LECTURES ON THE DISEASES OF WOMEN. CHARL£$ V . FELLOW OF THE HOYAL COLLEGE ; KXAMINElt IN MIDWIFERY AT THE ROYAL COWEGE OF SURGEONS OF KNCI.IM, PHYSICIAN ACCOUCHEUR TO ST. BARTHOLOMEW'S HOSPITAL j AND PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN. Al'THOR OF "LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD."' SECOND AMERICAN, FROM THE SECOND LONDON EDITION PHILADELPHIA: BLANC H'A RD AND LEA. 1861. wp W5/6 L PHILADELPHIA : - COLLINS, PRINTER. PETER MERE LATHAM, M. D., PHYSICIAN EXTRAORDINARY TO THE QUEEN, AND FORMERLY PHYSICIAN TO ST. BARTHOLOMEW'S HOSPITAL; WHO FIRST SHOWED ME HOW TO BTtJDY, AND HOW TO PRACTICE MEDICINE; WHO HAS OFTEN GUIDED MB BY HIS ADVICE; STILL OFTBNBH TAUGHT ME BY HIS EXAMPLE j A N I) W H 0 S M 0 0 T II E D BY HIS D N W E A li I E D K I N I) X E S S THE EARLY DIFFICULTIES OF MY CAREER j TO MY RESPECTED TEACHER, MY GENEROUS FRIEND, I MOST GRATEFULLY, MOST AFFECTIONATELY, THIS BOOK. ADVERTISEMENT TO THE SECOND EDITION. The kind indulgence with which the first part of these Lectures was received, has already rendered a new edition of it necessary. A shorter time, too, than I feared has sufficed for the fulfilment of my pledge, and the completion of the work. The second part has been published separately, for the convenience of purchasers of the former volume. 1 Many subjects, indeed, that deserve a longer notice, are touched on here but slightly, and others, of a purely surgical nature, are completely passed over, for I have not ventured to teach concerning matters with reference to which I feel myself to be still altogether a learner; while I have always regarded mere compilation, uncontrolled by large experience, as more apt to perpetuate error than to diffuse truth. But I have a more agreeable duty to perform than that of confessing my shortcomings, and pleading in their extenuation. To one of my colleagues at St. Bartholomew's Hospital 1 [Part II. of the American edition may be had separately by tho8e who received the first portion as published in the " Medical News and Library."] 1* VI ADVERTISEMENT. I have been constantly indebted wherever the aid of the surgeon was necessary; and Mr. Paget's dexterous hand, and sound judgment, and ready friendliness, were always given almost without the asking. Many cases, those especially of ovarian disease, we observed and treated together; and my opinions have often been modified, and my conduct influenced by his suggestions. My readers will reap the benefit; it is for me, with best and warmest thanks, to acknowledge the obligation. 61 Wimpole Street, October, 1858. ADVERTISEMENT TO THE FIRST EDITION OF THE FIRST PART. These Lectures are a first instalment towards the discharge of that debt which the opportunities of a hospital and the responsibilities of a teacher impose upon me. A second volume, which will treat of all the remaining diseases of the female system, will appear, if health and strength are spared me, within three years from this time. I have published this part separately, because I believe that students and junior practitioners stand in much need of that help which, with reference to an important class of these ailments, it may per haps afford them. To almost all persons there is probably more of pain than of pleasure in looking back upon a work on which much time and labor have been expended, so wide is in general the distance between the endeavor and its fulfilment. To myself, the consciousness of doubt has often, while engaged upon these Lectures, been very painful, and the sense of imperfect knowledge has pressed heavily upon me, and does so still. I commend the book, however, to the kindly judgment of VIII ADVERTISEMENT. my professional brethren, as embodying the results of ten years of observation in the wards of a hospital, and of the honest attempt to gather from each day's added experience something more or better, for the use of those who look to me for help and guidance. Wimpolb Street, April, 1856. CONTENTS. LECTURE I. PAGE Chronic Inflammation and its Results, continued; Treatment of the Affection; Cases considered requiring Local Treatment of Ulceration.— Cervical Leucorrhcea 104 LECTURE VIII. Inflammatory Affections of the Uterus.—Chronic Inflammation and Ulceration of the Os Uteri; Examination of different Opinions on this Subject 87 LECTURE VII. Diseases of the Uterus.—Inflammation and Kindred Processes.—Hypertrophy of the Uterus, and Acute Inflammation 70 LECTURE VI. Disorders of Menstruation.—Dysmenorrhcea 02 LECTURE V. Disorders of Menstruation.—Amenorrhcea, concluded. —Menorrhagia . 47 LECTURE IV. Menstruation and its Disorders.—Amenorrhcea 351 LECTURE III. Introductory.—Examination of Symptoms, concluded. —Modes of Examination 24 LECTURE II. Introductory.—Symptoms of Diseases of Women . . . . . .17 X CONTENTS. LECTURE IX. PAGE Uterine Tumors and Outgrowths.—Fibrous Tumors, continued: Their Treatment . - 225 LECTURE XVII. Uterine Tumors and Outgrowths.—Fibrous Tumors, continued: Their Diagnosis, and Deviations from Ordinary Symptoms; Their Prognosis . . 213 LECTURE XVI. Uterine Tumors and Outgrowths.—Fibrous Tumors: Their Structure, Pathology, and Symptoms 197 LECTURE XV. Uterine Tumors and Outgrowths.—Mucous, Fibro-cellular, and Glandular • Polypi.—Mucous Cysts of Uterus.—Fibrinous Polypi .... 187 LECTURE XIV. Misplacements of the Uterus, continued. —Inversion of the Uterus.—Ascent of the Uterus 172 LECTURE XIII. Misplacements of the Uterus, continued. —Versions and Flexions; Their Symptoms, Diagnosis, and Treatment 156 LECTURE XII. Misplacements of the Uterus, continued. —Versions and Flexions.—Anatomy and Pathology of Anteversion and Retroversion, and of the Corresponding Flexions.—Congenital Obliquity 146 LECTURE XI. Misplacements of the Uterus, continued. —Prolapsus Uteri, and the Allied Misplacements of Vagina, Bladder, and Rectum: Their Symptoms and Treatment 127 LECTURE X. Misplacements of the Uterus.—Prolapsus Uteri, and the Allied Misplacements of Vagina, Bladder, and Rectum, their Nature and Mode of Preduction 117 CONTENTS. XI LECTURE XVIII. PAGE Ovarian Tumors and Dropsy: Their Symptoms and Diagnosis . . . 380 LECTURE XXVII. Ovarian Tumors and Dropsy.—Pathology of the Disease further considered: Its Course and Causes 3G6 LECTURE XXVI. Ovarian Tumors and Dropsy: Their Morbid Anatomy 352 LECTURE XXV. Inflammation of the Ovaries themselves.—The Aoute and Chronic Forms of the Disease.—Displacement of the Ovary.—Note on Hernia of the Ovary, and on Cysts of Uterus 339 LECTURE XXIV. Inflammation of Uterine Appendages, etc., continued: Exceptional Cases. — Treatment of the Affection. —Hemorrhage about the Uterus, or Uterine Hematocele 325 LECTURE XXIII. Inflammation of Uterine Appendages and of the Pelvic Cellular Tissue: Its Causes, Symptoms, and Course 30K LECTURE XXII. Malignant or Cancerous Diseases of the Uterus, continued: Their Treatment 290 LECTURE XXI. Malignant or Cancerous Diseases of the Uterus, continued: Their Pathology, Symptoms, and Diagnosis 2G9 LECTURE XX. Malignant or Cancerous Diseases of the Uterus: Their Morbid Anatomy . 253 LECTURE XIX. Fibrous Polypi.—Recurrent Fibrous Tumors.—Fatty Tumors of the Uterus. —Tubercular Disease of the Uterus 237 XII CONTENTS. LECTURE XXVIII. PAGE Diseases of the External Organs of Generation 484 LECTURE XXXIII. Diseases of the Urethra and Vagina 447 LECTURE XXXII. Diseases of the Female Bladder 433 LECTURE XXXI. Ovarian Tumors and Dropsy: Their Treatment, continued: Extirpation of the Disease 422 LECTURE XXX. Ovarian Tumors and Dropsy: Their Treatment, continued: Curative Measures .... 407 LECTURE XXIX. Ovarian Tumors and Dropsy: Their Prophylactic and Palliative Treatment. 395 J LECTURES ON THE DISEASES OF WOMEN. LECTURE I. INTRODUCTORY. Review of subjects already considered in the Lectures on Midwifery—Reasons for having postponed the Study of the Diseases of Women—Twofold knowledge requisite for their study—Dangers and mistakes arising from want of it—Illustrative cases. Symptoms of these diseases furnished by disturbance of function, alteration of sensibility, and change of texture. Symptoms of first two classes considered. Gentlemen" : Some of you, perhaps, remember that I endeavored, at the commencement of my Lectures on Midwifery, to point out to you the various respects in which the generative system plays a more important part in the organism of woman than in that of the man. I called your attention to its constantly recurring activity, as displayed in the periodical return of menstruation, to its far-reaching influence as manifested in the various phenomena which attend upon pregnancy and labor, and to the impress which the whole body bears of the special adaptation of every part for the most complete performance of its functions. I pointed out to you, how, as the child grows, the womb grows'with it; how its lowly organized tissues become developed; its vessels increase in size; nerve-matter is deposited within the sheaths, so delicate as to have been almost imperceptible before; and the uterus becomes at length what old anatomists have not hesitated to call it— Miraculum Naturas. And next I described to you the means by which all the dangers and the difficulties of parturition are surmounted; and then told you how all the grand functions of the uterus being thus completed, its tissue undergoes degradation and decay, its vessels shrink, its nerves dwindle to their former size, all the emunctories of the body bearing their part in the removal of the now useless materials; while, at the same time, nature labors to form a new uterus, fitted to go through the same marvellous changes, and answering the, same important ends. I entered then into such details, not for the 2 18 IMPORTANCE AND DIFFICULTIES purpose of exciting idle wonder, but in order to lead you to the obvious inference that processes so complicated must be very apt to become disordered ; that it must, therefore, be your duty, and ought to be your pleasure, to acquaint yourselves with them and their disorders ; that you might learn to know what is healthful, to correct what is contrary to nature, or to render ills that are unavoidable as small as possible. Thus convinced, as I trust, of the importance of the study, you have completed the examination into the physiology of the female sex, in so far as the reproductive processes are concerned, and have inquired, moreover, into the various circumstances by which the generative organs are liable to be disturbed in the performance of their highest functions—the signs-of such disturbance, and the means whereby it may be remedied. But, as the generative system in women has functions which it performs independent of those highest offices which it discharges when a germ has been impregnated, and becomes developed to a new being, so their disturbance is not without serious influence on the whole or ganism. The establishment of the sexual power at puberty, and its extinction with advancing age, both exert important influence on the constitution; at both of these epochs there is an increased liability to disease, and at the former a marked increase in the rate of mortality. All through the time of sexual vigor, too, a thousand causes may derange the regular recurrence of the manifestations of its activity, and thereby throw the whole complex machinery of the body into disorder. The disorders of the sexual functions, then, and the way in which they react on the general health, or are acted on by it, call manifestly for some of your attention; but even when you have familiarized yourselves with them most completely, your acquaintance with the diseases of women will be but just beginning, for the organs which subserve these functions may be themselves diseased. These organs, too, are complicated in their structure; formed of various tissues, but bound together by sympathies so close that one part cannot be the seat of suffering without all suffering together; and hence it is often no easy task to unravel the tangled web of symptoms, and to find out where the mischief is, and what it is, to which so many manifestations of disease are due. I have deferred till now inviting you to enter on the study of these affections, on account of the many difficulties by which it is attended, and on account of the need you will find in pursuing it of that special knowledge which you have acquired while attending lectures on midwifery, as well as of that acquaintance with practical medicine which careful observation in the wards of the hospital can alone supply. Knowledge of both of these kinds is equally necessary; the want of the one or of the other is the cause of those two errors into which practitioners not infrequently fall. Some men regard the local ailment as everything; others almost lose sight of its existence; and it is difficult to say which of these two errors is the more mischievous. A woman applies to a practitioner who is guilty of the first-mentioned error, complaining of painful and scanty menstruation; he at once adopts mechanical means for her relief. He introduces bougies to 19 OF STUDY OF DISEASES OF WOMEN. widen the canal, and to remove some, perhaps imaginary, contraction of the cervix uteri, by which he conceives the escape of the menstrual fluid to be impeded; and he even incises it, to make sure of enlarging its calibre. After undergoing much pain of body, and much distress of mind, the patient finds herself at the end of these manipulations no better than when they began; the cause of her sufferings lay deeper, and was to have been found in the derangement of her general health, which would have attracted the notice of a better physjcian, and which well-directed measures would probably have cured. Let me mention another case as illustrative of the opposite error. A patient seeks for relief on account of profuse menstruation, attended with discharge of coagula, but accompanied with little or no pain. General treatment is adopted, the patient is confined to the recumbent posture in a cool and well-ventilated room, astringents are given internally, cold is applied locally, and no sign of disorder of the general health is allowed to pass without appropriate means for its cure; but yet amendment does not follow, for the bleeding depends upon the presence of a minute polypus, which nothing but careful examination of the uterus could discover. In the one case, a crass mechanical treatment was adopted to cure an affection which depended on the state of the general health; in the other, general treatment failed to remove symptoms which careful investigation would have shown to depend upon a local cause. But I need not draw upon imaginary cases in order to enforce the caution that I am desirous of impressing on you; the records either of hospital or of private practice afford illustrations of it in abundance. A middle-aged woman complained of frequent desire to pass water, and of discomfort in voiding it; she was dyspeptic and out of health. Her urine was tested, and found to contain albumen ; and the irritable state of her bladder was assumed to be dependent on the disease of her kidneys. Treatment improved her general health, but brought no relief to her dysuria. At length careful observation discovered the albumen to be due to the admixture of vaginal discharges with her urine: a not infrequent source of it in women who suffer from leucorrhcea, while examination, which had been delayed too long, detected a small vascular tumor just within the orifice of the urethra, to the irritation produced by which her symptoms were due, as was shown by their immediate disappearance on its removal. A young lady, whose health had never been robust, began at the age of twenty-two to menstruate irregularly and scantily, and to suffer at the same time from pruritus of the vulva. For this symptom various local applications were resorted to, and more than once she underwent the distress of an examination which discovered nothing more than an increased degree of redness about the labia and nymphae. At length, with the decline of her general health, she came under the care of another physician, who ascertained that sugar was present in her urine. The pruritus, like the itching of the urethra in the male subject, was the consequence and the symptom of the diabetes of which the poor girl eventually died. A woman was admitted into the hospital a few years ago in a state of extreme suffering; her countenance was very anxious; she lay in 20 SIGNS OP SEXUAL DISORDER. bed with her knees drawn up, dreading the slightest movement; her abdomen was intolerant even of the slightest pressure. She was reputed to have peritonitis, and had been bled for this, as well as abundantly salivated before her admission, yet without relief. But with all this her skin was perspiring, and her pulse was soft, and not increased in frequency. Her history was, that after vague uterine ailments for a month, she was suddenly attacked by violent pain in the womb, attended with bearing-down efforts equal in intensity to those of labor. !These subsided, but the pain was referred to the bladder, and desire to pass water became very frequent. This too abated, and the next complaint was of violent pain in the shoulder, which was encountered by active measures for the relief of alleged inflammations of the shoulder-joint; and the pain in the shoulder suddenly ceasing, the severe abdominal suffering at once succeeded it. A hot hip-bath gave almost immediate relief, though the patient screamed when moved in order to be placed in it; and a full dose of opium was followed by some hours of quiet sleep. The next day no pain was complained of except over the pubes, and this soon disappeared under the use of anodynes; and steel and good food completed the cure of a case of hysterical peritonitis. Now these cases, to which it would be very easy to add many more, are all examples of the error of making too little or too much of symptoms indicating disorder of the sexual system. Your general medical knowledge must keep you from the latter; it is my special duty to arm you against the former, or rather as much as in me lies to defend you from both. With this view I propose to-day to make a few introductory remarks upon the signs and symptoms of disease of the generative organs in the female, and on the means of investigating them. There are three modes, in some or all of which these affections manifest themselves —namely, by causing disturbance of function, alteration of sensibility, or change of texture. The ovaries are the grand organs of sexual activity in the female; and during the whole time that sexual fife continues, they are employed in the healthy individual in bringing ova to maturity, and then in extruding them at certain periods when they have attained a state of fitness for further development, if subjected to the fecundating influence of the semen. Accompanying this internal process, the consequence and the evidence of the local congestion which attends it, we observe a periodical discharge of blood constituting menstruation. The regular return of menstruation, its accomplishment within a given period, attended by a certain average amount of discharge, and by no more than a certain average degree of discomfort, are regarded by women, and with propriety, as conclusive evidences of the healthy state of the sexual functions. In every inquiry, therefore, with regard to supposed disease of the generative apparatus, the mode in which this function is performed must engage your careful attention. You know menstruation to be merely the sign of a more important process going on deeper within the organism. The non-appearance of the discharge, then, or its suppression, suggests at once many important in- DISTURBANCE OF FUNCTION. 