so that interstitial and parenchymatous ovaritis coexists in cases of long standing. The final result of the inflammation is to cause partial or com- plete change of the tissues of the ovary. The condition described as atrophy of the ovary is in many cases the result of chronic in- flammation. Sym,j)tomatology. — The history of chronic ovaritis includes both local and constitutional symptoms. The constitutional derange- ments are not acute, but are usually marked by depression of the nutritive and nervous system. The reflex derangement of the di- gestive organs is manifested by capricious appetite, nausea, and sometimes gastralgia. The bowels are usually constipated and tympanitic. There is usually nervous debility attended with great emotional disturbance. I believe that I have seen more marked de- rangement of the brain and nervous system caused by chronic ova- ritis than by the reflex influence of any other affection of the sexual organs. These constitutional symptoms are progressive, the patient's general health becoming more impaired month after month as the disease advances. The local manifestations are pain and derange- ment of menstruation. There is often menorrhagia, in fact that is the rule but in cases of long standing I have seen amenorrhoea. The ovarian pain is usually increased for several days before menstrua- tion, and is relieved to some extent when the flow has lasted a day or two. The menstrual pain is much more severe and persistent if there is a uterine disease accompanying that of the ovaries. The ovarian pain varies according to the ovarian tissue affected. When the stroma alone is the site of the disease the pain is less severe. Much more suffering is experienced when there is circumscribed peritonitis or salpingitis. All these symptoms are aggravated by standing, walking, riding, or sitting in a stooping position for any great length of time. Most comfort is obtained by the recumbent position. Sexual excitation 4GJ: DISEASES OF WOMEN. and coitus cause so niueli suffering that tlic patient shrinks from both. There are exee])ti(jus to this, but not many. Physloal Signs. — The ovaries are tender to tlie touch and the pain excited by ])ressure lasts for a long time as a rule. The char- acter of the })ain excited by the touch is ovarian in character. When the ovary is enlarged or changed in form it can sometimes be nuide out by the bimanual toucli. The ovary is usually moval)le, and its separation from the uterus can be distinguished. It will be observed that the symptoms and physical signs of chronic ovaritis closely resemble those mentioned as occurring in ovarian hyjier- aimia. The fact is that the two affections have many features in common, Ilyperoemia being a part or the initial stage of inflamma- tion the manifestations of the two affections are alike. Between ovaritis and ovarian neuralgia there is a close resem- blance, but the differences are also equally marked. In neuralgia there is no evidence of inflammation, it is not continuous, and very often the ovary is not tender. The diagnosis can only be made by a due consideration of the history as related to the cause, duration, physical signs, symptoms and progress of the affection. Prognosis. — If the patient has the good fortune to be placed early under treatment, the chances of recovery are favorable. This is still more certain if only one ovary is affected. The disease may go on in one ovary to complete destruction of the organ by hyper- plasia of its cellular tissue and atrophy of its glandular elements, and after this premature atrophy all suffering may subside except occasional neuralgic pain : and the other ovary may perform the ovarian function. In case the disease is complicated with in- flammation of the neighboring pcritonoBum, and there is marked destruction of tissue from the inflammation, and suppuration takes place, relief can only be given by removing the ovaries. There is not a great mortality from this affection : I have never seen a fatal case, but I have seen several in which life was not worth living. Causation. — Ovaries that are not fully develojied are ]iredisposcd to chronic inflammation. I risk making this statement for three rea- sons : 1. In the cases that have come under my care there has been evidence of imperfect develojiment of the sexual organs shown by the general state of the patients. Perhaps it would be more correct to say an arrest of growth rather than an arrest of development. 2. Pathological investigation shows that the young and immature follicles are first affected. 3. Because the general law is that, in all cases of imperfection of development and growth, there is a pre- DISEASES OF THE OVARIES. 4G5 disposition to disease. In such organizations the chronic ovaritis may come from any of the causes which produce ovarian hypersemia, and which have ah-eady been enumerated. Imperfect invokition of the sexual organs following parturition, either premature or at term, is no doubt the starting-point of chronic ovaritis. This is to be jDre- sumed from the fact that some cases can be traced to a preceding confinement or miscarriage. Long-continued endometritis may cause chronic ovaritis. This has been claimed on the theoretical ground of anatomical resemblance or identity of the endometrium and the glandular stmcture of the ovaries. This in itself would not be suf- ficient reason for such an opinion, because we know that extension of the inflammatory process from one organ to another is not influ- enced by similarity of tissue. But the fact is correct, apparently, though the theory explaining it may be fallacious. I have carefully recorded the history of a number of cases in which there existed endometritis first, and then chronic ovaritis appeared. It is possible, also, that the causes which give rise to acute ovaritis might, under certain circumstances, give rise to the chronic form. Of this I have no personal knowledge. Treatment. — Every means should be employed to improve the general health of the patient, and relieve, as far as possible, the local pain and general nervous excitement. Tonics, generous diet, and open air — when the patient can be taken out — and bromides to quiet ex- citement. When the bromides are required for too long a time, other remedies may be used, such as lupulin, camphor, valerian, or cannabis Indica. Counter-irritation by blisters, iodine, and the actual cautery often prove valuable. The bowels should be kept free, and the patient should maintain the recumbent position; in case the pain is aggravated by locomotion, she should have the necessary exercise by massage. In regard to alteratives, which are expected to act more directly upon the ovarian inflammation, I can only say that I have apparently seen benefit derived in cases that were treated early in the progress of the disease. I prefer to give small doses — say, a fifteenth of a grain — of the bichloride of mercury thi*ee times a day for" a week or two, and follow that with iodide of iron or iodide of sodium — the latter in case the patient's strength is not greatly re- duced. The chloride of ammonium and the chloride of gold have been recommended, but I have not seen any benefit derived from them. If this plan of treatment fails to give relief, and the patient is suf- fering so that her life is useless, the ovary or ovaries should be re- moved. In case that only one ovary is diseased, and the other is 31 466 DISEASES OF WOMEN. normal, the affected one only should l)e removed. To decide which course to [)ursue is often dilMcult, and must always depend upon the judgment of tlie operator to decide while operating. So far as I can learn, there is less likelihood of erring in removing both. Many of the cases in which one ov^ary was removed have had subsequent trouble mth the other. Displacement of the Ovaries. — The ovaries have been found dis- located in a variety of ways. Cases are recorded in which the ova- ries descended through the inguinal canal after the manner of the testicles. The most interesting of these is one reported by Percival Pott, who removed both ovaries that were found in the usual posi- tion of an inguinal hernia; and still another is mentioned by Tait, in which the ovary found its way outside of the inguinal ring, and there developed a cystic tumor, which was removed by a S])anisli surgeon. The ovaries have been found dislocated laterally and high up in the pelvis. They are, in such cases, usually fixed in the malposition by adhesions. Hart and Barbour mention a case seen in the practice of Prof. Simpson, in which an ovary was found in the infundibulum of an inverted ovary. The following cases were published in the " St. Louis Cour. Med.," April, 18S6,\v J. C. Tedford : An Ovary expelled from the Anus. — The patient, Mrs. S., £ged about twenty-eight years, had been married nearly ten years, and had had tlii-ee children, all now living, and three miscarriages, occur- ring eacb time at an early period of uterogestation. "While being treated for inflammation of the left ovary, metritis, and retroversion, November 27th, a sound, meeting no obstruction, was introduced four inches into the uterine canal. January 9th a small foetus was expelled. January 14th she asked her husband to assist her up to the chamber. This he did, when she was taken with a severe tenes- mus or disposition to strain, and had severe pains in the abdomen. As she expressed it, she could not resist the straining efforts until a tumor was expelled from the anus. I was sent for, and went direct to her bedside, and found her lying upon her side, and a tumor, as above stated, protruding from the anus, very red in color. It did not seem large enough to be the womb ; but, to make a start toward a solution of the case, I introduced my finger into the vagina, and found the womb all right, but higher up in the peh-is than com- mon for it, and turned to the side. I then introduced my finger into the rectum, and discovered that the tumor had a pedicle extending up into the rectum to a point almost as high as could be reached ^atli the index-finger, but, by finn pressure upward, I could feel the pedicle pass over a shelf, as it were, out of the bowel through a rent DISEASES OF THE OVARIES. 467 in the rectum, as I then supposed it to he. Thi« shelf over which the pedicle came felt to he iiia&sive and thicker just under the ])edi- cle than at any other point in the walls surrounding it. The tumor itself seemed to he much larger at one end than at the other. It was, as l)efore stated, red at its largest end, and faded in color toward the smaller end, and was quite solid to the touch. I could make nothing out of the tumor hut an ovary. Dr. Faulk confirmed my diagnosis, and ligated and cut away the tumor or cystic ovary. This prolapsus was not attended at any time by any great degree of haem- orrhage, but the operation was followed by a constant discharge of bloody, watery fluid from the rectum. As stated before, the perito- neal coat of the expelled ovary was very red and cone-shaped ; the further from the womb was the larger, perhaps, one and a quarter or one and a half inch in diameter, tapering down at the other end to nearly the size of, or perhaps a little larger than, the natural ovary, and more solid. On opening the cyst, it was found to be tilled with an almost transparent, whitish substance, tinged a little yellow, and semi-solid in consistence. This substance filled the tumor from one end to the other, showing the ovary to be in a cystic con- dition throughout. The coat of the cyst under the pentoneal coat was of a yellowish white color, and quite firm in texture. The pa- tient was put upon a treatment of opium and quinine internally, and antiseptic washes for the vagina and swabbing of the rectum with the same solution. Later, a second seeming tumor appeared to come out, and was a direct continuation of tissue from just above the pedicle of the for- mer operation. General peritonitis gradually advanced, with con- stantly increasing tympanites, until January 20, when death quietly closed the scene at 3.15 p. m. Post-mortem twenty-four hours after death. The womb and broad ligaments were of a dark-red color, and relaxed in texture. The left ovary was absent, but the stump from which it had been cut was very conspicuous, and had at some period after the ligation and amputation of the ovary slipped out from the ligature into the pelvic cavity. The rectum and lower portion of the colon up as high as the lower ihac fossa were quite solid and firm to the touch, as if filled nearly full of something. What was that something i The ligature upon the stump or pedicle showed not only the point of entrance of the ovary into the bowel, but showed as well that that portion of the bowel was invaginated. This gave light upon the coming down of the second tumor into the rectum on the third day after the first operation. 408 DISEASES OF WOMEN. Such cases are so very rare that they are of little interest except as curious tliin<;.< wliich may ha})pcii. Prolapsus of the Ovaries. — Downward dislocation of the ovaries is (juite a coniinon atfcctiou compared with all the other displace- ments. It is the only atfection of this class wliich has an interest to the gynecologist derived from the frequency of its occurrence and the great suffering to which it gives rise. On that account it de- serves more than a passing notice, such as I have given to the other forms of displacement of the ovaries. Prolapsus of the ovaries I have described as occurring in two degrees — complete and inc(jniplete. This classification is based upon the fact that displacements of the ovaries must in practice have the natural division. In the incomplete form the ovary has simply de- scended from its normal position until it has reached the side of the sac of Douglas or the utero-sacral ligament, where it lodges. In the complete form the ovary rests in the most dependent portion of the sac of Douglas. Fig. 189 shows the position of the ovary in com- FiG. 189. — Ovary displaced and bound down in the cul de sac by adhesione. ro, right ovary ; lo, left ovary. plete and incomplete prolapsus, and the relation of the prolapsed organ in relation to the uterus and sac of Douglas. The figure also shows what is sometimes found in practice — namely, complete prolapsus of one ovary and incomplete prolapsus of the other occur- ring in the same suhject. While prolapsus of both ovaries in dif- fering degrees, or both in the same degree, may occur, I more fre- quently find one displaced, w^hile the other is in its normal position DISEASES OF THE OVARIES. 469 The left is the one most frequently disiilaced, or else it causes the most suffering, and on that account attracts more attention than the right, and is oftener discovered. Prohipsus necessitates a stretching of the supports of the ovary, or it may be an elongation from an increase of tissue, the result of hyperplasia or new development. Prolapsus does occur without complications or coexisting aiiections, which cause the displacement. Such cases are not very common, and they are probably the result of arrest of development. In many cases, perhaps the majority, there is some accompanying affection which has some part in the causation of the prolapsus. The ovary itself is often enlarged from inflammation or some degenerative changes. In other cases the sup- ports of the ovary are elongated from imperfect involution after con- finement. Retroversion of the uterus is also frequently associated with prolapsus of the ovary. A not uncommon and a very unfor- tunate complication is the formation of adhesions from peritoneal inflammation. Syinptomatology . — The degree of suffering arising from disloca- tion of the ovaries is extremely varying in different cases. This is due largely to the fact that, if the ovaries are quite normal and sim- ply displaced, but little inconvenience is experienced by the patient. It is rare to find this state of things, because the ovaries are often diseased, or else displacement soon leads to congestion, tenderness, and pain. As a rule, then, in displacement of the ovaries there is pelvic tenesmus and pain on walking or standing, relief from which is obtained by the recumbent position. In this the history differs from inflammation of the ovaries. There is usually backache and pain along the thighs, and pain and tenderness during and after sexual intercourse. There is pain after defecation, especially when the left ovary is displaced, which is most frequently the case. This pain is peculiar and, I believe, diagnostic. It comes on during or imme- diately after the action of the bowels, and continues for an hour or two. It is a dull, aching pain located in the region of the ovary, and radiates to the abdomen. It produces in many cases faintness and nausea, compelling the patient to lie down until it subsides. It is easily distinguished from the acute, smarting pain due to haemor- rhoids or fissure of the anus, on account of its location and character. There is in some cases derangement of menstruation, usually menor- rhagia. The pain in the ovary is generally aggravated at the men- strual period. The constitutional symptoms are generally produced from the confinement of the patient, made necessary by the suffer- ing caused by taking active exercise. There is often headache, 47(1 DISEASES OF WOMEN, mental depression, indigestion, and aniemia, ending in geuenil de- bility. It should be understood that the symptoms alone will imt suffice to make a diagnosis, because in many cases they arise more directly from the condition of the ovary rather than from its mal- position. Phi/iuld be tried. Pregnancy in the uterus bicomis may be detected by finding the other hora of the uterus, and perhaps the ovaries may be found nor- mal. These conditions are rare, and will not frequently come up as questions of diagnosis in ovarian affections. Small, subperitoneal fibroids of the uterus differ from ovarian cysts in being firm to the touch, and generally accompanied with enlargement of the uterus and menorrhagia. They are, when small, usually united closely to the uterus. An ovarian cyst is likely to be mistaken for a fibroid of the uterus when it is very tense and adherent to the uterus by inflammatory adhesions. Here, again, time will determine, because the ovarian will grow faster than the uterine tumor, and will show its characteristics more clearly the larger it grows. A fibroid tumor of the ovary can not be distin- guished from a tense ovarian cyst or a fibro-cyst of the ovary in all cases by physical signs, but the history will help materially in mak- ing a diagnosis, and, when the fibroid becomes large enough to rise out of the pelvis, its solid character will be easily made out. Xeither can a fibro-cyst of the ovary be distinguished from a multiple cystic tumor in which the cyst-walls are very thick. But the diagnosis of the exact composition of such tumors is not of any practical importance in relation to treatment. From what has been said it will be seen that the question to be OYSTIO TUMORS OF THE OVARIES. 493 decided is, Whether the tumor found in the pelvis is ovarian or not ; and, when that is settled, the next question which arises is, What is tlie nature of the tumor? If it can be determined that the tumor belongs to the first class of ovarian neoplasms, that will suffice for such cases. It is otherwise in tumors of the second class, because in malignant affections it is important to make a diagnosis early. If the tumor is of the first class, no harm can come from waiting, while, if it is of the second, surgical interference may be necessary while the tumor is yet small. The physical signs of malignant ovarian tumors will be spolcen of in another chapter, but I may briefly state here that the density and irregularity of outline, so commonly found in malignant disease elsewhere, are wanting in the cystic tumors of the ovary. The constitutional disturbances are usually developed early in malignant diseases, while it is otherwise in the benign forms. Pelvic hematocele, pelvic peritonitis and cellulitis may, after the acute stage of these aiiections has subsided, present certain physical signs, which may lead one to suspect an ovarian cystic tumor. But the history of such aifeetions will put the diagnostician on his guard, so that time may be given to see whether the tumor which has been discovered grows, as it will do if it is a cystic ovary, except in rare cases of an ovarian cyst arrested in its growth by inflammation or other causes. Physical Signs in the Second Stage. — By the time that such a tumor has escaped from the pelvic to the abdominal ca\dty, and at-, tracts attention by its presence there, it wdll have attained a size equal to that of the gravid uterus at the fifth month of gestation. In patients of spare habit it might be noticed sooner, but quite as often it escapes notice until a much later period. The physical signs which are of most value to the diagnostician in the second stage are enlargement of the abdomen, especially of the lower poii;ion ; some irregularity in the form of the abdomen, one side being larger than the other, and the lower being larger proportionately than the upper ; the tumor is Avell defined and movable in the cavity of the abdo- men, most freely from side to side. It is elastic and fluctuating, the fluctuation extending through the whole tumor if a mono-cyst, while, if a multiple cystic tumor, the fluctuation may be limited to sections of the tumor. The tumor does not change its form to any extent when the position of the patient is changed, neither does the form of the abdomen change. It is attached to the pelvic organs, and, if drawn upward, will drag the broad ligament up with it. The gross and mici'oscopic appearances and chemical composition of the 4'J4 DISEASES OF WOMEN. fluid ol)tainc'd by aspiration are also to be regarded. The contents of the cyst are characteristic, to some extent, of the affection, and Anally tlie presence and appearance of the cyst as seen after open- in<^ the abdomen. The signs are very few, and neither of them alone is diagnostic. In fact, each of them may be found in other conditions than cystic ovarian tumors ; hence arises the difficulty of making a diagnosis. The signs and the means of detecting them may now be discussed. By inspection the increased size of the abdomen is detected. In the second stage this is most marked at the lower portion. The increase in size may be uniform, the two sides being alike, or one side may be larger than the other, and in some cases there is an irregularity of outline of the tumor, which gives a nodular appear- ance upon inspection, and Avhich is also apparent to the touch. A tumor, large enough to be noticeable in the abdomen, is usually in the center, and, when it is eccentric, it is because of adhesions, as a rule. The irregular outline or nodular appearance is indicative of a multiple or multilocular tumor. By palpation the tumor can usually be distinctly outlined. This is always the case, unless the tumor is very flaccid, and there is much fat in the abdominal walls, or the bowels are distended, but it is rare that these two conditions are found together. By grasping the tumor in both hands, it can be moved from side to side in the abdominal cavity. It can l)e felt sliding about under the abdominal walls. When there are extensive adhesions, this valuable sign, mobility, is wanting. By inspection the mobility may be detected by causing the patient to take deep inspirations and expirations, which -w-ill cause the tumor to move up and down beneath the abdominal walls. This movement will be absent if there are adhesions. The vaginal touch may detect a portion of the tumor in the pel- vis, or may show that the round globular mass rests on the pelvic brim. The uterus can be made out, in a large number of cases, as normal, and not directly connected with the tumor, although it may be displaced. Beyond this, the touch per vaginam only gives valua- ble negative evidence. Palpation also shows that the tumor is clearly outlined and easily distinguished from the neighboring organs in some cases. When the cyst is tense, the tumor can be easily out- lined, but when flaccid, as often occurs, it is not by any means easy to map out its boundaries. Percussion assists in outlining the tumor when it is not clearly defined to the touch. The flatness on percussion over the tumor CYSTIO TUMORS OF THE OVARIES. 495 contrasted with the tympanitic resonance of the intestines, will indi- cate its size and position. The consistence can be determined by palpation, whether solid and very hard, solid and soft, or fluid and fluctuating. Fluctuation, as a sign of encysted fluid, may be obtained in several ways. If the tumor is a monocyst and is large enough to touch the walls of the abdomen on both sides, diametrical fluctuation can be obtained by placing the fingers upon one side, and percussing diametrically oj)- posite. The fluctuating wave will be easily found if the contents of the cyst are markedly fluid. If the tumor is divided into several sacs, fluctuation can only be obtained by j)alpating sections of it. Resting the fingers of one hand at one point on the abdomen, and percussing at another point a little distance from that at which the fingers rest, a surface wave will be produced. In case the fluid is semi-solid, and does not give the clear wave on percussion, fluctua- tion may be produced by placing the fingers of both hands upon the tumor some distance apart ; then, by making pressure with the fin- FiGS. 196, 197. — Area of dullness in ovarian tumor and in ascites (Barnes). gers of one hand, the contents of the cyst will be pressed under the fingers of the other. This is fluctuation by displacement, not by the wave produced by pressure. The fact that fluctuation is limited and does not extend through- out the whole abdominal cavity is most valuable evidence that the fluid is encysted. Further evidence of this is also obtained by an- other sign, that is, the tumor does not change its form when the position of the patient is changed. By turning the patient first on 496 DISEASES OF WOMEN". one side and then on the other, it will be observed that while the tumor may gravitate to the lower side it does not change its form. In the second stage it can be ascertained that tlie tumor ifi at- tached to tiie l)i-t>ad ligament. This sign is obtained l>y passing the finger of one hand into the vagina and then pnsliing up the tumor with the other. By this means the tumor will be observed to drag upon the broad ligament. In I'egard to the signs obtained by an examination of the con- tents of the cyst, it may be said, that it is not often that this need be resorted to in the second stage, but when it is, the reader should turn to the descri])tion of the contents of ovarian cysts for all de- sired information on this point. The physical signs of ovarian and other abdominal tumors obtained by laparotomy are, of course, peculiar to each. The de- scriptions of these appearances may help one to recognize such tumors when seen and felt, but much experience in observation is necessary to toll what a tumor is when one sees it in the abdominal cavity. The ambitious and rash may open the abdomen to make a diagnosis, and be unable to recognize that which they find. "While I clearly appreciate the value of laparotomy as a means of diagnosis in obscure cases, I am as fully aware that it should only be under- taken by one possessing comiDrehensive knowledge gained by exten- sive experience. There are certain other affections and conditions which resemble to some extent ovarian tumors in the second stage. The chief of these are pregnancy, normal and pathological, neoplasms of the uterus, such as fibroids and fibro-cysts; distended bladder; fecal impaction ; encysted fluid in the peritoneal cavity, e. g., in tubercu- lar peritonitis ; cysts of the kidney, liver, or spleen ; enlargement and displacement of the spleen, kidney, oi- liver; cancerous disease of any of the abdominal organs, omentum or abdominal glands ; and parovarian cysts. Pregnancy, in its normal state, differs greatly from ovarian tu- mors in all respects but the fact that both gravid uterus and the tumor occupy the abdominal cavity, still a number of cases have been reported in which an error in diagnosis was made, and ovari- otomy undertaken when the case was one of pregnancy. In sev- eral of these cases the trocar has been thrust into the uterus, the operator believing that he was tapping an ovarian cyst. At the present time such a mistake can only be made through want of knowledge or want of attention. One might, in trying to make a diagnosis, mistake the pregnant uterus for an ovarian cyst, but upon CYSTIC TUMORS OF THE OVARIES. 497 opening tlic alxloniun one having knowledge enough to warrant him in undertaking ovariotomy ought to be able to tell the one from the other by sight. When there is any doubt, it is far better to wait until tlie end of the time of gestation. This can always be done. There is no good reason for removing an ovarian cyst until it is as large or larger than the uterus at full term of gestation in doubtful cases. While I believe in removing ovarian tumors in the second stage of their development when the diagnosis is clear, in case there is room for doubt, whether the case is one of ovarian cyst or of preg- nancy, time will decide, and there is no valid argument against wait- ing. The fact is that those who are the least capable of making a diagnosis are the most inclined to operate early, and this I presume accounts for the mistakes recorded. I need not give the differential diagnosis between ovarian tumors and normal pi'egnancy ; the symptoms and signs of the former have been given, and those of the latter can be found in any text-book on obstetrics, if not already familiar to the reader, and they are so very different that by contrast the diagnosis can be made. Extra-uterine pregnancy usually comes up for diagnosis in con- nection with the first stage in the growth of ovarian tumors, as has already been stated. It is only the abdominal variety which in any way resembles ovarian tumors in the second stage. The signs of a living child in the abdomen are so perfectly diagnostic that they can hardly be mistaken. In case the child is dead, more difficulty might be experienced in making a diagnosis. The history of the case and hallottement or the ability to move the dead child in the sac, will usually suffice to settle the question. Rupture of an ovarian cyst and the extensive adhesions which follow, most closely resemble ventral pregnancy after the death of the child, both in history and in physical signs, and 1 can under- stand that it might be impossible to discover the exact nature of the trouble without the aid of laparotomy. Fortunately, under these circumstances it would be perfectly right to employ this method of making tlie diagnosis, because it is part of the appropriate treat- ment in either case. In the cases of abdominal pregnancy that I have seen the diag- nosis was very easy ; so much so that no one with any experience could have made the mistake of suspecting ovarian tumor. Uterine Fibroids and Fibro-Cysts, when large, present some of the evidences of ovarian tumors. The position of the tumor in the S3 498 DISEASES OF WOMEN. abdomen, and its shape and mobility, are the same as those of some ovarian tumors, and these are the only resemblances. In fibroids, the uterus is enlarged as shown by the touch and sound. The tumor is solid and is intimately eomiected with the uterus, in fact forms a part of it. In the majority of cases the cav- ity of the uterus can be probed, and will be found enlarged in ease the tumor is uterine, while it will not be if the tumor is ovarian. Distended Bladder has been mistaken for a cyst of the ovary, but only at a first examination or by one not used to such cases. When the bladder is overdistended there is incontinence, usually the urine coming away constantly, or in spurts when the patient moves. This leads the medical attendant to suppose that the blad- der must be empty and that the tumor is an ovarian cyst, but the catheter readily settles the question, and it should always be used in cases with such histories. Fecal Impaction has always been mentioned as one of the condi- tions whicli might be mistaken for an ovarian tumor, but I have not considered such a thing possible. The irregular form and solid character of the fecal mass differs in every respect from ovarian tumors of all the benign variet}'. Encysted Dropsy of the Peritonseum. — This is an extremely rare affection and occurs in the progress of tubercular disease as a rule, and follows an attack of peritonitis. The physical signs differ, in that the fluctuation is not so general as in ovarian cyst, and the fixa- tion is complete. The surface of the abdomen is not so prominent as in case of a cyst, but often has irregular depressions, as well as elevations, and the veins are not prominent. The general health is greatly reduced early in the progress of the disease ; nutrition is markedly impaired, and there is often sep- ticaemia in case that there is pus encysted. The vaginal examination is often quite sufficient to settle the diagnosis, by showing that the pelvic organs are normal and can be outlined and separated from the mass in the abdomen. When this can be accomplished, ovarian disease is at once excluded. Enlargement and Cysts of the Liver, Spleen, and Kidneys. — In all of these the diagnosis, so far as the exclusion of ovarian disease, can be easily made if the cases are seen early, or a correct history can be obtained. It is found thai| in them all the enlargement begins above and on one side, and, as a rule, is fixed there from the begin- ning, and the pelvic organs can be separated from the tumor above, and proved to have no connection with the morbid growth, and to be normal. These two diagnostic facts will suffice in most cases to CYSTIC TUMORS OF THE OVARIES. 499 settle the question, but additional evidence can be obtained from the general history of the growth and its effects upon the general health, also the composition of the fluid in cysts, which should be obtained by aspiration in doubtful cases. In regard to the differential diagnosis in cancer of the pelvic and abdominal organs, this will be discussed in connection with these affections, and hence is omitted here. Parovarian Cysts, or serous cysts of the broad ligament, as they are called, are not very easily recognized at all times. Fortunately it would be no very great mistake to remove one of these cysts suppos- ing that it was an ovarian cyst. They are very rare as compared with ovarian cysts, they grow slowly, and occur mostly in young per- sons. The general health does not suffer, as a rule. The physical signs differ in no way from those of the ovarian monocyst, except that the fluctuation is more distinct and the fluid differs, being clear like water and without albumen. Tapping, or rather exploratory aspira- tion, is the means to be employed to settle the diagnosis, and should be practiced when there is a doubt. Affectons which resemble Ovarian Neoplasms in the Third Stage. — There are only a few affections which resemble ovarian cysts in the third stage. These are ascites, uterine fibro-cysts, and very large uterine fibromata. The first mentioned, ascites, is the most likely to be mistaken for ovarian cyst. The chief points of difference in history are, that as- cites is, as a rule, preceded by some acute disease or general ill- health, suggestive of some chronic disease of the liver, heart, or kid- neys. There is anasarca also in most cases of ascites, and the pa- tient is generally ansemic early in the progress of the disease. The enlargement of the abdomen comes on rather suddenly, and is not confined to its lower part ; that is, it is not circumscribed. The ex- pression of the face, while showing anaemia in ascites, is not anxious, as it usually is in ovarian cyst. The history of ovarian cyst in growth and general constitutional symptoms is almost the reverse of ascites. The physical signs of ascites difffer from ovarian cyst, chiefly in that the fluid in ascites changes its position with every change in the position of the patient. When the patient is placed upon the back, the abdomen is symmetrical and flat ; in the erect position, the lower portion bulges from the gravitation of the fluid, and the same change in the position of the fluid occurs when the patient is turned toward either side. With these changes in the position of the fluid, there is a change in the resonance on percussion. The flatness is 500 DISEASES OF WOMEN. found at the mosi de])ciuleiit part, while the resonance is found at the up])er. In large cysts there is dnlhiess or flatness on percussion at all points except the flanks, where there is always resonance, except when the colon is distended with gas and fixed deep in the side, so that the fluid of ascites can not gravitate below it ; and in ovarian cyst there may be dullness on percussion in the side due to fecal im- paction of the colon. There is another exception to the rule that in ascites there is always resonance at the highest point of the abdomen whatever the position of the patient may be, and that is when the disturbance of the abdomen is extreme, and the mesentery is not long enough to permit the intestines to rise to the top of the fluid while the pa- tient is upon the back. There is also a difference in the fluids, which gives some help in the diagnosis in case aspiration is practicable, as it may be in doubtful cases. TJterine Fibro-Cysts or Fibromata seldom attain sufficient size to resemble ovarian cysts, but occasionally they do so. The fibro-cysts of the uterus more closely simulate the ovarian cystic tumors than the fibromata. The difference in the history and the fact that the uterus is involved in the tumor in fibro-cyst and free in the other form, are the chief points of difference. This subject was discussed in treating of the diagnosis in the second stage of ovarian tumors, and need not be repeated in full in this connection. In the study of the differential diagnosis of ovarian neoplasms and other affections which resemble them, much help may be given by contrasting the points of difference by placing them together in opposite columns. The following arrangement of the facts in differential diagnosis I have taken from Peaslee's valuable work on ovarian tumoi-s. 1 have ventured to make some immaterial changes of place and position of these groups of facts in regard to the general text, but \^ath some sucb trifling exceptions the whole is copied from the original. CYSTIC TDMOIiS OF THE OVARIPLS. 501 SUMMARY OF FACTS IN THE DIFFERENTIAIi DIAGNOSIS OF OVARIAN NEOPLASMS IN THE FIRST STAGE. Differential Diagnosis of Hydrosalpinx and Ovarian Cyst. Hydrosalpinx. Ovarian (Jyat — Third Stage. Very rare; convoluted at first; mono- Not rare nor convoluted ; two forms. cystic. Of very slow growth; probably eight Kapid growth. or ten years at least. Health not early impaired; Much sooner impaired. Fluid at intervals discharged per vagi- Not thus discharged. It contains albu- nam. It is generally clear, but va- men, but no mucus. ries ; contains mucus. Refills slowly after tapping. Fills rapidly. Differential Diagnosis of Normal Pregnancy and Ovarian Cyst. a Tialf Ovarian Cyst, second or third stage. Normal Pregnancy five and months or more. Enlargement sudden and rapid ; sym- metrical, or inclined slightly to right side. Features natural, healthy. Superficial veins of abdomen not en- larged. (Edema of ankles not un- common after seven months. Chest not conical. Fluctuation not very distinct, unless much liquor amnii. Menstruation arrested. Vaginal touch detects softening and ap- parent shortening of the cervix and enlargement of the uterus. Ballottement feels impulse of foetus. Fetal heart-sounds detected. Movements of foetus felt. Enlargement of mamrafe. Umbilical areola in first pregnancy. Has developed within six to nine months. Follicles around the nipple equally de- veloped in both mamma} ; become white on stretching the skin. Exception. If foetus be dead, of course, the movements and heart-sounds cease. Enlargement gradual ; asymmetrical till in the third stage. Features emaciated, anxious. Veins are enlarged ; oedema in late stages, in exceptional cases, one to two years after commencement. Chest conical, if very great disten- tion. Very distinct, especially in monocysts. Not arrested till third stage has com- menced. No change in these respects but uterus is displaced, usually behind the cyst. No result. Very rarely is imitated. None. None. Occurs in exceptional cases only. None. Has developed within one to three years. Unequally developed, and remain of the same color as the areola. 502 DISEASES OF WOMEN. Differential Diagnosis of Uterine Fibroma and Ovarian Cyst, Uterine Fibroma. Slow growth. Natural e.\pre8sion, even if large. Coinplexion darker and coarser. General liealtli good. No emaciation. Abdomen very asymmetrical. Abdominal veins not enlarged. Action ot kidneys normal. No amenorrhoea. Menorrhagia often. Tender on pressm-e ; more so during menstruation. Elasticity marked ; no true fluctuation. Surface lobulated and firm. Ovarian Cyst — Third Stage. More rapid growth. Changed expression. Paler and thinner. Health im])aired. Emaciation. More symmetrical. Eidarged ; esi)ecially if a polycyst. Kidneys inactive. Amenorrhoea. No tenderness. Fluctuation distinct. Smooth, except polycysts ; yielding. Per vaginam, tumor is dense and firm, Compressible, fluctuating, detached and often continuous with uterus, from uterus, which is normal, which is large and heavy. Uterus moves with tumor. Does not thus move. Uterine cavity elongated. • Not elongated. Tapping gives negative results. Positive results. Exception. — In case of the subperito- neal pedunculated variety, size of the fetal head, the uterine cavity may be normal, and the tumor be moved independently of the uterus. Differential Diagnosis of Uterine Fibro-Cyst and Ovarian Cyst. Ovarian Cyst — Third Stage. Occurs earlier than thirty years, as weU as later. More rapid and more common. Expression characteristic. Pale. Emaciation. Uterine Fibro- Cyst— Third Stage. Occurs after thirty years, almost al- ways. Slow growth at first. Rare. Expression good till very large. Complexion dark and injected (facies uterina), sometimes florid. No ema- ciation. General health for a long time good. Abdominal veins not enlarged. Umbilicus not prominent. No amenorrhoea. Menorrhagia seldom. Kidneys normal. Tender on ])ressure at first. Elasticity, then evident fluctuation. Surface lobulated at first; may remain so. Cyst-wall of livid hue ; very vascular. Has failed by end of second stage. Enlarged. Umbilicus prominent. Amenorrhoea. Kidneys inactive. Not tender. Fluctuation throughout its course. Not lobulated, except in polycysts. Cyst-wall of lighter color ; less vascu- lar. CYSTIC TUMORS OF THE OVARIES. 503 Per vaginain, firm at lirst. Often con- tinuous with uterus. Uterus moved witli tumor, if at all. Uterine cavity elongated generally. Fluid yellow, serous, witli little albu- men, or fibrinous-like lymph, and spontaneously coagulable. But it may be dark brown or hferaorrhagic. Exception. — If the fibro-cyst be a sub- peritoneal outgrowth, the uterus may be moved independently of it, and its cavity is not elongated. Fluctuates. Not continuous with tho uterus. Indei)cndent of tumor. Not elongated. Light in monoeysts not before tapped ; highly albuminous; sometimes col- loid. Differential Diagnosis of Cyst of the Serous Cyst of Broad Ligament. Very slow growth; rare; always mono- cystic. Mostly in young persons. Expression natural ; not much emacia- tion. General health slightly impaired, though in third stage. Abdominal veins less prominent. Fluctuation remarkably distinct. Uterus lies low generally. Per vaginam, fluctuation very clear. Fluid contains no albumen, and is clear as spring-water. (Specific gravity, 3005.) Scarcely ever fills after tapping. Very seldom fatal. Broad Ligament and Ovarian Cyst. Ovarian Cyst — Third Stage. Common; growth more rapid; two forms of cystoma. Occurs at all ages. Expression changed ; emaciation. Decidedly impaired. Veins more developed. Less distinct. Not depressed, but behind tumor gen- erally. Less clear. Contains much albumen, and is not perfectly transparent. (Specific grav- ity, 1015 or more.) Fills again after tapping. Almost always fatal at last. Differential Diagnosis of Encysted Dropsy and Ovarian Cyst. Encysted Dropsij. Is extremely rare. Slow increase. Preceded by attack of peritonitis. Features natural. Health not bad. No dyspnoea or deranged digestion. Abdomen not prominent, at points even depressed. Veins not enlarged, nor lower extremi- ties ojdematous. Fluctuation not strong; limited in ex- tent, fluid being in front of intes- tines. Per vaginam, no tumor felt, and gener- ally no fluctuation. Ovarian Cyst — Third Stage. Common, and grows rapidly. Preceded by good health. Features peculiar. Health impaired. Both are decided symptoms. Everywhere prominent. Veins enlarged. Extremities not very seldom oedematous. Fluctuation decided. Intestines on sides of cyst. Tumor felt, and fluctuation. 504 DISEASES OF WOMEN. Uterus in place ; sometimes fixed by Behind tumor generally. adiiesions. But little liuid obtained by tajjpinj,'. Larger quantity obtained, or very large, J'luid lias characters of ascitic fluid and Has other characters; no flakes unless flakes of fibrin. there has been inflammation of the cyst-wall. Differential Diagnosis of Ascites and Large Ovarian Cyst. Ascites. Previous ill-health. Enlargement comparatively sudden. Face full, puffy, leaden. Patient on back; enlargement is sym- metrical, flat in front. Patient on the side; flatness on sides. Suddenly rising from the back; fluid bulges between and to the sides of the recti muscles. Patient sitting up ; abdomen bulges be- low. Skin of abdomen smooth, tense, shin- ing. On superficial view, abdomen very much enlarged, (Edema of extremi- ties in all cases, and at last of abdo- men also. Floating ribs not bulging. Navel prominent and thinned. Fluctuation very decided and clear; diffused through abdomen, but avoids highest parts in all positions, and al- ways has a hydrostatic level. More distinct in erect position. Percussion gives a clear tympanitic sound at highest portions of abdomi- nal cavity in all positions. Is dull elsewhere, and changes with the po- sition. Aortic pulsation not felt through ab- dominal walls. Vaginal and rectal touch detect fluctua- tion at once. Uterus normal in size, mobility, and position ; sometimes prolapsed. Fluid, a light straw-color; coagulates Ovarian Cyst. Good health previously. Enlargement gradual. Face emaciated ; peculiar. Enlargement is not usually symmetri- cal ; never till third stage ; prominent in front. No change of flatness. Sometimes cyst protrudes thus slightly, if not adherent. Little, if any, change of abdomen. natural or Abdominal integuments merely thinned. Superficial view, less enlarged only in exceptional cases. (Edema false Chest conical from bulging of ribs. Navel not thinned. Less clear and decided ; limited by the cyst. May remain at the highest parts; has no hydrostatic level. More distinct in recumbent position. Clear sound only at part^ not corre- sponding to the cyst, and in both flanks; dullness over it in all posi- tions. Pulsations are transmitted through the cyst to the abdominal walls. Fluctuations less clear, and may not be reached at all, or not exist in case of polj'cyst. Uterus displaced behind the cyst gener- ally. Fluid a darker shade; of various hues CYSTIO TUMORS OF THE OVARIES. 505 spontaneously ; contains albumen and aiiKJobold corpuscles. Annaraia supervenes early. Uydragof^ues and diuretics produce tem- porary relief. Exceptions. — If there be a very large accumulation, may be dullness at highest point of abdominal cavity, patient being on the back. Or the intestine may be glued down. But deep percussion may elicit tympanitic sounds. And one or both flanks may be clear from gas in the colon. in polycysts; abounds in albumen or colloid matter. No amosboid corpus- cles. Never coagulates spontane- ously. Comes on late. These remedies, as a rule, produce no effect. Exceptions. — May be tympanitic sound in cyst if it communicate with intes- tine. One or both flanks may be dull from f?eces in the colon. Differential Diagnosis of the Three Varieties of Ovarian Cysts.— Third Stage. Monocyst and Oligocyst. Slower growth. Not un- common. Peculiar expression comes later. General health fails much later. Abdomen symmetrical ; if monocyst salient, pointed. Enlargement from thirty- five to forty -five inches. Surface smooth if mono- cyst. Tumor disappears after tapping. (Edema of lower extremi- ties very rare ; abdomi- nal veins less enlarged and later. Adhesions less common and less firm. Inflammation of cyst-wall not common. Ulceration of cyst-wall not common. Spontaneous rupture not common. Poly cyst. Dermoid Cyst. Rapid growth. More Congenital, Very slow. common. Very rare. Comes much earlier. Latest of all. Fails early ; by end of Very late. second stage. Not symmetrical ; not Not symmetrical, pointed. Sometimes to fifty - five Smallest ; generally thir- or even seventy-eight ty to forty inches, inches. Lobulated ; irregular. A monocyst, as a rule. Does not disappear. Does not completely col- lapse. Very common. Veins en- Very uncommon, larged early. Adhesions the rule, and Adhesions not very rare. vascular. Not so common. Most common, propor- tionally. More common. Most common of all. Far more common. Very uncommoD. 506 DISEASES OF WOMEN. Comoa iiiucli earlier. Less (listiDCt aud circuin scribed. Very late. Fluctuation more obscure. Uterus lower, and the liuctuation also, or none at all. Shorter, as a rule. Not clear, brownish. dense, {gelatinous, or albumin- ous. Contains also blood-pig- ment and blood-corpus- cles. Uterus lower; fluctuation dull. No rule. Light color, curdy, no al- bumen, partly soluble in ether. Contains epithelial scales, sebaceous matter, crys- tals of cholesterine, hairs, etc. ; a single hair is pathogDomonic. Amenorrlicea comes later. Fluctuation distinct and throughout if a mono- cyst, and from any point to all others. Per vaginam, uterus is higher, and the fluctua- tion also. Pedicle longer, as a rule. Fluid limpid, amber, blu- ish, or greenish, viscid, with much al!>uraen. Contains epithelial scales, cholesterine, and fatty granules, and the ovari- an glomeruli. Exception. — An oligocyst of but two or three con- stituent cysts with tliin partitions may give all the signs of a monocyst. Prognosis. — The progno.sis in ovarian tumors varies greatly. Before ovariotomy was practiced, it ran almost certainly a fatal course. This is well described by West, and, as his description gives us an opportunity to show how much modern surgery has done to lengthen life and alleviate suffering in these cases, I will quote it in full : " We have symptoms of the same kind, as we see toward the close of every lingering disease, betokening the gradual failure, first of one power, then of another ; the flickering of the taper, which, as all can see, must soon go out. The appetite becomes more and more capricious, and at last no ingenuity of culinary skill can tempt it, while digestion fails even more rapidly, and the wasting body tells but too plainly how the little food nourishes still less and less. The pulse grows feebler, and the strength diminishes every day, and one by one each customary exertion is abandoned. At first the efforts made for the sake of the change, which the sick so crave, are given up ; then those for cleanliness ; and, lastly, those for com- fort, till at length one position is maintained all day long in spite of the cracking of the tender skin, it sufficing for the patient that respiration can go on quietly, and she can suffer undisturbed. "Weariness drives away sleep, or sleep brings no refreshing. The mind alone, amid the general decay, remains undisturbed, but it is not cheered by those illusory hopes which gild, though with a CYSTIC TUMORS OF THE OVARIES. 507 false briglituess, the decline of the consumptive, for step by step Death is felt to be advancing; the patient watches his approach as keenly as we, often with acuter perception of his nearness. We come to the sick chamber day by day to be idle spectators of a sad ceremony, and leave it humbled by the consciousness of the narrow limits which circumscribe the resources of our art." If there is malignant disease, or if there are so many adhesions as to make the removal of the tumor unwarranted, the prognosis is, of course, most unfavorable. If, however, the case is one in which ovariotomy is indicated, the best of results may be expected. The advances made in sm-gery have been especially noticeable in that which pertains to the abdo- men, and, as a result of this great advance, the mortality in cases which are treated by the majority of ovariotomists is only from thir- teen to fifteen per cent, while, under the skillful manipulation of Keith, the pioneer of ovariotomists, the mortality has been reduced to ten per cent. This magnificent operator has had seventy-six con- secutive cases without a single death. The removal of the ovaries that are not (so far as can be ascer- tained before operating) diseased for the relief of certain nervous symptoms, and also for the relief of painful and otherwise incurable diseases of the uterus, is not by any means always satisfactory. The artificial production of the menopause at an early period of life no doubt may produce derangements of the nervous system quite as grave as the condition for which the ovaries are removed. Causation. — Ovarian cysts may occur at any period of life, and have occurred before birth, at the age of one year, three, eight, and twelve years. It is rare, however, that this form of ovarian disease appears before puberty ; from this period to the menopause it occurs, as a rule, and is especially liable to arise between the ages of thirty and forty years. From the statistics which have been collected, we must infer that the unmarried are more disposed to develop this affection than those who are married. Several cases have been re- ported in w^hich sisters have suffered from ovarian cystoma ; this has led some authors to think that there may be some inherited predis- position. I am inclined to think, however, that these may be coin- cidences, and I should certainly be more inclined to attribute some such influence to heredity in these cases had the patients been mother and daughter, rather than sisters. There is no reason to believe that one ovary is more prone to cystic degeneration than the other, al- though, as a rule, but one ovary is affected ; this occurrence of dis- ease in both ovaries occurs in only about ten per cent of the cases. 508 DISEASES OF WOMEN. In regard to the causation of ovarian tumors of all kinds, it will be seen that very little is known. The subject is one whicli from its very nature is extremely difficult to investigate, and it will proba- bly be many years before the influences whicli are active in produc- ing these tumors are understood. When the cyst is developed from Graafian follicles, it is pre- sumed that some affection of these follicles — intlammation, perhaps — may cause the dropsy or accumulation of fluid. Dr. Ncjeggerath believes that degeneration of the blood-vessels gives rise to cystoma. CHAPTER XXYIIL OVAKIOTOMY. The operation of removing ovarian tumors lias been generally known as ovariotomy. Every one understands the meaning of the term, established by usage, as indicating the removal of the ovaries when the subjects of morbid growths. Since Dr. Battey introduced the procedure of removing the normal ovaries the term oophorectomy has been used more frequently, and there appears to be a disposition among some to use the term ovariotomy when speaking of the re- moval of ovarian tumors, and oophorectomy when referring to the removal of the ovaries when not enlarged. This use of two terms which mean exactly the same thing is confusing in any case, but much more so when an attempt is made to make the terms indicate different operations. I shall use the term ovariotomy in all cases when treating of the removal of the ovaries, no matter what their condition may be. Ovariotomy has in the past been the term used for the operation which includes the removal of the Fallopian tubes with the ovaries. In nearly all the ovarian tumors the Fallopian tube is so united to the neoplasm that removal of the one necessitates the removal of the other. The operation first practiced by Tait and Hegar of removing the tubes when diseased along with the ovaries, is now quite generally spoken of as removal of the uterine apj^endages. This is a very un- satisfactory way of expressing the fact. It is absurd to speak of the ovaries and tubes as aj)pendages of the uterus. One might as well speak of hysterectomy as the removal of the ovarian appendage. In the evolution of development the uterus is added to the ovaries and tubes in the higher animals, and ovaries, tubes, and utenis have independent structures and functions ; hence, neither one is an ap- pendage to the other. To designate the operation of removing the ovaries and Fallopian tubes, I shall use the term tubo-ovariotomy. 510 DISEASES OF WOMEN. GENERAL CONSIDERATIONS OF OVARIOTOMY. Before taking up the details of the operation, I sliall call atten- tion to certain general facts which belong to all Hurgical procedures, and have a special bearing on ovariotomy. While most that will be said pertains to the removal of ovarian tumors, it will be equally applicable to the removal of the small-sized di.^eased ovaries or nor- mal ovaries and tubes, the more modern operation. I have long entertained the opinion that ovariotomy is the most difficult operation in the whole field of surgery. This is, however, a matter of opinion, and may be an error on my part, but it is posi- tively certain that a thorough knowledge of surgery and all attain- able dexterity and skill in operating can be employed M-ith advan- tage in removing ovarian tumors. This operation differs from all othei's that I know of, in the number and variety of complications which it affords. It is seldom that two cases exactly alike occur in the practice of any surgeon, hence it is not until a very large num- ber of cases have been seen that the operator is prepared to meet all the conditions which may come before him. To the operator of limited practice, the operation in this respect often presents the characteristics of a new investigation. To this extent, then, the operation is unlike anything else in surgery. Most all other operations are, to a great extent, definite ; the anatomy being the same and the modus operandi fixed according to well-defined rules. The surgeon has it in liis power to learn such operations by practice upon the cadaver, until he may be almost master of his work (if he has in him the surgical diathesis) before touching the living subject. iJ^o such opportunity is offered to acquire the art of doing ovariot- omy. The division of the abdominal walls, the first and simplest step in the operation, may be studied and practiced upon the cada- ver, but here ends the value of dissection as a special aid to the ova- riotomist. Books and lectures, then, are the most available sources of in- formation, but this reading and listening to others talking, although a means of acquiring a knowledge of science, is a poor way of learn- ing how to perform an operation. It is true that one may familiarize himself Mnth all the steps of an operation and the complications which may be found in each case, and he may be able to recall them at will, and think of them clearly before and after an operation, but to recognize the indications and promptly meet them while operating, can only be learned by prac- tical observation. OVARIOTOMY. oil Tlie first essential, tlien, is to know liow to operate — a self-evident proposition this, which need not he made here were it not for the fact that many try to perform ovariotomy who are not (jiiaiificd to do so. It is a notorious fact that this most important of operations has been performed by many who had no claim to being called sur- geons. Obstetricians who, having turned their attention to some of the plastic operations of gynecology and succeeded, have next taken to ovariotomy. A few, bolder still, have made their dehut in sur- gery as ovariotomists, without any previous surgical experience. Why men should be found who will undertake this operation while they would shrink from iridectomy or lithotomy, is a difficult ques- tion to answer. Perhaps the difficulties in the way of learning to do this operation may account for it. It is clearly evident that one should be well grounded in the science and art of surgery before taking up ovariotomy. The consummate surgeon can readily transfer his art to this department of abdominal surgery with far more hope of success than one who seeks to acquire skill by practicing ovariotomy as his maiden effort. The best and surest way of all to qualify for this operation is to secure facility in general surgerj^, and then to take lessons of some successful operator ; to witness, and if possible to assist in, a sufficient number of operations so as to see the different kinds of cases and the various complications. By such means the surgeon can secure one great element of success, a knowledge of manipulations. N^ext to knowing how to operate is how to obtain competent assistants. An operator of large experience may be able to do the operation with assistants who know little, if anything, of the operation, his famil- iarity with the work being such that he can give much of his atten- tion to those who are helping him, and so command success. It is quite different with one of more limited experience. His whole time and attention are taken up with that which he is doing himself, and if his assistants are unacquainted with their duties, they gener- ally hinder rather than help. It is a sad sight to see a beginner, with untrained assistants, trying to do ovariotomy. The ease with which such assistants make simple things complicated and lose time in hurrying is quite extraordinary. I know this from having played the 7'dle of operator and also assistant when I did not know either of the parts. Skill in diagnosis is a means of success of prime importance, and for many reasons should have been disposed of first ; but I put the operation first in my argument simply because I believe that more failures come from poor operating than from errors in diagnosis. 512 DISEASES OF WOMEN. The text-books give all the rules and means of diagnosis so fully that no one needs more theoretical instruction — but here again much practice is needed. Diseases of the ovaries present such variety of physical signs that a very large experience is required to see all the dLfferent kinds of cases. Ovarian tumors differ so in their form, composition, and complications in the way of adhesions, that their real nature is difficult to make out. Again, there are many abdom- inal tumors and products of disease which simulate in their physical signs ovarian tumors so closely, that experts of long practice are at times unable to make a correct diagnosis. Still, great accuracy can be attained in diagnosis by long and careful observation. In many affections we can successfully adapt our treatment to the deranged conditions manifested, although the exact nature of the pathology may be unknown ; but in ovarian tumors we must have rather definite ideas of their character before we can begin their surgical treatment. Ovariotomy, as an operation, differs so much with the different operators, both as regards the methods of procedure and results ob- tained, that I propose to notice some of the conditions upon which the success apparently depends. Dexterity on the part of the operator and all available means which save time and secure accuracy are obvious necessities, and need not be urged in this connection. In an operation of such magnitude the question of anaesthetics requires a passing notice. Sulphuric ether has still the best reputation. Its administration should be prompt and carefully kept up. The less ether that the patient takes the less the danger and the better the condition of the patient afterward. Fifteen or twenty minutes wasted in anaesthetiz- ing give just so much unnecessary blood-poisoning, and this to some extent retards recovery. Giving nitrous-oxide gas first, and follo^ving it up with ether, is the most rapid way of anaesthetizing. I have seen this method employed by others with great satisfaction. I use ether altogether, and administer it with the apparatus already described, and am perfectly satisfied with the method. I believe that the great majority of ovariotomists use ether as an anaesthetic, and I am perfectly satisfied with it when it is given in the way that I have mentioned. There arc a number of points of importance which miglit be dis- cussed in this connection in regard to the different methods of sur- geons of doing certain parts of the operation. When describing the operation I shall give the methods which in my judgment are the best, but a general discussion of some of these matters appears to be necessary. OVARIOTOMY. 513 In the management of the pedicle, for example, we find that even the renowned operators do not all agree. Tiirough the influ- ence of the most successful of all operators, I am firmly convinced that the cautery gives the best results, and I am also satisfied that it is because the method of using it is not fully understood that it is not more generally employed. The object is to desiccate at least half an inch of the end of the stump and to avoid charring it. This can only be accomplished by strongly compressing the pedicle, using a heavy clamp, with blades half an inch thick, and then heating it Fig. 198. — Cautery clamp. with a very heavy cautery until the portion in the grasp of the in- strument is thoroughly desiccated. The stump thus treated looks like a piece of translucent horn. The divided ends of the vessels are completely closed, which guards against haemorrhage. I pre- sume that the end of the stump does not slough, but becomes hydrated, and finally organized. The advantages of the cautery may be briefly summarized as follows : It is a reliable way of controlling haemorrhage ; it leaves the stump in a condition requiring the least reparatory care ; and, finally, it avoids all sources of irritation such as that to which the ligature gives rise. I have recently employed a cautery clamp which, I think, has some merits worthy of notice. It compresses the pedicle on four sides. The long blades keep the tissues from spreading, while the short sliding blade presses the tissues against the other cross-bar. The advantage of this is that the pressure upon the pedicle is equal nt all points, and it thereby gives a smaller stump. The trouble with the old straight clamp is, that it spreads out the pedicle too much, and while it firmly holds the central or thickest part, the outer edges are liable to slip out of its grasp, 34 514 DISEASES OF WOMEN. The next, and perhaps the most iiuportaut, essential of success is cleanliness, or, to put it tecLuicallj, the antiseptic method of operat- ing. Surgeons were beginning to feel a certain sense of security in performing ovariotomy when they carried out all the details of the Listerian method ; but more recently they have found that carbolic acid in place of saving patients, sometimes sacritices them. When the danger of carbolic-acid spray in ovariotomy was first announced many surgeons thought that Thomas Keith had given up antiseptic surgery ; but that great siu*geon is still as earnest and enthusiastic in his war against dirt as he ever was. Although he has given up the use of the spray, because he found that the good that it did v.as counterbalanced by its injurious effects, he still retains all the other known elements of antiseptic surgery. These elements I under- stand to be, first, to keep wounds free from extrinsic germs, which are in themselves injurious to living tissues, or which favor morbid action in the tissues ; and, on the other hand, to provide for the es- cape of morbid material which may be developed in wounds. To prevent the entrance of septic germs perfect cleanliness of every- thing which pertains to the operation is necessary. The carbolic- acid spray can at most only disinfect the air in the operating-room, . and consequently it is only one fraction of the antiseptic method of operating. Clean operators and assistants, clean instruments, sponges and everything which may directly or indirectly come in contact with the patient before, during, and after the operation, are all of the highest importance. Still more, it is absolutely necessary to keep all things clean during the operation. A clean, fair start may be made ; but during the operation the operator s hands and the insti-u- meuts may become contaminated by contact with the contents of the cyst, and the patient be exposed to septicaemia. This has often occurred when the spray has been thoroughly and faithfully used. Indeed, if too much dependence is placed upon the spray, there is great danger of contamination from want of care in other respects. Some of the fluid contents of the cyst may enter the abdominal cav- ity, or the hands of the operator or his assistants may become soiled from the same source, and mischief may be wrought in that way. In short, it is exceedingly difficult to guard against all sources of un- cleanliness in this complicated operation. I think, then, that if all the other essential elements of antiseptic surgery are carefully ob- served, the spray may be left out and still the highest success can be attained. But spray or no spray, too much can not be said in favor of antisepsis in relation to ovariotomy. There is still another fact which stands out prominently, and OVARIOTOMY. 515 upon wliicii success depends, and that is the management of the dead material which may be unavoidably left in the abdominal cavity, or that may accumulate there after the operation. Blood or bloody serum or the contents of the cyst that may be left or may accumu- late in the peritoneal cavity is dangerous, and should be removed by drainage. It is true that within the last year or two there has been some difference of opinion regarding the value of drainage. Some of tlie great men in London have laid it aside as a rule, while Keith still employs it and insists that he saves many of his patients by it. I believe that I can see tliat those who employ drainage have the best of it. I incline to this view because Keith, who practices drain- age when necessary, has had the highest number of successes ; and because the reasoning against drainage by those who have given it up does not appear to fully liarmonize with the facts in the case. It is claimed that if ovariotomy is performed with all the attendant means of antiseptic surgery, including the spray, any fluid which may be left or that may accumulate in the peritoneal cavity is harm- less. Spencer Wells states that fluids do not accumulate after the use of antiseptics, or if they do collect they do not putrefy, but are absorbed without injury. ISTow it is difficult to understand how antiseptics used in the operation could prevent the accumulation of serum in cases where there were many and extensive adhesions, and, on the other hand, it is equally incomprehensible that carbolic acid in sufficient quantity should remain in the abdominal cavity to disinfect the fluids which transude from broken surfaces. Without daring to decide the matter or to express any positive opinions, I may state that the truth appears to me to be this : Antiseptic operating will lessen the danger to a very great degree, but there will always be cases which call for drainage. The value of drainage depends largely upon the mode of using it. The metliod which I have usually seen practiced in this country is to pass a tube through the lower angle of the wound down into the sac of Douglas, and then to close its outer end with a cork. This cork is removed several times a day, and the fluid pumped out. This gives a kind of intermittent drainage wliicli is very imperfect. The method which I obtained from Dr. Keith is much better. In place of closing the end of the tube he passes it through the center of a piece of rubber cloth, and then places a carboUzed sponge upon the end of the tube. The rubber cloth is folded over the sponge, and tied securely with a string. The tube and the sponge are thus 516 DISEASES OF WOMEN. exeliuled from the air, and aiiy Huid wbicli accumulates wells up through the tube, and is taken up by the sponge. Tbe 8]>onge is changed several times a day, and any residual tluid which may re- main is |)umped out at each dressing. In this way continuous drain- age is kept up, and still a perfectly antiseptic dressing is maintained. This may aj)pear to be a simple matter, but it constitutes the differ- ence between perfect and imperfect drainage. In a ca.se o])erated upon last summer, I obtained twelve ounces of iluid in thirty-six hours by this method of drainage, and the temperature of the pa- tient never rose above normal, excepting one day when it reached one hundred, and remained there for a few hours. This case alone would be sufficient to demonstrate both the safety and value of drainage. In addition to the requisite skill in diagnosticating ovarian tu- mors, it is highly essential to success to make a correct estimate of the patient's general condition before operating. An incipient disease of some of the organs of general nutrition may escape the notice of the ovariotomist, and cause a fatal issue, no matter how skillfully the operation may be performed. Prominent in this regard are diseases of the kidneys. These organs should be carefully interrogated in all cases before operating. The same mle applies to all the important organs of nutrition, because any cardiac, hepatic, pulmonary, or renal lesions, although not marked or threat- ening the life of the patient, may still be sufficient to turn the scale to the fatal side after such a fonnidable operation as ovariotomy. I well remember one case which illustrates this point. The pa- tient was over sixty years of age, and appeared fairly well. Her nutrition was poor, it is true, but it was supposed that was due to the size of the tumor. During the operation, while trying to control the haemorrhage from adhesions high up in the abdomen, I caught a glance of the liver, which was far advanced in fatty degeneration. She lived a week, but died, as I think, from her hepatic disease rather than from ovariotomy. Had a more complete diagnosis been possible in this case, I would have had one less on the unfavorable side of my statistics. I would not be understood as saying that patients should not be operated upon in case there is any constitutional affection which might complicate the case and lessen the chances of recovery, but every means should be employed to get the patient's health in as good condition as possible before the operation, when that is possi- ble. Sometimes the surgeon is not called until the patient has ad- vanced so far that no time is given for preparatory treatment. OVARIOTOMY. 517 In such cases patient and surgeon must take the risks. In regard to preparatory treatment no rules need be laid down beyond say- ing that any defect in health or strength, or functional derange- ment of any kind should be corrected. Good food, sleep, exercise, bathing, and pure air, with such medicines as may be needed to in- crease strength or meet any ordinary requirements, are indicated. 1 have found it of great service to watch my patients for some time before operating when they could afford the time, in order to learn their peculiarities, mental and physical. This often helps the sur- geon to manage them better after the operation. In brief, then, if the patient has not advanced far enough to demand immediate opera- tion, and her health is impaired, an effort should be made to build up her strength by tonics and good hygienic conditions. The time most favorable, in regard to the season of the year, I think, is, in this country, the autumn and early part of the winter and the first summer months. The coldest and hottest seasons should be avoided if convenient to do so, but more for the comfort of the patient than anytliing particularly unfavorable to success. I have Jiad exceptionally good fortune with cases that I have been obliged to treat in June and July, so that I have no special dread of the hot weather, if everything else is favorable. The spring I have found the most objectionable season. The confinement in- doors in winter in poorly ventilated houses appears to impair the health and strength very much. This holds good, to some extent, in both city and country. In regard to the menstrual period, it is best to operate from four to six days after and not less than eight or ten days before. The place for operating should be an institution for that purpose. A private hospital or an isolated room in a hospital, free from con- tagious and infectious diseases, should be preferred. The best, of course, is an isolated building, or a building reserved exclusively for abdominal surgery. When such a favorable place can not be had a private house is next to be preferred, and one that shall be in the best possible sanitary condition. The country has been strongly recom- mended as the best place to operate. I am quite sure that there is no good reason for this preference. If all the comforts and sani- tary conditions could be secured in a country house, and the best attendance, then the purer air of the country would be more desir- able than the city, but as a rule the wretched sanitary condition of most country houses gives no greater advantages over city houses for abdominal surgery. The immediate preparation of the patient for the operation con- sists in keeping the bowels regular by some mild laxative for sev- 518 diseasp:s of women. eral day.s before, and at tlie saiiie time giviiif;^ jtlain food whieli, in tlie experience of tlie jxitient, she knows agrees with her. I also give five grains of subnitrate of bismuth and the same quantity of charcoal twice a day for several days, to dispose of intestinal gases. This is important. It is much better and easier to operate when the bowels are empty, especially in the operation of removing the ovaries and tubes. On the morning of the day before the operation a medium dose of castor-oil should be given, and two or three hours before the operation I give one grain of opium and three grains of sulphate of quinine. The urine should be examined several times during the week pre- ceding the day set for the operation, and should there be evidence of any well-marked disease of the kidneys, the operation should be abandoned. If there is no renal disease, but an abnormally high temperature, the operation should be deferred until it is reduced, unless the high temperature is due to suppuration of the cyst. The dress of the patient should be flannel underclothing, with woolen stockings and a flannel dressing-gown, which opens in front, all the way down. Preferring to anaesthetize the patient away from the operating-table, I have this done in an adjoining room. Upon the bed or sofa on which the patient takes the ether is placed the top of the operating table, and upon that she lies. The table-top which I use is about twenty inches wide and five feet long, upholstered in leather, and provided with straps, by which to carry it. A warm blanket is wrapped around it, and it is placed on the side of the bed, and the patient is laid upon it when ether- ized, and carried to the operating-table. When the operation is fin- ished, she is carried back upon the table-top to the bed. This is a most convenient way of moving the patient, and pays well for the trouble of getting an operating-table with a movable top. I have a frame for the top made to suit, but, when operating away from my private hospital, the top only is used, and is placed on a small table, such as can usually be found in every house. The prep- aration of the room in which the operation is to be perfprmed should be made as follows : If it is a room built on purpose for abdominal surgery, it needs no further treatment than a thorough disinfecting, and then airing. The windows should be left open for a day, and then closed and the room filled with chlorine gas, and kept so until near the time for oj)erating, when air should be admitted, to make breathing easy and comfortable. The air admitted should be from the outside, and not from adjoining rooms or halls. If the opera- OVARIOTOMY. 519 tion is to be at a private liouse, the carpet and all drapery should be removed, together with all upholstered furniture, and the room and all necessary furniture should be disinfected with the chlorine gas. The temperature of the room should be maintained at about 75° F. The necessary instruments and appliances difEer to some extent with each operation. I shall give those which 1 use myself, and leave the choice of special instruments which may be deemed necessary to in- dividual inclinations or judgment. List of Instruments and Apijliances usually required iii the Operation.— '^(fdk^Q\ with fixed handle; dissecting-f orceps ; artery- FiG. 199. — Keith's short compression-forceps. forceps; six Keith's compression-forceps (Figs. 199 and 200); one vulcellum forceps; one fenestrated forceps; small, straight, blunt- pointed scissors ; large, straight scissors ; trocar and rubber tube. Fig. 200. — Keith's long compression-forceps These are placed together in an enameled pan filled half -full with a one-to-forty carboKc-acid solution. Twelve to twenty sponges, the exact numher to he carefully noted, prepared and placed in a double tin pail with hot water in the outer compartment ; six towels soaked in a one to-twenty carbolic solution, and put in the sponge pail ; No. 1, 3, and 11 prepared silk for liga- tures. These should be cut the proper length for ligating thick adhe- sions and the pedicle, and wrapped in gauze and put into the car- bolic solution. No. 4 silk for the abdominal sutures should be prepared in the same way ; No. 2 catgut ligatures ; Keith's needles, two for each ab- 520 DISEASES OF WOMEN. doiuiual suture (Fig. 201); Peaslee's needles; Keith's fine forceps for carrying the ligatures ( Fig. 2(J2) through the pedicle ; sutures to ^— - - - -mi, b.T\tMKMHSi.Ca. Fio. 201. — Keith's needle. be used with Peaslee's needle if required ; a sheet of rubber cloth, three by four feet, with an oval hole in the center, the border of Fig. 202. — Keith's hgature forceps. which is coated with sticking-plaster an inch wide all around ; long straps of saddle-girth to fasten the patient's limbs to the table ; a yard of gauze or cheese-cloth soaked in a solution of one part of carbolic acid to eight of glycerin for a dressing ; sheet of absorbent cotton large enough to cover the abdomen ; flannel bandage ; safety-jiins. Instrum^nU and Appliances that may he needed. — Cautery clamps; cautery irons; Baker-Brown's clamp (Fig. 203); curved Fig. 203.— BakerBiown Clamp. scissors : concave mirror ; counter-pressure instrument for tying liga- tures in abdominal cavity ; several drainage-tubes of different sizes ; piece of sheet-rubber, ten by ten inches, to cover the end of the drainage tubes ; twelve or more extra sponges ; twelve to twenty extra compression-forceps ; aspirator ; elastic ligature. These should be clean and placed within reach of the operator, but not mixed with the other in.struments named. The instruments to be used should be placed on a stand beside tlie operator, and also a basin with carbolic solution, or such disin fectant as the surgeon chooses to use for keeping the hands clean. OVARIOTOMY. 521 The sponges, ligatures, towels, and dressings may be placed beside the first assistant Assistants. — Three assistants are certainly needed, and one more may be required. One gives the ether, one stands on the left side of the patient, facing the operator, the third on the left of the op- erator, and the fourth one attends to the washing of the sponges. The chief assistant on the opposite side of the table sponges the wound during the incision of the abdominal walls, holds the vessels or adhesions when the operator is ligating them, supports the cyst when brought out, helps to apply the sutures to the wound, and ful- fills all orders of the operator. The second assistant supports the abdomen and cyst or tumor while the abdominal walls are being opened, and, when the cyst is being removed, he helps to expel it by pressure, and at the same time prevents the escape of the ab- dominal viscera. The assistants carry the patient from the bed to the table. A blanket is wrapped around her limbs, and a rubber bag of hot water (^STAND. WITH INSTRUMENTS AND BASINS/|^ Fia. 204. — Position of operator, assistants and accessories in the operation. Botli arms sliould lie close to the patient's side. placed at her feet. The strap is passed over the thiglis and around the table. The abdomen is made bare by opening the dressing-gown and raising the undergarment. The rubber cloth is spread over the 522 DISEASES OF WOMEN. patient, and the edges of the opening in the center stuck fast to the skin around the lower and central portions of the abdomen. One of the carbolized towels is laid over the thighs of the patient, upon which are placed the instruments which are first to be used. This diagram will show at a glance the position of all concerned. The several steps of the operation are as follows : 1. Maldng the incision in the abdominal wall. 2. Exploring for adhesions. 3. Tapping the cyst or cysts. 4. Treating adhesions and removing tumor. 5. Treating the pedicle. 6. Examination and treatment of the other ovary. 7. Cleansing the abdominal cavity. 8. Closing the incision. 9. Dressing the abdominal wound and placing the patient in bed. The details of the several steps in the operation in uncomplicated cases are as follows : The incision is made in the linea alba — ^traces of which can usu- ally be seen — down to the muscular layer. The length of the incis- ion should be about three inches, extending from one inch above the pubes upwards. The assistant should follow the knife with the sponge, and any bleeding vessels should be caught up in plain for- ceps. The tissues at the bottom of the wound should be picked up with a dissecting-forceps, and an opening made in the median line with the knife, the edge of which should be directed away from the tumor. When making this opening care should be taken to find the median line between the muscles. This is often done at the first trial, but, if the muscle is exposed, its sheath should be followed in either direction until the median line is found, and then another opening made there. The knife is then put aside, and one blade of the blunt-pointed scissors is introduced into the opening, and the incision completed by cutting in both directions. This usually ex- tends through the muscular layer; the fascia and the peritonaeum still remain. These should be opened in the same manner. A sound, finger, or the whole hand may be introduced to de- termine the presence and character of adhesions, if such exist. The trocar and cannula are then plunged into the cyst at the highest end of the incision, the trocar drawn back and handed to the assistant, who takes care that fluid does not enter the abdominal cavity. The cyst- wall should be seized with a lock-forceps between the cannula and left side of the incision. This is also handed to the assistant, who holds it and the trocar in his left hand, and makes the necessary OVARIOTOMY. 523 traction to withdraw the cyst, which he grasps with his right hand when it comes out, and holda it without making traction upon the pedicle. The operator pushes a sponge into the wound behind the tumor. The pedicle is then examined to ascertain its size and character, and whether it be twisted. The cautery clamp (if that metliod of treat- ing the pedicle is to be practiced) is then applied, and the pedicle di- vided within half an inch of the clamp. The operator then sponges the abdominal cavity, taking special care not to leave any fluid be- tween the bladder and the uterus. The assistant meantime takes care of the clamp. The operator examines the other ovary, and decides whether it requires to be also removed or not. One or more sponges are left in the abdomen while the pedicle is being treated v\^ith the cautery. Two carbolized towels are placed under the clamp, and the remains of the pedicle are removed with the cautery. The clamp is then loosened a very little by unscrewing, and the cautery applied until the clamp is heated throughout to a degree that will admit of the flnger being flrmly placed upon it. Before finishing the cauterizing, the clamp should be screwed up tight. "While the cauterizing is being done, the assistant should remove all fluid and debris with a sponge and forceps, and, if the towels beneath the clamp become heated, they should be changed. The clamp should be cooled with a moist sponge without touching the cauterized edge. The pedicle is then seized with two forceps below the clamp, which is gradually and with great care loosened. The stump of the pedi- cle should be watched for a few seconds to see if the blood inclines to pass up any of the vessels in the part that has been cauterized. If there is no sign of such taking place, then the stump is dropped back and covered with intestines, and the omentum over all. Should the operator decide to ligate in place of using the cautery, the pedi- cle is secured by a Baker-Brown clamp or two compression-forceps, and a double ligature is passed through the center of the pedicle with a Keith's ligature-forceps, and ligated in two halves. Care should be taken to cross the ligatures, so that when the two are tied they will draw the tissues together in one mass. When the pedicle is small and long, it can be tied before cutting away the cyst, aiid without using a clamp at all. The sponges should be recounted at this stage of the operation, to make sure that none is left in the ab- dominal cavity, an accident which has occasionally happened. A flat sponge is placed over the omentum and beneath the edges of the wound, and left there while the sutures are being introduced. All bleeding vessels in the abdominal wall should be ligated. Two 524 DISEASES OF WOMEN. Keith's needles are used for each suture, one at eacli end. The needles are introduced from the inside of the abdominal wall, and include the peritonaeum. This method of introducing the sutures is the quickest and the best when the incision is long or medium in length, but when the incision is short I prefer to use Peaslee's needle of smaller size than that which is usually found in the shops. The needle is passed from without inward, and the suture is carried through the double of the thread in the needle, and, as the needle is withdrawn, the suture- is brought into place. Having introduced all the sutures, the ends on each side are gathered together and held while the flat sponge is removed. The air should be pressed out of the abdominal cavity, and the sutures tied. Slip-knots are prefera- ble. The sutures should be close together, about four to the inch. Here and there a superficial suture may be needed to make the co- aptation as complete as it should be. The dressing of gauze, soaked in the one-to-eight solution of glycerin and carbolic acid, is applied, and over that absorbent cotton and a flannel bandage. The patient is put into a warm bed, and hot water-bags or bottles put around her, and one sixth or one quarter of a grain of morphine given hypo- dermically. Complications. — The several steps in the operation are liable to be complicated by a variety of conditions. The chief of these may be mentioned in the order in which they come. When there is much fat beneath the skin it is difficult to make a straight incision. In that condition the wall may be grasped in the left hand, raised up and transfixed with the bistoury and divided from within outward. This leads down at once to the muscular layer, and then the incision is finished in the usual way. Great vascularity of the abdominal wall, while easily managed, takes time. One or two bleeding vessels may be caught in plain forceps and con- trolled, but when there are many it is better to tie them because a number of compression-forceps are in the way during the operation. Firm adhesions of the tumor to the abdominal wall in the fine of incision are often a troublesome complication, which leads the opera- tor either to open into the sac before knowing it, or else to sepa- rate the peritonaeum from the abdominal walls. When the tumor can once be reached at any one point, it is very easy to separate the adhesions, but it is often difficult to get that one point. Enlarging the incision is a help, and it should be carried in the direction up or down according to the possibility of reaching a point where the cyst is free. Sometimes the exudation which forms the adhesion can be recognized when it is reached ; it is then easy to follow it up until OVAKIOTOMY. 