21 quiries which must be carefully followed up, till you can return to them a satisfactory reply. Is the system so feeble that', like an illthriven plant, its sexual power remains altogether in abeyance? or are the ovaries themselves diseased ? or does the internal process go on, while yet, owing to some mechanical cause obstructing the escape of the discharge, its outward manifestation is wanting? or is its appearance prevented by some disorder of the general system, or of the uterus, which incapacitates that organ from performing its usual office as a kind of safety-valve by means of which the congested pelvic vessels are relieved of their superabundant blood ? Or is perchance none of these suppositions correct, and is the real explanation of the suppression of the menses to be found in a physiological not in a pathological occurrence, and are the symptoms those of pregnancy, not those of disease? Such are the important questions which in every case of suppressed menstrual discharge you must endeavor to answer, and to which, both for your own reputation as well as for your patient's wellbeing, it is of the greatest moment that you should return a correct reply. Or, again, your patient suffers from what she conceives to be excessive menstruation, her health is breaking down beneath it. Whence comes the discharge? is it due to a state of general plethora, which nature endeavors to relieve by this outlet, though in her endeavors she exceeds the limits of safety? or are the vessels so weak that blood escapes from them with dangerous profusion? or is the hemorrhage due to neither of these causes, but to a breach of surface, to some ulcer of the womb from which the blood flows, or to some morbid growth, or formidable organic disease, the effect of which is rendered more serious just at those times when the uterus becomes more than usually congested ? These, and similar inquiries, possess a special importance at certain epochs of a woman's life; for when the sexual powers are on the decline, disease is especially liable to be set up, and you therefore regard all menstrual irregularities at that time with closer attention than at any former period. But there are other subsidiary functions performed by the generative organs, the disturbance of which is sometimes the occasion of mere discomfort, at other times the indication of serious disease. These organs present a great variety of secreting surfaces, which furnish matters of various kinds, subserving various purposes. A slight secretion moistens the interior of the Fallopian tubes, just as it does that of all viscera, and, except near the monthly periods of sexual activity, it is by little more than a mere halitus that the cavity of the womb itself is lubricated. The large mucous crypts or glands about its neck furnish a peculiar secretion, which is generally present at all times, though most abundant during pregnancy. The mucous follicles of the vagina pour out a somewhat copious secretion upon its surface; and the two glands which are seated, one on either side of its entrance, and which, under the name of Duverney's glands, correspond to Cowper's glands in the male, furnish an abundant discharge at the time of sexual congress; and, lastly, numerous mucous crypts and sebaceous follicles on the the interior of the labia, and about the vestibulum, supply a suitable secretion to lubricate those parts. From any or all of these 22 SIGNS OF SEXUAL DISORDER. sources secretion may be furnished, excessive in quantity, and more or less altered in character. The secretion may be a mere leucorrhoea, an increased flux from otherwise healthy tissue; it may be a purulent discharge from inflammation of a mucous membrane, or it may be furnished from an ulcer of the womb; or it may not be simple pus, but an offensive sanies from a wide-spread cancer of the organ, or of some part adjacent. Your patient may come to you in complete ignorance as to which of all these is the cause of the affection under which she is laboring: she looks to you for an answer to her doubts, and for relief to her sufferings. Diseases of these organs, however, are associated not merely with altered function, but also with disordered sensibility, and that not only of the part affected, but also of others more or less distant. There is hardly any more fertile source of erroneous diagnosis with reference to the diseases of women than the overlooking the import of some of these alterations of sensibility, and the not connecting with its proper cause the sympathetic affection of some, perhaps, distant organ. If a woman complain of a sense of heaviness in the pelvis, of bearing-down pain, of pain in the loins and about the sacrum, or shooting down the thighs, our attention is naturally directed to the state of her sexual organs, and we are not likely, with moderate caution, to overlook the real seat of her disease. In many cases, too, something beyond the seat of the disease may be learned if we notice the character of the pain from which the patient suffers, since this is usually of one kind if inflammation be present, of another if there be cancerous disease, of a third if there be displacement of the womb. These minutiae, too, are of all the more importance for us to attend to, since there are no other diseases in which that personal investigation by which so many questions can be at once answered is attended by so many difficulties, both from the natural repugnance of the patient to submit to it, as well as from the imperfection of our means of examination. But disease of these organs is not seldom attended by pain which is referred not to the real seat of the mischief, but to some other, perhaps some distant part. Women may apply to you, who seem out of health, and in whom you may, perhaps, at first, suspect the existence of uterine disease; but they appear annoyed at inquiries with reference to their sexual functions, or perhaps deny, and with perfect truth, the existence of any pain in the uterus or its immediate neighborhood. Perhaps, however, they may confess to pain in the rectum, especially at the time of defecation; or may speak of symptoms which they refer to haemorrhoids; or may complain of sciatica, or of lumbago. Always suspect the import of these sufferings; bear in mind the wide sympathies of the pregnant womb, and keep all your vigilance active; it is highly probable that these anomalous symptoms will resolve themselves into the effects of uterine disease. Nor are they merely strange and intractable forms of local ailment which should call your special attention to the uterus and its functions. The pregnant woman suffers almost invariably from nausea and vomiting; her appetite often becomes capricious, and her digestive functions are frequently ill performed; while it is far from unusual 23 ALTERED SENSIBILITY. for her to have attacks of headache, or of tic douloureux, though she may at other times enjoy a complete immunity from all such ailments. But just as disorder of the functions of other organs not seldom attends upon the physiological processes going on in the womb, so may it follow upon uterine irritation produced by disease; and a large proportion of the most obstinate forms of dyspepsia, and a still larger number of hysterical and nervous affections, have been excited and are kept up by disease of the womb. In a great many of these cases, minute inquiry elicits evidence of functional disorder of the generative organs, as shown by disturbed menstruation, by leucorrhceal discharges, or by painful sensations, although none of these symptoms may have been so marked as to have engaged the patient's notice; or she may have regarded them as trivial accidents not worth mention when compared with the other, and to her feelings the more important causes of her sufferings. 1 Need I guard myself against being misunderstood, against being supposed to say that, in the management of a woman who is dyspeptic, your attention is to be turned less to the state of her stomach than to that of her womb; or that if a woman suffer from neuralgia, you are at once to suspect the existence of uterine disease? I mean no such thing; but what I do mean is, that, in the treatment of diseases occurring among patients of the female sex, you should always bear in mind that, besides the ordinary causes of disease common to both sexes, there is another set of causes peculiar to themselves. Whenever, therefore, the ordinary principles of pathology fail to explain, or the ordinary proceedings of therapeutics prove inadequate to cure the ailments of any female patient, it behooves you to remember that, in her sex, and in its peculiar diseases, you may perhaps find a clue to the cause of her present symptoms, and discover indications which may show you how to accomplish their cure. 1 In vol. ii. of Lisfranc's Clinique Chirurgicale, 8vo. Paris, 1842, from p. 182 to p. 256, are some remarks, with illustrative cases, on errors of diagnosis in uterine disease, which, though not free from the characteristic faults of that writer, will yet well repay an attentive perusal. 24 SIGNS OF SEXUAL DISORDER. LECTURE II. INTRODUCTORY. Symptoms of disease of generative organs, furnished by alterations of size, texture, or situation, to be ascertained only by examination—General remarks on the subject—Examination either tactile or instrumental—Tactile examination of the abdomen, per vaginam, per rectum—Instrumental examination, by means of the Uterine Sound ; description of the instrument, and rules for its introduction ; examination with the Speculum ; varieties of the instrument; rules for its introduction ; attempt to estimate its value. There was not time at our last meeting for the due consideration of the third and last class of indications of disease of the generative organs —namely, those furnished by alterations of their size, texture, or situation. I must therefore direct your attention to them to-day. It is, I conceive, quite needless for me to preface what I have to say by any remarks upon the importance of these signs,-or upon the necessity of ascertaining the presence or absence of any of these changes in a great majority of the cases in which our patient's symptoms indicate some disorder of her sexual functions. The examination, however, by which alone this information can ba obtained, must be extremely painful to a woman's feelings, since she ,is not now, as in the time of labor, impelled by the extremity of her sufferings to submit to anything for the sake of relief. She seems, indeed, to be now peculiarly alive to every painful impression; and while she feels almost overwhelmed by a sense of humiliation at having to undergo an examination, of the necessity for which she may yet feel fully convinced, she will judge with painful minuteness each act of yours —any needless delay, any careless exposure of her person, any apparent want of delicacy or consideration. With the greatest care, indeed, you will not always escape from undeserved blame; without it, you will perpetually wound your patient's feelings, and if you do not injure your own prospects, you will yet fail to support the dignity of your profession, and will lead to the inference that there is at least one department of the art of healing incompatible with the tone, and manner, and feeling of a high-bred gentleman. The fami-' liarity which hospital practice begets with these ailments among women whose sensibilities are not always as keen as those of persons in a higher class of life, or the circumstance that they do not venture to express the pain which want of consideration may have caused them, leads but too often to carelessness, in these respeats, on the part of men who would yet shrink from the idea of inflicting a moment's unnecessary suffering upon any one. I am therefore all the more Examination op the abdomen. 25 anxious to impress upon you that the delicacy with which you ought to conduct all your investigations into the diseases of women, is not a thing that can be assumed for the nonce, but that it must be the habit of the mind, must therefore have been acquired now during your pupilage, and in the midst of your intercourse with the poor. We make ourselves acquainted with the existence of disease of the generative organs, either by manual examination or by ocular inspection; and for the purpose of making such investigations with the greater accuracy, we not infrequently employ instruments of different kinds. The simplest mode of examination, and that which causes our patient the least distress or alarm,, is that in which we employ our sense of touch alone, unaided by any apparatus whatever. It is perhaps scarcely necessary for me to remind you that, while it is our duty to use every means essential to the thorough investigation of our patient's condition, it is no less our duty to make no needless examination ; never to use an instrument when we can ascertain all that is necessary without it; never to resort to ocular inspection when we can feel a reasonable certainty that by the sense of touch alone wo have arrived at a true knowledge of the disease. We derive information from our sense of touch when applied either through the abdominal walls, or by the vagina, or the rectum. Examination of the abdomen is not always called for; when it appears necessary, it is well to begin with it. For this purpose, the patient should lie upon her back, with her knees drawn up so as to relax the abdominal muscles. It is very seldom necessary to apply the hand to the uncovered surface; the interposition of the patient's shift little, if at all, interfering with the accuracv of the examination. Care should be taken that your hands are not cold; if they are, this will not only annoy your patient, but, by exciting contraction of her abdominal muscles, may seriously impede your investigation. Placing both hands upon the abdomen, you make at first very gentle pressure, increasing it by degrees, as the patient becomes accustomed to it, and trying to engage her in conversation, and thus to distract her attention, if either pain or alarm should cause her to throw her abdominal muscles into action. You thus make yourself acquainted with the general contour of the abdomen, and by examining at either side, as well as in the centre, you detect any tumor which may be present there. Supposing any such growth to be discovered, you must examine well its form, its size, its attachments, its degree of mobility, and the amount of tenderness or pain which meddling with it occasions. Is it due to accumulation of feces in the large intestine; to enlargement of the liver or spleen; or is it, perhaps, merely the result of a general fulness of the abdomen, produced by flatus in the bowels, or by fat in the omentum, or beneath the integuments, rather than the consequence of any definite disease? If the tumor seem to arise from out of the pelvis, it is most probably formed either by the uterus itself, or by its appendages. If by the former, the chances are that it will be situated in the mesial line of the abdomen; if by the latter, that it will occupy one or other side, or at any rate that it will be learned to have occupied that situation when first discovered. Whether it is 26 SIGNS OP SEXUAL DISORDER. ' solid or fluctuating, even or irregular, will be other points for you now to make out, and you must then proceed to correct or confirm, by a vaginal examination, the impressions received on examining through the abdominal walls. It is seldom necessary, for the purposes of a vaginal examination, that the patient should be in any other than the usual obstetric position. On the Continent, where women are generally delivered on the back, they often assume that position whenever the state of the uterus needs investigation. Sometimes, too, when it is wished to appreciate the degree of prolapse or downward displacement of the uterus, or to estimate its increase in weight, or when the womb is high up and does not come readily within reach, the examination is made with the patient in the standing position; I do not think, however, that any of the alleged advantages of this attitude are sufficient to counterbalance its very obvious inconveniences. The patient, therefore, lying on her left side, the index finger of the right hand is introduced as for an examination in labor, and as it is slowly carried forward, attention is to be paid to the degree of pain excited in each part of its course. The state of the external organs must be noticed, and then that of the vagina—whether it is hot and swollen, or cool and relaxed; whether dry, or abundantly bathed in secretion. The cervix uteri is thus reached, and you observe whether or no it is tender, what are its length, and size, and texture; whether the os uteri is open or closed; whether its lips are small and even, or rough and irregular. You will bear in mind, that after frequent child-bearing, the cervix uteri is both shorter and broader than in the woman who has never given birth to children (changes which are especially marked in that portion of it which projects into the vagina, and is commonly called the portio vaginalis); and that the os uteri is frequently open, so as to admit the finger with but little difficulty. In this case, however, the inner surface of the os is smooth, and the tissue of the cervix soft and yielding; while if disease exist, the interior of the os will most likely be rough and uneven, and the substance of the cervix rigid. Sometimes a peculiar and almost velvety smoothness is presented by the surface of the os uteri, or the tissue generally has less than its natural firmness; and any of these peculiarities, or the presence of any foreign body between the lips of the uterus, should be well borne in mind, in order that you may afterwards compare the information obtained by ocular inspection with that previously gained by the sense of touch. While making this examination, you notice, moreover, the situation of the uterus, whether it still retains its natural direction, or has come to lie with its axis corresponding to the axis of the vagina; whether it is bent upon itself, or in any other way. misplaced. Examine next, whether the uterus is increased in weight; balance it on your finger, and appreciate as well as you can the size and weight of the organ. If you had discovered any tumor by examination through the abdominal walls, you should now try to ascertain whether there is any connection between it and the uterus, or between it and any other tumor that you may detect within the pelvis, and whether pressure on the one in any way modifies the position of the other. For this pur- 27 EXAMINATION BY VAGINA AND RECTUM. pose, too, it is usually advisable to let the patient lie on her back, when with one hand placed over the pubes and the finger of the other in the vagina, the size of the womb and the relations borne to it by any tumor can be made out far more accurately than is possible while the position on the side is maintained. When all the above-mentioned points have been ascertained, with as much gentleness as possible, the vaginal examination is over, and there is nothing more for you to notice, except it be the appearance or other characters of the discharge. Sometimes it is expedient to examine per rectum as well as per vaginam; if either the patient had made complaints of serious pain in the bowel, or if you had discovered a tumor situated behind or to one side of the uterus, or if on any account you are anxious to examine the posterior part of the pelvis, or of the uterus itself, as completely as possible. The only caution specially applicable to examination per rectum is, that, owing to the intervention of the intestine between the finger and the womb, that organ feels much larger than itjeally is; besides which, as the finger reaches less readily to a level with the cervix uteri when introduced into the rectum than into the vagina, there is some risk of mistaking the cervix for a prominence of the posterior wall of the uterus, or for a tumor in that situation, or for a retroversion or retroflection of the organ, when, in reality, no morbid condition whatever is present. Of late years it has become customary in many cases to aim at a greater completeness of tactile examination, by means of an instrument which is called the Uterine Sound. At different times, indeed, practitioners have in some special instance introduced a catheter into the uterus to satisfy themselves of the size of its cavity, or of the absence of any foreign body from its interior; or have attempted to rectify a retroversion of the unimpregnated womb, by means of an instrument introduced within it. 1 To the best of my knowledge, however, a Frenchman, M. Lair, was the first person who, rather more than twenty years ago, recommended sounding the interior of the uterus in order to ascertain whether the cervix is free from all impediments, and whether the cavity of the organ generally is in a healthy state. His book is illustrated with drawings of the instruments which he employed for this purpose ; 2 and he advised that they should be curved like a catheter at their uterine extremity, in order to facilitate their introduction. He recommends, moreover, that the sound should be introduced through a metallic cylinder or speculum, by which the mouth of the womb is to be first brought into view; a proceeding which, instead of facilitating the introduction of the instrument, must, in many cases, have rendered it altogether impossible. The practical defects of M. 1 The late Professor Osiander, of Gottingen, employed his Dilatorium Orificii Uteri, which is described in Rosenmeyer's dissertation, published at Gottingen in 1802, on three occasions, to reduce the retroverted unimpregnated womb. His cases were published in the Medicinisch Chirurgische Zeitung for 1808, according to Schmitt, who refers to them in his Essay, Ueber die Zuruckbeugung der Gebarmutter, 8vo. Wien, 1820. 2 Nouvelle Methode du Traitement des Ulceres, etc. de l'Uterus, 8vo. Paris, 1828. Deuxieme edition, p. 137. The first edition appeared about two years before. 28 SIGNS OF SEXUAL DISORDER. Lair's plans prevented their general adoption; and his recommendations were in consequence soon forgotten. To Dr. Simpson, 1 of Edinburgh, belongs the merit, not only of having recalled attention to the subject, but of having also invented a Uterine Sound, admirably adapted for the safe and easy exploration of the cavity of the womb. His instrument is made of flexible metal; and in shape and size, closely resembles a sound for the male bladder, having a similar curve, and its handle being flat, and roughened on one side in the same manner. The uterine end of the instrument terminates in a small bulb to prevent its injuring the interior of the womb, while a notch at every inch serves to indicate the distance to which the sound has entered the womb; and thus to mark the size of its cavity. A slight prominence at two and a half inches shows the average length of the cavity of the healthy womb, while a deep depression at four and a half inches marks a size, which, except under very special circumstances, the organ hardly ever exceeds. The mode of using the instrument is sufficiently simple. Two fingers of the left hand are introduced behind the cervix uteri, «,s the patient lies on her left side, and the sound is slid along the fingers till its point reaches the os uteri, when, by depressing the handle towards the perineum, and at the same time carrying the instrument gently forwards, it will enter the uterine cavity. I need not say that it must never be employed when the least ground exists for suspecting pregnancy, and that under no circumstances must force be used in its introduction. In the majority of cases the introduction of the sound causes some pain, though this is generally by no means severe, and is almost always of very short duration; and in no instance which has come under my observation have dangerous consequences resulted from its use, though awkwardness and foolhardiness have, I know, done mischief with this, as with almost every instrument that has ever been invented. The information which this instrument places within our reach is often extremely valuable, and of a kind such as otherwise we could not obtain at all, or could arrive at only very slowly, and by frequently repeated examinations. If, in a patient suffering from frequent hemorrhages, we ascertain the uterine cavity to be greatly increased in size, our immediate conclusion is that the womb contains some foreign body, as a polypus or fibrous tumor, the presence of which has excited, and serves to keep up, the bleeding. If we doubt whether a tumor proceeds from the womb, or its appendages, or from some other part within the pelvis, the sound enables us to estimate the weight of the organ, and to strengthen the inference drawn from this experiment, by completely isolating the womb from the tumor, and thus ascertaining positively their independence of each other. Or, lastly, if the uterus be bent upon itself either forwards or backwards, the diagnosis of this condition, which once was a matter of much difficulty, is now often arrived at with facility, by introducing the sound with its concavity directed towards the swelling we detect per vaginam, and observing whether or not this swelling disappears on turning round the instru- 1 In a series of papers in London and Edinburgh Monthly Journal for 1843. 29 EMPLOYMENT OF THE SPECULUM. ment. I will not now go into further detail on the subject, for I shall hereafter have to refer on many occasions to this valuable aid to diagnosis. The uterine sound, indeed, is not always applicable, nor does it when used always clear up our doubts; but I do not remember any instance in which a diagnosis based on the information which it afforded turned out afterwards to be erroneous. The idea of adopting some contrivance by which the condition of the uterus might be examined by the eye was not altogether unknown to the ancients, though for the most part these instruments, of which drawings may be seen in old works on midwifery, and which received the name of Speculum Matricis, were used for dilating the mouth of the womb during labor, rather than for examining its condition in disease. 1 An instrument similar in kind, however, appears to have been sometimes employed for the investigation of diseases of the uterus and vagina, though it never came into anything like general use. The introduction of the speculum into modern practice, as a means of facilitating the investigation of uterine disease, does not date further back than the year 1821, when the instrument was first employed by M. R6-camier. This, which was merely a cylinder, conical in form, rounded off a little at its uterine extremity, and bevelled at its other end, was next fitted with a small handle by M. Dupuytren, and afterwards a plug was adapted to it to render its introduction more easy. Various materials have been used in the fabrication of these instruments, but we owe the greatest improvement in this respect to Mr. Fergusson, of King's College. Instead of employing metal, which is very apt to tarnish, and never has a very powerful reflecting surface, or glass, which, though very useful when caustics are to be applied to the uterus or vagina, since they do not act upon it, is yet liable to be broken, and, moreover, owing to its transparency, does not reflect very powerfully, he adopts the following plan: A glass speculum is silvered on its outside, by which means the inner surface is converted into a mirror easily kept clean, and on which no caustics can act. The speculum is then enveloped in successive layers of cotton-cloth, each of which is covered with a solution of India-rubber; and when the glass has thus received a coating of sufficient thickness, it is varnished, and forms an instrument which is now in general use. Its funnel-shaped termination is intended to provide for the admission of as much light as possible; a point of the more importance in this country, from the almost universal practice of examining patients on their side, in which posture light has a less ready access to the parts than if, as on the Continent, the patient lay on her back. The object of the instrument being slightly bevelled off at its uterine extremity is, that the same advantage is thereby secured as if the diameter 2 of the cylinder throughout were greater. This sloping off of the instrument, however, must not be carried, as some have recommended, so far as to amount to an angle of forty-five degrees, since by so doing the inconvenience is en- 1 See some remarks and quotations referring to the early history of the speculum, in Balbirnie, Organic Diseases of the Womb, pp. 41-45. 8vo., London, 1830'. 2 This useful modification of the speculum was, I believe, first suggested by Dr. Warden, London and Edinburgh Monthly Journal, Dec. 1844. 30 RULES FOR THE countered of a fold of vagina falling down in front of the cervix uteri. The specula which I use may perhaps appear to you of an unnecessary length; but you must bear in mind that the vagina is a very extensile canal, and that when a speculum is introduced into it, it is stretched in length as well as in width, so that the ordinary length of the vagina is not to be taken as the measure for the length of the speculum. I believe the attempt to reach the os uteri fails from the shortness of the speculum oftener than from almost any cause, and quite agree with the opinion of the late Professor Lisfranc, of Paris, 1 that a speculum ought to be seven inches long. In spite of the general convenience of the cylindrical speculum, however, there are some drawbacks from its utility. Owing to the entrance of the vagina being narrower than any part of its canal, it happens sometimes that a speculum sufficiently small to pass without causing the patient severe pain, is not large enough to bring the whole of the os uteri into view. But even though its whole surface be exposed, yet the cylindrical speculum pressing the lips of the os together may prevent a good view being obtained of its interior, and may thus render the examination incomplete and unsatisfactory. To obviate these disadvantages, specula have been constructed on the principle of the old instruments, composed of two, three, or four blades, and so arranged, that by turning a screw or by closing the handle, the uterine extremities separate, and thus expose the os uteri to view without any enlargement of the other end of the instrument. The best known of them are the two-bladed speculum of M. Ricord; a three and a four-bladed speculum manufactured by M. Charriere, of Paris; and a two-bladed instrument recently invented by Mr. Coxeter, instrument maker to University College. M. Ricord's instrument, and to a less extent those of M. Charriere, have the inconvenience that folds of the vagina are apt to fall down between the blades, and thus conceal the os uteri from view. This objection does not apply to nearly the same extent to Mr. Coxeter's instrument; each blade of which being a half-cylinder, does not leave so large a space vacant when it is opened. Two or three different sizes, then, of Fergusson's speculum, and a Coxeter's bivalve speculum, which last it is worth while, for the sake of obtaining a better reflecting surface, to have electro-plated, are all the instruments you need for ocular examination of the uterus. On the Continent, the posture usually assumed by a patient when about to undergo a specular examination, is on the back, with the nates resting on the edge of a bed or table, and the legs bent up towards the body, or the feet resting on two chairs, between which the doctor stands. There can be no doubt but that in this position of the patient the os uteri falls more readily within the orifice of the speculum, and that light is admitted much more thoroughly than in any other attitude; but its apparent indelicacy is so serious an objection to it, that, except under especial circumstances, it is desirable to introduce the speculum with the patient lying on the left side. In 1 Clinique Chirurgicale, etc., vol. ii. p. 272. 31 EMPLOYMENT OF THE SPECULUM. this position, too, unless the os uteri be directed in a remarkable degree backwards towards the sacrum, a very good view can generally be obtained, provided the patient lie with her body directly across the bed, her hips close to its edge, and her thighs drawn up towards the trunk; in the same attitude, indeed, as we should place a person in, on whom we were about to apply the forceps in" labor. If the patient be not in bed, the same precautions as to her position must be taken as she lies down on a couch or sofa, and a very little care in the arrangement of her dress will prevent any exposure of her person. The speculum, having been previously warmed and lubricated, is then to be introduced with the right hand, while wifh the left you separate the labia and nymphoe. Care must be taken that the end of the speculum is passed thoroughly within the opening of the vulva, since, if this precaution be neglected, a little duplicature of the fourchette is sometimes pushed before the instrument, and much needless pain is caused to the patient. The great obstacle to the introduction of the speculum is met with at the entrance of the vagina, and this must be overcome by gentle effort, not by anything approaching to violence. The speculum then passes on with facility, and when it has entered for some distance } ? ou withdraw the plug, and possibly find that the os uteri is now within view. You must, however, bear in mind, that the folds of the vagina sometimes hang down at the further end of the speculum, leaving a small aperture between them, which may be mistaken for the os uteri; though, on moving the instrument a little, the contour of the orifice will alter, and the vaginal folds dispose themselves in a different form. If, although you have introduced the speculum for some distance, the os uteri do not appear, the probabilities are that you have passed beyond it, and that the instrument has gone up into the cul-de-sac of the vagina, behind the neck of the womb. In this case, by gently and gradually withdrawing it, the os uteri will most probably come into view; if it do not, you may move the speculum slightly from side to side, since it is likely that the uterus is not quite in the mesial line, and that thence arises the difficulty in getting sight of it. When once you have the os uteri within the speculum, a little manoeuvring will generally suffice to remove any fold of vagina which obstructs your view; while, if the neck of the womb be very large, you may be compelled to examine first the anterior and then the posterior lip of the organ; and in this case you will find a bivalve speculum much more useful than the cylindrical instrument. There are many other little matters of detail connected with the employment of the speculum well worth the knowing; but to be learned rather by personal observation and actual practice than by any description. Need I say that there are some cases, those of unmarried women for instance, in which nothing but the most urgent necessity would justify your employing the speculum; others, as the majority of cases of cancer of the womb, in which its use would furnish no important addition to your previous knowledge; and still others in which its employment must be postponed, if not actually interdicted; such, for instance, as cases of extreme sensibility of the parts, of inflammation or ulceration of the vagina or of the external 32 USE OF THE SPECULUM. organs? Eestrictions to its use, indeed, such as these, speak to the common sense and right feeling of every one too distinctly for there to be much hesitation in subscribing to them. But, while admitting them, some of you may be inclined perhaps to go still further, and to inquire of me, whether, on the whole, the advantages arising from the use of the speculum outweigh the evils resulting from its abuse; whether it helps us to so much additional knowledge, or adds so much to our therapeutical resources as to counterbalance all the suffering both moral and physical which its employment not unfrequently inflicts upon the patient? Now, if I had a strong opinion on the negative side of this question, I should certainly not have taken up so much of your time in describing the instrument, and in directing you how to use it. The restrictions which my present experience leads me to put upon its employment, will be best appreciated when I speak of each disease in the management of which it has been advised to have recourse to it; and whether my views be right or wrong, I do not apprehend much difficulty in expressing them. To answer the broad question, "What is your opinion of the speculum?" I feel, on the other hand, to be a very difficult matter, and to expose me to much risk of being misunderstood. I will, however, do my best to reply to the inquiry. Those who first introduced the speculum into practice, employed it for two purposes; partly as furnishing a new means of diagnosis, partly as enabling them to adopt various modes of local treatment, which, without it, were impracticable. Now I believe that the advantages of those topical medications for which the speculum is needed, have been greatly overrated; though there are some cases, and those such as have proved most rebellious under other plans of treatment, in which these local measures may be resorted to with the most signal advantage. In estimating the value of the speculum as a means of diagnosis, I think that the advances in knowledge of uterine disease, of which it was the indirect occasion by the impulse which it gave to their study, are sometimes confounded with those positive additions to our information which we owe exclusively to the use of that instrument. The former have been very great indeed, and I think candor compels us to acknowledge that they have been due almost exclusively to persons who, not content with our previous means of investigating uterine disease, have labored to increase thern by the employment of instruments. The latter have certainly been less considerable, but nevertheless the speculum enables us in many instances to decide at once, and with certainty, upon the nature of a case, which otherwise we should have understood only after long and careful watching, to discover some minute polypus which the fingers alone would not have detected, to determine the source of a profuse leucorrhceal discharge, and to decide whether it is furnished by the cavity of the womb, or by the walls of the vagina; or, from the redness, congestion, or abrasion of the os uteri to infer the state of the womb generally, and thus to conduct our treatment upon the sure ground of positive observation, not upon bare presumptions. At the same time, however, that 33 MENSTRUATION AND ITS DISORDERS. I hold the speculum to be in many cases of most essential service, I think that the endeavor of all of us should be to ascertain the minimum of frequency with which its employment is necessary. This is to be done not by decrying the instrument, still less by attributing dishonest motives to those who use it, but by soberly and honestly trying to test the value of the information which we derive from it, and learning to discriminate between those appearances which the speculum discloses that are of moment, and such as are of no importance. LECTURE III. MENSTRUATION AND ITS DISORDERS. Importance of disorders of menstruation ; their three varieties—Relation of tardy puberty to menstrual disorder. AMENOKUutEA, from local causes, from congenital absence or malformation of sexual organs, from retention of menses owing to impediments to their flow. Amenorrhcea, from constitutional causes—tartly development, influence of previous illness in causing it. Symptoms, chlorosis whereon it depends—state of the blood. Consequences of amenorrhcoa. Treatment —principles which should regulate it—attention to general health, to uterine functions. Vicarious hemorrhages, their import, their management. Importance of habit in all ailments of menstrual function. I CAlTjED your attention, in the first Lecture, to the importance of the menstrual function, and to the frequency of its disorders. 