525 the detachment is complete. When the cyst is exposed all the par- ietal adhesions should be loosened. This should be done by the hand. When the tumor has been of slow growth and is tense and the walls opparently thick and strong, a very great amount of force can be used in separating adhesions. If the tumor is flaccid it is well to steady it with a pair of for- ceps while separating the adhesions and before introducing the trocar. Parietal adhesions are treated before tapping the cyst, at least as far as they can be easily reached by the hand. EMPTYING THE TUMOR IN COMPLICATED CASES. In multiple cyst and multilocular cases in which the contents of the sac can be removed by tapping, the trocar and cannula are thrust into the nearest cyst and it is emptied in the usual way ; the trocar is then pushed into another sac, which in turn is emptied, aud so on, until all are emptied. To do this safely the tumor should be steadied with the left hand, while the trocar is used with the right, and this helps to make sure that the trocar goes into the sac and not into the viscera or abdominal walls. When the fluid contents of the tumor are semi-solid and will not flow through the cannula, the trocar and cannula should be removed, and the opening in the sac enlarged in the axis of the body ; i. e., the opening should correspond to the opening in the abdominal wall. A pair of forceps should be fastened near each end of the opening on the left side, and perhaps a small one at the lower end on the right side. These forceps are held by the assistant, and as the tumor becomes smaller he draws the sac out and down until the opening in the sac is below the level of the opening in the abdomen. The operator introduces his hand through this large opening into the cyst that is emptied, and breaks down the other cyst-walls and sweeps them out ; while the finger of the right hand is boring through the cyst- walls tlie tumor is steadied with the left hand on the abdominal wall. In this way the contetits of large tu- mors may be br(jken down and removed. While this is being done the edges of the rubber cloth should be raised so as to direct the fluid into the tub or basin at the side. When the tumor is very vascular and great bleeding is likely to occur in emptying the contents, the pedicle should be found if pos- sible and compressed with catch-forceps. Adhesion of the omentum and the abdominal and pelvic viscera 526 DISEASES OF WOMEN. is treated after the tumor is emptied of its liuid contents. The omental adhesions are most easily tied while attachod to the tumor, and that should be the rule, but if it is necessary to get the omen- tum out of the way before the operator has time to tie it i5roi)erly, compression-forceps may be put on, and the whole wrapped up in a carbolized towel, and left on the abdomen at the upper angle of the wound until the cyst is removed, when attention can be given it. It should then be tied in sections of about the width of two hn- gers. Dr. Keith treats adhesions to the bowels and mesentery by mak- ing traction upon the cyst and pressing against the adhesions with a sponge. In this way the adherent tissues can be pushed apart with less injury than in any other way. Pulling upon adhesions should always be avoided, if possible. Sometimes when there are many ad- hesions high up strong traction must be made, there being no other way of separating the timi adhesions, but it is a dangerous practice and only to be resorted to when it can not be avoided. Long bands of adhesions should be tied before being detached, and the following points should be observed ; to have no tension upon tliese parts ; to ligate as far from the free end as possible, and make sure that all bleeding is stopped before letting go the parts. The bleeding which comes from the broad adherent surfaces which have been separated, should be controlled by placing sponges in the abdomen and making pressure, and as soon as possible bleeding points should be looked for and the vessels ligated. When the sponges are removed the position of the bleeding vessels can be seen. When there are many adhesions high up in the abdomen, it is an advantage to iind the pedicle, clamp it with two spring catch-forceps, and divide it, and then remove the tumor from the pelvis first. When the adhesions are all treated and the tumor removed, the sponges which have been introduced should be removed, and the bleeding vessels caught up and tied. During this search for bleeding vessels in the pelvis the assistant holds the side of the abdominal wound with his left hand, and with a concave mirror in his right throws light into the pelvis. In using the mirror the assistant directs it so that he himself can see, knowing that if he can see the operator will see also. The artilicial light is to be used as little as possible, because if once begun it is difficult afterward to do ^nthout it. Drainage should be employed when from the number of adhe- sions there is seen to be a free transudation of serum ; when all the bleeding has not been or can not be stopped, and when either of the above conditions ai-e present even in a very limited degree and the OVARIOTOMY. 527 patient is feeble. In cases where it is doubtful wlietlier drainage should be employed or not, it is best to use it. When adhesions to the intestines or pelvic organs are so firm and extensive that they can not be separated with safety, Dr. T. F. Miner, of Buffalo, enucleates the tumor or cyst from its peritoneal covering. This can be done but it is often exceedingly difficult and there is left a large surface from which a free transudation takes place, and requires long-continued drainage. This method is not practiced much now ; at least, I hear nothing of it. When adhesions are very extensive and firm there usually has been inflammation of the cyst, and then its layers can not be sepa- rated ; this renders enucleation impossible. Treatment by Drainage answers in such cases if the cyst is small or of medium size. If the cyst is adherent to the abdominal wall it is laid open without being separated and its cavity thoroughly cleaned out, and a drainage-tube introduced, and kept in place. The sac is washed out frequently, and when it has contracted down it may be induced to close by the use of tincture of iodine and car- bolic acid. When not adherent to the abdominal wall, but so gen- erally adherent to the viscera that exploration is deemed impossible, the free portion of the sac should be trimmed off and its edges care- fully united to the incision in the abdominal wall, and then the di'ainage practiced. I am aware tliat an experienced and dexterous operator can man- age verj' bad adhesions, but there are cases where it is safer to use drainage. Five cases have been treated in this way in my own prac- tice, and four of them recovered. In the fifth, a bad case of rupt- ured cyst in which there had been very general peritonitis, the cyst was adherent everywhere. I could not find a single free spot, and the patient was very feeble. The sac was filled with inflamma- tory products, which were carefully cleared out, and large drainage- tubes used. She improved for a time and took food better than she had done before, but died at the end of a week, apparently from m'aemia ; the kidneys were found to be diseased. In case of very intimate adhesions to the liver, spleen, uterns, bladder, or intestines. Dr. W. L. Atlee did not detach them at all, but separated the peritoneal from the middle coat of the cyst at the point of attachment, and left it there. This also is not often neces- sary, but it may be the easiest and safest thing to do, and if drain- age is employed good results may be expected. In this I have had no experience. Arrest of Haemorrhage. — All adhesions in the form of bands ex- 528 DISEASES OF WOMEN. tending from the cyst to other parts sliould be tied before dividing them. This applies especially to adhesions of the omentum. Large bands sliould be tied with prepared silk ligatures. The iiner bands may be tied with catgut. In my own practice I use silk alto- gether. Intimate adhesions which liave to be separated by trac- tion leave bleeding surfaces, and if any large vessels are found they should be tied if possible. General oozing can usually be stopjied by pressure with a sponge. Hivmorrhage deep down in the i)elvis from vessels large enough to be ligated can be reached by throwing in the light from the mirror and using a long artery-forceps. The ligature can be easily tied by using the counter-pressure instrument employed in tying the sutures in the operation for restoration of the cervix uteri. To check oozing from surfaces like the uterus, liver, or spleen, pressure with sponges is to be performed as stated already. An application of persulphate of iron is made by some operators, and the thermo-cautery has also been commended. Both are objection- able, and should be avoided if possible. After-Treatment. — The description of the operation ended with the giving of a small hypodermic injection of morphia, and placing the patient in a warm bed in a room at a temperatm'e of about 70° F. She should be kept warm so as to induce a general circula- tion, and moisture of the skin from gentle perspiration. Keith in- sists upon keeping the hands covered because the perspiration will not come if the hands are exposed, and if it does start all right, put- ting the hands out from under the bedclothes will stop it. If there is nausea, sips of hot water should be frequently given. When all goes well there is very little after-treatment needed and the less em- ployed the better. The stomach should rest until the patient feels a desire for food or drink, and no food should be given by the stomach until flatus has passed from the bowels. Solid food is not given until asked for by the patient. Pain, if severe, should be re- lieved by hypodermic injections of morphia. Excessive vomiting may be controlled in the same way. Flatulence which gives dis- tress and does not pass off is most effectually managed by a sohition of quinine administered by enema. Dr. Keith told me about the use of quinine in this way, and I have used it very often and with the most satisfactory results. Six or eight grains dissolved in aro- matic sulphuric acid, with about half an ounce of water with acacia enough to make the mixture bland, is the formula used. When about to use it warm water enough is added to raise the temperature of the mixture to that of the rectum. OVARIOTOMY. 529 This I have found will relieve flatulence if it can be relieved at ill, and is at the same time a good way of supporting the patient, in fact, I believe tliat its action in relieving flatulence is by restor- ing the tone of the intestines. Should the stomach remain irritable and the patient be weak, she should be supported by soup and brandy administered per rec- tum. The bowels should usually be moved by enema about the tifth or sixth day. The patient may sit up about the fifteenth day, and return to her usual duties in about four weeks. The time must vary in each case according to circumstances. The management of the various complications which may arise after ovariotomy will be discussed with the histories of cases which will be given hereafter. Some points of interest regarding diagnosis and treatment will also be brought out in the clinical records. 35 CHAPTEE XXIX. ILLUSTEATIVE CASES OF OVARIAN NEOPLASMS. In giving the liistories of ovarian neoplasms it lias been deemed best to omit simple and typical cases, because they would add noth- ing to the description already given. The following complicated ones, on the other hand, will tend to convey clearer ideas of the pecuhar cases which are frequently met in practice, and the approved methods of management adopted at the present time. Monocyst of the Right Ovary ; Firm Adhesions to the Abdominal Wall ; Necrosis of the Posterior Wall of the Cyst ; Ovariotomy ; Re- covery. — The patient was hf ty-four years old, and the mother of four children. After the birth of her last child, the attending i:)hysician told her that she had a small tumor on the right side of the uterus. There was considerable intermittent pain in the region of the neo- plasm from the time that it was hist discovered up to the time that she came under the care of my associate. Dr. Palmer, four years afterward. The growth of the tumor was slow, scarcely noticeable for the first three years, but very noticeable during the last year. When she first came under the care of Dr. Palmer the tumor ex- tended above the umbilicus, and fluctuation was well marked. There was evidence of circumscribed peritonitis, and, although the tumor was movable, adhesions were being formed. The peritonitis was quite pronounced at this time, and the constitutional symptoms were well defined. She was treated for this, and in about two weeks the acute symptoms subsided, but she still remained weak. The doctor sent her home in the hope that she would gain strength, and the tumor being still small there was no urgent necessity for its re- moval. In a month she returned to the hospital not improved. She was losing flesh, the parts were still tender, the appetite poor, the pulse weak, and the temperature kept above 100° F. Another effort was made to get her into better general condition, but without success. She lost strength gradually, and it was de- ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 531 cided that the only chance for her was by removing the tumor. At this time the adhesions were firm and involved all parts of the ab- dominal wall which were in contact with the tumor. Just before the operation the pulse was 120 and the temperature 101°. When the abdominal incision was made, the adhesions were very firm and vascular, except in a small space just above the sym- phisis pubis. The cyst was emptied by tapping, and the lower por- tion, which was not adherent, was drawn out, and the pedicle grasped with strong fixation forceps, and divided. The adhesions were now easily reached and separated. The pedicle was then ligated, and the bleeding stopped by pressure with sponges. By managing the pedi- cle in. this way, the tendency to bleeding from the site of adhesions was lessened very decidedly. When all bleeding had stopped the wound was closed and dressed in the usual way. An examination of the cyst showed a portion of its posterior wall (about the size of one's hand) perfectly bloodless, of a dirty gray color and friable, indicating that it was necrosed. No doubt the death of this portion of the sac had taken place many days be- fore the operation, and I presume was the cause of the constitutional disturbance. From the facts in this case and from those observed in other cases of necrosis of the cyst- wall, I believe that the dead tissue causes a form of septicaemia, certainly in this case there was nothing else found to cause the -high temperature and pulse, and the subsequent history confirms this view. The operation was performed between eleven and twelve o'clock. She soon recovered from the ether, and showed no depression. At seven, in the evening her condition was better than before the oper- ation. The pulse was 112, temperature 99*5° F. and respiration 20. During the night she had slight pain in the abdomen and was given a hypodermic injection of morphine. She slept well, and had no vomiting. On the second day there was some slight distention of the abdomen from gas ; this was relieved by six grains of sul- phate of quinia in solution, given by the rectum. From this time onward her progress was very satisfactory. The temperature never rose above 99° F. Five days after the opera- tion the bowels were moved by enema. On the twelfth day she left her bed, and four days later was able to walk about the ward. About four weeks after the operation the left leg became swollen, and remained so for about a week. The cause of this was not certain. She was discharged from the hospital at the end of the fifth 532 DISEASES OF WOMEN. week feeling perfectly well and having gained flesh and strength surjirisiiiirly. Ovarian Cyst between the Broad Ligaments, Multiple Cyst of the other Ovary; Ovariotomy and Hysterectomy ; Eecovery. — This i»atient was under the care of my friend, Dr. F. II. Stuait, and most of the facts in the history of the case — before and after the operation — are given here as I obtained them from him. The lady was iifty-six years of age, and had passed the meno- pause about six years. At the age of thirty-nine years she had a pelvic abscess which opened into the bladder, and she was then sick for a long time. About three years before the time when this history was taken she noticed a tumor in the right iliac region. She w^as first seen by Dr. Stuart, April 30, 1886. lie found the uterus high up behind the symphysis, attached to an elastic tumor, which was immovable, and by external examination appeared to be larger than a fetal head and extending uji into the right iliac fossa. There were two other tumors of smaller size, one above and one to the left of the larger one. These appeared to be adher- ent to the first one, and were also rather immovable. 1 saw the patient the next day with the doctor, and confinned the diagnosis of ovarian cysts. On account of the adhesions, and as the patient was not suffering any great inconvenience, we thought it best to await further developments. She passed a very comfortable summer, but increased steadily in size, with a corresponding increasing discomfort in locomotion. About the 1st of December, 1886, she began to have frequent and painful urination, and some fever. After a few days of quiet and some quinine (as there was a decided intermittence in the ii'ritabiUty of the bladder), she became again quite comfortable. Immediately before the operation the physical signs were as fol- lows : The general outlines of the enlarged abdomen were irregular, three cysts could be majDped out, and fluctuation was distinct in each. The most dependent cyst was about the size of the uterus at the seventh month of utero-gestation. and occupied the center and lower region of the abdomen. It was not movable to any extent, and appeared to be separated from the other cysts except at the up- per and right side, where it seemed to be adherent but not firmly so. The two other cysts occupied the upper and left lower regions of the abdomen, raising the diaphragm and causing the lower ribs to project slightly. These two cysts could be moved together in the abdomen, but were closely united forming one tumor. The fluctua- ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 533 tion was very clear in each of tliem, but was not distinctly felt through the mass formed by the two. All around the circumference of the abdomen there was dull- ness on percussion, and distinct Huctuation, though broken at points where the divisions between the cysts were. These signs simply in- dicated the presence of a multiple cystic tumor. The umbilicus was high up, showing that the lower portion of the abdominal mus- cles was distended most, and in a space about five inches in diame- ter in the umbilical region there was tympanitic resonance and gurgling on pressure, showing the presence of intestines at that point. Taken altogether the abdomen appeared to be occupied by a large cystic tumor with a mass of intestines in a cup-shaped space in its center. By vaginal touch the uterus was found displaced upward and forward, and the cervix could be reached without difficulty, owing to its being crowded toward the pubes. Behind the uterus and ex- tending down into the upper and posterior portion of the pelvis a segment of cyst was found. The uterus was displaced by moving the cyst in front, and pushed forward by raising the cyst behind it. The examination indicated very certainly that there was a cystic ova- rian tumor of the multiple variety, but there was evidently more than that. The fact that the uterus was involved raised the ques- tion of uterine fibro-cyst, as well as ovarian tumor, but there was some doubt about the nature of the whole mass. It was possible that the uterus was simply adherent to the cystic tumor, and that the adhesions had been formed while the tumor was still in the pel- vis, and the uterus had been carried upward as the tumor grew. It also was presumed that there might be two cystic tumors, and that the uterus was attached to one of these. While the exact pathological conditions were not decided upon, two facts were quite evident ; tirst, that there was at least an ovarian tumor, and that the patient must obtain relief, if at all, by ovariot- omy. Ojjeration. — After making the abdominal incision, the first cyst was exposed, and adhesions of the omentum were found on the right side. The omentum w^as vascular and its adhesions covered the upper part of the tumor. After emptying the cyst by tapping, the omental adhesions were ligated and separated, and it was then found that this cyst had no connection with the cysts above, but was situated between the folds of the broad ligaments, and extended from one side of the pelvis to the other, between the uterus and the bladder. The uterus, being behind the cyst- wall and firmly attached to it, had 534: DISEASES OF WOMEN. been stretclied laterally so that its long diameter was transverse. The empty cyst was held outside of the abdominal wonnd at this stage of the operation by forceps, and the incision extended upward so that I could reach the other tumor, which I found to be a m.ulti- ple cyst of the left ovary. The four largest cysts were tapped separately, first the one on the right side, and next the one above and to the left, then the one that dipped down behind the cyst of the broad ligament and uterus, and lastly a middle one between the upper and lower cysts. There was a deep fissure between the two cysts on the left side through which the intestines found their way up to the abdominal wall, which accounted for the tymj)anitic resonance obtained during the examination. Tliis tumor had an ordinary pedicle starting from the left posterior surface of the broad ligament, which was ligated with silk, and the tumor removed. Having disposed of this tumor, I returned to the cyst of the broad ligaments, and upon laying it open and inspecting its cavity, I found at the bottom of it a paj)illomatous mass which had the ap- pearance of an epithelioma. I then undertook to enucleate this cyst, the lower portion of which was fixed in the broad ligaments, between the bladder and uterus, as already stated, but the adhesions were so firm and the vascularity so great, that this was impossible. I then tried to enu- cleate the inner wall of the cyst, but this was also impracticable. The thought occurred to me that I miglit stitch the cyst-walls to the sides of the incision in the abdominal walls, but as the cyst dipped down into the broad ligaments on both sides, two pockets would have been left, which would have been difficult to drain. The papillomatous mass in the central part of the sac would have been left also, and that, I presumed, would have interfered with the clos- ure of the sac. and the final recovery of the patient. It seemed as if the w^hole thing should be removed, but I could not take in all the tissue involved in any ordinary clamp. I then tied and divided the broad ligament on both sides from the outside toward the center, so as to f onn a pedicle which could be grasped in the clamp. The bladder was dissected from the cyst- wall far enough to let the clamp get down below the uterus and the most dependent portion of the sac. Keith's modification of Baker Brown's clamp was then applied, and the cyst and uterus removed. A drainage-tube was introduced above the clamp, and the abdom- inal wound closed from above downward. The operation was completed at noon, and five minims of Ma- ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 535 gendie^s solution of morplime were given hypodermically at once. She slept quietly for about two hours and then had some nausea, and vomited a mouthful of mucus. The remainder of the day was passed comfortably, the catheter was used, and sips of hot water were given. At midnight the temperature was 99f ° and pulse 86. The second day was without much to note except that the temperature went up to 101|-° but, toward midnight, it came down to 100° and the pulse was 86. There was some distention of the bowels which was relieved by quinine, given by the rectum. From this onward the patient did very well, the pulse was good and temperature ranged from 99° to 100°. She required morphine to keep her comfortable, but noth- ing more. After the operation the kidneys acted very well, the catheter be- ing used for two days, and after that the patient urinated without trouble and passed the usual quantity of water. On the tenth day, while urinating, the dressing of the wound became saturated with urine, showing that the upper part of the bladder had opened ; the dressings were removed, but the opening was covered by the clamp and could not be seen. Several times afterward when she urinated she passed a very small quantity of water by the urethra, the larger portion passing by the side of the clamp. Between the times when she urinated there was no leaking from the opening in the bladder. She was not permitted to urinate after this ; the catheter being used at regular intervals. For two days very little urine escaped from the opening, and then a little began to come, which made the wound unclean. It being quite evident that the stump, below the clamp, had un- dergone necrosis to a considerable extent, an elastic ligature was passed around the stump, below the clamp, in the hope that it would cut its way through the softened and dead tissues, and set the clamp at liberty ; it did so to a limited extent only, and, as it was very difficult to keep the wound clean, the clamp, on the fifteenth day after the operation, was carefully liberated by dividing the dead tissues of the stump with the knife and scissors. No haBmorrhage was caused. When the clamp was removed, it was found that the necrosis of the tissue extended farthest on the right side, and it was at this point where the bladder was open. At first it was thought that the blad- der had been included in the clamp ; but that did not seem possible, because of the extreme care taken to avoid it when applying the clamp, and also from the entire absence of all functional disturb- ance of the bladder during the ten days immediately succeeding the operation. 536 DISEASES OF WOMEN. After removing the clamp, and seeing how far the death of the tissues of the stump liad extended on the right side, it appeared that the opening of the bladder was due to this destruction of the tissues. The opening occurred on the right (as has been already stated), at the site of the old cellulitis, which she had years ago, and where the abscess discharged into the bladder, in all probability, and this may account for the death of the tissue below the clamp. During the operation it was noticed that the right broad liga- ment was thickened greatly, and changed in appearance, owing no doubt to the products of the old inflammation, and the damaged state of the tissue probably favored the necrosis ; this may have been also favored by the pressure of the abdominal wall. The pedicle was broad, so that it stretched the wound, and the pressure of the strongly retracted edges of the wound may have helped to strangu- late the right side of the stump, the vitality of which was of a low order. The dressing of the stump and abdominal wound now became a rather difficult task, owing to the escape of urine. Iodoform and absorbent cotton did best of all. Although the catheter was used, there still was some leaking above. The urethra became tender to the passing of the catheter, and then the doctor tried keeping it in the bladder continuously. This did well for a time, but had to be given up because of the pain caused. By the free use of cocaine the catheter could be used, so that the leaking in the wound was not great. During all this time her general condition was fairly good, but the wound healed slowly, and she needed morphine to keep her comfortable. About this time several of the ligatures used in tying the broad ligament on the right side came away through the wound. About five weeks after the operation, and while she was apparently well, except that the fistulous opening of the bladder remained and her strength had not returned fully, she was taken quite ill ; the tem- perature ran up to 103°, and the bowels became constipated ; the appetite was entirely lost, and she looked badly in the face, and lost flesh rapidly. There was a hard, irregular mass felt in the right side of the abdomen at this time, which was presumed to be a local inflamma- tion due to the ligatures used in ligating the omentum. The doctor and I were not without some fears that it might be the beginning of some malignant disease, but it proved not to be so. Quinine given by inunction and the rectum controlled the fever after a time, and then the stomach and bowels began to act again. ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 537 From this time her progress was favorable, and she is now (one year after the operation) perfectly well, A Papillomatous Monocyst of the Ovary. Ovariotomy. Fatal Termination from Haemorrhage. — The patient was thirty-five years old. She had had two children. For about one year before the ovarian tumor was detected she suffered from menorrhagia. When I first saw her she was quite anaemic from long-continued and pro- fuse menstruation, caused by polypoid fungosities of the uterine mucosa. She was promptly relieved by curetting. At that time the ovarian cyst was about the size of a pregnant uterus at four and a half months. The cyst increased in size rather slowly. She had two attacks of circumscribed peritonitis, one at the upper part of the cyst, which gave rise to adhesions to the abdominal wall above and to the left of the umbilicus. About eight months from the time that I first saw her, and after the slight attacks of peritonitis, she was attacked with severe pain in the region of the cyst, but there was no evidence of inflammation. At this time the cyst became very tense, and there was general tenderness and heavy pressure. These symptoms subsided for a time, but there were several attacks of this kind, each one being marked by a sudden increase in the tension of the cyst. The patient continued to be rather anaemic, there were wandering, ill-defined pains in the abdomen, and the general condition showed that she suf- fered more than is usual in cases of uncomplicated ovarian cystoma. This led to the determination to operate, though the size of the cyst did not demand immediate interference. When the wall of the abdomen was opened, and the cyst exposed, it was darker in color than it should be ; adhesions were found at the upper and left side, and also low down and near the median line. Tapping was tried, but the contents of the cyst would not flow. The sac was then opened, and its contents were found to be blood and old blood-clots with very little ordinary ovarian fluid. It was neces- sary to pass the hand into the cyst to evacuate its contents ; this caused fresh and profuse bleeding. The patient showed the loss of blood very rapidly; great haste was made to separate the adhesions, which were very vascular and required ligating. The depression became more and more marked, and it looked as if the patient would die on the table. The cyst was hurriedly re- moved, and the abdominal wall was closed. There was some oozing from the adhesions, and, as there was little time for sponging the peritoneal cavity and stopping the bleeding, which was only a very little oozing, a drainage-tube was used. The patient rallied a little, 538 DISEASES OF WOMEN. and tliere were ])opes that she might be saved. There was consid- erable discharge of bloody serum from the tube, which, in place of becoming less, as I expected it would, increased. Whenever the pulse improved, and the patient gained a little strength, the bleed- ing increased. It was never free enough to warrant my opening the abdomen to stop it, but kept on just enough to keep the patient down. At the end of the third day there was very little bleeding, and there was a promise of success, but then she began to show signs of heart-clot, and she died on the fourth day. The inside of the cyst was Uned with a layer of papillomatous material, which presented a cauliflower appearance not unlike that of epithelioma of the cervix uteri. The points of greatest interest in the history of this case are the frequent hfemorrliages which took place in the cyst during its growth and the unsatisfactory character of the operation which permitted the loss of so much blood. There is no doubt in my mind but that the attacks of distress and extreme and sudden distention of the sac were due to the haemorrhages in the cyst. This view of the matter was confirmed by the large number of blood-clots which were found during the operation. The evidence of these extra cystic haemor- rhages was so marked and pecuhar that I am sure a diagnosis could be made with certainty in similar cases. This would be a great gain, because it would enable one to operate before the frequent losses of blood had weakened the patient, and while the cyst was small, and could be more easily removed — two advantages which would tend to the safety of the patient. There were several unfortunate incidents in the operation which could have been in part prevented had I had more experience in such cases. In the first place, when the patient was anaesthetized, the cyst was handled with considerable force for the purpose of de- termining the presence and extent of the adhesions. This, I am sure, started the bleeding, which might have been avoided. When the cyst was opened, and the active ha?moiThage detected, I should have found the pedicle, and temporarily controlled it with com- pression-forceps. This ^vould have saved much of the haemorrhage, and then I could have taken time to treat the adhesions properly. These facts, I beheve, explain fully the failure in the case, and they throw much valuable light on the diagnosis and treatment of this peculiar variety of ovarian neoplasm. Ovarian Cyst between the Folds of the Broad Ligament. Incom- plete Removal of the Cyst ; the Remaining Portion treated with Drain- age; Recovery.--This lady was thirty-five years old, and had been ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 539 married nineteen years. Her general health had been fairly good, but slie did not menstruate until she was nineteen years of age. The menstrual flow had always been scanty and of short duration, and she never had been pregnant. These facts indicated that probably the sexual organs were im- perfectly developed. About one year before she came under my care she noticed a small tumor in the right side of the abdomen, low down. It steadily increased in size, and then she lost flesh and strength, and sirflicred from pain in the abdomen and back, and her appetite failed. When flrst seen by me she had a bronzed appear- ance, was feverish, and the pulse was fast and rather weak. She had the general appearance of one in the last stage of ovarian dropsy, and also cachectic. The tumor was about the size of the uterus at the seventh month of pregnancy. It was very hard, and fluctuation was very indistinct. Though not apparently adherent to the abdomi- nal wall the tumor was not at all movable. It was firmly fixed in the pelvis, and there was mucli tenderness. By the vaginal touch the hard tumor was found deep down in the pelvis, firmly fixed, and not the slightest fluctuation oi- elasticity could be detected. The uterus was pushed to the left and upward, so that it partly occupied the left iliac fossa. The irregularity of the surface of the tumor, as felt through the vagina, indicated that it was surrounded by the products of inflammation. The physical signs, as observed by the vaginal touch, were such as would indicate a uterine fibroid developed in the right broad liga- ment, but the character of the tumor, as felt in the abdomen, showed that it was a cyst. The question of fibro-cyst was then raised, but the history of the case was not in favor of this. While there was little doubt regarding the true nature of the tumor I fav- ored the diagnosis of ovarian cyst complicated by inflammation of the cyst-w^alls. The patient was placed under treatment in the hope of improving her digestion and general health, but beyond relieving her consti- pation and flatulence there was no real gain. Her pulse remained about 98, and her temperature fluctuated between 99° and 101°. During thp few days that she was under observation the cyst became a little less tense so that fluctuation could be more surely made out. The chief points of interest in the operation were as follows. The tumor, easily and fully exposed by an incision three inches long through the abdominal walls, was adherent to the omentum over its entire anterior surface. The cyst was emptied by aspiration of its con- tents which contained pus and lymph. The omentum was ligated 540 DISEASES OF WOMEN. in sections with silk, and detacbed from tlie cyst-wall. It was then found that tlie folds of the broad ligament covered the cyst com- pletely, and were so intimately blended with the walls of the cyst that they could not be separated to any extent. Careful and ])ersist- ent efforts were made to enucleate the cyst, but in vain. The open- ing in the cyst was temporarily closed with forceps, and the left ovary looked for. It was found far over on the left side and con- tained several small cysts. It was removed in the usual way. The major portion of the cyst-walLs and broad ligament was then re- moved, and the larger vessels ligated to control hemorrhage. An- other effort was made to enucleate the remainder of the cyst-walls, but they extended so deep down into the pelvis and the tissues were so exceedingly vascular and matted together by inflammatory prod- ucts that it could not be done. The remains of the ligament and cyst-w^alls were carefully stitched to the abdominal wound, the sac carefully sponged clean, and a large drainage tube introduced. The after-treatment and progress of the case were as follows : She had for the first two days considerable nausea and pain. For this she was given hypodermic injections of morphine. The sac was washed out thoroughly every four or eight hours according to her temperature. There was not much nourishment taken during the first six days. The pulse and temperature varied greatly. The pulse kept above one hundred most of the time, and the temperature fluctuated between 100° and 102° and occasionally 103°, but this high temperature never lasted long at a time. During the first ten days the morphine was required, and stimu- lants had to be used. In spite of the frequent washing out of the sac and free drainage there was some blood-poisoning. Quinine was freely given (whenever the temperature went up) by the rec- tum and by inunction. From the twelfth day onward there was not much of interest. The patient's nutrition was poor, the pulse and temperature kept a little above normal, and occasionally the temper- ature rose to 101°, rarely to 102°. The sac cavity gradually dimin- ished, and the discharge became less. At the end of the third week the temperature was normal and remained so afterward. She took food well, and began to gain strength and flesh. The cavity was very small, and the drainage-tube used was a piece of a No. 10 elas- tic catheter. The wound had completely healed, except where the tube was in place, at the end of the fourth week. Five weeks after the operation, and when the patient was up and apparently about well, there came a swelling quite hard at the side of the sinus, and the temperature went up to 102°. It was sue- ILLUSTRATIVE CASES OF OVARIAN NEOPLASMS. 541 pected that an abscess was formiug there, and in the hope of reach- ing it, if suppuration occurred, the opening was enlarged, and a tube of greater caHber introduced, but the swelling entirely subsided and the tube was removed. The patient was discharged in good condition two months after the operation. A Medium-sized Ovarian Cyst which could not be removed owing to the Character of the Adhesions ; treated by Drainage ; Recovery. — The patient, a German lady, thirty-four years of age, was admitted to the liospital, and gave the following history : She had had several children and had noticed a " lump " in the abdomen about one year before my first examination. This gradually but slowly increased, and at times there was pain but not severe, until about four mouths after she discovered the tumor. At that time she was seized with violent pain in the abdomen, especially on the right side. According to the history she evidently had at that time a severe inflammation. This slowly subsided under the care of her family physician, but she did not regain her health, and continued to lose flesh, her bowels were constipated, and there was much pain and tenderness in the region of the tumor. The size of the tumor increased, and it was much more prominent on the right side. At my first examination, I found the tumor firmly fixed on the right side, the adhesions to the abdominal walls and viscera being evident at all points, especially high up in the lumbar region on the right side. The fluctuation though not clear, was sufiiciently so to indicate that the tumor was a monocyst. Her general condition was very poor, she was greatly emaciated, her skin was bronzed, and she had the general appearance of one suffering from malignant disease. Her pulse was feeble, and her temperature varied between 98° and 100°. She had pain and tender- ness in the abdomen, especially on moving. Efforts were made to improve the general health, but without effect. The points of special interest in the surgical treatment were the following : The abdominal wall at the point of incision was very vascular, and the adhesions were also thick and vascular, and were with difiiculty separated from the cyst-wall. On tapping the sac it was found that the contents contained lymph and some pus, show- ing that there had been inflammation of the interior wall of the cyst. On the left side the abdominal wall was separated sufficiently to en- able me to pass my fingers into the peritoneal cavity, and there I found the intestines adherent to the cyst-wall. I tried first to sepa- rate the adhesions but that could only be done by dissection, and the 542 DISEASES OF WOMEN. bleeding was sucli that I had to abandon that procedure. I then tried to dissect the peritona^'iun olf from the cyst-wall and leave it attached to the intestines, hut this was impossible. In a dissection about an inch long and half an inch in width I had to use three ligatures to stop the bleeding. I also found that every portion of the sac was fastened in by strong and vascular adhesions which I knew I could not separate without losing my feeble patient. The fact is I could not remove any considerable portion of the sac, only a very small portion in front. I thoroughly cleaned out the sac, and stitched the edges to the abdominal wall. This was easily done because the cyst was adherent all round to the abdominal wall, except on the left side. A large drainage-tube was introduced and the sac washed out with carbolized water twice or three times a day. The patient did well. She began to gain soon after the opera- tion, and continued to increase in strength slowly, but without in- terruption ; at the end of two weeks after the operation the sac had ' contracted very nmch, and there was considerable suj)puration. The long tube w'as removed, and a shorter one was used to maintain thej opening in the abdominal wall. The thorough washing out was kepf up, and about live times in all I distended the sac with ecjual pari of carbolic acid and tincture of iodine. This destroys the secreting surface of the sac, suppuration followed, and the sac contracted grad4 ually. At the end of two months there was little more left than solid mass with a narrov/ and not very deej) sinus in it. The patient was sent home, and directed to wash out the sinus daily. She was not seen again until live years after, when she returnee to the hospital to see my associate Dr. Palmer. She had greatlj improved in appearance, and stated that she had been quite wellj and had attended to her household duties since she left the hospita after the operation. The opening in the sac remained for foi months after she went home, but finally closed altogether, and gave no trouble afterward. She had a ventral hernia, which appeared a^ the point of the wound two years after the operation. I am satisfied that in certain cases in whioli the adhesions are extensive and very vascular that it is safer to leave the operatioi uncompleted, and employ drainage. I have had five successful cases treated in this way, and one vei bad case that proved fatal, but probably would have recovered hac the patient not had organic disease of the kidneys, of which she diec Mature judgment, based upon experience alone, can enable one to de termine when to employ drainage in place of removal of the tumor.1 The only way to determine this is to examine the extent of thej ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 543 adhesions, and whether or not they can be separated without injury to the abdominal viscera. Should the cyst prove unmanageable by tlie operator, the part of it which can not be removed should be left and treated by drainage, and washed out with antiseptics. I am well aware that an expert and experienced operator can manage very formidable adhesions, but, when an operator of limited ability en- counters adhesions that he can not handle safely, he will be more sure of success if he relies upon draining the cyst or that part of it which can not easily be removed. Recovery is sometimes tedious, but generally sure, according to my observations. The following cases of suppurating ovarian cysts, reported by Dr. Keith, together with his comments on them, are of such great value that I cpiote them in full : SUPPURATING OVARIAN CYSTS. The following narratives help to show that ojDeration ought to be the rule of practice in cases of acute suppurating cysts, or when typhoid symptoms come on after tapping : Ten years ago, when cases of ovariotomy were few, and there was little to guide one in unusual circumstances, a young woman in the last stage of ovarian disease came to me a long journey from the north. The fatigue of traveling was too much for the strength that was left, and she arrived completely worn out. It did not seem possible that, in such a condition, life could be prolonged many days, for the pulse was almost imperceptible, there was vomiting and diar- rhoea, oedematous limbs, and albuminous urine, while a profuse fetid discharge was going on from an opening near the umbilicus. The intensity of this putridity was such that one became aware of it before entering the house, and the antiseptics of those days were powerless to arrest it. Day after day I went expecting and hoping to find her dead, yet, though shriveled up like a mummy, with an aspect scarcely human, respiration went on for nearly a month, the brain retaining its clearness, acutely alive to what was going on around. To remove a putrid cyst in such a condition of feebleness did not at that time even occur to me ; yet, since then, I have oper- ated more than once under circumstances not less unfavorable, and, looking back upon this case now, I think that operation might have turned out well ; certainly death after it would have been the more merciful way. Soon again (December, 1864) there came another case of very large tumor. The patient had been jolted for some hours in a coach. 544 DISEASES OF WOMEN. and, in the hope of relieving the pain thus set up, tapping was per- formed after her arrivaL The pain was not relieved, abdominal distention from flatus became excessive, and typhoid symptoms rap- idly set it. Fearing a repetition of the slow-death process — which those who saw will not easily forget — ovariotomy was this time per- formed during the semi-delirium of septic fever. This was proba- bly the flrst time that surgery broke in upon an acutely inflamed peritonaeum. The intense lividity, amounting almost to blackness, of the abdominal contents, and the spongy tenderness of inflamed intestine, were then strange to me, though thought little of now. Kecent lymph was present everywhei-e, adherent bowel and mesen- tery hedged in a thick-walled cyst, the base of which was in a com- plete state of slough. Inflammation had gone on to gangrene, and there was intense putridity, just as in the previous case. After an operation which went on for two hours, the patient was placed in bed, cold, vomiting, and nearly pulseless. It seemed as if we had simply killed her, yet she got rapidly into heat, the restless delirium at once disappeared, there were warm perspirations, much sleep, and a recovery without a drawback. This case, which was at the time fully reported in the " Lancet," 1865, page 480, has been to me as a landmark. Since then I have ten times met with cases of acute suppurating cyst, besides two chronic cases. In all of these, save one, the chance of ovariotomy was given, however hopeless looking the case might be. In the exceptional case ovariotomy would also have been performed had it been possible to remove the patient from her poor home and un- favorable surroundings. She was seen with Dr. Menzies on the third day after her fourth conflnement. He had been called to her for the flrst time only the day before. A large ovarian cyst had existed with at least two of her pregnancies. The distention was so enormous that urgent dyspnoea had to be relieved at once by tap- ping. Upward of six gallons of fluid, containing much blood and pus, were got away, and ovariotomy was agreed on as soon as she could bear removal. This could not be accomplished, and, after three weeks, tapping was again had recourse to. This time the pus was intensely putrid, and, as the cannula got choked with pieces of fetid lymph, an incision, suflicient to admit two fingers, was made into the cyst, and its putrid contents thoroughly cleared out. For- tunately, the cyst was single ; a perfect recovery took place, and this p&tient has had two children since. None but the strongest of women could have borne the exhausting suppuration that went on for nearly four months. Pulse and temperature remained high, and ILLUSTRATIVE OASES OF OVARIAN NEOPLASMS. 545 of at least six weeks of her illness slie has now almost no remem- brance. Recovery in such circumstances must be rare ; yet it may be well to note that during the whole time she was supported en- tirely on milk and buttermilk, and had no stimulants whatever; neither was there any washing out of the cyst. Of the ten more or less acute cases operated on, eight recovered, while the two chronic cases got well easily. During 1872-'Y3 sev- eral came about the same time, and the following series of seven occurred fn the course of my second hundred operations for ovarian tumor, none of which have yet been published. To an onlooker, few operations look so hopeless as those for the removal of acute suppurating cysts. The general condition is always unfavorable, and, as a rule, ovariotomy is in these circumstances tedious and se- vere. To be believed in, such cases need almost to be seen. Suppurating Ovarian Cyst; Ovariotomy; Recovery. — Mrs. M., aged thirty-five, was sent to rae in the end of June, 1871, by Dr. Soutar, of Golspie. An ovarian tumor was detected toward the end of 1869. In January, 1870, she had severe abdominal pain. After a fortnight's rest, this passed off, but only to return with increased severity. Loss of flesh and rapid growth of the tumor followed, and it was nearly a whole year ere she was again able to be out of bed. During this time her sufferings, as told by a friend, must have been great. Often for weeks together she could not be moved from one position, while the changing of her dress, or the arranging even of the bedclothes, brought on such pain that her cries were heard in the street. It was eighteen months after her first illness that she was able to make the journey to town. I saw her after she had rested two days. The pulse was then 156 ; the temperature 103°. She was a tall, fair-complexioned, blanched-looking woman, ex- tremely emaciated ; the lips and fauces were very anemic ; the girth at the umbilicus was forty-six inches ; the lower part of the tumor felt solid, but fluctuation was distinct above the umbilicus ; the ab- dominal wall was hard, thickened, and oedematous ; the skin even in some places feeling as if adherent. It was evident that there were adhesions of a very unusual nature. Two days after this examination, with the assistance of Dr. Drum- mond, of Nice, I removed three gallons of thick pus by tapping some inches above the umbilicus. A large, prominent, hard tumor re- mained below this. Much relief followed, and for a few days the pulse and temperature somewhat fell. In three weeks the cyst had refilled ; the pulse was again rapid and feeble, varying from 120 to 36 546 DISEASES OF WOMEN". IGO ; the morning temperature was 101° to 102° ; that of the even- ing, 103° to 10-i°, sometimes higher. The skin was dry and shriv- eled, and she was, if possible, thinner than before. Ovariotomy was performed on the 13th of July, 1871. Sul- phuric ether w^as given. The incision extended from the umbilicus downward eight inches. The wall was much thickened, the peri- toneum of almost cartilaginous hardness, and the whole parts so un- usually vascular, that no time had to be lost in completing the oper- ation. The upper cyst was emptied of its purulent contents, the lower semi-solid portion thoroughly broken down, and the cyst- walls, weighing eighteen pounds, dragged out. There was not any part of the tumor non-adherent. The connections were of the ut- most firmness, especially those in the pelvis. Posteriorly, there was more adherent intestine and mesentery than I have met with except twice. The peritonaeum was thickened by old lymph. Large flakes, like pieces of cartilage, were peeled off the wall after removal of the tumor. Some of these were as large as the hand, and it was difficult to tell what really was the peritonaeum. All bleeding points were tied with Lister's ligatures, a broad, thick pedicle secured by a clamp, and the wound closed with silk sutures. The operation lasted upward of an hour ; much blood had been lost, and she was placed in bed with great fears for her immediate safety. She lay for some hours with an almost imperceptible pulse. She was restless, and great bursts of clammy perspiration broke out every now and then, such as one sees in those suffering from the shock of injury. Fortunately, there was no vomiting. By evening she was comfortably warm ; flatulence was troublesome ; there was much thirst. Pulse, 125 ; respirations, 32 ; temperature, 102.° She slept during the night, but got low and faint toward morn- ing, and there was some vomiting. Brandy and soup enemata were given every two or three hours. She improved toward evening. Flatus first passed forty-four hours after operation. The pulse was rapid and feeble, and she scarcely opened her lips for many days. In the third week there was pain and swelling in the right iliac fossa, and fluid formed. Four weeks after operation this swelling was punctured, and about a teacupf ul of yellow serum was removed by a syringe ; the rest was absorbed. She was al)le to return home in five weeks, and is now a strong, healthy woman. CHAPTER XXX. DISEASES OF THE FALLOPIAN TUBES. Before considering the various morbid conditions of the Fallo- pian tubes, I shall briefly review their anatomy. The tubes — one on either side — are contained in the broad liga- ments, and run transversely from each lateral corner of the uterus out to the ovaries, to which they are joined by a short, ligamentous cord. Each tube, or salpinx, is four to five inches long ; the right tube is usually slightly longer than the left. The diameter in- creases from the uterus toward the ovary ; and the canal similarly increases. They are formed of an external peritoneal covering, of an internal mucous surface, and of an intermediate proper muscular tissue, arranged in two layers, of which (1) the longitudinal seems to be a prolongation from the uterus ; while (2) the circular, pecul- iar to the tubes alone, ends as a kind of sphincter upon the abdomi- nal orifice. The mucous membrane is lined by cylindrical epithelium, the motion of whose ciha is toward the uterus. Numerous fusiform cells are found in an incompletely- developed connective tissue. The arteries arise from the utero-ovarian trunk, entering the substance of the tube at its lower border. The veins empty into corresponding vessels. The nerves come from the hypogastric and ovarian plexuses. A study of the development, in the embryo, of the female or- gans of generation, shows the closest structural relationships existing between the tubes and uterus. Some observers claim that part of the menstrual blood comes from the tubes. Anomalies of form and situation are frequent ; the tubes may be absent ; there may be only one tube ; alternate stenosis and dila- tation may exist ; and there may be marked difference in length be- tween the two tubes. Two abdominal orifices for a tube may exist, and fimbria from each may project into the peritoneal cavity. 54:8 DISEASES OF WOMEN. Again, tlie tube may be dislocated, twisted, bent into knuckles, or may have sulfered hernia along with portions of the intestine. The tubes may open into the womb abnormally low down, which may possibly account for placenta ])rievia in some cases. The tube may be completely separated from the ovary. A rare condition is hernia of the mucosa, where the muscular tissue is ab- sent or so weak that it allows the mucous membrane to protrude, forming a pocket into which the fecundated ovum may drop. Neoj^lasms may be found in the tubes ; among them tubercle, carcinomata, sarcomata, cysts, fibromata, myomata, lipomata, and papillomata. Morgagni's hydatid is a vesicle often hanging to a fimbria. Cysts, tubercles, and fibromata are the most frequent of these neoplasms, but even these are so rare that they need only to be mentioned here. So many morbid tubal conditions are either direct or indirect sequelee of salpingitis or " catarrh of the tubes" that this condition first demands attention. Salpingitis. — Inflammation of the tubes may be acute or chronic. Pathology. — In acute catarrh the mucous membrane of the tube is thickened, congested, and covered with neutral or acid mucus, muco-pus, or an opaque fluid which contains lymph-corpuscles and epithelial ceils which are changed in form or which have undergone granular degeneration. The longitudinal folds of the mucosa are effaced ; the fimbriae are obliterated or obscured by inflammatory products, and the ends of the tubes are usually closed. If not, the contents of the tube enter either the uterus or the abdominal cavity in which latter case pelvi- peritonitis results. In very severe cases (and sometimes in diph- theria) false membranes may be formed in the mucosa. Peri-salpingitis usually occurs in severe cases. The tube is in- creased in size, tortuous, and dilated irregularly, and when the puru- lent secretion accumulates the tube which is closed at each end be- comes greatly distended. This is known as pyosalpinx. In this condition the epithelia are flattened and the mucous and muscular coats are gradually thinned, so that rupture into the peritoneal cav- ity is not infrequent, in which case general peritonitis, or pelvi-peri- tonitis results. In rare cases the rectum has been perforated and the contents of the tube discharged through that viscus. Chronic catarrh is accompanied by the adhesions of the tube to the neighboring organs in some cases, the result of localized perito- nitis. The lower part of the uterus is adherent oftener than other adjacent parts. The ovary is also congested or inflamed in the ma- DISEASES OF THE FALLOPIAN TUBES. 540 jority of cases. The mucosa is much thickened, and secretes a fluid which is either thin and watery or thick and cheesy, not purulent as in acute salpingitis. Occasionally, chronic dropsy of the tube is the result of the secre- tion of serous fluid, and the tube may become distended and form a lai'ge cystic tumor; or, it may be converted into several distinct cysts without any intercommunication, since the tube between them has been totally obhterated by the inflammatory process. This is known as hydrosalpinx. In this condition all the coats of the tube sometimes become extremely thin. Dropsy of tlie tube may suddenly terminate when an opening of the duct into the uterus occurs ; this, however, is very rare. Cases are recorded where a hydrosalpinx has co:nmunicated with an enlarged and diseased ovary. Symptoms. — This affection so often follows gonorrhoea or endome- tritis that the symptoms of salpingitis are merged with those of the primary disease or are completely masked by them, until pelvic peritonitis occurs. This is the most dreaded outcome of salpingitis, and too frequently the first symptom which leads one to suspect its occurrence. Usually, however, when salpingitis occurs there is an increase in the symptoms so marked as to attract attention. The pain though less pronounced than that of peritonitis, is sufiicient to compel the patient to rest in the recumbent position. There is usu- ally some constitutional disturbance or slight symptomatic fever. In acute cases this fever is well defined, and attended with deranged digestion and nutrition. In short, it may be stated that the local and constitutional symptoms are the same as in other pelvic in- flammations, less acute than in pelvic peritonitis or pelvic hem- atocele, but as well marked as in pelvic cellulitis of a mild type. When pyosalpinx occurs there are symptoms of mild blood-poi- soning. Menstrual disturbances usually occur in salpingitis but not al- ways. It frequently happens that the severity of the symptoms is lessened, indicating that the inflammation has subsided, but it again lights up, and becomes for a time as marked as at first. Periodical watery fluxes with diminution in the size of a swell- ing in the region of the tubes, and accompanied by colicky pains, are indicative of tubal dropsy where the tube is incompletely closed near the uterine end. Physical Signs. — In the first days of the inflammation before the tubes are distended the chief sign is tenderness in the region of the tubes. When a tumor can be made out it is felt to be elongated, 550 DISEASES OF WOMEN. fluctuatinfi:, mo%'able, not separable from the uterus, and lying on one side in the retro-uterine space. By aspirating, a fluid which contains columnar ciliated epithelium is found. Of twenty one cases in which the fluid was examined by my colleague Dr. F, Ferguson, this epithelium was found in nineteen. This is a most valuable diagnostic sign, but as aspirating is not witliout danger it should not as a rule be resorted to. Except when the tube is enlarged a positive diagnosis of salpin- gitis can not be made. The condition with which salpingitis is apt to be confounded is a small ovarian cyst. It is impossil)le, often, to positively decide this question immediately. By waiting and watching the case the ovarian cyst will be found to gradually become larger without any increase in the constitutional symptoms ; while in tubal disease no increase in size occurs. Prognosis. — I believe that salpingitis may subside, but as a rule the tube is obKterated entirely or in part. When hydrosalpinx oc- curs there is not much chance of recovery. In pyosalpinx recov- ery can only be insured by removal of the tube. Causation. — Gonorrhoea of the uterine mucosa, and simple and puerperal acute endometritis are its chief causes ; but it may occur during the course of any acute infectious disease, from the presence of neoplasms or fi"om intense hyperaemia of the generative tract, as in prostitutes. It is possible that sypbilis may cause it just as it causes otitis or ozaena. Sometimes it is secondary to diseases of the ovaries. Microbes may find entrance into the tubes, and on this (not yet proved) statement, Sanger, of Leipsic, classifies salpingitis as S. gon- orrhoica, S. tuberculosa, and S. actinomycotica. He also bas a salpin- gitis septica including S. pysemica, ichorosa, purulenta, and diphthe- ritica, which are due to specific microbes identical with those produc- ing traumatic infection. Treatment. — Acute and subacute salpingitis, in the early stages, should be managed in the same way as other inflammations of the pelvic organs and tissues. Rest and anodynes for the relief of pain ; counter-irritation and attention to the bowels are the chief indica- tions. When the acute symptoms subside, iodine and mercury have been used locally, and massage and electricity also, with some possible good results. When once hydrosalj^inx or pyosalpinx are developed it is doubt- ful if any treatment except laparo-salpingotomy is eifective. Cer- tainly this is the cas2 in pyosalpinx. DISEASES OF THE FALLOPIAN TUBES. 551 Laparo-salpingotoniy, as linst ])riicticed by Tait and Ilegar is the recognized treatment in these otherwise incura])le diseases of the tubes, and the results are very satisfactory. It is not always possi- ble to ascertain whether hydrosal])inx or pyosalpinx exists ; hence it is wise to perforin laparotomy and remove the diseased tul)e if the subject of pyosalpinx ; should a hydrosalpinx be found it may be deemed best to try stripping the tubes or catheterizing and cleaning them out and restoring them to their normal situation, and trasting to curing the trouble thereby. This has been tried by Polk, but the results are not sufficiently well known to determine the merits of this procedure. In the former case the woman is sterile, in the latter not necessarily so. TUBERCULOSIS OF THE TUBES. Pathology. — In this condition the tubes are rigid, thick, and bound down by pseudo-membranes. The thickening results from infiltration. Acute catarrhal salpingitis usually co-exists. Both ends of the tube are usually closed but between them the cavity is much dilated, containing mucus, muco-pus, pus, or cheesy debris. The vessels of the tubes are enlarged and thickened and the nodules upon them, as weU as the nodules on the mucosa and in the muscularis contain the tubercle bacillus. SyTTijptomatology . — The tubercular diathesis which is usually present is the only indication of the nature of this affection. It may be possible to recognize the dilated tube by palpating the abdomen, and by manual examination when its immobility, size, tortuosity, and nodular feel, taken in connection with the constitutional conditions causes us to suspect tuberculosis of the tube. Possibly the dilated tube may be felt by a vaginal examination. German gynecologists advise that the secretions from the uterus should be examined for the bacilli which if found are evidence of tuberculosis. Treatment. — Were it possible to diagnosticate isolated tubercu- losis of the tubes, extirpation would afford a means of (possible) radi- cal cure. HiEMATOSALPINX. Blood in the tubes induces hypertrophy of the walls except at one point, which, growing thinner and thinner, forms a sac varying in size from a pin's head to an orange. Any portion of the tube 552 DISEASES OF WOMEN. may be the seat of such a tumor. Fatty degeneration or ulceration of the walls of the tube may induce rupture and peritonitis. At times the uterine end of the tubes permits of partial or complete evacua- tion of the tumor. Symptomatology. — The symptoms are the same as those of hydro- salpinx except that they are more acute at lirst, and at the time of the menses are all markedly increased in intensity. Ktioloijy. — Intense liyperaemia of the genitals, retroversion, typhoid fever, measles, and purpura hsemorrhagica have been known to cause hsematosalpinx. "When blood can not make its way out of the uterus it may flow back into the tubes. There is no doubt, how- ever, that the mucous membrane of the tubes alone is capable of being the source of the haemorrhage. Treatment. — Laparo-salpingotomy is the proper treatment, and if the diagnosis is made the tube should be removed before peritonitis occm*s. The prospects of a favorable result are then very good. ILLUSTRATIVE CASES. Salpingitis imcomplicated ; Recovery. — The patient was twenty- nine years old, and had borne three children. She had an endome- tritis following her last confinement, the cause of which was probably gonorrhoea. While under treatment for metritis, she became much fatigued, and was exposed to cold, and soon after was seized with severe but not very acute pain in the pelvis, symptomatic fever, loss of appetite, and tympanites. The temperature was 101°. A digital examination detected tenderness in the upper portion of both broad ligaments in the region of the Fallopian tubes. There was no fixa- tion of the pelvic organs, neither was there any swelling, except that the tubes could be more distinctly felt (by the bimanual touch) than usual. The diagnosis of salpingitis was made and confirmed by Dr. John Byrne, who saw the patient in consultation with me. A mer- curial cathartic was given, and followed by a saline laxative. Hot applications were applied to the abdomen, and the hot-water douche, which had been used for her metritis, was continued. Opium was given with bromide of sodium to relieve her pain and secure sleep. On the fourth day from the time of the attack blisters were appHed over the iliac regions, the bowels were kept free with saline laxa- tives, and she was kept at rest in bed. After this the vaginal douche was used, small doses of quinia were given during the day, and a dose of bromide and opium at bed-time. She slowly improved. At the end of two and a half weeks she was permitted to sit up, but DISEASES OF THE FALLOPIAN TUBES. 553 the dull, aching, throbl)ing pain returned in a modiiied degree. A few days after that her menstrual flow came on, and all her symp- toms returned and continued. The flow was unusually free, and the pain lessened as the time passed. The same line of treatment was continued, and she recovered slowly. She was able to be about, though still easily fatigued, and, at the next menstrual period, she was kept in bed, though she did not suffer much. After the menstruation had ceased, 1 made an examination by the touch, and found that the tenderness had gone, and I resumed the local treatment of the endometritis. She recov- ered entirely in four months, but has remained sterile. It is possible tliat we were mistaken in the diagnosis, but I am satisfied that we were right. Hydrosalpinx ; Repeated Discharge of the Contents of the Tube through the Uterus ; Recovery. — My friend Dr. William H. B. Pratt, called me to see a rather delicate and very refined lady, who gave a history of some rather obscure pelvic affection, which had ex- isted for more than a year. The doctor found, when he was first called to see her, that she had a retroversion of the uterus, and pre- sumed that this was the whole cause of her suffering. He was able to restore the uterus to its place, but could not keep it in place, be- cause a pessary or cotton tampon caused great suffering. This was the history at the time that I saw her. I also learned that she was unable to ride or walk for any length of time, owing to the severe pelvic and rectal tenesmus, which the erect position brought on. By a digital examination, I found the retroversion of the uterus, and also a cystic tumor, low down on one side of the sac of Douglas. The tumor was oblong and elastic, and there was distinct fluctua- tion. I suspected that it was an ovarian cyst. Treatment gave her some relief, but she did not recover. She had repeated attacks of pain in the pelvis, and suffered so much on taking exercise that she was obliged to live an invalid life. Some time after seeing her the first time, she menstruated more freely than normal, had more pain and discomfort than usual. Soon after the menses she had a sudden and free discharge of fluid of a whitish, turbid character, and was much reheved after it. I exam- ined her soon thereafter, and found that the cystic tumor had en- tirely disappeared. Her symptoms, though modified for a time, returned again, and again the tumor was found in the same place. Another discharge of fluid occurred, followed by relief and the dis- appearance of the tissues. This much of the historj^, in the way of fllling and emptying of 554 DISEASES OF WOMEN. tlie tube, was repeated a iiuinber of times with this difference — that the accumulation of fluid was less. I regret that 1 do not have notes of the length of time that the trouble lasted, but it will suffice to say that the patient recovered completely, and has had no return of her hydrosalpinx of seven years ago. Double Pyosalpinx ; Recovery without Operative Interference. — The notes of this case wei'e y-iven to nie bv Dr. liuckiiiuster. The history is a rare one, and is of special interest. I have in the past doubted if ever pyosalpinx ended in recovery withont removal of the tubes, but this case shows that such may occur. The patient was married, and twenty-live years old. She had an abortion pro- duced, and peritonitis and salpingitis followed this maltreatment. Dr. Buckmaster saw her two weeks after the time of the abortion. She was then suffering from severe pelvic inflammation. The tem- perature was at that time 104° F. There was marked pain, tender- ness, and abdominal distention. The products of the inflammation quite tilled the pehnis, and there was fixation of the uterus. She was treated in the usual way by the doctor, and, at the end of two months from the time that she first came under his care, " the in- flammatory products had largely disappeared, and the uterus was slifflitlv movable, but on each side there were two masses about the size of small lemons. Several days afterward there was a sudden discharge of ill-smelling pus. On examination at this time it was foimd that the mass on the left side had disappeared. Soon after this there was another free discharge of pus, and the mass on the right also disappeared. For three months subsequently there was a slight but constant discharge of jjus from the cervix uteri, but finally it ceased. Oiie year from the attack the patient was in fair health, but suffered from pelvic pain at times, which appeared to be due to adhesions of the peritonitis. The histories of many cases of pyosalpinx might be given in which no benefit could be obtained by general treatment, but were promptly relieved by salpingotomy. In fact, the only reliable treat- ment for the relief of this affection of the tubes is to remove them. The operation is the same as for the removal of the ovaries, and need not be described here. Those who desire full details of this subject are referred to the works of Lawson Tait, whose brilliant achievements in this department of surgery were the first and greatest. No case of haematosalpinx has come under my observation, hence the reader is again referred to Lawson Tait for cases illustrating this subject. CHAPTEE XXXI. PELVIO CELLULITIS. The anatomical distribiitiou of tlie pelvic cellular tissue is the same as that in all other parts of the body, and its function in this region is also the same as elsewhere. It tills in all the interspaces between organs and tissues, being most abundant where there is the greatest mobility, and it is the principal accommodating and protect- ing medium through which the blood-vessels and nerves are con- veyed to all parts of the body. In the pelvis it fills all the unoccupied spaces lying between the yJil. levator aui'. Fig. 205. — Diagrammatic transverse section of the pelvis (Luschka). 556 DISEASES OF WOMEN. pelvic organs, except between the peritomeuin and tlie middle por- tion of the fundus uteri. At that point it exists (if at all; in so small a quantity that it can not be demonstrated. Inflammation of the cellular tissue here located has received many names — pelvic cellulitis, peri-uterine cellulitis, parametritis, peri-uterine phlegmon, pelvic abscess, and inflammation of the broad ligaments. I prefer the term pelvic cellulitis, which was given to it by Sir James Y. Simpson because it indicates the nature and location of tlie disease. Inflammation of the cellular tissue may occur wherever that form of tissue is found, hence the term pelvic cellulitis does not definitely locate the site of the disease, and yet the name is as spe- cifically descriptive as any of the other terms used. Moreover, pel- vic cellulitis, limited to the areolar tissue around the cervix uteri, and between the folds of the broad ligaments, comes under the ob- servation of the gynecologist more frequently than in any other location in the pelvis ; hence it should be understood that the term pelvic cellulitis is bere applied to inflammation of the cellular tissue, located in the broad ligaments and about the supravaginal portion of the cervix uteri. Pathology. — This differs in no respect from inflammation of cellular tissue elsewhere, except so far as it may be moditied by the peculiarities of the location. There is, first, a stage of active con- gestion, followed by an effusion of blood serum, and later, an exuda- tion of the higher organized constituents of the blood, and, finally, suppuration. In some cases the inflammatory process stops short of suppura- tion, and the products of the inflammation are removed by absorp- tion, and tlie recovery is soon completed. This is called ending in resolution. There are a few cases in which the products of the mor- bid process are packed so densely into the tissues that the circula- tion is arrested and the cellular tissue destroyed, and a dead mass or slough is formed. These cases, fortimately rare, are very severe, and sometimes fatal. They are also complicated with inflammation of other organs in the pelvis, as a rule. In fact, fatal cases are generally complicated, the uncomplicated cases rarely proving fatal. When suppuration takes p ace, the pus usually makes its escape by some one of the following avenues, mentioned in the order of frequency as nearly as can be : Vagina, rectum, bladder, abdominal walls, saphenous opening, pelvic floor near the anus, pelvic foramina, obturator or saero-ischiatic foramen, and through the pelvic roof into the peritoneal cavity. PELVIC CELLULITIS. 557 T liave seen three cases in which the pus from an abscess in the broad h'gainent burrowed outward to the ihac fossa, and then ex- tended upward to the diaphragm, and in one it opened through the hnig into tlie large l)roneliial tube. Brief histories of these cases will be given at the end of this chapter. When the pus escapes into the vagina or rectum at the most de- pendent part of the abscess sac, the evacuation is usually complete, and the after-drainage favorable ; the walls of the abscess come to- gether, and the cavity is soon closed. The walls of the sac become thin by absorption, the fixation and swelling of the parts subside, and the recovery is complete. In examining a case in after years that I had treated for cellulitis, I found that all traces of the disease had disappeared, so far as could be ascertained by physical exploration, and the functions of the pel- vic organs were all performed normally, thus showing that the recov- ery was complete. This is the history of the pathology of the sim- plest cases of pelvic cellulitis. When the pus escapes into any other pelvic viscera at a point above the most dependent part of the abscess sac, the evacuation is necessarily incomplete, and the drainage imperfect. Chronic sup- puration and discharge will occur under such circumstances, and the duration of the case is very indefinite. This is often the result when the point of escape is through the abdominal walls or the pel- vic foramina ; but the same thing occurs sometimes when the open- ing is into the vagina or rectum or bladder, especially the rectum. Judging from several cases that I have seen, in which the open- ing was into the rectum, I am inclined to believe that the direction Fig. 206. — Pelvic abscess opening obliquely downward. Fig. 207. — Pelvic abscess opening obliquely upward. of the opening has something to do with keeping up the suppuration. When the opening is low down, and enters the rectum obliquely downwai'd, and the drainage is complete, the opening will close 558 DISEASES OF WOMEN. promptly (Fig. 200); but, if the opening into the rectum is direct or obliquely upward, tlie contents of tlie bowels will escaj)e into the abscess sac, and keep up suppuration for an indefinite length of time (Fig. 207). These conditions in the pathology of cellulitis afford a reasonable explanation, perhaps the true one, of the difference in progress be- tween cases that, up to the time of evacuation of pus, appeared to be alike. . There is yet another condition in tlie morbid products of the disease which retards recovery. In place of the suppurative pro- cess, involving the whole mass of inllammatory products, a number of small abscesses are found producing a honey-comb state of the parts, a number of small abscesses opening into each other by small sinuses, and all opening into some of the pelvic viscera, by one or more openings. This pathological condition delays the progress of the case greatly. All these exceptional peculiarities in the pathology which complicate the progress of the disease also tend to make the after-effects — i. e., the damage to the pelvic organs — greater. The walls of the abscess are thicker, and the scar left in the tissue contracts more, and hence, displacements are often found. Pelvic pains of a neuralgic character often follow, and the functions of the pelvic organs, uterus, rectum, and bladder are to some extent occasionally deranged. There is still another form of behavior noticed in some cases. Suppuration takes place at one point, usually a small one, and instead of the pus escaping in the usual manner, it finds its way into the circulation causing septicaemia, which is intermittent in character. The temperature and pulse run up high for a time and then sub- side, the fever being sometimes preceded by a chill or rigor. These paroxysms are repeated over and over again, the general nutrition of the patient being greatly impaired. The chief cause of pelvic cellulitis is septicaemia, and is usually traumatic in its origin. Injuries to the uterus and vagina during parturition or abortion develop septic material which is conveyed to the cellular tissue by absorption through the lymphatics pi-iucipally. It is possible that lymphangitis is primarily developed, and sub- sequently, cellulitis. Be this as it may, the fact is that two thirds of all the cases occur after abortion or parturition. Whenever cellulitis follows parturition, it may be presumed that it is caused by the absorp- tion of septic material from the parturient canal. It is possible, how- ever, that contusions of the cellular tissue occurring during parturi- tion may give rise to decomposition of the injured tissue and septic cellulitis, which, in that case, is autogenetic, and not due to absorption. PELVIO CELLULITIS. 559 The other and far less common causes of cellulitis arc surgical operations, the use of caustics, ill-fitting pessaries, dilatation of cervix uteri with sponge tents and direct blows, but with all of these the cause is septic, the morbid material being developed by the injury. Cellulitis occasionally occurs secondarily to some pre-existing in- flammation, such as endometritis, pelvic peritonitis, saljiingitis, and ovaritis. These last-named aifections, when they precede the cellu- litis, stand in a causative relation to it. It quite frequently hap- pens, however, that the above-named diseases are developed in the course of a cellulitis, and are caused by it, and hence become com- plications of the cellulitis. The duration of cellulitis varies very much according to the ex- tent of the inflammation, but more especially is the progress modi- tied by the termination of the inflammatory process. In case that resolution takes place, recovery may occur in a few weeks, but on the other hand, if suppuration occurs and the discharge of pus is incomplete, owing to the unfavorable point of escape, then chronic suppuration may go on for months or years. When suppuration takes place and the discharge of pus is at the dependent part of the abscess, the average duration of the disease is about six weeks. Much has been said about chronic cellulitis, but I have never been able to recognize any such condition. Chronic suppuration in a badly-drained abscess may go on for any length of time — this we often see ; also, frequent or repeated attacks of cellu- litis may occur, but a chronic or continuous inflammation such as we see in inflammation of mucous membranes, is something which I have never met with in practice. This is quite in accord with what we know of cellulitis elsewhere, where the process begins, pro- gresses, and ends and recovery follows, or, it may be, that the inflam- mation progresses to the stage of suppuration, and for some reason suppuration is kept up, but this is simply a chronic condition of one stage of the process. I think that the so-called chronic cellulitis, recognized and treated as such by some authorities, is nothing more than the products of the inflammation which remain after the inflammation itself has subsided. The consequences of pelvic cellulitis depend largely upon the extent of the tissue involved and the quantity of inflammatory exu- date. Sometimes, the tissues become infiltrated with the products of the inflammation which do not all break down in the suppurative process ; when this occui'S, it requires a long time to efiiect the absorp- tion of these products, and during that time, the patient is likely to 560 DISEASES OF WOMEN". suffer from derangement of tlie functions of the pelvic organs and also from pelvic pain. So, also, when the products of the inflamma- tion have all been disposed of, if much damage has been done to the tissues, which is usually the case, contractions follow which are apt to displace the pelvic organs to some extent, and to give rise to trouble ; and yet, in the majority of uncomplicated cases of cellu- litis, complete and perfect recovery generally takes place. This, I have frequently been able to verify by subsequent examination of cases that I have formerly treated. More than that, it not infre- quently happens that patients, after a well-detined cellulitis, recover and bear children, showing conclusively that the recovery was com- plete and perfect. In the clinical history of pelvic cellulitis, as manifested by the symptoms and physical signs presented, there is a great variation in different cases ; just as the extent of the local lesions differ in degree and extent, so the symptoms vary in their severity. There is usu- ally a decided symptomatic fever as indicated by the frequency of pulse and elevation of temperature. This may, or may not be pre- ceded by a chill or rigor which is promptly followed by fever. The temperature as a rule is not high, from 101-|° F. to 103° F. being about the range. There is also marked derangement of the digestive organs ; sometimes, there is some nausea and vomiting, almost always tympanitic distention of the bowels, and usually con- stipation. It is rare that there is any delirium or very marked de- pression of the nervous system. The patient usually complains of pain, the intensity of which varies considerably ; it is usually most marked in the rare cases which arise from causes other than parturi- tion at the full term. When the cellulitis follows delivery, there is abundant room for the products of the inflammation in the cellular tissues of the largely developed broad ligaments, and so the pain which is usually caused by pressure of these products, is not so great. In other cases due to injuries, intercellular haemorrhages, and the like, the tissues resist the distention and the exudation, and hence the pain is much greater, and there is usually decided disturbance of the function of the pel- vic organs. If the attack comes on when the menstrual period is near there may be a menorrhagia. There is also quite often vesical and rectal tenesmus. There is tenderness on deep pressure in the iliac regions, and the pain is usually aggravated by any movement on the part of the patient. This usually compels the sufferer to rest quietly on the back. Occasionally, some relief is obtained by drawing up the PELVIC CELLULITIS. 561 limbs while resting on the back, but this position is not by any means as frequently assumed and persistently maintained as in peritonitis. These symptoms, both general and local, usually continue without much modification, except that relief which may be obtained through the influence of medication, until the exudation is com- pleted ; then there is usually a lowering of the temperature and pulse, and relief from pain. The temperature, however, usually re- mains above 100° F. When suppuration begins, there is a renewal of the symptomatic fever; sometimes a chill precedes this recurrence of fever. On the other hand, if resolution takes place, the fever does not return to any very great extent. During the suppurative process until the time when the pus is discharged, the temperature remains usually above 100° F., sometimes, suddenly running up to 103° F., indicat- ing that there may be a little acute septicaemia. When the abscess opens and is completely emptied, there is usually a prompt and al- most complete relief from the symptomatic fever. In case that the pus remains imprisoned or .is only partially evac- uated, and the suppuration and discharge continue to go on, there is usually marked constitutional disturbance, manifested by high tem- perature which varies abruptly in degree ; at times running down almost to normal and again going up to 104° F., or to 104^° F. Physical Signs. — These necessarily differ according to the stage of progress of the inflammation. During the stage of engorgement, a digital examination usually detects only swelling of the parts and tenderness on pressure, and if the examiner's sense of touch is very acute, increased heat may be detected ; any effort to move the pelvic organs will usually cause pain. When the exudation takes place, the touch detects marked induration of the parts involved, and when it is complete, a well-defined tumor in both broad liga- ments will be found, or it may be that this njass is found on either side of the cervix. K the tenderness when pressure is made upon the abdominal walls is not great, and there is not much tympanitic distention, the tumor can sometimes be accurately outlined by the bimanual examination. Usually, however, not much can be accom- plished in this way because of the distention of the abdominal walls and the tenderness on pressure there. The size of the tumor of course depends upon the extent of the exudation ; in some cases it is not lai'ger than a small orange, in oth- ers, both broad ligaments may be split up, and so filled wnth the exudate as to extend above the true pelvis and come in contact with the abdominal walls, so that the mass can be easily identified by ab- 37 562 DISEASES OF WOMEN. dominal palpation. This I have seen in but one case, though I have frequently seen the tunior on one side large enough to be distin- guished in this way. The extension of the tumor upward out of the true pelvis, is much more frequently seen in cellulitis following labor, and it is a physical sign characteristic of cellulitis as compared with pelvic peri- tonitis. When the tumor occurs on one side, there is usually displace- ment of the uterus, that organ being pushed in the opposite direc- tion. When both broad ligaments are involved, the uterus may be carried ujDward and forward. In cases occurring in the non-puer- peral state, the uterus is often crowded somewhat downward ; in all cases there is most marked induration of the parts presented to the digital touch, and also fixation of the uterus. When i-esolution ter- minates the case, a gradual diminution of the tumor will be observed from time to time. When suppuration and evacuation take place, there is a more prompt reduction in the size of the mass. The physical signs sometimes change when suppuration occurs, but it is exceedingly difficult to detect the presence of pus in this location, although it is often important to do so. It is usually im- possible, also, to detect fluctuation, because the abscess can not be touched at two points far apart. One must rely then upon the soft- ening of the mass as felt by the index-finger, as the sign of suppu- ration. This is liable to be simulated by oedema of the abscess-wall, but this can readily be distinguished by observing that the parts pit on pressure. It often happens, however, that one can not decide re- garding the presence of pus, and if it is of great importance to so determine, the aspirating-needle should be employed. Treatment. — During the first stage of cellulitis, treatment should be employed with the view of controlling the inflammatory process, and, if not able to abort the trouble, to limit or circumscribe it as far as possible. To accomplish this, perfect rest should be enjoined, and all pain relieved or made tolerable by the use of opium. The opium should be given by the mouth in doses sufficient to give re- lief, and be repeated often enough to maintain that relief. In case the stomach is so irritable as to refuse the opium, then it should be administered hypodermically. There is at the present day some belief that quinine given in large doses often controls or modifies local and inflammatory action ; this appears to be so in some specific inflammations like pneumonia, and it possibly may have some such controlling influence in cellulit- PELVIC CELLULITIS. 563 is ; if the stomacli will admit of it, no harm can come from giving ten or fifteen grains of quinine in a day at the outset of pelvic cel- lulitis, and possibly mucli good may result. Opium, however, is the chief agent when there is much pain or restlessness in the first stage ; the opium not only reheves the pain but also keeps the bow- els at rest, which is quite desirable ; the bowels, however, should not be kept too long confined ; in fact, I make it a rule when a case is seen early, and the rectum is distended, to empty it by means of a mild enema, then the bowels should be kept quiet until the tem- perature and pulse come down and the pain subsides, when the bow- els may be again moved by enema ; this secures one evacuation be- tween the stage of exudation and suppuration. Local applications sometimes give the patient a certain amount of comfort, and, when such is the case, there should be employed warm poultices, or, better, flannels wrung out of hot water, and cov- ered mth oil-silk. The exudation may be limited to some extent, it is claimed by some authors, by the use of counter-irritants ; this, I think, is doubt- ful ; therefore, if they are used at all, the milder agents, like mus- tard paste, may be employed. During all this time the patient should be nourished as well as possible. If a vigorous subject, less care in the way of diet is necessary ; but, if feeble, an abundance of nourishing food should be offered. Prof. Yirgil O. Harden, M. D., of Atlanta, Georgia, has practiced aspiration with good results in the stage of serous infiltration. A case illustrating this mode of treatment will be given hereafter. When suppuration occurs, the majority of patients will bear at that time sustaining means, nourishing food, full doses of quinine, and, in some cases, stimulants. To sustain the patient is the chief object at this stage. If the case promises to end in resolution, that should be favored by counter-irritants, and the internal use of the preparations of iodine combined with tonics. When the abscess opens, and discharge fol- lows, sustaining measures are all that is necessary. If suppuration takes place, and the pus is not discharged, l)ut is retained, and causes septicaemia, it should be removed by aspiration, and this operation repeated if need be. If the accumulation occurs again and again after aspiration, the sac should be more freely opened and drained through the vagina. When the drainage is incomplete, because of the opening being too high up, an opening should be made at the most dependent part, and the drainage-tube inserted. In case that the imprisoned pus can 564 DISEASES OF WOMEN. not be reached tlirongli the vagina, and the patient's life is in danger from chronic sup])uratiou or septicaemia, the practice of Lawson Tait may be adopted — that is, opening the abdominal wails, and draining the abscess with a drainage-tube in the abdominal wound. The operation of opening the abdominal walls, and indirectly draining a pelvic abscess, involves all the difficulties and dangers of laparotomy. It is a very diiferent thing when the abscess sac is adherent to the abdominal wall. Making an opening at the adher- ent point, and draining the sac, is little more than opening an or- dinary abscess. These are the principal points in the treatment of cellulitis ; other details of the clinical history and treatment will be brought out in the history of cases. ILLUSTKATIVE CASES. A Case of Cellulitis uncomplicated, ending in Suppuration. — When this patient was twenty-six years old she gave birth to her second child. Tlie labor, for some reason unknown to me, was tedious, and her physician delivered her with forceps. She progressed fairly well until the fourth day, when she had a chill, followed by fever, her temperature running up to 100° and 102|^°. She also had pain in the pelvis and distention of the abdomen, but the lochia and milk , secretion continued, although in diminished quantity. Her general condition remained about the same, except that she obtained relief from opium given by her physician until four days afterward. At that time I saw her, and found, on examination, a large mass on the left side, filling the upper portion of the pelvis, pushing the uterus to the right, and extending above the superior strait, so that I could distinctly make it out through the abdominal walls. This mass was so closely united to the uterus that it appeared to be a part of that organ, but was as large as the uterus itself. There was ten- derness to the touch, marked induration, and yet the mass and the ; uterus were very slightly movable. Pain at this time was not great, and the patient only complained of a little local distress and discom- fort, and said that she felt weak. At the same time, her pulse and temperature were both above 100. There was also laceration of the cervix uteri, and the discharge was muco-purulent. At this time she had very little nourishment for her child, and yet there was a little. She was directed to have perfect rest, nourishing food, opium sufficient to keep her free from pain and to secure comfortable nights, with tonic doses of quinine. PELVIC CELLULITIS. 565 The disinfecting vaginal douche which had been used was con- tinued ; tonic doses of quinine, with fluid extract of ergot, were or- dered three times a day, and turpentine stupes were directed to be applied to the abdomen. One week later I saw lier again in consul- tation, and learned from her attendant that but little change had taken place in her condition ; the temperature was lower, her appe- tite had improved, there was ahiiost no pain, and she felt stronger. On examination, there was little if any change in the tumor, the physical signs being about the same ; the local discharge still con- tinued, but was less purulent and offensive ; the surface temperature varied from time to time ; occasionally the skin was hot ; at other times there was free perspiration. It was impossible at this time to detect the presence of pus in the mass in the palvis. Five days afterward I saw her again, when I learned that she had had a chill, followed by a rise of temperature and pulse ; she had also suffered from rather profuse sweating. At this time her general appearance was less satisfactory ; she had a somewhat dusky hue of face, the pulse also was not as strong, and the milk had stopped entirely. Just before the chill her bowels had been moved by enema, and both patient and physician were disposed to attribute the increase in her trouble to the effect of the enema, but it undoubtedly was due to suppuration having begun. On examination, the mass was felt to be softer at the most de- pendent part, and yet no distinct flexion could be made out. Qui- nine was given in somewhat larger doses, the vaginal douche was continued, and a little wine was added to the bill of fare. A few days after this her pulse and temperature improved con- siderably. She had then very little pain, but a sense of heat, full- ness, and dull aching in the pelvis. Four days after this there was a copious discharge of pus from the vagina, followed by marked improvement in the pulse, temperature, and general condition. The day following a marked diminution in the size of the tumor was noticed ; there continued to be a discharge of pus in diminishing quantity for nearly a week, but during that time she improved in general condition very decidedly. The mass gradually diminished, and the uterus also progressed in involution, and her strength re- turned, so that she became anxious to get up. She was kept quiet, however, for some time, until involution was complete, and all that remained of the inflammation was a small, hard, but not tender mass on the left side of the uterus and in the broad ligament, evidently the collapsed or the contracted walls of the abscess. From this time onward the improvement was steady and unin- 5G6 DISEASES OF WOMEN. terrupted, and she was soon able to resume her duties, with tlie exception of nursing her child. At the end of two months from the tirue of the attack, she was quite well, and no traces of lier trouble remained except a decided thickening of the broad liga- ment. A Case of Cellulitis, ending in Resolution ; the Cause Dilatation of the Uterine Canal by Sponge Tent preparatory to curetting. — A hidv twenty-eight years of age, who had been married seven years, had suffered for some tinie with menorrhagia, caused by fungosities of the endometrium, and, although the cervical canal was quite empty, it was deemed necessary to dilate the canal with a si^onge tent before removing the fungous growths. The sponge tent was introduced late in the evening, and remained during the following forenoon ; the curette was used immediately afterward, and the abnormal growths completely removed. Twenty-four hours after this she began to liave pain in the region of the left broad ligament, at the same time developing sjTnptomatic fever, the temperature running u]) to l(»li° F., and the pulse being accelerated. She also had a little nausea when the pain was most severe, with loss of appetite and some tympanitic disturbance of the bowels. On digital exam- ination, made three days subsequently, a somewhat ill-detined mass was found in the right broad ligament, which increased during the following forty-eight hours until it attained the size of a hen's egg. There was a little displacement of the uterus to the right, but very little. This mass was quite tender to the touch, and could not be moved ; neither could the utenis be moved without causing acute pain. Opium was given to relieve the pain, and the boweLs were allowed to remain constipated for about four days. A vaginal douche of borax and warm water was used twice daily, removing a muco- sanguinolent discharge. The pain gradually subsided, and at the end of four or five days the bowels were moved ; the fever also di- minished, the appetite slowly returned, and about this time the mass began to slowly diminish in size. At the end of two weeks the pa- tient was permitted to leave her bed and sit in her chair, but was not allowed to take any active exercise until after the next menstrual period. During that time she was confined to her bed, fearing that the inflammatory process might again be lighted up. After the period, which lasted about five days, she was permitted to resume her duties gi*adually, but was directed to rest quietly at the next menstrual period, which she did. Afterward, on examination, it was found that the mass in the broad ligament had wholly disap- peared, there was no tenderness and no evidence of congestion or PELVIC CELLULITIS. 5G7 any other trouble, and her subsequent history sliows recovery to have been complete. I am quite sure that the diagnosis in this case was correct, and 1 am also satisfied that the cellulitis was caused by the treatment. The case occurred at a time in my practice when I knew less about the management of fungosities of the uterus, hence, I used a sponge tent before using the curette, an entirely unnecessary procedure. I know now that there was dilatation enough, but I followed the rules laid down in the books, and so employed the tent to the disadvantage of the patient. I am satisfied also that this case was due to sepsis, for at that time less was known about antiseptic sur- gery, and I have no reason to suppose that the sponge tent and the instruments used were surgically clean. This, I believe, from the fact that, although I have often used the curette since then and oc- casionally sponge tents, I have never caused cellulitis. Uncompli- cated cellulitis rarely proves fatal ; it is only when peritonitis super- venes that there is amch danger in the early stages of the disease. The cases that end fatally do so usually in one of three ways : First, by acute septicaemia, which may take place immediately after sup- puration occurs ; second, by chronic septicemia and exudation from prolonged suppuration in badly-drained cases ; third, and very rarely, when the abscess opens into the peritoneal cavity, and at once sets up a septic and usually fatal peritonitis. Pelvic Cellulitis following a Haemorrhage into the Cellular Tissue. — A young, recently married lady, while very much fatigued from un- usual physical exertion, was suddenly seized with acute pain in the pelvic region. When called to see her, I found her lying in bed suffering from severe pain and some rectal tenesmus : the pulse was somewhat accelerated, but the temperature was normal ; the skin moist and cool. There was no constitutional disturbance beyond nervous excitation due to pain. On examination, I found a tender point low down and to the right of the uterus, there was also a swelling which extended to tlie right and downward a little way, apparently between the rectum and vagina. The pain was relieved by opium, and on the following day the swelling was found to have increased and become denser, and yet, there was no symptomatic fever. Two days later the physical signs remained the same, and there was also a marked discoloration or ecchymosis of the vagina, especially in the upper and posterior part of its walls. This discoloration, taken in connection with the history of the case, satisfied me that the case was one of hiemorrhage into the cellular tissues of the pelvis. 568 DISEASES OF WOMEN. The pain gradually l)ecaine less but there was ttill a feeling of fullness and ])re.ssure in the pelvis and an annoying rectal tenesmus, which made the patient feel as if great relief would he obtained if the bowels were moved. A mild laxative was given, followed by an enema, which secured a free evacuation of the bowels, but in place of relieving, this rather aggravated her sufferings. On the sixth day after the attack, the patient felt a little chilly, and soon after- ward developed fever ; there was also a slight recurrence of the acute pain in the pelvis. At this time the temperature was 102^° F., and the pulse about 110. On the day following this, an examination was made, and the mass in the pelvis appeared to be softer than it was before ; but this I think was due to cedema of the vaginal walls. The fever con- tinued for several days and then gradually subsided, and the tem- perature remained about 100°. The pain and general pelvic tenesmus continued, though not in a marked degree ; her condition remained about the same during the following week, then the pain became more severe, the tem])erature rose a degree or more, and she was more restless and uncomfortable. Two days after this a discharge of pus from the vagina occurred, quite profuse at first, and contmued in a modified way for a couple of days. The discharge contained black specks which were found to be shreds of clotted blood. Forty-eight hours after the discharge first appeared, a careful examination by the touch was made in the hope of discovering the opening of the abscess, but without success ; a very careful speculum examination was then made, and by the aid of the probe the opening was found to the right and a little below the cervix uteri. The openiog appeared to be just above the maes, which extended down, apparently, between the vagina and the rec- tum. A uterine dilator of small size was passed through the open- ing into the abscess sac and slow dilatation made. When the opening was suiSciently enlarged to admit a curette, a hirge piece of blood- clot was removed ; several strands of thick, prepared silk were intro- duced into the opening to keep up the drainage, and during the next few days considerable pus was discharged, together with shreds of old blood-clots. As the opening showed no disposition to close, the drainage was abandoned, and from this time onward the discharge diminished and the swelling and thickening of the tissues also slowly disappeared. Finally, the discharge stopped altogether, and thickening and indura- tion of the tissues gradually disappeared, and complete recovery took place. PELVIC CELLULITIS. 569 Pelvic Cellulitis caused by Amputation of the Cervix Uteri. — This patient came iuto the hospital about eighteen years ago with a very laiich enlarged and eroded cervix uteri ; in fact, the cervix seemed to be divided into two lai-ge, round masses, the surfaces of which were very irregular and so vascular that they bled ])rofusely on touch. This was before Dr, Emmet had told us about laceration of the cervix uteri and its consequences, and I supposed that the case was one of incipient malignant disease. This diagnosis was con- curred in by several of my colleagues, and amputation of the cer- vix was deemed the best mode of treatment, and the oi)eration was performed after the method commended by J. Marion Sims. In removing the posterior half of the cervix, I am satisfied that I went beyond the walls of the uterus iuto the cellular tissue ; sut- ures were introduced to bring the flaps together and to hold them there, and the operation appeared to be quite a success. At the end of the second day the patient developed all the constitutional symptoms of local inflammation and soon afterward the physical signs of pelvic cellulitis were manifested. The subsequent history of the case was that of ordinary pelvic cellulitis which ended in suppuration and discharge, which occurred at a point corresponding to the right angle of the junction of the flaps made in the amputation. The discharge soon ceased and all constitutional and local disturbance subsided, and the patient recov- ered from the acute attack. She subsequently did rather badly, there was considerable con- traction of the scar left by the amputation, and there was evidently some contraction of the parts involved in the cellulitis so that she suffered a good deal in after years with pelvic pain and dysmenor- rhoea, and it became necessary to dilate the remaining portion of the cervical canal in order to give relief. This case is mentioned simply to illustrate cellulitis as it occurs after operalions about the ceiwix uteri, and it no doubt was septic in its origin. The case was treated before the days of antiseptic surgery, and I have no doubt that I exposed my patient to all the septic influences possible in such an operation. Indeed, the management of the whole case was rather bad as it appears to me now, and I am inclined to believe that it was not at all malignant to begin with, and that amputation of the cervix was therefore uncalled for. Such a case now would be considered as a laceration of the cervix with areolar hyperplasia, and would be treated in the usual way. A Case of Pelvic Cellulitis ; the Abscess opening into the Eectum and Long-continued Suppuration occurring in consequence. — This patient 570 DISEASES OF WOMEN. was also seen in hospital ; she gave a history of liaving had pelvic cellulitis seven months before admission. About live weelcs from the time that she was taken ill she had discharges of pus from the rectum which were followed by marked relief. After this she con- tinued to have repeated discharges of pus in the same way ; for a few days at a time she would be comparatively comfortable, though never well ; then she would have a little fever, with considerable pain, and then a discharge of pus, which would give relief for a few days. These remittent attacks of j)ain and fever followed by a discharge of pus, continued at varying intervals up to the time that I saw her. On digital examination, I found fixation of the uterus, with evidence of induration in both broad ligaments and around the cervix, above the vagina. She was anaemic, emaciated, and had a somewhat cachectic ap- pearance. She was placed under ether, and a most careful examina- tion of the rectum made. The opening from the rectum into the cellular tissue was found about three inches up the rectal wall, by bending the probe into tlie shape of a hook. I was able to pass it from above downward and forward, showing that the opening ran from the rectum obliquely downward into the abscess about an inch. A counter-opening was made in the most dependent part of the sac through the vaginal wall ; the opening was made with the thermo- cautery. This 1 believe to be the best method of making counter- ojDenings in these old cases, as haemorrhage can be avoided and the lymphatics closed by the cautery, which to some extent guards against septicaemia. The opening in the vagina was maintained by small drainage- tubes which completely drained the abscess. The patient improved generally and locally, and after a time the drainage-tube was given up ; a little discharge continued from the opening for several days, when it closed. The case did well, and was soon dismissed from the hospital, although there still remained considerable induration and thickening of the tissues of the broad ligaments. Presuming that her recovery would be eifected in time, she was dismissed from the hospital ; but returned in about three months with a rectal abscess, which, when it was opened, proved to bo a rectal iistula. Evidently, the opening in the vagina had closed while that in the rectum re- mained, thus forming an internal rectal fistula. This was treated in the usual way and the patient iinally recovered. Pelvic Cellulitis ; Abscess discharges through the Saphenous Open- ing. — In this lady's fourth confinement calcareous degeneration of the placenta was found. It was retained for a long time in spite of PELVIC CELLULITIS. 571 all the ordinary efforts used to deliver it ; it was found necessary to detach it from the uterus, a very difficult task. She did very badly from the beginning, soon developing a metritis and celhilitis ; she remained in a very precarious condition for about two months ; the products of the inflammation formed a large mass on the left side which extended up to, and finally became adherent to, the abdominal walls. Full details need not be given, suffice it to say, that at the end of twelve weeks an abscess opened through the inguinal canal. Much relief followed the opening and the copious discharge of pus, but it continued to discharge for weeks, and although she had improved after the opening of the abscess, she began to nm down from this chronic suppuration, and her life was again despaired of. A probe was passed from the anterior opening and downward into the pelvis until its point could be felt on the left side of the cervix ; there was still, however, a very thick wall between the vagina and the end of the probe. After faithfully trying the effect of careful washing out and drainage, without success, a counter-opening was made through the vagina by means of the ther mo-cautery, and a drainage-tube carried through the opening in the abdominal walls down into the vagina. This tube was injected three times a day, and as the patient improved quite fairly the tube was draven down toward the vagina, leaving the outer opening free. No discharge occurring at the abdominal opening and the wound showing a disposition to close, the tube was gradually withdrawn, and finally removed entirely. The discharge continued for sume time after the removal of the tube, but finally ceased, and the patient recovered and has remained well ever since, a period of eighteen years. Pelvic Cellmlitis in which the Discharge was delayed, but finally re- lieved by Aspiration. — The history of this case has nothing peculiar in it except that it progressed as cellulitis usually does, until the time when the abscess was expected to discharge. It failed to do so, and the patient's general nutrition beginning to suffer, it was deemed advisable to use the aspirator ; this was done and the abscess, which was in the right broad ligament, was emptied of about eight ounces of pus. This gave great relief, but in time the abscess filled again, and again it was aspirated, but this time before removing the needle, the sac was carefully washed out with carbolic acid and water. Great care was taken not to inject quite as much as the quantity of pus removed, for fear that by overdistending the abscess, some thin point in the sac might rupture and cause mischief. There was considerable reaction after this aspiration, the pulse 572 DISEASES OF WOMEN. and temperature runniiio: up, but soon subsiding again. Nothing of impui'tauee occurred in the history of the case, and she recovered in due time. A Case of Cellulitis terminating in Multiple Abscesses, cured by enlarging the Opening and breaking down the Walls of the Small Ab- scesses. — This case had a liistory during its early stages, quite in ac- cordance with the ordinary progress of the disease, but after suppu- ration and discharge the patient was not relieved, and the suppura- tion continued. The opening was found to be a very small one, situated behind and to the left of the cervix uteri. After trying every possible means to improve her general condition witliout effect, the opening was enlarged by dilatation, the patient being an- aesthetized ; after dilatation, the finger was passed up into the mass, and the walls of several small abscesses broken do\\Ti. This was rather easily accomplished because the uterus and the mass of in- flammatory products were low down in the pelvis and within reach, and while the finger was passed through the opening, the other hand was placed upon the abdomen to act as a guide and to guard against breaking through into the peritoneal cavity. After this, the discharge was very free, and a number of shreds of broken tissue were evacuated. Drainage was kept up and the parts washed out daily until the mass had greatly diminished and the discharge had almost subsided. The drainage-tube was then removed and the patient slowly recovered. A Tedious Case of Cellulitis causing Septicaemia from a Very Small Point of Suppuration ; treated by Laparotomy and Drainage ; Recovery. — This case was seen in consultation with my friend Prof. Jewett, who gave me the following notes : The patient was thirty years old, and was confined March 3, 1S85, with her seventh child. She had ante-partum haemorrhage and inertia of the uterus, wliich rendered it necessary to deliver with forceps at the superior strait. The nurse was incompetent, drnnk, or stuj)id, or all three, and allowed the patient and her bed to remain filthy for two days. At the end of the third day, the patient developed cellulitis in the left broad ligament ; there was also a circumscribed peritonitis limited to the location of the cellulitis. At the beginning of the disease, the temperature ran up to 103° and the pulse to 140 ; this elevation was attained on the Yth of March, and from that time until the 15th, the temperature I'anged between 100° and 102°, and the pulse between 90 and 110, There was a marked difference between the morning and evening tempei'ature. PVom the loth until the 20th, the con- stitutional disturbance subsided, the local inflammation also dimin- PELVIC CELLULITIS. 5Y3 ished, and there was every reason to suppose that the cellulitis would end in resolution. From the 20th to the 28th she was a])pa- rentl}' convalescent, and was able to walk about, but on the 29th she had a relapse, the temperature running up in the afternoon to 104°. The following morning it was down to 97°, and from this onward to the 18th of April her temperature was most extraordinary in its variations. On the 4th and 5th it was 105° in the afternoon and 100° in the morning; from the 0th to the 11th it ranged between 100° in the morning and 103° and 104° in the afternoon. All this also in spite of quinine and other recognized antipyretics. From this date to the 18th, the temperature became more irregular, occa- sionally dropping down to 98-|°, and suddenly and at irregular times running up to 103° and 104°. It was thought that this variation of temperature was due to septicaemia, and yet no pus accumulation could be detected in the pelvis. Prof. Jewett practiced aspiration with negative results, but subsequently made a number of appointments for further explora- tions ; but the patient was an exceedingly intractable one, and her friends had no control of her, so that he was unable to carry out his wishes in this regard. The physical signs during all this time since the relapse remained about the same. The patient by this time was exceedingly ansemic, the skin was of a bronze hue, and the digestion and general nutri- tion very poor, and. altogether her condition was critical. On May 2d she submitted to an ansesthetic, and Prof. Jewett performed laparotomy. He made an incision through the abdominal walls directly over the tumor in the broad ligament, and, after mak- ing a small puncture in the tumor, opened up the cavity with the finger ; no pus was found, and not more than a teaspoonful of septic fluid was evacuated. The cavity was di-ained and irrigated with a bichloride solution for about four weeks, when it closed completely. The temperature never rose above 101° after the operation, and, after the first three days, it became normal, and remained so ever afterward. She rapidly gained in her general health, and in five weeks had completely recovered. Pelvic Cellulitis ending fatally from Septicaemia. — About sixteen years ago, while in charge of the lying-in department of the Long Island College Hospital, one of my cases developed a metritis and cellulitis after confinement. The case progressed in the usual way, differing in no respect from many cases of the kind, excejit that the products of the cellulitis were unusually great. The metritis subsided, and the cellulitis, which was located in the left broad liga- 574: DISEASES OF WOMEN. ment, went on to suppuration, and, while I was looking for the ab- scess to discharge, the patient began to show eigns of septicivinia. There was, no doubt, a large accumulation of pus in the broad ligament, but, as we were unable by physical signs to detennine that, I unwisely abstained from exploring the abscess. All constitutional treatment known to us was carefully em})loyed, but the ])atient died. On post-mortem examination, a very large abscess was found in the left broad ligament, and nothing more. The peritonaeum covering the abscess was congested, and there was much subserous (edema, but not the slightest evidence of any peritonitis. This case, like many others, illustrates very well two important points : First, that cellulitis occurs without the slightest pelvic ])eri- tonitis accompanying it, and this fact tells strongly against those who make no distinction between the two affections ; and, second, if this case had come under my observation in recent years, when I appreciate the value of aspiration and abdominal section and drain- age, as taught by Lawson Tait (all honor to him for this !), the case might have been saved. Great progress has been made in the management of cellulitis within the last few years in the employment of aspiration, counter- openings, drainage, and abdominal section and drainage, as the above cases have illustrated. Acute Cellulitis treated by Aspiration in the Stage of Serous Infiltra- tion (by Virgil O. Hardin, of Atlanta, Georgia). — '' The patient was twenty-four years of age, and had borne a child three months before^ The history of the patient showed that her menses had always been of normal character up to her pregnancy, and that she had never suffered from any symptoms which would indicate pelvic disease of any kind. Since her labor she had had tenderness of the abdomen and pain in walking and in micturition. Her general health, how- ever, had been good. On the day before I saw her she was seized with pain in the back, pelvis, hips, abdomen, and thighs. This pain was acute and excessive. Micturition and defecation became very painful, especially the latter. She had a slight chill, followed by high fever, thirst, and complete loss of appetite. When seen by me, she was in bed, tossing and moaning with pain, which was re- ferred principally to the pelvic region. Pulse, 120, temperature, 101°, skin hot and dry, face flushed, tongue coated. Vaginal and rectal examination were rendered impossible by excessive tenderness of the parts. The following morning she was fully ansesthetized, and a complete examination effected. The vagina was hot and dry. The cervix was lacerated on the left side. The womb was low in PELVIC CELLULITIS. 575 tlie pelvis, and was pnslied forward against the bladder. In the posterior fornix^ and occupying the wliole space between the cervix and the rectum, could be felt a rounded, bulging mass, which had a boggy, oedematous feeling. By a finger in the rectum this mass could be outlined, and felt to extend upward about an inch. No fluctuation could be detected, and, when pressed by the finger, the mass could not be displaced upward. Considering the condition to be that of pelvic cellulitis in the stage of serous infiltration, I decided to attempt to draw off the serum from the cellular tissue, hoping thereby to abort the disease and prevent the formation of solid plastic exudation, with possibly a subsequent abscess. Accordingly, an as- l^irator-needle was thrust into the tumor from the vagina at three different points successively, and about an ounce in all of serum tinged with blood was withdrawn. The tumor was then found to be so softened and diminished in size as to be scarcely perceptible to the touch. A quarter-grain of morphine was given hypodermic- ally, and the patient ordered to remain perfectly quiet in bed, and take only liquid diet. When seen twenty-four hours later, she had had a good night's sleep, the pain in the pelvis was almost entirely gone, defecation was no longer painful, appetite had returned, the pulse had fallen to 80, the temperature to 99°, and the patient begged to be allowed to get up. The mass in the posterior fornix could be felt only as a slight thickening. Two days later the patient was ap- parently in her usual health." Pelvic Cellulitis, with Certain Complications, which, so far as I know, have not been noticed or described heretofore. — The patient was thirty-seven years of age, and the mother of six children. She was confined in June, and was fairly well for five days. She got up on the fifth day, and tried to attend to her housework. Four days later, while about the house, she was taken with severe pain in the jielvis, and was obliged to take to her bed again. This much of her history was obtained from the patient. She was seen for the first time by Dr. J. H. Raymond about six weeks after her confinement, and he learned that she had had no regular medical care, and but very poor nursing, her poverty depriv- ing her of necessary attention. From the history and physical signs, the doctor made the diag- nosis of pelvic cellulitis of the left broad ligament. The tempera- ture at that time was nearly normal in the morning, but rose to 101° or 102° at night. There was marked constitutional distui'bance, such as generally obtains in long-continued suppuration or septi- caemia. 576 DISEASES OF WOMEN. The doctor urged her to go to tlie hospital, but she declined until August, about ten weeks after her confinement. During the inter- val from the time tliat she was first seen until she entered the hos- pital she was cojitined to her bed with her left thigh flexed upon the bodj, and the leg upon the thigh. AVhen she was admitted to the hospital she was very ansemic, had night-sweats, and had the general appearance of a tubercular patieut. The flexion of the leg and thigh continued, and there was false anchylosis of the joints. The tumor in the pelvis was much smaller than it had been, but there were pain and tenderness in the left iliac region, extending up to the lumbar region. The temperature ranged from 100° to 103°, being very irregular in its rising and falling. There was no point in the pelvis where pus could be detected, and, although there was some swelling in the left side of the abdomen, no signs of pus could be found after repeated examinations. She was able to take food and stimulants fairly well, and every means was employed to reduce the temperature and improve her strength, but without any favorable result. Hopes were entertained that the location of the suppuration would be found, and that relief might be obtained by aspiration or other means of evacuation. In spite of the constitutional treatment, she gradually declined, the anaemia became very marked, and the temperature increased, frequently being 101:°, and sometimes a frac- tion higher. She appeared to be doomed to die of septicaemia, and, as a last resort, it was decided to make a laparotomy, in the hopes of finding the source of the septicaemia. Immediately before giving the ether her temperature was 101|-°, pulse, 11:0, and feeble. The anchylosis of the knee- and hip-joints was with difficulty broken up, and then a more careful exploration of the left iliac region was made. There were swelling and hardening of the wall of the abdomen on that side, but not to any great extent. An as- pirating-needle was introduced at a number of points in the hope of finding pus, but without avail. The abdomen was opened, and a most careful exploration of the pelvis was made by the touch. The left broad ligament was considerably thickened and much less elastic than it should have been, showing the effect of the inflammation, which had subsided. Not the slightest sign of any point of sup- puration could be found, but, by the bimanual touch, with the fin- gers of one hand in the aljdominal cavity, and those of the other on the outside, I detected obscure fluctuation, indicating that an abscess or sinus extended along that side of the abdomen. The location of the pus having been clearly marked, the wound in the abdomen was PELVIC CELLULITIS. 577 closed, and an incision was made in the side down to the pus. It was found that the pus cavity was very small at its lower and most superficial end. It would not admit the little finger. This ac- counted for the fact that it was not found with the exploring needle. Passing a probe from the opening made upward, I found that the sinus was wider above, and extended up to the diaphragm. The cavity was washed out, and a drainage-tube introduced. Dr. Palmer, who aided in the ©iteration, conducted the after- treatment, and the following facts are taken from his record, as kept by the house-surgeon : The patient reacted well under the effect of morphine and atropia, given hypodermically at the end of the operation, and again in three hours. Whisky with hot water was given four hours after the opera- tion ; she retained it well, and from that time onward the morphine and whisky were given to meet requirements. Five hours after the operation the temperature was 99^°, pulse, 128, respiration, 28. Two hours later the pulse went up to 100|^°. The night was passed very comfortably, but she required morphine and whisky in large doses, not altogether because of the pain or exhaustion, but largely from the fact that she was used to both. For years she had been a drinker, and, during the long illness previous to the operation, she had taken morphine. At five o'clock on the following morning the tempera- ture w^as 102°, but in two hours it came down to 99°. From this time onward her progress was favorable, at times the temperature went up one or two degrees, but came down when the pus sac was washed out. She improved in strength but the sup- puration high up in the cavity continued, but in a much less degree. Her lung-trouble progressed slowly, but she seemed doomed to pulmonary phthisis. One month after the operation there was still a little discharge from the wound, but she did not apparently suffer from that to any extent, but her cough was worse, and the lungs not improving. At this time she returned to her home. The final re- sults I have not yet obtained. The following case was similar to the above, but terminated fatally, and a post-mortem examination revealed the exact nature of the lesions. The patient was thirty-seven years old, and had been confined of her fifth child four months previous to the time that I first saw her in consultation with Dr. R. L. Dickinson. From the history that we could gather, she had fever from the day after her confinement, and had been sick ever since. She was emaciated, and her skin dry and dusky ; the temperature ranging from 101° to 102° ; she had 38 578 DISEASES OF WOMEN. but little appetite, and was constipated. She rested on the right side with the legs and thighs flexed, and complained of severe pain in the right groin and leg. Owing to the tixed position of the right leg and the great pain which she sufl'ered in moving, a physical examination, was not easily made= The utems was apparently nor- mal and movable, but high up, at or above the brim of the pelvis, on the right there were evidences of inflammatory products. The diagnosis of abscess in the false pelvis was made, causing septicae- mia. She was taken to the hospital, and explorations were made with the aspirator, in the hope of finding the exact location of the pus. but with negative icsulrs. Laparotomy was perfonned by Prof. Charles Jewett. The pelvic organs were normal, except that there were evidences of a former cellulitis in the upper portion of the right broad ligament. The presence of pus was made out in the right iliac and luxabar reg-ions : the abdominal wound was closed, and an opening made above the right groin into the abscess. It was foimd that the abscess cavity extended upward along the spine for twelve inches. The subsequent treatment consisted in washing out the abscess cavity, and suppoiting the patient with nourishment and stimulants. She did not rally well, but gradually failed, and died the thii'd day after the operation. The autopsy showed that the abscess cavity extended from the right broad ligament upward Ijehind the kidney and to the right of the spinal column to the diaphragm. The psoas muscle was in- volved in the abscess, but there was no bone-disease, and it was the opinion of all who attended the autopsy that the disease began as a cellulitis of the right broad ligament. A case similar to the above came under my observation twelve years ago. Upon being admitted, the patient gave a history of cel- luhtis following confinement. She was in a very low condition from septicaemia. I found signs of suppuration in the left ihac region, and. on makino- an incision., I found a large abscess, which extended upward to. if not beyond, the diaphragm. The patient had a cough with purulent expectoration, but no well-defined signs c-f any disease of the lungs. After washing out the abscess sac with cai'bolic acid and water, the patient declared that she could taste the acid ; this led me to suspect that the abscess had opened into one of the larger bronchi : water colored with car- mine was injected, and the matter expectorated afterward was col- ored with the carmine. She died of exhaustion, and at the autopsy it was found that a sinus extended up beliind the diaphragm and opened into a Ijrouchial rabe. CHAPTEK XXXIL PELVIC PEEITOJSnnS. The peritonaeum whicli covers the pelvic viscera of the female dif- fers in no respect in its anatomical construction from tlie general peri- toneum, and its function is the same. It differs only in the organs which it covers, and in the fact that there is in this region a direct communication and union between the mucous and serous mem- branes at the opening of the Fallopian tubes. Fig. 208. — The pelvic peritonfeum as seen on locking into the brim (Hodge). 580 DISEASES OF WOMEN. From tlie fact tliat the perit(jna^uin is a continuous membrane, one would naturally suppose that an inflanimatiou beginning at one Fig. 209. — The reflections and pouches of the pelvic peritonaeum looking into the cul-de-sac from behind (Hedge). point would incline to extend to tlie whole membrane, so that gen- eral peritonitis would be the rule in the patholoiry of inflammation of this membi'ane. It is a fact, however, that the pelvic peritouseum becomes the seat of inflammation very often and without any general disposition to extend to the abdominal peritonaeum. The two affec- tions then, that is, pelvic peritonitis and general peritonitis, while thej are the same in their pathology, differ so in their clinical his- tory and causation, as to render them two separate and distinct affections. There is a form of peritonitis which occurs after parturition, in which the inflammation begins in the uterus and extends to the general peritonaeum and is known as metro-peritonitis, but tin's also differs entirely from peine peritonitis, which occurs far more fre- quently than either general peritonitis or metro-peritonitis. The pathology of pelvic peritonitis is the same as in inflamma- tion of serous membranes generally. There is first, subserous con- gestion, followed by a transudation of blood =emm, and then an exudation of plastic material, or the higher organized constituents of PELVIC PEKITONITIS. 581 the blood. Ordinarily, this ends the formative stage of the inflam- matory process, and the pi'oducts of the inflammation are disposed of flrst, by the absorption of the serous transudation and the organiza- tion of the exudate. This organization simply consists in the devel- opment of blood circulation, eitlier in or beneath the exudate, suffi- cient to maintain it in a vitalized condition and prevent its further degeneration and disintegration. The peculiar characteristic of this exudate is to form adhesions to adjoining tissues and to undergo contraction in its after-life, so that follovt'ing an attack of pelvic peritonitis, the parts in the grasp of the exudate become adherent, and are often drawn out of their normal position by its contraction. Occasionally, but rarely, the in- flammation of this serous membrane goes on to suppuration. When this form of peritonitis takes place, pus accumulates usually in the sac of Douglas ; there it sometimes is walled in by an exudation of lymph which unites the two folds of the peritonseum which form the sac. Occasionally, too, small abscesses may be formed in the exudate which is thrown out around the ovaries and Fallopian tubes. There is a wide range in the degree of severity in cases of j)elvic peritonitis ; in some, a cii'cumscribed spot of inflammation may oc- cur which gives rise to a little discomfort at the time, and, passing off", leaves no suspicion that there ever had been an inflammation there. Tliese cases we know occur from the fact that the traces of inflammation are found post-mortem. From these circumscribed and exceedingly mild attacks, we find all grades of severity, up to the most marked, where the whole pelvic peritonaeum is involved and suppuration occurs, and the case termi- nates fatally. In this respect, pelvic peritonitis strongly resembles pleurisy, the milder cases representing the circumscribed, dry pleu- risy, and the more severe corresponding to that of pleuritic em- pyema. There is also another form of pelvic peritonitis, in which there is an unusual transudation of serum which accumulates in the sac of Douglas, and corresponds to the ordinary pleurisy ^vith effusion. Judging from the number of cases of peritonitis met in practice, and also from observations made post-mortem, this is one of the pelvic diseases which occurs perhaps as frequently as any ; cer- tainly, it is much more common than pelvic cellulitis uncomplicated. It no doubt occurs quite frequently or occasionally in the progress of other pelvic affections, like cancer of the uterus, pelvic cellulitis, sal- pingitis, etc., but under these circumstances, it is a secondary affec- tion, and in that form need not be discussed here. 582 DISEASES OF WOMEN. In less severe cases the exudation gradually disappears, and the niol)ility and fniietional activity of the jtelvic organs may he again restored and the patient may be considered as having recovered. But this takes a long time before it is accomplished. When pelvic l)eritonitis terminates fatally, it usually does so because the inflam- mation has gone on to suppuration, and may be called a j)urulent peritonitis, and in that case the patient may die in a few days from — Blas& Fig. 210. — Retroverted uterus bound back by peritonitic adhesions ; a, 6, adhesions. (Winckel. ) the time of the attack, either from shock or acute septicaemia, or both, or inflammation may extend to the general peritonaeum, and in that way sacrifice the patient. Causation.— \ii regard to the causes of pelvic peritonitis, we find that non-parous women are most liahle to it, especially those who siLffer from imperfect development of the sexual organs and de- rangement of their functions, like dysmenorrhoea, for example. The immediate causes of pelvic peritonitis are of three kinds : First, where it is secondary, and e\Tdently caused by some affection or inflammation of some of the other pelvic viscera, like ovaritis, salpingitis, and endometritis. Second, traumatic influences, such as injuries of any kind, imprudence during menstruation, and all sur- gical operations or treatment. In those who have suffered long from displacements and flexions of the uterus and general irritability and congestion, injuries appear to be sufficient to set up a peritonitis, like the passing of a uterine sound, or the application of caustics to the uterus. Third, specific causes, such as the escape of septic mate- rial from the Fallopian tubes, in cases of endometritis and salpin- gitis, but more especially, the virus of gonorrhoea. In a large num- ber of cases the cause will be found in this specific virus ; this is the reason why pelvic peritonitis is such a common affection among prostitutes. PELVIC PERITONITIS. 583 The duration, termination, and after-consequences of pelvic peri- tonitis, depend largely upon the extent of the inllainmation and the cause which gives rise to it. In some cases where the exudation is limited recovery will take place in a few weeks, and but little after ill effects will be noticed, except occasional ])ain from time to time in the region of the exudate. In other cases where the whole pel- vic peritoniBum is involved, the iimbriated extremities of the Fallo- pian tubes become involved in the exudate, and are virtually de- stroyed. If this includes both sides, the function of the ovaries and tubes is arrested because of the damage to the structure. Desencration of the ovaries often follows under these circum- stances; sometimes they become inflamed and succulent ; at other times they become atrophied, due, no doubt, to the pressure of the contracting exudate and the interruption of the circulation in them ; in short, in some of these cases, the adhesions and the quantity of exudation so destroy the anatomical relations that on post-mortem it is almost impossible to recognize the tissues or organs. A mass of tangled adhesions and products of infl.ammation covering the uterus and broad ligaments, is about all that can be made out. When such patients live, they suffer greatly from pelvic pain and dysmenorrhoea, if the function of menstruation is not arrested, as it sometimes is, by the destruction of the ovaries. Symj>tomatology. — This varies according to the severity of the attack ; in average cases there is a well-defined symptomatic fever, the pulse being characteristic of inflammation of the serous mem- branes, being small and wiry, and running up from 110 to 130 ; the temperature is variable, often running to 103° F. and 104° F., and in severe cases to 106° F. At flrst, the skin is usually dry and hot ; there is marked de- rangement of the digestive organs, nausea and vomiting often occm'- riug ; sometimes in the severer cases vomiting of that greenish ma- terial so common in general peritonitis, occurs. There is usually marked tympanitic distention, and the patient prefers resting quietly on the back with the limbs drawn up, a position which seems to be the easiest ; there is usually a considerable disturbance of the nei*v- ous system, the patient being anxious, restless, and the facial ex- pression showing anxiety and dread. Sometimes there is delirium, but not usually, and when it does occur, I am inclined to think it shows that the ovaries are affected ; at any rate, and in several cases that I have seen, where I have every reason to believe that the ova- ries were also inflamed, there was great mental excitement, and tem- porary insanity in some. 584: DISEASES OF WOMEN. The pain in the pelvis is usually acute, much more so than in cellulitiri, and there is great tenderness to the touch ; the pelvic ves- sels are generally aifected, and there is marked rectal tenesmus, and, if the jjeritonaeura in front of the uterus is involved, there is vesical tenesmus also ; in fact, this vesical irritation is often an exceedingly annoying symptom. The physical signs obtained by a vaginal examination during the first stage simply reveal tenderness with some apparent thickening of the roof of the pelvis. Tliis may be limited to one portion of the pelvis, but in well-marked cases it extends throughout. When exu- dation has taken place, complete fixation of the uterus is found, and the roof of the pelvis, as felt through the vagina, presents the extreme hardness which is characteristic of peritonitis, and has been called the dealboard hardness by some. If nmch lymph is thrown out, especially if it is associated Avith considerable serum, a mass will be found behind the uterus occupying the sac of Douglas. At no time, however, do the products of this form of inflammation extend above the superior strait, unless as an exceedingly rare exception ; in ease that the disease goes on to the formation of pus, a well-de- fined tumor may Ije found in the sac of Douglas, and if this pus is discharged, the intense hardness at that point may disappear in part ; but if the entire exudation is lymph, it remains hard for a long time. There is almost always a displacement of the uterus as well as a marked fixation, and this fixation is likely to remain also ; as contractions occur subsequently the position of the uterus may be- come changed, and not only is the organ thus displaced, but it is fixed in this position. The difiierence between the physical signs of pelvic peritonitis and other diseases of the pelvic organs, such as cellulitis and pelvic liajmatocele, will be given in treating of the signs of the latter. Treatment. — The objects to be attained in the treatment of pel- vic peritonitis, are first, to control or limit the inflammation so far as possible, and to relieve the pain which is usually very great ; by accomplishing the latter, we do all that is possiljle to effect the former, the means employed to relieve pain, fortunately, having the greatest control over the inflammation. The great remedy then in the earliest stages of pelvic peritonitis, is opium ; Alonzo Clark was the first to discover the value of this agent in general peritonitis, and to him we owe most of our knowledge of the management of this affection, and it is equally available (that is, the opium treatment) in pelvic peritonitis. The quantity of opium to be given should be measured by the PELVIC PERITONITIS. 585 effect obtained ; tlie pain should be relieved and kept in abeyance by the regular administration of doses sutticient to accomplish this object ; when it is possible, opium or morphine should be given by the mouth, because in this way the patient can be kept more uni- formly under its intiuence ; it often happens, however, that the stomach is too irritable to retain it at the outset ; the morphine should then be given hypodermically until the stomach is quiet. In some cases where there is marked pelvic tenesmus, the opium may be given by the rectum ; it should then be given in solution or enema, because if administered in suppositories it is too slightly absorbed. Sometimes in giving the opium in this way it will aggravate in- stead of relieving the pelvic tenesmus, which is often an exceedingly annoying symptom. In many cases the patient has a constant de- sire to urinate, but all efforts to do so only increase greatly the suf- fering ; this induces the patient to resist the desire, so that there is a vesical tenesmus with retention ; under these circumstances great relief can sometimes be given by the careful use of the catheter. "Warm applications may be made to the abdomen in the form of fomentations ; counter-irritation, also, is often useful, which may be obtained by the use of mustard-pastes, turpentine stupes, etc. The bowels should be kept constipated by the free use of opium, and they should not be disturbed until the acute stage has passed off, when they should be relieved by the mildest possible means. If the patient is seen at the very onset of the attack and the rectum is found to be distended, it should be emptied at once by enema ; during the early part of the first stage if the stomach is as it usually is, very irritable, very little wtII be accomplished in the way of giv- ing nourishment ; the thirst may be alleviated by giving ice or very small quantities of effervescing waters. If there is great prostra- tion a little champa,gne and Apolinaris water or carbonic water may be given to relieve the thirst and sustain the patient. As soon as the stomach will admit of it, nourishing food, mostly fluid, should be given ; the beef -extracts, digested milk, and gruel will usually an- swer the best purpose. At the end of the acute stage, when the pain is subsichng or relieved, and the temperature and pulse are down, then the opium can be greatly reduced in quantity or given up entirely if the patient sleeps well ; usually, however, small doses will be required at night to secure rest. The next object in the treatment is to favor a further limitation of the plastic exudation, and to promote the absorption of the in- flammatory products ; this can be accomplished, if at all, by the use of counter-irritation. Small blisters applied in the iliac regions and 586 DISEASES OF WOMEJT. repeated, often give the patient relief from disturbance, and appar- ently favor the absorption of the inflammatory ])roduets. The best method of employing blisters under these circumstances is to a])ply two blisters on each side, to be kept there until it is thoroughly vesi- cated, then puncture the vesicle, and let out all the serum and allow the cuticle to fall down upon the cutis, and then apply over this ab- sorbent cotton, and allow it to remain undisturbed until healing is complete, which usually takes place in from two to four days ; blis- ters may again be applied in the same way. During this time the patient should be sustained by nourishment and tonics, quinine be- ing one of the most reliable agents. AVhen all acute symptoms have subsided and there is no evidence of any serum or pus accu- mulated in the pelvis, the further disposition of the inflammatory products may be favored by the use of iodine. The tincture of iodine may l)e applied through the speculum to the roof of the pel- vis, that is around the cei-vix uteri and upper part of the vagina, and iodide of iron may be given internally. Counter-imtants from time to time should be contiimed, one part of croton-oil dissolved in two parts of sulphuric ether to which are added three parts of tincture of iodine, makes a good application for keeping up continu- ous irritation; this should be painted over the lower portion of the abdomen, and repeated when the tine eruption which it produces bas disappeared. These remedies should be changed after a time to the iodide of potassium or the bichloride of mercury with chloride of iron, the latter being the most valuable as a tonic and alterative. While there are still some of the products of inflammation remaining in the pel- vis, or at least for a long time after the subsidence of the acute in- flammatory symptoms, the greatest possible care should be taken to guard the patient against undue labor ; standing, walking, or riding may produce a relapse, and hence, the patient should be made to carefully feel her way in sitting up and in taking exercise ; especially should this care be insisted upon at the menstrual periods. No rules can be laid down with reference to this except that any exer- cise which excites pain should be avoided ; short stages of exercise, followed l)y rest in the recumbent position, should be adhered to, a little more liberty being given every day, in case it does not pro- duce pain. All exercise of the sexual functions should be prohibited until pain and tenderness have subsided. In case there is an accumula- tion of serum or pus in the sac of Douglas, this should be removed by aspiration ; if pus is found, the cavity should be washed out PELVIC PEKITONITIS. 587 with a weuk solution of carbolic acid and water, or of bichloride of mercury, and if this does not relieve tiie pain, an opening may be made and drainage established, but this is usually unnecessary. ILLUSTKATIVE CASliJS. A Typical Case of Uncomplicated Pelvic Peritonitis. — A lady twenty-five years of age, who had been married for two years, and was sterile, began to menstruate first at fifteen, and had also had dysmenorrhoea slightly for the first years of her adult life, but it was much aggravated after her marriage. She was subject to attacks of pelvic pain, though not severe, after much exercise. At the time of the attack now under consideration, she was menstruating, and went out into company, and, I believe, engaged in dancing, and took cold on her way home. In the night she was seized with vio- lent pain in the pelvic region, with nausea and vomiting. She was seen early in the morning, and her temperature was found to be 102° F., and her pulse 120 ; it was also observed that she was a feeble-looking person of a tubercular diathesis ; there was much ten- derness to the touch in the lower portion of the abdomen, and also considerable tympanitic distention. On digital examination, there was evidently an increase in ten)perature, with congestion and marked tenderness in the region of both broad ligaments and behind the uterus. There was no fixation apparent nor hardening of the tissues, but, owing to the increased tenderness, it was difiicult to make a very critical examination. The rectum was distended with fecal matter. A hypodermic injection, consisting of ten minims of Magendie's solution of morphia, was given, and warm water was injected into the rectum ; the immediate effect of the enema and evacuation was to increase the pain, and in two hours afterward it was necessary to give five more minims of Magendie's solution hy- podermically ; this gave considerable relief, but it did not produce sleep. In the middle of the day she was found to be still restless, with an anxious and somewhat pinched expression, and expressed herself as fearful of some dangerous trouble. Another hypodermic injection was given, because she still had nausea, but no vomit- ing ; late in the evening she was still in much pain, having come partially out from under the influence of the opium ; she was still nauseated, and her temperature was 103^]° F., and her pulse over 120 ; she complained of some headache, felt hot and feverish, and yet she was in a perspiration. Fifteen more minims of Magendie's solution was given, which secured for her several hours' sleep. Early in the morning she was found wakeful and restless, and the 588 DISEASES OF WOMEX. pain bad returned ; her stoinacli still i)eing irritable, anotber ten minims of Magendie's solution of morpbia were given ; during tlie nigbt, while awake, small pieces of ice were given, which were grate- ful to her, but she was still thirsty, and begged for a large drink of cold water ; she was given half a wine-glass of cold Vichy every half-hour when she desired it ; she retained some of this, and in the forenoon took a little clear coffee, which she relished and retained. She still continued to suffer from nausea, great abdominal tender- ness, and considerable pelvic pain; she also complained of a very urgent desire to urinate, but any effort to do so gave her so much pain that she resisted tlie desire ; the nurse was directed to pass the catheter, which she did, and drew off less than half a pint of urine of a remarkably dark color. At night she again had fifteen minims of the solution of morphia, which gave her a few hours' sleep, when she again awoke with pain ; ten minims was then given, which car- ried her through the night fairly comfortable. On the third day after the attack, upon digital examination, the parts of the portion of the pelvis within reach were found to be hard, and the utenis fixed. The hardness and fixation extended entirely across and behind the broad ligament and the uterus ; a diagnosis of pelvic peritonitis was then made without hesitation. The nausea at this time was less marked, so that she retained the Yichy- water and coffee and tea, and occasionally a little beef-tea ; but these were ad- ministered in small doses, care being taken not to give her the Yichy immediately before or after she took any of the others. Every little change in the temperature was observed at this time. It had required from forty-five to fifty minims of Magendie's solu- tion to keep her comfortable during the twenty-four hours up to the end of the third day ; after that the opium was given by the mouth, twenty minims of Squibl)'s liquor opii comp. were given every three, four, or six hours, according to the disturbance or pain which she had, and from twenty-five to thirty minims at bed-time. This was suflicient to keep her tolerably comfortable, and to secure a suflicient amount of sleep in the night and an occasional nap during the day. About this time she suffered very much from tymjxmitic distention ; occasionally she could raise gsts from the stomach, but this gave her very little relief. On the fifth day six grains of quinine, dissolved in sulphuric acid, and added to an ounce of siru]) of acacia and a little warm water, was given by enema ; this was retained, and pro- duced partial relief from tympanitic distention. About a week from the time of the attack the pelvic peritonneura was evidently covered with a marked exudation, especially that por- PELVIC PERITONITIS. 589 tion forming the sac of Douglas, while the fixation and induration involved the entire roof of the pelvis ; it was most marked behind the uterus, extending down to a point on a level of the surface of the cervix uteri. On about the eighth day a marked improvement had taken place in her general condition; the temperature was 101-^° F., and the pulse a little above 100 ; her tongue was still thickly coated, but was beginning to clean off on the end and sides ; the nausea had mostly subsided, but she had no appetite ; she was able, however, to take a fair amount of fluid nourishment — beef -extract, digested gruel, and milk, with a little tea and coffee from time to time ; she still had thirst, and took considerable water. We were able at this time to reduce the quantity of liquor opii comp. about five drops every three or four hours, with twenty-five drops at bed-time. At this time we began the use of small blisters, and continued to keep the lower por- tion of the abdomen in a state of irritation for the next ten or twelve days ; she was also given a pill three times a day, composed of one grain of quinine, one tenth of a grain of extract of belladonna, one half grain of comp. extract of colocynth, and one fourth grain of ipecac ; this, after a couple of days, excited some peristaltic action of the bowels, and, after an enema of soap-suds, the bowels moved. This relieved the tympanitis considerably, and, although she felt greatly distressed immediately after the movement of the bowels, she was apparently better for it. All this time she had a good deal of irritation of the rectum and bladder, and a constant sense of fullness and distress in the pelvis, with pain that varied very much in severity. From this onward she suffered very little, although obliged to keep quiet in bed ; she continued to take a fair amount of nourishment and solid food, such as rare steak and a chop, which with toast and milk, were added to her bill of fare. The quantity of opium was diminished until she only took one dose at bed-time ; the pills were continued, and the bowels moved every third day by enema ; the temperature had now come down to 100° F., and the pulse to 95, but there was still very little apparent difference in the condition of the pelvis. This line of treatment, including the counter-irritation, was continued until the end of the third week ; at that time she was permitted to sit up a little in bed, and was able to turn from side to side wdthout much discomfort. She continued in this way for three days longer, when the pain l)egan again, and the pulse and tempera tm'e ran u]) ; her stomach became again disturbed, although there was no vomiting, and the 590 DISEASES OF "WOMEN. opiiiin had to be given in small doses more frequently, in order to relieve lier — in short, there was every ai)pearance of a lighting up of the acute trouble, but the temperature did not go beyond 101° F., or the pulse beyond 110, and she was exceedingly irritable, nervous, and despondent at this time ; the menstruation then came on, and after a day her pain began to subside a little, and at the end of the third day her condition was about what it was before the relapse took place. This undoubtedly was simply a dysmenorrhoea from a lighting up of the inflammation. After the menstrual flow subsided, she improved in her general condition very decidedly, and, at the end of tlie flfth week from the beginning of the attack, she Nvas able to sit up a little while in bed, and to be occasionally lifted into her reclining-cliair. Her tempera- ture and pulse were nearly normal, but she was quite weak, and still had some disturbance in the region of the pelvis ; mildei- forms of counter-irritants w^ere employed, occasionally using a mild mustard- paste, and sometimes painting with the tincture of iodine ; she was then put under general tonic treatment, including quinine and iron. The bowels were kept regular by the pills which were prescribed before. At this time there was still marked fixation and induration in the location of the pelvic peritonaeum, and from this onward the treatment consisted in good, generous nourishment, wine, and tonics; the iodide of iron alternated with bichloride of mercury and chloride of iron was continued off and on for about six months ; at the end of that time her health was about as good as it was before she was taken ill, although she suffered more from her dysmenorrhoea than formerly, and was obliged to keep in bed during the menstrual period. About this time an examination was made when the indura- tion had partly disappeared, but not wholly ; there was still fixation of the uterus, and efforts were now made to relieve her dysmenor- rhoea, wliich was evidently due to an anteflexion of the body of the uterus, by enlarging the canal by gradual dilatation ; the first at- tempt at this, however, gave rise to so much pain and suffering that no further efforts were made in that direction at that time. A vag- inal douche of hot water was ordered, but that did not give her any apparent relief, nor did it appear to influence the disposition of the inflammatory products. Tincture of iodine was applied around the cervix uteri and upper portion of the vagina once a week for a month or two, and this appeared to be beneficial ; at least she im- proved while this was being employed, but I presume that the con- stitutional medication had most to do with her progress — in fact, my PELVIC PERITONITIS. 591 experience with this case and many others has satisfied me that local treatment in old cases of pelvic peritonitis does harm ten times to once that it does good. She was kept upon her general tonic and alterative course of treatment for six months after suspending all local treatment, and then it was found that there was a marked im- provement in the local condition ; as soon as tlie slight moljility of the uterus was established, the induration and fixation much more rapidly diminished. The patient passed from under my observation, but returned again in two years to be treated for dysmenorrhcea, and I then had an opportunity of examining her carefully, and found considerable mobility of the uterus, and also of the broad ligament ; the marked induration had wholly disappeared — in fact, the only trace of her former peritonitis remaining was a small mass in the most dependent part of the sac of Douglas ; this did not appear to give her any trouble ; there was also less anteflexion of the body of the uterus. I was then able to treat her for her dysmenorrhoea, and succeeded in relieving her to some extent, but not wholly. Four years after I heard of this patient, and she had still maintained fair health, but suffered slightly at her menstrual periods. A Case of Circumscribed Pelvic Peritonitis of the Mildest Charac- ter. — A young lady of somewhat delicate organization, who had suf- fered from irregular and painful menstruation, was seized about the time of one of her periods with violent pain in the left ovarian re- gion ; she was out at the time the pain came on, and I believe was overfatigued ; she returned home and went to bed, and I saw her several hours afterward ; she then had tenderness on deep pressure in the left iliac region and also had pain there of an acute character. Her temperature was below 100° F., but her pulse was over 100 ; she was somewhat nervous and restless ; I gave her a dose of bromide of sodium with a few minims of liquor opii comp., and ordered it to be repeated during the night if she did not sleep. One more dose was necessary to give her a comfortable night, and in the morning when I saw her there was no constitutional dis- turbance except a loss of appetite and some flatulence ; her pulse w\as a little rapid and there was still pain and tenderness, but not marked, in the left side. In the evening of that day her menstrual flow began and continued normally though more free than usual ; this improved her condition somewhat, and although she continued in bed for al)Out a week on account of the return of pain upon trying to sit up, still she made a good recovery, and was around as usual the week following. For a number of weeks she had occasional at- 592 DISEASES OF WOMEN. tacks of pain and tenderness on that side, especially at her men- strual periods. This attack passed off, and she was in fair health until three years afterward, when from exposure she contracted double pneu- monia, of which she died. The pliysician who attended her at that time obtained a post-mortem examination, and, knowing that she had been a patient of mine at former times, invited me to be present ; nothing of interest being found in the thorax I suggested the pro- priety of examining the pelvic viscera in the hope of determining the pathological conditions which gave rise to her irregular and somewhat painful menstruation. 1 had at this time entirely forgot- ten the attack above described, and only remembered it when we found the ])roducts of the pelvic peritonitis on the left broad liga- ment. The fimbriated extremities of the Fallopian tube were matted together by the old exudate, and the peritonaeum covering the outer portion of the tube and extending downward showed evi- dence of an old inflammation ; the ovary, however, did not appear to be affected, except that two or three iimbrias of the tube were ad- herent to it. This case illustrates the circumscril)ed mild form of pelvic peritonitis which occurs quite frequently no doubt, but is overlooked, except when found at post-mortem. Septic Peritonitis Terminating Fatally. — This case illustrates the other extreme from the one just related. A strong, healthy servant- girl had leave of absence on Saturday, and staying out too late, tried to save time by crossing a 13 eld instead of taking the road home ; and upon jumping a fence near the house, she was sud- denly seized with the most violent pain in the pelvis ; she reached home with great difficulty, and was helped to bed by her fellow-serv- ants ; nausea, and vomiting came on, and she became pale, faint, and covered with cold, clammy perspiration ; the physician of the fam- ily, Dr. "Woodruff, was sent for in the night, and by the judi- cious use of morphine hypodermically and stimulants administered by the rectum, he succeeded in bringing her out of her state of par- tial collapse. Her temperature then rapidly ran up to 105° F., and her pulse to 130 ; there was extreme tenderness of the abdomen and distention ; the vomiting continued so ]3ersistently that it M'as impossible to administer nourishment or medicine by the mouth. The physician made a diagnosis of peritonitis which he believed to be general, and I saw her with him in the morning and, concurring in his diagnosis, we continued the use of opium, but her pulse had improved and the stimulants were suspended. The temperature and pulse continued very high and her general appearance was more like PELVIC PERITONITIS. 593 that of a case of puerperal peritonitis tlian any otlier, but there was still some hope entertained of saving her until Tuesday afternoon when she began to vomit that greenish material so often seen in gen- eral peritonitis. Her pulse became feeble and very rapid ; her temperature in the vagina ran up to 106° F., and she appeared like one passing into a state of collapse. She became more and more depressed, and died of shock on Wednesday morning. The case being somewhat un- usual, a grave question was raised as to the causation ; and hence a most careful post-mortem examination was made. On opening the abdomen we found that a few coils of the small intestine had dipped into the upper part of the pelvis, and were ad- herent by recent soft exudate to the upper part of the uterus. The sac of Douglas was found nearly full of pus, and the whole pelvic peritonaeum was covered with the products of acute inflammation. On carefully removing the pus and some soft lymph from the sac of Douglas and broad ligaments, a recent opening was found in one of the ovaries which led to a cyst not larger than a hazel-nut ; in this cyst were found a few drops of brownish-looking fluid which was preserved for microscopical examination. The general peritonaeum, except that covering the intestine which rested upon the uterus, was perfectly normal. Nothing else abnormal was found in any of the organs of the body ; the heart was rather below the average size, and so were the blood-vessels ; beyond this all was normal. It is clearly evident that this girl had small ovarian cysts, the contents of which were highly septic, and when the rupture occurred this fluid set up peritonitis, which being highly septic in character, developed the violent attack which overwhelmed the patient's nerv- ous system. A Case of Pelvic Peritonitis caused by Gonorrhoea, and followed by Pyosalpinx. — This lady was twenty-six years of age, and had always enjoyed very good health until she was married. Two years after her marriage she was suddenly taken with acute vaginitis and ure- thritis ; she then came under my care, and I then made a diagnosis of gonorrhoea and subsequently procured unmistakable evidence from her husband that such was the nature of the attack. The vaginitis and urethritis yielded promptly to treatment, and she was dismissed apparently well, but returned to state that she still suffered from uterine leucorrhoea ; I then found a well-marked cerv- ical endometritis with some remaining vaginitis of the upper portion of the vagina. AVhile she was under treatment for this she suddenly 39 594 DISEASES OF WO!0:N. developed a pelvic peritonitis, wliich was not especially severe but in which there was considerable exudation, as indicated by the fixation and induration of tlie pelvic organs. Under ordinary treatment she progressed fairly well, but the case was unusually tedious. At the end of the year 1 considered her well, but she still had some pelvic pain occasionally, although the products of the intianimation had been almost entirely disposed of, so that there was mobility of the pelvic viscera and very little hardening of the parts except in the sac of Douglas where there still remained some of the old exudate which presented a somewhat irregular, nodulated condition to the touch. At this time she was again taken ill with the symjitoms of another attack of pelvic peritonitis ; the pain and tenderness on this occasion, however, were limited to the left side, and a tumor was soon developed which was elastic to the touch ; this led me to sus- pect that this was a case of salpingitis instead of peritonitis, and when the acute symptoms subsided somewhat, I endeavored to con- firm my suspicions by aspirating the tumor; I found pus and was able to draw off about an ounce and a half of it ; the sac soon filled up again, and she suffered a great deal of pain and constitutional disturbance, evidently due to a sliglit septicaemia. As the case was one of long duration, she became discouraged with my treatment at this time, and on the advice of friends, went to the hospital. I learned afterward, that while in the hospital she was operated upon, the distended tube being removed after the manner of Lawson Tait. A Case of Pelvic Peritonitis, followed by Permanent Displacement of the Uterus, Dysmenorrhoea, and Cystitis. — This was a married lady, about twenty-nine years of age, who had suffered most of the time from dysmenorrhoea and sterility, caused by anteflexion of the body of the uterus with slight retroversion. During the treatment for this malformation of the uterus she was attacked with pelvic peri- tonitis, the exciting cause being a rather forcible effort to correct the retroversion. The pelvic peritonitis ran its ordinary course, and terminated in recovery ; but afterward the uterus was found in a markedly retroverted condition, and bound down to the posterior wall of the sac of Douglas ; the bladder was also drawn backward with the uterus, and held in that position. This gave rise to dys- menorrhoea quite as marked as that from which she suffered before her peritonitis. The malposition of the bladder caused by the ad- hesions rendered it impossible to completely empty that organ, and the partial retention of the urine developed a very troublesome cystitis. PELVIC PERITONITIS. 595 All efforts to restore the uterus and bladder to their normal po- sitions were without avail. The dysiiienorrhoea was partly relieved by treating the cervical endometritis, which she also had, and dilating the internal os a little. The cystitis was controlled by long-continued local treatment, but she still suffered from some pelvic tenesmus, and, in fact, remained something of an invalid during the hve or six years that she remained under my observation. Pelvic Peritonitis, which went on to Suppuration, the Pus accumu- lating in the Sac of Douglas ; treated by Aspiration ; and Recovery. — This patient was a lady who had married and had borne two chil- dren, became a widow, and married a second time, and who had contracted gonorrhoea, which led to a severe attack of peritonitis. There was nothing peculiar in the clinical history cf the case, except that it was very severe, but she progressed fairly well up to the time when the acute symptoms should have disappeared. Her tempera- ture and pulse continuing high, and her general nutrition showing- evidence of some septic influence, it was presumed that pus had been developed somewhere in the pelvis, and, as there was a large tumoi or a well-defined mass in the sac of Douglas, the aspirating-needle was introduced in the hope of finding the location of the suppura- tion. Over two ounces of sero-purulent fluid were drawn off, which improved the patient's condition almost immediately ; she had less pain afterward, her pulse and temperature improved, and her gen- eral nutrition also ; this improvement, however, was only for a short time, when the former symptoms returned, and aspiration was again practiced with the result of finding a small quantity of pus. The sac was at the same time washed out with a solution of bichloride of mercury, and from this onward she did well, although she did not fully regain her original health ; she still had attacks of pelvic pain at times, and active exercise usually brought on pelvic tenes- mus. The last time that she was examined, about a year and a half from the time of the pelvic peritonitis, there was still considerable fixation of the pelvic organs and induration, showing that the prod- ucts of the bygone inflammation had not by any means been all dis- posed of. CHAPTER XXXIII. PELVIC HEMATOCELE. Pelvic hsematocele is, as the term indicates, an accumulation of blood in the pelvis, or, more strictly speaking, in the sac of Douglas, or else in the cellular tissues of the pelvis. Of course, the accumu- lation of blood is merely the result of some other lesion, and conse- FiG. 211. — Subperitoneal pelvic htematocele. U, displaced uterus ; B, empty bladder. PELVIC HEMATOCELE. 597 quently pelvic hasmatocele is secondary to the lesion which gives rise to it. There are two forms of pelvic hsematocele, distinguished accord- ing to the location of the accumulation of blood : Subperitoneal pelvic hgematocele, or that in which the haemorrhage occurs in the cellular tissues (Fig. 211), and intra-peritoneal hsematocele, in which the blood accumulation is in the pelvic cavity — that is, in the sac of Douglas (Fig. 212). The subperitoneal variety is not always a very serious affection, while the intra-peritoneal variety is one of the most dangerous dis- FiG. 212. — Inti'a-peritoneal pelvic hajmatoccle. eases which comes under the observation of the gynecologist ; there- fore, the former will be dismissed with a few remarks later, while the most of what follows will refer to the intra-peritoneal variety wholly. The sources of the hsemorrhage giving rise to this affection which have so far been accurately determined are from rupture of blood-vessels of the ovaries or veins of the broad ligaments, and from rupture of an aneurism of some of the pelvic arteries, reflux of blood from the uterus or Fallopian tubes, and general transuda- 598 DISEASES OF WOMEN. tion from tlie smaller blood-vessels in certain conditions of tlie blood, such as that of purpura, for example. Rupture of the sac in cases of extra-uterine pregnancy has also been mentioned as a source of hoBmorrhage, giving rise to pelvic hagmatocele. But, as extra-uterine ])regnancy is a matter wholly by itself, it need not be considered in this connection. It will be seen from this that the conditions which give rise to haemorrhage may all be classed under two heads — first, some condition of the bloodvessels which favors their giving way, and, second, the conditions of the blood, which favor haemorrhage, such as we find in persons of the haemorrhagic diathesis. The extent of the accumulation depends to some extent upon the size of the rujDtured vessels. If the haemorrhage is extensive, the loss of blood and shock may cause a fatal tei-mination in a few hours. This shock is due to the impression made upon the peri- tonseum by the sudden effusion of blood, which acts as a foreign body. If this does not occur, and the haemorrhage ceases, then pel- vic peritonitis, sometimes general peritonitis, supervenes, and the products of the inflammation are thrown around the blood-clot, and in this way it becomes walled in. If, again, the patient survives the acute peritonitis, the serous portion of the blood is slowly disposed of by absorption, and in time the solid clot softens down by degrees, and is also disposed of in the same way ; and, again, the patient may recover with the pelvic organs damaged l)y the inflammatory pi'od- ucts, which remain and behave very much as in simple pelvic peri- tonitis. Occasionally, however, it happens that, in place of the blood-clot being disposed of in this way, it breaks down, and sujd- puration of the products of the peritonitis occurs, and death ensues from septicaemia. This, then, gives three well-defined stages in the progress of pel- vic hsematocele : Firet, the stage of hsemoi-rhage ; second, the stage of pelvic inflammation ; and third, the stage in which the clot is disposed of by absorption, or breaks down, and gives rise to sup- puration. The extent of pelvic peritonitis, and the subsequent disposal of the clot, or the extent of suppurative action which may take place, depends to some extent upon the quantity of the blood accumula- tion, and also upon the patient's general condition at the time, and the character of the blood. In case the patient is not in \agorous health at the time of the haemorrhage, and if the haemorrhage is great, the shock is more likely to prove fatal ; or, if that does not take place, then the extent and character of this inflammation, and the tendency to decomposi- PELVIC HiEMATOOELE. 