1 told you that almost every serious ailment of the generative system, at least during the period of sexual activity, betrays itself by some disturbance of menstruation; and I may further add, that such disturbance is often the first, and sometimes for a considerable period the only, symptom of even grave disease. But you also know that disordered menstruation does not invariably depend on local mischief, that derangement of function does not always imply altered structure, but that a woman may menstruate scantily, painfully, or in excess, and yet no part of her generative organs may differ in appearance from those of a person in whom that function has always been performed in the most healthy manner. The disorders of the menstrual function, then, being so numerous, so important, and dependent on such various causes, it will be our best course to study them first, and afterwards to examine into other diseases of the sexual system, in which, though disordered menstruation may occur as a symptom, it is yet not the only one, nor that which calls for the chief consideration in the treatment of the patient. There are three grand classes, to one or other of which it has long been customary to refer the different disorders of menstruation. Either the menses do not appear at that period of life at which their occur-3 34 DISORDERS OP MENSTRUATION. rence is naturally expected, or they become suppressed in persons in whom they have already occurred, or their discharge is attended with extreme pain, or it is excessive in quantity, or over frequent in its return. I propose to consider in its turn each of these three varieties of disordered menstruation, which have respectively received the names of Amenorrhcea, Dysmenorrhcea, and Menorrhagia. It is, as you know, wisely ordered that the power of perpetuating the species is the last of nature's gifts, and one which she does not accord until the whole system has, in other respects, attained nearly to its perfection. Of this new power in woman, menstruation is both the sign and the consequence, indicating that the ovaries have become capable of bringing to maturity the germs, which need only to be impregnated in order to become developed to new beings. In our climate, the date of the first occurrence of menstruation is between the fifteenth and sixteenth year; 1 but the changes at puberty in the maiden, like those at dentition in the babe, are not accomplished all at once, but extend over a period of several months, during which disease is more frequent, and, as our Tables of Mortality show, more fatal, as compared with the male sex, than at any former time. 8 The anxiety with which parents regard the approach of this epoch is, then, not unnatural ; nor is it without good reason that this anxiety is increased more and more in proportion as delay occurs in the appearance of the first menstruation, since, when the menstrual function has been even once properly performed, many of the dangers of puberty may be regarded as already passed. Mr. Whitehead, of Manchester, to whom the profession is indebted for some very interesting researches into these subjects, ascertained that the risk of some unfavorable accident complicating the .first establishment of menstruation is very much greater when that is tardy in its occurrence than when it is premature; and that in between a third and half of all cases in which it is delayed to nineteen years and upwards, its appearance is associated with either local or constitutional disorders: a statement with which my own experience coincides. 3 1 Mr. Whitehead, of Manchester, gives fifteen years six and three-quarter months as the average deduced from 4000 cases, in which he made this point the subject of inquiry. See p. 47, of his Treatise on Abortion and Sterility. 8vo. London, 1847. 2 Thus MM. Quetelet and Smits, in their work, Sur la Reproduction et la Mortalite de 1'IIomme, 8vo., Bruxelles, 1832, show that while in childhood the mortality of the two sexes has been equal, or that of the male has predominated, the female mortality at once rises between fourteen and eighteen years of age to 1.28 to 1 male death ; sinking again in the succeeding four years to the proportion of 1.05 female to 1 male death. 3 Mr. Whitehead's table, lib. cit. p. 48, yields the following results:— First menstruation. Total number Number Percentage of of cases. unfavorable. unfavorable. From 10 to 14 years . . . 1141 224 19.63 Between 15 and 16 . 1728 324 18.75 " 17 and 18 . 892 247 27.69 From 19 and upwards . . 239 97 40.58 Total . . . 4000 892 22.30 aver. In 566 cases in which I ascertained the date of the first menstruation, either excessive pain, excessive discharge, irregularity of its return, or disorder of the general AMENORRHEA FROM MALFORMATION. 35 The mere circumstance, indeed, of a girl having passed the age at which menstruation usually appears, without performing that function, is not of itself a reason for medical interference. The date of puberty varies very widely, and one woman may menstruate at ten, and another at twenty years of age, without the health of either being of necessity impaired. Usually the absence of menstruation in otherwise healthy young women is associated with the absence of some of the other signs of puberty, indicating a generally tardy sexual development, just as, without apparent cause, one tree will produce blossoms and bear fruit later than another. This, however, is not always the case, and instances are sometimes met with of persons in whom pregnancy has preceded menstruation: completeness of sexual power having existed, though not manifesting itself by its ordinary sign. Such cases were a greater puzzle to physicians in former days than they are to us, who know that the discharge of blood is not the essential part of menstruation, but that the maturation and extrusion of ova may occur independent of it. One instance of it has come under my own notice, in a woman who, never having menstruated, married at the age of twenty, and immediately became pregnant; nor did the menses appear till after the birth of the first child, though she subsequently menstruated regularly, and had a numerous family. This, however, is very rare, and there would always be reason to apprehend that a woman who had not menstruated before marriage would remain sterile afterwards. Besides, it is possible that the non-appearance of the menses depends upon some congenital malformation, which might even prove a bar to sexual intercourse, such as absence of the vagina or its imperfect formation. If, then, your advice be asked as to the propriety of any young person marrying who has not menstruated, I should advise you to recommend delay; and if still further urged, to withhold your sanction until you had ascertained that no serious defect of structure is present. The pain of such an investigation would fall far short of the distress which would be entailed upon all parties if a woman with some important malformation of her sexual organs were to contract marriage. 1 Amenorrhcea from imperfect formation of the sexual organs may depend either upon causes which altogether prevent the performance of the menstrual function, or on such as merely interfere with the discharge of the menstrual fluid. Cases of the former kind are fortunately very rare, since, depending on the absence or defective formation of the uterus or ovaries, they are completely beyond the reach of remedy; those of the latter description generally admit of cure. In some of the health, occurred with the frequency shown in the following table. The conclusions to which it leads are the same as follow from Mr. Whitehead's more extended researches. First menstruation. Unfavorable. Percentage of unfavorable. Under 15 228 41 17.9 Between 15 and 17 . 220 33 15. " 17 and 19 ... 92 22 23.9 At 19 and upwards 26 11 46.1 Total ... 566 107 25.7 aver. 1 An important case illustrative of this subject is related by Dr. Meigs, at p. 119 of his translation of Colombat on Diseases of Females. 8vo. Philadelphia, 1845. 36 AMENORRHEA FROM MALFORMATION. former class of cases the sexual character has been altogether imperfectly developed, and the woman has never experienced any periodical occurrence of symptoms such as usually prelude the appearance of the menses, while in others the women have been liable to periodical attacks of pain in the back and loins, and to all those indications of suffering by which the menstrual flux is often attended, and have presented in their outward form all the indications of perfect womanhood. It is not easy to account for all of these differences, since, in some instances, where the sexual character was but imperfectly marked, the ovaries were found after death sufficiently well formed, though the uterus was absent, or merely rudimentary. A few cases are on record of alleged absence of both ovaries, in spite of the otherwise natural formation of the sexual organs. Such cases, however, are excessively rare, and the probabilities are that in many instances the organs were present, though in a very undeveloped condition. Somewhat less uncommon are the instances of absence of one ovary; a malformation generally associated with absence of the other uterine appendages on the same side, and sometimes also with absence of the corresponding kidney: a circumstance which will not surprise you if you bear in mind the mode of development of the urinary and generative apparatus, and the intimate relation which subsists between them at an early period of foetal existence. Much less uncommon than the absence of either ovary is the persistence of both through the whole or the greater part of life in the condition which, they present in infancy and early childhood, with scarcely a trace of Graafian vesicles in their tissue. This want of development of the ovaries is generally, though not invariably, associated with want of development of the uterus and other sexual organs: and I need not say that women in whom it exists are sterile. Two instances have come under my own notice in which there was reason to suppose that some defect of development of the ovaries was present. The first patient was a woman aged forty-three, who had been married for twenty years, but had never menstruated, nor had ever been pregnant. In her case the sexual organs were well formed, though the uterus was small, and sexual appetite existed. The other case was that of a young girl about twenty years of age, who was for some time under the care of Dr. Eoupell, suffering from those vague symptoms of disorder of the general health which so frequently exist when the appearance of the menses is delayed. She presented the general signs of puberty, but her vagina was very small, and her uterus was not larger than that of a young child. I do not know what became of her eventually, but it is quite possible that the evolution of her sexual organs, though long delayed, may at length have taken place, and have been followed by the due performance of their functions. Conditions 1 such as these which I have been speaking of interest us 1 Numerous references to cases of absence of the ovaries, or of their imperfect development, are to be found in Chereau, Traite des Maladies des Ovaires, Paris, 1844, pp. 73—91 ; and Meissner, Frauenkrankheiten, vol. ii. p. 28 ; and Dr. Thudicum, of London, has published in the Monatschrift f. Geburtskunde, April, 1855, p. 272, a verycareful analysis of twenty-one cases, collected from different sources, in which the uterus was either altogether absent, or merely rudimentary. 37 AMENORRHEA FROM MALFORMATION. rather as physiologists than as practitioners: we can only guess* at their existence, and can do nothing for their remedy. Though not so obscure, still quite as hopeless, are those cases in which the uterus alone is absent, or, as is more frequently the case, is represented by one or two small bodies, of the bigness of a bean, or even smaller, made up of true uterine tissue, rudiments, as it were, of the deficient organ. This absence of the uterus may coexist with a perfectly natural condition of the external organs; the vagina, which is usually much shorter than natural, terminating in a cul-de-sac. The only instance of this malformation which I have seen, existed in a young woman of little more than twenty years of age, who had been married but a few months, and who applied to the late Dr. Hugh Ley, in consequence of some obstacle to complete sexual intercourse. Iler appearance was that of a well-developed woman, and her external genitals were quite natural, but*the vagina was not above an inch and a half in length, and terminated in a blind pouch, above which no uterus could be felt, neither could any trace of the organ be discovered on examination by the rectum. Besides these cases, however, in which the non-appearance of the menses is due to a cause wholly beyond the power of art to remedy, there are others in which the ovaries are present, and perforin their functions properly, in which the uterus also exists, and the periodical hemorrhage takes place from its lining; but the effused blood finds no means of escape, owing to congenital closure of the os uteri, or to the absence or occlusion of the vagina. The non-appearance of the menses from any of these causes is unquestionably very rare, and no instance of it has come under my observation. To judge by the recorded accounts of such cases, however, they all present a certain general resemblance to each other, and are all characterized by the occurrence at, or soon after, the ordinary period, of the usual signs of puberty, the appearance of the menses alone excepted. While these are absent, the premonitory symptoms, which in general usher them in, are experienced with even more than ordinary severity. These symptoms subside, and again recur after the lapse of about a menstrual interval, till, after many months, enlargement of the abdomen becomes apparent, and increases by degrees with each periodical exacerbation of the patient's sufferings. The history of the patient, the absence of menstruation long after the period when it usually shows itself, and this in spite of the occurrence of the constitutional symptoms which generally accompany it, when coupled with the progressive enlargement of the abdomen, lead in the course of time to the cause of the symptoms being recognized, and to surgical means being adopted for their removal. Still, there are several circumstances which concur to prevent the abdominal enlargement from becoming apparent so early as might at first have been anticipated. Wherever any mechanical obstacle exists to the flow of the menses, they are almost invariably poured out in far smaller quantity than natural; a fact which I shall have again to refer to when I have to speak of some forms of dysmenorrhcea. In the next place, it must not be supposed that the blood poured out into the 38 AMENORRHEA FROM IMPERFORATE HYMEN. uterine cavity collects there uninfluenced by the vital processes which go on in the rest of the economy. On the contrary, the absorbents are very active in getting rid of the effused blood; and microscopic examinations show that it undergoes alterations of the same kind as take place in blood poured out elsewhere, and is removed by a similar process. 1 But besides this, the blood itself seems in some instances to escape through the fimbriated extremities of the Fallopian tubes into the abdominal cavity, where sometimes it is absorbed without giving rise to any dangerous symptoms, though, in other cases, fatal peritonitis has followed this occurrence. 2 One other caution with reference to these cases may not be out of place here, and that concerns the prognosis which we may express with reference to the result of any operation for their cure. Though generally favorable, it yet must be borne in mind, that a fatal result due to the occurrence of inflammation, has sometimes- followed an operation as simple as the mere division of an imperforate hymen; and that this has in some instances been produced by blood being poured through the Fallopian tubes into the abdominal cavity; notwithstanding that an opening in the vagina existed of ample size to allow of its ready escape in the natural way. 3 Attacks of inflammation of the sexual organs in women who have already menstruated, and have even already borne children, are sometimes followed by amenorrhcea; either from abiding mischief inflicted on the ovaria altogether putting a stop to the performance of the function, or from cohesion between the edges of the os uteri, or agglutination of the walls of its cervix, or from injury to the vagina, sloughing of its walls, and subsequent obliteration of its canal. In some of these cases, as in cases of congenital malformation, the menstrual fluid may collect within the cavity of the womb, and require to be evacuated by a surgical proceeding. Mere obstruction of the passages through, which the menstrual discharge ought to flow, seems, however, to be sometimes followed by its complete suppression. I have known the menses permanently to cease after severe labor, followed by obliteration of the os uteri, and adhesion between the vaginal walls, even though there was no reason for supposing that either the body of the womb or the ovaries had been the seat of any serious inflammatory mischief. Though I have made these few remarks on the non-appearance or suppression of the menses from causes requiring surgical interference, I wish to call your attention chiefly to cases of amenorrhcea from causes which require the interference of the physician. But before going into any details on this subject, I will once more remind you, that the mere postponement of the appearance of the 1 See the interesting account, by Dr. H. Muller, of his examination of the retained menstrual blood in two cases of congenital atresia vaginas, in Henle and Pfeuffer's Zeitschrift, vol. v. 1846, p. 140. 2 A series of papers by M. Bernutz, in the Archives de Medicine for June, August, and December, 1848, and for November, 1849, bear on this subject, and may be consulted with advantage. 3 As in a case related by M. Marchand de Masse, in the Archives de Medecine, July, 1851. AMENORRHEA FROM IMPERFORATE HYMEN. 39 menses beyond the time at which they usually show themselves, does not of itself call for interference, does not even warrant anxiety. Like all the other processes of development, so that of the generative system admits of considerable variations in point of time without of necessity passing the limits of health. Indeed, just as one child cuts its first tooth at seven months, and another not till a year old, so one girl may menstruate at fourteen or fifteen years of age, and another not till seventeen, without any obvious reason existing for the early performance of the function in the one case, its tardy accomplishment in the other. Mothers are often anxious about their children, if they do not menstruate till somewhat later than the average period; or even as that period approaches, will often attribute to its influence the most diverse symptoms of disordered health; and will urge on you the employment of emmenagogue medicines as essential to their removal. Again, the occurrence of serious illness of almost any kind a few months, or even a few years, before the arrival of the period of puberty, will often postpone for a long time the manifestation of its signs, and, in particular, the appearance of the menses. Not long since I saw a young woman, twenty years of age, who had never menstruated, who, perhaps, never will. Her health had been good until she experienced a severe attack of scarlet fever at the age of fifteen. Her recovery from this illness had been very slow, and she was dwarfed by it in body, and apparently in mind too, and her feeble frame was unequal to the task of bringing her reproductive powers to perfection. In idiots, with whom the imperfect development of mind is generally associated with imperfect development of body, puberty is almost always late in its occurrence. It appears, too, from the elaborate Report on Cretinism, presented to the Sardinian Government in 1848, that in extreme degrees of that condition the reproductive powers are never developed at all; in less degrees, menstruation appears late, and continues scanty and irregular through life; while even in cases of the slightest description, the average date of the first menstruation is as late as the eighteenth year. 1 Further, even when there is no bodily disease, nor any local cause rendering impossible the due performance of the sexual functions, it must yet be borne in mind that those functions are seldom completely performed from the very moment when they give the first indication of their activity. It often happens, that after the first menstruation there is an interval, not of one month, but of two or three, before the menses again make their appearance; or, perhaps, that the signs premonitory of menstruation are followed by a discharge, not of blood, but of mucus, the menstruce, albce of old writers. We know that such discharges, though once regarded as morbid, are far from being necessarily so. If the congestion of the uterus attending the menstrual effort be slight, the quantity of blood poured out from the organ will be but small, and mucus and epithelium corpuscles will then 1 Rapport de la Commission cree par S. M. le Roi de Sardaigne pour etudier le Cretinisme. 4to. Turin, 1848, see p. 25. 40 AMENORRHEA IN OPPOSITE STATES OF THE SYSTEM. make up the bulk of the discharge. In such a case, however, menstruation may be as really performed, as in the woman from whose sexual organs hemorrhage takes place with the greatest abundance. Time rarely fails to bring the function, in a few months, to the strictest conformity, in all respects, to those laws by which it is governed in the healthy and fully developed woman. Still, after every allowance has been made for cases of mere tardy development, and for those in which the complete performance of the sexual functions is accomplished by degrees, as well as for others in which the activity of the reproductive powers is postponed almost indefinitely by previous bodily ailment, there yet remain a number of instances where the non-accomplishment of the menstrual process, at the time when the changes of puberty are usually completed, is the prominent symptom of disordered health, and seems to be the chief occasion of all the various forms of illness with which it may be associated. There are two different classes of symptoms, with one or the other of which the non-appearance of the menses is in these cases usually associate —symptoms differing widely in their general characters, but probably far less widely separated in their essential causes. In the one case the condition is apparently of plethora, in the other of anairnia; but the tendency of the former is to pass into the latter, and this transition often takes place very rapidly. A girl, previously in good health, approaches the time-of puberty; some of the changes characteristic of it take place, the form assumes the contour of womanhood, and nothing but the occurrence of menstruation is wanting to announce the completion of, the change. The menses, however, do not show themselves, but the girl begins to suffer from frequent headache and a flushed face, frequent backache, pain in the hypogastrium and constipated bowels, a furred tongue and a full pulse, and all these signs of constitutional disorder undergo a marked increase at stated periods of about a month. At length menstruation occurs, though, in all probability, scantily, and attended with much pain, and then for several months together there is no sign of its return; or perhaps, when the proper period comes round again, the bleeding, instead of taking place, as it ought to do, from the womb, occurs from the stomach, or less frequently from the intestines. The general health was at first probably not seriously disturbed, or at least its disorder was limited to certain times of peculiar suffering, but by degrees the patient becomes habitually ailing, the appetite foils off, the powers of digestion are weakened, the strength becomes unequal to ordinary exertion, the pulse grows feeble and frequent, and the face itself assumes the pallid sallow tinge whence the term chlorosis has been selected as the most appropriate designation of the condition; while the stethoscope detects a peculiar sound attendant on the passage of the blood through the cavities of the heart and along the arterial and venous trunks, and which is known to be significant of changes in its composition, often of diminution of its quantity. In other instances, the signs of plethora have not at any time been present, but the health, never very robust, fails more and more as the 41 AMENORRHEA IN RELATION TO CHLOROSIS. period of puberty approaches; the feeble pulse, the cold skin, the bloodless countenance, the deficient and depraved appetite come on by degrees, while the outward signs of puberty appear slowly and imperfectly. The frail child never passes completely into womanhood, but fades and droops in the transition stage, through which she has not strength to pass. , In cases of both these kinds there is unquestionably a certain degree of obscurity, though scarcely more than we should find in the endeavor to explain how in infancy the state of the general health influences dentition, or the process of teething reacts on the general health. The weakly child cuts its teeth painfully, tardily, irregularly; and there seems to be no essential difference between cases in which the health falls off before any teeth have actually appeared, and those in which the symptoms come on after one or two of the teeth have cut through the gum. In both cases we look beyond the local phenomena for the explanation of the symptoms; and we do the same in the girl at puberty as in the infant in whom the period of dentition has commenced. In the case of the girl at puberty there seems, however, to be another element to be taken into consideration, namely, the composition of the blood. Of all the various processes of development which at different times go on in the system, none seem to make such great demands upon the circulating fluid as those which concern the reproductive organs. During pregnancy, even in a healthy woman, certain changes in the blood (a diminution of its red particles, an increase in its watery elements) are of constant occurrence; while in some instances those changes are so considerable as to give rise to disorder of the general health precisely similar in all its characters to chlorosis. 1 The growth of the womb, the development of the foetus, are, indeed, accomplished, for they are subject to a law not easily broken through; but they are accomplished at the expense of the woman's constitution, and leave her often incapable of suckling her infant, and probably liable to all that class of inflammatory affections, the remote cause of which, as of phlegmasia dolens, for instance, is to be sought in some morbid state of the blood. To originate a new function, to bring to perfection a hitherto unexercised power, makes larger demands on the strength than are required for its continued activity. The feeble phthisical child fails, as the time of womanhood approaches, to menstruate, and the signs of chlorosis gradually manifest themselves in her, while, in spite of advanced tubercular disease, the grown woman sometimes continues to menstruate with regularity, or even to bring forth children. These, however, are, it must be confessed, exceptional occurrences; the tendency of almost all diseases which originate in, or in their course produce 1 The merit of the first observations on chlorosis in pregnancy must be divided between M. Cazeaux, of Paris, and the late Professor von Kiwisch, of Prague, though the claims of the latter appear to be the stronger. The best remarks on the subject will be found in Cazeaux, Traite des Accouchemens, Paris, 1850, pp. 291—301; Kiwisch, Die Geburtskunde, Erlangen, 1851, vol. i. p. 227, and vol. ii. p. 33; and Scanzoni, Lehrbuch der Geburtshilfe, Vienna, 1849, vol. i. p. 192. 42 AMENORRHEA: important alterations in the blood, is to disturb, to impair, and at length to interrupt the performance of the reproductive functions. In one instance only, 1 out of all the cases of phthisis among women that form the materials of M. Louis's great work on that disease, did menstruation continue up to the time of death; and it suffices to watch with moderate care any one suffering from uterine cancer, in order to feel satisfied, that even though hemorrhage should still occasionally take place from the diseased womb, yet the periodical activity of the reproductive organs ceased when once the cancerous cachexia had become developed. There is another peculiarity connected with the sexual functions in woman, which must not be left altogether without notice, since it suggests a reason why their tardy or imperfect development, or their subsequent disorder, should be associated with symptoms to which we nowhere else find the slightest analogy. It is a law of the female economy that, for some thirty years of life, unless interrupted by pregnancy, or its results, a certain quantity of blood shall be periodically discharged from the system. This periodical discharge alone engaged the attention of observers in bygone times, and various hypotheses were framed, which, differing in other respects, yet agreed in this—that they all regarded the menstrual function as a great depurative agent, a means supplemental to the lungs themselves, for eliminating superfluous carbon from the system. Though we, with the light of modern physiology, are able to look deeper than our predecessors, and can see in the discharge of blood from the sexual organs, the outward sign of a still more important process going on within; we yet must not forget that it cannot be a matter of indifference to the health of a woman whether the excretion of four or six ounces of blood takes place every month, or not; that the arrest of this phenomenon, or its non-occurrence, cannot but be associated with much constitutional disorder. We find, indeed, that even when with the lapse of years, the time arrives at which the discharge naturally ceases, its cessation is almost invariably followed by a class of symptoms which show that the balance of the circulation has been disturbed, while many months are often needed to complete its readjustment. The liver now has extra work to do in the depuration of the blood, its disorders are now more frequent than at other times, and though hemorrhages not unfrequently take place which relieve the overtasked organ, yet they often pass the limits of health, and become themselves a fresh cause of suffering, or even an occasion of danger. But the very accidents to which there is a disposition when menstruation ceases, may also precede its occurrence. If menstruation is postponed beyond the ordinary period, the system suffers in the same way as it often does at its cessation. The same double duty is thrown on the liver, the same disposition to its disorder exists, the same tendency to congestion of different viscera manifests itself, and frequently the same outbursts of hemorrhage give temporary relief to the con- 1 Louis, Recherches sur la Fhthisie, deuxieme ed. Svo., Paris, 1843, p. 334. ITS RELATION TO CONSTITUTIONAL DISORDER. 43 gestion, too often also at the expense of the general constitutional vigor. No one who is familiar with the symptoms that are often associated with granular degeneration of the kidney will be at a loss to understand how local plethora may be associated with an altered and impoverished condition of the circulating fluid, or will fail to see how it may sometimes happen that leeches, purgative medicines, and active exercise, may take that place in the cure of amenorrhcea which tonic remedies, ferruginous preparations, and wine occupy in general. The exact mode of applying these principles in cases where menstruation has never occurred, must vary much in different instances, though in all, our chief endeavor must be directed to the establishment of that function through the medium of the general health, rather than by means of remedies acting, or supposed to act, immediately on the sexual system. While then the tardy occurrence of puberty, just as the tardy appearance of the teeth in infancy, furnishes, when unattended by constitutional disorder, no indication for medical interference, the first question that in these cases presents itself is, whether the symptoms which accompany the amenorrhcea are those of simple debility or of that kind of plethora which may yet be associated with an altered and deteriorated state of the circulating fluid. But though the decision of this point, with a view to the adoption of a suitable constitutional treatment, claims our first attention, there is yet another which must not be wholly lost sight of. When its establishment is long postponed, the performance of the menstrual function generally takes place painfully, difficultly, and for a long time imperfectly, while, as already mentioned, it sometimes happens that the blood which is not poured out from the uterus makes its escape through other channels; such a discharge, too, vicarious of menstruation, sometimes continues to recur for months together, not merely injuring the patient's health, but, through the mysterious influence of habit, offering a serious impediment to the proper performance of the menstrual function. How, and why this is so, I will not pretend to explain. Deficient innervation of the sexual organs has been assumed to be its cause by some; while others have spoken of some special density of the uterine tissue, preventing the ready outflow of blood ; or of some peculiar thickness of the blood itself, which therefore could not escape from the pores that otherwise would give it exit. Statements of this kind, however, are but the expression of very crude hypotheses; they add nothing to our knowledge, they do not even present it to us in a clearer form. What we have to do with is the fact, that there are certain periods more or less well marked in the regularity of their return, when a special disorder of the nervous and vascular systems, and various forms of local suffering, referred more or less distinctly to the womb or to the parts adjacent, announce a sort of imperfect menstrual effort, and that at those times various local measures addressed to the uterus are not unfrequently succeeded by the establishment of menstruation, though the same measures, if had recourse to at another time, would be altogether unavailing, or even positively mischievous. 44 AMENORRHCEA. —PRINCIPLES OF TREATMENT. Treatment then resolves itself into what is to be done for the improvement of the general health, and what is to be done on special occasions with a particular view to the excitement of the uterine function, while it follows as a necessary corollary, that when no sign of menstrual effort shows itself, then no local measures are indicated. In cases where general debility characterizes the patient's condition, tonics in the widest sense of the term are indicated; and by them I understand not merely tonic medicines, or preparations of iron, though they will almost always be appropriate, but the tonic influence of pure air, healthful pursuits, and exercise short of fatigue. In these cases, too, the one great danger to watch against, is that of the supervention of phthisis, and a winter's residence at Torquay or Ventnor is useful in many instances, not only as a means of guarding the delicate lungs from the cold of many inland places, but also because the warm climate and the sea air appear of themselves to have a beneficial influence in favoring the healthy development of the reproductive system. The constipated state of the bowels, which is so troublesome a symptom in these cases, must be encountered, not by drastic purgatives, but by gentler aperients, among which the watery extract of aloes has a well merited reputation. In some instances all preparations of iron have the effect of increasing the sluggish state of the intestines, but this difficulty can in general be got rid of by combining the iron with some aperient salt. 1 At other times the delicate stomach is unable to bear the mildest ferruginous preparation, and in these circumstances, chalybeate mineral waters will often produce good effects, far beyond what might be anticipated if we regarded merely the quantity of the remedy they contain. The waters of Spa and Pyrmont are especially suitable to cases of this description; the former being the milder and better borne by patients whose digestive power is very feeble. Both these waters are very well prepared at Brighton, but patients of this description benefit as much by the change of scene, the healthful exercise, the sort of busy idleness of a watering-place, as by the virtues of the spring to which it owes its reputation. Even when a state of apparent plethora predominates, much the same kind of treatment is nevertheless appropriate; with the exception, however, that the preparations of iron are often not needed at all, while a much more active system of purgation is generally indicated. A nutritious, though not a stimulating diet, the shower-bath, and horse exercise, are remedies of greater power than any which Apothecaries' Hall contains. The sluggish state of the liver, which constitutes one of the great difficulties that in these cases we have to contend with, must not lead us to the too frequent use of mercurials, especially of mercurial purgatives. There are some exceptional cases, 1 (No. 1.) J£. —Ferri sulphatis gr. ix. Magnesiae sulphatis 3iij. Acid, sulph. dil. gss. Syrupi aurantii Aquse carui, ad 2jvi.—M. ter quotidie. 45 AMENORRHCEA. — USE OF EMMENAGOGUES. however, where other remedies fail to excite a due secretion of bile, in which the steady employment of small doses of bichloride of mercury, persevered in for several weeks, while a generally tonic plan of, treatment in other respects is continued, proves of most essential service. But while the general health must be administered to by means such as I have just described, the appearance of any attempt at menstruation, as it indicates a different object to be aimed at, so calls for an immediate change in the remedies to be employed. The patient should be kept quiet, and if there be any considerable suffering, or much disturbance of the circulation, it is desirable that she should remain in bed, while the hot hip-bath, night and morning, rendered still more stimulating in cases where the local pain is not very considerable, by the addition of some mustard, will often have the effect of inducing the menstrual flux. It is at this time that the stimulant diuretics, such as nitrous ether, turpentine, spirits of juniper, or the domestic emmenagogue, gin, sometimes prove useful, and by increasing the congestion of the pelvic viscera, induce a hemorrhage from the uterus, and relieve the patient from much suffering. Much care, however, is needed in the employment of any of these remedies; while all violent measures, such as- the administration of cantharides, or of the oil of savin in large doses, or very powerful local stimulants, such as vaginal injections of liquor ammonite mixed with milk, or the introduction of nitrate of silver into the uterine cavity, by means of Lallemand's porte-caustique, appear to me to deserve reprobation, as both uncertain and unsafe. Electricity, applied by means of the ordinary electro-magnetic apparatus, one disk being placed over the pubes and the other over the sacrum, has in some cases been of service, though its results, just as when employed for other purposes, appear to vary much, and causelessly. It was at one time anticipated that the ergot of rye would prove a very valuable emmenagogue, and indeed it was employed as a popular means of inducing menstruation long before its introduction into obstetric practice. Though it has been tried, however, in various forms of powder, tincture, infusion, and essence, and though experiments have been made with its essential principle, the ergotine, yet its peculiar power over the muscular activity of the womb does not appear to extend to any other function of the sexual organs. In some instances, the pain experienced in the uterine region with the return of each menstrual period, is very severe indeed; and in such cases, while stimulating hip-baths are out of place, the application of leeches to the hypogastrium not only relieves the pain, but is often followed by the occurrence of menstruation. The explanation that used to be given of this fact, founded on the circumstance that excessive congestion of a secretory organ often puts a stop to its aetivity, is scarcely applicable now that we know the menstrual discharge to be a simple hemorrhage, not a secretion. The fact, however, still holds good, and the practice founded on it is worth remembering. I have already referred to the occurrence of hemorrhage from various organs as an occasional attendant on amenorrhcea, and have 46 AMENORRHEA. —VICARIOUS HEMORRHAGES. suggested an explanation of its cause. Medical writings 1 are full of illustrations of this vicarious menstruation, as it is often, though not quite correctly, termed; and from them it appears that the hemorrhages may occur, not merely from any of the mucous surfaces, as the stomach, intestinal canal, or air-passages, but also from any casual wound, from the surface of an ulcer, from the nipple, from the eye; in short, from almost any conceivable part of the body. Now it is no part of my object to occupy your time with a detail of these mere medical wonders; but there are several things with reference to them which I wish you to bear in mind. The first is, that after the arrival of the period of puberty, the non-appearance of the menses, or their accidental suppression, is likely to be followed by occasional outbursts of hemorrhage, which by no means invariably correspond with any real activity of the sexual organs, or observe any distinct periodicity of return. Next, it is to be remembered that such discharges, not being genuine menstruation, may nevertheless take place from the uterus, and amenorrhcea and a seeming menorrhagia may alternate with each other. Such hemorrhage, too, may be extremely profuse; and even within my own observation it proved fatal to a young lady, in whom it succeeded to long-continued suppression of the menses, and whose uterus, as far as could be ascertained by examination during life, was perfectly healthy. Lastly, the occurrence of this hemorrhage does not in any material respect alter the indications which we are to pursue in our treatment, or the which we must endeavor to accomplish them. If so profuse as to be hazardous, the discharge must be checked by appropriate means; but it is to the state of the general health, and the excitement of the true menstrual function, that our chief care must be directed. Habit, " the memory of the body," 2 as John Hunter beautifully terms it, while it plays a prominent part in many of the functions of the animal economy, exerts over none so powerful an influence as over those of the sexual system of the female. The hemorrhage vicarious of menstruation, in its first occurrence, perhaps the result of mere accident, needs but to return two or three times for its cure to become difficult. After a time, even though the general health may be perfectly good, and though the ovaries, as far as we can tell, perform their office properly, yet with each return of that excitement of the circulation which should relieve itself through the medium of the uterus, the longestablished habit interferes, and bleeding takes place from the lungs or from the stomach, or from the surface of the body, instead of from the womb. But the application of this fact is wider than to the mere determining the prognosis of cases of hemorrhage vicarious of menstruation, though it will at once be obvious that they admit of cure easily, or with difficulty, in almost exact proportion to their duration. The principle which it involves is to be borne in mind in the management 1 Abundant references may be found in Brierre de Boismont, De la Menstruation, &c. 8vo., Paris, 1842, chap. vi. p. 374; and in Meissner's Frauenkrankheiten, 8vo., Leipsig, 1845, vol. ii. p. 860. 