599 tion and snppurcation, are rendered greater in case the blood is in any way abnormal. A limited quantity of normal blood in the sac of Douglas does not necessarily give rise to very great trouble, but we can readily suppose that, if blood is abnormal, as in the case of scorbutus or purpura, then it is more likely to be irritating, and hence the greater wdll be the inflammation and tendency to suppuration. The accom- panying figures, 211 and 212, illustrate the two varieties of pelvic hsematocele, classified according to location. Causation. — The causes of pelvic hsematocele are necessarily predisposing and exciting. There are three predisposing causes — certain changes in the blood-vessels of the pelvis, overdistention of the vessels which enfeebles their walls, and degeneration of the walls of the blood-vessels, which renders them more easily ruptured under extra pressure. Any one of these conditions of the blood-vessels may be produced by continued hypersemia or, more especially, engorge- ment. It is well known that congestion on the venous side of the circulation tends to degeneration of tissues of all kinds, and the walls of the blood-vessels prove no exception. Hence, in cases of long- continued congestion of the pelvic organs from any cause, such as obstruction of the portal circulation, imperfect involution after JDar- turition, or in persons whose occupation compels their continued standing or sitting, the strength of the walls becomes impaired, and they are liable to rupture. On the other hand, in certain abnormal conditions of the blood, such as that found in purpura or scorbutus, there is a tendency to haemorrhage from the small vessels under extra pressure. It follows, also, that the predisposition to haemor- rhage will be most marked during the period of ovarian activity, and also at the menstrual ]3eriod. The exciting causes of pelvic hsematocele are, in a word, anything which can produce overdistention of the blood-vessels, sudden check- ing of the menstrual flow, maintaining the erect position for any' great length of time, violent exercise and overexertion, and the like, injuries or falls, and when the haemorrhage comes from the Fallopian tubes or the uterus, it is caused by some obstruction of the cervical canal or the Fallopian tubes. Symptomatology. — In the majority of patients who have this affection, the haemorrhage is often preceded by symptoms indica- tive of some pelvic affection, but these need not necessarily be suffi- ciently marked to call the attention either of the patient or the phy- sician to them ; so it may be said that the symptoms of pelvic hsem- atocele are developed suddenly. The symptoms, of course, differ 600 DISEASES OF WOMEN. as the disease progresses, each stage having its own characteristic manifestations. When the haemorrhage occurs, there is first, severe pain in the pelvis, followed soon after by all the evidences of shock, such as faintness, coldness of the extremities, pallor, and cold, clammy perspiration, a feeling of nausea, and sometimes vomiting. If the temperature is taken at this time, it will be found to be subnormal, and the pulse irregular and rapid, although sometimes it is slow and feeble. In a short time to these symptoms are added well-marked pelvic tenesmus, including vesical and rectal tenesmus, and tympanites. If the haemorrhage stops and the patient recovers from the shock, then inflammatory symptoms are developed. These constitutional and local symptoms are exactly the same as tliose observed in peritonitis, because they are due to the peritoneal inflammation which usually starts up about forty-eight hours after reaction from the haemorrhage. If the patient passes through the inflammatory stage and the blood accumulation is disposed of by absorption, the symptoms will then be altered to a modified pelvic tenesmus with occasional pain of a mild character and a general malnutrition, indicating some source of a mild form of septicaemia. On the other hand, if suppuration and breaking down of the blood- clot take place, the constitutional disturbances as indicated by high temperature, rapid pulse, and deranged nutrition, will show the sep- ticaemia which usually takes place under those circumstances. Physical Signs. — In the stage of haemorrhage there are simply tenderness and distention of the sac of Douglas, indicated by a mass which fluctuates on pressure ; the tumor is soft, smooth, and uni- form. After coagulation has taken place the mass becomes solid, but is still soft and yielding to the touch ; the uterus is displaced, usually upward and forward, so that the cervix will be found just behind or above the symphysis. The rectal touch will also show that the tumor presses upon the bowel ; abdominal palpation made after the tympanitic distention has subsided, will often show the mass extend- ing up to the superior strait and sometimes higher, and in one case that I saw, the blood-clot extended upward half-way to the umbiHcus. After inflammation takes place this mass becomes surrounded above with the products of the inflammation which increase the density of the tumor and also give it a more perfect fixation. After the inflammation has subsided and the serous portion of the blood has all been absorbed and the solid clot has undergone considerable contraction, the mass that was originally smooth to the touch, now PELVIC HEMATOCELE. 601 becomes quite irregular. As the case advances still further and the blood-clot breaks down and suppuration occurs, the mass may be- come softer and give the impression of obscure fluctuation to the touch. The great difficulty which the diagnostician encounters is to distinguish between pelvic cellulitis, pelvic peritonitis, and hsemato- cele. It is also stated that pelvic haematocele may be confounded with retroversion of the uterus, extra-uterine pregnancy, flbroid tumors, and inflammation of a small ovarian cyst which is lodged in the sac of Douglas, and hydro- or pyo-salpinx. There is very little likelihood of confounding so grave an affection as pelvic hsemato- cele, the clinical history of which is so marked, with any of the above-named conditions, except it might be an acute inflammation of an ovarian cyst, located in the sac of Douglas, or a Fallopian tube, very greatly distended with serum, pus, or blood. In either of these conditions — except the latter — if a diagnosis could not be made, and it was important at once to do so, the use of the hypodermic syringe used as aspirator, would settle the question definitely. Treatment. — During the stage of haemorrhage this consists in using means to arrest the hsemorrhage, relieve the pain, and sustain the patient against the shock and loss of blood. To control the haem- orrhage the patient should be placed on the back with the head and shoulders slightly elevated, in order that the blood as it accu- mulates in the pelvis may, by its own weight, make pressure upon the rupture in the vessel. Cold applications to the abdomen have been recommended, but usually are not well borne. Pressure made by applying a compress and bandage is more likely to do good ; to relieve the pain and sustain the patient, morphine given hypoder- mically is the most reliable and valuable of all remedies ; under the circumstances the opium acts as a stimulant as well as a relief to pain. In case the shock is great and liable to prove fatal, stimulants should be used hypodermically or by the rectum ; but in many cases the rectum will not retain them owing to the irritability caused by the hsematocele. It has been proposed by Dr. M. A. Fallen to open the abdomen, remove the blood, and stop the hgemorrhage by ligating the rupt- ured vessels. This, theoretically, appears to be good surgery, but unfortunately it can never have any very wide practical application ; the fact is it should never be undertaken in cases where the shock and depression are great, because the patient would most certainly die under the operation, and in the less severe cases of haemorrhage which are not attended by any great shock, it can usually be arrested by milder means. I can conceive of no condition where laparotomy 602 DISEASES OF WOMEN. would be justified, except in cases where the haemorrhage is slow but persistent. If one is satisfied that a haemorrhage is going on in the pelvic cavity, which persists in spite of all ordinary efforts to check it, and the patient does not suffer from shock, then lapa- rotomy might be undertaken ; such cases, however, are extremely rare, and it is difiicult to diagnosticate the conditions above men- tioned ; hence, I think that it will be seldom, if ever, that this prac- tice will be followed. However, abdominal surgery has attained such a degree of perfection in the hands of some, at the present day, that it is well to keep this mode of treatment in mind as a possible means to be employed. When the inflammatory stage begins the treatment should be the same as that already advised in cases of pelvic peritonitis, and if the case progresses favorably the treatment should be continued on the same principle. If, however, suppuration takes place, and the pa- tient is placed in danger of septicaemia, the question arises how to relieve that condition. There are two methods, either or both of which may be employed if the location of the pus can be reached through the vagina ; aspiration may be practiced, and if that gives relief it may be repeated if need be ; if, however, this fails, the needle may be again introduced until the pus is reached, and being left there as a guide, a larger opening may be made, and drainage established ; or laparotomy and drainage may be practiced. Years ago, Kecamier proposed to evacuate the blood-clot as soon as the patient had sufficiently rallied from the shock of haemor- rhage ; by so doing he hoped to lessen or avert entirely the inflam- matory stage and the long tedious and sometimes dangerous process of disposing of the clot. Nelaton took up this practice, but soon found that it was a dangerous proceeding, inflammation and septi- caemia of a dangerous character being very liable to follow. It is possible that to-day, with the great improvements in sm-gery, this practice might give better results than in years past ; one thing I am sure of, and that is if the blood-clot is not disposed of in a quiet and favorable way but sets up a suppuration after the inflammatory stage is past, T should be in favor of evacuating it. This I have tried successfully in one case, a rather desperate one it was too, and with perfect success. I would not, however, advise operating except under the conditions named, because, if the evacuation of the clot is undertaken before it is walled in by inflammatory products, there is ver}^ great danger of starting up another hemorrhage which might not be controllable, and again there is more danger of exciting peri- tonitis which might become general, and end fatally. PELVIC HEMATOCELE. 603 ILLUSTRATIVE CASES. A Case of Pelvic Hsematocele uncomplicated. — A lady of some- what phlegmatic temperament who was also ehlorotic, had suffered all her life from dysmenorrhoea in a marked degree, and also scanty menstruation as a rule, although at times this was more free. She had been twice married, the last time for eight years, but had never been pregnant. In taking her previous history at the time I lirst saw her, I found that she had symptoms of some former pelvic dis- ease, probably general congestion as indicated by her dysmenorrhoea, leucorrhoea, and pelvic tenesmus which was aggravated on walking. She had lived a somewhat indolent life taking very little phys- ical exercise. When I saw her first I learned that on the last day of her menstrual flow she had been riding and walking more than usual, as she had some visitors whom she was entertaining by tak- ing them about the city. While getting out of her carriage she slipped and fell on the sidewalk ; she was taken with pain in the left side of her pelvis, and had to be helped into the house, and immediately went to bed ; her pain increased in severity, and she became very faint and nauseated ; I saw her about two hours after this slight accident, and found her suffering from partial shock ; her pulse was exceedingly feeble and rather rapid ; her temperature was 97^° F., and her skin was cold and clammy ; she was sighing frequently, and had an expression of extreme anxiety and distress ; she had vomited frequently and was exceedingly nauseated ; she complained in a low whispering voice of a violent pain in the vaginal pelvis. There was considerable tympa- nitic distention of the abdomen with marked tenderness in the epi- gastric region. On digital examination I found considerable tender- ness, but not as much as might have been expected. There were signs of fluid in the sac of Douglas, but this was eas- ily displaced by the touch ; a diagnosis of pelvic hsemorrhage was made, and hypodermic injections of morphine were given sufficient to relieve her pain ; a little brandy-and-water was also administered at first, but this she almost immediately rejected ; an abdominal band- age and compress were applied without giving any distress for two or three hours, but at that time she complained of its tightness, and it was necessary to remove it ; bottles of hot water were applied to the feet and limbs and also to the arms, which were kept under the bed-clothing. All this gave her relief from pain to some extent and the shock did not apparently increase, and yet she showed very little disposition to rally. About three hours afterward some brandy 604 DISEASES OF WOMEN. and beef-extract were given by enema, and repeated at intervals of two or tliree hours for some time ; the hypodermic injections of morphine were also repeated as often as every three hours durini: the tii*st twelve hours. During this time she was given a grain and a half of morphia altogether. She then began slowly to recover from her shock, the haemorrhage evidently having stopped ; lier pulse became more rapid and a Httle fuller ; she breathed more nat- urally, and her skin became warm ; she also had less of that extreme faintness and depression ; still she remained nauseated althougli she was able to retain very small quantities of brandy and Seltzer-water and beef-extract ; the pain however was not any less except when controlled by the morphine. In addition to this she complained of marked pelvic tenesmus, especially of the bladder and rectum. She described this feeling as one of great fullness, weight, and pressure in the pelvis, which she fancied would be relieved by free evacua- tion of the bowels. She remained in this condition with very little change ; taking opium freely and very little nourishment for about forty-eight hours ; at that time the physical signs showed that the sac of Douglas was tilled with blood which was now beginning to coagulate as shown by the less pelvic fluctuation on touch. Her temperature now rather rapidly increased, running up to 103° F., her pulse became more rapid and fuller ; the pain also increased, and nausea and vomiting again returned. She was now very tym- panitic and had acute tenderness on touch in the lower part of the abdomen ; in short, she had all the symptoms of acute pelvic peri- tonitis with unusual marked constitutional disturbance, owing no doubt to the general depressed condition due to pelvic haemorrhage. On the fourth day there were well-defined evidences that the products of the pelvic inflammation were being developed ; there was much greater hardening of the parts, and the mass in the sac of Douglas was solid or more solid as indicated by the touch. From this onward the physical signs were those of a pelvic peritonitis with an unusual accumulation in the sac of Douglas. The progress of the case from this time was that of a severe pel- vic peritonitis^ and the treatment was the same as has already been described, hence nothing further need be said on that subject. At about the end of the third week the physical signs were the same, except that on examination a mass appeared behind the uterus which was somewhat irregular, small depressions and elevations being de- tected here and there ; the temperature and pulse had both come down, and yet remained above 100 ; the patient was now able to take a fair amount of nourishment, and her bowels were moved, but with PELVIC HiEMATOCELE. G05 the greatest possible difficulty ; laxatives and repeated enemata were given each time that an evacuation was obtained, and she also suf- fered great distress when the bowels moved. About this time she be- gan to show decided malnutrition ; she had lost considerable flesh, was pale and rather slightly bronzed looking, and her skin was dry and ill conditioned, giving the impression that the absorption of the serous portion of the blood was probably causing a mild form of septicfiemia. From this time onward her progress was exceedingly slow but entirely satisfactory under tonics, nourishing diet, and mild counter-irritation over the hypogastric region; she gradually re- gained her strength. The pain and discomfort in the pelvic region had become very trifling except when she tried to take exercise. There was no change in the physical signs except that the mass in the sac of Douglas had greatly diminished in size, and the uterus which had been pushed upward and forward close to the pubes, had returned in part toward its normal position. The hardening of the pelvic roof and the fixation of the jDelvic organs remained about the same. It is needless to follow the progress of this case from day to day ; suffice it to say that she made a very slow recovery, that at each menstrual period she suffered great disturbance, and that for a long time was unable to walk or ride without suffering pain. Tonics, alteratives, and nourishing diet were given which improved her gen- eral condition. Ten months after the attack there were still signs of an excessive exudation in the pelvis, and also the remains of a blood-clot in the sac of Douglas ; still, from this time onward she was able to enjoy life in her own somewhat indolent way, but could not walk or ride without suffering more than in former yeai'S. A year and a half subsequently I had the opportunity of examining the pelvis, and found that there was still considerable fixation of the pelvic organs, and also some hard, irregular, small masses in the sac of Douglas, but she did not appear to suffer very much from these, and her gen- eral health was fairly good. Pelvic Haematocele ; Evacuation of a Clot ; Recovery. — A French- woman, occupied as polisher in a watch-case factory, where her duties required her to occupy a standing position all day long, was suddenly taken ill while at work ; violent pain, followed by faintness, came on while she was at work. She was carried from the factory to her home near by, and one of my assistants was called to see her. He attended to her immediate wants, and saw her again afterward, when he made a digital examination, and found a fluctuating mass in the 606 DISEASES OF WOMEN. sac of Douglas. On the second day he gave me a detailed history of the case, and we came to the conclusion that she must have had a pelvic liaemorrhage ; the inflammatory action soon set in after she rallied from the shock which occurred, and was very severe at the onset of the disease, and she was again in a most dangerous condi- tion. Being poor, her surroundings were very unsatisfactory, and, by advice of the doctor, she was removed to the hospital; she was admitted about ten days after the time that she was taken ill. At that time the pelvis appeared to contain one solid mass, so that noth- ing could be distinguished except a somewhat shortened vagina and the cervix uteri, which was curled up and hrmly iixed behind the pubes. Her bowels were very much distended, and she suffered ex- tremely from pain and tenesmus ; her general condition was very wretched, indeed, and, as it was impossible to move the bowels, the question arose, What could be done to relieve the extreme pressure in the pelvis which threatened to destroy the organs and tissues, and prove fatal ? I had the extreme good fortune to secure the counsel of the late Prof. William Warren G-reene, and we decided to evacu- ate the blood-clot in the hope of thereby saving the life of the pa- tient ; accordingly, an incision was made through the posterior vag- inal wall into the most dependent part of the tumor, which extended well down into the middle line of the pelvis ; a large blood-clot was found, which was broken up and evacuated, and the cavity cau- tiously washed out. ISTo haemorrhage of any amount followed, and she was very much reheved. I succeeded then in moving the bowels, which, while it distressed her at the time, subsequently gave her relief. The improvement lasted but a little while, however, for she soon develojDed a violent septicfemia, and it now appeared as if she certainly must die ; she became delirious, her pulse was extremely rapid and feeble, her temperature was 105^° F., and she was bathed in clammy perspiration ; her breath also had that peculiar sweetish odor characteristic of septicaemia or pyaemia. There was a free discharge of pus at this time from the wound. Every effort was made to sustain her by stimulants and quinine, given by the mouth and rectum also, and the sac was washed out carefully and frequently with boracic acid and water. For two days it seemed as if she might die at any time. A free and profuse diarrhoea came on, and lasted for several hours, and, at a consultation held by the surgical staff of the hospital, all agreed that she had very little chance of recovery. The treat- ment was thoroughly carried out, and soon the blood-])oisoning began to diminish, the sac became smaller, the discharge less free, and, PELVIC HiEMATOOELE. 607 finally, the wound closed, and she recovered from all but the prod- ucts of the inflammation, and these remained slightly diminished up to the time that she was discharged from the hospital, three months from the time that she was admitted. When she left the hospital her general health was fairly good, but there was still fixation of the pelvic organs, and marked induration extending across the pelvis behind the broad ligament and uterus. I found out afterward that she took care of her household after her return from the hospital, and about six months afterward returned to her occupation in the factory, where she remained at work when last heard of, two years from the time she was first taken sick. A Case of Subperitoneal Hsematocele ; Recovery. — A lady, whose age does not appear in my notes, was married, and had three chil- dren, and was under my care for endometritis, associated witli a good deal of general congestion of the pelvic organs. She was progressing fairly well until one day, when she went to New York shopping ; she walked and stood considerably, and on her way home in the afternoon, after crossing the ferry, decided to walk to her house, a distance of about three quarters of a mile ; she did this because she was somewhat proud of her improvement under treatment. When about haK through her short journey, she was seized with pain in the left side of the pelvis, which became so severe that she was obliged to sit down on the door-steps of a house near by, and, after resting for a short time, she managed to get home, went to bed, and applied a mustard-paste over the painful side ; the next day or two she re- mained in bed, the pain gradually diminishing, though it did not wholly disappear. Four days afterward she rode to my office, and, on digital examination, I found a round, rather flat tumor in the left broad ligament, low down ; it was somewhat solid to the touch, and tender. Being very desirous of knowing what this peculiar and sud- denly developed tumor could be, I introduced a small aspirating- needle, and drew off a few drops of blood-serum and a few very minute shreds of blood-clot, but failed to find anything more, al- though I made a strong effort to do so. I then withdrew the needle, and found that it contained a long shred of blood-clot ; this satisfied me that she had had a haemorrhage into the cellular tissue of the broad ligament. I watched her with care and anxiety, but there was no inflammatory action established at that point, and the tumor slowly and completely disappeared. Subperitoneal Pelvic Hsematocele discharging into the Pertioneal Cavity, and ending fatally. — The following case is taken from the work of Thomas on " Diseases of Women " : " In a case which I saw 608 DISEASES OF W0ME5T. with Dr. Emmet, we were unable to make a diagnosis of a tumor wliicli lay obliquely anterior to the uterus. In twenty -four hours the patient fell into a state of collapse, and, as we saw her thus, the nature of the tumor, which we were doubtful about on the previous day, became evident. Upon a post-mortem examination, an ante- uterine ha?matocele as large as a goose's egg was found under the peritonaeum, through which it had broken, discharged a portion of its contents into the peritonaeum, and caused collapse and death. This is the only ante-uterine, but not the only subperitoneal, haema- tocele with which I have met." For an illustration of subperitoneal pelvic hsematocele giving rise to cellulitis and suppuration, the reader is referred to a case given under the head of " Pelvic CelluUtis." DISEASES OF THE UEIl^AEY OEGAKS. CHAPTER XXXIY. ANATOMY AND DEVELOPMENT OF THE BLADDER AND UEETHEA. This portion of the present work is undertaken witli the full assurance that the medical profession is in need of a systematic and practical treatise on the diseases which affect the urinary organs of the female sex, and that such a treatise should be included in every work on gynecology which lays claim to being complete. Those engaged in active practice often encounter cases of cystic disease among their female patients, many of which are exceedingly trouble- some if not altogether impossible to manage. There is, moreover, but little in English literature, at least, to aid them when thus per- plexed with the difficulties of diagnosis and treatment. In considering this important subject after the plan which I have adopted, much will be purposely omitted, which, though interesting, is not absolutely necessary to a clear understanding of its essential principles. The conflicting views of various authors regarding un- settled questions will, when possible, be entirely disregarded in order to make room for the more practical points which the physician is expected to carry with him in his daily practice. In short, it will be my purpose to supply, so far as I may be able, the deficiency in this branch of medical literature, the existence of which a busy life in private practice and in teaching medical students and post-gradu- ates has demonstrated. To proceed systematically, I will first take up the form and struct- ure of the bladder and urethra, and the relations which they bear to other organs and tissues in the female, and then pass on to the con- sideration of their development. Anatomy of the Bladder. — The bladder is a musculo-membranous sac, situated in the anterior part of the true pelvis. Its form varies with the age of the individual and the degree to which it is dis- 40 610 DISEASES OF WOMEN. tended. In childhood, the vertical diameter is the longest ; in mid- dle life, the transverse ; in old age, from the sagging of the infe- rior fundus and gradual atrophy of the pelvic organs, the vertical again becomes the longest diameter. When empty, its walls are closely coajDtated, and it lies behind the pubes. Between the pubes and the bladder is a space containing loose fat. When moderately filled, it rises slightly above the pubes, and assumes a somewhat ovoid shape, which is much more marked during distention. In the fe- male the bladder has a shorter antero-posterior and a greater lateral diameter than in the male. The bladder in the female is, for accuracy and convenience of description, divided into corpus (body), fun- dus (base), and cervix (neck) (see Fig. 213). The corpus is all that portion of the organ lying above an imaginary plane, passing through the vesical openings of the ureters and the center of the symphysis pubis. That part lying below this plane is the fundus or base, and is variously divided. The portion which lies between the vesical openings of the ureters behind, and the vesical orifice of the urethra in front (Fig. 214), is known as the trigone, or vesical triangle. That portion of the base lying just behind the ureteric openings is known as the bas fond. This is usually but a slight depression in early and middle life, but in disease and advanced age it often becomes a deep pouch or sac. This is more often the case in the male than in the female. The cervix or neck of the bladder is that funnel- shaped space at the apex of the trigone, where the bladder and ure- thra merge into each other. The bladder has three coats — two complete and one partial or incomplete. From without inward these are the serous (incomplete), the muscular, and the mucous. The serous investment of the blad- der, like that of all the abdominal and jDclvic organs, consists of peritonaeum, of which I will speak more fully when I come to con- sider the ligaments and topographical relations of this organ. The middle or muscular coat has a peculiarly efficient fiber ar- rangement. Its layers have been divided into two — external and internal — but so frequent and so intimate are their interlacements that, though when minutely considered they are two, practically they act and appear as one. The main direction of the outer fibers is Fig. 213. — Diagram of the bladder to show corpus and fundus. ANATOMY OF THE BLADDER. 611 longitudinal ; of the inner, circular. There is also a thin stratum of muscular fiber lying just under the mucous membrane, and con- tinuous with the longitudinal fibers of the urethra. The main iibers are of the unstriped or involuntary kind, and take their origin chiefly from the neck of the bladder. According to some authors, the sphincter vesicae is formed by a strong band of muscular fibers, varying from one eighth to half an inch in thickness. By others, and these are perhaps the best au- thorities, it is claimed that there is no true anatomical sphincter of the bladder. The function of the sphincter vesicae is said to be per- formed by the closing together of the longitudinal folds of the tis- sues at the junction of the bladder and urethra, or by the transverse semicircular folds that close over each other. At the base of the bladder two httle muscular slips arise from the portion usually designated as the sphincter vesicae, and find in- sertion about the vesical openings of the ureters. These muscular fasciculi are but imperfectly developed in the female, and probably have little if any specific action. The lining or mucous coat of the bladder is like that of the ure- ters and urethra. It consists of a basement membrane, supporting two or more layers of epithelium, in some parts squamous, in others cylindrical, the whole lying upon an elastic, cellulo-vascular bed that is fitted into the meshes of the reticulated muscular coat beneath. This mucous membrane is nowhere attached closely to the sub- jacent muscular layer, save at the trigone, the neck, and about the orifices of the ureters. Owing to the general looseness of attach- ment when the bladder is partially or wholly contracted, the mucous membrane is thrown into rough, uneven folds everywhere, save at the points of close attachment already mentioned. In the trigonal space the membrane is thinner, more closely ad- herent, and the surface epithelium is usually of the medium-sized, squamous variety. The nerve-supply to this small space is very rich, and, in consequence, it is the most sensitive part of the blad- der. Although Savage denies the presence of glands or papillae in the raucous membrane of the bladder, Holden and many others main- tain (and correctly, I think) that the membrane is studded with numerous little glands and follicles, whose function is to supply mucus to the internal surface of the organ. They are most numer- ous at and about the vesical neck. The trigone in the female is a smaller space, and has less dis- tinctly marked boundaries than in the male. That little elevation G12 DISEASES OF "WOMEN. of uuieons membrane lying at the very apex of the trigonal space, and known as the nvula, is also but little develoj^ed in the fe- male. Running between the vesical orifices of the ureters, Jurie claims to have found what he calls the iuter-uretenc ligameiit, in the ends of which he asserts that the ureteric orifices are imbedded. To its action he attributes tlie power that the bladder has of preventing regurgitation into the ureters. I will speak more fully on this point presently. Normally, the bladder has thi'ee openings, one for each ureter, and the urethral orifice. The openings of the ureters lie on each side of the median line at the l^ase of tlie bladder, about one inch and a half behind the vesical opening of the urethra, and about two inches apart. The ureters pierce the bladder- wall obliquely, and their openings are so minute as to be hardly \dsible to the naked eye. Their points of entrance are marked by a slight puckering in the mucous membrane. The third opening is the ostium urethrse internum, which is a diagonal slit at the juncture of the vesi- cal neck and u rot lira. According to Ru- tenberg, the color of the vesical mucous membrane in the liv- ing subject before dilatation is a dull, grayish red ; but, as dilatation proceeds, and the irregular folds are straightened out, it becomes grad- ually a brighter red, and, when complete distention is accom- plished, the minute arteries can be seen forming a beautiful interlacing network on the bands of the muscu- lar reticulag. "Whenever it has been my good fortune to see this membrane in the living subject, it has appeared to me as being of a Fig. 214. — Base and neck of the bladder (Savage), a, sym- physis pubis. 1, 1, Ureters. 1', Ureteric openings. 2, 3, Uterine artery and veins. 4, Outline of cervix uteri. 5, Vesical neck. 6, Arcus tendineus and vesico- pubic muscles. 7, 7, Pubo-coccygeus muscles. ANATOMY OF THE BLADDER. 613 grayisli-pink color, not unlike that of tlie iniicous membrane of the cervix uteri when anaeuiic. The vascular supply of the bladder is very free, being derived from the superior, middle, and inferior vesical arteries, and branches from the uterine artery. They all arise from the anterior trunks of the internal iliac arteries. The anastomoses of the arterial twigs are numerous and free. The veins are also numerous and large, form- ing by interlacement and connection thick, tortuous plexuses about the base, sides, and neck of the bladder, and finally terminate in the internal iliac veins. This plexus about the neck of the bladder com- municates freely with that of the labia minora, uterus, and rectum. These venous plexuses are the chief elements in the so-called "haem- orrhoids of the bladder." In their tortuous course these veins are accompanied by lym- phatics that seem to have their origin in the submucous cellular tissue of the bladder. They enter the glands situated about the internal iliac artery, and from there go to the lumbar glands. The nerves of the bladder are of two kinds — sj^inal and sympa- thetic. The spinal nerves are branches, usually from the fourth, sometimes from the third, and rarely from the second sacral nerve. They terminate chiefly in and about the neck and base of the blad- der. The sympathetic nerves have their origin from the hypogastric plexus, which lies in front of and on the last lumbar and first sacral vertebrae. It is formed by a mazy interlacement of numerous gan- glionic fibers, and branches from the spinal nerves, especially the second sacral. Ganglia are common, more particularly at the point of junction of the spinal and sympathetic nerves. This plexus sends branches to all parts of the bladder, and to the vagina, uterus, and rectum. This common nerve-supply to the various pelvic organs must be borne distinctly in mind in order that the functional de- rangements and neuroses of the bladder, hereafter to be described, may be thoroughly understood. Anatomy of the Urethra. — The female urethra is a musculo-mem- branous canal, from one to two inches in length, the average being about one inch and three eighths. Its diameter is greater than that of the male, being about one fourth of an inch. It lies in the median line, just under the pubic arch, and is held in position by the median pubo-vesical ligament. In the erect posi- tion it has a direction upward and backward, and at all times, when normal, its axis closely coi-responds to that of the pelvic outlet. It terminates anteriorly at the base of the vestibule by an ojiening 614 DISEASES OF WOMEN". k J known as the meatus urinarius, and posteriorly at the neck of the bladder. It has a cellular, a double muscular, and a mucous coat. Accord- ing to Robin and Cadiat, its mucous membrane is richer in elastic tissue than any other in the body. The epithelial covering of the anterior or lowest portion is of the pavement variety, and closely resembles that of the vagina, except that it is not so large. Figs. 217 and 218 show the difference between the 1/^. ^|s: ^ two. Posteriorly and superiorly it is like that "^ ' -^ ^ ' Q-f ^]^Q bladder — columnar and squamous. Scattered throughout are little papillae, con- taining blood - vessels, and near the meatus there are numerous lacunje surrounded by villous tufts. There is also a number of small mucous glands, that in old people often con- tain black particles, like the j^rostatic concre- tions of the male. Upon each side, near the floor of the fe- male urethra, there are two tubules large enough to admit a No. 1 probe of the French scale. They extend from the meatus urinari- us upward, from three eighths to three quar- ters of an inch. Fig. 215 is a drawing from a section of the urethra, laid open by division of its posterior or vaginal wall. The tubules, having been distended by probes passed into them, are plainly seen. Fig. 216 shows the same thing from the opposite side, the ure- thra having been laid open by section of its ante- rior wall. The space between the tubules is the | ^ ''' \ floor of the urethra. From these it will be ob- , served that the tubules run parallel with the long axis of the urethra. They are located beneath the mucous mem- brane in the muscular walls of the urethra. This is represented by Fig. 217, which is a draw- ing taken from a transverse section of the ure- thra, about a quarter of an inch from the meatus. The mouths of these tubules are found upon the free surface of the mucous membrane of the urethra, within the labia of the meatus urinarius. fig. 216.— Urethra laid The location of the openings is subiect to slight ^f ° with probes in -■• =" . . •' ^'^ Slvene's glands (an- variatiou, according to the condition and form terior wall divided). Fig. 215. — Urethra laid open with probes dis- tending the glands (pos- terior wall divided). ANATOMY OF THE URETHRA. 615 of the meatus. In some subjects, especially the young and very aged, and in those in whom the meatus. is small, and does not pro- ject above the plane of the ves- tibule, the oritices are found about an eighth of an inch with- in the outer border of the mea- tus. When the mucous mem- brane of the urethra is thickened and relaxed, so as to become slightly pi'olapsed, or when the meatus is everted, conditions not uncommon in those who have borne children, the openings are exposed to view upon each side of the entrance to the urethra. What is here described is rep- resented in Fig. 219. The labia of the meatus have been slight- ly everted to bring the orifices into view. The upper ends of the tu- bules terminate in a number of divisions, which branch off into the muscular walls of the ure- thra. By injecting one of the tubules with mercury, and then dividing it, the openings of the branches can be easily seen. This description of the anatom.y of these glands is taken from dissections and microscopical examinations made by Drs. B. F, West- brook and J. M. Van Cott, Jr. I have called them glands because they differ in size and structure from the simple follicles found in abundance in the mucous membrane. When I first discovered these glands I presumed that they were mucous folKcles that were accidentally of unusual size in the subject examined, but, having investigated more than one hundred of them in as many different subjects, and finding them constantly present, and so uniform in size and location, I became satisfied that they were worthy of a separate place in descriptive anatomy. The dissections made by Dr. Westbrook, and the pathological lesions to which these structures are subject, confirm this belief. So far as I know, the anatomy of these glands has not been de- scribed, nor have the diseases to which they are subject been referred Fig. 21*7. — Transverse section of urethra with irland on either side. 616 DISEASES OF WOMEN. to by pathologists. At least tliis much may be said, that the stand- ard text-books on anatomy and gynecology in English, German, and French contain no reference to them. It is easy to understand why these insignificant glands should 1 \ k\«i.N«n^^- Fig. 218. — Longitudinal section of urethral glands. have been overlooked by anatomists, or, if noticed at all, classed with other mucous follicles. It is only when their pathology is under- stood that their real importance becomes appai*ent. I know nothing about their physiology. They serve some pur- pose in the economy, no doubt, but what is their function is a ques- tion to be answered in the future. This will doubtless be attended to at an early date, as the subject is worthy of investigation. The pathology of these glands, so far as has been investigated up to this time, is of great practical interest, and there remains, no doubt, much still to be studied. Clinical observation has already shown that they are subject to inflammation of various degrees of intensity and duration. The meatus urinarius in the female differs from that of the male in being a puckered and somewhat prominent, rather than a slit-like ANATOMY OF THE UEETHRA. 61' A s.^nt The meatus everted, showing the mouths of the glands. and depressed opening. The mucous membrane of the urethra is thrown into longitudinal folds throughout, save when opened and unwrinkled during micturition or by arti- ficial dilatation. When at rest it is a closed canal. Beneath the mucous membrane there is a thick fibro-elastic network into which the mucous glands dip. These are lined with cylindrical epithelium and surrounded by a network of veins. This submucous areolar tissue has direct vascular connec- tion with the muscular layer that sur- rounds it by means of cavernous venous si- nuses, partly in the muscle and partly in the elastic connective tissue. Thus there is an arrangement almost exactly like that of the corpus cavernosum penis in the male. The venous plexus of the urethra is situated chiefly at the sides, in what is Fig. 219. known as the urethro-pubic space. The muscular layer is double, the outer portion being composed of both circular and spiral fibers mixed, and the inner of longitudinal fibers only, and these two layers are so closely bound together by the cavernous venous sinuses as to be in reality but one. Dr. Uffleman claims to have found an additional external layer, the fibers of which are voluntary. He divides this layer into two — an external and an internal — the former longitud- inal, the latter transverse. These make what he calls the outer or voluntary sphincter of the bladder. From the vesical neck to a point about half-way down it wholly invests the urethra, forming only a partial investment from that point to the meatus. Luschka claims to have found a sphincter of the urethra and vagina. He describes it as being smooth and circular, from one sixth to one third of an inch broad, lying directly behind the vesti- bule, and girdling both the vagina and urethra. Its function, he says, is to close the urethra by pressing it against the urethro-vagi- nal septum. Being closely adjacent to the cavernous venous tissue of the urethra, it locks its fibers posteriorly with those of the mus- culus transversus profundus. In the female as in the male, the urethra pierces the triangular subpubic ligament, two layers of which extend around it ; one back- ward and the other forward. 618 DISEASES OF WOMEN. There is great diversity of opinion as to the nature of the vesi- cal opening of the urethra in the female. According to Winckel and Simon it is a diagonal slit, the mucous membrane of which is longitudinally and superficially corrugated. According to Savage, it is a triangular opening ; and according to Holden and others, a funnel-shaped opening. It of course varies somewhat with age, size of urethra, vesical contraction, or quiescence, and in the li\nng and dead subject ; and hence the diverse opinions of the various ob- servers. Anatomical Relations of the Bladder and Urethra. — Having dis- cussed the anatomy of the bladder and urethra, it remains to exam- ine the topographical relations of these organs. This is very neces- sary to a proper understanding of the influence of other organs in causing diseases and displacements of the bladder and urethra. The bladder of the female lies lower in the pelvis than that of the male, between the pubes anteriorly, the uterus posteriorly, the vagina and uterine cervix inferiorly, and the small intestines superi- orly. The organ when empty lies behind the symphysis pubis, its highest point slightly overtopping it. In this position it occupies but httle space. When partially or wholly tilled it rises above the pubes to a varying extent. In doing this it alters but slightly the position of the other pelvic viscera, although relatively its position is somewhat changed. Anteriorly the bladder is separated from the posterior face of the pubic symphysis by intervening cellular tissue, Inferiorly it forms a close attachment to the anterior vaginal wall by means of a dense cellular cushion which increases in thickness from before back- ward. The bladder rests upon this vesico- vaginal septum as far up as the point where the body and neck of the uterus join each other. Posteriorly and somewhat superiorly to the bladder lies the uterus, and superiorly and postero-laterally are the ovaries and broad liga- ments. The close attachment of the vesical neck to the arch of the pubes, by the pubic ligament anteriorly and the vagina inferiorly, makes a kind of wedge that gives but little surface for bagging do^vnward if the vagina holds its proper position. Though imperfectly, still to a certain extent, this arrangement resembles the perinasum in the male. Superiorly, the organ is held in position by a number of ligaments ; five false and five true. The false ligaments (one supe- rior, two lateral, and two posterior), are formed of peritonaeum. This membrane is reflected from the inner face of the anterior ab- dominal wall to the bladder investing it superiorly, laterally, and, to KELATIONS OF THE BLADDER AND URETHRA. 619 a certain extent, posteriorly. It joins the organ in front, dipping down just above the pubic summit to the superior vesical surface, and passes as far backward as the point of contact between the vesi- cal base and uterus, which is at the junction of the uterine body and cervix. Although this peritoneal covering of the bladder is lirnily adherent, it never leaves its uterine or other attachments, however much the bladder may be distended and rise above the brim of the pelvis. That portion of the bladder lying behind the pubes, that resting on the vagina and uterine neck, and a small posterior and lateral portion have no serous investment. The true ligaments are also five in number — two anterior or vesico-pubic, two lateral, and the superior or urachus cord. Laterally, the round ligaments of the uterus pass over the blad- der-wall, and just below and posteriorly the ureters enter that organ. These ducts, the excretory ducts of the kidneys, are usually de- scribed as passing downward, forward, and inward, after entering the cavity of the pelvis, to the base of the bladder, and after passing for an inch between the muscular coats of that organ opening into it by constricted orifices. In their course they pass along the sides of the cervix uteri and upper part of the vagina, and at their points of entrance into the bladder are from one half to three quarters of an inch in front of the cervix uteri. It is very important that the re- lation of the ureters to the bladder should be borne in mind, espe- cially in the operation of gastro-elytrotomy. Garrigues, who has in- vestigated this point, says : " The ureter does not lie in the broad liga- ments, it does not keep the same direction on reaching the wall of the bladder, and it does not lie close up to the wall of the cervix, as taught by anatomical authorities. After having crossed the iliac vessels the ureters diverge, running dowmward, backward, and a lit- tle outward on the wall of the pelvis, behind the broad ligaments to a point near the spina ischii. Then they lead downward, forward, and considerably inward so as to converge toward the bladder. They pass beneath the base of the broad ligament, lying in the abundant cellular tissue found in this locality. They cross the cervix at some distance from behind, at an acute angle, so as to come in front of and below it. They lie outside and above the anterior part of the side wall of the vagina on a spot as large as the tip of the finger. On reaching the wall of the bladder they turn rather sharply inward and go downward until they open with a small slit into the inte- rior of the bladder at the outer angle of the trigonum vesicae. But 620 RELATIONS OF THE BLADDER AND URETHRA. on dissecting the bladder from the nterus and vagina their substance is seen to continue as a sohd ridge bstweeu the two apertures, and forming the base of the trigone (Jurie's inter-ureteric ligament.) " The illustration of Gar- rigues makes this descrip- tion very clear (Fig. 220.) Just in front of the small lateral space lacking serous investment the ob- literated umbihcal arteries pass uj)ward and forward to the summit of the blad- der reflecting the perito- nseum, and thus fonning a double pouch on either side. The relations of the m'ethra are as follows : it lies just under the pubic symphysis, and, piercing the deep perineal fascia, extends from the vesical neck, at the ostium ure- three internum, to the meatus urinarius or ostium urethrse externum, situate at the base of the triangular space known as the vestibule. Its anterior three fourths are imbedded in the vaginal wall. The meatus urinarius lies about four fifths of an inch below the clitoris, in the vaginal margin of the vestibule. The vesical end of the urethra is about the same distance below the lower surface of the pubic symphysis. Its course is upward and backward forming a very slight curve. Development of the Bladder and Urethra. — With this brief sketch of the structure of the bladder and urethra their development may be next considered. It would be very interesting, from a scientific point of view, to examine the process by which the bladder and uretlira are formed in the embryo ; but it would, I think, be rather tedious to take up the subject in all its minutiae. A few of the more important points in the process of development must l)e un- derstood, however, in order to comprehend the malformations which are occasionally met with. Most, or at least many, of the malfor- mations of the urinary apparatus, like those of other organs are due to arrest of development at various stages of that process. A clear Fig. 220. — The relations of the ureters (Garrigues). u, uterus ; b, bladder ; wr, ureter ; u, urethra ; T, vagina ; f, Fallopian tube ; 0, ovary ; b, broad ligament ; >% round ligament. DEVELOPMENT OF THE BLADDER AND URETHRA. 621 conception of the normal, therefore, will aid in better understanding the abnormal. The urinary organs are developed in separate portions or sec- tions having distinct points of origin, and by the union and fusion of these parts the entire apparatus is completed. The bladder is formed from a portion of the allantois. When the abdominal plates of the embryo close around that portion of the allantois that forms the umbilical cord, they also shut in a portion which forms the urinary bladder. There remains, for a time, a di- rect communication between that portion of the allantois from which the bladder is formed and that which makes the cord, which takes the name of the urachus. The canal or duct in the urachus is usu- ally obliterated before or soon after birth, so that all that remains of it is an impervious cord known as the superior vesical ligament. It will thus he seen that the bladder is developed from the allantois, which may be called one center of development for the urinary ap- paratus. The centers of development for the ureters are the same as those for the kidneys. Indeed, the ureters are processes that are developed from the kidneys, and extend downward until they unite with the bladder, and finally open into it. While the bladder and ureters are being thus formed, the lower portion of the alimentary canal — that which forms the rectum — be- comes separated from the section of the allantois that forms the bladder. Into this space, between the rectum and bladder, Miiller's ducts descend, and, uniting, form the vagina (see Figs. 53-57). Posterior to Miiller's ducts and anterior to the rectum, a mass of tissue is developed which helps to form the recto-vaginal wall above and the perinseum below. Anteriorly Miiller's ducts unite with the lower portion of the bladder, and aid in the formation of the urethra, or, at least, the up- per portion of its posterior wall. The lower or external portions of the genito-urinary organs are formed from an ovoid eminence which appears in the median line of the lower anterior part of the trank of the embryo. At the lower part of this eminence there appears a fissure, which, incurvating and uniting with the lower portion of Miiller's ducts (vagina) forms the terminal portion of the urethra and the introitus vagiuse. From this same center of development the labia majora, the labia minora, and the vestibule are formed. CHAPTER XXXV. MALFOKMATIONS OF THE BLADDER AND URETHRA. Malformations of the Urethra. — Malformations, as has already heen said, are usually the result of arrested development. Yarious fail- ures in the processes necessary to form the complete urethra result in a number of malformations. The most important of these may be classified as follows : 1. Defectus ure three totalis. 2. Defectus urethrse externus. 3. Defectus urethras internus. 4. Atresia urethrfie. In the first form (defectus urethree totalis) there is, as the term implies, entire absence of the urethra. It is said to be due chiefly to an ari'est in the development of the vagina at a point where it should form the main portion of the posterior wall of the m'ethra. It is very probable that there is also an arrest of development of the clitoral process. Coexisting with this malformation other developmental defects are generally but not invariably found, for it has been known to exist with an otherwise perfect genito-urinary apparatus. Petit tells of the case of a child, four years old, who had neither urethra, clitoris, nor nymphse, but had a comj^aratively wide vagina. Langenbeck men- tions the case of a girl, nineteen years of age,*in whom the bladder and vagina formed a common canal. She was incontinent up to the age mentioned, and is reported to have gained control of the bladder afterward. The second deformity (defectus urethrae externus) is due to the absence of the lower and anterior portion of the urethra. It has been called " hypospadias in the female." One of the most marked cases has been recorded by Von Mosengeil. The subject was a girl eight years old. The opening in the urethra was situated below a large clitoris, having a very full prepuce. It was much higher than MALFORMATIONS OF THE BLADDER AND URETHRA. 623 the normal situation of the meatus urinarius. There was a groove running from the lower border of the vestibule up to the opening of the urethra, and it appeared to be formed from the anterior wall of the urethra. The upper portion of the urethra held its noraial rela- tions to the bladder and vagina, but was only half an inch in length. The bladder, in comparison with the other organs, was larger, and had a number of saccules. It will be observed that in this case the upper portion of the urethra was complete, and that there were present in the lower portion of the canal an anterior and two rudi- mentary lateral walls, the posterior wall alone being absent. There is another form of defectus urethrse externus or hypos- padias, in which the lower part of the canal is entirely wanting. In such cases there is but one opening between the clitoris and peri- nseum, and but one canal, this dividing into vagina and urethra at some distance from the outer opening. An interesting example of this w^as observed by Willigk, in a woman, who died at the age of forty-six. The uro-genital canal, at its opening, was about the size of a catheter, and ran in a curved direction under the pubes. About an inch and a half from its outer opening it divided into two pass- ages, one anteriorly, V long — the urethra, and one posteriorly, 2" to 10'' long — the vagina. The third deformity (defectus urethrse internus) is that in which the internal or upper portion of the urethra is wanting, and is a comparatively rare affection. The only cases, so far as I know, are given by Oberteufer and Duparcque. In Oberteufer's case, as I understand it, the lady was forty-two years of age, and all her life had passed water from the umbilicus. Her vagina was normal, and so were the external genital organs. The upper or internal portion of the urethra alone was wanting. Duparcque's case was one in which the urethra was pervious as far as the bladder, but was there closed. This case, however, appears to me more properly to come under the head of atresia urethr^e. The fourth class (atresia urethrse) is a comparatively common affection. There are two forms of congenital atresia mentioned by authors. The first is produced by imperfect development of the vaginal process, or of both the clitoral and vaginal segments. Du- parcque's case was of this kind, the urethra being open up to the bladder and there closed. It was a form of defectus urethrsB in- ternus witli atresia at the upper end of the canal. In this case the bladder and ureters were greatly distended. The other form of atresia is found when the clitoral and vagi- nal processes are both defective. In such cases there is no trace of G24 DISEASES OF WOMEN. a urethra, except an imperfect vaginal wall which extends obliquely downward and closes the bladder. E. Rose relates a case of this kind in which the bladder, kidneys, and abdomen were filled with water. The urethral malformation was not the only one in this case, the vagina and uterus suffered from an arrest of development and were both double or rudimentary. Before leaving this interesting subject I w^ill mention another rare malformation. It is an obstructive anomaly, and consists in a double condition of the urethra. The only case, so far as I know, which has been described with any accuracy, is that of Furst. He observed in a preparation taken from the body of a young virgin the following peculiarities : In looking at the anterior bladder-wall at the first glance only one urethral orifice was to be seen, but one tenth of an inch forward toward the meatus the single urethra was seen to bifurcate ; a fine septum, nearly straight, divided it from right to left into an anterior and posterior half ; these continued with an ever enlarging and diverging septum until they opened into the vagina about one tenth of an inch apart. In this Avay they twisted, so that the anterior or superior one opened toward the right, while the posterior (the one in the region of the bladder) opened into the vagina on the left. The left urethra opened with a caliber of one fifth of an inch into the median line of the vagina. The right ojDened on the right of the median line, having a caliber of only one tenth of an inch. The length of the whole urethra was one inch. It is of very rare occurrence that the double condition of the allantois persists in this manner, and, considering all the changes that the sinus uro-genitalis has to undergo, it seems strange that blending did not take place. It is also interesting from the fact that the allantoic openings into the cloaca can only take place by a very rapid and early interruption of development. The uterus and vagina, in this case, were perfectly normal. Symptomatology of Malformation of the Urethra. — The symptoms that arise from malformation of the urethra arc incontinence in the one class of cases, and retention of urine in the other. When the urethra is deficient in part and the bladder perforate, urine con- stantly escapes ; and from the wetting, the excoriation, and the odor, the unfortunate subject is kept in continual misery. In eases where there is an abnormal contraction of the vagina the urine can be retained, partially at least. This is supposed to be effected by the small size of the genito-urinary sinus, and, possibly, a voluntary contraction of the sphincter vaginte muscle which may act as a sort of sphincter and aid in the retention of urine. MALFORMATIONS OF THE BLADDER AND URETHRA. 025 Atresia of the urethra and the consequent retention of tlie urine cansc hydrops of the bladder, ureters, and kidneys, and also ascites, as has already been mentioned. Distention of these organs occurs in utero^ and such malformed children are usually born dead, or die soon after birth. So great is this distention of the bladder and al)- domen in some cases that delivery is difficult or impossible until the fluid is evacuated by puncture. I remember seeing one such case. The head was delivered, but there was great difficulty in de- livering the body. The abdomen was enormously enlarged by the overdistention of the urinary organs. The child was very feeble, and after moaning for a few hours, died. No effort to relieve the bladder was made because a diagnosis was not reached until the lit- tle one was dead. This malformation usually leads to fatal results, and our knowl- edge avails us little save in accounting correctly for the cause of death. The only natural way that the evil effects of this malforma- tion can be obviated is by the occurrence of another developmental anomaly, viz., fistula of the urachus, the urine then escaping from the umbilicus. Atresia is an undoubted factor in the production of urachal fistula. I shall speak more fully of this when I come to consider vesical malformations. When defectus urethrse externus occm's in patients whose uro- genitals are otherwise normal, the function of the bladder and re- productive organs may all be performed easily and uninterruptedly. Coitus has been possible, and conception has been known to occur in such cases. Diagnosis. — In making a diagnosis of these defonnities reliance can not be placed on the symptoms alone. A physical examination of the parts is necessary. The general relative appearance of the external organs must be observed, and if the vagina is large enough to admit the speculum it should be used, and if there is any malfor- mation internally it can easily be discovered and its exact location and nature ascertained. There is usually very little trouble with such cases, but where the entrance to the vagina is so narrow that it will not admit a sound or speculum, the diagnostic skill of the physician will be severely taxed. Such cases resemble imperforate hymen, or acquired atresia of the vulva, and one case, at least, has been mistaken for an hermaphrodite. Under such circumstances an attempt should be made to pass the sound into the bladder, and by introducing the finger or another sound into the rectum the pres- ence or absence of a vagina may possibly be made out. If the patient is an adult, and the case one of imperforate hymen, meu- 41 626 DISEASES OF WOMEN. strual fluid will probably be found in the va£:ina. Should there still remain any doubt, the only resource would be to try dilatation of the introitus vaginas, and see what lies beyond it. Treatment. — The treatment may be either radical or palliative. Where there is an entire absence of the urethra, with the existence of vesical fissure, or in persistence of the sinus uro-genitalis with partially developed urethra, the pi'oduction of an artificial canal has been suggested. This may be done by dissecting from the vaginal wall a flap from under the symphysis. It should be about one third of an inch in breadth, and after being turned with its epithelial sur- face inward, should be united with the freshened edges of the vesi- cal fissure. It is objected by some authors that even if the opera- tion is successful, the patient will be but little benefited, the new urethra being devoid of muscular tissue, and consequently lacking the power of contraction. The passing of urine into the vagina, however, will be done away with, and the general condition of the patient will be greatly improved by the use of an artificial urinal. This of itself is a great point in favor of the operation. Heppner believes that the method of producing an artificial ure- thra by trocar puncture of the soft tissues and sewing up the vesical fissure is dangerous, because vessels of considerable size are liable to be injured ; a further disadvantage being that the canal tends to dose. The cases of Carbol and Middleton bearing on this point he puts aside as unreliable. He moreover maintains that reduction of the vesical fissure to the size of the urethra is a disadvantage, since the anterior wall of the fissure will be without any muscular tissue. The experience of those who have treated fistula has 1 )een, so far as he knows, that linear clefts, even of greater caliber, hold back the urine better than round openings of smaller size, the former allow- ing more complete coaptation of the edges. In Heppner's case, there being only nocturnal incontinence, he contented himself \vith applying a bandage in the manner suggested by Sawostitzki. A girdle was put around the lower part of the ab- domen, and to it was fastened a little olive-shaped compress, by means of a steel spring, something after the manner of a truss. When put into the vagina this compress pushed the posterior vesi- cal wall toward the pubic symphysis, thus closing the opening and reheving the incontinence. The patient soon became used to the instrument, and obtained great relief from it. Atresia of the urethra can only be cured by operation. Carbol operated in 1550 on a servant-girl in Beaucaire, who had suffered from this difficulty from her youth up. The urine flowed from a MALFORMATIONS OF THE BLADDER AND URETHRA. 627 coxcomb-like growth, some four fingers in length, at the umbilicus. The stench that arose from her body was intolerable. Carbol per- forated in the i-egion of the urethra, and successfully removed the growth at the umbilicus by ligation. In the case of a child, seven days old, who had never passed urine, and whose bladder was enormously distended, Middleton pushed a trocar through in the direction of the absent urethra, emptied tlie l)ladder, and kept tlie opening pervious. Oberteufer s patient, who had atresia urethra? and urachal fistula, relieved herself somewhat by wearing a large sponge over the um- bihcus secured in position by a bandage. In such cases as this the apparatus usually employed in urinary fistula should be made use of. MALFORMATIONS OF THE BLADDER. These malformations follow the general rule of being in most in- stances due to some defect in the normal process of development. Those which are of sufiicient importance and especially demand atten- tion are : 1. Fissure. — The most frequent and prominent anomaly of devel- opment in the bladder is that of fissure. It consists in partial or complete absence of the anterior vesical wall, and is usually accom- panied by malformations of other organs. The anus and umbilicus in these cases, as a rule, lie nearer than normal to the pubic symphy- sis. There are various grades of this affection. There may be sim- ple fissure of the lower part of the bladder, with the opening about three quarters of an inch in breadth, as has been seen by Desault, Palletta, Gosselin, Coates, and others. In the cases reported by them the symphysis pubis was but loosely united. There may also be fissure of the clitoris. A higher grade of this malformation is that in which the fissure is near the umbilicus, the lower part of the pelvic cavity and the pubic symphysis being closed, and the lower part of the bladder, urethra, and external genitals normal. This condition is next in order to patency of the urachus — fistula- vesico-umbili calls. In the latter case, the urachus may remain pervious its entire length, and open into the ring of the umbilicus. The highest grade is that in which the whole anterior wall of the bladder seems to be absent. In these cases the inferior abdominal region is generally much shorter, and the umbilicus nearer the base of the pelvis. The abdominal walls ai'e divided, and the resultant 628 DISEASES OF WOMEN. lissure is filled uj) by the bladder-wall, the mucous membrane of which is puli'ed out and red, and (gradually merges into the skin of the abdomen. It is often wrinkled, thickened, moist, sliiny, and the edges dry and covered with thickened epidermis. On each side of the lower portion of the everted bladder are situ- ated the orifices of the ureters. They usually appear as little ex- crescences, but are sometimes hidden in the folds of the membrane. The i^ubic bones are imjierfectly developed, and the pubic symphy- sis never closed, save by a ligamentous band, the bones lying from half an inch to three inches apart. These separations of the pubic bones, as has been shown by Dubois, Duj)uytren, Mery, and Littre, are congenital. As a rule, in such cases, the urethra is absent. The clitoris is either divided A\ath a ])ortion on each side of the upper part of the imperfectly formed labia, or there may remain but a trace of it, or, again, it may be entirely absent. The hymen can be seen beneath the fissure. The vagina may be absent, as in cases observed by Herder and Eschenbach, and the uterus may be divided by a septum. Atresia vaginae and impei-fect ovaries have also been found In such cases. This grade is known as eversio or exstropia vesicae. If there is simply a fissure of the bladder the organ may be pro- lapsed through the fissure (inversio vesicae cum prolajjsu per fis- suram). This must be distinguished from inversio vesicae cum j^ro- lapsu per urethram and exstropia per urachum. That this may be clearly understood, it must be remembered that inversion of the bladder occurs in three ways : First, by a protrusion of the organ through an opening or fissure in its own walls (the form now under discussion) ; second, by an inversion through the urethra ; and third, by an inversion through a pervious urachus. The ui-eters, as a rule, are considerably widened. Isenflamm found them dilated from three quarters of an inch to more tlian an inch ; Petit as much as two inches ; Flagani and Bailie found them to be four inches ; Desanlt three inches ; and Littre two and one half inches, and containing small calculi. Their course, as a rule, is changed, sinking deeper into the pelvis, and thence rising up into the bladder. There are, however, exceptions to their enlargement. Bonn, in one case, observed as long ago as in 1818, found their length and breadth normal. Winckel also speaks of a case where both kid- neys and ureters were normal. The anomalies known as epi- and ana-spadias belong under the head of vesical fissures. 2. Double Bladder. — Cases of double bladder, says Yoss, are be- MALFORMATIONS OF THE BLADDER AND URETHRA. 629 coming quite rare as pathological knowledge advances, for many of these were probably cases of pathological division of the vaginal wall. Mollinetti mentions, in his " Anatomico-Pathological Disserta- tions," the case of a woman with five bladders, live kidneys, and six ureters. Blasius describes a case of perfect division of the bladder into two separate halves, which at the vesical neck ended in one common urethra. Each bladder had one ureter. The subject was a male adult. Isaac Cattier has found this anomaly in little children. One case was that of a child lifteen days old. The bladders were separated by the rectum to such a degree that a finger could be laid between them. Sommering found this condition in a child two months old. In one that was born miserably nourished, and lived but twelve hours, Schatz found perfect division of the whole geni- tal apparatus, double bladder, and double congenital vesico-vaginal fistula. In double bladder, the double allantois, instead of forming one passage, forms two, with a ureter opening into each. Testa gives a case of perfect separation by the vaginal wall. Scanzoni found, in making a post-mortem examination on the body of a tuberculous woman, a division of the bladder into two lateral halves. He does not say, however, whether the division was com- plete or whether the septum was pervious. Sometimes horizontal septa are formed that are due probably to a crumphng up of a part of the bladder while growing, or a com- mencing closure of the urachus lower down than usual. Koser, of Marburg, had a case of urachal cyst, which, when enormously distended, reached as far as the umbilicus. By means of a small connection with the bladder it was filled when that org-an contracted, and, finally, it and the bladder were emptied by contrac- tion of the abdominal muscles. Vesical cysts and diverticula may be confounded with the anomalies resulting from arrest of devel- opment. The slightest grade of anomaly is that in which, as Chonsky has observed, there is no full septum, but simply a band or seam, appar- ent externally. Etiology. — The original urinary sac of the embryo, it will be remembered, is the allantois, which takes its origin as a Gul-de-sao from the rectum, and is, consequently, an offshoot of the intestine. It is formed by the bagging of the cloaca, which bagging is due to the collection there of urine from the primitive kidneys. This allan- tois, especially in the human species, is double, and remains only a short time. After the fourth week of embryonic life, the layei*s 630 DISEASES OF WOMEN. coalesce, and the diWsion ceases. Yet the original double form may remain for some time beyond the normal period, if there are any hindrances to union. Roose and Creve maintain that the cause of this malformation is the failure of the pubic bones to unite. Meckel takes exception to this, and says that the bladder in its primitive condition shows itself as a simple, plain sm'face, which only becomes a cavity by the grow- ing toward each other and union of its edges. Duncan and, at a later date, A. Bonn, and, still later, B. S. Schultze and Thiersch, held that vesical iissure had, as its primary cause, an atresia of the urethra, with great dilatation of the bladder, the distended organ pushing aside, first, the recti muscles, later, the cartilaginous pubic bones, and, finally, bursting. E. Rose, on the contrary, maintains that these cases of bladder-fissiu-e are cases of perjDetuated urachus, and are due to developmental failure in the bladder itself, remain- ing open as far as the urethra. He says positively that the edges of recent preparations of the bladder show a fresh, smooth surface, and that there is no trace whatever of any cicatrix or callosity. He mentions one case of tearing and rupture where the evidences were plainly to be seen. Moergelin, who was unable to find proof of rupture as a cause of this anomaly, says that, if there was a quan- tity of urine in the bladder, greatly distending it, there would be a reopening of the urachus or a bursting into the abdominal cavity, rather than a rupture through the abdominal walls. He looks favor- ably on the idea of a bursting of the allantois before the abdominal walls have closed in front of it. Against this, however, is the fact that Hecker extracted a foetus with atresia, having an enormously dilated, unruptured bladder. He found in the abdominal walls a cicatrized slit covered by perito- naeum. This makes manifest the possibility of a ruptm-e of the ab- dominal walls, and also of the bladder, occumng at a comjDaratively late date. In the case related by Rose no information is given as to whether there was a normal umbilical cord or not, whether there was any urachal fistula, whether the abdominal ring was closed entirely, or whether the fissure was confined to the inferior part of the anterior vesical wall, as described by Gosselin, Bertet, and others. In their cases it was not possible for the fissure to have originated by the re- opening of the urachus. In any event, most of the late authors are agreed that hindrance to the outflow of urine has most to do with the production of this anomaly, and it may, as Rose has shown, and as has been said before, arise from atresia or absolute absence of the urethra. MALFORMATIONS OF THE BLADDER AND URETHRA. 631 Another possible mode of causation of this malformation is by the falling of some of the larger aljdominal organs into the pelvic cavity, compressing the m'ethra, and hindering its formation. E. Rose once found the right kidney in the pelvis, and Winckel has recorded a case described by one of his students, Dr. Kriiger, where the left lobe of a considerably enlarged liver and a quantity of small intestines were so tightly wedged into the pelvis as to cause marked bulging of the perinseum. Such a condition, coming at a time when the urachus and urethral end of the bladder are firmly closed, must tend to form a vesical fissure. Perfect eversion of the bladder may, however, be found at a very early date, even before the two halves of the allantois are joined, as in cases related by Friedlander, E. Rose, and Winckel. Lying be- tween, and in front of the single- or double-everted bladder or blad- ders, there are sometimes found, as in Rose's and Winckel's cases, bands of perforated skin-folds, behind which a sound may be passed. Their presence may be explained in this way : That the underlying serous connective tissue (Rathke's membrana reuniens inferior), which closes the abdominal cavity before the development of the skin and muscular system, is the covering of all urachal fistulge, open bladders, and persistent allantois. Then, where the urine j^ressure is the greatest, the bladders move upon each other, so that no further development can take place between them ; but the abdominal plates develop themselves around and between them. This intermediate development, owing to the imperfection of the lower connective tissue, becomes a band or rim where the two conically formed bladders push together, so that they can not become a symmetrical whole, but have an intermediate arch. In these cases the cause probably lies in the patency of the urachus and the eversion of the bladder ; also the open condition of the abdominal walls, inter- ference with the development of the lower parts of the musculi recti, and, later, the imperfect development of the pelvis. There can, however, be a fissure of the abdominal walls without a fissure of the bladder, the closed organ protruding from the ab- dominal fissure (ectopia vesicae). Lately Ahlfeld has brought forward the hypothesis that eversion of the bladder is complicated with and dependent on a pulling down- ward of the ductus omphalo-meseraicus, making an obtuse angle in- feriorly, whereby, the rectum being pushed forward, it pushes the inferior wall of the allantois before it. Communication between the rectum and the allantois ceases, and the allantois, becoming enor- mously distended, bursts. Ruge and Fleischer contend that in this 632 DISEASES OF WOMEN. affection the duct of the umbilical vesicle is implicated, and hold that the tense cord (duct) in question is a continuation of the uraclius. Winekel is of the opinion that burstiniii; of the bladder at an earlj stage from urine-pressure is the weightiest cause in the produc- tion of bladder fissure. Against the idea of Hose, which is that eversio vesicie does not take place from rupture, Winckel says that the presence of scars is not absolutely necessary to prove the point, for the abdominal walls are not yet joined, and therefore can not be ruptured ; jmd, moreover, he has often seen children immediately aiter birth in whom the umbilical cord was normal, and yet an ever- sion of the bladder existed. He raises the query as to why we can not have ruptui-e of the bladder at an early period, since we know that it occurs later in life, as in women with retroflexion of the gravid uterus. Another fact that he advances in favor of the view that rupture of the bladder is due to urethral obstruction is that it occurs oftener in males than in females, the former having a canal mucli more favor- able to such obstruction, for, of sixteen cases of vesico-umbilical fist- ula, given by Stadtfeldt, fourteen were males and two females. Dr. Wunder, of Altenberg, in 1831 observed the cases of two boys, aged respectively eight and eleven, with congenital e version of the blad- der. It is interesting to note that their mothers were sisters. The various causes that give rise to vesical fissure produce also imperfectly developed pelvic bones, dislocation of the head of the femur, and other malformations from pressure. The excessive dilata- tion of the bladder drives the horizontal rami of the pubes asunder, and the changed direction and imperfect growth of the pelvic bones cause a lessened acetabular circumference and consequent slipping out of the head of the femur. Thus does Voss explain the disloca- tion occurring in one of his cases. It will be found on touching the red mucous membrane of an exposed bladder that it is exceedingly sensitive. In such a case the urine may be seen oozing from the uretei'S and diibbling over the surface. The mucous membrane is often protruded and wrinkled up by the movements of the bowels, and can, in case the bladder- opening is great, be inverted through the fissure (inversio vesicae per fissuram) or through the urachus (inversio vesicae per urachum). If the fissure is small it may remain for years without any inversion. If the prolapsed mucous membrane is replaced and indirect pressure is made on the dilated ureters, the urine will spurt from the m'eteric orifices. Sometimes these patients have partial control over their urine; MALFORMATIONS OF THE BLADDER AND URETHRA. f]83 as in cases where an nrnl)ilical hernia exists witli umbilical fissure, the posterior wall of the bladder being forced into tlie opening plugs it up. Such a case is described by Paget. The hernial sac, which was about the size of a goose-egg, completely plugged the umbilical foramen by pressing firmly against the posterior bladder- wall. If the patient desired to urinate, the contraction of the blad- der caused a gradual disappearance of the hernial tumor ; and when it had entirely disappeared he passed urine from the umbilicus and then through the urethra. After the urethral flow began the stream from the umbilicus ceased, and no urine passed at that point unless strong pressure was made upon the abdomen. Another way in which partial retention may be accomplished in imperfect eversion is by the greatly thickened muscular walls acting as a sort of sphincter. Such a case given by Voss is that of a female child, twenty months old. When lying down and quiet, the urine did not flow away so freely. The bladder-wall was nearly one inch in thickness, and the ureters, though three inches broad, were greatly narrowed at their point of entrance into the bladder. In fissures situated low down there may be coincident inguinal hernia, as is illustrated by a case related by Bertet. This complica- tion may act so as to aid in the retention of urine. From the con- stant flow of urine, the inferior end of the fissure and neighboring parts become moist, red, eroded, and sometimes incrusted and ulcer- ated. There are various painful sensations, as itching and burning, and the patient becomes a nuisance to herself and to those about her from the offensive urinous odor that is constantly given off. The edges of the mucous membrane in time become changed, and resemble skin in appearance. At other points, oftentimes, the membrane is much changed, having upon its surface loose, villous growths, that bleed readily when touched, and give the impression of a malignant new-formation. By reason of a separation of the pelvic bones there is an irregu- lar, uncertain gait. The pelvic diametric proportions, as observed by Moergelin, are in these cases much changed, the transverse being much greater than the antero-posterior, the dissimilarity increasing as age advances, the proportion being sometimes trebled. Women with these troubles, however, have borne children. A close inspection of the ureteric openings being possible in these cases, the interesting observation may be made that in action the kidneys seem quite independent, the one of the other, the right discharging urine and the left none, or the reverse, or both may dis- charge together. 634 DISEASES OF WOMEN. Diagnosis. — the diagnosis of iiraclial listula is comparatively easy, for the aifection is at once recognized by finding the ureteric orifices with the m-ine flowing from them. As to frequency, the following statistics are of importance : In 12,689 new-born children, Sickles found this malformation to occur twice in twenty-seven cases of developmental anomalies. In thirty-five hundred ])irths occurring in the Dresden Institute, from 1872 to 1875, Winckel saw one case. Velpeau, in the year 1 833, mentions seeing and finding on record more than one hundred cases of this kind. Percy says that he has seen it twenty times in his own practice. Winckel saw five cases, three of which were girls, and two boys. Phillips saw twenty-one cases, all girls ; but in AVood's twenty cases, only two were girls. Prognosis. — The prognosis is usually unfavorable. The cliildren are weak and puny, and, as a rule, die early. They are, however, seldom destroyed by the fissure itself. Many of them are born liv- ing, and can be kept alive, and some attain a fair age. Lebert saw in Salpetriere Hospital, Paris, an old woman with this affection. Operative procedures and the various apparatus to prevent trick- ling of urine are of little avail. This, however, is only the case in total eversion. Urachal fistulse, simple fistulse, above the pubic symphysis, and even those situated inferiorly, where the pubic bones are united, may be readily cured by the ordinary operation for fistula. Treatment. — Stadtfeldt operated in eight cases of urachal fistula, in seven of which he obtained perfect heahng. In deep fistula he recommends freshening of the edges of the skin and mucous mem- brane, and attempting union by the first intention. In cases where the edges extrude themselves very much, he puts on either a clamp or ligature. Winckel favors operative procedure since, in that way, the ab- normal protrusion can be removed. Sometimes, as recommended by Paget, it will be sufficient to freshen the edges, put in insect-pins, Hgature, and union may be expected in from two to four weeks. In fissura vesicae, superior or inferior, an attempt might be made to draw the edges together, and even to loosen the skin in front by incision, so as to remove traction from the edges. In that case it will be necessary to freshen the edges and put in sutures. The re- sult, unfortunately, is not uniformly successful. In earlier times, in cases of true eversion of the bladder, no one dared to operate, and the only alleviation granted to the patient was such as could be obtained by a properly-adapted urinal. Ku- MALFORMATIONS OF THE BLADDER AND URETHRA. 635 merons appliances have been invented for this purpose, some of them very useful. Gerdy was the first to operate for eversion by closure. Failing to bring an inverted bladder back into place, he tried to fonn a suf- ficient sac by partial excision of the ureters. The patient, a man, was attacked with peritonitis and nephritis, and died. Jules Roux, in 1853, proposed cutting out the ureters, and unit- ing them with the rectum. Simon tried this once, and succeeded ; but the patient died six months after from peritonitis and exhaus- tion. At a later date, he again attempted to treat this malfoi-ma- tion by operative procedures. He made one inferior and two lateral flaps, but these became gangrenous. Ten years later, these attempts were more successfully made by John Wood and Holmes, and their results recorded by Podruzski. The first one, however, who obtained a perfect result was Dr. Daniel Ayres, of Brooklyn. He cut a long flap from the under and lower side of the abdominal walls, turned the skin-side in, and united it with both edges of the bladder. A full account of this case will be found at the close of this chapter. Since then I have seen three cases, but as they were not patients of mine I had no opportunity to interfere surgically in their treatment. Subsequently, Wood operated on a girl one year and a half old, whose bladder-fissure was continuous with the uro-genital sinus, so that the os and cervix uteri were always wet. He raised one flap from the neighborhood of the umbilicus, and another from the soft parts, and turning the skin-side in, covered them with a larger flap from the other side. The mucous membrane, however, pushed through inferiorly, and broke the fresh adhesions. Ashhurst's case was more successful. He cut a piece from under the umbilicus, and joined it with two flaps from the sides (they being somewhat turned) so that their upper edges met each other in the median line. They were joined by sutures, and through each side of the upper flaps two pieces of malleable iron-wire were carried, then drawn through the lateral flaps, and twisted over little rolls of plaster. Ti-action was thus relieved. The flaps healed by the first intention. The sutures were removed on the eighth day. The rest of the wound healed by granulation. When in the up- right position, incontinence of urine still continued ; but when lying upon her back, the patient was able to retain urine for about two hours, her general condition being thus greatly improved. Ashhurst gives a resume of twenty cases of eversio vesicae, oper- ated on up to his time. Fourteen of these were successful — Ayres, 636 DISEASES OF WOMEN. Holmes, "Wood, Morey, and Barker, each being credited witli one. Three were unsuccessful, by Holmes and Wood ; and three resulted fatally, by Richard, Pancoast, and Wood. In the last two death resulted from causes other than the operation. In all cases when the skin is turned in, the growth of hair al- ready present or to come will be apt to give rise to incrustations. Thiersch, in his six cases, allowed the flaps to granulate on their raw surface before applying them. When the flap-union is perfect, he advises closing completely the upper part of the bladder. The diagnosis of double bladder may be made by urethral dilata- tion and exploration by the finger and catheter. Destruction of the bladder-sej^ta is not to be thought of. In case of the existence of urachal cyst causing difficult urination, one might try extirpation of the cyst by cutting into the abdominal walls, and after freshening their edges unite them with those of the bladder. ILLUSTKATIVE CASES. Extroversion of the Urinary Bladder. (By Daniel Ayres, M, D., LL. D.) — The patient was admitted to the Long Island College Hos- pital, ]S"ovember 1, 1858, and a history of the case recorded by the house surgeon, Dr. Ostrander. She is twenty-eight years of age, born of healthy parents, both of whom were free from deformity ; her height is below the aver- age of females, and she is unmarried. She declares her health to have been always good, appetite and digestion excellent, bowels regular, and the catamenia in all respects normal. She states that, on the 5th of July preceding, she was delivered of a well-developed child, having carried it to maturity without extraordinary difficulty. Labor commenced with free haemorrhage (footling f»resentation), and lasted two hours, at the end of which time the child was born, having died in process of delivery. Peri- nseura uninjured. She reports having made a tolerable recovery, though for a long time weak, and her present appearance is some- what anaemic. Shortly after she began walking about symptoms of prolapsus uteri came on, becoming gradually worse, until the organ projected external to the vulva, attended with dorsal, dragging pain, difficulty of locomotion, and gastric disturbance. In quest of relief, she entered the Brooklyn City Hospital on the 1st of September following her confinement, and remained there one month. Here she states that a variety of pessaries were tried, none of which could be retained, and finally a surgical operation MALFORMATIONS OF THE BLADDER AND URETHRA. G37 was performed, tlic nature and character of which is not very appar- ent. A short article, descriptive of this case, appeared in the " Vir- ginia Medical Journal" for January, 1859, written by the house surgeon of that institution. Tlie writer states tliat an attempt was made to retain the prolapsed uterus " by removing an inch of mu- cous membrane from the bottom and sides of the vulva, and unit- ing them by two ligure-of-eight sutures, which were removed on the sixth day, when no adhesion was found to have taken place." Tlie writer continues : " The patient was allowed to get up on the fourteenth day, when the prolapsus was found to exist nearly as much as before," etc. It is obvious that no effort was made to relieve the congenital deformity, and that she was discharged in much the same condition as when she entered. Finally, a species of stem-pessary was contrived which was in- tended to support the uterus, while kejDt in position by strings passed around the thighs. This, however, proved very inefficient — the uterus slipping by the instrument upon the slightest extra exer- tion. Moreover, the parts had now assumed an irritable condition, partly due to increased friction of the apparatus, and undue attention to cleanliness, added to the causes already noted ; altogether, her de- plorable condition was scarcely susceptible of being made worse. I may here remark that the figures, both before and after the operation, have been photographed from accurate plaster- casts, taken directly from the patient — a very difficult and delicate procedure, for which I am much indebted to the skill and kindness of my colleague Dr. Bauer, and our valuable assistant, Mr. J. F. Esslinger. Fig. 221 is an exact representation of the parts at the time of presentation to the clinical class of the Long Island College Hospi- tal, for the purpose of critical examination. The prolapsus, having been carefully and completely reduced, was found to retain its place so long as the patient maintained the recumbent position. The distance between j3ubic abutments was estimated at about three inches. The bladder (a) formed an oval, elliptical tumor, mammillated upon the surface, which in the recumbent position measured two inches in its long, and one inch and a quarter in its short diame- ter. This was soft, elastic, or bright vermilion color, and covered with a thick tenacious mucus ; bleeding readily when rudely han- dled, and so exquisitely sensitive, that while under the full influence of chloroform, and insensible to the knife, a sponge passed over the exposed bladder excited reflex motions. 