8 Works, Palmer's edition, vol. i. p. 274. 47 SUPPRESSION OF THE MENSES. of all the ailments that disturb the menstrual function. It is not enough to take precautions till menstruation has for the first time occurred ; the period for its return should, even in the healthiest girl, be watched for, and all previous precautions should be once more repeated; and this should be done again and again, until at length the habit of regular, healthy menstruation is established; and if this be once secured, the risks of its subsequent disorder will be very much lessened. Need I say that this truth bears with tenfold force on all cases in which menstruation has been tardily, painfully, or difficultly accomplished; for in these the bad habit has to be broken through, and a new one formed. If this be not accomplished during the first few years of womanhood, it will, in all probability, never be attained. LECTURE IV. MENSTRUATION AND ITS DISORDERS. Amenorrhea, continued—Suppression of the Menses —Their premature cessation— Irregularities before final extinction of function—Various causes suspending the menses—Treatment. Menorrhagia—Its two principal causes—1st, constitutional; 2d, local—illustrations of each. Treatment of both classes of cases—general precautions—cases requiring antiphlogisticmeasures—cases requiring tonics and astringents—local remedies —conditions calling for the plug, and for intra-uterine injections. We were engaged during the last Lecture with the study of those cases in which the menstrual discharge has never made its appearance. Another, and equally important class, still remains for consideration, in which menstruation is either interrupted or suppressed. It is of course out of the question to attempt an examination of all the various circumstances that may give rise to suppression of the menses, or that may lead to their permanent cessation; for a very large number both of constitutional disorders as well as of local diseases tend directly to produce this result. Reference has already been made to the remarkable influence of phthisis in its more advanced stages in leading to suppression of the menses, and many other cachectic diseases exert a similar influence on the menstrual function; while severe uterine or ovarian inflammation, various forms of ovarian degeneration or of uterine tumor, often suspend menstruation for months together, sometimes put a final stop to its occurrence, many years before, in the natural course of events, the sexual powers would lose their vigor. But besides those cases in which a definite reason can be assigned for the arrest or cessation of the menstrual discharge, there are others occasionally met with, in which it disappears as the result of a prema- 48 SUPPRESSION OF THE MENSES. ture senescence, just as we have observed it sometimes to come on late in life in consequence of the tardy occurrence of puberty. Thus while the average duration of the menstrual function is about thirty years, and the age of its cessation in the majority of instances, at or a little after forty-five, it has been known to continue less than ten years, and to cease before the age of thirty, and this, too, without any peculiarity in the history of the woman suggesting an adequate reason for so wide a deviation from the ordinary rule. 1 To a great extent the date of the cessation of the menstrual function is, I apprehend, a matter of indifference, and just as some persons of our own sex retain sexual vigor to extreme old age, while with others it soon grows feeble or becomes sluggish, so women may long retain their reproductive powers, or may lose them early, without their health being better in the one instance, or less good in the other. Cases, however, are sometimes met with, in which a permanent cessation of the menstrual function is associated with the same state of health, the same condition of general debility, as I have already referred to when speaking of the non-appearance of the menses, and accompanied with all that category of symptoms which constitutes chlorosis. In these circumstances the same general treatment, the same chalybeate remedies as are suited to the young girl, find their fit application in the illness of the matron, and generally with the result of improving the health and reproducing the menstruation. Sometimes, indeed, though the health amends under appropriate means, yet the sexual functions are never re-established; a result with which although far from usual, it is nevertheless important that you should be acquainted. But there are many instances in which, though menstruation is not finally arrested, yet the function is suspended for a time, and this accident is attended by very various degrees of constitutional disorder. At the commencement of sexual activity and towards its close, menstruation is often irregular, in the one instance owing to the organs not having arrived at perfection, in the other owing to the gradual loss of their power. So frequent, indeed, is this irregular menstruation as a prelude to its final cessation, that women have a homely phrase, the " dodging time," by which they designate the period of its occurrence. I have already told you how in the former case you must watch over the function, and endeavor to bring on by degrees its regular performance. In the latter, you must confine your attention to the general health, without endeavoring to re-excite the activity of organs which are thus giving evidence of their waning powers. 1 Elaborate tables showing the duration of menstruation, and the age at its cessation, are to be found in Brierre de Boismont, op. cit., pp. 209, 211 ; in Mr. Whitehead's Treatise on Sterility and Abortion, &c, 8vo., London, 1847, p. 150; and in Dr. Tilt's work on the Diseases of Women, 8vo., 2d ed., London, 1853, pp. 44 and 40. My own observations on the subject, though they have not furnished me with any instances of the cessation of the menses under thirty, yet correspond with the others in showing the differences to be very wide indeed in this respect between different and apparently equally healthy women. In my cases the age at cessation of the menses varied from thirty-one to fifty-eight, and the duration of the function from twelve to thirty-eight years. RULES FOR ITS MANAGEMENT. 49 The irregular menstruation in the above case is almost a physiological occurrence; its suppression, in other circumstances, may be due to a great variety of causes; it may be owing to pregnancy ; to pregnancy, unsuspected by the person who seeks your advice. 1 refer to this chiefly in order to remind you that in every case of causeless suppression of the menses, just as in every case of abdominal tumor in women, you must bear in mind the possibility of pregnancy. I do not mean by this that you are to doubt every woman's word, or to question every woman's chastity, even in thought, but that, bearing in mind how little you can know of the intimate history of many of your patients, you must not allow your respect as men, your gallantry as gentlemen, to make you quite lose sight of what may much import you as physicians. Independently of pregnancy, however, mere sexual intercourse not infrequently arrests menstruation for a time, so that in recently married women, the existence of pregnancy is sometimes suspected for two or three months, till, at the end of that time, the hopes are dissipated by the unwelcome return of the menstrual discharge. Habitual sexual excesses, though they sometimes have an opposite effect, and induce menorrhagia, yet, in the great majority of cases, suppress menstruation altogether, or render its return irregular, and the quantity of discharge small. 1 Any sudden shock, either acting locally on the uterine organs, as the application of cold to the vulva, or through the medium of the general system, as when a person gets wet footed, or suffers during menstruation from exposure to wet or cold, will often check the menstrual flux. In many ol'these cases, too, the sudden arrest of the discharge is followed by extreme uterine pain and tenderness, by all the symptoms of intense uterine congestion, sometimes, indeed, by actual uterine inflammation. The mind, too, reacts upon the body, as we see perpetually illustrated in the case even of those functions that might be supposed most independent of its influence, and many instances might be related of sudden grief, or fear, or anger, at once arresting the menstrual discharge. But various though its causes may be, yet the treatment of suppression of the menses rests for the most part on very simple principles, and those the same in almost all instances. Two points require attention; first, to re-excite menstruation at once, if possible; second, to provide for its re-establishment when the proper period once more comes round. If the hot hip-bath, or a warm bath, bed, and a cordial or diaphoretic, fail to reproduce the menses when suddenly checked by cold, or by any other cause, we must wait patiently till the next menstrual period comes round, unless indeed urgent symptoms supervene, betokening great congestion, or inflammation of the uterus, and they may require free local depletion, or even venesection, and other active measures to arrest their progress. With the return of the ensuing menstrual period, the greatest care 1 See on this subject the remarks of M. Parent-Duchatelet. De la Prostitution dans la Ville de Paris, vol. i. p. 228. 4 50 MENORRHAGIA : must be taken to secure the proper performance of the function, by the use of all those means which I mentioned in my last lecture, when speaking of amenorrhcea. The importance of doing this cannot be overrated, since many cases of habitual dysmenorrhoea, due probably to a state of chronic irritation or inflammation of the ovaries, date back to some accidental suppression of the menses; and the suffering has been confirmed by want of due care at the return of the next few periods. It is no part of my plan to occupy your time with passing minutely over ground already often trod before; and, therefore, in considering the different disorders of the menstrual function, I shall content myself with pointing out to you the grand principles by which your management of them must be regulated, rather than attempt to enter into detail concerning any. This being so, we may now pass from the-consideration of cases in which the menses have been' scanty, or suppressed, or have failed to appear in due time, to th?'study of disorders of menstrual function of an exactly opposite /character, to cases of is termed menorrhagia, or excessive menstruation. This excess of menstruation may show itself either in the great profuseness of the flow, or in\its long duration, or in its frequent return. It is, as you will find hereafter, by no means a matter of indifference, in which of these respects the excessive menstruation first or chiefly shows itself, since from these variations important conclusions may often be drawn, both as to the cause of the ailment and its means of cure. It must, however, be borne in mind, that menstruation seldom continues long to be excessive in one respect alone; but if the menorrhagia be not speedily checked, the patient will menstruate not only in greater quantity, but for a longer time, and at shorter intervals than natural. Divisions and subdivisions of menorrhagia into many different kinds, have been needlessly multiplied. The only classification that seems to me of real practical utility, is that which recognizes two forms, depending, either— 1st. On some cause seated in the constitution generally. 2d. On some affection of the sexual system. This distinction should never be lost sight of in practice, though we may seldom meet with instances in which the actual line of demarcation is drawn with the same precision as we attempt to observe in our nosologies. One caution is, perhaps, worth giving, before I say anything more about menorrhagia. It is, that every excessive hemorrhage from the unimpregnated uterus, during the years of sexual activity, is not necessarily menorrhagia. Women themselves are apt so to regard all losses of blood during that period of their life, and practitioners are too often guilty of the same oversight. Menorrhagia is an excess of menstrual discharge, an over-abundant hemorrhage, the cause of which, in the first instance, is that congestion of the sexual organs which attends the maturation and escape of an ovule from the ovary. As I mentioned yesterday, outbursts of bleeding may take place from the ITS CAUSES TWOFOLD. 51 womb in some cases where the menses have been long suppressed, affording relief to the system, or even by their excess, jeopardizing the patient's well-being, and this with no more real reference to the function of which menstruation is the sign, than exists in a case of hemorrhage from the bowels, or of bleeding from haemorrhoids. In the same way, too, a patient may bleed to death from a cancer of the womb, or from a polypus, or fibrous tumor of that organ, and j r et such hemorrhage may be no real menorrhagia. In this case again the distinction cannot always be drawn, for the incipient uterine disease may at first have betrayed its existence by the excessive congestion of the sexual system, and consequent abundant discharge of blood at a menstrual period, but with the advance of the mischief, bleeding may take place at any time, and independent of any special occasion of uterine excitement. I need not say that a distinction does not cease to be useful because it is not always practicable to make it. But to return, 1 menorrhagia was stated to depend in some instances on causes acting through the medium of the general system. Thus, for instance, some years ago I saw a widow lady of about forty years of age, whose time was divided between a sojourn in this country for two or three months at a time and a residence during the other part of the year in a somewhat damp situation in Ireland. Menstruation was always regular in the time of its recurrence and natural in quantity during her stay in this country, but for some two or three years her return to Ireland had been followed by an excessively profuse discharge at each menstrual period, and by its continuance for more than twice as long as usual; symptoms which subsided once more after a few weeks' stay in England. How the change of climate acted in this case it is not possible to say, though illustrations of a somewhat similar influence of locality in modifying the uterine functions are far from unusual. Cases are sometimes met with, in which an altered state of the cir- 1 Premature menstruation, menstruatio prtecox, has been classed by some writers as a form of menorrhagia. I have preferred, however, passing over the subject, since cases of precocious puberty in either sex concern the physiologist rather than the physician. Two remarks only suggest themselves as in place here. First, that those instances in which the sexual system has been stimulated to premature activity by various injurious influences both physical and moral, are not genuine cases of precocious puberty; and second, that neither are all cases to be so regarded in which once, or oftener, sanguineous discharges have taken place from the sexual organs of infants and very young female children. Cases of genuine precocious puberty in which the whole body has undergone in early childhood the various changes that usually take place in later years, and announce the arrival of womanhood, are far less common than the numerous references to be found to their occurrence in medical works would at first lead one to imagine. A very sound criticism on many of the earlier cases is to be found in Naegele, Abhandlungen, &c, aus dem Gebiete der Krankheiten des weiblichen Geschlechtes, 8vo., Mainz, 1812, pp. 312—328. Numerous references, though some of them are of doubtful authenticity, are to be found in Meissner, Frauenkrankheiten, vol. ii. 8vo., Leipsig, 1845, pp. 723—739; and in Busch, Das Geschlechtsleben des Weibes, vol. iv. 8vo., Leipsig, 1843, § 243, pp. 459—465 ; and, lastly, an interesting case, with very sensible remarks on many previous histories of cases of premature menstruation, will be found in a small tract of 47 pages, by Dr. Reuter, Ueber die Prsecocitat der Menstruation, 8vo., Wiesbaden, 1846. 52 MENORRHAGIA —PROM CONSTITUTIONAL CAUSES. culating fluid, such as even our rough chemistry can detect, coexists with and appears to be the exciting cause of menorrhagia. In cases of granular degeneration of the kidneys, menorrhagia is far from being of uncommon occurrence. The altered, attenuated blood seems to escape more readily than natural from the uterine vessels when they are congested at the return of a menstrual period; and three or four cases of supposed disease of the womb have come under rny notice, in which the most careful examination could detect no local cause for the profuse menstruation, but in which the urine was discovered to be loaded with albumen. The hint which this fact suggests as to the expediency of examining the urine, even though no symptoms should seem to point to the existence of renal disease, is worth remembering, and the test tube will help to clear up many an obscure case of supposed uterine ailment. You are not to be specialists, even though chance should lead you to have most to do with one special class of ailments, but you are to be physicians, and in proportion as you learn to estimate aright the influence of the disorders of one part on the functions of another, will you be likely to prove good and successful practitioners in the treatment even of local diseases. Somewhat similar in their nature are those cases of menorrhagia met with most frequently towards the decline of sexual activity, in which with general disposition to plethora of the abdominal vessels, a sluggish livei', and constipated bowels, menstruation is sometimes irregular in its occurrence, often anticipate the proper date of its return, and is often excessive in its quantity. Such hemorrhages are not of necessity menstrual, though they usually take place at or near a menstrual period, the congestion of the womb which then exists favoring the occurrence of profuse bleeding at that time from the uterus rather than from any other organ. A tendency to hemorrhage is a frequent attendant on many conditions of debility, and we look, probably with propriety, on some change and deterioration in the circulating fluid as accounting both for the general feebleness, and for the local accident. In women whose strength has been exhausted, or whose blood has been impoverished by prolonged lactation, the reappearance of the menses often takes place with an undue abundance of discharge, often in such quantity as to constitute real menorrhagia; while in many instances the long duration of the hemorrhage is at least as trying to the patient as the profuseness with which it flows. Here then is another illustration of menorrhagia from constitutional causes. But though in cases such as these the sexual system is not the part first in fault, yet no serious disorder of its functions can take place, still less can recur frequently, without being accompanied by some sign of uterine ailment. A sense of weight in the pelvis, a feeling of bearing down and sympathetic pains in the back, tell that the uterus is heavier than natural, and that its vessels from habitual congestion are overloaded with blood; while the mucous discharge which persists in the intervals between the menstrual periods is but the effect of the same condition, which, increased at the time of each ovarian excitement, gives rise then to the profuse outflow of blood. Moreover, MENORRHAGIA—FROM LOCAL CAUSES. 