638 DISEASES OF WOMEN. The integument immediately surrounding tlie bladder was found red and puckered, but very soft, delicate, and free from liair be- tween the bladder and point of sternum. The labia majora {o, o,) thick, fleshy, and luxuri- antly covered with hair, were gathered into folds swelling away toward either thigh ; these were carefully shaved previous to taking the cast and per- forming tlie operation. The nymph?e occu- pied isolated positions on each side of the vul- va, and are designated in all the figures by the let- ters h, Ij. Between these and the vagina Ijelow no trace of clitoris or urethra could be distinguished, but the J- whole surface was cov- Biadder ^red witli mucous mem- exposed, forming a bright vermilion tumor; 6,6, braue, COntinuOUS with labia minora ; o, o, above labia majora ; c, vagina ; -. . •■ ■, . . c/, anus. tne vaginal lining. Here, then, we had to contend with two formidable difficulties, either of which was a problem in itself, viz., aggravated prolapsus from an entire ab- sence of an anterior support, added to the original congenital mal- formation. To fonn an estimate of the value attached to surgical operations in these cases, we can not do better than quote the opinion of Prof. Erichsen, of University College, London. Having collected the experience of the profession on this topic, his eminent position at the center of surgical science, added to his well-knoAvn and exten- sively recognized erudition, renders him at once a i-eliable and com- pendious authority on the subject. " This malformation," says he, " is incurable. Operations have been planned, and performed with a view of closing in the exposed bladder by plastic procedures, but they have never proved success- ful, and have terminated in some instances in the patient's death ; they do not, therefore, afford much encouragement for repetition.-' Fig. 221. — Extroversion of the bladder. MALFORMATIONS OF THE BLADDER AND URETHRA. 639 So unsatisfactory have been the results of these operations that the profession lias not been favored with their general plan, their details, nor the causes of failure. It must be evi- dent, however, that op- erations based upon the principles of plastic sur- gery alone offer pros- pects of success. The most probable source of failure, and one which challenged our early attention, was the disastrous result to be apprehended irom urinary infiltration, which, by its irritating character, would neces- sarily destroy all pros- pect of union, if it did not induce extensive sloughing of the abdom- inal parietes ; peritonitis and purulent phlebitis are likewise probable sources of danger, unless carefully guarded against. Indeed, these may all become inevitable consequences of attempting to accomplish too much at one time ; and it was there- fore determined to arrange our proceedings with a special ^^ew, if possible, to avoid them. The indications which it was proposed to follow were : 1. To form an anterior wall for the exposed bladder, 2. To restore the urinary canal. 3. To establish the anterior fourchette of the vulva. 4. To supply means to prevent the prolapsus, and to collect the renal secretions. The delicate character of the integument above the bladder and its well-known transmutability into the conditions of a mucous mem- brane peculiarly adapted it to supply the anterior cystic wall, and thus fulfill the primary indication. With these objects in view, the operative proceedings were di- vided into two stages. The first consisted in raising a flap from the anterior portion of Fig. 222. — e, Linear cicatrix, formed by the flaps cov- ering the bladder ; b, b, nj'mphcE brought together, and inclosed by the vulva. 640 DISEASES OF WOME.NT. the abdomen, including the superficial fascia, turning its cuticular surface down over the exposed bladder as far as its inferior border, and securing the lateral union of the Hap in that position, while a free exit below was maintained for the urinary discharge ; an im- portant result, still further assisted by the dependent situation of the outlet of the ureters already alluded to. By these means it was proposed to accustom the highly sensitive bladder to a gradual and methodical compression while the flap it- self was insured ample space to undergo such swelling as might be anticipated from its new position and the unusual stinmlation of a new secretion. Time was likewise given for the necessary trans- mutation of tissues to make some progress. The steps of this procedure will perhaps be better understood by a more detailed state- ment of the "first operation, in connection with the di- agrammatic plates. Figs. 223 and 224. It was performed on the 16th of November last, the patient being thor- oughly under the influ- ence of chloroform, and a sugar - loaf - shaped flap having been previously marked out upon the ab- dominal integument ; its base, E, F, three inches in width, was situated three fourths of an inch above the cystic tumor, and ex- tended tive inches in length, with its apex to- ward the ensiform cai'ti- FiG. 223. — A, Bladder, covered by deep flaps ; d, b, nymphie ; c, vagina ; d, anus. lage. The dark line E, H, G, I, F (Fig. 223), indicates its form, position, and the line of incision. This flap being left snfliciently large to meet the elevated form of the bladder and allow for shrinkage, was quickly but carefully separated from its cellular attachments, down to the line E, F, while two lateral incisions, E, J, and F, K, were continued directly downward and toward the nymphge, to serve as beds for receiving the sides of the new flap. MALFORMATIONS OF THE BLADDER AND URETHRA. 041 The iutegmiients covering the hiteral and inferior portions of the abdomen, extending from G to J on one side, and from G to K on the other, were now sufficiently separated from their cellular attach- ments to the muscles beneath to insure their sliding freely, and meet- ing without tension at the mesial line, G, N (Fig. 224). When brought into this position they completely covered from view the raw surface of the Hap already turned over, and investing the blad- der, with the exception of a triangular space, J, N, K (Fig! 224), f onned by the coaptation of the lateral flaps ; this was temporarily covered by reflecting back upon it- self the corresponding tri- angular free end of the deep flap, J, C, K (Fig. 224), and attaching it along the line, J, N, K. Numerous points of in- terrupted suture were used to I'etain the parts in situ^ assisted by long strips of adhesive plaster, compresses, and a reten- tive bandage around the body. It will be observed that the lower portion of the cystic tumor was thus temporarily left free and partially ex- posed, while no portion of cut or denuded surface remained uncov- ered. The patient received a large dose of opium, and was strictly maintained in the recumbent position upon a bed, properly pro- tected; such additional measures being adopted as would secure cleanliness. As the parts subjected to operation began to swell, she com- plained of irritation and pressure upon the bladder, which, however, were promptly met with morphine alone, and subsided in the course of a few days. Now was exhibited the great importance of leaving the tumor partially uncovered, while all the cut surfaces were in close contact, and thus freed from the action of irritating secretions ; important facts duly dwelt upon and recently enforced with great 42 Fig. 224. — a, Bladder ; b, b, nymphae ; c, vagina ; d, anus. 642 DISEASES OF WOMEN. stress by the distinguished Prof. Syme, of Edinbiiro;h, whose con- tributions to the surgical treatment of the urinary organs have alone placed both hemispheres under permanent obligation to him. On the fourth day after tlie operation all sutures were removed, the wounds having healed by first intention or primary adhesion, with the exception of a spot the size of a ten-cent piece, situated just above the point of the triangle, and where the deep tiup had been reflected over the bladder. At this point the lateral abdominal flaps were necessarily raised up from the tissues beneath, and could not be brought into contact even by the use of compresses. This, however, granulated kindly, and was nearly cicatrized on the Tth of December, when the second and last operation was performed, as follows : The patient being under the influence of chloroform the lower triangular flap, J, N, K (Fig. 224), was dissected from its recent and temporary attachments, both lateral and deep, and turned down over the vulva as indicated by the dotted line, J, C, K. Two incisions, J, L, and K, M, were now carried from the ex- ternal angles of this triangle, perpendicularly toward and terminat- ing just behind the nymphse, B, B. The lateral flaps bounded by the lines N", J, L, and N, K, M, and including the labia majora, were then freely dissected from over the abutments of the pubic bones until they could be readily slid to meet each other at the central line, 'N, C, which, being a continua- tion of the line G, N, reduced the whole to a single linear wound, occupying the " linea alba." (See Fig. 222.) During the operation several arterial branches bled freely, and were arrested by torsion and the free application of ice, after which the flaps were confined at the mesial line by points of inter- rupted suture, the most inferior one, viz., at L, and M, being made to include the apex C, of the triangular flap. Fearing to depend on sutures alone to secure the approximated flaps, and the use of adhesive plaster being excluded by the irregu- larity and jDOsition of the parts, the whole surface between the jjoints of suture was hermetically incased by strips of patent lint, soaked in collodion and accurately applied. In addition to this, pieces of muslin were by the same method firmly attached to the labia majora, at some distance from the mesial line, and to these sutures silk was fastened in such manner as to form a lacing across and over the wound. By means of this dressing all tension was removed from the sutures, urine was totally excluded, while rapid and perfect ad- hesion soon followed. MALFORMATIONS OF THE BLADDER AND CRETHRA. 643 Thus a urinary canal was formed which would admit the little finger to be passed up one inch and a half. The anterior four- chette of the vulva was firmly established, and the mons veneris as- sumed its prominent and natural appearance. The last cast of the parts representing her present condition (Fig. 222) was taken on the 4tli of January, 1859, previous to which time, the parts being all firmly united, she was permitted freely to walk about, and left the hospital to spend the holidays with her friends. No artificial support whatever was applied, in order to as- certain how far the operation would succeed in preventing the pro- lapsus. After a severe test, the anterior fold of the vagina alone de- scended, and that for a short distance, forming a pale, oedematous tumor, occupying the vulva, about the size of an English walnut. The anterior fourchette of the vulva remaining firm and resisting, a light, oval pessary, made of vulcanized rubber, and perforated, was introduced into the vagina and readily retained in situ. After thor- ough trial, this was found to support the parts completely, and with- out the slightest uneasiness, even under active exertion and straining. This was a better result than had been anticipated, inasmuch as it was intended to rely mainly upon a disk-shaped pessary, sup- ported by a foot attached to a simple apparatus which we had con- structed to act as a reservoir for the urine. January 20, 1859. The patient was again examined at the hos- pital, in the presence of a number of medical gentlemen, she having walked a distance of two miles without experiencing any incon- venience. The parts were all found sound and firm, and her gen- eral health and spirits much improved. Patent Urachus with Calculus. (H. D. Yosburgh, M. D., " New York Medical Record," September 22, 1877.) — Several months ago I was called to see J. H, B., fifty, a mechanic, of spare habit, and always in good health. He complained of soreness and constant pain at the umbilicus, and on examination I found the natural de- pression filled up by a rounded tumor, apparently the natural tissue enlarged by swelling. There was also circumscribed hardness of the tissues around the umbilicus. The parts were red and very tender to the touch, having every appearance of an ordinary erysipelas. At the time of my visit he told me that a score or more of years before, after a similar experience, his attending physician at that time removed a " stone " from the umbilicus. I applied a poultice, and awaited developments. The above condition continued from day to day, with the exception that the tumor projected more and 044 DISEASES OF WOMEN. more from tlie umbilicus, and the circumscribed hardness decreased. Any movement of the body or handling of the tumor produced se- vere cuttin*)^ pain in the part, The tniiior was exquisitely tender. No constitutional symptoms accompanied the; tn^uble. On the tenth day from my first visit 1 niade an incision into the tumor for the purpose of cx^jloration, about half an inch in depth, when I came upon a hard substance wliich, after consi(leral>le ditH- culty, I removed, and found to be a concretion, smooth and ovoid in 8haj)e, about the size of a medium liickory-nut, and of the color and appearance of a phosphatic calculus, with a strong urinous smell. After the removal the wound readily healed. The ordinary retraction of the tissues within the navel fossa took place, and the man has sulfered no inconvenience since. What was the concretion ? In the " Medical Record," No. 354, Dr. Rose's article describing a patent urachns called this case to mind, and I have transcribed the above from my notes of the time. I can not conceive this concretion to have been anything else than a calculus formed from urinary deposit in a patent urachns. No treatise within my reach mentions anything of the kind, and the novelty of the case is my reason for reporting it. In this man there was doubtless a similar calculus formation something more than twenty years before. Very Rare Form of Monstrosity of the Female Genito-Urinary Or- gans (" Gazette des Ilopitaux.") — In the words of M. Tillaux, at the Hospital Lariboisiere, there is at present a small, deformed woman, twenty-six years of age, who presents an exstrophy of the bladder, with complete absence of the vagina. The external organs of gen- eration are represented only by the orifice of the uterus, which is situated in the median line almost on a level with the skin, and by rudimentary labia minora and majora which are not united in front. The clitoris, urethra, and anterior wall of the bladder are absent. The ureters open into the rudimentary bladder near the median line. Palpation shows that the pubic bones are separated in front by a space that is about as wide as five fingers, and the pelvis seems to be enlarged to that extent. The umbilical cicatrix is located at the middle of the superior border of the exstrophic bladder. The cei-vix uteri forms a slight prominence into which the skin is attached. It is conical in form. The cavity of the uterus is of nearly the normal depth, but rectal examination shows that in shajjc the organ retains the peculiarities of childhood. The patient began to menstruate at the age of fifteen 3'ears, and since then has been perfectly regular. Operative Treatment of Ectopia Vesicse. (By Prof. Trendelen- MALFORMATIONS OF THE BLADDER AND URETHRA. 645 burg, Bonn ; " Centbl. f . Chirg.," 18S5, No. 49.)— Former methods are criticised. Thiersch's fiap-closure, e. g., does not secure use of the bladder musculature. Trendelenburg's first attempts to secure direct union of a vesical and urethral iisssure by joining its lateral edges were begun live years ago. His plan is by dividing the sacro- iliac synchrondrosis on each side to mobilize the iliac- flanges, and then by lateral pressure to approximate them in front. Finally, the fissure thus narrowed is, after reposition of the bladder to be directly closed by freshening and suturing its edges. Inferiorily the union is to be continued at least to the beginning of the pars bulbosa ure- thrne. Division of the sacro-iHac symphysis is in children simple, and, when carefully done, not dangerous. The child is laid on its belly, and a finger introduced into the rectum to determine the po- sition of the incisura ischiadica major and superior gluteal artery. A long cut is then made over said symphysis ; this is gradually deep- ened until strong lateral pressure makes the pelvic flange yield. On account of the large pelvic vessels it is not permissible to cut through the deepest portion of the symphysis. Toward puberty and later in ' life this operation would have to be done with the chisel, and would be more serious. The construction of a continuously active com- pressing apparatus that could be tolerated for weeks proved diffi- cult. Tourniquet arrangements were not borne. A girdle crossing in front, with extension weights of ten to fifteen pounds attached, has of late proved satisfactory. Where previously the spinse sup. ant. were seventeen centimetres apart, they approached to within eleven and a half centimetres. The two pubic symphysis stumps, formerly two inches apart, were now almost in contact. It is well to delay the operation for the fissure some six or eight weeks. This second operation begins with freshening the fissure borders ; he then frees the edges of the bladder somewhat, and unites with Lem- bert's sutures. The urethra has usually been included in the oper- ation. A catheter is left for a few days. In all cases as yet the union to the extent of urethra and bladder-neck has subsequently separated. In a two and a half year old boy the remainder of the bladder held and the prolapse was remedied. He thinks that by further perfecting his operation it may prove successful. Operation for Congenital Extroversion of the Bladder of an Infant Five Days old.— (By H. C. Wyman, M. D., Detroit, Michigan, '' Xew York Medical Record," December 12, 1885). — From the umbilicus down to the triangular ligament there was a failure of development causing an extroversion of the posterior wall of the bladder, show- ing the orifices of the ureters and an absence of the dorsum of the e4:6 DISEASES OF WOMEN. penis. Dribbling of urine from the ureters was constant. Under cliloroform incisions were made on either side through the integu- ment and superiicial fascia just forward of the anterior superior spine of the ilium two inches upward, to secure relaxation ; the edges of the Ussure were then pared and fastened together Avith harelip pins with intermediate sutures, and the wound dressed with oxide of zinc and absorbent cotton, a drainage-tube for the urine be- ing left in the wound. The penis was not touched, being reserved for a secondary operation. The recovery was rapid and perfect. The child died from convulsions two months later, before the opera- tion upon the penis could be performed. CHAPTER XXXVI. FUNCTION OF THE BLADDER. The function of tlie bladder is to act as a reservoir for the urine, and at proper intervals to expel it through the urethra. The tilling of the organ with urine is a comparatively slow and gradual process, the fluid entering it from the ureters drop by drop, or in a very small stream. As it enlarges it does so in the direction of least re- sistance, viz., laterally and superiorly. The lateral being its long- est diameter, it enlarges first in that direction, until after a time a limit is set by the bony pelvic boundaries, when it rises from the pelvis somewhat, thus escaping from the pressure below. This movement of the bladder is facihtated by its serous surface gliding easily over that of the adjacent organs. The bladder receives its nervous supply partly from the mesen- teric ganglia of the sympathetic, and partly from the lumbar portion of the spinal cord : it has therefore nerve-filaments from both the cerebro-spinal and sympathetic systems. The sphincter vesicae is in health in a state of tonic contraction which results in retaining the urine in the bladder. This act is entirely involuntary and uncon- scious and is performed in a perfect manner both during the waking and sleeping hours. When it is desired to evacuate the bladder this sphincter is relaxed by an act of the will conveyed through the cerebro-spinal fibers, but this relaxation once accomplished, the further act by which the organ is emptied is performed without the intervention of the will. The experiments of Kupressow demon- strate conclusively that the nervous center which presides over con- traction and relaxation of the sphincter vesicae is located in the lum- bar region of the spinal cord. And it may be accepted that with other functions of a protective nature the spinal cord maintains the normal action of the urinary organ. There has been considerable discussion among different authors as to whether closure of the vesical urethral orifice is a voluntaiy or 648 DISEASES OF WOMEN. an involuntary act. Witte and Rosenthal maintain that the closure is due to " tonicity from nerve force," whicli resists tlie urine press- ure. Kuprossovv holds the same view, bu.sing his opinion on a se- ries of experiments which he made, and further maintains that the sphincter vesicae is at the neck of the bladder to eject the urine completely out of the urethra, in place of standing guard and hold- ing the vesical outlet closed. By others it is claimed that this musculo-elastic ring hinders the entrance of urine into the urethra, but that the tension of the bladder-walls when the organ is tilled overbalances this elasticity, and a drop of urine escaping into the urethra brings the necessity for urination to the senses, and the act then becomes a voluntary one. It has been found, however, in cases of urettro-cystic vaginal fist- ula, where the upper part of the urethra and neck of the bladder were totally destroyed, that, after the healing of the parts, the an- terior or lower end of the urethra was practically able to control the urine. The act of emptying the bladder is a very important and inter- esting process, and is not so simple as might at first be imagined. As the organ has three openings and is emptied by the concentric contraction of its muscular coat, the urine is not only expelled through the urethra, but there is a tendency to regurgitation or backward pressure of the fluid into the ureters. The backward flow is effectually prevented by a very complete and interesting ar- rangement. The protection is threefold : First, by the oblique direc- tion that the ureters take in piercing the vesical wall ; second, by the two muscular slips already mentioned, that pass from the sphincter vesicae to the insertions of the ureters. As the bladder gradually fills these slips are tightly drawn, and thus partially or wholly close the ureteric orifices. Moreover, it may be presumed that as these muscular fasciculi have their origin in the vesical neck, they act most vigorously during urination, when the bladder pressure tends to cause regurgitation into the ureters. Their greatest use is, in all probability, during the act of mictm'ition. This view is borne out by the fact that these little muscles are in a rudimentary condition in the female, the urethra being shorter and the force necessary to empty the bladder much less than in the male ; and further, by the well-known fact that when the hypertrophy of the muscular walls of the female bladder does occur, these fasciculi are proportionately enlarged. Third, by a ligamentous band, not described in the text- books of anatomy, which runs from one ureteric opening to the other, inclosing their vesical ends, and is kno'wn as the inter-ureteric FUNCTION OF TOE BLADDER. 649 ligament. Its mode of action is this : as the bladder gradually fills, the openings of the ureters are carried farther a^jart, and with them the ends of the ligament. Being elastic it yields to a certain extent, and after a time^ being able to yield no more, pulls upon both openings, closing them more or less completely. During urin- ation the tension of the ligament gradually decreases, and then the muscular fasciculi and the oblique direction in which the ureters enter the bladder come into play, the ligament being of use only during filling and distention. If from any cause the bladder is not emptied at the proper time, the organ is not only injured by overdistention, but more serious results may follow if the retention continues for some time ; although the bladder is too full to receive any more urine, the kidneys con- tinue to secrete until not only the bladder, but also the ureters, renal pelves, and kidney-tubes become overfilled. When the press- ure on the urinary side of the Malpighian tuft equals that of the blood-stream in the glomerulus, secretion of urine at once ceases, and we have a mechanical suppression. After death the bladder, ureters, and renal pelves are found to be greatly distended, and the kidney pale, of a bluish, pearly color in the cortex, and oozing urine from the cut surface. Maas and Punier (" ^ew York Medical Kecord," October 1, 1881) have performed experiments on animals and men which demon- strate to their satisfaction that the bladder, whether healthy or dis- eased, as well as the urethra, possesses the faculty of absorption in a greater or less degree, varying with the substance used. Their methods when experimenting on animals were as follows : The bladder was fully exposed, both ureters tied about half an inch above their termination, then divided above the ligatures, and the urine conducted outside of the body by means of glass cannulse in- troduced into the central ends. The bladder was then evacuated by a catheter through which the solution experimented with was in- jected, the catheter withdrawn, and a ligature drawn tightly around the urethra between the prostate gland and the neck of the bladder ; sometimes after tying the ureters a.nd urethra the bladder was emp- tied by a Pravaz syringe, the medicated solution injected tlirough the cannula of the latter and the puncture closed by ligature. In a second series of experiments the abdominal cavity was not opened, but after drawing off the urine the solution was injected through the catheter, and the mouth of the latter plugged. The substances used were ferrocyanide of potassium, salicylate of soda, cyanide of potassium, strychnine, atropine, curare, apomorphia, and 650 DISEASES OF WOJIEN. pilocarpin. All of these substances were absorbed, but some so slowly that their physiological action was not manifested ; thus atro- pine seemed to have no effect upon the animal, but a small (piantity of its urine collected during the continuance of the experiment and instilled into the eye of another animal rapidly caused dilatation of the pupil. The diseased bladder wtis also found capable of absorb- ing the same substances. In their experiments on man, Maas and Punier used iodide of potassium and pilocarpin. As regards the excretion of the former, they call attention to the fact that in some individuals it rapidly passes off by the urine, in others by the saliva, and in others by only one of these paths to the exclusion of the other. The method used was the following : Taking only individuals with healthy bladders, the latter were evacuated by a Nelaton catheter, after which in twenty-eight cases they injected fifty grammes of a ten-per-cent so- lution of iodide of potassium, following this up in thirteen other cases with an injection of one or two centigrammes of muriate of pilocarpin half an hour later. The iodide was detected in the saliva in lifty-seven per cent of the first, and seventy-seven per cent of the second series, but usually in small quantities only. The dis- eased bladder was found to absorb much more promptly ; iodide of j)otassium was detected in the saliva when only 2*0 were used. A solution of 0'4 morphine in 2*0 of distilled water used in this way, acted very plainly as an anodyne. Pilocarpin made up into a bougie with cocoa-butter, and introduced into the urethra (both healthy and diseased), manifested its specific effects. L. Schafer found that after producing vesico-vaginal fistulae in animals there was increase of from two to three per cent, and some- times from four to five per cent, in the amount of urine passed over that passed before the fistulae were made; and he feels convinced that under normal conditions of urinary secretion the amount of urine in the bladder is gradually diminished by a slight though reg- ular absorption of its watery elements. If this be true, we may look to a too rapid absorption as one of the causes of gravel and urinary calculi. On the other hand, however, Susini found that after injecting jDotassium iodide and belladonna into his own bladder, and retaining them for many hours, no trace of the former was found in tlie saliva, and no appearance of the specific action of the latter was made man- ifest. Ailing agrees with Susini, and the experiments of P. Dubelt also support this view. After careful consideration of the evidence pro and con^ I am strongly inclined to the ^dew that the bladder FUNCTION OF THE BLADDER. G51 does not absorb anything, save possibly a little water, unless its epithelial surface is displaced or destroyed. When abrasion does occur, absorption is ra[)i(l and its effects marked. The fact that the mucous membrane of the bladder is able to absorb liquids after ero- sion of its epithelium throws much light on the cause of some of those peculiar constitutional symptoms accompanying chronic cysti- tis, and known by some authors as annnonasmia. The inner surface of the bladder is lubricated by a very thin se- cretion of mucus. This can be demonstrated by putting some fresh, normal urine in a clean bottle. In a short time a slight hazy cloud will settle to the bottom. When examined microscopically it will be found to consist of a few epithelial scales and mucous fibrillse — long, fine, and often interlacing. In disease this secretion becomes greatly increased, and is then thick, viscid, and ropy. The normal secretion when tested chemically is found to contain an abundance of the earthy and alkaline phosphates. A healthy woman urinates from four to six times in every twen- ty-four hours, and passes in all from thirty-five to sixty ounces of urine, the average being about forty-live ounces. The amount passed varies much with the season of the year, more being passed in winter than in summer ; it varies also with the amount of fluid ingesta, rest, and exercise. Neither limpid nor concentrated urine are well borne by the bladder. The pressure of the urine in the bladder being of importance in both health and disease, I deem it advisable to give here the results of some experiments by Schatz, Odelbrecht, Hegar, and Dubois. These experiments were made with the manometer, an instrument which by means of a column of mercury may be adapted to regis- ter the exact pressure in the bladder. They found the pressure to be from twelve to sixteen inches while standing, in the recumbent posture it was only from four to six inches. The pressure in the recumbent position Dubois be- lieved to be due not to visceral pressure from above, but to the nat- ural tonicity of the distended organ ; for in the cadaver, after re- moving the other viscera, the pressure in the bladder indicated four inches, plainly due to the elasticity of the organ itself. The same has been observed in cystocele, in which the visceral pressure is also absent. The pressure is about the same in both sexes, and at all ages. It was found to rise from one half to one inch with each inspiration, and to fall about the same with each expiration. In laughing, coughing, etc., it rose as high as from twenty to sixty inches. In 652 DISEASES OF WOMEN. diseases of the spinal cord, such as myelitis, and after injuries to the vertebroe, Dubois found a marked decrease in bladder pressure. These curious observations on the varying degrees of pressure arising from change of posture are not without value. They help one to understand why, in some diseases of the bladder, patients should maintain the recumbent position. CHAPTEE XXXYIL FUNCTIONAL DISEASES OF THE BLADDER. It has been the rule among pathologists to class under the head of functional diseases all those in which no lesion of structure was discoverable in the organs concerned. Although we are still obliged to accept this nomenclature, the progress of pathological knowledge in the past few years has weeded out many of the so-called functional affections : and as this knowledge advances, and new and efficient means for observation and study arise, we shall be able to root out many more, thus doing away with much of the vagueness and uncer- tainty in which this class of affections is shrouded. But even with the improved facilities for diagnosis at our command, there are still many diseases in this list. Owing to the obscurity at present sur- rounding the subject of reflex or sympathetic disorders, i. e., the abnormal condition of an organ or organs, near or distant, affecting the function or nutrition of another organ, we are obliged to put these affections in this class also. Under this head then will be considered : I. Derangements of function in which there is no recognizable organic lesion. II. Derangements of function due to diseases of the nutritive and nei-vous systems, and to abnormal conditions of the urine re- sulting therefrom. III. Derangements of function due to inflammatory and other affections of the pelvic organs, such as metritis and pelvic perito- tonitis. It will be observed that in this arrangement of the subject, al- though a number of structural diseases are considered, they aU stand in a causative relation to the disturbed action of the bladder, the latter being free from any organic lesion, and only disturbed in the discharge of its duty by influences outside of itself. Before discussing these functional disorders in detail, it will be 654 DISEASES OF WOMEN. necessary to fix clearly in the mind their various manifestations ; these are : frequent urination, or polyuria ; difficult urinatinixton Jlicks. He claims in this way to deaden the reflex iriitability of the membrane. I must insist on this — that opium shall be used in such cases with great care, and never continued long. If this rule is neglected, it will lead many nervous padents to contract the opium habit, which disease is worse than irritable bladder. Debout recommends the use of bromide of potassium by the mouth, and also in suppository, combining with it in the latter tinct- ure of opium and belladonna. I prefer hydrobromic acid to the bromide of potassium. When the trouble is due to masturbation, moral and mental in- fluences must be brought to bear, as well as medication and regula- tion of diet and habits. In these cases the bromides will be of serv- ice. If all other treatment fails to accomplish the desired result, resort should be had to mechanical means, viz., the rapid and forcible dila- tation of the urethra. Some authors, indeed, think so highly of this method that they boldly assert that time spent in medication is tima lost. Astonishing and very gratifying results have certainly followed its use in a number of cases. Hewetson i*eports in the "' Lancet" (page 4, vol. xii, 1875) that in this manner he cured a case of cysto- spasm of fifteen years' duration. This procedure is spoken of in the highest terms by Teale ("Lancet," page 27, vol. xi, 1875), as also by Sj)iegleberg, Tillanx, and others. In the cases where this treatment gives relief, I believe that there is some inflammatory condition present, or at least something more than a neurosis. When due to malaria, the treatment is usually simple and satis- factory. Quinine in full doses, as recommended l)y Briclieleau (" Arch. gen. de med."), for one day, and then in small doses before meals for a week, will usually cut the trouble short, and prevent its return. The digestive organs require attention when they are out of order, as they usually are. If due to hysteria, the Original disease should be treated, not, however, neglecting the local trouble. When accompanying acute or chronic systemic diseases, it is only relieved when the original disease is cured, altliough in the mean time the annoyance may be greatly alleviated by the treatment already recommended. FUNCTIONAL DISEASES OF THE BLADDER. 663 UXUSTRATIVE CASES OF FUNCTIONAL DISEASES OF THE BLADDER, IN WHICH THERE IS NO RECOGNIZABLE ORGANIC LESION. Neuralgia of the "DTrethra and Neck of the Bladder. — A married lady, who had never been pregnant, was iirst seen when she was twenty-six years of age ; she had then been three years married. She was well developed, and, although of a marked nervous tempera- ment, had always enjoyed good health. From puberty onward she had suffered pain at her menstrual periods, but not of severe charac- ter. When she was twenty-four years old she was chilled while rid- ing a long distance on a cold day, which was followed by frequent and painful urination. This was somewhat relieved by rest and diuretics. From that time she was subject to violent attacks of spas- modic pain in the urethra and bladder. The pain was of a sharp, lancinating character, generally coming on before and after her men- strual period ; it was, however, brought on at any time by nervous excitement or great fatigue. During the pain there was some diffi- culty in urinating, but the pain was neither relieved nor increased by the act. The duration of the pain varied, but usually did not last more than twenty-four hours. At times she became almost frantic, so great was the suffering. Large doses of opium would relieve her, but, as it caused very distressing after-effects, she avoided taking it, except when the attacks were exceptionally severe and prolonged. When she first came under my care she had a flexion of the uterus, with slight general tenderness of the pelvic organs, which accounted for her mild dysmenorrhoea, and I presumed that that might be the cause of the neuralgic pains in the bladder and urethra. She was treated for the uterine affection, and obtained complete relief from the painful menstruation and tenderness of the pelvic organs gener- ally, but no relief was obtained from the periodic attacks of pain in the urethra and bladder. She acknowledged that it was not quite so severe at her menstrual periods, but was " bad enough in all con- science," as she expressed it. Careful and repeated examinations of the urine were made when she had pain, and when she was free from it, but no trace of any renal, vesical, or urethral disease was obtained. The urethra and neck of the bladder were examined with the endoscope several times, but were found to be normal. Suspecting that the neuralgic pain — for such it apparently was — might be due to malaria, she was given fifteen grains of quinine within a period of eight hours, followed by Fowler's solution of arsenic in doses of three minims after each meal. The arsenic treatment was continued for several weeks, and 664 DISEASES OF WOMEN. gave her some relief, the attacks being less violent, but still she suffered greatly. Moderate dilatation of the urethra was then practiced. This ag- gravated the trouble. Several different remedial agents, inchidiiig opium, hot water, aconite, infusion of hops and belladonna, were in- jected into the bladder, but none of them gave any relief. The citrate of iron and quinia in tive-grain-doses was then prescribed t(» be taken before meals, and Parrish's compound sirup of the phos- phates in drachm doses to be taken after meals. When the pain came on she was directed to take every three hours a drachm of camphor- water containing eight grains of muiiate of ammonia, and to use a vaginal douche of hot water. This treatment usually re- sulted in mitigating the pain, but did not completely abolish it. Thirty minims of the compound spirits of ether and five minims of the tincture of cannabis Indica every four hours were substituted for the camphor- water and muriate of ammonia and M'ith good effect. Under this treatment her attacks were far less frequent, and the re- lief from pain was prompt. She was so much pleased with her im- provement that she took a trip through the West and retunied quite well, and has remained so for the past eiglit years. More re- cently I have had a case which resembled this one in many respects, particularly as regards the character of the pain and its causation, in which a four-per-cent solution of muriate of cocaine instilled into the urethra and bladder gave relief. A Peculiar Form of Neuralgia not yet described, excited by a Desire to Pass Water and by Micturition. (By Dr. Putegnat, of Lmieville. (Gaz. Hebdom de med. et chirurg., April 15, 18G4.) — The following two cases, out of six published by the author, will give an idea of this peculiar neuralgia, which consists on the one hand, in a special sensation in the bladder, and on the other, in symptoms of a neurosis of the ulnar nerve. M. X., aged fifty, with chestnut hair, of a ner\'ous and san- guine temperament, very abstemious, in affluent circumstances, lead- ing a very active life, occupying very iiealth}' apartments, free from all diathesis, except a slight rheumatic affection, liable to coryza in cold, damp weatlier, has never had any other nervous complaint be- yond headache and occasional gastralgia after eating dressed salads or raw fruit. From time to time, at varying intervals of weeks, months, and even years, without any apparent physical or moral cause, in all electric, barometric, and thermometric conditions of the atmosphere, as soon as his bladder is full, and he has a strong desire to pass FUNCTIONAL DISEASES OF THE BLADDER. 605 water, he feels along the urinary passages, especially in the pcrinaeiun a peculiar sensation of numbness, not very painful, but acute, burn- ing, lancinating, and unpleasant from the accompanying sense of prostration. This strange sensation next affects the slioulders, conies down both arms, along the course of the ulnar nerve only, and gives rise in the forearm, the little and the ring fingers, to the same sensation as when the ulnar nerve is strongly compressed at the elbow. The pain is more acute on the left than on the right side, lasts about twenty or thirty seconds, and after diminishing gradually, disappears without leaving any trace behind it. M. X., of Luneville ; living in healthy rooms ; very active, easily moved and excited ; subject to headaches and to rheumatic pains ; free from any diathesis ; very abstemious ; complains, for several successive days, but at irregular intervals, and without any known cause, of a strange sensation along the outer border of the left forearm, on the inner side of the thumb, and the outer surface of the index-finger especially. This sensation he compares to the one produced in the last two fingers of the hand by compression of the ulnar nerve at the elbow. The painful sensation only comes on whenever he has a strong desire to pass water, persists during micturition, and ceases com- pletely immediately afterward. On analyzing the six cases of the author, we find four of them to have occurred in females. The mean age of the patients is forty- six ; the oldest being fifty-two, and the youngest thirty-six years old. They are all in easy circumstances ; five occupy healthy apart- ments, the sixth only living in damp rooms on the ground floor. Three patients have had gastralgia ; the fourth sciatica, and great troubles have shaken his nervous system ; the fifth is subject to vio- lent headaches ; and the sixth, a female, seems to have epileptiform seizures, and has a double neuralgia. From the above, then, it may be concluded that neuralgia and great nervous excitability are pre- disposing causes of this strange neuralgic affection. In one of the four female patients the catamenia had ceased ; in three they had not, and in two of these the neuralgia showed itself before and during the menstrual periods. Uterine congestion seems then to be a predisposing cause also. Four of the six patients had had rheumatic pains ; but the other two having never suffered from such pains, this can not be consid- ered as the exciting cause of the neuralgic affection. The desire to pass water, and especially the act of micturition, brings on the sensation, wliich only appears at those stated times, 60(5 DISEASES OF WOMEN. and it reaches its maximum intensity at the beginning of the mic- turition. It has all the characters of neuralgia, and can even aggra- vate, as in one case, an already pre-existing neuralgia — that of the median nerve. As to tlie precise seat of the sensations, we find them affecting the four extremities of one patient, but the upper limbs only of the re- maining five. In three cases they simulate to pei-fection neuralgia of the ulnar ; and in two they are felt in the tips of all the fingers. In one case tliey coincide with and intensify pains in the course of the median ; and lastly, as in the first case we have given above they are felt in the distribution of the left radial nerve. The first patient complains of pain in both shouldei'S, especially the left ; the fourth, of pain in both arms and hands, but chiefly in both breasts, and in the left breast more than the right ; the sixth, again, of pain in both forearms and hands, but more marked on tlie left side. Hence, the left side of the body would seem to be either the only one affected, or the one most affected. Ihe patients always distinguished clearly the special painful sen- sations felt in the urinary passages from the normal sensations due to a distention of the bladder and the subsequent desire to pass water. Retention of Urine Due to Hysteria. — A single lady, thirty-one years of age, of delicate organization and pronounced nervous tem- perament, yet very quiet and self possessed in manner, suffered for some time Math difiiculty of urination. At times she could urinate very well, at others she was obliged to try repeatedly before she succeeded. She was a lady of high culture and liberal education, but was not interestedly occupied, and hence she had much time for introspection. She called her physician who prescribed remedies, but iinding that they did not give her relief, made an examination of the pelvic organs but could find no cause for her inability to urinate with facil- ity. Soon after she was taken with com{)lete retention which was re- lieved by the catheter. This continued for weeks, requiiing the doctor to visit her three times a day, and occasionally at night, to pass the catheter. For some reason which was not very evident and could hardly be due to weakness or suffering, she remained in bed most of the period duiing which the catheter was used. Be coming weary of such close attention, the doctor tried letting her wait, to see if a full distention of the bladder would have any good effect. This caused her so much pain that the doctor felt somewhat FUNCTIONAL DISEASES OF THE BLADDER. G67 mortified at his want of feeling- in permitting her to suffer. Dur- ing this time he had tried a number of remedies, but without effect. At this stage of the history I was called in consultation ; I could Und no evidence of any organic disease, local or general. The urine was found ujjon examination to be normal. I suggested to the attending physician that the trouble was hysteria, but he as- sured me that she was singularly free from all evidences of that affection. Indeed, he had found her a remarkably calm and sensible lady, and \Q.r^ free from nervousness of every kind. The impression that I received was that there was a very decided hysterical element in the case, and I advised full doses of bromide of potassium and a sitz-bath when she desired to urinate. I also recommended that she should go to Saratoga, and drink Hathorn water. She did this, and the water gave her diarrhoea, and her retention was immedi- ately relieved. Frequent TTrination Due to Hysteria. — A lady twenty-three years of age, in very good general health, and living in very easy circum- stances, had some disappointment which caused her much distress. She had faintings of a mild character which alarmed her mother and called forth much sympathy. About this time she began to suffer from frequent urination. This did not yield to the treatment employed by the family physician, and she was brought to my office for advice. Her health was at times excellent, but she was greatly annoyed by this frequent urination. The urine was nonnal except at times when it was of a very light color. She could sleep all night without being disturbed by a desire to urinate. If by chance she did not go to sleep immediately on retiring she was obliged to urin- ate every few minutes, and if she was awakened in the night she had to urinate many times before she could sleej) again. Any little mental excitement, such as going to church or to the theatre, would bring on the trouble, so tliat she had to give up all public duties and pleasures. Systematic exercise and occupation, cold baths, bromide of sodium, and a full assurance on my part that she would soon recover, helped her greatly. She was commanded in a very decided way to resist the inclination to such frequent urin- ation, and she obeyed orders. Soon after this her attention was attracted in another and more interesting direction, and she recovered completely. Frequent Urination from Perverted Sexual Function. — A girl nineteen years of age who had a good general organization and en- joyed good health up to puberty at fourteen, sought advice regard- ing impatience of her bladder. She was obliged to return home 668 DISEASES OF WOMEN. from boarding-scliool because she luid to ui-inate so often that she could not attend to her studies and recitations. Her general nutri- tion was good, she menstruated regularly, freely, and without acute pain. Her nervous system was depressed. She was sometimes lan- guid, low spirited and fretful, at other times she was bright and dis- posed to be cheerful. Her manner was rather timid and ex'cited. Her hands were clammy, and her eyes dull, and had dark streaks under them. Her chief symptom was the frequent urination which parsisted but was much worse at times than at others. Occa- sionally she would pass the night without getting up more than once or twice, but during the day she was often obliged to urinate every half-hour. There was very little pain except occasionally a little smarting at the meatus. She complained of heat and burning about the vulva and occasional aching in the region of the ovaries. She was easily fatigued and had backache, especially on standing and walking— leucorrhoea ti'oubled her only at times. I suspected at first that she had either cystic and urethral con- gestion, or else hysteria giving rise to excessive renal secretion of limpid urine, but an examination of the quantity and composition of the urine proved the contrary. She was put in charge of a very competent nurse who was directed to find out the habits of the patient. The report of the attendant was that she had begun to indulge in masturbation soon after puberty, and that the hal)it had gradually grown upon her. Her nurse surprised her by relliug her the cause of her sufiering, and readily gained her consent to make all due efforts to recover her self-control. By care, occupation, and exercise out-of-doors, and the moral control of her nurse, she began to im- prove. Bromide of sodium was given when she was very restless and irritable, but no other medication, except the free use of bathing. In about two months the frequent urination had disappeared, al- though she would occasionally have a day or a night when she suf- fered in that way a little. She now has two children, and enjoys life very well, being free from her former symptoms and no doubt cured of her former habit. Frequent and Difficult Urination from Sexual Continence. — The patient, a strong and active lady in good circumstances, was married at twenty-one years of age, and had her first bal)y before she was twenty-two. She nursed the child for eighteen months. Her menses came on when the child was one year old. About three years after her marriage, her husband, a strong, \ngorous man, died FUNCTIONAL DISEASES OF THE BLADDER. QCj'J of pneumonia. Several months after the loss of her husband she began to sutler at times from frequent urination, and also had some difficulty in voiding the urine, requiring voluntary efforts. Tliese attacks would pass oif, and she would be comfortable for days, when th'j same irritation of the bladder would return. She was always made worse by excitement, often being kept awake nearly all night after spending the evening in company. Her symptoms became so troublesome that she sought advice of a physician, who treated her for cystitis by giving medicines of va- rious kinds. When she tirst came under my observation I found her in perfect health in every way. The urine was normal, and caused no pain when she passed it. I was easily able to exclude all diseases except deranged innervation from a possible malarial influ- ence. The periodical character of the attacks favored this view of the case, but the use of the anti-malarial remedies gave no relief. I then ordered her to take more active exercise and a limited quantitj^ of plain food, to bathe frequently, and to avoid excitement as far as possible. Bromide of sodium was also given when her suffering was most severe. She improved on this treatment for a time, in fact she became so much better that I lost sight of her for nearly a year. She returned to say that her former symptoms had returned, and were about as troublesome as before. The same treat- ment was employed but did not help her very much. She was now rather nervous and restless, and disposed to be emotional. Three months afterward she was married, and left the city on an extended wedding-tour. Upon her return she reported herseK as perfectly well. A Case of Malarial Irritation of the Bladder in the Female. (By Henry K. Leake, M. D., Dallas, Texas. Abstract of a paper read before tlie Texas State Medical Association.) I desire to record an observation, which I have recently made, exemplifying the effect that the malarial poison may exert upon the female blad- der ; an observation which may appear commonplace since, as is well known, it has not escaped mention by Prof. Skene in his excel- lent work on the "■ Diseases of the Bladder and Urethra in the Feuiale" as well as by other authors of equal or less prominence, who have attended to the same subject. Nevertheless, considering the mere allusions by these writers to irritation of the bladder in women, which may be caused by the presence of malaria in the system, on account, doubtless, of the rare occurrence of this affection, it may be questioned whether the latter has been sufficiently individualized as a distinct and independent GTO DISEASES OF WOMEN. malady, deserving especial prominence in the nosology of diseases of the bladder, which seriously disturb the functions of this sensitive viscus. There is the additional reason, also, for reporting the ex- perience which I have had of this peculiar and interesting disorder, in the fact that much obscm'ity yet surrounds the entire subject of disturbance of the functions of this organ in the female, the integrity of which is so vital to the comfort, happiness, and safety of the in- dividual. Moreover, such conditions often tax the diagnostic acumen of the physician to the utmost, and even when by the exclusive method, rigorously employed, many causes of ii'ritation of the bladder may be eliminated from the problem in hand, there will yet remain in particular cases, other causes which may elude discovery, thus ob- scuring the pathogeny and defeating every measure of treatment which is attempted. About March 1st, of the present year, a lady, whose health has been uninterruptedly good, thirty-seven years of age, the mother of six children, the last of which being an infant of four months, ap- plied to me for treatment for what she considered the ailment to be, incontinence of urine. She stated that the condition had come on gradually, at the first amounting to a mere frequency of urina- tion during the day, without any attendant pain or other symptom which attracted her attention. This frequency had increased, how- ever, to such an extent as to seriously embarrass her in the perform- ance of domestic duties, and prevent her from visiting friends, or doing necessary shopping. Moreover, she soon became troubled at night, often rising six or, perhaps, a dozen times, in obedience to the urgent calls for micturition. The amount of urine passed at each discharge was not large, but exceeded in quantity that ordi- narily retained in cases of acute cystitis, which the affection in many respects closely resembled. There were no deposits in the urine worth noting. It appeared to be somewhat higher colored than noi-mal. There was also a superabundance of nmcus, in the form of large tiocculi, but no pus or blood. As the case progressed, the desire to evacute the liladder was preceded by a sharp twinge of pain, which the patient averred was " low down at the very neck of the bladder," but which was imme- diately relieved on emptying the viscus. There was no tenderness at any point except a slight pain experienced when the neck of the bladder was firmly pressed toward the pelvis. The frequency of micturition increased to almost constant drib- FUNCTIONAL DISEASES OF THE BLADDER. 671 Tjlinp^ from the bladder, both daily and nocturnally the cloud of iiiuciis in the urine was much augmented, and while the color ap- peared to remain unchanged, there was evidently a large excretion of solid matter composed probably of phosphates. The uneasiness elicited at the neck of the bladder by pressure on this part soon changed to actual soreness. At the end of the second week the case had passed into one of apparently serious import, and was operating with telling effect on the vitality and mental equipoise of the patient. The tripod of treatment, namely, rest, opium, and alkalies, upon which Van Buren and Keyes cogently protest the successful manage- ment of cystitis rest, was relied on to relieve what I now feared was a case of this distressing disease, the cause of which I could not then determine. The constitutional effect of belladonna was evoked also to mitigate the symptoms, and finally hot-water vaginal injections were employed for their well-known analgesic and anti- phlogistic effects upon the pelvic viscera. Such measures gave only temporary relief, the features of the case resuming their original character whenever the effect of medi- cation — which was occasionally suspended to ascertain the status quo of the disease — had passed off. At the beginning of the third week from the first appearance of the symptoms, the patient complained of slight chilliness toward evening, and it was observed that this was followed by fever, the thermometer in the mouth registering 101.° These symptoms were interpreted to indicate the constitutional expression of the local in- flammation existing in the bladder. Hence, no special attention was directed toward them. The chilliness was repeated, however, on the third evening, and on the fourth day at the same hour reappeared as the prodrome of a marked rigor, followed by an abrupt rise of temperature of 103° succeeded by sweating and a return to the normal temperature in about four hours, thus clearly demonstrating a well-defined periodicity of the febrile movement. Suspicion being now aroused as to the essential nature of the case, the patient was promptly placed on ten-grain doses of the sul- phate of quinine, to be taken every four hours with mercurial and saline purgatives, the latter being indicated by the appearance of the tongue and the confined state of the bowels, which was due not alto- gether to the opium administered, since this physical modifier had been exhibited both freely and simultaneously. The substitution of the quinine for the treatment previously pursued, like the fabled wand of the magician, broke the spell of 672 DISEASES OF WOMEN. encliantment, wliicli, by its subtle and potent influence bad beld tbe patient \vitb relentless grasp for tbree weeks and bad trans- formed a bopeful and contented disposition into one of nielancboly and apprebension. At tbe end of four days from tbe administration of tbe first dose of quinine tbe patient was virtually convalescent. During tbis period no opiate was employed nor any otber medicine but quinine taken, save an occasional dose of neutral mixture, cbiefly for its su- dorific effect. Nevertbeless tbe irritation of tbe bladder did not re- turn, and tbe close of tbe week found tbe patient, altbougb deblH- tated by tbe trying ordeal tbrougb wbicb sbe bad passed, enabled to resume ber accustomed duties. Periodical Attacks of Frequent and Painful Urination and Vesical Tenesmus caused by Malaria. — About two years ago a patient came to my college clinic complaining as follows : In tbe afternoon of eacb day sbe experienced a sense of beat and burning in tbe bladder and uretbra, witb a frequent and irresistible desire to urinate. Evacua- tion of tbe bladder, attended witb a great deal of smarting and pain in tbe uretbra, did not give complete relief but left some vesical tenesmus wbicb increased in severity as tbe bladder became dis- tended. Tbese symptoms persisted during tbe niglit and kept ber awake, but toward morning ber sufferings entirely left ber, and sbe became quite comfortable until tbe next afternoon. Tbis condition bad existed for nearly two montbs, and accordingly ber digestion be- came impaired and ber strengtb diminisbed. Tbis was attributed by ber to tbe want of sleep, and no doul)t in part was due to tbis cause. Tbe urine was examined, and found to be normal except tbat it contained a sligbt excess of pbospbates. Sbe was carefully exam- ined, and no evidence of organic disease was found. Wbile sbe al- ways enjoyed full bealtb and bad been a vigorous woman, s^be bad bad an attack of malarial fever about six montbs before I saw ber, and about tbe time tbis bladder trouble came on sbe said sbe bad symp- toms of ber former ague. From tbe facts in ber bistory I ventured to state to my class tbat tbis was a functional derangement of tbe bladder and uretbra caused by malaria, wbicb would promptly yield to judicious doses of quinine. I accordingly prescribed twenty grains of quinine to be taken between early morning and noon, to be followed by two-grain doses before meals witb four drops of Fowler's solution of arsenic after meals. Sbe was ordered to report at tbe clinic tbe following week. Sbe did so, and declared tbat sbe bad been perfectly well since tbe first day sbe took tbe medicine. Tbe quinine and arsenic in small doses were continued for tbree FUNCTIONAL DISEASES OF THE BLADDER. 073 weelvs, at tlic end of wliicli time she reported herself as having been well and free from all irritation of the urinary organs. No change in the character of the urine could have occurred to produce such mai-ked periodicity in the functional derangement of the bladder and urethra ; moreover, the urine was found to be nor- mal, and she completely recovered on the use of quinine. Vesical Tenesmus and Frequent Urination due to Prolapsus and In- flammation of the Ovaries. — In prolapsus of the ovaries and inflamma- tory affections of these organs irritation of the bladder often occurs. This is illustrated by the following case : A young girl of twenty-one was brought to me suffering from great distress in the pelvis, which was much aggravated by standing or walking. Her suffenng was constant, but was tolerable when she remained in the recumbent position. She began to complain about six months before I saw her, and about the same time she found that she was obliged to urinate too often, and that there was an un- easy feeling in the bladder most of the time, a feeling as if the bladder had not been fully evacuated. She was much worse at her menstrual periods. Upon a thor- ough examination I found both ovaries prolapsed, slightly enlarged, and exceeding tender. In every other respect she was perfectly well. In consultation with her physician, a course of treatment for the ovarian disease was decided upon. This was fully and faithfully tried for over one year, but at the end of that time she was worse. She was then quite impatient, being very nervous and irritable from her coniinement and suifering. Her parents and friends were quite weary of seeing her suffer. Her bladder irritation was no better ; in fact it was a great source of suffering. She could not urinate without getting uj), and the erect position increased her ovarian pain. The ovaries were still prolapsed and just as tender, in fact, more so than they had been. The complete failure of treatment so far indicated that removal of the ovaries was the only thing that promised to give her relief. Accordingly the ovaries were removed, and she made a rapid recov- ery from the operation and was completely relieved not only from her ovarian pain but also from the frequent urination and vesical tenesmus. It should be stated that at no time was there any evidence of cystitis found upon frequent and careful examinations. u CHAPTER XXXYIIL FTINCTIONAL DISEASES OF THE BLADDER (cONTTNUEd). Having considered the vesical derangements in which there is no recognizable organic lesion, and which may be local nem-oses, or may be due to hysteria, disorder of the sexual function, malarial or ovarian affections, I will now invite attention to the second class of these disorders, I. Derangements of function due to diseases of the nutritive and nervous systems, or to abnormal conditions of the urine which re- sult therefrom. This class naturally subdi^ddes itself into : 1. Derangements occurring in both acute and chronic diseases. 2. Derangements due to consequent abnormal conditions of the urine. 1. Of the derangements which occur in the course of acute dis- eases, such as retention and incontinence of urine and frequent m-in- ation, nothing more than the mere mention is necessary. They rarely require any treatment, except possibly in the case of reten- tion, when catheterization is to be employed, and they cease as soon as the acute stage is passed. Those, however, which are due to chronic affections of the nutritive and nervous systems are more permanent, and often tax the resources of the physician to the utmost. The two most important are : {a) Paralysis of the bladder, and, (5) Incontinence of urine. {a) Paralysis of the Bladder. — This affection has also been de- scribed under the names of weakness or palsy of the bladder, and vesical atony. It occurs in two forms : First, from causes residing in the organ itself ; second, from those due to outside influences. As affections in the first form Avill be fully described in another place I shall here simply mention them. They are : Fatty degenera- tion and atropliy of the muscular walls of the bladder, a common FUNCTIONAL DISEASES OF THE BLADDER. 075 cause of paralysis of tliis viscus in old women ; overstrain of the muscular structure from prolonged retention, voluntary or involun- tary ; displacements and inflammations of neighboring oi'gans ati'ect- ino- its position or nutrition ; and abdominal and pelvic tumors. In fevers of a serious type the power of nerve conduction may he either lost or impaired, and a partial or total vesical paralysis re- sult, with overdistention and dribbling of mine. The second form is due to influences acting from without the bladder, and includes acute and chronic meningitis; apoplexies of the brain or spinal cord ; sopor ; delirium ; myelitis of the lower part of the spinal cord ; inflanmiation of any kind primarily affect- ing or involving in its results either the lumbar nerves or ganglia ; endarteritis deformans of the pelvic arteries ; lumbar or renal ab- scesses ; blows or fall upon the loins, supra-pubic region, or head ; shock or disease of the vesical or lumbar nerves from the prolonged use of opium or poisoning by it, and also shock due to overdisten- tion of the organ itself. Symptomatology. — Except in cases of injury of the brain and apoplexies, the invasion of the disease is usually very gradual. This is especially the case in the aged, and sometimes, though rarely, in young people. The patient first observes that the urine is expelled from the bladder with less force than usual ; that the act of empty- ing the bladder is more slowly accomplished, and that after a time the organ is unable to expel its contents without considerable strain- ing and aid from the abdominal muscles. At a later date, if the disease goes on unchecked, the stream is less and less forcibly ejected, intermits, and the bladder, after much straining, is but partially emptied. Finally, partial or complete retention follows. The female bladder seems to be capable of more distention than that of the male. Lieven, in a case of supposed ovarian tumor, re- moved by catheterization about nine pints of urine. The patient was a woman thirty-three years of age. The fundus of the bladder reached as high as the ensiform cartilage. I once saw a case exactly like this, except that the bladder only reached to about two inches above the umbilicus. More than a gallon has been drawn off by Hofmeier and others. A peculiarly interesting experiment bearing upon the dilatability of the bladder was made by Budge. He found that section of the lower part of the spinal cord, when the bladder was considerably distended, allowed increased reflex action of the sphincter, and enormous distention then took place — even more than could be pro- duced by force, after death. This is especially interesting in rela- 070 DISEASES OF WOMEN. tion to vesical paralysis and retention due to injury or disease of the lumbar portion of the spinal cord. In some cases of overdistention the resistance of the sphincter is overcome somewhat, and a constant dribbling of urine takes })lace. It has been called by some authors incontinentia parodoxa. These cases are liable to be mistaken for those of pure incontinence. In rare cases rupture of the bladder may take place ; more com- monly dilatation of the ureters and hydronejDhrosis. If the condi- tion of vesical distention be not soon relieved, vesical catarrh, trae inflammation, ulceration, and death take place. In cases due to in- jury or disease of the spinal cord, low down, there seems to be a paralysis or peculiar condition of the nerves presiding over the nu- trition of the vesical mucous membrane, and destructi\e changes are not uncommon. Diagnosis. — The diagnosis though easy, is sometimes not made, owine: to careless observation or ionorance. When called to a case where there is supposed distention of the bladder, the abdomen should first be examined to see if there are signs of a tumor, and then a catheter should be passed if that be possible, to determine whether an abnormal amount of urine is present. If this is the case, and the tumor gradually subsides as the urine flows, the diag- nosis is at once made. When, however, a catheter can not be passed into the viscus, fluctuation should be sought both through the vagina and on the surface of the tumor. If the diagnosis be still obscure, the aspirator-needle should be passed into the tumor, and its fluid contents carefully tested. The age of the patient, the duration of the disease, and its time and method of invasion will aid in settling the question. The trouble may, however, occur at almost any age, and the fact that a little nriue has been passed at short intervals will tend to deceive. In the early stages of the disease an idea can be gained as to its progress by carefully noting the amount of urine passed at each micturition, the amount passed in twenty-four hours, the length of intervals between urination, the force of the stream, whether the bladder is fully or but partially emptied, and whether the stream intermits. The urine should be examined often, else cystitis may get a tirm foothold before its existence is recognized. In drawing off the urine for testing or other purposes, the catheter should be ahsolutel I) clean. Incontinentia paradoxa nmst be difl[erentiated from incontinence due to mechanical causes, such as abnormal urine, or the pressui-e of neighboring organs upon the bladder. i FUNCTIONAL DISEASES OF THE BLADDER. 677 Prognosis. — If the disease be uncomplicated tlie prognosis is good. Paralysis of the organ accom})anying the fevers, d3'seiitery, peritonitis, and the like, usually disappears with the cure of the original disease. If the paralysis be accompanied by disease of the bladder-walls, or if it occurs in weak, debilitated constitutious, or has been of long duration, or occurs in old age, the prognosis is not good. A cure, if eifected at all, will be only after long and tedious treatment. When due to centric causes or to serious spinal disease or injury, or when it occurs in old people, or with meningitis, or with sys- temic trouble, the prognosis is vei'y grave indeed. Causation. — Deranged innervation due to the central lesion already mentioned, either cerebral or spinal, may be regarded as the principal cause of this affection. If the paralysis has been of long duration nutritive changes may occur in the bladdei', but as these will be discussed under the appropriate head I need say noth- ing of them here. Treatment. — In all cases where there is fear of vesical distention, the bladder should be emptied at stated intervals. ^y way of helping the patient to pass water herself, hot hip-baths may be tried and fomentations over the bladder. The sound of water falling from one vessel into another often accomplishes the same result. If these means do not succeed the catheter must be used. And here attention may be called to a very important practical point in connection with the use of the catheter. When the blad- der has become very much distended it can not be thoroughly emp- tied unless pressure is made upon the abdominal walls ; if this press- ure is made while the catheter is in the bladder, and then discontin- ued, air will be drawn through the catheter into the bladder and decomposition of the urine will thus be favored. Marked distention can usually be relieved by the catheter. In some cases, however, the bladder rises up into the abdomen and puts the urethra upon the stretch, thus changing the direction of its axis from the normal to one from below directly upward, the canal being nearly parallel to the posterior surface of the pubic symphy- sis. In these cases passing the catheter will tax the skill somewhat. Great care must be used to avoid injuring the urethra. In emptying a greatly distended bladder a binder should be ap- plied to the abdomen and tightened gradually as the urine flows. It is not safe to draw off all the urine at once. It is better to take away about half, and then after a- time to draw off more, until the organ is empty. Syncope and even death, which is said to have G78 DISEASES OF WOMEN. occurred in these cases after rapid emptying of the organ, are prob- ably due to the sudden removal of the pressure on the abdominal organs, wliich so deranges the circulation as to cause these serious results. Tliu sudden removal of pressure from the vesical walls, vrhich that pressure rendered antiemic, now allows intense conges- tion, and the vesical walls Ijcing paralyzed catarrh and cystitis result. Therefore, for many reasons, a distended bladder should be emptied slowly. W^hen, for any rea?on, a catlieter can not be introduced into the bladder, hot hip-baths should be again tried, and opium given in suf- ficient amount to relieve pain and any spasmodic action that may exist. If, after this, there is failure to enter the bladder (and it is only in very rare cases that this occurs), recourse should be had to the aspirator, and after having punctured the bladder, the ui-ine should be drawn slowly and carefully, in the manner already de- scribed. In commencing vesical paralysis, and when incontinentia para- doxa exists or has existed, the patienr should be taught to use the catheter herself several times daily until the vesical power returns. It is of the utm(jst importance that the catlieter be absolutely clean. After each time that it is used it should be thoroughly rinsed in a chlorine solution, and put away in carliolized oil or vaseline. A great deal of vesical catai'rh is undoubtedly lighted up by foul cath- eters. This is especially the case in hospitals, where the same in- strument is often used on a number of patients. In cases of commencing or established paralysis the effect of the induced electric current may be tried. One pole thoroughly insu- lated up to the point to be used should be placed in the bladder, anil the other over the pubic symphysis and loins, letting the cur- rent flow in various directions, through, over, and into, the affected organ. The German authors, especially Winckel, by whom this method is highly recommended in this and like affections, say that the sitting should last but about five minutes. Forcibly distending the uretlu-a and washing out the bladder with a solution containing salicylic acid has been tried and recom- mended. I can not see the expediency of this unless vesical catarrh exists ; and even then washing must be done gently and carefully, and without previous dilatation of the urethra. Attention should be paid to the general health. The food should be good and nourishing, and the alimentary canal kept in a proper condition to receive and digest it. AVines (especially champagne), beer, and ale may be of use. I can at least say if stimulants are FUNCTIONAL DISEASES OF TIIK BLADDEE. f379 ever given in diseases of the bladder it should be in cases like these now under consideration. These ])atients are usually more com- fortable in the standing or sitting, than in the prone posture, be- cause then the weight of the abdominal viscera replaces to a cer- tain extent the natural tonicity of the organ. As they are usually M'orse in winter than in summer it is advisable, if the case is chronic and the patient able to bear transportation and rich enough to meet tlie expense, to send her to a moderately warm climate during the winter months. This will apply in most of the diseases of the bladder. If the trouble be purely atonic, camphor or musk may be used internally. Tincture of cantharides, in from five to twenty drop doses, three times a day, has been recommended as a vesical excit- ant. I can not indorse its use without the caution that besides the tendency to irritate the kidneys and produce congestion and nephritis, it may light up a severe cystitis. In these cases it may ])roduce serious trouble without causing much pain to give warning of the danger, as the paralysis lessens the sensitiveness of the blad- der, so that destruction of tissue may occur without producing the usual pain and suffering. Strychnia has been extensively used in this complaint, and with good results in some cases. Its failure to do good in many in- stances is undoubtedly due to the fact that it was not given in suffi- ciently large doses. It may be safely pushed as high as tlie one- twentieth of a grain three times a day, stopping for a few days if any of its characteristic symptoms appear. It has also been used hypodermically in the neighborliood of the bladder. Ergot has been found useful in cases where tlie paralysis was due to ex]30sure to cold, or prolonged retention from any cause. The fresh powder has been recommended, and may be given in doses of from eight to sixteen grains, four or five times daily. It is more pleasant and probably more effective to give its equivalent of the fluid extract. Alliers has used it with decided success in cases of vesical paralysis due to centric troubles, such as apoplexy. He has used as much as forty-five grains in the twenty-four hours. It is highly spoken of also by Roth, Jacksch, and others. Rutenberg (" AYienner Med. Wochenschrif t," 1875, No. 37) has recommended, in cases where there is destruction of muscular tissue or incurable paralysis from any cause, to make an opening into the bladder just above the pubic symphysis, keeping the fistula open, and closing the urethra by operative procedures. The ui-ine can thus be retained, unless the patient bends forward and downwai'd 680 DISEASES OF WOMEN. or lies upon lier abdomen. A urinal would, of course, be necessary to protect the ])atient. I think I should prefer to produce a vesico-vaginal fistula, and adapt an apparatus to receive the urine. {h) Incontinence of Urine. — Enuresis nocturna is usually an affec- tion of childhoud, but has been known to persist up to the age of thirty years. In some children it is hereditary, the mother having suffered in early years, and all the children born to her being affected in the same way. Of aU cases, these are the most difficult to manage. They often persist until pubert}', when they recover of themselves. The subjects of this affection are usually of the weak, nervous type, although apparently healthy children have been known to suffer from it, but usually only at intervals. These cases of incontinence may be divided into two distinct varieties: First, the anaesthetic variety. An excellent example of this class is seen in infants who, up to a certain age, wet the bed and their diapers. In the infant this is not disease ; it is simply a good normal example of this condition ; the incontinence in severe fevers illustrates the abnormal phase of the same thing. Second, the hyper- aesthetic variety, which is really nothing more than irritable bladder. Each variety may exist alone, or both be combined in the one case. In the first variety the retaining power is defective, the resisting power of the sphincter being insufficient to retain the urine or wake the child. When it is put to bed, it sleeps soundly through the night, and the nerve susceptibility to urine-pressure on the neck of the bladder, being lowered beyond the normal degree, fails to wake the little subject and impress it with the necessity of calHng the sphincter muscle into action sufficiently to resist the expulsive power of the bladder- walls. In short, in sound sleep the ])alance between the resisting power of the sphincter and the contractility of the walls of the bladder is disturbed, and the urine flows away without the child's even dreaming of its unfortunate behavior. In other forms of this affection the brain takes cognizance of the desire to urinate, but too late to control the act. This is seen in children who awake crying when imnation is but just begun or half finished. In this case the fault probably lies in the vesical nerves. In the second variety there is an irritable condition of the blad- der (vesical hyperaesthesia), which renders the expelling power greater than that of resistance or retention, and, while the will and cerebration generally are lost in sleep, the contents of the bladder are unconsciously passed before the subject wakes to resist the act. Closely allied to this is the peculiar affection known as vesical chorea, FUNCTIONAL DISEASES OF THE BLADDER. 681 in wliich tlie child while awake, it may be in school, in church, or at play, suddenly experiences the sensation that it is about to make water, but, before it is possible to resist, the urine is forcibly sj^arted out. There are usually choreic movements of other muscles or groups of muscles. This affection is the most annoyini^ when the little ones are nervous, cross, and fidgety. It may be accompanied by nocturnal enuresis. It is apparently more common in the male than in the female child. An irritable condition of the bladder may coexist witli an an- £esthetic condition of the sphincter vesicae — i. e., the two causes of incontinence may be combined. Irritable bladder, it should be remembered, may be due to some systemic condition — that is, a simple neurosis or to abnormal urine, or reflex irritation from anal Assure, ascarides in the rectum, fistula in auo, hfemorrhoids, or vulvitis. Enuresis nocturna is not only a filthy habit, and a source of great annoyance to parents, but, moreover, by keeping the genitals wet and irritable, strongly predisposes to masturbation. Then, too, other serious results may happen. The constant wettings are dangerous, in that they may produce many serious complaints from causing the child to " take cold." Prognosis. — In some cases the cure is easily and speedily ef- fected ; in others, the disease cures itself at or just after puberty ; but in a few — a very small percentage — no medical or other means seem to aid the sufl^erer at all. Treatment. — That the treatment is not uniformly satisfactory is seen by the number of remedies that have been tried. The proper way — and I can not call attention to this too often — here, as else- where, is to find the cause producing the disease, if it be discovera- ble, and it generally is. The treatment will, of course, differ in the two classes, and be greatly modified by diathesis and idiosyncrasy. In anaesthesia, local or general, stimulation is indicated. In hyper- SBsthesia, irritability should be allayed. Winckel, Barclay, and Brugleman speak very highly of the use of the syrupus ferri iodidi, the last-named gentleman having by its use cured a gii-1 perfectly of incontinence in the sliort space of four- teen days. This result was probably due more to the effect of the medicine on the blood and general system tlian to any s]3ecific action on the bladder. The sirup of the iodide may be given in from ten to thirty minim doses three or four times daily, according to the age of the patient. Although belladonna has been lauded by many as a specific in 682 DISEASES OF WOMEN. this disorder, its success is by no means general. The drug is usually given by the mouth in from five to twenty drop doses of the officinal tincture. It would be better to begin with small doses in young children, and gradually increase tbem ; for, although n(j serious re- sults may come from its exhibition in the routine dose — ten drops — the parents may be greatly alarmed by the peculiar redness of the skin produced in some cases. It is maintained by some medical men that the good effects are not obtained unless the administi'ation be pushed to tlic appearance of the scarlet rash. There is, I think, no proof of the correctness of this statement. A combination of belladonna and chloral hydrate has been used and well spoken of. Winckel, however, though using them in cer- tain cases tor a long time, and daily increasing the amount of chloral, has had but poor results, and even in those cases where the patients improved the benefit was seldom permanent. These drugs may be given singly or together, in suppository or by the mouth. If given together, they should not be combined uutil the time when they are administered, lest the chloral lose its power. Narcotics with tinctura ferri chloridi have been recommended by Campbell Black. Winckel speaks well of five to ten drop doses of tinctura thebaica, to a child fro-i ten to fourteen years of age, just before retiring. According to Sauvage, cold baths and cold douches to the spine at night are of great service. Dr. Kelp (" Le Mouvement Med.") reports that he has, on sev- eral occasions, drawn attention to the value of subcutaneous injec- tions of the nitrate of strychnia in the treatment of obstinate cases of nocturnal incontinence. He practices the injections in the neigh- borhood of the sacrum. A single injection of a very small (piantity of the drug suflices to arrest the affection for a certain time, and when it reappears the operation can be repeated. His latest paper cites the case of a young woman, eighteen years of age, who had suffered from enuresis every night for several months ; it came on after an attack of scarlatina, and persisted in spite of all precautions. The first injection produced a respite of several nights, and the second produced a permanent cure. The patient was a strong, healthy girl, and had never suffered from enuresis previous to the attack of scarlatina. Such a plan of treatment I regard as useful only when there is deranged innervation, characterized by weakness. It would be diffi- cult to get a child to submit to these injections, and I should in any case, whether child or adult, expect the incontinence to return as soon as the strychnia was discontinued. FUNCTIONAL DISEASES OF THE BLADDER. 