53 since the menstrual effort returns every twenty-eight days, the congested womb has not time to recover itself between each period.. The blood has scarcely ceased to flow before it is again determined to the organ by a renewed ovarian excitement; and, its tissue being looser, its vessels more dilated on each succeeding occasion, allow more and more readily of the escape of blood, till at length no interval is left at all, but the flow goes on constantly, and menstruation is marked only by a larger hemorrhage than takes place at other times. The influence of habit, too, to which I referred when speaking of amenorrhcea, is not less marked in cases of menorrhagia, tending to perpetuate the evil, and to render its removal difficult, long after the cause to which it was originally due has ceased to be in action. Some inferences applicable to practice may be deduced from what has already been said. 1st. The importance of determining whether the cause of the menorrhagia is to be sought in the state of the general system or of the sexual organs. 2d. The necessity of bearing in mind that even when the ailment depends on a constitutional cause, it will yet bo attended by certain local symptoms; and further, that the latter may persist long after the removal of the former. 3d. It follows as a corollary from the two preceding statements that it is essential in every case of long-continued menorrhagia to determine by careful examination the presence or absence of local disease; and this the rather since the early stages of organic uterine affections are not only often accompanied by menorrhagia, but also are often unattended by any other symptom. But there is a second class of cases in which menorrhagia occurs as the result of some cause acting directly on the sexual system. We meet sometimes with instances of what seems like a special susceptibility of the sexual system, in which any sudden excitement, even though, unconnected with the sexual functions, is followed by hemorrhage, lasting perhaps only for a few hours, or for a day, but sometimes continuing longer, and even passing into regular menorrhagia; while in all patients who are liable to this accident menstruation is almost invariably profuse. A similar effect is produced by causes acting directly on the sexual system, and hence, while in some cases we find the unaccustomed stimulus of sexual intercourse lead to suppression of the menses, we also observe it in other instances followed by their excess. Menstruation in these cases generally continues to observe its proper periods of return, but lasts on each occasion much longer than natural; while abstinence from intercourse for a season, and moderate use of it afterwards, are almost always followed by the menstruation resuming its natural character. More difficult of cure, however, are those cases in which, from some cause or other, the marriage is sterile, and especially those in which, from disparity of years, or from constitutional feebleness on the husband's part, the act is but imperfectly accomplished. In these circumstances a sort of chronic ovarian irritation and chronic congestion of the womb are kept up, which lead to a degree of hypertrophy of the uterine substance and 54 MENORRHAGIA : to profuse bleeding from its lining membrane. Menorrhagia, too, sometjmes occurs in prostitutes from the constant over-excitement of their sexual organs, and its cure is almost impossible by any means short of the complete abandonment of their habits. The local causes, however, which may give rise to menorrhagia are manifold. Whatever produces undue ovarian excitement, whatever causes undue uterine congestion, is likely to occasion it, while any circumstance that renders the womb larger, its texture looser, its vessels of greater size than usual, by just so much facilitates its occurrence. Premature exertion after delivery is often followed by hemorrhage. If this hemorrhage is not speedily checked by treatment, and its return guarded against by watchful care, it soon assumes the menstrual type, and soon also becomes exeessive in quantity, from the very circumstance that it takes place from an organ in which the processes of involution are as yet incomplete, aud whose vascular supply is much more abundant than it would be if menstruation were delayed till the lapse of the ordinary period after delivery. From a similar cause the foundation of menorrhagia is often laid in a want of due care at the time of the first appearance of the menses after a miscarriage; an occasion, by the bye, on which you should not fail to impress on your patient the need for what may seem to be almost exaggerated precaution. This condition of the womb, too, sometimes persists for long periods after the delivery or the miscarriage to which it was originally due; or in weakly persons exists even independent of any appreciable cause, and this to so great an extent that the uterine sound may sometimes discover the length of the uterine cavity to vary as much as half an inch within the course of a single week. This state of relaxation of the tissue of the womb likewise coexists very frequently with a granular, abraded, or ulcerated condition of the os uteri; local affections which, slight though they may seem, yet help to keep up an habitual congestion of the womb, and thus furnish an ever-present occasion of menorrhagia. Other causes still might be enumerated as giving rise to excessive menstruation, such as blows or other injuries inflicted on the uterus during a menstrual period. Inflammation of the uterus, especially, I believe, of its lining membrane, has this effect in very many instances, and not only produces it on a single occasion, but gives rise to a state in which menorrhagia often becomes habitual. Misplacements of the uterus, as retroflexion or anteflexion, are often associated with it, and various organic diseases, as polypus, fibrous tumor, or cancer, which eventually produce constant hemorrhages, at first manifest their existence in many cases by an increased flow of blood at the ordinary menstrual period. Lastly, various affections of the ovaries are attended by the same result, and misplacement of those organs, their inflammation, or their degeneration, is often characterized by abundant and over-frequent menstruation. Each of these causes of menorrhagia, however, as well as all the different affections of the uterus itself, must engage our attention at a future day, and may therefore be passed over now without further notice. INDICATIONS OF TREATMENT. 55 In entering on the consideration of the treatment of menorrhagia, it is almost superfluous to observe that this can be by no means uniform, but must differ almost as widely as the various causes to which the excessive loss of blood is due. In every instance, however, we have to fulfil two indications, of which sometimes the one, sometimes the other is the more urgent; namely, to arrest the present hemorrhage, and to remove the cause on which it depends. The principles which must guide us in endeavoring to accomplish the latter are too obvious to need more than the very briefest reference. In those patients, for instance, in whom the menorrhagia is but a sign and a consequence of general debility, the tonic remedies and ferruginous preparations which tend to invigorate the health and to improve the composition of the blood, will of themselves have a most powerful influence in checking the excessive discharge at the menstrual period, ln some of these cases, too, the menstruation is excessive relatively to the patient's strength, rather than absolutely, compared with the quantity of blood lost by women in general at a menstrual period. This is so not unfrequently with women in whom menstruation appears during suckling; and in such circumstances it usually suffices to wean the child, and to give some simple tonic in order to effect the patient's cure. Less amenable to treatment, of course, are those cases in which the alteration in the circulating fluid depends on some deep-seated cause, such, for instance, as exists in crises of granular degeneration of the kidney ; though in such it is at once obvious that our attention must be directed chiefly to something more than the mere suppression of the present hemorrhage. Again, the excessive hemorrhage that occurs in connection with a state of general plethora of the abdominal vessels, showing itself in a disposition to haemorrhoids, a sluggish action of the liver, and in a constipated state of the bowels (a condition most frequent towards the decline of the sexual powers), admits less of remedies immediately addressed to the suppression of the bleeding than of attempts to remove it by indirect means. These are the cases in which a carefully regulated diet, whence all stimulants should be banished, great attention to the bowels, with the habitual employment of small doses of saline aperients, such as the sulphate of magnesia, the potassio-tartrate of soda, or some of the aperient mineral waters, as the Pullna water, for instance, continued for weeks together, will seldom fail to be successful. In such cases, too, as well as in those of younger women, in whom, with a general state of plethora, and rather sluggish condition of the bowels, the menses are with every month becoming more and more profuse, an active aperient taken the day before their expected occurrence often has a most remarkable influence in restraining the excessive hemorrhage. But there are many cases in which the sexual organs themselves either are the immediate cause of the menorrhagia, or in which changes that they have undergone tend in great measure to perpetuate or to aggravate it. In all the more important forms of uterine or ovarian disease, the menorrhagia is but one out of several symptoms 56 MENORRHAGIA : each of which may claim our attention and necessitate our interference. Here, then, the empirical recourse to measures for checking the hemorrhage may be either out of place or useless; and just as the peculiar state of the constitution calls for consideration in some cases, so the precise character of the local ailment requires investigation in others. Not to enter, however, into details which would occupy much time now, and must yet of necessity be incomplete, I will endeavor to furnish you with some general rules applicable to cases of menorrhagia in general, and then to give you special directions for the management of those in which the amount of the bleeding, or its persistence, or the state of the patient's health, requires that decided measures should be adopted for its suppression. Under all varieties of condition, there are certain precautions which the known liability of any woman to menorrhagia should lead her to adopt with the return of each menstrual period. First among the rules may be mentioned the strict observance of the horizontal posture, from the commencement of the discharge, and the maintenance of it till the discharge ceases. If with this be associated due care that the bowels are not constipated, and the pelvic viscera consequently not congested at the onset of the period, it is surprising how many cases of obstinate menorrhagia will be relieved in a very short time, and the hemorrhage restrained within proper limits, and this even though all kinds of remedies had previously been long and fruitlessly employed. To secure this benefit, however, it is necessary that the precaution be repeated for two or three successive periods, and that afterwards a much greater degree of care should be taken at the return of each menstruation than many women are ready to observe. But while these precautionary measures are alike applicable to all forms of menorrhagia, the management of the case in other respects differs completelj'', according to whether the hemorrhage assumes an active or a passive character. Tn the latter case, we employ astringent remedies both generally and locally, and this with a confident expectation of success; in the former, astringents would be out of place, and wc rely on antiphlogistic measures, of greater or less activity, according to the urgency of the symptoms. There is one variety of excessive menstruation dependent on a state of intense uterine congestion, if not on actual inflammation of the organ, in which the profuse loss of blood is associated with general febrile disturbance of the system, with a very distressing sense of weight and bearing down, great abdominal and uterine tenderness, together with pains of a periodical character, like those of threatening miscarriage, or of the early stage of labor. These symptoms, to which the name of metritis hcemorrhagica has been applied by some continental writers, require both for their relief, as well as for the suppression of the hemorrhage, the abstraction of blood from the arm, or the free application of leeches over the lower part of the abdomen; measures which are most efficacious if taken just before the occurrence of a menstrual period, or within the first day or two from the commencement of the discharge. But there are, besides, other cases in which, TREATMENT OF THE ATTACK. 57 though the symptoms are less urgent, yet any attempt directly to stop the discharge would be equally unsuitable. Such are all those instances of menorrhagia that are associated with a state of general plethora, where a flushed face, and a full pulse, and an aching head, at the commencement of the period, become by degrees relieved as the blood flows, and where the hemorrhage seems to be almost salutary, were it not that it tends to become excessive, and tends also to become habitual, persisting long after the cause which first occasioned it has ceased. In these cases a modified antiphlogistic treatment must be pursued; small doses of the sulphate of magnesia with sulphuric acid, and the tincture of henbane, if much uterine pain be present; or the nitrate *of potash, with tincture of digitalis, must be given, and will scarcely ever fail to check the bleeding. Cases presenting an active character, however, or calling for any approach to antiphlogistic measures in their treatment, are decidedly exceptional. Menorrhagia is most commonly met with in conjunction with a state of debility, and the obvious indication in the majority of instances is to check the bleeding as promptly and by as direct means as we can. With this view it is desirable, in all cases of passive menorrhagia, particularly when the affection has been of long standing, to employ astringent remedies, such as alum, gallic acid, lead, or matico, from the moment when the discharge commences, and not to delay their administration until the hemorrhage has become considerable. Of the four remedies which I have just mentioned, the gallic acid and the matico are those in which I have the greatest confidence, while I place the least reliance on the acetate of lead. I do not know, however, of any special indication by which we can judge beforehand of the probability of one or the other remedy proving specially appli- (No. 2.) B.. —Magnesiae sulphatis $W. Acid, sulph. diluti 3j« Tinct. hyoscyami 3ij- Aquae cinnamomi §jss. Aquae purse §iv. —M. ft. mist., cu jus sumat cochl. ij ampla 4ta quaque hora. (No. 4.) R. —Aluminis 3j ss » Solve in Aquse purae 3 V. Adde Tinct. cinnamomi co., • Syrupi papav. alb., aa $iv. —M. ft. mist., cujus sumat cochl. ij magna 3tia vel. 4ta quaque hora. (No. 6.) R.. —Plumbi acetatis 3ss. Aceti destillati Tinct. opii ttl,xx. Syrupi papav. alb. giv. j Aquae purae, ad §vj.—M. ft. mist., sumat cochl. ij magna 4ta quaque hora. (No. 3.) ty.—Potassse nitratis 3j- Tinct. digitalis rri,xl. Syrupi limonum $iv. Aquse purse ,^vss. —M. ft. mist.,cujus sumat cochl. ij ampla 4ta quaque hora. (No. 5.) R. —Acidi gallici gtt. xlviij. Syrupi simplicis ro'iv. Aq. cinnamomi ijss. Aquae purae giij.—M. ft. mist., sumat cochl. ij magna 4ta quaque hora. (No. 7.) R.. —Fol. piperis angustifoliae (Matico) gss. Aquse ferventis §vj. Macera per horas ij et cola. , ty. —Liquor, colati 3vss. Tinct. card. co. 3iv. —M. ft. mist., sumat cyathum vinosum 4ta quaque hora. 58 MENORRHAGIA: cable in any particular case, but am accustomed to employ each in succession, provided one should fail to produce the desired effect. The ergot of rye has been employed by some practitioners in cases of menorrhagia, and this not simply on account of its action on the uterus, but also from its supposed styptic property. I cannot say, however, that it has seemed to me possessed of any power of arresting uterine hemorrhage, independent of that which it exerts through the medium of the muscular contractions of the womb, while even as a means of exciting them it has in my hands failed far oftener than it has succeeded. Of all preparations of the drug, the infusion of 3ij of bruised ergot in Ivj of boiling water, is the only one in which I am disposed to place much confidence, all the different essences and tinctures which are in such general use having seemed to me almost equally inert. Of the essential principle of the ergot (ergotine) I have no experience, but I know that it has not justified the high expectations of the French physicians who first introduced it into practice. Within the past three years a valuable addition has been made to our means of checking hemorrhage from the uterus, by the employment of digitalis in large doses. The discovery that it was possessed of marked haemostatic powers, independent of its indirect influence exerted through the circulation, was made almost by accident. Dr. Kobert Lee, of St. George's Hospital, and Mr. Howship Dickinson, his obstetric assistant, pursued with much diligence the observations first made in the wards of that institution, and came to the conclusion that the digitalis arrests menorrhagia by virtue of its direct action on the muscular tissue of the womb. In support of this opinion, Mr. Dickinson mentions 1 that while the cessation of the hemorrhage was by no means constantly associated with any change in the frequency or the force of the circulation, severe pain referred to the womb was almost invariably experienced after the administration of a large dose of the infusion, and was speedily followed by the expulsion of a gush of coagulated blood; effects which were commonly repeated after each dose. I have given the digitalis in a considerable number of cases, but have never observed this latter result, though I have always questioned my patient closely as to any sensation which followed the medicine ; and even where its action has been most marked, I have not found that pain accompanied the cessation of bleeding. At the same time, its action is by no means proportionate to the influence which it exerts on the circulation; for though a diminution in the frequency of the pulse was always observable, yet those cases in which the peculiar power of the drug over the heart's action was most marked, were by no means the instances in which hemorrhage was soonest checked; while sometimes, though it became necessary to suspend the remedy altogether, the bleeding continued unabated. The cases in which, in my hands, the digitalis proved most useful, were cases of simple menorrhagia, often of long standing; but either unaccompanied by appreciable changes in the womb, or at most associated only with some degree of hypertrophy. In many instances, too, 1 Medico-Chirurgical Transactions, vol. xxxix. p. 1. TREATMENT OF THE ATTACK. 