083 In cases where the vesical irritability is due to abnormality of tlie urine, such as lithiasis, oxaluria, and acidity, these conditions should be corrected in the manner I have already pointc-d out. If to ascarides, anal fissure, and that class of rectal trouble, M^hen the cause is i-enioved the result will usually disappear also. In imta- bility the usual soothing and denuilcent drinks, such as have been already recommended, should be used. Oil of sandal- wood has acted remarkably well in some of these cases. Bromide of sodium and tincture of mix vomica have been effectual in some cases. In the ancesthetic variety, where the anaesthesia is more or less marked, special or local and general stimulants should he employed. Narcotics are as hurtful here as they are useful in the hypersesthetic class. Strychnia by the mouth, in suppository, or hypodermically, often produces good results, as also quinine, whether the presence of malaria is suspected or not. Tonic and astringent injections into the bladder are sometimes of service. In cases of abnormally small bladder, forcibly washing it out, distending the organ a little more each time, is well spoken of. In one such case, where there was irritability, Winckel produced a cure by first injecting a solution of nitrate of silver, and following it witli sulphate of morphia. This treatment, however, applies more to the irritable than to the anaes- thetic type. The little patients are very hard to operate upon, and, unless great care is exercised, much mischief may be caused by local treatment. Winckel claims good results from the use of the electric current, applied in the manner I have spoken of under the head of paresis vesiccTe. When the bed- wetting is due to pure carelessness, laziness, fear, or dread of the cold air in rising, in idiots and half-witted children, much may be gained by proper education. There is a general plan of prophylaxis recommended by common sense, viz., the heartiest meal should be in the middle of the day; but little water should be taken toward evening ; the food should be plain and unseasoned ; the bowels should be kept regular ; no coffee or tea should be allowed ; the little patients should be put to bed early, after it is assured that the bladder is first thoroughly emptied ; they should he upon a hard bed, with not too much covering; the air in the room should be maintained fresh and pure ; the genitals should be kept clean and dry ; no i)laces of amusement should be visited after dark ; and they should be awakened occasionally to urinate, especially at about the time the parents are going to l)ed. When it is discovered that they have wet the bed, they should be 084 DISEASES OF WO^rEN■. awakened, and talked to and reasoned with, if they are able to com- prehend what is said and meant. Children should not go to school too early, or stay too long. If the enuresis be due to masturbation, the parents must be cautioned to watch closely, and to use everv means in their power to stop it. A child should never be whipj)(sive vene- real indulgence, constipation of the bowels from torjjor of the portal circulation, the excessive use of stimulants, and the use of improper articles of food. Treatment, — The treatment should be directed to equalizing the circulation. Diaphoretics, warm, stimulating foot baths, hot applica- tions over the epigastrium, and, above all, rest in the recumbent position. If the bowels are confined, tbev should be emptied by saline lax itives. AVhen there is much irritation of the bladder, caus- ing frequent urination and vesical tenesmus, pulv. doveri with cam- phor should be given, or su^^positories of belladonna and morphine introduced into the vagina. Under this treatment the trouble will usually pass off in a short time. It may, however, go on to the de- velopment of cystitis. Occasionally bleeding occurs in active or acute congestion of the bladder, and that leads me to speak of heemorrhage from the bladder. Haemorrhage from the Bladder. — Haemorrhage from the bladder, or (if I may be allowed to coin a word) cystorrhagia, is usually due to some important disease of the bladder, and is, therefore, rather a symptom than a disease. For this reason I will at present confine my remarks to hagmorrhage when caused by acute congestion, which I have just considered, or to varicose veins of the bladder. The bleeding may take place from the free surface of the mucous membrane, and mingle at once with the urine or coagulate in the bladder. It may also take place beneath the surface of the mucous membrane, and form ecchymoses, like the spots seen beneath the skin in purpura. We may also have a condition known as hsemo- globinuria, in which only the coloring matter of the blood is found in the urine ; in such a case we should, of coui^se, find no blood-cor- puscles. The quantity of blood varies greatly in different diseases, and in the same disease in different persons. In congestion of the bladder blood- globules will often be foand in the urine only on microscopic examination, while at other times the urine will have the appeai'ance of being all blood. Again, the blood may coagulate, and be passed in clots, or the coagula may remain in the bladder, finally break down, and be passed as a chocolate-colored or blackish matter. Symptomatology/. — The symptoms of haemorrhage do not differ from those of congestion or the onset of cystitis, except when small clots form, distending the urethra, and causing pain in urinating. It 46 706 DISEASES OF WOMEX. is very rare that bleeding from these causes is sufficient to prostrate the patient. As bleeding may take place at any ]>oint in tlie urinary tract, it is important always to locate the luxMnorrhago. When coming from the bladder in any quantity, it is usually jjassed in small clots, and is seldom so intimately mixed with the urine as when it comes from the kidneys or ureters. This statement is not exact, and at best gives but a probable idea of the true facts. To complete the diag- nosis, we must resort to something more trustworthy. Sir Henry Thompson gives a very ingenious method for determining as to whether pus found in the urine comes from the kidneys or bladder, and V^an Buren and Keyes advise the same plan for detecting the source of hsemorrhage. The method is this: " A soft catheter is gently introduced first within the neck of the bladder, the urine drawn olf, and the cavity washed out very gently with tepid water. If the water can not be made to fl.ow away clear, the inference is that the blood comes from the cavity of the bladder. If it will flow away clear, then the cath- eter is closed for a few moments, the patient being at rest, and the few drachms of urine which collect may be drawn off and exam- ined. The bladder is now again washed out, and if, after a single washing, tlie second flow of injection is clear, while the drachm of urine was bloody, the inference is again complete that the blood comes from one or the other kidney." When it is known that the patient has had no Iddney-disease, nor symptoms of renal calculi, the endoscope may be employed, and possibly the bleeding-point found. This has been done with the instrument which I have described, but one may fail to find it if it be high up laterally or antero-laterally, or be covered by a fold of the mucous membrane. Hsemorrhage from the urethra might mislead, but is easily de- tected if it is remembered that in this case bleeding occurs between the acts as well as during micturition. It may also readily be dis- covered with the endoscope, provided the tube be not too large. Causation. — The causes of vesical haemorrhage, or cystorrhagia, are numerous. Congestion, varicose veins, villous cancer, lesions of structure, as in ulceration and sloughing of nmcous meml)rane from injury or cystitis, and obstruction to, or interference with, the portal circulation. This may possibly explain the fact that haMuorrhage occasionally occurs in those suffering from malaria. Perhaps the vesical haemorrhage occurring in the intense heat of summer in the tropics may be thus explained. In malaria the obstruction to the ORGANIC DISEASES OF THE BLADDER. 707 circulation through the portal system, acting as a predisposing cause, the intense congestion of all the internal organs dnring a chill or from exposure to cold would certainly tend to produce cystorrhagia. In purpura, the eruptive, typhus, and typhoid fevers, bleeding from the bladder may occur ; but, as it is there secondary to the main disease, nothing need be said about it in this connection. The most marked predisposing cause of cystorrhagia in women is a tendency to the haemorrhagic diathesis, so connnon among chlo- rotic females. Treatment. — The treatment must largely depend on the cause. In all cases rest in the recumbent position should be insisted on. A large number of haemostatics have been recommended, and some of them, such as aromatic sulphuric acid, tannic and gallic acids, in moderate doses, are doubtless of some value. I have, however, de- pended chiefly on doses of opium sufiiciently large to quiet the desire to urinate, and alkaline diluents to render the urine non-irritant, when it was found to be excessively acid. If the bleeding-point or points can be discovered with the endo- scope, applications of acetic acid, persulphate of iron, or nitrate of silver may be made. Great care must be taken in using these reme- dies, lest inflammation and ulceration of the bladder result. Nitrate of silver and strong acetic acid are more to be feared than the others. When the haemorrhage is so free as to excite fears of prostration, ice may be employed. Small smooth pieces should be introduced into the vagina at regular intervals as long as the patient can com- fortably bear it. Ice may also be applied to the hypogastrium. When the blood coagulates and forms a large clot in the bladder, it should be allowed to remain until it breaks down and conies away of itself. The experience of surgeons is that there is much more danger in attempting to remove the clot than in letting it alone. There are two dangers in removing coagula from the bladder. One is, that doing so will almost certainly start the bleeding again ; and the other is liability to injure the bladder, and cause inflammation. Let the clots take care of themselves, keeping the patient quiet and comfortable (with opium, if necessary) until the coagula are disposed of. Lime-water has been recommended as a solvent of blood-clots by Dr. J. H. Ledlin, of Pittsfield, Illinois, and, in the case reported by him, and which is narrated with the cases of hasmorrhage in this chapter, seems to have acted well. In one case of traumatic vesical haemorrhage that came under my care, a large clot formed in the bladder, and urination was com- pletely arrested. I was unable to determine whether the inability 708 DISEASES OF ^\•OMEN. to urinate was due to tlie i)resence of the clot or to loss of contractiU; power of the vesical walls from the injury. The patient suffered »• much, however, from the pain caused by retention that I was obliL''«il to use the catheter. I ein})l(n'ed the tiexible instrument of Ja(pU's, and, by carefully worming it in past the clot, I sncceeded from time to time in drawing off enough of the urine and broken-down clot t<> relieve the lady until she was able to reheve herself. I was careful not to disturb the clot. Allusion has been made to varicose veins of the bladder, called by some hiemorrhoids of the bladder. This condition is chiefly found in pregnant women, especially those who have borne several childi'en. The cause is interrujition of the venous circulation by pressure of the gravid uterus. The veins of the anterior vaginal wall, introitus vulvse, and labia, will often be found in the same condition. Occasionally prolapsus of the bladder ^^^ll also be found. This affection gives rise to tliose symptoms of pelvic distress and frequent urination that are so troublesome in some pregnant women. It must be kept in mind, however, that the same symptoms may come from pressure which does not produce varicose veins. If it is found that the patient feels relieved to some extent in the recumbent position, and the urine is normal, this troul)le may be suspected, and, if the symptoms are sufficiently urgent, a local examination should be made, which will re\'eal a varicose condition of the vessels of the urethra and vaginal walls, and from this it may be inferred that the same condition exists in the bladder. If the diagnosis is still doubtful, the endoscope will aid in settling the question. This affection is relieved or passes off altogether after confine- ment, and the best that can be done usually is to give rest and try to make the patient comfortable until the end of her " term." Should the trouble continue after delivery, especially if there is cystocele or prolapsus of the bladder, much good may be done by restoring and keeping the organ in place. This can best be accom- plished by using the cotton pessary or a roll of marine lint packed loosely into the vagina, like a tampon. The patient can be instructed to use this herself. Attention should be given to the general healtli, and particularly to the condition of the bowels and portal circulation. Kest in bed, and the use of cool water as a vaginal injection, may also be of use. Should ha3morrhage occur from this condition of the veins, it may be treated as described in the discussion of that subject. ORGANIC DISEASES OF THE BLADDER. 709 ILLUSTRATIVE CASES. Case of Hsemorrhage of the Bladder ; Blood-clots dissolved by Lime- water. — J. II. Letllin, M. D., Pittsfield, Illinois, in a letter to the '•' Medical Record," November 8, 1879, says : I have a patient, a man who for years has siLffered greatly from hsematuria. The blood comes from the kidneys. At times the haemorrhage is very profuse, and clots the bladder. Heretofore I have always succeeded in wash- ing it out with a double current catheter. Last Saturday I was called to see him. He had lost a great quantity of blood, and was suffering very much from vesical tenesmus ; I passed my catheter, and injected a stream of water. All at once the stream, returning, would stop. By withdrawing the instrument I could start it again, but he insisted there was a foreign body in there. I must say that the previous day he had experienced excruciating pain along the course of the ureter; I suspected stone, and sounded him, but could not discover one ; still, my instrument touched something ; I repeated the washing out of the bladder until the water returned colorless. I then made up my mind that there was a clot, with the coloring matter washed out, and, recollecting your account of dissolving the false membrane with lime-water, I threw in one half pint of lime-water, allowing it to remain half an hour. When it passed off it resembled what you describe as the appearance of the false membrane after lying in lime- water. He also passed a large piece of fibrin, which had evidently been acted on by lime-water, although not sufficiently to dissolve it entirely. Had it not passed away, I am convinced another injection would have dissolved it entirely. He is now quite comfortable, all sense of a foreign body in the bladder having passed away. Haemorrhage from the Bladder due to Malarial Influence. — This patient was a lady of twenty-one, married two years, never pregnant, and of a slightly strumous constitution. For several days she had to urinate more frequently that usual. She then began to be restless at night. These symptoms developed into well-marked fever in the afternoon and first part of the night. With this came frequent urin- ation, with pain and haemorrhage from the bladder. The blood came from the neck of the bladder evidently, from the fact that it was mixed with the urine, but was dark in color, as it would have been if from the kidneys. There was no blood passed after the bladder was empty, as would have been the case if it came from the urethra. The temperature was 103° F. in the evening ; normal in the morning. This continued for two weeks, at which time I gave qui- 710 DISEASES OF WOMEN. nine, gr, x, in tlio morning. After the quinia, tlie fever and bleed- ing st<)i)ped, and did not return. Slie was for over a year well, tlien lier tr(Hible returned — that is, she had painful urination without haem- ori'hage. I found the cause to be a polypoid growth, which looked like a wart, in the anteiior wall of the urethra near the meatus. I removed it by snare, with the result of relieving her completely. CYSTITIS. This is a disease that is much more common among women than is generally supposed. It is necessary, therefore, to infjuire carefully into the etiology, pathology, and therapeutics of this aliection, which causes great suffering on the part of the patient, and taxes the high- est skill of the ablest surg^eons. To the several forms, grades, or degrees of tliis disease various names have been given, such as acute, subacute, and chronic cystitis, cystitis mucosa (catarrh of the bladder), interstitial cystitis, peri- and epi-cystitis, croupous, diphtheritic, and gonorrhoeal cystitis. This medley of names should not be allowed to lead to confusion, but this fact should be firmly fixed in the mind, that, with the exception of the last three (the etiology and pathology of whi-jh are somewhat different), they are all simply steps or stages in one general process. Thus a patient may have received an injury of the bladder by the use of a catheter, causing an acute cystitis. This may end in con- valescence, or merge slowly into the more chronic form, having very likely as an inteniiediate step catarrhal cystitis. This, too, may go on to recovery ; but, if tlie process extends, and its severity increases, ulceration takes place, and the submucous and intermuscular tissues become involved, producing interstitial cystitis. If the intiammation extends still further, and involves the serous coat of the bladder, either by extension or ulceration, with or without perforation, we shall have peri- or epi-cystitis. In this example I hope I have made clear the fact that names are only given to denote the degree of in- tensity of the inflammatory process, and the character and extent of the tissue involved. Inflammation of the mucous membrane alone is by far the most common form, and hence, in using the term cystitis, reference is usually made to inflammation of that membrane only. When other tissues are involved, or the character of the disease is peculiar, some qualifying word is added to distinguish it. Acute inflammation of the bladder, other than that due to local causes, is emphatically denied an existence by many authors. The I ORGANIC DISEASES OF TUE BLADDER. 711 stateinents made are usually too l)road and sweopiiicf to be sustained by tlie facts observed in actual practice. 1 am inclined to believe that cases of acute cystitis from exposure to cold and wet do occur. It must, liowever, be admitted that such cases are very rare, and some that have been considered as acute idiopathic cystitis may have been but a development of acute inflammatory disease upon a pre- existing abnormal condition. It is also possible that those wbo deny the existence of acute idio- pathic cystitis may base their belief upon the fact that in what is called acute inflammation of the bladder all the phenomena of well- detined inflammation are not 23resent, while others consider hyper- ;vmia of the mucous membrane and derangement of bladder function all that is necessary to constitute cystitis. Thus the aj^parently dif- ferent opinions that exist among authors upon this subject may arise from conflicting views as to what really constitutes inflammation. I prefer to class this condition (of congestion, hypersecretion of mucus, abnormal exfoliation of epithelium, and irritability) among the inflammatory aifections, and call it acute cystitis. Such an affec- tion as this is met with in every-day practice, and I know of no bet- ter name for it. With this understanding, then, I will pass to a discussion of acute cystitis. Pathology . — As acute cystitis soon terminates in resolution, or merges gradually into chronic cystitis, I think it best to give the pathology of both diseases at once, they being, as I have already said, simply different in degree of intensity and duration. The morbid anatomy of cystitis is the same as that of inflamma- tion of mucous membranes in other parts of the body. In the more acute forms the membrane is swollen and relaxed, and of a bright or deep red color, from hyper^emia. The surface is partially or en- tirely covered with a thick, tenacious mucus. There is exfoliation of the epithelium, as shown by the partially denuded condition of the membrane, especially at the top of the rugae, and pus and loose cells are found in the sulci between the folds. In some instances, especially in cases of acute cystitis caused by extreme overdistention due to mechanical or other retention, there may occur a throwing off" of the whole or only a part of the mucous membrane of the bladder. This is more apt to occur when the re- tention and overdistention are caused by various accidents of the puerperal state or during delivery. That the separation of the mucous membrane is not due to direct injury caused by the child's head or instruments carelessly used, but to the effect of overdisten- 712 DISEASES OF WOMEN. tion, is shown by the fact that the vesical neck, w hicli is subject to the most direct injury, seldom shows separation of its mucous mem- brane. That injury to the organ may predispose to separation, or even determine it when already predisposed to it by sumo other cause, there can be no doubt. Most of these cases of separation of the mucous membrane have occurred in women, and almost all fol- lowed delivery. The bladder which has participated in the general congestion of the pelvic organs incident to the puerperal state is in aTi excellent condition to allow such separation to take j)lace. The manner of its production is probably as follows : A woman at full term is delivered after a long and tedious labor, with or with- out the use of instruments, of a healthy child. The child's head or the forceps may have done violence to the urethral mucous mem- brane by crowding the urethra against the unyielding pubic bones. Swelling of the mucous membrane results, and retention of urine (if the patient be not relieved by the catheter^ follows and persists for a varying length of time. The doctor, the nurse, and the pa- tient herself are often led to believe, from the constant or inter- mittent dribbling of urine, that there is an irritable condition of that organ, with frequent urination. The truth is, that this drib- bling (stillicidium) is almost a certain sign of an overfilled bladder, aud if the patient be not relieved the distention will gradually in- crease. The organ having reached its limit of distention, or being stretched to its utmost, tlie pressure within is so great as to cut off the supply of blood to the submucous tissue, and thus to the mu- cous membrane itself. This is more readily accomplished, as the muscular fibers are pulled apart and the mucous membrane thereby allowed a certain amount of bulging, by which its blood-supi)ly is seriously interfered with. If the distention be relieved early enough, nothing worse than an acute cystitis results ; but if not re- lieved, partial or total death of the membrane occurs, and it is sooner or later thrown off. Although death of the membrane may not take place in every case, or in one half of the cases of overdis- tention, it is no argument against this method of its production. Nor yet is it an argument in favor of the idea that it is caused by instrumental \aolence to the body as well as the neck of the viscus ; for that the latter can not be the only cause may be seen from the fact that it has occuiTed in the male (Liston per Barnes). It is probable that there are several causes, and that these may work to- gether to produce the result. From the uniform exfoliation it would look, however, as if the most important cause was a uniform pressure cutting off the blood-supply, and thus causing death of the ORGANIC DISEASES OF THE BLADDER. 713 part. It is even to be conceived that where marked iiijurv ha« heen done the membrane by overdistention (though not sntK<'ient in it- self to cause death), too rapid relief of retention causing congestion, irritation by catheter, peculiar systemic conditions, and the intense inilanmaation which follows may finish the work. viz. : fully carrv out the impression already made by the overdistention. This affection is not a common one, and though cases may sel- dom be met 1 desire to lay stress upon the great importance of jxiv- ing strict and individual attention to the condition of the uriruiry organs in pregnant and parturient w^omen. The catheter can tell more of the condition of the patient's bladder in such cases than any nurse, and can do no harm whatever when a soft instrument is used with care. Experiments on dogs have proved that the detachment of the membrane begins at that part of the bladder just op])osite the vesi- cal neck. At this point the membrane bulges out with a collection of blood and serum beneath it, and this bulging gradually extends to other parts. Meantime, in the bladder, the mucus poured out to shield the membrane causes the urine to decompose, and incrusta- tions of amorphous and triple phosphates are found on the surface of the exfoliated membrane. The color of the mucous membrane is usually either a deep red, greenish red, or black, and it may come away either in pieces or as a whole. In some cases (Mr. Wells's second case, Barnes) part of the muscular as well as the mucous tissue sloughed off and came away. In Mr. Liston's case the entire mucous membrane came away through a supra-pubic opening made by that gentleman to relieve retention. This occurred in the case of a male adult. Some of these patients have recovered, and it is believed by Schatz that the reproduction of the membrane commences at that portion of it always left at the vesical neck. That the completion of the sloughing does not takes place until sometime after the injury is done, and that the membrane itself may block the urethra and cause further retention, is illustrated by the following case, taken from Barnes's able lecture in the " Lancet." January 2, 1875. The case was under the care of Dr. Wardfll, at the Infirmary, Tunbridge Wells. " A woman was admitted with retention of urine. Fetid urine was drawn off. A fn-tus of three or four months was expelled followed by its placentii. Then incontinence ensued. The urine was still offensive, and loaded with mucus. Twelve days later she was seized with great pain over the pubic region. Next morning the house surgeon was 714 DISEASES OF WOMEN. called to see her on account of excessive pain. lie felt a substance being expelled, and saw a mass protruding through the meatus uri- narius. This was expelled in half an hour. At the moment of ex- jHilsion the urine gushed out in great force and in large quantity. Instant relief followed, and she perfectly recovered, Tlie substance looked as if it were the whole mucous coat of the bladder. Its inner surface was coated with gritty deposits. Its minute structure is not described." Barnes has no doubt but that the retention was in this case caused by retroversion of the gravid uterus. One of ]\Ir. Spencer Wells's cases, also cited by Barnes {loc. cit), is very instructive : " A woman, aged 22, had a natural labor with her lirst child. The bladder was not emptied for sixty-two hours. Five pints of turbid, bloody urine were then drawn off. Cystitis fol- lowed, then incontinence of urine, and a train of distressing cerebral symptoms, ending in death two months after delivery. The bladder after death was found to contain a detached cast, lying loose, cov^- ered wdth gritty dejDOsits of urates and phosphates. The walls of the bladder were thick and contracted, the muscular iibers being distinctly visible. The cast resembled degenerated epithelium. On boiling a piece of it in dilute acetic acid, much of the saline matter became dissolved, and some of the tissue became clear, look- ing like smooth muscular tissue which had begun to degenerate, as shown by the deposit of fatty or albuminous particles in its sub- stance." Further pathological results may follow the prolonged retention of urine. The bladder having reached a certain point where no more ui-ine can enter it, and even before this time, the ureters are filled from the urine above, and as the renal pelves till, both they and the ureters are put greatly on the stretch. The kidneys con- tinue to secrete urine until the pressure in the urinary tubules equals that of the blood in the glomerulus. At that point all secretion ceases, and pressure on the emulgent veins becomes so great that de- generative changes are apt to take ]')lace. In some cases after the pressure is relieved, acute uei)hritis results. The urine folh)wing such a condition of distention is loaded with hyaline, granular, and epithelial casts, and epithelial elements from the kidneys. The following case, which occurred in the practice of Dr. Geo. W. Gushing, of this city (the doctor having kindly furnished me with a report of it), may serve as an illustration of what I have been saying : " Mrs. S., of New York, aged twenty-six ; married eight years ; one child ; catamenia regular ; appetite fair ; bowels sluggish ; no ORGANIC DISEASES OF THE BLADDER. 715 dysuria previous to present attack. Has been under treatment for the past two months for cervical endometritis. Local applications of mild astringents and glycerin, with injections of borax. Tonics and laxatives internally. Theie being some tendency to tubercu- losis, slie was given cod-liver oil. "I was called to see this patient May 29, 187Y. She told me she was suli'ering from internal haemorrhoids, and that the rectal tenesmus was very distressing. She had had similar attacks before, and seemed to have no doubt as to what the trouble was. As she was menstruating I made no examination, but advised rest and a laxative powder, to be followed by morphia suppositories. " May 30. — Bowels moved since last visit with considerable pain. Complained of some vesical irritation, but had passed urine. Not much relief. ''''May 31st. — No better. An examination showed no haemor- rhoids. Menses ceased. Vaginal examination revealed a very sensi- tive spot, with hardening on the right side, between the rectum and vagina. Pulse and temperature slightly elevated. Vesical and rec- tal tenesmus, but no trouble in passing water. Made diagnosis of probable pelvic abscess. Advised poultices to the perinaeum, warm applications over the abdomen, and gave anodynes. Patient much relieved by the treatment, but still having severe pelvic distress. " June ^d. — Condition the same. '■'June 3d. — Found the vesical distress increased. Her husband said that she had passed urine during the night. Was called to her in the afternoon, and found her in great suffering. Said that her husband had misinformed me, and that she had passed no urine for about thirty hours. I examined the abdomen, and found dullness well up to the umbilicus. Introducing a catheter, I drew off a large (piantity of very offensive, high-colored urine, with much relief to the patient. For the next two days I was obliged to use the cath- eter. An examination of the urine drawn off was made, and showed the presence of renal epithelium, granular, hyaline, and epithelial casts, and considerable albumen, as also epithelium from the bladder and ureters. '"'• June 5th. — I found a tendency of the inflammatory products in the pelvis to point about the center of the perinaeum, and, though not quite sure of pus, I punctured and evacuated quite a large amount of it. " Since then the treatment has been the use of alkalies and sooth- ing drinks — tr. ferri cliloridi — and washing out the bladder with lukewarm water containing salt and a little carbolic acid. The ab- 71G DISEASES OF WOMEN. scess remainiiif^ open and very sluggish for some time, I put the patient under ether, and performed the operation for fistula in ano. At the present writing, October 30th, Mrs. S. is in excellent condi- tion, having gained in tlesli and strength, and being no longer trou- bled with the vesical disoi-der." This case is not only interesting as showing the serious changes that may occur in the kidneys from vesical distention, but as illus- tratiner the occurrence of retention of urine from reflex nei*vou8 in- fluence. Abscesses about the rectum are esjieeially prone to cause retention. Although in this case the mischief done to the kidneys was soon corrected, it does not follow that it will be so readily accomplished in all cases, especially if the retention continues un- relieved for any length of time. CHRONIC CYSTITIS. Pathology. — In chronic cystitis the redness of acute inflamma- tion gradually gives way to a muddy gray color, the membrane being smeared in places with a dark yellow muco-purulent secretion. As the disease advances, there is excessive cell growth on the free mu- cous surface. Patches of ulceration appear here and there, attended with the formation of pus and occasional, though usually slight, haemorrhages. Sometimes, at the portions destroyed by ulceration, the process of hyperplasia is established, and a polypoid material is developed. This has the appearance of exuberant granulations, as seen on a healing sore. At other times, and even in portions of the same organ in which hyperplasia occurs, the process of ulceration advances. The submucous intermuscular tissue partakes of the inflammatory trouble, and thickening of the vesical walls results. The decomposed urine, mixed with pus, mucus, blood, and shreds of membrane, forming the chocolate-colored fluid found in the advanced stages of this disease, acts as an irritant on the unhealthy membrane, and produces deeper or fresh ulceration. In advanced cases, with deep ulceration, the muscular flbers (which resist the destructive processes longest) are occasionally seen, stretching from one side of an ulcer to the other, forming a sort of bridge. "When the end of one of these Hbers becomes detaciied, it floats like a filament in the contents of the bladder. In some cases the salts of the urine are deposited, and form incrustations on the ragged mucous membrane. I remember that one of my patients frequently passed lumps of material that on examination proved to consist of all these products ORGANIC DISEASES OF THE BLADDER. Y17 of* destructive inflammation, among which were mixed deposits of tlie urinary .salts in the form of hard, gritty pnrticles. In cases of long- stamling, the vesical ends of the ureters are obstructed by swelling and hypertrophy of the bladder-walls. This jiroduces obstruction to the free flow of urine, and leads to dilatation of the ureters and renal pelves, and in some cases organic disease of the kidneys follows in the train of pathological sequences. I will refer to this subject again. When the disease has destroyed the mucous membrane partially or wholly, and extends to the muscular parietes, we have what is known as interstitial cystitis, and, if the serous coat becomes in- volved, there is also pericystitis. This latter is simply an inflam- mation of that portion of the pelvic peritonaeum which covers the bladder. In interstitial cystitis, after destruction of portions of the mucous membrane by ulceration, the areolar tissue beneath it and in the muscular walls gives way, the muscular tiber generally becomes thickened and burrowed by ulcerated cavities, irregular in form, and surrounded by cicatricial tissue. The extreme hypertrophy of the muscular coat found in the bladder of the male under these circum- stances does not so commonly exist in that of the female. In epi- or peri-cystitis the peritoneal coat is found to be hyper- semic and thickened by exudation, and the adhesions which follow bind together the bladder and the neighboring organs. Perforation of the pentonseum sometimes occurs, allowing infiltration of the urine. This usually develops general peritonitis or septicaemia, or both, and death almost inevitably follows. I have already stated that the walls of the bladder, including the serous coat, may become involved by the extension of a primary inflammation of the mucous membrane. This is undoubtedly the usual mode of occurrence, but, in some cases, I think that all of the bladder coats may become inflamed at the same time, making an inflammation in toto. At least, it is a fact that in some cases the mucous, muscular, and serous layers of the organ in question become involved in such rapid succession as to prevent us from detecting its progress from one tissue to another. The inflammatory process, having traversed the mucous and nms- cular coats, and involved the serous, especially where ulceration of the mucous membrane accompanies it, is likely to extend to the other portions of the pelvic peritonaeum and cellular tissue if the patient lives sufficiently long. It will be observed that in this condition there is about the same pathological anatomy as in pelvic peritonitis and cellulitis where in- 718 DISEASES OF WOMEN. flammation of the bladder- walls is caused by, and consequently sec- ondary to, the pelvic inflammation. In such condition the kidneys and ureters are usually found diseased. In some cases the cellular tissue about the bladder becomes greatly increased, and occasionally abscesses form, as in ordinary pelvic cellulitis. I am satisfied that the disease described in some of the text-books as idiopathic pericystitis is, in almost all cases, when it occurs in women, a pelvic peritonitis originally, the bladder becoming affected secondarily. One of the most serious results of intense vesical inflammation is gangrene. The bladder becomes distended from paralysis of it3 muscular walls, and its contents are found to be a brownisli colored fluid, consisting of decomposed urine, shreds of broken-down nmcous membrane, altered blood, pus, epithelial elements, and urinary salts. The mucous membrane is found to be soft, pultaceous, and altered in color, the latter varying fi'om a deep, charred black to a dark greenish or greenish yellow. The submucous connective-tissue layer and the muscular coat are softened, discolored, and infiltrated ^\^th malodorous pus. The peri- tonaeum is also injected, and in places discolored, sometimes per- forated, and having undergone fatty degeneration. This complica- tion usually occurs in the course of chronic cystitis with considerable ulceration, and in which an acute inflammation is lighted up, there not being sufficient vitality left to prevent rapid and deep gangrene. These extreme forms of cystitis are rare, and occur generally in connection with abnormal cases of lal)or, A pregnant woman having a cystitis of a mild form is liable to develop acute general cystitis at her confinement. Again, inflammation and gangrene of the blad- der sometimes follow instrumental or manual delivery in which severe contusions of the bladder have occurred. I desire now to call attention to some of the effects of cystitis on the ureters and kidneys. That form of vesical inflammation known as chronic cystitis may travel up the ureters to the kidneys, produc- ing ureteritis, pyelitis, pyonephrosis, or renal abscess. This affec- tion seems more commonly to attack the left ureter and kidney. I say seems, that being simply my opinion, derived from the cases that I have seen or of which I have read. I know of no statistics upon the subject. This complication is not so common in females as in males, which is owing, perhaps, to the fact that their short ure- thra, being, as a rule, free from stricture, and seldom obstructed otherwise for any length of time, the inflammation of the bladder ORGANIC DISEASES OF THE BLADDER. 719 has less tendency to extend, is less severe, and, as a rule, is earlier and more easily treated locally than in the male. It can not be denied that the damming back of urine into the ureters and renal pelves is a factor in the production of disease in these parts. Suppose tliat an inflamed ureter becomes blocked up from any cause (a mucous, purulent, or blood phig ; by the impaction of a small calculus from the kidney ; thickening of its mucous mem- brane; or hypertrophy of the bladder-walls), the urine l)eliind the point of obstruction greatly distends the ureter and renal pehds, de- composes, and produces acute pyelitis, which often leads to destruc- tion of the kidney on that side. In post-mortem examinations of such cases it will be found that the mucous membrane of the dilated ureter and pelvis of the kid- ney is swollen, pulpy, and of a dirty-drab, grayish, or greenish color, and possibly with incrustations of saline matter upon its surface. The renal pelvis may be sacculated, and the pouches may contain shreds of membrane, thickened, dirty pus, and saline matter. The kidney, when free from organic lesion, is always sympathetically affected, being enlarged and congested. Abscesses of the kidney itself have been found in these cases. The inflamed and dilated pelvis of the kidney, gradually enlarg- ing, flattens out, and implicates the papillae, and later the pyramids in the inflammatory process, until, finally, the whole organ is con- verted into a sacculated abscess. When there is destructive inflammation of the kidney (tlie ureter not being obstructed, and the pus having a free exit), the organ shrinks until it is converted into a little shriveled body, weighing from a few drachms to an ounce or two. If the purulent matter has not free exit, it fills the kidney, and becomes thick and putty-like, cutting like fresh cheese. This may be the case where the punilent matter can not or does not escape from the kidney, the ureter being perfectly free throughout. The septa between the saccnli are occa- sionally calcified. The pyi^amids alone may suffer, their tissue being converted into purulent matter, the whole having the appearance of soft putty, in some cases studded with calcareous masses. When the purulent matter is washed out, the hole left looks as though the pyramid had been punched out, so smooth and clean cut are its edges. Again, the kidneys may be studded with miinite al)scesses. Where one kidney is wholly or partially destroyed, the other, if healthy, is, as a rule, largely hypertrophied. In some cases of long standing the affected kidney docs not break 720 DISEASES OF WOMEN. down into purulent matter, but by a slower process, probably that of chrouic congestion, becomes granular and contracted. The study of the renal complications of cystitis is a very interest ing and instructive one, but it is too extensive to permit of anything like a full discussion here. For a more elaborate consideration of the subject, I must refer to the special books on renal diseases. Symjytomatologij. — The various forms of cystitis being simply stages of the same disease, I shall speak of their symptoms all nuder one head. They may, for convenience sake, be divided as follows: 1. Symptoms referable to the organ or its contents. 2. Symptoms referable to neighboring organs, that suffer either from sjnnpathy or through direct extension. 3. Spuptoms referable to various conditions of the general sys- tem, as : {a) The vascular system. {!)) The digestive tract, {c) The cutaneous surface, {d) The nervous system — cephaHc and sul)- cephalic. 1. The symptoms referable to the organ itself are chiefly de- rangement of function — viz., pain, tenesmus, and frequent urination. The symptoms vary in severity according to the extent and intensity of the cystitis. In the mildest form of the trouble there is frequent desire to pass water, which often comes with unusual force. Mic- turition is followed by a desire to strain, called vesical tenesmus, as if the organ had not been fully emptied. In the more acute cases this gives rise to the most intense agony, the patient remaining on the vessel for hours at a time. The sensation of a few drops of urine i-emaining in the bladder may pass off in a few moments, but, as a ]'ule, returns after each micturition. As the disease advances, and ulcerative changes take place, this vesical tenesmus returns in full force, and the powerful squeezing together of the bladder-avails during and after urination produces intense pain. Sometimes pains shoot up into the breast or the re- gion of the umbilicus. There is often a dull, heavy aching in the perinaeum. In nearly all cases there is continuous backache, or, more correctly, sacral pain. These pains seem to be most severe in cases of long standing, where, upon an already ulcerated surface, an acute inflammation is set up by errors in diet, medicines, violence in cath- eterization, i-apid changes in temperature, and the weather. The condition of the urine in acute or chronic cystitis is of im- portance, but if reliance is placed upon it alone for a diagnosis there will be many disappointments. The specific gravity is usually low in the more chronic types, varying from I'OOS to 1-018, being usu- ORGANIC DISEASES OF THE BLADDER. 721 ually about I^OIO. In the primary acute form the gravity is little if anything below the normal, and, if there is marked fever, may rise as high as 1*030. In acute attacks engrafted on a chronic state, the gravity is usually low. When the speciiic gravity is low in acute cystitis, if not dependent on the diluent drinks and diuretics given, it is probably due to a slight sympathetic hypersemia of the kidneys. The low gravity in chronic cystitis is possibly due to the same cause, and a urine not only proportionally but really deficient in the urin- ary salts is excreted. To tliis may be attributed many of the ursemic (ammonsemic) symptoms accompanying the disease, which are sup- posed by many to be due to absorption of decomposed urine. That such absorption might take place after ulcerative processes had be- gun, or even slight epithelial erosion had taken place, there can be no doubt ; but it is a question whether we are to look to the absorp- tion from the eroded bladder as the only method of their production. I shall speak of this more fully very soon. The reaction of the urine in acute cases, when the affection is not due to, or accompanied by, retention, is at first usually acid. If there be retention, the reaction is usually alkaline, due partly to the fixed alkali of the mucus which is present in excess, but chiefly to the ammonia disengaged in the breaking down of the urea. In chronic cystitis the reaction is almost invariably alkaline, being in- tensely ammoniacal. In the primary acute form, the color is but slightly altered. The presence of a little blood may give to the urine a smoky tint, and if decomposed it will look hazy and perhaps contain sparkling crystals of the triple phosphate. In the chronic form the nriue is of a pale, dirty yellow hue, and may be of a deep red from the presence of considerable blood. The odor is ammoniacal in the acute type, if the urine be de- composed, otherwise it is normal. In the chronic form it has not only an ammoniacal but a peculiar pungent odor of flesh. This is usually known as organic^ from the fact that it is due to the amount of organic material present. The sediment in acute cystitis is usually mucus, sometimes pus (white and clinging to the bottom, or somewhat fiocculent). It may be tinged with blood, or rendered denser and whiter from the pres- ence of the amorphous and triple phosphates. In chronic cystitis the sediment is commonly heavy, and of a dirty brown or brownish yellow color. Flakes of pus, shreds of tissue, as well as blood and epithelial elements, cause it to vary greatly in different cases. When the intense alkalinity of the urine has rendered the pus gelat- 47 722 DISEASES OF WOMEN. inous, the sediment is seen as a ropy mass that clings tenaciously to the bottom of the vessel when inverted, or slides about in a jelly- hke mass. Microscopically, this sediment presents a varied and interesting appearance. In the acute form numerous HbrillaB of mucus, a few pns-corpuscles, and possibly blood-globules are to be seen, and if de- composition has taken place, the amorphous and trij)le j)hosphates. In chronic cystitis pus-corpuscles are usually present in large amount. There is also a varying amount of mucus, triple and amor- phous phosphates, spheres of the urate of ammonia, organic delris^ and in some cases epithelial elements. In the advanced stages of chronic cystitis epithelial elements of any kind are very rarely found. It is only in the earlier stages that normal and transitional forms of vesical epithelium are present. Even then dependence must not be placed upon that alone in making a differential diagnosis, lest a pye- litis may be mistaken for a cystitis, or vice versa ; the transitional forms of epithelium from the bladder closely resembling the nor- mal epithelium from certain other parts of the urinary tract. The return to a healthy condition is marked by the disappearance of pus ; the reappearance of epithelium in the urine, first transitional, then perfect ; while the products of inflammation decrease in amount and finally disappear altogether. When there is sympathetic congestion of the kidneys, small light granular and hyaline casts may be found. If organic renal disease is present, large, small, and medium-sized hyaline, light and dai'k granular, and pus casts will be found, as also epithelial and blood casts. In some cases, where extensive de- structive change has taken place in the kidneys, no evidences are found in the urine, either during its progress or after its completion. Upon testing the urine chemically, albumen will be found in proportion to the amount of pus oi- blood present. If renal disease co- exist, the amount of albumen will be greatly increased. In chronic cystitis without renal disease the amount of albumen in a number of cases studied varied from one sixteenth to one fifth of the bulk of urine. There is usually a real excess of both fixed and volatile alkaline salts, as also of the earthy and alkaline phosphates and the chloride of sodium. In the advanced stages, where there is a depraved condition of the blood, urohaematin is present in a marked degree, and urea is either somewhat or decidedly diminished. In other cases, and at first, the urea may be present in normal amount. 2. Symptoms Referable to Neighboring Organs. — These are not especially marked. In some cases, with the intense vesical tenes- ORGANIC DISEASES OF THE BLADDER. 723 raus, there may exist an irritable condition of tlie rectum, with some tenesmus and pain at stool. The uterus is often congested, which causes a free leucorrhoea ; subinvolution often occurs after the confinement of those who have had cystitis during pregnancy. Extension of the inflammation in extreme cases may cause metritis and pelvic cellulitis and perito- nitis. The symptoms thus arising will be characteristic of the dis- ease of the organs or tissues involved. Menstruation may be \ariously disturbed ; menorrhagia, metror- rhagia, or amenorrhea resulting either from congestion, inflamma- tory extension, or reflex nervous influence. Neuralgia of the uterus or ovaries may also be produced in this way. I have just said that subinvolution of the uterus is almost sure to follow a pregnancy occurring during the existence of a chronic vesical inflammation, and I am inclined to believe that the same result is produced in some cases by an acute cystitis following delivery. Renal disturbances upon which I have already touched will be spoken of more at length hereafter. 3. Symptoms Referable to Disturbances of the General System. — These symptoms may be due to reflex nervous influence, or to di- rect blood-poisoning. For convenience sake I will first consider : («) The Vascular System. — Although there has been much dis- pute among authors as to how and by what the general poisoning is caused, there seems to be no question as to whether such a poison- ing really does take place. As general systemic effects may be pro- duced by two separate blood conditions, I will discuss the subject under two heads, prefacing their consideration, however, with the remark that, as a rule, the two conditions exist together. They are : first, abnormal ingredients existing in the blood ; and, second, a poor condition of the blood itself (antemia). The poisoning of the general system that usually complicates cystitis of long standing may be produced in three ways, viz : 1. Organic renal disease, or renal hyperaemia (sympathetic), leading to imperfect elimination of urinary salts. 2. Direct absorption of one or more of the ingredients of the decomposed urine (ammonaemia, urinsemia). 3. Absorption of purulent or septic matter, produced by decom- position of sloughing tissue and organic debris. 1. Probably in almost all cases of chronic cystitis the kidneys are kept in a more or less active or passive liyperaMuic state ; and while eliminating a normal amount of fluid, fail to rid the blood of 724: DISEASES OF WOMEN. the acciimu latin or salts ; and thereby a slow, steady blood and tissue poisoning is brought about. So slow is it, that the system seems to establish a certain amount of tolerance for the poison. A French experimenter has fouud that a small amount of urea is daily eliminated by the mucous membrane of the bowels in health, and we know that in renal diseases, with partial or total sup- pression of urine, the bowels are largely concerned in the elimina- tion of the poison from the system. In this manner may be ex- plained the occasional attacks of vomiting and almost uncontrollable diarrhcea in bad cases of cystitis. Of course, when destructive renal disease com})licates the cystitis, the general poisoning is more marked and more readily explained. 2. In the chapter on the function of tlie bladder I pointed out that experimenters had pretty well established the fact that a nor- mal vesical mucous membrane was unable to absorb anything except possibly a little water, but that where erosion of the epithelial surface or ulceration existed, absorption was possible. This being the case, it will at once be seen how easy it is for a patient suffering with chronic cystitis to become poisoned by the absorption of decomposed, ammoniacal urine in the bladder. Whether the materies morbi be the urea, the ammonia, or all or part of the urine, is not as yet definitely settled. This form of poisoning by absorption has been denied on the ground that the urine remains but a short time in the bladder owing to the intense vesical tenesmus, and that the eroded surface is faii'ly well shielded from contact with the urine by mucus or gelatinous pus, and that therefore there is neither time nor opportunity for absorption. As against these arguments, let me say that of all kinds of urine, the highly limj^id seems the most easily absorbed ; that poisoning is not supposed to be due to the fresh urine that comes directly from the kidneys, but to its decomposing sediment, caught in the meshes of the mucus and muco-pus. Fur- ther, the intense vesical tenesmus, while keeping the bladder com- paratively empty, thoroughly mixes the decomposing unne with the mucus, thus at each micturition applying freshly charged de- composing matter to the eroded and ulcerated surface. It will also be observed that in some cases where, by the use of oj^iates or in the course of the disease itself, the tenesmus wholly or in part al)ates and the urine remains in the bladder for a longer period than usual, the patient, while feeling greatly relieved by not having the inces- sant calls to urinate, still begins to experience a peculiar sensation of sleejnness and the other manifestations of systemic poisoning. That this is not due to the opiates or other remedies used, is evident OKGANIC DISEASES OF THE BLADDER. 725 from the fact that as large or larger closes of the same remedies do not produce these peculiar results when given at times when the vesical tenesmus is marked. It is undoul)tedly explained by the fact that the bladder has more time to absorb a part of its contents, which, when absorbed, produce these results. 3. Blood contamination due to the absorption of purulent or sep- tic matter. — This material may be the liquor intris^ the disinte- grated corpuscles of pus, or possibly the whole corpuscles, as also the decomposed shreds of sloughed membrane and organic debris. I think there is little doubt but that such material is at times ab- sorbed, and gives rise to the peculiar septiesemic or pyaemic symp- toms. The chill, fever, and sweating, with peculiar head symptoms (all to be spoken of more fully hereafter), the sudden diarrhoea, with copious black, offensive liquid stools, are probably caused in this way. Whether the general symptoms are produced at the time of each absoj'ption, or whether by slow degrees the poisonous material col- lects, and, tolerance being finally exhausted, nervous disorder, with a powerful effort at excretion by the bowels, results, we do not know. 4. Depraved blood condition — (anaemia). — In cystitis of long standing, owing to frequent haemorrhages, poor digestion, excessive diaphoresis and diuresis, and reflex nervous influences, the blood be- comes poor in red corpuscles and fibrin. Injuries on persons thus affected do not heal readily, and poor tissue renovation is a general accompaniment of this affection. Cerebral anaemia is an accompanying complication, due to the same cause, and various ab- normal nervous phenomena result from poor nourishment of nerve- tissue. All the fluids and solids of the body are but poorly con- structed, and imperfect performance of function necessarily results. This i30or blood condition, as I have already said, is manifested by the presence of urohaematin in the urine. (J) The Digestive Tract — Anorexia, especially at the morning meal, is a common accompaniment of chronic cystitis. In some cases this is the only meal where the appetite does not invite the patient to partake. A longing for peculiar foods is also very common, the patient often having lost the desire before the article in question reaches her. The common symptoms of disordered digestion ai'e usually present, and the affection may be either of the nervous type, or of the chronic catarrhal form ; it is usually a mixture of both. If, as is believed, the poisonous material absorbed from the bladder and the non-eliminated urinary salts find vent through the aliment- ary canal, we have no trouble in discovering a cause for the catar- 72G DISEASES OF WOMEN. rlial disorder. The uervous disorders are readily explained by tlio effects of the abuoriiial condition of the blood, and the broken and sleejjless nights which interrupt and retard the nutrition of the nervous system. The bowels are usually irregular and constipated, and require daily enemata to open them. This costiveness is occasionally in- terrupted by a profuse watery diarrhoea, which would seem to be an effort of nature to relieve the blood of its abnormal contents, as I have already said. It may last for days or for only a few houre, and the discharges are usually rich iu the carbonate of ammonia. The septicemic diarrhoea differs usually in the great prostration ac- companying it, the chai'acter of the stools (black or greenish black, and very offensive, the organic odor quite or partly hiding the ammoniacal odor), and the fact that it is usually preceded or accom- panied by chills, fever, and sweating. If checked too abruptly, head symptoms, mild muttering delirium, etc., are likely to follow. The results of imperfect digestion are seen in the poor, un- healthy condition of the patient's flesh and skin, and all the signs of malnutrition present. ((?) The Cutaneous Surface. — The skin of patients with chronic cystitis is usually sallow, loose, and has a lifeless feel. Indeed, one might almost make a diagnosis from the comjjlexion alone. Sweat- ing of the palms of the hands and soles of the feet is common. In low states of the system the patients are especially liable to night- sweats. The perspiration sometimes has a urinous odor. I have al- ready spoken of the septicaemic diaphoresis. {d) The Nervous System. — I will first consider the symptoms appertaining to the brain and its function, and then to the sub- cephalic nervous system. There is a peculiar brain condition, supposed by some to be caused by cerebral annemia ; others attribute it to a peculiar poison circulating in the blood. By anaemia of the brain in this connec- tion is meant not only lack of blood in that organ, but an exceed- ingly impoverished condition of the blood there circulating. Those remedies that tend to lessen the amount of blood in the brain, as bromide of potassium and ergot, produce most unpleasant symp- toms in these cases, such as dizziness and fainting. Medicines which act in a manner to congest the brain, if given in small doses, improve this condition, as also do the ferruginous tonics, especially iron by hydrogen. From this it would appear that this pecuUar con- dition is due more to the amount and imperfect constitution of the blood circulating in the brain, than to the absorbed or non-eliminated ORGANIC DISEASES OF THE BLADDER. 727 urinary matter. Against this theory, however, is the fact that when the vesical tenesmus is least and the urine remains in the bladder longest, and hence the blood-poisoning is presumably the greatest, the weak and somnolent feeling is the worst. Both causes probably act to produce this condition. By some, however, this cerebral aufemia is attributed partly to the poor blood condition, but chiefly to imperfect circulation due to want of exercise. This view is supported by the fact that digitalis and exercise in the open air greatly improve these patients. When septic complications arise and the patient becomes very low, or when the septic diarrhoea is checked too suddenly, low, mut- tering delirium with hallucinations commonly results. This has been alluded to before. The mind is usually markedly affected, the patients feeling " blue," morose, lacking hope, confidence, and spirit. At times, indeed, they become so despondent as to seriously contemplate suicide. The little rest that they get at night is often broken by horrible dreams and nightmare. I am now speaking of the most severe cases. The subcephalic nervous system is seldom affected beyond oc- casional irregular action of the heart, chills, fever and sweating, and occasional neuralgia. Pains in the nipple, abdomen, arms, legs, hands, and feet, are by no means rare. The vesical pain has already been referred to. Of course all these symptoms that I have spoken of as accompanying cystitis, do not occur in each case, nor are the greater part of them peculiar to cystitis alone. I now pass to diag- nosis. Diagnosis. — The diagnosis of cystitis is generally easy in marked cases, but in mild attacks care is necessary to distinguish it from other conditions that cause similar symptoms. Frequent urination occurs in many other troubles, such as pro- lapsus uteri, adhesions from pelvic peritonitis, with abdominal tu- mors, and in various neuroses. Pregnancy, also, sometimes gives rise to annoying frequency of micturition. Frequent urination from prolapsus is worse when the patient is standing or walking, and is relieved wholly, or to a great extent, by the recumbent position ; while in cystitis, position makes no marked difference. I have seen one very interesting exception to this general rule. The patient had a complete prolapsus for many years, and when in the erect position she could retain the urine for an ordinary length of time, but when she was reclining the most urgent desire to urinate came on, and she could only retain a very small quantity of urine. The cause of this I found to be iniiannnation of the neck of the 728 DISEASES OF WOMEN. bladder. When in the upright position tlio urine settled down in the dependent portion, but while recumbent the pressure came on the tender part. In adhesions from pelvic peritonitis, abdominal tumors, and pregnancy, the desire to urinate only comes on wdien the bladder is partly tilled, and is about the same day and night. Frequency of urination is not usually accompanied by tenesmus, except when due to cystitis. In the various forms of vesical neuroses frequent urina- tion is very irregular, the patient at times being almost entirely free from it, and at other times very much troubled. The frequent and painful urination of cystitis may be simulated by urethritis and other painful, irritable conditions of the uretlira. The distinction can be made usually, from the fact that in urethral disease there is no vesical tenesmus, or if any, it is much less than in cystitis. There are acute pain in the act of urination, and a burn- ing sensation in the urethra, wdiich sometimes cause sympathetic vesical tenesmus ; but when this latter passes off the bladder will tolerate distention to the fullest extent. The urine should be carefully examined and the results as care- fully considered. Implicit dependence, however, must not be placed on the condition of the urine. Acute or chronic congestion may produce considerable mucus that is sometimes mistaken for pus that has become gelatinous by the action of strong alkali. Pus may be present in the urine from suppuration of the upper urinary pas- sages (pyonephrosis, renal abscess, and pyelitis) ; from abscesses of neighboring organs or tissues opening into the bladder, as in colitis and pelvic cellulitis. When there is doubt on this point, Sir Henry Thompson's method of procedure as recommended l)y Van Buren and Keyes for detecting the source of blood should be tried. A differential diagnosis between cystitis and pyelitis, by means of the urine alone, is almost an impossibility, especially in the later stages of the former. Thompson's method, the endoscope, and the presence or absence of a tumor in the loins, with the gen- eral sjnnptonLS, must be the guides. Xo dependence can be ))laced on the epithelium, as transitional forms from the bladder, as already explained, are very likely to be mistaken for the normal epithelium of the renal pelves, and lead to error. To make a positive and reliable diagnosis, resort must be had to physical exploration of the organ. The methods of exploration are palpation, percussion, and auscultation of the abdomen ; examination of all the pelvic organs by the touch and speculum ; and lastly, ex- ploration of the bladder by the catheter, or sound. ORGANIC DISEASES OF THE BLADDER. 729 By palpation and percussion of the abdomen tenderness and dis- tention of the bladder may be detected, if either exists. By the same means it may be ascertained whether the bladder is contracted and its walls thickened, rigid, or relaxed. Auscultation will possibly reveal friction sounds in cases where inflannnation has extended to the serous coat, and caused roughen- ing by exudation on the peritoneal surfaces. These may seem to be rather delicate points in examination, but in obscure cases we must avail om'selves of all the means that can give the slightest evi- dence. Examination of the pelvic organs by touch will detect any disease of these organs that may either cause or complicate the cystitis. Displacements and inflammatory ailections of the uterus, vagina, or rectum, pelvic peritonitis, or the products of a former attack of that disease, ovarian diseases and tumors, should be carefully sought for, and — if present — their relations to the vesical trouble carefully studied. Cystitis produced by or producing pelvic cellulitis and peritonitis has the same symptoms as ordinary purulent vesical inflammation, plus those of well-defined pelvic inflammation. There are usually pain and tenderness of the pelvic organs, and the symj)tomatic fever of local inflammation. In those cases where, from gluing together of the pelvic organs, the bladder-walls are separated and kept upon the stretch, inconti- nence often results, sometimes overdistention with dribbling. In such cases the cystitis may be entirely secondary to the pelvic ad- hesions, and consequent vesical distention. The urethra should be examined with care, for some of its diseases present a natural history closely resembling that of some vesical affections. By a careful use of the catheter or sound introduced into the bladder, the degree of tenderness of that organ can be determined, and the presence of foreign bodies, such as a stone in the bladder, can be excluded. The sound being in the l)ladder, the finger may be introduced into the vagina, and the posterior and inferior walls be examined as to their thickness and tenderness. In supposed cystitis the neck of the bladder ought always to be examined with a view of detecting ulceration and fissures at that point. These fissures give rise to symptoms very closely simulating cystitis, and the differential diagnosis can only be made by tlie en- doscope. The endoscope affords the only means of ascertaining the exact appearance of the interior of the bladder. The extent of congestion, 730 DISEASES OF WOMEN. the degree and extent of ulceration, and other lesions can be observed in this way, and this instrument should be used in all cases where the diagnosis is doubtful, or when the case does notyelid to supj)06ed proper treatment. The chief value of the endoscope is in examining the urethra and neck of the bladder. When, by the use of this in- stnimenfc, urethral disease can be excluded, the diagnosis of cystitis may be made by exclusion. If this is not satisfactory, then the bladder should be emptied, washed, and thoroughly cleaned of all inflammatory products. The catheter should be left to drain oif the urine as fast as it flows into the bladder. This urine, coming almost directly from the kidneys, will show if any renal disease exists. Sometimes the bladder is too irritated to permit the presence of the catheter ; then the patient should urinate as soon as there are a few drachms secreted, and, if there should be any evidence of renal disease, the diagnosis would be complete. When from an examination of the urine or the symptoms it is impossible to tell whether disease of the kidneys complicates the vesical trouble, recourse may be had to the ophthalmoscope, by means of which renal disease, retinitis albuminurica, may often be diagnosti- cated. Causation. — The cause of acute cystitis may for convenience be classed under five heads, each of which will be studied separately : 1. Direct injuries, such as blows in the vesical region, falls, fract- ures of the pelvic bones, violent copulation, sudden uterine displace- ments and pressure therefrom, contusions and injuries during labor, foreign bodies, rough catheterization, and overdistention from reten- tion of urine. 2. Abnormal urine. 3. Inflammation of adjacent organs. 4. Constitutional diseases. 5. Drugs, improper food, and the virus of gonorrhoea. These causes also pertain to chronic cystitis, whether it begins as an acute or subacute alfection. 1. Direct Injuries. — Blow^s over the vesical region, falls, and espe- cially fracture of the pelvic bones, caused by some great force, usu- ally produce acute inflammation of the bladder, with or without rupture of that organ. The bladder, when full, is, of course, more readily ruptured than when empty, rupture in the latter condition being almost an impossibility. This item of knowledge can be turned to practical use in traveling, either by rail or \^ ater, by remeuibering to frequently empty the bladder. In cystitis from severe and direct injury, even without any perceptible traumatic lesion of the mucous ORGANIC DISEASES OF THE BLADDER. 731 membrane, there is apt to be marked Ini'morrhage, irmch greater, indeed, than in cystitis from other causes. Sudden displacement of other pelvic organs, as the uterus, may act in two ways: First, by pressure on the bladder, or by dragging it out of place ; second, by blocking the urethra by pressure. These displacements may be due to falls or blows, and it is not an uncom- mon occurrence for the gravid uterus to topple over by its own weight. Supposing a retroversion of the gravid utenis, the cervix Av'ould compress the urethra against the pubes, while the utero- vesi- cal ligament would drag the upper part of the bladder downward and backward. Even after the uterus has been replaced, and the pressure on the urethra removed, with relief of the vesical overdis- tention, the retention is likely to persist, and overdistention recur, for b}' the pressure the urethra becomes much tumelied, and the muscular and elastic tissue of the vesical walls overstretched and partly paralyzed. If the distention has been great and prolonged, there may be partial or total sloughing of the vesical mucous mem- brane. In retention of urine, and consequent overdistention of the blad- der during or after labor, from either injury or carelessness, acnte cystitis is very apt to occur. Here injury of a serious nature may be done to the urethra by pressure against the pubic bones by the child's bead, with or without the intervening soft cushion of tlie anterior nterine lip. This is especially the case in slow, tedious labors, where the pressure is almost continuous. The extent to which the bladder may be distended without rupt- uring is quite wonderful. My friend Dr. Bodkin invited me to see a lady with him in consultation, who went without urination for four days and nights after her confinement. The bladder reached above the umbilicus, and contained about three or^iii^vy joots-de-chamhre full of decomposed urine, which was drawn off by the catheter. The bladder remained paralyzed for three months afterward, but finally regained its expelling power. At the time I saw ber she was suf- fering from cystitis, brought on by the maltreatment. In justice to the medical profession, I ought to say that this lady was attended in her confinement and for a time after by a member of the so-called 7iey) school of medicine. The ignorant or careless use of instruments during delivery is also a cause of serious vesical inflammation. In all these cases the catheter should be used several times daily, and with great care, until the organ has regained its power, and the contused urethra fully recovered itself. I may digress here long enough to say that 732 DISEASES OF WOMEN. the soft-rubber catlieter is the only one that 1 liave used for years. The old female silver catheter is the most dangerous instrument I have ever seen. It should be discarded forever. In cases where the bladder has been perfectly healthy, and the catheter pa.ssed a number of times by way of experiment, the points of membrane with wliich the instrument had come in contact were abraded and congested, thus showing the danger attending the unskillful use of this instrnment. If the frequent introduction of the instrument into a healthy bladtler produces these results, how easily must the blad- der of a pregnant woman be iutiamed under such treatment, for the organ has been for a time more or less congested, and during labor perhaps severely bruised ! The question has been raised as to w^hether the irritation and in- flammation following catheterization in some cases is not due to the introduction (during manipulation) of air, either pure or containing germs that will cause decomposition of the urine. The experiments of P. Dubelt, in which the air was injected into the bladder, show that it is perfectly harmless. Moreover, the same experimenter found that the injection of decomposing urine into the bladder did little or no harm, unless the mucous surface was abraded. What- ever may be the effect of such things on a healthy bladder, I do not doubt but tliat the introduction of germs by means of air or a dirty catheter, decomposing urine, or the rough or too frequent use of a catheter, would produce an acute exacerbation in an organ already diseased. The influence of decomposed or decomposing urine in producing inflammation of the bladder will be more fully spoken of again. Forcible and excessive copulation is a decided exciting, as well as predisposing, cause of acute or subacute cystitis, and, if persisted in, a chronic inflammation of the bladder is usually the result. Foreign bodies in the bladder, such as pieces of wood, pins, needles, hair-pins, bodkins, 'and the like, that are sometimes slipjied in by hysterical girls and those w^ho masturbate, excite acute inflam- mation if not speedily removed. 2. Abnormal Urine. — No known abnormality of the urine will, I think, excite acute inflammation in a perfectly healthy bladder. In a bladder, however, that is suffering from chronic congestion ; in one whose walls bear deposits of tubercle ; in cases where some slight degree of inflammation already exists, then abnormal urine may and does give rise to marked inflammatory trouble. As a rule, however, inflammatory vesical disease precedes urine decomposition. In cystitis following overdistention, the retained urine, being mixed ORGANIC DISEASES OF THE BLADDER. . 733 with mucus thrown out by the irritated and tense mucous membrane to shiekl itself, rapidly decomposes, and still further aggravates the abnormal condition of the membrane. Women sometimes from abnormal modesty, more often from the lack of opportunity, retain their urine until the bladder is dis- tressingly overdistended, and the urine partially decomposed. Of course this is wrong, and can generally be avoided, but is neverthe- less a frequent cause of disease of this organ. Where there is considerable suppuration of the upper urinary passages (renal abscess, pyelitis, or pyonephrosis), the acid urine loaded with pus has, or seems to have, an irritating effect on the vesical mucous membrane, and in some instances probably lights up a cystitis, and certainly aggravates one when already existing. Deposits of the amorphous phosphate of lime, or of the ammonio- magnesian phosphate, often greatly aggravate and render serious a previously mild cj^stitis, but seldom if ever produce acute inflamma- tion in a healthy bladder. This may be said also of uric-acid gravel and other crystalline urinary sediments, they being at most only able to produce some hypersemia of the membrane with a little excess of the mucous secretion. Urine which is already decomposed, or decomposing, as I have already said, can produce acute cystitis only in an already diseased bladder, or in one where abrasions of the epithelial surface exist. To show how some of these causes may combine to produce cys- titis, let me take, for example, the bladder of a pregnant woman, which has for some time shared congestion with the other pelvic organs. Retention and some distention of the bladder occur from some cause ; a clumsy physician attempts to pass a metallic catheter, and does it roughly and rapidly, and relieves the viscus of its con- tents. A slight catarrh of the mucous membrane, the surface of which is somewhat abraded, ensues. By the catalytic action of the mucus present in it, the urine is rapidly decomposed. The decom- position is often aided by germs introduced with the catheter. Car- bonate of ammonia, being set free from the broken-down urea, as- sists in alkalizing the fluid, precipitating the amorphous phosphates thereby, and forming, with the phosphate of magnesia already pres- ent, the ammonio-magnesian, or triple phosphate. The urine is further alkalized by the alkali of the mucus. The bladder-walls not having fully regained their tone, a little decomposed urine remains after each micturition, and aids in decomposing that which is next secreted, and would otherwise be normal. The mucus increases in amount, the ammonia is more rapidly set free, and the mucous 734 DISEASES OF WOMEN. membrane more and more irritated, until a true acute cystitis is set up. Such cases are of almost daily occurrence. The decomposed urine alone, however, produced witiiout the overdistention or without the abrasion would not have occasioned a true acute cystitis, but might possibly by slow gradations have worked up a subacute cystitis. The rule, if it may be called such, is the one that I have already given — viz., that some abnormality of the urinary organs (as catarrh) almost invariably precedes urinary de- composition. 3. Inflammation of Adjacent Organs. — Acute cystitis may arise from the exten^^ion of inflammation from neighboring organs, as in vaginitis, metritis, uterine and vaginal cancer, extra-uterine pregnancy, abscesses of the colon or other organs opening into the bladder, pelvic peritonitis, cellulitis, etc. Gpnorrhfjeal inflammation of the urethra may extend to the bladder. As gonorrhoea of the female urethra is comparatively rare, such an extension is seldom seen. When it does invade the urethra, it is very apt also to extend to the bladder, and is very severe. Inflammation of the renal pelves and ureters may extend to this organ, and cause cystitis, the usual course, how- ever, being from the bladder to the ureters and the kidneys. 4. Certain diseases of the general system affect the bladder, such as the eruptive fevers. In scarlet fever, and measles especially, I have noticed that the mucous membrane of the bladder suffers, to some extent, like the mucous and tegumentary tissues elsewhere. Diseases of the heart and liver act more as predisposing causes, by producing chronic vesical congestion, than as exciting causes, and when they do produce cystitis it is usually of a low chronic type. Old age, when the has fond is greatly deepened, acts more as a pre- disposing cause, by allowing the collection and decomposition of urine. Paraplegia and other affections of like nature, by allowing overdistention and decomposition, as a rule, produce cystitis, but of a low form. 5. Drugs, Improper Foods, and the Virus of Gonorrhoea. — Of all drugs, cantharides is undoubtedly the most active in producing tnie acute cystitis. In many cases it produces simple irritation and hy- persemia, stopping short of actual inflammation. Arsenic and tur- pentine also produce irritation and active hyperaemia, but seldom if ever go further. Alcoholic beverages persisted in for a length of time act more as predisposing than as exciting causes. They may, however, produce a low grade of cystitis, or, like the medicines given above, light up an acute process in an already diseased vesical membrane. Dr. A. ORGANIC DISEASES OF THE BLADDER. Y35 Jacobi has seen aggravated cases of cystitis caused by tlie free and long-contiiuicd use of large doses of the chlorate of potassa. The various foods can not produce acute cystitis in a healthy bladder, but may aggravate an already diseased condition. The prohibition, th(!refore, of stimulating condiments, alcohol, asparagus, and onions, in these diseases will at once suggest itself. I have al- ready spoken of gonorrhoea as a cause of cystitis, and need not dwell on it here. M. Eugene Monod (" Annales de Gynecol.," May, 1880), in dis- cussing the question of cystitis, presents the following conclusions : 1. The urinary symptoms incident to pregnancy proceed from two dilferent causes, to each of wliich there corresponds a distinct clinical group of symptoms. The first group receives its ex- planation from the pressure produced by the gravid uterus, which leads to retention of urine. The second is caused by vesical con- gestion which results from the predisposition of the bladder to in- flammation, owing to its close vascular connection with the uterus. 2. During the first weeks of utero-gestation, there may occur a variety of acute cystitis which is unquestionably caused by the de- velopment of pregnancy. 3. Immediately after, or during the first weeks following nor- mal delivery, there may arise a variety of cystitis which, owing to the time of its appearance, deserves to be called post-puerperal cys- titis. 4. The anatomical relations between uterus and bladder, as well as their vascular interconnections, account for the frequency of ves- ical disorders accompanying many uterine maladies. Certain phys- iological changes of the bladder during menstruation, and at the time of the menopause, also influence the establishment of bladder troubles. Thus there is seen to exist a whole class of vesical in- flammations belonging only to women, and, contrary to the gener- ally accepted opinion, cystitis is by no means rare in women. CHAPTER XLI. ORaANIC DISEASES OF THE BLADDER (cONTINUEd). TREATMENT OF CYSTITIS — CROUPOUS AND DIPHTHERITIC CYSTITIS— CYSTITIS WITH EPIDERMOID CONCRETIONS. Cystitis requires both local and constitutional treatment, and withal it is a troublesome disease to manage, especially in its chronic form. The constitutional treatment consists, first of all, in so regu- lating the character of the urine that it shall be unirritating to the diseased organ. Pain and vesical tenesmus should be relieved if possible. The skin should be kept in a healthy and active condi- tion and the bowels regular and free, in order to prevent all strain- ing at stool and secure free action of the portal circulation. Free elimination by the skin and bowels will give the kidneys and blad- der less to do. To overcome existing constipation, saline laxatives should be used. A glass of purgative mineral water, given an hour before breakfast, answers very well in most cases. Cold-water ene- mata are advised by good authorities. Winckel recommends the use of saline laxatives, pushed to a point where intestinal hypersemia is produced and maintained for a time. He believes that the blood may, in this manner, be to a cer- tain extent diverted from the bladder ; and I am of the belief that the practice is a sound one. A case of my own is of interest as showing the benefit effected (supposably) in this way. A lady had catarrh of the bladder of some months' standing, which I had been treating in the usual way, with only slight benefit. She was one day attacked with cholera morbus with serous purging and vomiting, the former almost as severe as that of Asiatic cholera. The efi^ect, for a time was to almost suspend the action of the kidneys. AVhen she recovered, she was delighted to find that her cystitis had left her. Among the conditions which produce irritating urine, and hence tend to produce cystitis or to aggravate it if it already exists, are malnutrition from any cause and the strumous, gouty, and rheu- matic diatheses. When either of these is present it should be ORGANIC DISEASES OF THE BLADDER. 737 treated for the general good of the patient and the indirect effect upon the bhidder. The diet of natients suffering from this disease must be care- fully regulated. Milk will be found to agree excellently in most cases. In the hands of Dr. George Johnson, of England, an exclu- sive milk diet has cured several cases, some of great severity and long standing. He says : " The milk may be taken cold or tepid and not more than a pint at a time, lest a large mass of curd, difficult of digestion, form and collect in the stomach. Some adults will take as much as a gallon in the twenty-four hours. With some persons the milk is found to agree better after it has been boiled, and then taken either cold or tepid. If the milk be rich in cream, and if the cream disa- gree, causing heartburn, headache, diarrhoea, or the symptoms of dyspepsia, the cream may be partially removed by skimming. Constipation, which is one of the most frequent and troublesome re- sults of an exclusively milk diet, is to some extent obviated by the cream in the unskimmed milk. When the vesical irritation and ca- tai-rh have passed away, solid food may be combined with the milk, and a gradual return made to the ordinary diet." I have tried this method of treatment in several instances with decided benefit. I may briefly state that the bill of fare usually given consists largely of fluid foods, as milk, yolk of egg, soups, and beef essence. Lean meat in small amount, and other solid or semi-solid foods that are easily digested and nutritious, may also be allowed. The cause, whatever it may be, should be removed, if possible ; and the reme- dies must be adapted to the stage and condition of the inflammation. In the acute stage aggravated by exposure to cold, diaphoretics should be freely used, and the patient made to rest as quietly as pos- sible. Diuretics should be given if the urine is loaded with solid material, and the alkaline salts are to be preferred. Vichy water or flaxseed tea with citrate or nitrate of potash, will answer very well at the beginning of the treatment. In using such salines, it serves admirably to give them in an infusion of buchu in case the patient's stomach does not rebel at the taste of it. This of itself is a most valuable remedy in almost all bladder affections. Care must be taken, however, not to push diuretics too far. Sufliciont to bring the urine to its normal proportions, and make it slightly alkaline if naturally acid, is all that is required. In the early stages of acute cystitis, as well as in irritable blad- der, Sidney Einger and other authorities strongly commend the use 48 738 DISEASES OF WOMEN. of minim doses of tincture of cantharides repeated every hour, and even oftener, but I have not seen very good effects from its use in cystitis. One or two leeches to the anterior vaginal wall may be tried, and hot applications to the epigastrium in acute cases. To relieve pain, opium is indicated. Dover's powder is very valuable, and may be given with ordinary doses of camphor. If there is any ol)- jection to anodynes given in this way, or if there is sympathetic rectal tenesmus, suppositories of morphia and belladonna should be used. While I have said that opium may be used at the onset of acute cases, and to relieve the suffering in old eases that can not be cured, I must impress upon the mind the great harm that may come from the injudicious use of this drug in cystitis. It deranges the digestive organs and the secretions generally, especially that of the kidneys ; and, by changing the quantitative composition of the urine, renders it irritating to the bladder. In some cases, where frequent urination and tenesmus are very severe, owing to excessive nervous irritability, twenty-grain doses of the bromide of potassium, every four hours until relieved, act very nicely ; indeed, this succeeds in cases where opiates fail entirely. Recently I have used hydrobromic acid and find that it acts even better than the bromide of potassium in some cases. The comparatively new drug, eucalyptus globulus, is worthy of a trial in obstinate cases. From its well-marked benetieial action in albuminuria and other affections of the urinary tract. Dr. AV. Ander- son was led to try it in cystitis, and he reports it as decidedly useful. Dr. J. J. Mulheron, of Detroit, gives it in doses of twenty minims in subacute cystitis with good results. As this remedy has tonic, antiperiodic, and antiseptic properties, it might be especially suit- able in malarious districts. An infusion for injection in cases where the urine was decomposed, would most probably give good results. Benzoic acid is perhaps the drug that would be found most use- ful in the largest number of cases. It often seems to act like a spe- cific, giving speedy and permanent relief. It may be given in about ten-grain doses, in infusion of buchu, three or four times a day. As the acid is sparingly soluble in cold water, an equal proportion of borax may be added to the mixture. To insure a perfect solution, one may prescribe the l)enzoate of ammonia, which in the same dose acts admirably, and is more palatable. In the more advanced stages of the disease remedies are used for their direct effect upon the mucous membrane, and much good is ORGANIC DISEASES OF THE BLADDER. 739 obtained in this way. The drags which have tlie best reputation in urethritis are employed in cystitis. Balsam of Peru and of copaiba, oil of turpentine, and tar-water are the most important of this class, and should be given in capsules in the same way as for gonorrhoea. Oil of sandal-wood is also valuable in chronic cases. When the pain is not severe, and the urine is loaded with mucus and pus, astringents should be given. Tannin continued for a con- siderable time is of very great value. Decoction of uva ursi, in half-ounce doses, may also be used for this purpose. In place of these, I have employed, witli occasional good effect, a mixture com- posed of two ounces fluid extract of buchu, one ounce tincture of conium, and one grain and a half sulphate of morphia, giving tea- spoonful doses every three or four hours. When pain is not severe, the morphine should be omitted. Dr. B. A. Segur, of this city, has used salicylate of soda in puru- lent cystitis, and found that the quantity of pus in the urine rapidly decreased under the use of this remedy. Dr. Sansom, of London, found that the administration of carbolic acid and the sulpho-carbolates to animals prevented the decomposi- tion of urine, although he could not detect any of the salt in the secretion. He gave the sulpho-carbolates, and afterward collected and preserved the urine, which after six months had not decomposed. This fact should be kept in mind, and turned to account in cases where there is a tendency to decomposition from retention or other causes. An English physician reports, in the " Canadian Practitioner," that he has met with no case of offensive urine (intestinal -vesical fistula excepted) that ten or twenty grains of boracic acid given every three hours would not cure. All these remedies may be tried in cases that are seen early ; but, when they fail, or when the acute stage of the trouble is long past before advice is sought, then local treatment must be employed. The bladder should be washed out, and medicated injections used. This every surgeon will feel com- petent to do, no doubt, but I must give some general directions as to the methods of manipulating, as I feel assured that much of the good which ought to come from this kind of treatment is lost, and harm done instead, by not clearly knowing how to perform this op- eration, which I consider both difiicult and very important. There are certain rules which ought to be carefully obsei'ved in washing out the bladder. The catheter should be sufficiently soft and flexible to be incapable of injuring the bladder or urethra ; it should be surgically clean ; the bladder should be emptied slowly, 740 DISEASES OF WOMEN. especially when withdrawing the last of its contents, otherwise the bladder will contract abruptly upon the catheter, and be injured thereby ; instillations should be made very slowly (the bladder can not be rapidly distended without injury), and the quantity used should not be more than the patient can tolerate without ])ain. An ounce is sufficient, and much less will suffice if more gives pain. When the quantity which can be borne is determined, the instillation and withdrawal of that quantity can be repeated until the desired effect is obtained. By carefully following these i*ules, the possible benefit of local treatment can be obtained. Neglect of these will certainly bring disfavor upon the method. Some years ago I employed a rather complicated arrangement for washing out the bladder, consisting of a reiiux catheter with a fountain attachment. It was the best that I could lind at that time, but I have long ago discarded it for a sim- pler and much better instniment. I use now a soft-rubl)er catheter, having attached to it a piece of rubber tubing, these being joined by a piece of glass tubing, the whole being about two feet in length. A small glass funnel is introduced into the end of the rubber tube, and this completes the instru- ment (Fig. 229). This is used as a cathe- ter to empty the bladder of urine, and then, leav- ing it still in place, the washing out is accom- plished by pouring the so- lution to be used into the funnel, and raising it high enougli to make it floAV into the bladder. The funnel is then lowered to permit the fluid to escape, and the process is repeated as often as may be necessary. Any desired quantity of fluid can be instilled into the bladder at any degree of pressure that may be necessary for the comfort of the patient, and the fluid can be drawn off slowly or rap- idly by elevating or depressing the funnel. It is very important not to let air enter the bladder, and this can be accomplished by letting the patient retain a few drachms of urine before beginning the treatment. When the catheter is introduced, and the urine in the bladder drawn off", enough of the urine will remain in the catheter to fill it, and, by filling the funnel before elevating, the fluid used will Fountain-sjTinge for washing bladder. ORGANIC DISEASES OF TOE BLADDER. 741 meet the urine in the catheter and exchide the air. In case the blad- der is empty, the catheter should be hlled before introducing it into the urethra, and tlie air will be exchided in that way. When once the process of washing is begun, the exclusion of air is easily man- aged by regulating the elevations and depressions of the funnel, so that the catheter and tube will be kept full all the time. This instrument fulfills all the indications perfectly, and very little practice is necessary to enable one to use it with facility. When the bladder has been thoroughly cleansed in this way of all inflam- matory products, medicated applications may be made in the same manner. The quantity of fluid instilled, the length of time it is left in the bladder, and the time occupied in making the instillation and withdrawing it can all be regulated according to the will of the sur- geon and the toleration of the patient. Much care should be taken in lubricating the catheter so that it can be introduced readily. Oil has been used for this purpose, and I believe that some surgeons use it still. Castile soap and water or vaseline answers much better. The oil decomposes, and renders the catheter unclean unless great care is taken to wash and disinfect the instrument very thoroughly. In fact, it is hardly possible to keep a catheter clean for any length of time if oil is used as a lubri- cant. Yaseline is best, and, if that is not at hand, then soajD will an- swer. Cleansing the catheter after use requires more than a passing notice. I have found that if a soft-rubber catheter is simply washed after use in the ordinary way — i.e., by washing it off with warm water, and then rinsing it in a mild solution of carbolic acid — say five per cent — it becomes very foul. A catheter used in that way for a few days will be found swarming with bacteria on the inside. Such an instrument is dangerous, and should never be used. In my private hospital each patient has a catheter for herself alone, and, when she is through with it, it is destroyed. After each time that a catheter is used it is well washed in hot water, and then kept in a ten-per-cent solution of carbolic acid, and once in every twenty-four hours it is kept for fifteen or twenty minutes in boiling water. With all this care the catheter can be kept clean and safe for use. Simply washing out the bladder is often beneficial, and ought to be repeated frequently. It should always be done before using any medicated apj^lication. Warm water alone is usually employed, but the addition of chlorate of potash or common salt makes it less u'ri- tating to the bladder. I prefer borax or common table-salt, using about sixty grains to the pint of water. It is generally conceded that salt and water are more acceptable to serous and mucous mem- 742 DISEASES OF WOMEN. branes than any other fluid, because more like the normal secretion of these parts ; but I have not found it any better, if as good, as borax, When there is ulceration or suppuration, carbolic acid and water make a most valuable wash. A drop to the drachm or there- about is the proper propoi-tion. Having prepared the bladder for local applications by carefully washing it out, the material to be used may be selected from a long list of remedies. I shall mention only a few — those which I believe to be the most valuable. I need hardly say that anodynes have been tried most faithfully. The painful character of the disease suggests their use, but they are neither reliable nor very eifectual. The mucous membrane of the bladder is not intended to absorb, and, therefore, very little of the anodyne effect of opium, or any of its preparations, is obtained when injected, even when the dose is very large. Should there be ulceration, then the local and constitutional effects of morphia will be produced by absorption. Braxton Hicks uses one or two grains of morphia to the ounce of water as an in- jection, allowing the patient to retain it as long as possible, and claims good results from its use. Remedies which produce local ansesthesia do relieve the pain to some extent, but not altogether, by any anodyne action, such as we get from opium given by the mouth or rectum. Cocaine relieves the pain for a short time, but not long. Its chief value is to benumb the parts so that curative applications may be more easily made. In some cases it acts as an irritant. Chloral hydrate is recommended to relieve the pain. I have used it in solution, ten to fifteen grains to an ounce of water, and found benefit from it. The astringent and alterative injections most beneficial and most commonly used are nitrate of silver, sulphate of zinc, tannic acid, and acetate of lead. My rule is to use one or two grains of either to the ounce of warm water, and to increase the quantity if no good effect comes from the small doses, but to carefully avoid injections strong enough to cause much pain. Chlorate of potash is valuable, and perchloride of iron is said to be useful. Infusion of hydrastis Canadensis has been used, and great virtue is claimed for it. I have tried it, and believe that it acts well in some cases, but still it fails, like the rest, in others. When the urine is alkaline and offensive from long retention, which is occasionally the case in prolapsus of the bladder, then nitro-hydrochloric acid, of the strength of two minims to the ounce of water, should be used. Whenever pain is caused by any of these astringent injections, morphia should be used afterward, as directed by Braxton Hicks. ORGANIC DISExVSES OF THE BLADDER. 743 In obstinate cases a strong solution of nitrate of silver is one of the most reliable remedies. Twenty grains to the ounce of water has been used with great benefit, and it does not cause as much pain as might be supposed. Very small quantities only can l)e used at a time — not more than iive or ten drops. The only trouble which I have experienced is in being sure of injecting that small quantity and no more. My favorite method of making such applications to the interior of the bladder is by instillation, as it is called. 1 take a glass tube of the size and shape of a No. 8 or 9 male sound, with a small rubber bulb attached to the straight end. The curved point is introduced into the solution to be used, the bulb is compressed by the thumb and finger, and then relaxed, which draws up the desired amount. The tube is then carried into the bladder, and, by . Fig. 230.— Instillation tube. again compressmg the bulb, the fluid is easily deposited in the organ (Fig. 230). If a larger quantity is to be used, it can be introduced through the instrument used for washing out the bladder. In fact, I seldom use the pipette now except for medicating the urethra. There is one rule that should be followed in using nitrate of sil- ver in the treatment of cystitis, which is this : If a strong solution is used, only a few^ drops should be employed, and, if a large injec- tion is made, the solution should be mild. I am indebted to Prof. John W. S. Gouley for this valuable guide in the use of this remedy. Normal urine has been highly recommended as an injection in cystitis. The urine from a healthy person is obtained and used in the same way as the other injections described. I have always looked upon this treatment with a little suspicion. It may be of value in cases where from some derangement of the general system the urine secreted is abnormal, and therefore irritating to the bladder, and where constitutional treatment can not remove that condition. When the urine secreted can be kept in a normal state, it must, it seems to me, be as acceptable to the bladder as the same kind of urine from another person. Theoretically, one would expect that healthy urine poured into the bladder from the kidneys would be more likely to cm*e cystitis than if it were injected through the urethra. However, this method may be of value ; but one thing is certain — it fails like all other injections in certain cases. Iodoform has been used locally in cystitis, and with good effect ; but I regret to say that I have not used it enough to test its merits fully. 744: DISEASES OF WOMEN. One great obstacle often met with in using instillations is a ten- der or inflamed urethra. This difficulty 1 have recently been able to overcome by using cocaine. It is appHed as follows : I take a pipette like the one described above but larger, fill it with cocaine solution, and introducing the tapering part of it into the meatus, force the solution along the urethra and into the bladder. This often makes the rest of the treatment easy. Another direct method of treating the bladder has been employed by Dr. Robert Xewuian, of New York, w'ho has made some useful contributions to the therapeutics of vesical disease. He employs the endoscope of Desormeaux to make the diagnosis, and makes direct applications to the diseased parts through that instrument. In ulceration, he has been very successful in his practice. He applies a solution of the nitrate of silver (twenty grains to the drachm of water) to the ulcerated surface, and by carefully regulating the amount, finds that the pain is less than when a weaker solution is used in the ordinary way. I have done the same thing with greater facility by using the endoscope which I have described. The in- strument is introduced, and the ulcerated part found ; the glass tube is drawn out, and the application made directly to the diseased part, through the rubber speculum. Forcible and extreme dilatation of the urethra has been advocated in the treatment of cystitis by many surgeons otherwise well informed. Within the past few j'ears the medical journals have contained the histories of many cases of cys- titis said to have been cured by this operation. This is all quite er- roneous. Cystitis can no more be cured by dilating the urethra than could a gastritis be cured by dilating the sphincter aui. It is a fact that if the urethra be destroyed by overdistention, inconti- nence will follow, and the perfect drainage of the bladder may cure the inflammation ; but verily the cure is worse than the disease. I am sure that the mistake in regard to the value of this operation in cystitis comes from its having been practiced in cases of acute cystitis which would have ended in recovery without any sur- gical treatment, and again in cases of inflammation of the upper third of the urethra which have been mistaken for cystitis. On the one hand the operation gets the credit of curing a disease which cured itself, and on the other of curing a disease which did not ex- ist. It will be observed that in the cases which I give at the close of this section, the urethra was dilated with no benefit, and to these I could add many others which were treated in the same way with a like result. All the means of treatment yet described will fail in some of the ORGANIC DISEASES OF THE BLADDER. 745 worst cases of chronic cystitis. Indeed, this has led to the last re- sort, as I look upon it, namely, cystotomy for the establishment of vesico-vaginal fistula to drain the bladder and set it at rest. The perfect rest obtained by the urine flowing out through the fistula as soon as it enters from the ureters places the inflamed surfaces in a condition to recover, and the patient is relieved from the constant pain and the torments of urinating every few minutes night and day. This is certainly a great triumph, and is especially applicable in cases that are incurable by all other means. Indeed, it is adapted to cases which are incurable by this operation, because it gives relief from pain, and makes the last days of an incurable sufferer tolerable. Dr. Willard Parker, I believe, was the first to do cystotomy for the cure of cystitis in the male, and Dr. T. A. Emmet adopted the operation, and has practiced it extensively among his female patients. In fact, he has become a zealous advocate of this method of treating cystitis. In his book on gynecology, in speaking of cystitis in women, he says that our management of this affection is limited to one procedure, and that is vaginal cystotomy. Such a dogmatical statement is quite in opposition to facts well known to many in the profession. Drainage by vesico-vaginal fist- ula is neither the surest, safest, nor simplest method of treating cys- titis in women, but only one method to be employed in those rare cases which do not yield readily to other means. While writing on this subject some years ago, I obtained from one of the resident surgeons of the Woman's Hospital the statement that cystotomy was performed for the relief of cystitis on seventeen cases in that institution, and that four were cured and thirteen im- proved. This shows about twenty-four per cent of recoveries, and this I stated in my book on " Diseases of the Bladder." Dr. Em- met in his book on gynecology objects to this statement of mine as not being in accordance with a published report of the Woman's Hospital. The report referred to was not published at the time that I prepared my manuscript, nor did I see it until after my book was published. I presumed that the interne of the hospital gave me a correct report, but be that as it may. Dr. Emmet's own statistics (as given in his book, page 788) of the hospital practice are less favor- able to cystotomy for the cure of cystitis than those quoted by me. They show but about twenty per cent of recoveries, whei-eas my statement obtained from the interne was twenty-four per cent. This shows that if I made a mistake it was in favor of the operation ; or else if I was correctly informed of the results of that operation at 74G DISEASES OF WOMEN. that time, then the subsequent hospital experience of Dr. Emmet has been more unsatisfactory. Dr. Emmet's method of making the fistulous opening is by dividing the vesico- vaginal septum with the scissors, and then introducing a glass tube to keep the opening from closing. This is the most difficult way of operating and the most painful to the patient afterward. The wearing of this tube has been a torture to those that I have seen u-sing it. There are two other methods of operating. One is to make the opening, and then stitch the mucous membrane of the bladder to the raucous membrane of the vagina, thus preventing the closing of the opening, and at the same time enabling the edges of the wound to heal in a short time, a great gain in itself. The other method is to make the opening with the galvano- or thermo-cau- tery. Dr. M. A. Fallen was the first to operate with the thermo- cautery. This is what he savs about it : " The main difficulty hitherto has been to keep the incision open after the use of the scissors or knife. Artificial means must be resorted to, such as an India-rubber tube passed from the urethra through the opening, which is annoying and painful ; or a glass button introduced, which is difficult to retain, and when retained is apt to beget vesical tenesmus. I believe that the use of the actual cautery at a red heat will be found to answer all purposes. If the platinum tip is at a white heat it cuts through too rapidly, and we are apt to have as much haemorrhage as with the knife or scissors. Haemorrhage is sometimes quite serious after incision of the vesico-vaginal septum, particularly if the scissors or knife strike the tortuous, enlarged veins, often ramifying upon or under the mucous membrane of the bladder. If the platinum tip of the cautery be heated to a white heat, it cuts through as rapidly as the knife, and therefore the haemorrhage is to be expected ; besides, the thin pellicle of slough following the white-heat tip soon peels ofi, and union might ensue. To avoid both bleeding and contraction, the red-heat tip should be slowly passed along the site of the proposed opening, dividing first the mucous membrane of tlie vagina, and then resting for a moment or so to allow the adjacent vessels to contract and become throm- botic. The submucous connective tissue is then burned, and after- ward the bladder-wall itself. Extreme delicacy of manipulation is required upon the part of the surgeon, lest he burn directly into the cavity of the bladder, which should be avoided if he wants to make sure of a result that will prevent hgemorrhage, contraction, and subsequent union. '• The care after an operation of this kind consists in daily cleans- ORGANIC DISEASES OF THE BLADDER. 747 ing the bladder thoroughly with demulcent warm fluids, such as starch or flaxseed water. The pain in the bladder following the burning is comparatively slight, and usually subsides within thirty-six or forty-eight hours." Dr. John Byrne, of Brooklyn, operates in a very easy and satis- factory manner. He has a forceps, one blade of which is intro- duced into the bladder and the other into the vagina to grasp the vesico-vaginal septum. The blade in the vagina is fenestrated and the blade in the bladder is grooved. The thermocautery knife is introduced through the fenestrum of the forceps and the septum is divided, the knife being guided by the forceps. This method makes the operation simple and easy, and the after treatment is also greatly simjDlified, One serious drawback to cystotomy is the incontinence which keeps the patient in such an uncomfortable state by the constant trickling of urine from the fistula, I tried to obviate this trouble to some extent by using a hollow-globe pessary, made of hard rub- ber, with a tube attached to it. The globe is perforated with nu- merous small holes all around, except for about half an inch from where the tube begins. The globe is introduced into the vagina, and the tube projects through the introitus. The urine collects in the globe, and escapes through the tube ; and by attaching a piece of flexible tubing to it the urine can be conveyed into a vessel. When the introitus vulvae is small and the sphincter vaginae perfect, this answers very well, especially during the night, when the patient is in the horizontal position. When worn during the day, it is ne- cessary to have a rubber bag attached to the leg of the patient to act as a receptacle. Encouraged by my success with the globe-pessaiy, I had another made, shown in Fig. 231. It is the ordinary Smith's pessary, with an oblong cup on the upper anterior portion of it, which ^- fits over the fistula, and collects the urine and guides it out to a urinal. In artificial fistula, made in the center of the va- gina, this pessary answers a , 111 Fig. 231. — Skene's urinal cup-pessary, a, rep- most valuable purpose. ^ ^^^^^^^ ^^^ p„,terior portion winch sur- I was led to devise this rounds the cervix uteri ; 6, the cup ; and c, <•■!'• . • . 'J.! the tube which conveys the urine from the way of rehevmg patients with ^„p ^^ ,,,, ^„.i„^, vesico-vaginal fistulas by hav- ing one under my care who was in no condition to be operated on 748 DISEASES OF WOMEN. for the cure of fistula, owing to general ill-health. She also had severe vulvitis, and the urine constantly passing over the iriHamed surface drove her almost insane. Her suffering was terrible ; so to relieve her until I could operate I had made the perforated stem globe-pessary, or whatever one may see tit to call it. I come now to what I believe to be another important part of the treatment of these obstinate cases. I allude to drainage by means of the self-retaining catheter. Years ago I had a very trou- blesome case of cystitis, which I faithfully tried to relieve by all the means at my command, but without success. My patient was obliged to urinate every fifteen or twenty minutes, day and night, and the pain and want of rest were fast wearing her out. In the hope of securing rest at night I introduced a Situs's self-retaining cathet2r with a rubber tube attached, to convey the water to the urinal. The result was very gratifying. She could sleep well, and gained in health and strength rapidly, and the cystitis gradually improved. Since that time I have resorted to drainage by catheter in cases which resisted the ordinary treatment. A description of this plan of treatment will be found in the " Proceedings of the New York Obstetrical Society," recorded in the "American Join*nal of Obstetrics," for February, 1874. This method has been successfully practiced by Hunter McGuire, a com- plete history of his case being published in the " Richmond and Louisville Medical Journal " for June, 1874. Dr. McGuire took a piece of tubing about tw^elve inches long, and made holes in about four inclies of the end of it with a shoemaker's punch. He passed a silver tube into the bladder, and then pushed the gum tube through it until the perforated four inches were coiled in the bladder. This was retained in place by tapes fixed to the tube and to a bandage passed around the patient's body. The tube became obstructed by mucus, but was easily cleared by injecting warm water thi'ough it. But this long piece of tubing being frequently expelled by the blad- der, the doctor tried a shorter piece, and found it was more readily retained. The patient after a time went about and attended to her household duties while wearing the tube, and in about four mouths made a perfect recovery. This method of drainage is an improvement on Sims's catheter, but still is not all that we require. Since my first case I have found that a good self -retaining catheter for this purpose is Holt's, made of perfectly flexible rubber, and, in place of an eye in the point, is cut into strips near the end, and made to spread out like an umbrella (Fig. 232). ORGANIC DISEASES OF THE BLADDER. 749 Another instrument for drainage is a catheter devised by Prof. Goodman, and described in the " Richmond and Louisville Medical Journal," for February, 1S69, as being used in the treatment of vesico-vaginal fistula, and I have recently learned that he has used it for years in treating cystitis. The following is Dr. Good- man's description of his cath- eter : '' It is about two inches in length, and bent to cor- respond to the curvature of the nrethra ; at the lower or ^i«- 232.— Holt's catheter, with its modification, external end there is a button ten sixteenths of an inch in diameter, and at the other, or external, end a shouldered, cup-shaped expan- sion, varying from five sixteenths to seven sixteenths of an inch in diameter, and beveled on the convex aspect of the instrument, in order to make it easier of introduction, and perforated with a num- ber of small holes. The stem, intervening between these two por- tions, is one and one half inch in length, a quarter of an inch in diameter, with as large a bore as is compatible with the requisite strength. This catheter is self-retaining in all positions of the pa- tient ; first, by reason of the bulb at its upper extremity, which passes beyond the urethra into the bladder ; second, on account of its curved shape ; and third, in consequence of the button being overlapped and grasped, as it were, by the vulva. At the lower end there is a slight projection, or knob, over which an India-rubber tube may be slipped, this being inserted into a bottle at night, or into a urinal when the patient is up ; her person may thus be kept per- fectly clean." I like this instrument for the purpose of draining the bladder, when the j)atient can tolerate it; but I believe that the sharp point of the conical end which rests in the bladder is objec- tionable, and I can see no good reason for having it so. I had the point made larger and I'ounder (Fig. 223), and found that it answered certainly as well, and was easier to introduce. In drainage by any method it must be remembered that the instrument should be frequently removed and cleaned, and the bladder occasionally be washed out at the same time. Fig. 233. — Skene's modification of Goodman's self-retaiuinc; catheter. 750 DISEASES OF WOMENT. Fortunate it is that we have this method of treatment now at our command. By this means we can restore to health and comfort many of those cases which luive hitherto been considered hopeless. I believe tliat a normal condition of the urethra is a prerequisite to drainage. When there is tenderness of the urethra, the patient can not tolerate the catheter ; this form of treatment would be more popular if this point had not been overlooked. Where there is haemoiTliage into the bladder, the rules already given are to be followed. In cases of exfoliation of the whole or a part of the mucous mem- brane of the bladder, and the organ is evidently trying to expel its contents, the urethra should be sufficiently dilated to allow the mass to pass, or it may be removed by the forceps, if this can be done without force. After its extraction antiseptic and disinfectant meas- ures should be resorted to. Injections of lime-water, Aveak solutions of carbolic acid or salicylic acid should be used, and the organ washed out once or twice daily with warm water. Above all, mine should not be permitted to remain in the tender organ for any length of time. In passing the catheter, especially in cases where the bladder is bound to neighboring organs, care should be taken to let no air enter, for Winckel has seen vesical catarrh follow its introduction, and makes it a point, even after using Rutenberg's apparatus, to wash out the organ with some antiseptic. Prognosis. — In acute cystitis occurring in a healthy subject the outlook is good, recovery being usually attained in from one to three weeks. When occm'ring in the course of pregnancy, or after de- livery, the prognosis is not so good, there being a tendency for the diseasB to become chronic, and, even if cured, it leaves a weak state of the organ afterward. The prognosis in diphtheritic and croupous cystitis depends mainly on the systemic disorder, and is, therefore, grave. AVhen due to displacements of the gravid uterus, the prognosis will, of course, depend on the abihty to replace the womb. In can- cer of the womb, vagina, anterior vaginal wall, or of the bladder it- self, the prognosis is the same as in malignant disease generally. In chronic cystitis, with ulceration, the prognosis is very serious ; for, with the tendency to haemorrhage, extension to the peritonaeum, perforation, blood-poisoning, with low systemic condition, extension to the renal pelves, and destruction of one or both kidneys, a fatal termination comes sooner or later, and may come when we least expect it. ORGANIC DISEASES OF THE BLADDER. T51 About one half of the cases of exfoliation of the vesical mucous membrane have recovered. Gangrenous inflammation, involving, as it usually does, all the coats of the bladder, is tlie most speedily and certainly fatal of all the forms of cystitis. Hygiene. — There are certain points to be considered in the man- agement of all cases where, from certain circumstances, vesical dis- ease is to be expected, and also where it already exists. In pregnant women, where the pelvic organs are constantly tend- ing to congestion, attention should be given to the patient's circula- tion ; friction to the legs, feet, and arms ; daily warm baths ; mod- erate exercise, alternated with periods of rest in the recumbent position, and astringent or saline vaginal injections should be em- ployed. Upon the least suspicion of malposition of the uteras, that organ should be examined, and, if malposed, replaced. The diet should be bland and unirritating, yet nourishing, and any indigestion corrected as speedily as possible. An occasional saline laxative will prove of use when there is constipation. Tonics will be found serv- iceable in some instances. In women not pregnant, where there is a tendency to vesical dis- ease, the same plan should be followed, with the addition of injec- tions of water, as hot as can be borne, into the vagina every night, as recommended by Dr. Emmet, l^ot less than a gallon should be used. Where from any cause retention exists, or there is a tendency thereto, the urine should be drawn carefully with a soft catheter, well soaped, being sure that the catheter is perfectly clean, and that no air is permitted to enter the viscus for the reasons already given. Winckel believes that in every institution for lying-in women each patient should either have a new catheter assigned to her, or one rendered absolutely clean by some efficient chemical process. * To the enforcement of this rule Winckel attributes the great exemption from vesical inflammation enjoyed by the patients in the Dresden House for Child-bearing Women, I must fully indorse the teaching of this great authority. I have seen so much bladder trouble brought on by the careless use of foul catheters that I have come to look upon clumsy operators and un- clean instruments as the most common causes of cystitis. In weakness of the detrusor vesicae (which is not an uncommon affection in pregnant women), Winckel has achieved great success with injections of simple warm or medicated water into the bladder. In irritable bladder, -sWth a tendency to congestion, a solution of borax may be injected with good results. Every woman, even at the risk of disturbing company or neglect- 752 DISEASES OF WOMEN". iug important duties, should evacuate the bladder regularly, and never long resist the desire to urinate. ILLUSTKATTVE CASES. Chronic Cystitis with Intermittent Drainage ; Death from Perfora- tion of the Bladder. — The patient was under my care fi-oiii xS ovember 0, 18G9, to February 10, 1870, while suffering from a (cystitis, which began after one of her confinements several years before. At that time she had a. well-marked cystitis of the punilent variety. She was treated by injections — the method in vogue at that time — with some benefit. I also employed drainage part of the time by intro- ducing a catheter in the evening, and letting it remain all night. This gave her great relief, and permitted her to sleep — a blessing which she had not enjoyed for sev^eral years. She was improving in her general health, although her local disease remained about the same, or at least only a little improved. She expected to return for further treatment, but, her husband becoming paralyzed, she was obliged to give up the care of herself to look after her family. From that time up to July, 1882, she continued to suffer tortures during the day, while she was obliged to be up and around attending to her household duties. At night she obtained relief by wearing tlie cath- eter, which she had continued to use ever since she was taught to do so, twelve years before. Her sufferings were almost beyond descrip- tion, but, having an iron constitution and extraordinary will-power, she managed to live until the summer of 1882. During June and July of that year she failed more rapidly. Having heard of dilata- tion of the urethra as a cure for cystitis, she urged her physician to try that operation. He did so, and repeated the operation one week later. The only effect of this treatment (as stated in the notes of her history, which I obtained) was to reduce the number of evacua- tions from one hundred and sixty to one hundred in twenty-four hours. Her physician then injected her bladder in the hope of re- lieving the inflauimation and also overcoming the contraction, which was very marked. Immediately after the first and only injection she was seized with violent abdominal pains, and rapidly developed a peritonitis, which proved fatal on the second day. On post-mortem it was found that the bladder was adherent to all the viscera around it, the result, no doubt, of a former pericys- titis. Upon the posterior wall of the bladder, and directly opposite the urethra, there was a nipple-like projection outward, with an opening at its apex large enough to admit a lead-pencil. This pro- tuberance had been produced by the long use of the hard catheter. ORGANIC DISEASES OF THE BLADDER. Y53 The instrument liad worn tliroiigh the inner walls of the bladder until the parts had become less resistant ; it then pushed the remain- ing muscular tissue and peritonsenm outward, and formed the nipple- like projection. At the time of the fatal attack, the catheter had made its way through all the coats of the bladder except the thick- ened peritonaeum. The rupture of the peritonaeum was caused by the injection. That was the belief of the physician in attendance, and the history points definitely to the same conclusion. The blad- der was firmly contracted and in distensible ; its retaining capacity did not exceed half an ounce. The muscular wall was over half an inch thick ; the mucous membrane was entirely destroyed by the inflammation. Purulent Cystitis; Recovery after Two Years' Treatment. — This patient was a lady possessing a remarkably good organization. She was married, and had one child. Her age was thirty when her illness began. While riding horseback she was thrown off, and sustained some apparently slight injuries. Her health up to this time had been very good, but from the time of her accident — September, 1878 — she had symptoms of cystitis. She was residing in the far West at the time of the accident, and, as 1 did not see her for several years after, and have not been able to correspond with the surgeon who then at- tended her, I do not know the relation which the injury sustained at that time bears to the development of the cystitis. I only know that the one followed the other immediately. The cystitis persisted, and the constitutional symptoms increased from time to time. She then returned from the West to New England to be under the care of her father, who is a physician of known ability and large experience. He gave her every attention, and placed her in the care of a neigh- boring physician, who has a high reputation as a gynecologist. With- out giving full details of her treatment at that time, I may fairly state, upon information received from her father and her physician, that all the recognized ,means of treatment were tried, including complete dilatation of the urethra on two occasions. The cystitis was not at all relieved by the treatment, and the constitutional symp- toms increased continuously, until she became confined to bed. Hav- ing a highly sensitive nervous system, she suliei'ed greatly from want of sleep and the constant pain of cystic tenesmus. I first saw her in consultation about a year from the time when she was first taken ill. It was then that this much of her history was obtained. She continued under treatment for six months longer, and, at the end of that time, she consulted one of the best known and most worthy authorities in New York. He advised cystotomy and drainage for 49 754 DISEASES OF WOMEN. six months or longer, stating at the same time tliat, in view of tlie failure of her former treatment to give relief, there was nothing else left to be done. She declined to submit to the operation at that time. Her father sent her to me about two and a half years later. At that time she was obliged to urinate about every hour, night and day. She suffered from constant tenesmus, and her nervous system was greatly debilitated. Dr. McCorkle examined the urine for me, and found that it contained a large quantity of pus, and that there was a remarkable absence of epithelial cells. The doctor's report was that the specimen was pus, containing a small quantity of urine, and evidently came from a bladder which had entirely lost the upper layer of its mucous membrane. The diagnosis then made was chronic purulent cystitis. It appeared to me that the case was one which called for cystotomy ; but, knowing the objection of the patient to that operation, treatment was undertaken, and the results soon gave some slight encouragement. The constitutional treatment was at tirst chiefly tonic in character, and subsequently she took sahne waters, litliia waters, bromide of litliia, and, finally, buchu, benzoin, tar, turpentine, and the like. These last preparations, however, did not help her, and were not long continued. The local treatment was at first instillations of a warm solution of borax. Half an ounce was instilled at a time, and repeated until from eight to twelve ounces were used at each treatment. The instillations were always made with very low pressure. As the sensitiveness of the parts diminished, the quantity used was increased up to one ounce, but never beyond that. Three months of this treatment showed im- provement. There was less pain, and the patient's general health had improved considerably. About this time nitrate of silver was used, and, later, sulphate of zinc in solution of various degrees of strength, but this always caused pain. Indeed, the suffering caused by this kind of treatment was great, and the benefit which followed being very little, it was given up. I then began to use instillations of an infusion of hydrastis Canadensis, containing a small quantity of salicylate of soda, which was used to prevent decomposition of the infusion. I am now satisfied that the salicylate was of value in its effect u]:)on the suppurating mucous membrane. The hydrastis was very faithfully used, first by myself, and subsequently by the jjatient, who made the instillations with unusual intelligence and care. The result was a gradual diminution of the pain and lessening of the frequency of urination. The pus diminished in quantity, and simultaneously young epithelial cells appeared in the urine, and in- creased in number as the pus diminished. At the end of one year ORGANIC DISEASES OF THE BLADDER. 755 of treatment the local and constitutional symptoms had all disap- peared. The urine was normal, and the patient had fully recovered, excepting that she was obliged to urinate about every four hours. This was owing to contraction of the bladder. To overcome this, gradual distention was practiced. The patient was directed to re- tain her urine until discomfort, not pain, was felt. Injections were used, each time distending the bladder a trifle more, always stopping short of causing pain. About two years from the time she first came under my care she was perfectly cured of the cystitis, and had regained her normal retaining power. Four more years have passed, and there is not the slightest evidence of any return of the former aifection. Cystitis treated by Cystotomy without Benefit. — This lady, tliirty- fom* years of age, is married, and had four children. She is said to have had retroversion of the uterus, which was held in its abnormal position by adhesions. She was treated for this displacement in the Woman's Hospital of New York, so she said, and, while under treat- ment, a cystitis was developed, which continued until I saw her. After leaving the hospital, she became pregnant, and her sufferings increased. Two years ago, when her last child was four weeks old, she consulted a physician here in Brooklyn, who advised cystotomy, and soon after he performed the operation, using the cautery. She experienced some relief from the operation, but she still suffered very acutely. Being led to hope that in time the operation would cure her, she bore her afflictions for nearly a year, when she con- sulted me on the 5th of September, 1881. I then found her to have the tubercular diathesis, rather well marked, but there was no appar- ent disease of the lungs at that time. The vesico-vaginal fistula made by the operation was large enough to admit the little finger, and the drainage of the bladder was quite complete. Yet, strange to say, she had constant pain in the bladder, and a desire to urinate. These symptoms I found to be due to inflammation and ulceration of the urethra and bladder below the fistula. The disease at this location caused pain and irritation, which provoked reflex action, such as that which arises from the presence of urine in the bladder, but in a much greater degree. General tonic treatment was advised, and local treatment employed to relieve the inflammation of the urethra and neck of the bladder. Locally, she improved slowly. The pain and vesical tenesmus subsided almost wholly, but she has not yet recovered completely. My object was to cure the local dis- ease, and then close the fistula. This I shall never be able to do. While the local disease is improving, she is developing phthisis pul- 756 DISEASES OF WOMEN. inoiialis, which precludes all thought of operating to close the fistula. The facts in this history, which I trust will be borne in mind, are, that this patient was of a tubercular organization ; that cvstotoniy did not cure her cystitis and urethritis, nor relieve her suffering to any marked extent. Cystotomy for the Cure of Cystitis without Benefit ; Death from Phthisis following Pneumonia contracted while under Treatment— Six years ago I had a case of cystitis under observation, which illustrates the same facts in pathology and therapeutics as in the case just re- lated. I shall give a very brief outline of the history simply to show the result obtained by another method of doing the same operation. This patient was a married woman, who had several cliildren. She was of a highly nervous temperament, and came from a tubercular family. She consulted me for cystitis, the cause of which is not recorded in her history. I treated her with injections for several months without benefit. I also dilated her urethra, with the same result. In fact, I believe she rather grew worse, in place of better, while under my care. Her general health failed noticeably at any rate, and she gave signs of a tubercular deposit going on in her lungs. Her friends urged her to enter the Woman's Hospital in New York. She did so, and was under the care of Dr. Emmet, who performed cystotomy, which he did by incision and keeping the fistula open, first by his glass tube, and afterward by dilatation with the finger. After the operation, she had an attack of pneu- monia — at least, she told me this when she returned from hospital. Upon her return home, I found that she had been much relieved of her most urgent symptoms by the operation. Still, there was cys- titis remaining, and she had vesical pain and tenesmus. The tuber- cular disease of the lungs had progressed rapidly, and that portion of her lung which was involved in the pneumonia never cleared up. Her strength rapidly failed, and she died before the cystitis subsided. CROUPOUS AND DIPHTHERITIC CYSTITIS. Croupous and diphtheritic diseases of the bladder are very rare, and therefore require but a brief notice here. From the difficulties that have existed in the detection of the exact pathological conditions in diseases of the bladder, we may presume that mild attacks of these affections have been overlooked or not correctly diagnosticated. But, even granting this, we are compelled, from the few recorded cases, to believe that croup and diphtheria of the bladder seldom occur. OEGANIO DISEASES OF THE BLADDER. 75T What little exact knowledge we possess on this siil)ject has been obtained to a great extent froni post-mortem examinations, and from this statement it will be inferred and correctly too, that these diseases, especially diphtheria, tend to end fatally. From the names employed one would naturally suppose that these affections were exactly the same as the diseases of the mucous membrane of the air-passages, known as croup and diphtheria. Be that as it may, it will suffice for my present purpose to have it un- derstood that in these diseases of the bladder there is developed an exudation or membrane like of that of croup or diphtheria. The pathology of the local lesion in these two diseases differs only in the depth of tissue involved and in the character of the membranous fonnation. Thus in croupous cystitis, the false mem- brane, while moderately adherent, is usually on the surface, covers the whole or most of the mucous membrane of the bladder, and sometimes portions of the outer genitals, and is fibro-epithelial in structure. The diphtheritic membrane, on the contrary, dips deeply into the mucous membrane of the bladder, exists usually in scattered patches, and is denser and more fibrous in character, its interstices being filled with little rounded cells and some fatty and granular matter. Exfoliation of the affected portions of the vesical mucous mem- brane usually results from this diphtheritic inflammation, as in the analogous affection in the throat. When the membrane comes away, ulcers of varying size and depth are left to mark its former site. The destructive processes are not alone confined to the mu- cous and submucous tissues, but in some cases involve the muscular coat of the organ. The whole vesical surface, not covered with the membranous exudate, is of a deep-red color, and in some places ecchymotic, especially about the exudation. The inflammation is truly acute, and passes rapidly from the stage of mucous exudation to that of epithelial exfoliation and pus formation. SymjptoTnatology . — The symptoms in no way differ from those of acute cystitis, save tliat as a rule they are more intense and the con- stitutional symptoms are more severe. The nervous system is usu- ally profoundly affected. There is pain before, during, and after micturition — pain that may be purely local, felt in the outer genitals, or radiate in all directions. When the shreds of broken-down membrane separate, they may block up the urethra, and cause retention and decomposition of urine. Retention, however, may be produced at any time by in- 758 DISEASES OF WOMEN. tense inflammatory tumefaction of the urethra, which is often in- volved. Tliis exfoHation of false membrane must not be conf(junded with the sloughing of the mucous membrane of the bladder caused by pressure from overdistention or very severe inflammation. As the symptomatology of these diseases is very much the same as those of acute and chronic cystitis, it may be best not to enlarge upon them here, as that would involve much useless repetition. Diagnosis. — Microscopical examination of the urine, but more especially of the tissue shreds, will afford much reliable information. When a membrane is found consisting of librillae interspersed with numerous small nucleated cells, ha\Tng undei'gone fatty degenera- tion, and involving the superficial mucous or muscular layer, the case may be set down as one of diphtheritic cystitis. The urine rarely affords any positive information ; and really it is useless to attempt to make a differential diagnosis between these diseases and ordinary cystitis in which there is much destruction of tissue. Thus far I have had no opportunity of examining croupous or diphtheritic disease of the bladder with the endoscope, and can not say how much information could be obtained in this way. I pre- sume that much could be gained by this instrument, and I base this opinion upon the examination of several cases of catarrhal and croupous inflammation of the rectum. In these cases the distinction between catarrh and croup could be easily and positively made by the endoscopic appearances, and I believe that what has been done in determining rectal disease could be accomplished in diseases of the bladder. In these cases the vesical walls are very fragile, and this should be borne in mind in using either catheter or endoscope. This con- dition would preclude the distention of the bladder with air and examination with Rutenberg's apparatus. Prognosis. — This is very grave indeed. Treatment. — This, in brief, is to keep the patient perfectly quiet, to let the diet be the most sustaining, the drinks free and bland, and to keep the bladder pretty well emptied, to allay the pain and spasm by the judicious exhibition of narcotics, preferably by the vagina, in suppository. The bladder should be washed out daily with warm water, containing a little of Labarraque's solution or a little carbolic acid. Much relief of both pain and spasm will thus be afforded, even when the inflammation is at its highest. Tissue shreds should be removed as soon as their presence is as- certained. ORGANIC DISEASES OF THE BLADDER. 759 CYSTITIS WITH EPIDERMOID CONCRETIONS. This is a very rare affection of the bladder, and I only mention it as a pathological cunosity. Rokitansky supposes it to be due to, or a sequence of, chronic cystitis. It consists in an unusually rapid formation of epithelium by the vesical mucous membrane, resulting in the shedding of quite large white, shining plates or bodies of this caked scale. The following case, related by Lowenson (1802), is thus given by Winckel. The patient spoken of by him, suffered from mitral stenosis, and came into hospital in a morilmnd condition. After death her bladder was found to be enormously dilated. From it were taken a great number of small, rounded yellow masses, lying between a number of plates of dullish color, the general appearance being that of yellow pea-soup, with some of the hulls left in. The whole of the internal surface of the bladder was covered with flakes, many of them having these little balls interposed and superimposed. Their diameter varied from one twenty-fifth to one half inch. These attached flakes were tolerably firm and bright, something like mother- of-pearl. From the mucous membrane itself, after removal of these flakes, pieces of membrane could be stripped off. Except in these places the mucous membrane seemed normal. The urethra and ureters were normal, but the kidneys were in a condition of granu- lar atrophy. On microscopic examination it was found that the young, often- times fatty degenerated epithelial cells (in the commencement), as they approached the surface, took on gradually all the changes of the very large epidermic cell, becoming non-nucleated and granular. The little balls consisted of grains of fat, calciform concretions, lit- tle nuclei, and epidermic cells. There was considerable stearine but no cholesterine. Reich claims lately, however, to have found the latter in the vesical mucous membrane of a man fifty-six years old, who suffered from catarrh of the bladder. Treatment. — Of course I have no experience, never having seen a case, but on general principles I would suggest that the treatment would be to relieve any inflammation or irritation that may be pres- ent, the exhibition of alkalies and arsenic (in small doses) by the mouth, daily washing out of the bladder, removing all scales or plates that form, and the application of a strong alkaline solution to the diseased surface. I am unable to give the symptoms of this disease. The same may be said of the diagnosis. I presume, however, that an examination of the urine would enable one to determine the nature of the trouble. CHAPTER XLII. NON-INFLAMMATORY DISEASES OF THE BLADDER. DISLOCATION OF THE BLADDER. II. Non-inflammatryry diseases of the Madder. These are : 1. Dislocations. 2. Foreign bodies. 3. Rupture. 1. Dislocations. — -These may be of six kinds : {a) upward ; (5) backward ; (c) forward ; {d) lateral ; {e) downward ; in addition to these, we may have (/") inversion of the bladder. Some of these are, even in their worst form, not tnie disloca- tions, but represent some hindrance to the proper distention of the organ or its position when distended. Of all dislocations, the most important are the upward, backward, and downward. All of them, however, interfere more or less with the vesical function. Marked dislocation of a healthy bladder often gives rise to less disturbance than slio-ht dislocation of an alreadv irritable orojan. Dislocations of the bladder have various causes, the most com- mon and troublesome being abnormalities of structure and position of the uteiTis and vagina. As a matter of fact, these dislocations are usually secondary to some affection of the other pelvic organs. This necessitates a de- scription of their causes as well as the conditions under which they occur, thus deviating from the general order followed in this work. («) Dislocation Upward. — The upward dislocation of the bladder may be caused by the dragging up of the organ by the gradual rising from the pelvis of the gravid uterus. This, however, is a rare affec- tion, and only occurs, I think, in cases where there has been previous inflammatory action in the pelvis, gluing the parts together. In most pregnancies the bladder retains what is, under the circum- stances, its normal position. Bands of adhesion passing from the NON-INFLAMMATORY DISEASES OF THE BLADDEPv. Y61 bladder to the various aljdominal and pelvic viscera may, when sliort- ening takes place, produce this dislocation. It may also be produced by ovarian tumors, and, in some cases of uterine retroflexion and retroversion. The dislocation accompanying the last two affections is, however, usually more backward than upward. The other most probable causes are tumors about the neck or base of the organ, tumors of the cervix uteri, pelvic deformities, and pelvic exostoses. The symptoms are usually those of irritable bladder. In some cases of pelvic tumor the pressure on the neck of the bladder, forc- ing it against the pubes, produces ^retention. This is purely me- chanical. In other cases, where there is no obstruction to the out- flow, but pressure on the bladder, there may be incontinence ; and, again, from traction on the muscular walls, patients are unable to contract and ex23el the vesical contents, and retention results. I saw a case, in consultation with Dr. A. W. Ford, of Brooklyn, in which the patient had retention of urine, so that she could not m^inate while standing, but was compelled to lie down before the bladder could be emptied. The retention lasted one week, and was brought on by the efforts to urinate, which wedged the uterus in the pelvis, and compressed the neck of the bladder. She was relieved by urinating while on the hands and knees. (b) Dislocation Backward. — This dislocation stands next in order of importance and unfavorable results to downward dislocation. It may be caused by tumors of the abdomen or by pehdc adhesions, but the most frequent cause is backward dislocation of the uteinis, such as retroflexion and retroversion. Retroversion affects the bladder in the same manner as prolapsus, except when the uterus is very much enlarged, and is throAvn backward and impacted in the pelvis, so that the cervix presses firmly on the urethra. In such cases urina- tion is impossible. Examples of this are seen in retroversion, occur- ring in the early months of pregnancy or after delivery. Schatz gives a case due to retroflexion of the uterus during pregnancy, produc- ing the same trouble in the bladder as retroversion. Winckel saw a case in the body of a non-puerperal woman, in which the uterus was lying almost horizontally in the pelvis, with its fundus adherent to the rectum. That part of the bladder that was drawn most backward had a diverticulum, containing a calcu- lus. The neck of the bladder was fastened dow^n posteriorly by tight bands of adhesion that passed from it over the nterus to the rectum. In retro-displacements of the bladder, with no pressure on the 762 DISEASES OF WOMEN. vesical neck, tlie symptoms are usually those of irritation, causing frequent urination and tenesmus. I give here tlie following cases Fig. 234. — Retroversion of the gravid uterus (after Schatz). The bladder pulled upwr.rd and backward, and the urethra, u, put great- ly upon the stretch. as they are of interest, and may serve to fix more clear- ly in the mind the general points. ILLUSTRATIVE CASES. The first is a case of chronic retroversion of the uterus, causing marked vesi- cal trouble in a nervous wom- an. The cause of the blad- der trouble is here double : first, vesical neurosis, and second, a displaced uterus. Mrs. H., aged thirty-six. Marned five years, and a widow three years, of a marked nervous temperament. Has never been pregnant. Menstruation always normal, and general health fair in early life. Her general system has been much reduced by nursing her husband, who died of phthisis. Nervous system also much im- paired. When first seen, all the functions except those of the blad- der were performed well. She suffered night and day from frequent urination, but there was no pain either during or after the act, unless she tried to hold her water for a few hours, when there was great pain after the completion of evacuation. Nervous excitement, pleasant or unpleasant, made the trouble much worse. Her urine was normal. On examination, complete retroversion of the uterus was found, with shortening of the anterior vaginal wall ; the bladder was much contracted, but otherwise normal. The uterus was restored to its place, and held there by a pessary. Hydrobromic acid in thirty-min- im doses was given four times a day. She made a rapid recovery. The next is a case of vesical tenesmus and partial retention from a sudden retroversion of the uterus. Mrs. G., aged forty-three, the mother of four children. Widow for several years. She was a strong, healthy lady, and had been on her feet all day attending to her household duties, and in the even- ing, while hanging some pictures, slipped from a chair, and fell heavily to the flooi", striking on her feet. She was at once seized with a desire to urinate, and soon after pelvic tenesmus came on. The desire to urinate was constant, and, after strong expulsive NON-INFLAMMATORY DISEASES OF THE BLADDER. 763 efforts, she was able to pass a little urine from time to time, but without rehef. The bowels became distended and tympanitic. On the following day she was ordered anodynes, but they gave very little relief. On the next day she was examined, and the uterus was found to be completely retroverted, and the bladder full, but not overdis- teuded. Replacing the uterus gave her great relief at once, and she has remained well and free from all bladder trouble since the acci- dent occurred, some two years ago. This was a case of acute retro- version of the uterus, producing an intensely painful affection in a normal bladder. (c) Dislocation Forward. — Forward dislocation of the bladder, unless it be througli the open abdominal walls, is very rare. Some change in its shape from pressure of organs or tumors from behind may occur, but this is really not a true displacement, except in some rare and marked cases. The most frequent cause is pressure from the anteverted and enlarged uterus in either the virgin or puerperal state. Anteversion of the uterus usually causes frequent urination, perhaps as much so as prolapsus ; but whether this frequency is due to the fundus uteri resting on the bladder, or to the supersensitive- ness of the whole pelvic organs, which usually accompanies this dis- location, I have not always been able to determine. I have been in- clined to the belief that the latter was the case. In this displace- ment (anteversion) the uterus is generally enlarged and elevated, so that the body and fundus rest upon the bladder, and imj)ede its dis- tention. True dislocation of the bladder forward is the rarest of all dis- locations, only three cases being on record. It has been variously called ectopia of the unfissured bladder, ectopia vesicae totalis, and prolapsus vesicae completus per fissuram tegumentorum abdominis. The first name is too vague, the last best of all, but rather lengthy for every-day use. The three cases on record are by G. Yrolik, Stoll, and Lichten- heim. In all these the bladder was protruded througli a small slit in the abdominal wall, and appeared as a bright-red, rounded tumor at the lower and anterior part of the abdomen. In Lichteuheim's case only was the tumor reducible. The pubic bones were separated about two inches. The urine could be retained perfectly, and the patient was able to micturate in a small stream. Microscopical ex- amination of the outer covering of the bladder-walls proved it to be mucous membrane, hke that lining the interior of the organ. In G. Yrolik's case, according to Winckel, there is doubt as to 7Gi DISEASES OF WOMEN. whether it was a true vesical ectopia. He believes it to have been a gaping of the fissured abdominal walls over a diluted uraeluis, the latter communicating with the bladder by a small opening. In Lichtenheim's patient no operative measures were thought of, for, beyond a little excessive secretion of the external surface, no trouble was experienced. If, however, from the protrusion of the tumor or other cause, difficulty in passing or retaining urine be pres- ent, an attempt should be made to close the abdominal fissure. If it be large, two or more fla]5s may be needed to accomplish the de- sired result. The operation is very like that for fissure, already de- scribed, only more simple. If an operation is not desired or consented to, the patient should wear a concave compress, and, by attention to bandaging, keep the surface of the organ in as nearly a normal condition as possible. {d) Lateral Displacements. — Lateral displacement of the bladder is not very often met with. It is generally due to inguinal or fem- oral hernia, tumors at the side and base of the organ, and contract- ing pelvic adhesions. There is generally more or less distortion of the urethra that may hinder the outflow of urine or prevent the easy introduction of a catheter. Irritability may result, but it is not so common as in the other varieties, the organ being generally but slightly displaced, and, soon getting used to the disturbing cause arising from the malposition, produces but little disturbance. One case of this kind I have seen which was of interest. The patient was a young lady, who had had a pelvic peritonitis, which left her with pelvic tenesmus, ovarian pain, and some vesical tenes- mus and difficulty in emptying the 1)ladder. One of my assistants, while examining her, found a fluctuating tumor on the left side, which he supposed to be an ovarian cyst, but which proved to be a left lateral displacement of the bladder fixed in its malposition by adhesions. Causation. — Its causes are of two kinds — predisposing and excit- ing. Of the predisposing, the most common are a loose, fiabl\y con- dition of the vesico-vaginal septum, excessive venosity of same (these may be due to pregnancy or to a general systemic condition), ab- normally capacious vagina, unusually large introitus vagina?, total or partial loss of perineal body, and the tendeuc}' of the bladder to pouch inferiorly as age advances. As exciting causes, we have %'iolent expulsive efforts, as in def- ecation, lifting heavy weights, and especially child-bearing. The latter is probably one of its most common causes, for not only do we have expulsive efforts of the most violent kind, but a lax, spongy NON-INFLAMMATORY DISEASES OF THE BLADDER. 765 condition of the vesico- vaginal septum — i. e., tlic anterior vaginal and posterior vesical walls, which are pushed downward before the advancing head. Another common cause is prolapsus uteri, though in many cases the cystocele precedes the prolapse of the womb. Whichever is the cause, the one aggravates the other. In slight prolapse of the uterus, the vesical symptoms are only those of irritation ; and it is a strange fact that the irritation is often as great in the first degree of prolapse as in the third. Other less frequent causes of cystocele may be tumors in the posterior vesical or anterior vaginal wall, stone in the bladder, vesi- cal diverticuli, violent efforts at urination, and marked pressure from above. The bladder begins to sag inferiorly as age advances, and conse- quently the tendency to prolapsus advances, as does the age. The number of pregnancies may, however, have more to do with the fre- quency than the tendency to pouching in old age. (e) Dislocation Downward. — I have reserved this malposition to the last, because it is the m.ost important. There are various grades of tlie dislocation, the most marked of which is known as cystocele vaginalis. Pathology. — This affection may be conveniently divided into three grades. In the first, there is but a slight bagging of the or- gan. In the second, about one half the bladder lies below the nor- mal level of the anterior vaginal wall, giving the organ an hour- glass shape, the urethra entering the upper segment just above the point of partial constriction. In the third or highest grade, the whole bladder lies below the level of the normal anterior vaginal wall. The urethra in these cases has a direction from above back- ward and downward. The ureters in the last two grades are so bent and obstructed by pressure, that dilatation and hydronephrosis may result. Such instances are given by Phillips, Froreiss, Yirchow, Bi'aun, and Winckel. The vesico-uterine pouch is, in cases of marked vesical and uterine prolapse, greatly increased in size, and may contain a loop of intestine. In some rare cases it may become constricted superiorly, and exist as a closed sac. In chronic cases the vesical mucous membrane becomes hyper- trophied, and, in the lower segment especially, congested and oedem- atous. To this may be superadded cystitis and ulceration, which often follow in cases of long standing. Symptomatology. — In the first grade of downward dislocation 766 DISEASES OF WOMEN. the symptoms are those of irritable bladder, such as frequent and sometimes painful urination. AVhen tlie displacement has existed for a considerable time, the bladder seems to accommodate itself to the new relations, and the calls to urinate become less frequent. In cases in which the prolapsus of the bladder is slight and there is dila- tation or prolapsus of the upper third of the urethra, partial inconti- nence occurs, a very annoying symptom. Every time the patient coughs, lifts a heavy weight, steps suddenly down from the curb- stone into the street, or even indulges in a hearty laugh, there is a sudden escape of urine. In complete prolapsus of the uterus and bladder, we find instead of frequent urination, difficult urination, and in the worst cases, re- tention. Partial retention always occurs in the marked cases, and the urine remaining in the bladder decomposes, and in time causes cystitis, which greatly aggravates the patient's sufferings. Such cases are very like those occurring in old men, and due to retained urine by reason of an enlarged prostate gland. There is usually a dragging pain experienced in the region of the umbilicus, which is due to traction on the urachal cord, and also a constant sense of pain and uneasiness, due partly to the vesical and partly to the uterine malposition. To fully empty the bladder in the worst cases, it is necessary to relax the parts by lying down, and then force out the urine by press- ure on the vaginal tumor. Cystitis is a common secondary affection, and is due to decompo- sition of the retained urine, and to chronic congestion with oedema and hypertrophy of the mucous membrane. Wiuckers experience has, however, differed from that of most observers, he having failed to find a single instance of cystitis in sixty-eight cases of cys- tocele. From pressure on the ureters there may result dilatation and hydronephrosis, and if marked or long-continued, urremia. There may also be set up that condition known as pericystitis, and the lower vesical segment be rendered irreducible owing to the formation of adhesions. If cystocele occurs in a patient already suffering from cystitis, the original trouble is of course greatly aggravated. Cystocele may interfere with delivery during childbirth. In one such case, McKee, being unable to push a catheter into the bladder, punctured the tumor with a lancet, and delivery was rap- idly accomplished. In another case, a certain physician mistook the vesical tumor for the bag of waters, and punctured it. I NON-INFLAMMATORY DISEASES OF THE BLADDER, 767 Diagnosis. — This is readily made. The patient should he laid upon her hack, with the thighs flexed on the hody. If the tumor is already down it should be examined carefully, and also the position and condition of the neighboring organs. If possible, a catheter should be passed into the bladder, to ascertain if it enters the tumor and the direction it takes in so doing should be observed. The tumor should be slightly compressed, and notice taken whether the urine flows from it through the catheter. An attempt should also be made to try to reduce it. The urine should be carefully ex- amined for pus, mucus, albumen, epithelial elements, and the amount of urea should be determined. Prognosis. — The r)rognosis is generally good ; but in giving an opinion the degree of dislocation, the size of the tumor, the condi- tion of its mucous membrane, whether it is reducible or not, the age of the patient, and the gravity of the producing cause, must all be taken into consideration. In young patients, Sims, Simon, Hegar, Yerf, and others claim to have obtained radical cures. Some of these cures were not, how- ever, lasting. Scanzoni claimed that he had never seen an opera- tion for this displacement that resulted in a permanent success, and that his own operations were by no means satisfactory. My own experience entirely accords with that of Scanzoni. Treatment. — The treatment consists in reposition and retention. The former is easy, the latter hard to accomplish, as prolapsus uteri and cystocele generally go hand in hand ; one can not be treated without the other. Having pushed the uterus up into position, emptied the bladder and replaced it, some mechanical ^^-1, means should be sought to retain y^^L ^Ak one or both organs in place. raF ^i^^^ ing the prolapsed bladder I de- m^ ^^^^^|p^ ^"*^^Sb vised the pessary shown in Fig. ^t^ " ^^^^^^^^^^^j^ 235, and it has been found to ^i^^gj^^F^ accomplish the obiect fairly well Fi«- 235.— Pessary for prolapsus of the ^ 1 • "!i • • bladder (bkene). The mam portion, a, when the pelvic floor is not m- surrounds the cervix uteri, and b sup- iured ports the bladder and upper portion of ** ' . •Ill *^^ urethra. The other part, c c, joins I his pessary is adapted and the main portion in front of the uterus, introduced in the same way as a and rests on the posterior \yalls of the '' vagina. retroversion pessary, an account of which will be found under the head of the treatment of retro- version. TC8 DISEASES OF WOMEN. The facility of introduction and removal is one of the minor, but bj no means unimportant, qualities of this pessary. Several sizes are made, wliich answer in most of the forms of displacement of the bladder ; but a case will occasionally occur in which it is necessary to first take measurements, and have the in- FiG. 236. — ^Pessary holding up the bladder. strument made exactly to suit. This can be easily done. The pa- tient is placed on her left side, and after introducing the speculum, the uterus and bladder are restored to their proper positions ; then a thin strip of sheet lead is bent to the size and shape of the ante- rior walls of the vagina and cervix uteri. This form will enable the instrument-maker to produce the required size and shape of the pessary. I have also devised another form which suits some cases. It is like the retroversion pessary which I use, but the sides anteriorly are made more curved and very much thicker than the ordinary one, Fig. 237. Should a pessary fail to accom- plish the desired result and the case grow daily worse, the operation may be performed which was first done Fig. 237. — Modification of the retrover- sion pessary, used in prolapsus of the bladder. NON-INFLAMMATORY DISEASES OF THE BLADDER. 769 by Joubert, then by Baker Brown, and subsequently carried out and improved by Sims. It consists in the excision of an ellipti- cal or V-shaped piece from the anterior vaginal wall, and bring- ing the edges together by sutures. When healing has taken place the vagina is markedly narrowed, and the bladder has an improved, if not a perfect floor to rest upon. This operation is seldom called for, and I believe that it should be limited to cases where there is marked thickening of the vesical and vaginal walls. AVhen the operation has been performed, I have found it necessary to use a pessary, to prevent a return of the prolapsus. If there be a lacer- ation of the perinseum this too is to be remedied. In fact, the great majority of cases of prolapsus of the bladder are due to some imper- fection of the pelvic floor, and I have therefore obtained by far the best results by restoring the pelvic floor. I have also found that it was better to bring together as much tissue as possible in the posterior vaginal wall and at the vaginal outlet. In cases of but slight downward dislocation, and where, from a relaxed condition of the vaginal wall and septum, vesical prolapse is to be feared, the employment of a proper pessary will suffice. ILLUSTRATIVE CASES. Frequent Tlriiiatioii due to Prolapsus of the Bladder. — The patient was thirty-two years old, and had given birth to five children. . She had always been well and strong, and at the time that I saw her sbe was in very good general health. After her last confinement, one year previous, she began to suffer from frequent urination. At first she obtained relief from emptying the bladder, but subsequently the desire to urinate, though not very urgent, was constant when she was upon her feet. On lying down she obtained relief and retained the urine all night, but upon rising and going about the tenesmus re- turned. By digital examination I detected a prolapsus of the bladder, but only in a slight degree. There was considerable relaxation of the pelvic floor and of the vaginal walls, but no laceration of either. In all other respects she was quite well. The urine was normal. She was ordered to rest for a few days, most of the time reclining, and to use vaginal injec- tions night and morning of sulphate of zinc, sixty grains to the quart of warm water. Afterward a pessary was used shaped like Graily Hewett's anteversion pessary, but having the anterior bars thickened. 50 770 DISEASES OF WOMEN. Immediate relief was given by the pessary, and she was able to walk and stand as she used to in former times. Tlie zinc-douche was kept up once a day, and she was cautioned ao;ainst walking or standing too long. At the end of six weeks the pessary was re- moved to see if she could do without it. In a few days the old symptoms began to return, and tlie pessary was replaced to her en- tire relief. From this time onward the pessary was clianged once a month for a smaller one. Seven months afterward the instrument was removed, and the injections of the zinc solution continued for one month longer. She had no further trouble. Prolapsus of the Bladder caused by Laceration of the Perinaeum. — This lady was forty-one years old, of large form, and had an excel- lent constitution ; she had two daughters, the youngest seven years of age. For nearly six years she had suffered from vesical tenesmus and frequent urination. These symptoms were greatly aggravated by the erect position. In fact, for a long time she was quite comfort- able while sitting or lying down, especially the latter. Her symp- toms gradually increased, and within the past two years she has had partial incontinence. Any sudden motion such as is caused by cry- ing or sneezing would cause a spurt of urine which was most dis- tressing to her. She became quite helpless although in perfect health. Being unable to stand or walk for any length of time and having partial incontinence she remained in the house all the time. She had been treated with all kinds of drugs, but, as might have been expected, without any relief. I found that she had a laceration of the perinseum, and also a bilateral laceration of the cervix uteri. The bladder was prolapsed and the upper third of the urethra pre- sented the usual signs of the ordinary cystocele. She was admitted to my private hospital, and after having been submitted to prepara- tory treatment the cervix was restored. While she was recovering from that operation the bladder was kept in place by the tampon, and astringent vaginal injections were used. One month later the pelvic floor was restored, and as much tissue brought together as pos- sible. After the operation the pelvic floor was kept well sup- ported with a compress and T-bandage. The astringent injections were continued. Six weeks from the last operation she was per- mitted to take exercise, but the pelvic floor was supported for two months longer. After restoring the pelvic floor it was necessary to use the catheter to draw the urine ; that excited some irritation of the bladder, but this was relieved by injections of borax and water. She made a perfect recovery, and has remained quite well for more than four years. NON-INFLAMMATORY DISEASES OF THE BLADDER. 771 Cases of Displacement of the Bladder due to Displacement of the irterus and Causing Retention of Urine. — (I). Berry Hart, M. D., " Ob- stet. Jour.," Great Britain and Ireland, August 3, 1880): Case I. — A. B., aged eighteen, was seen in Prof. Simpson's out- patient clinic, on account of white discharge and pain on making water. Ocular examination of the external parts showed a recent laceration of the hymen and glairy discharge from the ostium vaginae. On vaginal examination the cervix was found normal in all respects, except that the os looked downward and forward ; bimanually, a fluc- tuating tumor, reaching up a little above the level of the pelvic brim, was felt in front of the partially retroverted unimpregnated uterus. The catheter introduced drew off twenty-seven ounces of urine. Case II. — Mrs. C. was admitted to Prof. Simpson's ward on ac- count of retention of urine, necessitating catheterism ; bimanual ex- amination showed a large tumor in the hollow of the sacrum, marked elevation of the os uteri above the symphysis, and a fluctuating tumor in the hypogastric region, reaching almost as high as the umbilicus. This j^hysical examination and the history of fom" months amenor- rhoea made the diagnosis of retroversion of the gravid uterus per- fectly plain. What concerns us here, however, is that the bladder contained only about twentj^-three ounces of urine, a less amount than in the previous instance. Case III. — Along with Prof. Simpson I saw at the Maternity Hospital a patient with rigidity of os uteri, supposed to necessitate early application of the long forceps ; supra-pubic inspection and palpation revealed a fluctuating tumor bluntly triangular in shape, with the apex down. Exact measurements showed that vertically it extended four inches, and transversely for about the same distance. The catheter passed deeply up, and drew off only two ounces and a half of clear urine, and some time afterward the same apparent dis- tention occurred, when three ounces and a half were removed. Af- ter the bladder was thus emptied, the furrow between cervix and uterus could be felt two fingers' breadth above the symphysis pubis. These three cases are typical instances, and evidently call for expla- nation. In the first case narrated the bladder was simply distended. It had pushed the intestines up, tilted the uterus back, but its posterior wall was still in its normal position. The peritonteum was still on the summit of the bladder, but, of course, was stripped to a certain extent from the lower part of the posterior aspect of the anterior abdominal wall. Thus the bladder, though its summit was only at the level of the brim, was considerably distended. Now, in the 772 DISEASES OF WOMEN. retroversion of the gravid uterus, the bladder was certainly distended, supi-a- pubic palpation, however, misled as to the amount of disten- tion, and for the following reason : Ths cervix uteri wa.s tilted high up behind the symphysis pubis, and consequently the blad- der, to whose posterior angle the cervix is attached, wafi swung up, as it were, into the abdominal cavity, a movement permitted by the anatomical relations behind the pubis. The peritoneal relations were the same as in Case I. In the third case, the bladder was, of course, drawn up, as I have already shown,* and its relations were as follows : In front it touched the anterior abdominal wall ; behind, the child's head, the cervix, of course, intervening. In this way the anterior and posterior vesical walls were in contact, and thus a film of urine, as it were, gave the appearance of distention. As I have before pointed out, the peritonaeum is stripped off the bladder more or less.f The conclusions advanced are : 1. The retro-pubic anatomical attachments of the bladder admit of its distention and passage up- ward. 2. Supra-pubic palpation gives no sure indication of the amount of urinary distention. 3. When the summit of the blad- der is above the pubis, it may be (a), a j)ure distention (Case I ) ; (b), distention plus a tilting up (Case 11) ; (c), drawing up of the blad- der, with almost no distention (Case III). The reason why gynecologists use a long gum-elastic catheter is very evident. I have already described the empty bladder in the non- parturient female as forming a Y-shaped ligure on vertical section. During parturition, however, the urethra is elongated, and forms with the bladder, on vertical section, a continuous tube.;}: Only that part of the bladder above the pubis is available for the recep- tion of urine, so that in this way the path for the catheter to travel is increased. In Braune's section of a woman in labor, the distance for the catheter to travel is about four and a half inches, more than twice what it is normally. In the last place, the distended female adult l)ladder is quite comparable in its anatomical relations to the distended fetal one. This may point to the explanation that the ultimate changes which convert the urinary bladder from an abdominal organ into a pelvic one is chiefly in the bony pelvis itself. Eetrocession and Forward Transposition of the Uterus. — The vari- ous forms of displacement of the bladder described thus far, ai'e usu- * "Edinburgh Medical Journal," April, 1879. f "Edinburgh Medical Journal," September, 1879, "Edinburgh Obstetrical Transac- tions " (Pait II, p. 142). I See " Die Lage des Foetus," Braunc, Tab. C. NON-INFLAMMATORY DISEASES OF THE BLADDER. ^TS ally associated with uterine dislocations, and are familiar to those who have given attention to gynecology. There remains to be no- ticed two forms of displacement of the uterus not generally described by authors, but which markedly disturb the functions of the blad- der, viz., retrocession und/orward transposition. In the first form, the uterus, without any change in the relation of its axis to the plane of the superior pelvic strait, is found to rest far back in the pelvis, and is fixed there. In the second form, the reverse of this exists, the uterus resting just beliind the pubes. Figs. 240 and 241, will show these conditions. The best example of retrocession I have ever seen was in a pa- tient who had had a severe pelvic peritonitis sonietirae before she came to me. The uterus was firmly fixed in the posterior portion of the pelvis, and the bladder was drawn backward, and was exceedingly ii-ritable. This condition caused her great trouble, as she could never Fig. 238. -Forward transposition of the uterus. The bladder will be seen somewhat flat- tened against the pubc.s, and the urethra pushed out of its axis. completely empty the organ, except when the catheter was used. Owing to the fixation of these organs in their malposition, it was impossible to relieve her from the frequent and difficult urination, and she remained a great sufferer, until she died of phthisis pul- monalis. DISEASES OF WOMEN. To illustrate the forward transposition, I may mention a case that came under my notice several years after she had had an intra- peritoneal pelvic haemutocele. Her physician told me that she had Fig. 239. — Retrocession of the uterus. The vagina is here found lengthened, and the bladder and urethra pulled upward and backward, a, adhesions, b, bladder. severe inflammation following the internal haemorrhage, and nearly lost her life therefrom. She was confined to her bed for many months, and after recovery she suffered from frequent urination. Night and day she was obliged to pass water every two hours, and if she went longer than that, she had pain which was not relieved till some time after emptying the bladrler. The uterus was situated at its proper elevation, and was just behind the pubes. The bladder was compressed from before backward, and (as the uterus was lirraly fixed in its forward position) of course it could never be fully distended. There was no disease of the bladder, so far as could be ascertained from an examination of the urine, or of the organ itself. No treatment that was employed gave anything more than temporary relief. (/) Inversion of the Bladder.— This affection stands next in rai-ity of occurrence to complete prolapsus of the bladder through a fissure in the abdominal walls. It is sometimes denominated as extrover- sion of the bladder through the urethra. NON-INFLAMMATORY DISEASES OF THE BLADDER. 775 By some authors it is supposed to be a simple protrusion of the mucous coat of the bladder through the urethra, but by others to be a prolapse of the whole organ. In support of the latter belief is the fact that after death Joubert, Rutly aud Leoret found a sinking in or partial inversion of the whole organ. Moreover, Meckel claims to have found under the labia minora, and protruding from the meatus a mass of tissue that on careful examination proved to consist of all the elements of the several coats of the bladder. Burns thinks it much easier for a prolapse of the whole organ to take place than a separation and prolapse of the mucous membrane alone. Streubel, after a careful review of the literature of the sub- ject, was able to find but one case in which the mucous membrane was alone prolapsed. As the posterior vesical wall in the empty organ lies over the vesical opening of the urethra, it is easy to com- j)rehend how this dislocation might occur from sudden straining efforts, pressure of the overloaded colon, or pressure of a heavy uterus. Vesical tumors with long pedicles coming out through the urethra, by weight or from traction, might produce this result. The process of extroversion is generally slow. De Haen, quoted by Streubel, gives a case, however, where from force, the bladder, rec- tum, and vagina were all prolapsed together. It will be understood that in order to have the bladder turned inside out, the urethra must be abnormally dilated. It may occur at any age. Weinlecher saw it in a child but nine months old ; OKver, in one of sixteen months ; Crobs, in one from two to three years ; Streubel, in a girl fourteen years old ; and Thom- son and Percy, in women aged respectively forty and fifty -two. Symptomatology. — The patients, even before the tumor appears, feel strong pressure in the organ on urination, and may have stop- pages in the stream and retention. After a time these symptoms become aggravated, a small red tumor appears at the meatus, and with each urination enlarges. With the appearance of the tumor comes pain. In some cases, when the desire to urinate is felt, severe contraction of the bladder takes place, but no urine flows. Then suddenly the little tumor disappears inside, and the urine flows freely. With each appearance of the tumor there is considerable constitu- tional disturbance, and after a time the appetite is lost, and the suf- ferers emaciate rapidly. From continual traction on the ureters, they may become inflamed, and also the kidneys, and urremia super- vene. Blood is sometimes pas-ed with the urine. Cystitis may occur, which increases the suffering and danger. The mucous mem- brane may become hypertrophied, congested, aud even oedematous. 776 DISEASES OF WOMEN. The constitutiona] symptoms bear no relation to tlie amount of tissue extruded or the area of mucous surface ex]>osed. Diagnosis. — Fortunately, this allectioii is a rare one, for the diag- nosis is by no means easy. The surface of the tumor should be ex- amined, and the nature of its epithelium carefully noted. Reduc- tion should he tried, and, if successful, examination should be made by the sound in the bladder, and the finger in vagina or rectum (the latter in infants), to ascertain, if possible, whether there be any thick- ening of the membrane or a tumor in the viscus. If on the surface of the protrusion the orifices of the ureters can be found, the diag- nosis is at once settled. Polypoid projections of the mucous mem- brane must be differentiated from protrusion of the viscus itself. Such cases are described by Baillie and Patron. From prolapsus of the urethral mucous membrane, which I shall hereafter describe, this condition is to be differentiated by the absence in the latter of the ureteric openings and the position of the meatus urinarius. In urethral prolapse the orifice is situated either centrally or superiorly, while in vesical protrusion the meatus surrounds the pedicle. In the latter there is a large strong pedicle ; in the foraier none. Treatment. — The treatment naturally divides itself into prophy- lactic and curative. To prevent partial extroversion from becoming complete, narcotics and demulcents should be given by the mouth and rectum, or injected into the bladder. Opium, hyoscyamus, and belladonna may all be tried. Local cauterization and washing out with tonic injections might prove serviceable. These preventive means are usually sufficient, provided the urine is normal and the mucous membrane healthy. If either of these abnormalities exist, they should be corrected. If the tumor is down, its reposition should be attempted. Gentle manipulation with the finger should be tried, and, if the mass can not be put back in this way, a well-oiled blunt catheter should be used, making pressure with it in the direction of the axis of the urethra. If this is very painful, and there are spasmodic contrac- tions of the abdominal muscles, which prevent replacement, the patient should be etherized, and success may then follow. She should be on her back, or in the Sims's position. To prevent prolapse after reduction, the catlieter may remain in situ for a time, or the colpeurynter or tampon may be used. Schatz's pessary for urinary incontinence may be employed advantageously, as its use tends to contract the vesical neck. Astringent injections may be used. No operative procedure is required. CHAPTER XLIIL NON- INFLAMMATORY DISEASES OF THE BLADDER (CONTINUED). FOREIGN BODIES IN THE BLADDER. Foreign bodies found in the female bladder are divided into three classes by Winckel, as follows : {a) Those that come from the body, entering the bladder by per- foration. (h) Those which have their origin in the bladder. {&) Those that are introduced from without through the urethra. I will adopt this classification, believing it to be the most natural and convenient. (a) First then, as to those that come from the body, entering the bladder by perforation. That cysts ever originate in the bladder is doubted by some and denied by others. In most cases where they are found in this organ they can be traced to dermoid cysts of the ovary which have found their way into it, thus accounting for the presence of hair, teeth, and other tissues in this viscus. These things are never found there unless such a cyst has opened into the bladder. The contents of these dermoid cysts may become nuclei for calculi, and lead to seri- ous trouble. I think there can be no doubt but that some of the cysts found in the bladder have their origin there. Mucous follicles certainly do exist in the bladder, and are liable to have their orifices blocked or occluded, and by secretion behind the point of obstruction grad- ually form cysts. Interestmg cases, where the cysts evidently had their origin in the bladder itself, are related by Paget, Liston, and Campa. It is, however, undoubtedly the fact that most cysts of the bladder have their origin outside that organ. Cysts of the ureters and urachus may open, into the bladder. Hydatid cysts have been found, but are less frequently seen in this 778 DISEASES OF WOMEN. country than in almost any other. Iceland is especially cursed with them, about one sixth of the j)opulation Kuffenn<5 from tliem in some part of the body. They may appear in the urine, white and pearly in appearance, or be of a dirty yellowish color, from prolonged soak- ing in foul urine. Treatment. — These cysts, or their contents, if giving rise to any trouble, should be treated in the same manner as the neoplasms, of whicli I shall speak later. In the treatment of hydatid cysts, iodide of potassium has been especially recommended. Having never had occasion to use it for this purpose, I can say verj- little for or against it. Other Foreign Bodies. — Various parts of the fcetus have found their way into the bladder by ulceration during extra-uterine preg- nancy, and pieces of ulcerated intestine, masses of feces, fecal con- cretions, and biliary concretions, are some of the curious things that have been found in this viscus. In gun-shot and other injuries to the pelvic bones, osseous splinters have found their way into the viscus, and been evacuated through the uretlira, or have passed into the vagina or rectum by ulceration, or have remained, forming nuclei for calculi. Various parasites may penetrate the walls from the immediate tissue or neighboring organs, or come down from the kidneys, such as the echinococci, already spoken of, the distoma haematobium or the iilaria sanguinis hominis. Joints of tape-worm, the ascaris lum- bricoides, and the thread- or seat-worms have also been found here, entering either through a fistulous opening, existing between the bladder and intestine, or through the urethra. In acute destructive change in the kidneys (pyonephrosis and abscess), pus and pieces of renal tissue are not unfrequently carried down into the bladder, and ma}', by frequent incrustation with the urinary salts, result in the formation of calculi. Of themselves, they give rise to very little, if any, irritation, and are consequently of no importance save in relation to the destructive changes going on in the kidney, of which they tell the story. If such discharges from the kidneys continue for a long time, they cause cystitis. Renal calculi may become dislodged, and be swept down into the bladder, there to enlarge by further incrustations, or pass out through the urethra. Symptomatology. — The symptoms of the various foreign bodies in the bladder differ only in degree. They are at first those of irri- tation ; later those of acute or subacute inflammation. Bodies round, smooth, and soft, are, of course, less irritant than those that are rough NON-INFLAMMATORY DISEASES OF THE BLADDER. 779 or sharp. Cysts, tlierefore, bits of flesh, aud their liiie, as a rule, give rise to no very severe symptoms, while splinters of bone and calculi occasion much more severe manifestations. Pain and tenes- mus will vary with the character of the offending body. If the mucous surface be abraded or torn, hsematuria will result ; and, if the foreign body remains in the organ, and continues to irritate it, cystitis will follow, and the patient suffer increased agony. The extension of the inflammation upward, and involvement of one or both kidneys, will give rise to pain in the back, hectic fever, partial or total suppression of urine, and consequent urasmic symp- toms, ending fatally. The urine shows the various appearances of cystitis, of which suflicient has already been said, and also the signs of renal involve- ment, if such be present. Treatment. — Any foreign body, when known to be present in the bladder, should be removed at as early a date as possible. In the adult female this may be readily accomplished by dilatation of the urethra, or, if the body be too large, by Simon's vesico-vaginal section. In cases of fistulous communication between the bladder and in- testine or other organ, an attempt should be made, in the mamier already spoken of, to close the opening. Echinococci and other parasites should be treated with the vari- ous remedies recommended for their destruction elsewhere, always, however, removing the offending body from the bladder first, and trying to prevent further invasion by proper medication. If cystitis be present, this will be attended to in the prescribed way. Hydatids in the Bladder. — Dr. J. A. McKennion, of Selma, Ala- bama, reported a case in the " American Medical Weekly," Louisville, Kentucky, in 1874 or 1875. The purport of this report, according to my recollection, is that it was a case which, when first seen, had every indication of cystitis, with great thickening of the walls of the bladder. Frequent micturition caused the patient to exclude her- self from society for two years before a correct diagnosis of the case was formed. She was becoming prostrated from constant dysuria, and, in order to give her quietude, Dr. McKennion says, I attempted to introduce a Sims's catheter, to be ret"ained during the night ; but, meeting with an obstruction in the bladder, and, by manipulation with catheter, finding that she was insensible as to the point of the instrument, I concluded that a hydatid formation was present, and designed at once to have it expelled if possible. 780 DISEASES OF WOMEN. I would say here one of the strongest arguments in my own mind at the time of hydatid formation was, when force was used to pusli up the instrument fartlier, a small amomit of liuid escaped, and no blood. I injected into the bladder two drachms of liq. sodae chlor. (French preparation). In about an hour violent spasms of the blad- der occurred, the urethra dilated, and there was expelled into the vessel about a pint of hydatid. The shape and attachment of these resembled the cactus ; the sacs were transparent and well dcHned. There was but slight haemorrhage. This I attributed to the forciljle distention of the urethra. It is now over five years since their ex- pulsion, and up to this day my patient has had no more inconven- ience with her bladder. Fortunately, my case was a female, and she is well ; this might not have been if it had been one of our own sex.—Ji^eiv Yor'k Medhal Record, Xovemher 20, lSSO,p. 588. (b) Bodies having their Origin in the Bladder Itselt — Under this head come calculi, which may be of various kinds, as uric acid, triple and amorphous phosphates, oxalate of lime, and cystine. The latter are quite rare. Again, the calculi may consist of more than one of these ingredients. Time will not allow me to enter into the extensive field embrac- ing the etiology and treatment of stone. For a comprehensive study of this matter, I must refer the reader to any one of the many excel- lent works on that subject. Calculus. — I shall only speak of one or two points in connection with calculus that are of especial interest in the study of disease of the female bladder. Stone in the bladder is not so common among women as among men. This, I presume, is o^-ing to the large and easily dilatable urethra of the female, which permits small renal cal- culi to pass out ; calculi of the same size in the male being retained in the bladder, and serving as nuclei for larger ones. Symptomatology. — The symptoms are simply those of a foreign body in the bladder, varying with the size, shape, and number of the stones, and also their roughness of surface. Frequent urina- tions, tenesmus, pain before, during, and after urination, some- times incontinence, and always more or less cystitis. Hgematuria is not at all infrequent, and the urine presents all the characters of bladder inflammation, as shown by the presence of pus, epithelium, and, sooner, or later, numerous crystals of the tiiple and amorphous phosphates. The constitution suffers from the constant pain and frequent urination, and the patient gives all the symptoms of a severe cystitis. Diagnosis. — This is comparatively easy in the female bladder, NON-INFLAMMATOPwY DISEASES OF THE BLADDER. 781 for between the judicious use of the sound, conjoined manipulation, and the bladder speculum, a stone can hardly escape detection un- less it be very small or completely encysted. Pi'ognosis. — The prognosis in vesical calculus in women is good, provided the kidneys be not seriously disordered. The cystitis usu- ally disappears soon after removal of the foreign body, under proper treatment ; and even if renal disease exist, it may also sub- side. Causation. — The causes of stone in the bladder are about the same in both sexes, and so I need not dwell long on tliis part of the subject, I may call attention to one cause of the formation of stone in the bladder of the female. In cystocele, a mass of mucus or shreds of membrane and triple and amorphous phosphates gradu- ally collect in this abnormal pouch, and form a nucleus for stone. It is a curious fact, too, that women are particularly liable to have stone after the operation for closure of vesico-vaginal iistula. There has been considerable discussion as to whether calculi, discovered soon after this operation, existed undiscovered in the bladder before the operation, or were formed rapidly after it. Henry F. Camp- bell, M. D., of Virginia, relates one case in favor of the former view, and Dr. T. A. Emmet several in favor of the latter. The belief has been advanced that irritation in the bladder mod- ifies the urinary secretion sufficiently to cause deposit of the urin- ary salts, and thus account for the formation of stone after the operation for fistula. It is claimed that reflex nerve action is ex- cited by the operation, the inflammatory action about the edges of the wound, or by cystitis already existing. This idea that the reflex nerve influence modifies the urinary se- cretion sufficiently to result in the formation of stone in these cases, is, I think, hardly tenable ; for in hundreds of cases of cystitis, where the reflex action does undoubtedlj^ exist, no stone is formed. Then, too, the secretion is as a rule rendered more watery, instead of concentrated, a condition in which precipitation of tlie urinary salts would be very unlikely to take place. A middle position on this question seems to me to be the most rational, and stones found after operations for closing fistula might be due to any one of three causes : («) Calculus already existing in the bladder, escaping detection by being pocketed, or so small as to lie beneath a mucous fold, and rapidly increasing in size after operation, due to the retention of the salts of the urine (deposited by decomposition), that formerly es- caped by means of the fistula. 782 DISEASES OF WOMEN. (J) Calculi, small or large, existing in the kidneys or renal pelves, and washed down after the operation In- the increased flow of limpid urine : these, too, increasing in size hy incrustation. (c) Calculi, the formation of which commences directly after closure of the wound, due partly to retained products of decomposi- tion, possibly to modified secretion, or to small nuclei swept down from the kidney, or, what is much more likely, to nuclei consisting of pieces of mucous shreds, blood-clots, or po.ssibly incrustations on one or more of the sutures which may be exposed in the bladder. I am quite sure tliat the formation of calculi after closing a ves- ico-vaginal fistula is favored by the presence of the catheter in the bladder during the healing process. The drainage is imperfect and if the bladder is not frequently washed there is every facihty for the deposit of urinary salts and the formation of stone. I am the more persuaded that tliis explanation is correct from the fact that, since I have permitted my patients to empty the bladder in the natural way after the operation, I have not had a case of stone following this operation. Treatment. — The female bladder presents an inviting field for experiments on the treatment of stone by solvents ; but as the opera- tion here is so easy and its results so good, it seems hardly justifiable to recommend any other method of treatment. In patients, how- ever, who object to the operation, it may be tried. For a full and interesting account of experiments and statistics on the solvent method, I refer to Mr. Koberts's most excellent work on " Urinary and Renal Diseases," The stone being found and its size determined, it may either be removed by cystotomy or crushed. If the stone be small and soft, it may be advisable to crush it, washing out the fragments through the open speculum in the moderately dilated urethra, thus saving the urethral mucous membrane from laceration by the sharp frag- ments ; or better still the debris may be removed by Bigelow's method. If much cystitis be present, however, or if the stone be large, it is advisable to perform vaginal cystotomy. In this way a stone of large size may be removed from any ])art of the bladder, and an opening for drainage is left to act beneficially on the inflamed organ by giving vent to the urine and its sediment. The bladder should be carefully washed out daily with a warm solution of salicylic acid (1 to 600 or 1 to 400). If drainage is desired, care must be taken to keep the incision open, for it closes very readily. I have spoken several times already as to the method of per- NOX-mFLAMMATORY DISEASES OF THE BLADDER. 783 forming vaginal cystotomy. Emmet dwells especially and justly on the necessity of fixing the vesico-vaginal wall rirmly with a tenacu- Jmn before commencing the incision, which may be made with either a knife or scissors. A calculus in the bladder, if interfenng with labor, or if liable to be caught between the child's head and the pubes, should, if possible, be pushed up out of the way. This is seldom successful, and as much damage may be done the bladder by the crushing of its walls, it is best to puncture and remove the stone at once in case there is time during the labor and the attendant is prepared to operate. Should it be impossible to operate before labor is completed, it should be done as soon afterward as practi- cable. It should be borne in mind that the vascularity is greater in the puerperal state and hence every preparation should be made to arrest li£emorrhage. ILLUSTRATIYE CASES. Foreign Bodies in the Bladder. — By L. H. Dunning, M. D. ; read before the " Indiana State Medical Society " : Case I. — Mrs. A., aged thirty-eight, married, a lady of culture and refinement, was delivered, four years previously, of a liydro- cephaloid child. The delivery was instrumental. "Whether from long pressure of an abnormally large head, or from maladroit use of instruments, I know not, a vesico-uterine or vaginal fistula re- sulted. The precise location of the original opening of the vaginal or uterine extremity of the fistula I am unable to state, as two operations had been done for its closure, both of which were un- successful. The last operation was done in June, 1883, and in the following December I was consulted in consequence of intense pain and burning in the region of the bladder, and pain at the close of the act of urinating. The patient stated she had, a few weeks previously, passed a small stone by the urethra, and now thought there was another and larger one present. An examination with the sound confirmed her diagnosis. I proceeded to remove the stone, assisted by Dr. S. L. Kilmer. The urethra was dilated with a three-bladed dilator, the stone crushed with a Thompson's lithotrite, and removed with Bigelow's evacuating apparatus. We were both confident all the stone was removed. The patient made a good recovery, but was not entirely relieved of the bladder symp- toms. In March, 18S4, I was again called to remove a stone, w^hich the patient stated she had felt with the lai"ge end of a shawl-pin in- troduced into the bladder through the urethra. This time, assisted by Dr. M. L. Morse, a large quantity of stone was removed in the same manner as at the first operation. The lithotrite was introduced 784 DISEASES OF WOMEX. tliree times, and, the last time it was withdrawn, we found within the grasp of its closed blades a silver-wire suture, with the loop cut, but the twist intact. The whole was coated with a phosphate-of-lime deposit. We now felt confident we had secured the foreign body around which the calculus had collected. The patient stated to us that she had been aw'are ever since the last operation for iistula that there was a wire left behind, and that she had once visited the sur- geon to have it removed, but it could not be found. There are many other points of exceeding interest connected with this case, but they are not pertinent to this subject, hence will be omitted. There was a band of dense cicatricial tissue extending transversely across the fundus of the bladder. Posterior to this band was a pocket, in the bottom of which was the vesical extremity of the fist- ula. In this pocket lodged the stone, and was evidently made sta- tionary by the suture, which remained partly imbedded in the tissues. That the wire rendered the stone stationary finds support in the fact that, July 18th, four months after the wire was removed, a fourth large calculus had formed in the bladder, and was quite movable. This last calculus was readily crushed, and voluntarily expelled from the bladder along with water freely injected into the organ. Since this fourth stone was removed, there have been no signs or symp- toms of a calculus in the bladder. Case IT. — Mr. B., a laborer, aged fifty-seven years, was brought to me, by Dr. Kettring, September 19th, of last year, for the re- moval of a foreign body from the bladder. The patient stated that, about the niiddle of August, he passed a cigarette-holder into the orifice of the urethra ; that it slipped away from him, and passed down into the urethra, and, in his efforts to remove it, pushed it into the bladder. Being a mechanic, he had invented an instrument with which he attempted to remove the body, without success. I sounded the bladder, and found the holder lying obliquely across the organ. I judged it to be about two and one half inches long, and as thick as a small lead-pencil. A Xo. 1 8^ sound dropped readily into the bladder, and, since the urethra was of so large a caliber, and the patient had frequently passed his instrument along its track, I concluded to attempt its removal without further dilatation. A Thompson's lithotrite was introduced, and the body seized ; but I was made conscious that the instrument did not grasp it at the end, so I withdrew the lithotrite and introduced a sound, and endeavored to bring the long diameter of the holder in line with the urethra. Now, with l)ut little difficulty, the end was grasped by the blades of the lithotrite, and I proceeded to withdraw the whole. It soon NON-INFLAMMATORY DISEASES OF THE BLADDER. 785 became evident that we had not rightly estimated the size of the holder, for, although it, together with the instrument, entered the prostatic portion of the urethra, we had considerable difficulty in making it advance through the membranous portion. However, avoiding much force, but keeping steadily at work, wath the aid of Dr. Kettring, I succeeded in witlidrawing it to within one inch and a half of the orifice of the urethra. Further than this we could not advance ; so the urethra was incised posteriorly down to the end of tlie holder, and, by applying pressure from behind, made to enter the incision, and was finally entirely withdrawn. We were surprised to see the size of the holder and its breadth when in the grasp of the lithotrite, thirty-five millimetres. There was a moderate amount of haemorrhage from the urethra or bladder; probably from tlie mem- branous portion of the urethra, since that is the most constricted por- tion of the canal. The bladder was washed out with tepid water, and the patient taken to his home in a closed carriage, the operation having been done at my office on account of the patient's refusing to have it done at home for fear of exposure. Soon after reaching home, the patient had a chill, followed by fever. In the next twenty-four hours he had three chills, each time followed by in- creased fever, the temperature ranging from 102° to 101° F. The urine passed was freely mixed with a considerable quantity of mucus and a little blood. 20th, 1.30 p. M. — Patient seen by Dr. Kettring and myself. Had a temperature of 106°. He voided urine in our presence ; it was quite bloody, and, upon close examination, was found to contain a wedge-shaped piece of mucous membrane twelve millimetres long, four millimetres broad, and about two millimetres thick. This was not examined with the glass, but was supposed to be from the mem- branous portion of the urethra, since at that point there w^as the most resistance. There were also voided at this time several small grains of gravel, some as large as wheat-grains Patient complained of con- siderable pain. Bladder was washed out with warm carbolized water. Twenty grains of quinia sul. were given ; one grain opium and ten grains of acetate of potash every four to six hours, and a milk-diet ordered. Further than this, I will not attempt to minutely detail the history of the case, but will simply outline it. In the next twenty- four hours the patient had four chills. The temperature ranged from 101° to 101°, and the pulse from 108 to 120 per minute. "^ Patient perspired profusely, and was at times delirious ; great nervousness ; prognosis was regarded unfavorable. Whisky, in 3 jss doses, every hour, when the temperature mounted high, was added to the treat- 51 78G DISEASES OF WOMEN. ment. Dr. Kettring washed out the bladder twice every day, using for this purpose a soft-rubber catlieter and a rubber bag. We de- bated the advisability of this proocdure, but found that, by this means, we removed a considerable quantity of turbid urine, small clots of l)lood, and occasionally small grains of gravel ; and further, the cleansing of the bladder seemed to afford tiie patient relief ; so we decided to persist in it as long as its use was indicated. 22d. — Patient slightly delirious; pulse, 112; temperature, 101°; slept moderately well last night : has had no chill since 9 p. m. yes- terday. Dr. Kettring found morphine, gr. one sixth, ar. spts. ammo., 3jss, very eflScient in relieving or aborting the chills. At noon to-day patient seemed much better ; at 9 p. m. temperature had fallen to 100°, and pulse to 90 ; Imt the urine had accumulated in the blad- der, and had to be removed by catheterization. 23d, 7.30 A. M. — Patient rational ; has slept well during the night, and voided urine frequently ; pulse is 70, and temperature normal ; the nervous symptoms have nearly disappeared ; had symp- toms of a chill last night, which quickly disappeared under the effects of the morphine and ar. spts. of annuo., with the addition of ten drops of chloroform. From this time forward the recovery was uninternipted. In one week the patient was able to sit up. A few days later he was walk- ing about the streets, and in two weeks after the operation resumed work. Thus happily terminated a case that at one time was exceedingly alarming, in consequence of tlie intense urethral fever that devel- oped. It would undoubtedly have proved fatal had it not been for the skill and unremitting attention bestowed upon the case by Dr. Kettring. Stone in the Bladder; Lithotrity by a Siagle Operation. (N. A. Powell, M. D., Edgar, Ontario.)— S. F., aged now five years, first presented symptoms of trouble referable to the urinary organs in October, 1S76. Pain, partial incontinence, and the pa-^sage of blood and mucus continued from this time, and in January, 1878, a bit of "gravel" the size of a split pea came away. During the following spring the desire for urination became almost constant, and vesical tenesmus was marked. On June 12th, my friend. Dr. Blackstock, of Hillsdale, was called to see her, and on tho 13tli, under an anaesthetic, he e.camined, and found a calculus at tlie neck of the bladder. An operation for its removal was advised, and pending this, anodynes were freely given. On July 9th, the writer, in cunsulta- NON-INFLAMMATORY DISEASES OF THE BLADDER. 787 tion, saw the case for the first and only time. The child was said to be failing very fast ; she was much emaciated ; was suffering severely, and seemed to gain a respite from her pain only when violently rocked while in the knee-chest f)osition in a cradle. Pulse 140, temperature 102^° F. Chloroform, replaced later by ether, was given, and a stone found jammed into the upper part of the urethra. This was displaced upward, caught in the blades of a smaller Weiss and Thompson lithotrite, and crushed. The scale showed five eighths of an inch separation of the blades. Further comminution of the fragments was effected by means of long polypus forceps. Evacua- tion was accomplished by the same, aided by the frequent injection and aspiration of warm water through a large-sized Eustachian catheter, to which a strong rubber bulb had been attached. This last was the best substitute at hand for Bigelow's or Clover's appa- ratus. The vagina was too small to admit a linger without undue stretching, but water could be retained in the bladder by pressure upon the urethra. The first calculus being removed, suprapubic pressure brought two other and smaller ones within reach, and these were treated as the first had been. The distance between the outer surfaces of the blades of the forceps used when grasping the largest fragment re- moved was three tenths of an inch; this, then, was the limit of urethral dilatation. The lithotrite was used for crushing five times, the forceps twenty or thirty times. The time occupied was one liour and a quarter. The bladder being washed and aspirated till, as nearly as possible, freed of its solid contents, the child was put to bed with hot applications over the pubes and to the extremities, and a full anodyne was given. The detritus collected at the time of operation weighed 241 grains ; subsequently seven grains more were obtained from the strained urine. For the history of the case after this, I am indebted to notes kindly sent me by Dr. Blackstock or his assistant Mr. Gould, who, with my students Messrs. Shepherd and Bremmer, gave assistance during the operation. " Partial control of the urine returned on the day following the lithotrity, and complete control, except during the night, after three days. The desire to void urine occurred about every hour for several days, and at the end of a week, about every third hour. Slight haematuria was noticed for two days." Under date August 2Tth, I hear that "the child's general health is good. She is gaining in flesh, and has no symptoms of her former trouble." The above case would a year ago, hardly have merited transerip- 788 DISEASES OF WOMEN. tion from the case-book of a country physician to the pages of a medical journal. But since the appearance of Dr. Bigelow's paper on litholapaxy * the whole subject of the tolerance of the urinary ])lad(ler for prolonged instrumentation has come up for reconsid- eration, and this is offered in evidence. From Civiale down, all lithotritists, so far as the writer's knowl- edge extends, have held that the visits of a lithotrite to the interior of a bladder must be strictly limited in point of time. Though ex- perts may, at times, have given themselves more latitude, they have always taught others not to exceed five minutes for any one crush- ing. Of late years, also, the tendency has been to confine the opera- tion within narrow and yet naore narrow limits, treating by it only such moderate sized stones as could be got rid of in from two to four sittings. It remained for the Harvard professor to demonstrate that the calculus-containing bladder of an etherized man might be manipulated for one, two, or more hours, and yet not resent it by cystitis or subsequent atony ; provided that no sharp fragments were left in it to do outrage to its lining membrane. Although the case just given occurred in a female child instead of in an adult male, it seems to support Dr. Bigelow's conclusions as to vesical tolerance. Surely the delicate tissue of a child's bladder is ill adapted for pro- longed contact with instruments, while the proportion of the organ covered by peritonaeum in the child being greater than in the adult, there would seem to be a greater danger of serous inflammation. Yet, here all irritation promptly subsided when the irritant was re- moved, although its removal took one hour and a quarter. May we not expect like results when even large stones are crushed in the male bladder, and evacuated by the new method ? Statistics so far — seventeen cases, sixteen successful — seem to point that way. It may be asked why the urethra was not more widely dilated in this case ? My answer is that too large a proportion of those thus treated have been made dribblers for life by it. The case with which stretching may be accomplished, and the free access which it gives to the bladder, will strongly tempt a surgeon who docs not look beyond the operation he has to do at the future life of his patient. Prof. Simon, of Heidelberg, made f many accurate meas- urements to determine the extent to which the adult female urethra may be dilated without the risk of incontinence. His limit is in width, eight tenths of an inch : in circumference, (1-3 cen., (==2*4 inches). This would allow a finger to pass, but not a finger plus a * " American Journal of Medical Sciences," Januan-, 1878. f Translation in "New York Medifal Journal," October, 1875. NON-INFLAMMATORY DISEASES OF THE BLADDER. 7^9 pair of forceps. Mr. J. R. Lane thinks no stone larger than an acorn should be removed entire through the urethra of an adult female, and none larger than a bean through that of a chiid. Dr. Hunter McGuire, of Richmond, Va., states that many cases of so- called successful operations by dilatation and extraction have, to his personal knowledge, been followed by incontinence. Rapid dilata- tion, however, seems to be less dangerous than slow. In jjroof of this, I may, in conclusion, mention that I have knowledge of the case of a girl, aged twelve years, into whose bladder a pair of sequestrum forceps was pushed, a calculus seized and extracted vi et armis^ dilating and lacerating the urethra as it came. The stone was as large as a pigeon's egg. Absolute incontinence existed for twelve days, but was followed by recovery. Stone sacculated in the Bladder of a Female. (By Charles Will- iams, F. R. C. S., Ed., Surgeon to the Norfolk and Korwich Hos- pital). — Cases in which a vesical calculus is impacted in a cyst situated in the walls of the bladder are so extremely rare that I consider it a duty to record this very interesting example : A line, healthy girl, aged three years, living in Norwich, came mider the care of the late Mr. George Hutchison in the year 1873, having for several months previously suffered from very decided symptoms of stone in the bladder. It had been noticed by her mother that from the time of her birth she had experienced diffi- culty, as well as occasionally severe pain in passing urine, and that sometimes she voided blood mixed with it, and was in the habit of straining so violently as to produce prolapsus of the rectum. On sounding the bladder, which was an unusually capacious one, it was with some difficulty that a calculus could be detected. At the wish of the parents Mr. Hutchison resolved to remove the stone by dilatation. Mr. W. H. Day assisted at the operation, and I was requested to administer chloroform. The urethra was freely and quickly dilated with Weiss's trivalve dilator. There was considera- ble trouble to find the stone, and when found a still greater trouble to seize it with the forceps, (and it was particularly noticed that, although the patient was thoroughly under the influence of the anaesthetic, the getting hold of the stone with the forceps occasioned severe straining) ; the blades could not be made to grip the calcu- lus ; they continually slipped off, bringing away pieces of the stone. At last it became absolutely necessary to ascertain what occasioned the difficulty. For this purpose the urethra was still further dilated, and the neck of the bladder was also divided with a probe-pointed bistoury. The stone could now be felt with the point of the finger 790 DISEASES OF WOMEN. immovably fixed in the floor of the bladder on tlie patient's left. It appeared to be of the size of a pigeon's egg, and was inclosed in a sac, through the neck of which a small portion protruded into the vesical cavity, and it was oflp this nodule that the forceps so continu- ously slipped. Many efforts were made to dislodge it — first with a scoop, then with the fingor, which could barely reach it, and next with the forceps ; they all proved unsuccessful. Several portions were broken off the uncovered portion, but the main piece was left in situ, as it was considered undesirable to make any further at- tempt to remove it, tbe patient having been a long time under the influence of chloroform, and apparently in a very exhausted con- dition. The next day the child had voided very little urine. A catheter was introduced, and a small quantity of sanguineous urine flowed out. She was very drowsy, and had been so since the operation. When aroused she took milk and brandy very freely, but immedi- ately afterward became drowsy again. She did not appear to have recovered from the influence of the chloroform. The next day she died. No post-mortem examination was permitted. I am induced to believe that this child died of chronic chloroform- poisoning, and not from the effects of the oj^eration, which was by no means roughly performed, and that there was very little blood lost. She never thoroughly revived, but became comatose, and died in that condition. It is difficult to imasfine what could have ffiven rise to the formation of the sac. There never was an obstruction to the escape of the urine, such as stricture or prostatic enlargement might engender, for neither existed. We are taught that a cyst is usually formed by the straining necessary to expel the urine ; the mucous membrane is forced between the bands of muscular fibers, hypertrophied in consequence of the strain to which they are sub- jected. Nothing of the sort can apply in this case, and it is not easy to believe that the stone was the cause of the cyst, which it might have been, had it been situated close to the neck of the bladder. When impacted in this situation, tlie very pressure to which a stone is subjected by the constant and long-continued action of the bladder to expel it, causes the mucous membrane to ulcerate through, and the stone is in due time forced into a cavity, which enlarges as the stone grows, and in this way it may form a tumor in the vagina. An effort is then made by nature to contract the opening, which in this child was nearly accomplished ; but the calculus was far from the neck of the bladder, and could barely be touched with the point of the finger, so that a different explanation of the formation of the NON-INFLAMMATORY DISEASES OF THE BLADDER. 791 cyst is required ; and as no examination was allowed to be made, it seems to me to be almost impossible to suggest in what way the sac was formed. Sabulous matter, or a few urinary crystals, may prob- ably have been deposited originally in a mucous follicle, lacuna, or fossa, and gradually augmented in (quantity, and in this way the sac inclosing the calculus may have been produced. The motiier of tlie girl at four years of age suifered from stone, whicli was removed by the late Dr. Edward Iiibbock ; it was the size and shape of a wal- nut. She has suifered from incontinence since that time. I believe that it would have been very much better to have re- moved tliis stone by cystotomy. Had the patient lived she would have suifered from injured urethra. (c) Foreign Bodies introduced into the Bladder through the Urethra. — Of these it may be truly said that "their name is legion," for in the literature of the subject we find recorded a most numerous and diverse list of objects found in the bladder of the female. Some of these objects were forced into the bladder by accidents, such as falls or blows ; others were intentionally introduced into the urethra for the purj)Ose of masturbation, and then pushed or drawn into the bladder. The same may occur in auto-catheterization, the instru- ment being sometimes broken off in the bladder, and at others, drawn bodily into the viscus. Hysterical and foolish women, with or without the intention of masturbating, have passed all manner of things into the bladder, as pins, needles, matches, sand, charcoal, bits of glass, bodkins, and tooth-brush handles. Masturbators have also forced in various articles, such as twigs, small wax candles, penholders, nails, pencils, and the like. Cathe- ters and clay-pipe stems, that have been used for purposes of cathe- terization, have been broken off and left in the bladder. Pessaries, which have been badly fitted, or worn too long, have passed l)y ulceration from the vagina into the bladder. 8yi)iptor)iatology . — The symptoms need not be given in detail, as they are the same as those caused by any foreign body, usually aggra- vated, however, if the body be shai-p and have jagged edges. Bleed- ing is not uncommon, and pain varies in amount and severity with the kind, size, and shape of the foreign body. Hysterical women have been known to conceal the pain and tenesmus for a long time. If the bodies be small and blunt, they may give rise to but little pain or tenesmus, and, remaining in the bladder undisturbed, form nuclei for calculi. I doubt if a modification of the urinary secretion by reflex nerve influence (excited by these bodies) is necessary to 792 DISEASES OF WOMEN. cause incrustation, or form calculi. The hypersecretion of mucus and decomposition of urine is all that is required. Treatment. — The treatment of a foreign hody in the bladder is summed up in two words — remove it. This must first he tried through the urethra. A pair of forceps (those known as the alli- gator forceps being the best) are guided to the object, which is to be seized and removed. If this is difficult, tlie operation may be done through the speculum. If the bodies be small, they may possibly be washed out. If they are so situated that their removal by the urethra is impossible, vaginal cystotomy may be performed, and the foreign bodies thus removed, using such after treatment as will re- lieve any cystitis, which may have been produced. CHAPTEK XLIV. NON-ENTLAMMATOKY DISEASES OF THE BLADDER (CONTINUED). RUPTURE OF THE BLADDER. Rupture of the bladder may be classified according to its loca- tion and extent, as follows : I. Complete and incomplete. II. {a) Occurring at a point where the bladder is covered with peritonaeum. (b) Where the bladder is not covered with peritonaeum. I. In the complete rupture all the coats of the organ are divided, while in the incomplete variety one coat at least remains undivided. Pathology. — The complete form of rupture is the most common, and the location at which it most frequently occurs is the posterior and upper part ; that is, the part where the walls of the bladder are the thinnest, and probably where there is the greatest exposure to the causes of the injury. There is another reason given why rupture is more frequent where the bladder is covered with peritonaeum, and that is because the peritoneal covering is not so elastic as the other coats. When the laceration occurs within the limits of the peritoneal coat, and is complete, the urine escapes into the peritoneal cavity, and produces shock and peritonitis, which usually prove fatal. In rupture at any point not covered with peritonaeum, infiltra- tion of urine takes place in the tissues beneath, not within, the peri- tonaeum. This infiltration is sometimes very great, extending from the cellular tissue of the pelvis to the labia and thighs. The clinical history of these two varieties diifers in its char- acteristics because of the fact just mentioned — that in the one va- riety the urine escapes through the rapture into the peritoneal cavity, while in the other the urine infiltrates the tissues in and about the pelvis. T9J: DISEASES OF WOMEN^. In the one, peritonitis is speedily developed, as a rule, and gen- erally proves fatal ; in the other, the progress is slower, and the chief danger is from septictemia. There is another class of cases having a pathological history which holds an intermediate position between the two already described. In this class the history points to the fact that the rupture has been at a point destitute of peritonaeum, or else the rupture has been incomplete, not involving the periton.eum. This gives rise to symptoms of severe internal injury, but less severe than in complete rupture, which is followed by a sudden giv- ing way and escape of urine into the peritoneal cavity, and subse- quent peritonitis. This opening into the peritoneal cavity at a pe- riod remote from the injury, is due to pressure or ulceration or sloughing, which completes the rupture. Symptoinatology . — The symptoms of rupture of the bladder are ordinarily developed as follows : There is usually shock in a mai'ked degree, and if the pelvic bones are broken — a frequent complication of this injury — the patient is unable to move after having rallied from the shock. Severe pain is felt in the hypogastiic region, and a continual desire to urinate, without the power to void tlie smallest quantity of urine, or possibly but a few drops mixed witli blood. The constitutional symptoms indicate great prostration, which rapidly ensues. The patient has an anxious look, the countenance is pale, the pulse feeble and fluttering, respiration sighing, skin clammy ; the abdomen in a short time becomes tympanitic. There is also a rise in temperature after a time, but during the shock the temperature may be sub-normal ; delirium, convulsions, and coma may occur, and death may take place in a few hours in severe cases, or it may be delayed a few days. A fatal result occurs sooner in complete than in incomplete rupture. If the patient sur\dves the shock or collapse, life may be en- dangered by the development of pei-itonitis or septic.^mia. The physical signs of rupture are few and by no means reliable. I must therefore give more attention to the clinical history and symptoms, incidentally bringing out the only physical signs obtainable, such as the empty state of the bladder found when that viscus has not been emptied in several hours, and the withdrawal of a small quantity of bloody urine by means of the catheter. The surgeon is not able to make a certain diagnosis in all cases, as the symptoms are not always pathognomonic. The statement of the patient that she received a blow over the hypogastrium, or that while in the act of straining she felt something give way, are valu- NON-INFLAMMATORY DISEASES OF THE BLADDER. Y95 able as evidence when acute pain and other symptoms of ru])ture follow. The evidence obtained from tlie use of the catheter is of value, especially when it is known tliat the patient had not urinated for several hours prior to the accident. LTnder these circumstances when the bladder may contain a small quantity of bloody urine or when the bladder is empty, there is strong evidence of the bladder being lacerated. But the evidence pointing to rapture is by no means always certain. And again very often signs and symptoms whicli the diagnostician depends upon most are absent, and those that are present are liable to mislead. This is very unfortunate, but true. The diagnosis is especially ob- scure when there has been a long interval between the receipt of the injury and tlie development of characteristic symptoms. It is there- fore necessary to watch a patient in whom there is suspicion that rupture of the bladder may have occurred. The symptoms may be for a time concealed and then develop rapidly. The first symptoms may be delayed or be obscure and not attract attention, because the vesical rupture may be involved with other injuries whose symp- toms for the time hide the more dangerous lesions. As a rule, it is rare to find any external signs or mark of injury on examination of tbe abdomen. When much depends on the history given by tbe patient regarding the nature of the accident and the condition of the bladder at the time, it frequently happens that she is not able to answer questions correctly, because of the shock and the fact that this accident often occurs while the patient is intoxicated. Strange as it may appear, in exceptional cases the patient may have no difficulty in urinating, and indeed may pass a large quan- tity of water. Cases have been recorded where the patient regained the power of voluntary urination after the catheter was passed for tiie first time. Although it is important to make a diagnosis early in all cases, yet it is of equal importance to know whether the rupture is com- plete or incomplete. This can be done by noting the fact that in the one case tliere will be infiltration of the unue into the cellular tissue of the pelvis, and in the other such infiltration is absent. It is often necessary to pass the catheter both for diagnosis and treatment, and great care should be taken in its introduction, for sometimes by using too much force it is accidently pushed through the viscus into the abdominal cavity. Prognosis. — Tlie chances of recovery are not favorable, espe- cially when the urine passes into the peritoneal cavity through a 796 DISEASES OF WOMEN. rupture high up. Wlien the rupture is incomplete or does not in- volve the peritoneal coat and treatment is early employed, the pros- pects of saving the life of the patient are encouraging. Causation. — The predisposing causes of rupture are certain con- ditions of the walls of the bladder, such as atrophy, fatty degenera- tion, ulceration, and sacculation ; overdistention from stricture or other causes, and alcoholic intoxication which favors overdisten- tion, and exposure to the exciting causes of the accident. The empty bladder may be lacerated in connection with injuries of the other pelvic organs, but it is a fact that in the majority of cases the bladder has been less or more distended at the time of the accident. It should be borne in mind, however, that rupture has occurred a great many times when the bladder was normal and not overdis- tended, there being no predisposing conditions present that could be recognized. The most common determining causes are blows over the region of the bladder. These may be sustained in a variety of ways, such as direct blows or knocks, falling from a height upon something which violently strikes upon the hypogas- trium. Rupture often occurs in connection with severe injuries which fracture the pelvic veins. In such cases it is not possible to say whether the rupture occurring under such circumstances is due to the direct blow or to laceration by pieces of the broken bones. Rupture has occurred sufficiently often in the puerperal state to warrant placing this condition in the list of predisposing causes. One can see how a distended bladder might be ruptured during the violent labor -pains or the contortions of instrumental and manual delivery, and this accident has occurred in that way. In a number of cases, however, the rupture has not taken place un- til after delivery, showing that the labor gave rise to retention, and that to rupture. So far, then, as the puej*peral state is related to rupture of the bladder it may be said that a full bladder may be ruptured by the direct violence done during delivery, but quite as often retention occurs in the puerperal state, and the rupture is caused by overdistention. In a similar way rupture has occurred in displacement of the uterus which caused retention of the urine. The bladder has frequently been wounded during ovariotomy and hysterectomy when there were adhesions, but this accident does not come under the head of rupture now under consideration. Treatment. — The first indications are to relieve pain and shock if either is present. These objects can be attained usually by opium and stimulants. If there is infiltration of urine into the pelvic cellular tissue the urine should be removed by punctui'ing or incis- NON-INFLAMMATORY DISEASES OF THE BLADDER. 797 ing the parts atfected. [Next, and most important of all, the bladder should be continuously kept empty by retaining the catheter in the bladder. The catheter should be a flexible one of soft rubber with a perfect eye very near the end. It should be made to enter the bladder only far enough to secure perfect drainage and not far enough to disturb the wound in the bladder. Yaginal cystotomy has been recommended as a means of drainage, but I feel sure that the catheter is a simpler, and certainly as reliable a means of accom- plishing the object. The management of the graver cases, in which the rupture opens into the peritoneal cavity, must be of the most heroic character in order to be effectual. The great object is to cleanse the peritoneal cavity of urine and blood. This has been done when the case was seen early, by pass- ing the catheter into the peritoneal cavity through the rent in the bladder. When this can be done easily it may answer that purpose, and the patient may be treated by rest and opium ; but, unless the catjieter passes without much effort and the one catheterization is sufficient, this method should not be persisted in. Laparotomy appears to offer the best chances in these very for- midable cases. If the patient is seen early, and before extensive peritonitis has been established, I believe the best that can be done is to open the abdominal cavity, and thoroughly remove all blood and urine that have accumulated. When this has been accom- plished the wound in the bladder should be accurately closed with sutures. In case the edges of the wound are very irregular, and will not fit together accurately, they should be trimmed suffi- ciently to give a clean and complete coaptation. The after-treat- ment should then consist in draining the bladder, as already mentioned, and managing the patient as in laparotomy for any purpose. ILLUSTRATIVE CASES. Case of Rupture of Female Bladder associated with Abortion (by T. Lawrie Gentles, L. F. P. S. G., Derby).— On October 13th I was requested, at 3 a. m., to visit a woman in a neighboring street, who was said by the messenger (her husband) " to have had a mishap." On reaching the house I found a well-made woman of thirty-six lying on her left side in bed, vomiting large quantities of a dark- brown, pungent-smelling liquid. The pillows were drenched with the fluid, so also was the carpet in front of the bed, and on the walls opposite to the patient were stains of a similar nature. There was also half a pint of vomit in the chamber-vessel. The woman was in 798 DifciEASES OF WOMEN. a state of collapse ; a cold; clammy perspiration stood on her face, her hands and feet were like ice, and her pulse was iiiij)er< e]>tihle. There was no one in the house except her husband and two little children, the latter occupying the same bed as the patient; while, to add still mure to the ghastliness of the scene, the younger of the children (a babe of nine months) was vainly endeavoring to reach its dying mother's breast in order to obtain its usual nourishment. I made a rapid examination by the vagina, but found a closed OS uteri, and no marked traces of hcemorrhage. I observed, however, that the abdomen v/as greatly distended. I tried to administer some ammonia, but the patient was unable to swallow ; she gave me one agonizing look of dread, moved her lips as if t j speak, and then died, the death taking place within a quarter of an hour after my arrival at the house. My first impression was that the woman had died of internal haemorrhage ; the only things which seemed to militate against tliis being the redness of the lips and the copious vomiting. This idea of hsemorrhage seeuied also confirmed by what the husband said at the bedside — viz., that " his wife had had a good many clots come from her, and that her linen was very much stained." I refused, of course, to give any certificate, and communicated with the coroner. In collecting evidence for the inquest, the follow- ing facts were clearly brought out ; first, that the woman Avas a drinker ; secondly, that she had had a drinking-bout for some days ; and thirdly, that she had had occasional difliculty in passing urine. In regard to the first two points, the husband's evidence was most conclusive, and showed clearly that vzhe.i tlie poor woman had one of her drinking-fits on, she would not only consume large quantities of beer (her favorite drink), but also all the spirituous liquors she could lay her hands on. In regard to the third point, the hus- band also made clear the fact that his wife had often suffered from retention of urine, but, "so far, had always got over it." At the inquest, further details of evidence brought to light the fact that the woman had complained of pain in her belly for two or three days previous to death. She had, however, been "up and down stairs" until 1 p. M. of the day preceding her death ; but when her husband came home at 6 p. m., he found her in great pain, and was told by his wife that "she had been losing blood." A good many clots were in the chamber-vessel, and these he threw away into the ash- pit. The pain getting no better, and finding that his wife was " altering for the worse," he came for a medical man as already stated. NON-INFLAMMATORY DISEASES OF THE BLADDER. 790 At tlie autopsj there were no external signs of violence found, except a slight abrasion on the forehead, and another on the lower lip, and a small bruise on the inner side of the right thigh, none of which were of recent date. On cutting through the abdouiinal walls, the great depth of fat and its extreme " wateriness " arrested our at- tention, the knife going through the tissue with a distinct "swish." Suspecting an accumulation of fluid in the abdominal cavity, a small incision was made at first. No sooner was this done than a reddish- brown liquid began to well up. Sonae of tliis was drawn off, and the opening enlarged, when nearly six pints of fluid were removed. The stomach and. intestines, having been carefully examined, were then taken out, in order to facilitate further search for the lesion. The first thing which we noticed was a pint of blood lying in the pelvic basin ; and, on making more minute search, a rent was discovered in the posterior wall of the bladder — a rent large enough to admit four fingers. Here, then, was the cause of death. There were some fresh adhesions on each side of the bladder and the pelvic walls; there were also similar adhesions between the bladder and uteiiis. All these adhesions, however, were extremely soft, and broke with the slightest pressure. The walls of the bladder itself also seemed much thinner than usual. No flakes of lymph could be discovered in the fluid removed from the abdominal cavity, and neither did the peritonaeum exhibit any great degree of vascularity. It may be, however, I think, safely affirmed that a large portion of the fluid found was effused from an irritated peritonseum, the other portion of the fluid being, of course, urine from the ruptured bladder. On opening the uterus, signs of recent delivery presented them- selves ; on observing which I asked my son to tell the husband to rake up " the clots " from the ash-pit. The husband did so, and one of the " clots " was found to be a foetus, three inches in length. Now comes the question : When did the rupture of the bladder occur, and had uterine action anything to do with it ? Supposing that the "pains in the belly," of which the woman complained for two or three days before death were the commencement of the abortion, it is reasonable to infer that, when true expulsive efforts on the part of the uterus began, these efforts would be aided by the action of the abdominal muscles ; and, supposing still further, that the bladder was at that time distended to its fullest cajjacity, it is perfectly possible that the pressure of the al)dominal muscles would be the "last straw" necessary to produce the fatal lesion, I am, therefore, inclined to think that the rupture took place in the after- noon of the 12th, I ought to have stated that, although, when the 8uO DISEASES OF WOMEX. husband came lioine at 6 p. m. on that day he found his wife in bed, she, nevertheless, " kept getting out of bed, trying to pass urine, but could not." There can be little doubt that the alcoholic condition of the patient would rob her of her sense of attending to the calls of nature; and it is mL4ancholy to think that, if she had only been seen earlier, a simple catheterism might have saved her. As a piece of concurrent evidence of the habits of the patient, it maybe stated that the liver was a genuine "nutmeg"; that the kidneys were thoroughly disorganized (the cortical substance being rarely distinguishable) ; and that the spleen was exceedingly soft. The heart was small and fatty. The lungs were fairly healthy, but there were extsnsive adhesions in the right pleural cavity. The head was not examined. — British Medical Journal^ January 6', 1883. Cases of Rupture treated by Laparotomy. — (A. G. Walter.) — Ten hours after a severe injury, no urine was found by the catheter. The abdomen was opened in the linea alba by an incision beginning one inch below the umbilicus and terminating one inch above the pubes, to the extent of six inches. The intestines were found inflated, their peritoneal coat, as well as that hning the interior of the ab- dominal walls, already showing evident marks of congestion. A soft sponge was then cautiously introduced into the abdomen, with which the extravasated fluid, consisting of urine and blood, was carefully removed from the pelvis and between the convolutions of the bowels, amounting to nearly a pint. A rent was found at the fundus of the bladder, two inches in extent. The cavity of the ab- domen being cleansed of the noxious agent, the wound of the blad- der was left to itself, as no urine was seen to escape from it. The abdominal wound was closed by strong Carlsbad needles, secured by silver wire (only skin and fascia being stitched, while the peritonaeum was left untouched); a flannel bandage encircled the whole abdomen. The patient, awakening from the anaesthetic sleep, felt relieved of pain and the desire to urinate, so distressing before the operation ; vomiting did not return ; opium in one-grain doses was ordered ; abstinence of drink and perfect quietude of body, with retention of the catheter, were strictly insisted upon. He soon began to doze, had a comfortable night, was free from pain the next morning, com- plaining only of soreness in the abdomen, without tympanites, sick- ness, or calls to urinate ; thirst less urgent. The treatment being vigorously continued, for drinks iced barley-water, water only in very small quantities, with pieces of ice, being allowed. Xo un- pleasant symptom followed ; urine in small quantities, but free of NON-INFLAMMATORY DISEASES OF THE BLADDER. 801 the admixture of blood, passing by the catheter. On the third day the intervals between the doses of opium were lengthened to two hours; on the fifth, to three, and thus gradually decreased as all signs of inflammation had passed. At the end of a week the abdominal wound appeared to be closed by iirst intention ; the stitches, however, were not removed till a week later. The gum-elastic catheter was replaced by a new one every two days, and was not withdrawn for two weeks after the injury had been received, and then only for a short time. At the expiration of two weeks, with the absence of all pain and tenderness, opium was omitted. The intestines were re- lieved by warm-water injections on the tenth day, when mild nour- ishment was ordered. Between the second and third week the catheter was permanently withdrawn, and only introduced every four hours for the evacuation of urine. After the third week, the patient left his bed. He has remained well, working at his trade, and feeling no impediment in his urinary organs. (Alfred Willett). — An incision some Ave to six inches in length, from the umbilicus to the pubes, was made in the mesial line and carried through the parietes. All bleeding points having been se- cured, the peritonaeum was opened, and at once several ounces of dull, brownish fluid, with strong urinous odor, escaped. The intes- tines were greatly distended, and instantly bulged out through the wound. The peritonaeum generally was highly injected, and adja- cent surfaces were glued together. Passing my hand into the pelvis I detected a laceration of the bladder. The coils of gut were only slightly more adherent here than in the abdomen proper ; I satis- fied myself that there was no protrusion of bowel into the lacerated bladder. The omentum was raised from off the intestines, and so much of the latter as lay in the pelvis was drawn up, laid upon the upper part of the patient's abdomen, and protected from harm and chill by flannels wrung out of moderately hot water. There was about half a pint of bloody, urinous fluid in the pelvis, and when this had been sponged away, a rent of the bladder some three and one half inches in extent was exposed. It extended diagonally across the fundus, having a direction from before backward and from right to left. The appearance was that of a nearly straight tear through all the coats of the bladder, except at its most dependent parts, where it was jagged and uneven. The bladder was flaccid, but, of course, quite empty, and at the site of rupture its walls were fully half an inch in thickness. I brought the toi'n edges easily in apposition, and united them by eight interrupted sutures of fine Chinese silk. The sutures were placed at intervals of rather less than half an inch, and seemed 52 802 DISEASES OF WOMEN. to close the rent completely. Before returning the intestines I cleaned out the abdomen as thoroughly as I was able ; but the mes- entery of the gut lying outside the abdomen acted as a transverse diaphragm, and I was disappointed to find on replacing these coils that some of the fluid had been pent up above it. Owing to gaseous distention, very considerable difficulty was experienced in rei)]acing all the intestines ^vithin the abdomen, and I was quite unable to in- troduce my hand and cleanse the upper part of the peritoneal cavity as satisfactorily as I could have wished ; but the patient's shoulders were raised in order to make the pelvis more dependent, and all fluid that found its way there was removed. The intestines that had been lying out of the abdomen during the operation were sponged over with warm water and carefully cleansed before returning them. So extreme was their distention that to enable me to introduce sutures, and close the external wound, Mr. Langton, who assisted me, was obliged to spread out his hand and restrain the bowels from forcing their way through the wound, withdrawing his hand gradually as the successive sutures, also of Chinese silk, were tightened. Through the lower angle of the abdominal wound I passed a carbolized drain- age-tube into the pelvis, securing it to the edge of the external wound, which was then dressed precisely as after ovariotomy. A Thompson's catheter was introduced and retained in the bladder. On being replaced in bed, hot bottles were placed beside the patient, and he was well covered up. The wound in the abdominal parietes was found on the autopsy to be adherent almost along its whole line ; not much swelling of abdomen. The intestines immediately behind the wound were adherent to it. All the coils of intestine in the lower half of the abdomen were adherent to each other and to the abdominal walls by recent lymph. The intestines in contact with the bladder were adherent to it. There were about two ounces of bloody fluid at the back of the peritoneal cavity ; about an ounce of this lay just above the bladder. The opening in the bladder was everywhere well closed, except between the posterior two stitches, where there was an orifice through which water injected per urethram escaped very freely. Even here there appeared to be an attempt at repair. Elsewhere the edges of the wound were adherent. There was very little sign of inflammation in the interior of the viscus. (Christopher Heath). — Man, aged forty-seven. Pubes being shaved and washed with carbolic lotion, an incision was made in the middle line just above the pubes for two inches, and the tissues divided down to the peritonaeum, which appeared blue, the recti mus- cles, which were firmly contracted, being held aside by retractors NON-INFLAMMxiTOKY DISEASES OF THE BLADDER. 803 with difficulty. The peritonaeum was then picked up and a cut made into it, when a gush of tiuid, hke that drawn off by the catheter, came out. A large quantity of clots was then taken out from the peritoneal cavity. The finger introduced into the peritoneal cavity found a long rent in the posterior wall of the bladder high up. This was sewed up by a continuous catgut suture firmly tied at both ends. The clots were removed as far as possible from the peritonaeum, and the cavity sponged out after injection with warm water, and a long large-sized drainage-tube was inserted at the lower angle of the wound, the upper part of the wound being brought together by deep and superficial sutures. A catheter was passed into the bladder, to which was afterward attached some India-rubber tubing leading into a vessel under the bed. Hot poultices were applied to the al)douien, and one grain of opium was administered every four hours. Tlie fur- ther history shows great relief and improvement, but on the fourth day after the operation the patient became rapidly worse and died. Autopsy. — Small intestines considerably distended. For two inches around the abdominal wound the intestines were adherent by recent lymph to each other, and to the abdominal parietes. Above and on each side of these adhesions there was no trace of peritonitis. On tearing away these adhesions some coils of intestines' were seen lying over the pelvis glued together, and to adjacent parts by recent blood- stained lymph. On lifting these coils upward, the recto-vesical pouch of peritonaeum was exposed, containing about six ounces of clotted blood, black in color, and moderately offensive odor. There was a rent in the mid line of the posterior wall of the bladder two inches in length, extending upward as high as the apex. The lower third of the rent was gaping ; the edges of the rest were approxi- mated by the catgut suture, the lower end of which was free and loose. CHAPTEE XLY. NON-INFLAMMATOEY DISEASES OF THE BLADDER (CONTINUED). NEOPLASMS, HYPERPLASIA, ATROPHY. Owing to the very imperfect facilities for observing the internal surface of the bladder during life, the study of vesical neoplasms up to within a few years was chiefly post-mortem, and of course their therapeutics was almost nil. At the present time, however, by means of the endoscope, the microscope, and the operation of cystotomy, more accurate methods of diagnosis and of rational and successful treatment have been developed. The neoplasms of the bladder may be classified as follows : Benign. — Myxoma, fibroma, myoma, myofibroma, tubercle. Malignant. — Epithelioma, encephaloid, scirrhus, sarcoma. Tumors of the bladder and deposits in its walls are by no means common, and those of a benign nature are less common than those that are malignant. There has been some dispute as to whether some of these neoplasms are malignant. This is especially the case in regard to the villous growth, the German and some English authorities ranking them as essentially malignant, while some American authors, as Yan Buren and Keyes, deny in toto that they have any such property. More will be said of this when I come to the class in which I have placed them ; not that I am satis- fied that they are malignant, but for lack of positive evidence of the new idea, temporarily at least, I adhere to the old one. Benign Growths. — Myxomata, Mucous Polypi, and Polypoid Hy- pertrophies, while having nearly the same anatomical characters, are really different affections as regards etiology, symptomatology, prog- nosis, and treatment. Mucous polypi are isolated hypertrophies of the mucous mem- brane, varying in size, and giving rise to trouble only in proportion to their size. They may exist at birth, or be develo]3ed at any time during life, being more common, however, in youth and middle NON-INFLAMMATORY DISEASES OF THE BLADDER. 805 age. The mucous membrane covering them is thickened and pulpy, and that about their base and in their immediate neighborhood is somewhat thickened, and more vascular than normal. If the polypi are situated at or near the neck, or in other portions of tlie bladder, where their long, narrow pedicles admit of a blocking of the urethra, the entire mucous membrane of the organ suffers, as in all cases of retention and decomposition of urine. If the obstruction is great, and the organ requires spasmodic and irregular muscular effort to empty it, there will be, sooner or later, not only cystitis, but mus- cular as well as mucous hypertrophy. These growths may be as small as the head of a pin, or as large as a goose-egg ; they consist of hypertrophied and hyperplastic connective tissue, covered by soft, pulpy, hyperplastic mucous membrane, that bleeds easily on touch. They may coexist with uterine fibroids. Their favorite seat is the posterior wall of the bladder. General polypoid hypertrophy of the mucous membrane con- sists in an irregular thickening of the mucous membrane through- out, accompanied as a rule by hypertrophy of the muscular and serous coats. There is an increased blood-supply, the membrane be- ing bright red in color, the capillaries dilated, and the whole mass bleeding easily on the touch. It has somewhat the appearance of fresh granulations. Upon the free surface of the mucous membrane, .there is, as we should expect, an excessive cell proliferation, these cells being in a transitional condition, i. e., occupying the position between imperfect and perfect, and not all of the same degree of perfection or imperfection of development. There may be either serous or gelatinous infiltration, giving it a heavy, sodden look. Upon the surface are often found incrustations of the urinary salts. It appears to me that there has been an undue complexity of classification of this subject, especially among the German patho- logists, some of whose differences are too minute to be of any prac- tical value from either a pathological, diagnostic, or remedial point of view. Tumors which they call villous or papilloma vesicEe are, in many, if not all respects, idontical with the so-called polypoid hyper- trophy of the vesical mucous membrane. For all practical purposes they are essentially the same. They have been described as enlarged papillae, the vessels of which are dilated, and their walls thinned. They only differ from the polypoid hypertrophy in increase of vascularity, and the fact that they are u^ially limited to the trigone. Underlying and about them is a thin, wavy stroma of connective tissue, that becomes in- creased as the disease advances. 806 DISEASES OF WOMEN. The surface of these growths varies very much in different cases ; in some looking like large granulations, in others having more body, being more compact, and looking sumewhat like a raspberry or mul- berry. Occasionally, they are slightly pedunculated. Their surface has an epithelium resembling the superficial layer of the bladder, unless proliferation is veiy rapid, when the cells lose their identity, and take a multiplicity of forms, to which may be attributed, perhaps, their having sometimes been mistaken for cancer cells when found in the urine. Fatty degeneration of the most superticial cells is by no means uncommon. As the villi increase in size and number, the connective-tissue stroma, while increasing about their base, dimin- ishes in the prolongations themselves, leaving little besides a mass of tortuous, thin-walled, dilated vessels hanging free in the Ijladder. The rest of the mucous membrane is usually soft and hyperplastic, and, if there be any stoj^page to the free outflow of urine, inflamma- tion may coexist, with incrustations, and possibly dilatation of the ureters. The muscular coat is also usually slightly hypertrophied. Fibroid tumors and myo-fibromata are very rarely found in the bladder. When they do exist they have all the characters of the libroina or myo-fibroma found elsewhere, and give rise to the same changes in the vesical walls and ureters that other tumors do, viz., retention with liypertrophy, or dilatation, cystitis, and inflammation of the ureter. They may have their seat in any part of the l)Iadder- wall, and occur at any period of life. Syrnjytomatology. — The symptoms of vesical neoplasms are di- visible into local and constitutional ; the former being by far the more important. The local symptoms, if the tumors be of any size, are those produced by a foreign body in the organ, viz., irritation, and sooner or later inflammation. Obstraction to urination sometimes occurs when the tumors are in a position to block the urethra, and by the sloughing off or de- tachment of small fragments, which may or may not be incrusted. These are forced into the urethra, and obstruct the outflow of urine. Pain in one form or another is almost always present. It may consist of a simjDle uneasiness in the hypogastric region, or amount to actual pain. It may have its seat in the hypogastric region in the perinEeum, or more rarely at the end of the urethra. It may also be felt in the loins, or along the thigh and knee. It is usually more intense, as all the symptoms are, during the menstrual flow. This is not so in all cases. Frequent urination and vesical tenesmus are as a rule present, NON-INFLAMMATORY DISEASES OF THE BLADDER. 807 but are not proportionate to the size of the tumor, a very small neo- plasm often giving rise to most intense spasm. Haemorrhage is by no means infrequent, and in some cases is very severe and not readily checked ; in others it is slight, simjjly tinging the urine or imparting to it a smoky appearance, that is characteristic of the presence of a small amount of blood or blood- coloring matter in acid urine. When the haemorrhage is extensive, and the bladder is distended by the fluid or clotted blood, retention of urine is apt to occur, and sometimes obstructive suppression, that may lead to most serious results. Hgematuria is as liable to occur with the benign as with the ma- lignant growths, and consequently is of little value in differential diagnosis. The effects of prolonged or repeated hsiemorrhage upon the constitution are often most serious, and the patients are apt to be anfemic and also cachectic in appearance. I have had one case in which haemorrhage was the only symptom present. The presence of the foreign body in the organ soon gives rise to inflammation, which is seriously aggravated if retention accompany it. The urine is then found loaded with mucus, muco-purulent or purulent matter, epithelial scales, tissue shreds, bits of tumor, and the triple and amorphous phosphates. Intense and repeated vesical tenesmus aggravates the inflamed condition of the membrane, and after a time leads to muscular hyper- trophy and increased haemorrhage. In these cases, as in cystitis from any other cause, dilatation of the ureters, with a traveling upward of the inflammation and destruc- tion of the kidney, may result. This dilatation and the evil after- results are more apt to occur if the neoplasm be of sufficient size to obstruct the free outflow of urine, as at every spasmodic and forcible contraction of the hypertrophied organ some urine is dammed back in the ureters, dilating them gradually. When the ureteric openings are dilated, so that urine regurgitates at each vesical contraction, serious lesions result, as ureteritis, pyonephrosis, renal abscess, or, if the process be &low, gradual renal atrophy, uraemia, and finally death. The general system may or may not suffer severely for a long time. In most cases it does. The usual train of symptoms, such as loss of sleep, disorder of digestion, sweating, and blood contamina- tion are developed in regular sequence. The patients become thin, and have a worn, anxious expression, and, as I have already said, are apt to be both anaemic and cachectic. If renal troubles complicate this affection, casts, renal cells, and 808 DISEASES OF AVOMEN. albumen may appear in the urine. In renal abscess-atrophy, or pyo- nephrosis, however, the urine may be examined for weeks without showing any renal tissue, casts, or epithelium, there being simply an abundance of pus. DiafjuosU. — The diagnosis of vesical neoplasms is made cliiefly by physical signs. The methods employed in their investigation may be arranged under two heads. Direct. — Bimanual touch, speculum, endoscope, curette, catheter, palpation. Indirect. — Uri ne. Direct. — An intelligent employment of the methods classed under the first head is all that is necessary to make a clear diagnosis in some cases. The bimanual touch will i-eveal the presence of the tumor, if it is of any great size, and also its size and fixation in one place. This fixed position is of much importance as distinguishing a neoplasm from other foreign bodies, stone, for example, which is movable, and can be pushed from one side of the bladder to the other. The use of the endoscope will show at once the appearance of the tumor, if it is favorably located, and by scraping away a little with the curette (through the siDeculum), its nature may be discov- ered by a microscopical examination. The use of the catheter or finger in the bladder, or one in the bladder and the other in the vagina, may be resorted to in cases where the diagnosis is difficult. But these are extremely painful manipulations, are not free from danger, and, consequently, should not be resorted to unless there is failure by other means. Indirect. — An examination of the urine in these cases will lead to the suspicion of the presence of some neoplasm in the bladder, from the occurrence of tissue shreds and bits of the tumor in this fluid. A piece of tumor will sometimes become detached and be expelled with the urine, and by careful searching it may be found. This can be placed under the microscope, and thus the examiner may be able to tell exactly what kind of a growth exists. Prognosis. — With our jiresent means for exploring and operat- ing upon the inside of the female bladder, the prognosis of benign neoplasms is very good, if the operation for removal be performed early enough in the disease. Operation, however, at any time gives promise of good result. There is danger of relapse, as we learn from the cases of Simon, Hutchinson, and others. If the operation be carefully done, even incontinence of urine may be avoided, and complete, and permanent recovery follow. Without operation patients have lived as long as NON-INFLAMMATORY DISEASES OF THE BLADDER. 809 nineteen years, in some cases suffei'ing but little ; and it may be well to say that not all of these cases are accompanied by cystitis, a little pus and blood in the unne at intervals, with occasional frag- ments of tumor, being all that is found. Causation. — The causes of these neoplasms are veiy obscure, in- deed, no definite facts can be adduced in favor of any of the causes given by the various authors. Some speak of them as due to the irritation of calculi, calculous fragments, and incnistations. These, however, may be readily secondary to and produced by the neo- plasm, being the effect rather than the cause. Moreover, it is known that while persons carrying foreign bodies of various kinds in the bladder for a length of time, are very apt to have cystitis, neo- plasms are seldom found, and are very rare under any circumstances. Some authors look, with a show of reason, I think, to the irrita- tion from blood transudations into the bladder-walls, as a cause. This is borne out by two well-authenticated cases occurring, one in the practice of Plutchinson, of England, the other in that of Winckel, of Germany. The etiology of these neoplasms needs further care- ful study, before any cause or causes can be pronounced upon with certainty. The free and intelligent use of the modern means of physical exploration in all affections of the female bladder will in a few years throw much light upon this subject. Treatment. — There is really but one form of treatment for these benign neoplasms, viz., removal. The method will differ with the size of the growth. If the tumor be not of large size, it may be seen, reached, and removed through the urethra. This may be accomplished by twisting it off by means of a pair of forceps, ligating its pedicle, and allowing it to slough off or by passing the wire of the galvano-cautery around it. If the pedicle be not sutM- ciently distinct, or the mass too soft to come away in mass, it may be broken down and removed in pieces, either by the linger and for- ceps, or by the curette and forceps. The haemorrhage, which as a rule is not great, may be controlled by injections of iced water, ice to the pubes, and sometimes by tamponing the vagina. Some oper- ators have found it necessary to apply directly to the bleeding sur- face the liquor ferri sesqui-chloridi (Braxton Hicks). The after treatment consists in washing out the organ thoroughly yet carefully with warm water to which may be added salicylic acid (1 part to 60). The pain may be controlled by opium, either by the mouth or rectum. The urine should be kept slightly alkaline, and under no circumstances allowed to remain in the bladder long enough to decompose and irritate or overdisteud it. 810 DISEASES OF WOMEN. If the tiinior is too large to admit of removal ])er urethram Si- mon's operation should be resorted to. Also in cases where the tumor is so situated as to be beyond the operator's reach through the ure- thra. I have already fully described this operation. A T-incision is made into the anterior vaginal wall, the bladder opened, inverted through the opening, and the tumor is thus brought into easy posi- tion for any operative procedure. When removed, its base may be cauterized, and the bladder replaced. "When the surface has entirely healed, the wound in the vesico-vaginal septum may be closed. Union soon takes place in most of these cases, if not interfered with. The after treatment should be the same as when the tmnor is removed through the urethra. I need hardly say that when the general system is below par, it should be attended to. Polypus of the Bladder. — Dr. Godson showed a polypus which he had recently removed from a woman aged sixty, who was under his care in St. Bartholomew's Hospital. He first saw her a year ago, when she complained of bleeding from the vagina. The uterus and vagina were found healthy, there had been no recurrence of the haemorrhage until a week since when the patient again presented herself. On examination a tumor the size of a walnut was found at the orifice of the vagina. It had at first sight the aspect of a firm fibrinous clot ; it was discovered, however, to protrude from the urethra, and to be connected by a narrow pedicle with the fun- dus of the bladder, which organ it partially inverted. Dr. Godson applied a catgut ligature, and separated it with scissors. A micro- scopical examination showed it to consist of fibro-cellular tissue, with a few muscular fibers covered over with mucous membrane. Such polypi are of extreme rarity, and it was fortunate that the subject of it was a woman. — {Obstetrical Journal, Aj)7'il 1879, p. 28). Excision of Papilloma of Bladder. — ]\I. C, aged thirty -four, was admitted to the St. Mary's Hosjiital, under the care of Mr. Norton, suffering from the effect of long-continued haemorrhage of the bladder. On examination j)^^" urethram, a tumor one inch square, coated with phosphatic calcuhis, but not nuich raised above the mucous membrane, was discovered oceup^-ing the trigone about half an inch from the sphincter. It was evident that the tumor must be removed, and the patient submitted to the risks attendant upon a severe operation, or she must be left to endure the tortures brought about by the contractions of the bladder upon the growth after micturition, and with the certainty of an early death from hsemor- NOK-INFLAMMATORY DISEASES OF THE BLADDER. 811 phage or from blood-poisoning. It was impossible to remove the growth through the urethra, and it was decided to cut the mass away by opening the vagina. It was considered that the growth could not be cleared without cutting through the urethra, and the opera- tion was performed as follows : The spring-scissors were inserted, one blade into the bladder nearly up to the tumor and the other into the vagina, and closed ; the front wall of the vagina was then incised centrally to within half an inch of the uterus, and the vaginal wall, which was found not to be incoi-porated with the growth was dissected from the bladder; the growth was then seized with the vulsellum forceps, and drawn forward, and was then excised by the scissors and removed. Bleeding was averted by the actual cautery, and the lateral flaps of the vagina approximated by sutures. To prevent further hsemorrhage a catheter was inserted, and the bladder compressed by plugging the vagina ; no haemorrhage of importance took place. The temperature remained below normal, and the pulse rose to 120. Severe vomiting persisted until the tenth day after the operation, when she was considered out of danger. On the twelfth day, when apparently in health, she vomited, and shortly afterward fell asleep, in which sleep she died from syncope. At the autopsy the wound was green, and sloughing upon the surface, but healthy immediately beneath. ISo peritonitis or cellulitis was present, or any thrombosis of vesical, pelvic, or iliac veins. A microscopical examination showed the tumor to be a papilloma. Since writing this case Mr. Norton had operated upon a second case of tumor of the bladder, which had completely recovered from the effects of the operation. — The Medical Press mid Circidar^ May U, 1879; and Medical Record, Jidy 26, 1879, pp 82 and 83. Tubercle of the Bladder. — Tubercle of the female bladder is a comparatively rare affection. Winckel, of Germany, in 2,505 autopsies, found it but four times. Though not often existing as an accompaniment of pulmonary tuberculosis, it does not occur alone, but is usually accompanied by similar deposits in the intestines, kidneys, liver, and elsewhere. It is usually found in early life, though cases have been recorded where it occurred as late as the sixty-fifth year. The favorite site for its first appearance is at the vesical neck, or about the meatus urinarius, these places being rich in minute glands and follicles. The deposits appear as minute white or yellowish white points on a red, indurated base. After a time, owing to their coalescing and breaking down, large spots of ulceration result. With these deposits in the bladder there are very apt to be simi- 812 DISEASES OF WOMEN. lar deposits in the kidneys and ureters, giving rise to destruction of the former and tubercular pyelitis in the latter. Symptomatology. — The symptoms are at first those of irrita- tion, and later of true cystitis, with ulceration, induration, and hypertrophy. Diagnosis. — The diagnosis may be made by means of the endo- scope, if there is opportunity to make early and repeated examina- tions. If by chance the deposits are located at the neck of the bladder, where they can be seen and watched going on to ulcera- tion, the diagnosis is not impossible. The history of the case and the presence of the tubercular diathesis will also aid in the final conclusions. The urine examined by the microscope is found to contain a granular matter mixed with the pus of cystitis which is sooner or later produced. In case the microscopist is fortunate iu finding the bacillus tuberculosis the diagnosis is sure. Prognosis. — The prognosis is bad, as there usually exists serious trouble of the same nature elsewhere, and as local treatment accom- plishes very little, the end comes much sooner if the kidneys and ureters are involved in the disease. Treatment. — Local treatment is out of the question, except such as may allay the irritation or inflammation to a certain extent, and prevent undue pain and spasm. This is not leadily done. Daily cleansing of the viscus with warm water; opium, and belladonna suppositories, or enemata of atropine, are the best methods of treat- ment. Warmth, attention to diet, general tonics, cod-liver oil, and the various remedies used in phthisis pulmoualis should be advised. Malignant Growths. — These are not common, although occurring more often than the benign growths. They are usually secondary, and may be of different varieties, as sarcoma, scirrhus, encephaloid, epithelial, villous, and even colloid cancer. Sarcoma, scirrlms, colloid, and epithelial are very rare ; encephaloid and villous are more common. Symptomatology. — The symptoms are the same as those of the benign tumors, differing only in the greater extent and severity of the pain, and, as a rule, less hemorrhage. The condition of the gen- eral system is usually low, the patient soon becoming feeble and cachectic. Cancerous deposits in the kidney and extension of the inflammation up the ureters, may produce renal destruction and consequent uraemia. Diagnosis. — The only means of making an absolute diagnosis is by using the endoscope, and removing a bit of the tumor with NON-INFLAMMATORY DISEASES OF THE BLADDER. 813 the curette, and submitting it to a microscopical examination. Sarcoma and scirrlms may exist either as distinct tumors or as diffused indurations. The encephaloid variety usually grows rap- idly, and is very soft, and easily broken down. I have already said that cancer of neighboring organs may open into the bladder and produce most serious results, sooner or later involving the bladder- tissue in the destructive process. In any case, adhesion to the neighboring organs takes place, and the disease is liable to extend. Thrombosis of the veins of the vesical neck is apt to occur and lead to embolus elsewhere. Peritonitis is a frequent accompaniment. The favorite seat of cancer, especially of the villous form, is at the trigone. Some authors deny the existence of villous cancer, saying that it is simply a luxuriant growth of vesical papilloma, and base their opinion upon the nature of its structure and certain facts in its clinical history. " They never lead to secondary can- cerous deposits elsewhere. They do not spontaneously ulcerate. The lymphatic glands are not implicated. There is no characteristic cachexia. When they kill, death seems due purely to loss of blood and exhaustion from pain." — Van Buren and Keyes, j)' ^57. Most German authors claim that this growth is malignant, and think that in drawing deductions, such as I have given above, the observers saw only cases of simple non-malignant papilloma. Causation. — Nothing is known about the causes of malignant disease of the bladder, excej^t that which is known about malignant disease elsewhere, consequently, that subject need not be discussed here. Treatment. — If the disease is not too far advanced, extirpation or breaking down of the tumor may be advisable, but except in the case of epithelioma, and the so-called villous cancer, but Kttle good is to be hoped for. When removal is not advisable, we must look to narcotics and tonics to prolong the patient's life and relieve the intense pain and tenesmus. If the tumor is generally distributed throughout the bladder, or has its origin in a neighboring organ, extirpation is out of the question. Sarcomatous Tumor of the Bladder. — Dr. L. A. Stimson, at a society meeting, exhibited a tumor of the bladder removed from a gentleman sixty-three years of age. 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