59 this hypertrophy was apparently due to imperfect involution of the uterus after delivery or abortion, occurrences which in a good many instances had been the starting point of the evil. In such cases I have been accustomed to give 3iv of the infusion of digitalis every four hours, the patient remaining in bed, and being cautioned at once to discontinue the medicine if it produced faintness or dizziness. In most cases when it proved of benefit, it gave some earnest of this within twenty-four hours from its first employment, while if no effect were produced within forty-eight hours, I have always discontinued its further administration; and iu no instance have I continued its use for longer than between three and four days. The existence of a very considerable degree of exhaustion, and the necessity for giving wine or brandy do not contraindicate a trial of digitalis, though in cases of great feebleness I generally begin with only 5ij instead of 3iv for the first few doses. The medicine has seemed to me of little or no utility in cases where the hemorrhage depends on tumor or other organic disease of the womb, and even in other circumstances I know of no means by which we can determine beforehand, with any considerable certainty, that it will prove successful. In spite of all these drawbacks, however, the digitalis is a very valuable medicine in cases of menorrhagia; in no instance have I seen any serious mischief result from its employment, and in many cases it has certainly effected great good. In the great majority of instances the observation of precautions and the employment of internal remedies such as I have recommended, suffice to restrain the loss of blood within safe limits; and it then remains only by judicious treatment in the interval to guard against the recurrence of hemorrhage at the next menstrual period. But now and then we meet with cases in which these measures prove nearly useless, or in which the loss of blood on former occasions has already been so considerable, or so often repeated, as to render each ounce of almost inestimable importance for the maintenance of the patient's health, possibly even for the preservation of her life. Rarely though it happens, you must yet bear in mind that women sometimes die from loss of blood at a menstrual period, and this wholly independent of uterine disease. Two instances of this occurrence have come under my notice; I have already referred to one case, and the second was even more important, since the person was not only in previously good health, but an examination after death ascertained that not only her uterus, but every organ of her body was free from any sign of disease. She was a young woman who, having been sentenced to transportation for some offence committed in Scotland, was sent by ship during a stormy season from Edinburgh to London. Menstruation appeared during the voyage, but her exhaustion was not unnaturally attributed in great measure to sea-sickness. She improved on being landed, and though menstruation continued profuse, yet she made no complaint to the officers of the prison. At length having fainted one day, she was removed to the infirmary of the institution. No profuse loss of blood took place during the three or four days that she was there, but only a slight draining, which went 60 MENORRHAGIA : on in spite both of astringent remedies and of cold applications,.and under which she sank exhausted. . A small coagulum was found within the uterus, but nowhere was there any trace of disease. Now the bare possibility of any such occurrence happening is reason enough for watching most anxiously every case of very profuse menstruation, and for being ready with appropriate means to combat the symptoms as they increase in urgency. One of the first and most obvious means of checking bleeding from any part consists in the application of cold. After the menses then have continued for two or three days, provided they do not show any disposition to abate, the loins and vulva should be sponged every few hours with cold water, and the patient should besides have an enema of about four ounces of cold water night and morning. If in spite of these means, which, however, are generally successful, the loss of blood should still continue, wet cloths must be applied to the vulva, and astringent injections thrown into the vagina, for which purpose I know of nothing better than the infusion of matico. If even these means should fail, there remain then but two resources, the plugging the vagina, and the injecting the cavity of the uterus itself. The expediency of resorting to either of these measures must be determined by a careful consideration of the patient's general condition, quite as much as by the mere amount of the hemorrhage. It is not indeed in general while blood is flowing profusely that the necessity for their employment arises, but at a later period, when, with great depression of the vital powers, blood still drains away in quantities so small as at another time would be of no importance. I need give you no special directions as to how to plug the vagina, except to remind you that you will find the speculum of service in enabling you to introduce a considerable portion of the tow, wool, or whatever material you may employ, much more speedily, and with much less irritation of the vaginal walls than would otherwise be practicable. I am not without hope, however, that a simple apparatus, first employed by two German physicians, MM. Braun and Chiari 1 may enable us to get rid of the inconveniences inseparable from the use of the ordinary plug. Their contrivance is an India-rubber bottle, to which is attached a metal tube furnished with a stopcock, and also a ring to which straps can be fastened for securing it in its place after it has been introduced into the vagina. It is introduced empty, and may then be distended with cold water to any extent so as to form a most efficient plug, while its withdrawal requires nothing more than to turn the stopcock and let off the water. I have made two alterations in it which I think will increase its usefulness, and which consist in adapting its tube to that of an ordinary Eeid's syringe, in order that it may be filled more conveniently; and in substituting the soft and yielding vulcanized India-rubber for the hard caoutchouc flask of the original inventors. The injection of the uterine cavity, though a powerful means of repressing hemorrhage, is yet a proceeding of much hazard, which has 1 Klinik der Geburtshiilfe, 8vo., Erlangen, 1852, lste Lieferung, p. 125. USE OF INTRA-UTERINE INJECTIONS. 61 given rise, in many instances, to severe inflammatory symptoms. Its use should therefore, I conceive, be limited to cases (and these are by no means of frequent occurrence), in which, though hemorrhage may for the moment be restrained by means of the plug, it yet returns so soon as that is withdrawn, while remedies fail to exercise any influence on its flow. Such a case was that of a woman aged fifty-one, who was admitted into the Middlesex Hospital under my care on September 21st, 1818. Her health had been good till about a year before, when her menstruation became irregular and over-frequent, and in the previous April she had an attack of hemorrhage, for which she was treated with advantage in University College Hospital, though bleeding returned soon after her discharge from that institution, and had ever since recurred frequently. On her admission, her appearance was extremely anaemic, her pulse small, and her voice almost inaudible. She complained of constant pain in the lumbar and right iliac regions, increased after each attack of flooding; but a vaginal examination discovered nothing wrong about the uterus, except that it was somewhat larger and heavier than natural. The whole class of astringent remedies and astringent injections were employed with varying result till November 16th; the bleeding sometimes ceasing for a day or two, and then again returning. On that day, however, the discharge was so profuse that it was considered necessary to introduce the plug. This means arrested it; but at 11 A.M. on November 17th, the plug having been removed for six hours, hemorrhage again returned, and greatly exhausted the patient. After being reintroduced, and allowed to remain for twelve hours, the plug was once more withdrawn, and no return of hemorrhage took place; the infusion of matico, which the patient began to take about this time, appearing to restrain the bleeding very effectually. During the remainder of November, and the first few days of December, improvement continued, but the patient now again experienced frequent returns of hemorrhage, either in the form of a draining away of a pale sanguineous fluid, or in that of frequent sudden gushes of profuse bleeding. Previous to any profuse gush, she complained of pain in one or other iliac region, most frequently the right. Remedies seemed to have completely lost all influence, and on December 18th, though the hemorrhage was not at that moment very profuse, yet the patient was reduced by it to a state of extreme exhaustion, her pulse was scarcely perceptible, her voice a mere whisper, and her stomach rejected everything. The os uteri was open wide enough to admit the finger as far as the first joint, but its tissue seemed quite healthy, and under the speculum the appearance of the os was perfectly natural. About three drachms of a mixture of a scruple of gallic acid in an ounce of water were now thrown into the uterine cavity, and no considerable pain was excited by the injection. At the same time pure brandy was given to rally the patient's powers, and as soon as her stomach could bear it, the infusion of ergot of rye was administered every few hours. It is needless to detail the daily treatment adopted from this period, for convalescence, as might be anticipated, was tardy. 62 NEURALGIC DYSMENORRHEA. From the time of the injection of the uterus, however, the hemorrhage completely ceased, its place being taken by a puriform discharge just tinged with blood, and no hemorrhage reappeared until the 26th of January, when it was neither excessive in quantity nor of long duration. At intervals of rather less than a month hemorrhage recurred, though it was always readily controlled by treatment, and on April 10th she was discharged from the hospital, well, though still rather weak; her life having to all appearance been saved when in most imminent peril by the injection into the uterine cavity. • I have no experience of the employment of turpentine as an injection into the uterine cavity in cases of uncontrollable hemorrhage. I should fear to employ such an agent, which, indeed, has been followed, 1 when thus used, by violent inflammation of the womb. The infusion of matico, a solution of gallic acid, or a mixture of one part of the muriated tincture of iron and nine parts of water, would appear to me to be safer remedies. A small glass syringe, not carrying above half an ounce, fitted to an elastic catheter, open at the end, is the best apparatus to employ for, injecting the uterus. No advantage would be likely to result from throwing a large quantity of fluid into the uterus, while the danger of its escape through the Fallopian tubes into the abdominal cavity, and of its thus exciting peritoneal inflammation, has been shown by the experience of many practitioners to be by no means imaginary. LECTURE V. MENSTRUATION AND ITS DISORDERS. Dysmenorrhea—its three varieties—neuralgic, congestive, mechanical. Symptoms of neuralgic form ; of congestive form, sometimes attended with expulsion of a membrane. Relation of congestive dysmenorrhcea to rheumatic, or gouty diathesis. Mechanical dysmenorrhcea, from contraction of cervix uteri, a rare occurrence. Treatment of the neuralgic form ; various sedatives, and their comparative results— of the congestive form; depletion, and how to apply leeches—treatment of the rheumatic variety—of the mechanical form ; cautions with reference to its treatment. I fear you may think that I am'uttering a very superfluous truism when I remind you that almost every function of the body, if ill performed, is performed with an unusual amount of pain. The feeble stomach is pained by the presence of the food which it is unable to digest; the eye whose vision is imperfect, is pained by the effort to decipher even the most legible characters; and the head of the con- 1 See a case related in Ashwell's Treatise on Diseases of Women, 8vo. 1843, p. 155. 63 NEURALGIC DYSMENORRHEA. valescent aches on the first attempt to resume his ordinary mental occupations. Just so, the menstrual function when deviating from its most exact performance, either in excess or in defect, is almost always attended by suffering far exceeding that discomfort by which, in the case of healthy women, it is usually accompanied. Amenorrhcea and menorrhagia are both almost invariably associated with suffering, and in the case of the most various disorders of the sexual organs, an undue amount of pain at each menstrual period is a symptom scarcely ever absent. But, besides these instances in which the pain is but one among many ills for which the patient seeks our aid (and probably even in her estimate by no means the gravest), there are other cases where the suffering of menstruation is so intense in its severity, or so importunate from its continuance, as to constitute a distinct affection, and to claim a place in our nosologies as dysmenorrhcea. It has been customary to recognize three different varieties of this dysmenorrhcea, or painful menstruation; and the distinction of neuralgic, congestive, and mechanical dysmenorrhcea, terms which interpret themselves, seems to me to rest on good grounds, and to merit being generally adopted. There are some instances in which pain alone, unattended by any other symptom, is the only important respect in which menstruation differs from a healthy state. This neuralgic dysmenorrhcea occurs most frequently and in its simplest form in young women whose sexual system has not been developed till a comparatively late period, and who have not begun to menstruate till a year or two after the average date. The pain, in such cases, precedes menstruation for a day or two, generally reaches its greatest intensity in the course of the first thirty-six hours of the catarnenial flow, being sometimes so intense that the patient writhes on the floor in agony, and then by degrees subsides, though it does not cease entirely till the period is over. Though severest in the uterine and pelvic regions, the pain is not in general limited to those situations, but is experienced also in the back and loins, is referred to either groin, and shoots down the inside of the thighs. The pain, too, is aggravated at intervals, and becomes paroxysmal, like that of colic or of labor, while the whole abdominal surface is so tender as scarcely to bear the slightest touch. In addition to these pains, all radiating more or less obviously from the sexual organs, there is often much suffering in other parts. Intense headache is very frequent, often confined to one side of the head, or presenting the well known characters of clavus hystericus; or, in other cases, the stomach is disordered, and the patient distressed by constant nausea or frequent vomiting. In many instances, various other hysterical symptoms manifest themselves, often, indeed, with peculiar intensity, and I knew a patient in whom an attack of hysterical mania ushered in on more than one occasion a menstrual period. This neuralgic dysmenorrhcea, however, is by no means invariably associated with a hysterical temperament, and patients who suffer most intensely during menstruation, sometimes manifest no 64 CONGESTIVE DYSMENORRHCEA. symptom of hysteria, but, on the contrary, are remarkable for quiet self-possession and well-regulated minds. In some instances, it seems as if the disorder of the nerves extended to the whole system, while in others it is limited to those which supply the sexual organs, and is then usually of shorter duration on each occasion, though not by any means of necessity slighter in the suffering which attends it than when the sympathies which it awakens are more extensive. Even when pain has altogether subsided after the cessation of a menstrual period, any excitement of the sexual system will, in very many instances, suffice to reproduce suffering. In married women affected with this form of dysmenorrhcea, sexual congress is almost invariably extremely painful, while pregnancy is attended by more than the ordinary degree of local discomfort, and the pain of parturition amounts to intolerable anguish. I have referred to this neuralgic dysmenorrhcea as occurring in its simplest form in young women in whom there was a tardy, and perhaps an incomplete development of the sexual system. It is, however, by no means limited to such persons, but sometimes comes on after years of healthy and comparatively painless menstruation. I have known menstruation become painful during convalescence from some serious illness wholly unconnected with the sexual functions, and continue so, long after the patient had in other respects regained her usual health. In other cases, the sudden suppression of the menses by cold, or some other accidental cause, is succeeded by obstinate dysmenorrhcea; and this, although no obvious uterine ailment had followed the accident. At other times, inflammation of the uterus, after delivery or miscarriage, is followed by painful menstruation, which persists long- after every trace of inflammation or of its consequences has completely disappeared. But there is another form of dysmenorrhcea which has been termed the congestive, from the peculiar circumstances that attend it. Unlike the purely neuralgic variety, it is less frequent at the commencement of sexual vigor than as an acquired condition at a later period of life. A sense of weight about the pelvis, and a tendency to haemorrhoidal affections, generally exist in the interval between the menstrual periods; and these symptoms increase considerably a few days before the discharge comes on. During the first twenty-four or thirty-six hours of each menstruation, the discharge in general is but scanty, and the pain is very severe. At the end of this time, however, sometimes even sooner, the hemorrhage often becomes abundant; and as the blood flows the pain abates, and then ceases altogether. The congested womb ached till nature bled it; just as the head aches, when the brain is congested, till the cupping-glasses or the leeches have relieved the over loaded cerebral vessels. Sometimes in these cases the menstrual flux at no time becomes abundant, and consequently the relief which nature gives is very partial. When this is so, the womb continues to ache and throb during the whole of the menstrual period, and is left afterwards tender and painful. When this is not the case, however, the end of the menstrual period generally leaves the patient in a state of comparative comfort. For the 65 CONGESTIVE DYSMENORRHEA. next week or ten days she continues to enjoy a comparative immunity from suffering; but then the symptoms gradually return, and reach their climax of severity with the commencement of the next menstruation. In some instances of this form of dysmenorrhcea, not only is the amount of blood lost at a menstrual period insufficient to relieve the congested womb, but it is absolutely as well as relatively scanty. In some of the cases the discharge having continued for a few hours, ceases, and then comes on again; while, though scanty, it is intermixed with small coagula, owing, probably, to the blood having been poured out so slowly as to allow of its coagulating within the uterine cavity; an occurrence prevented during healthy menstruation by its comparatively rapid flow into the vagina, where its fibrin is at once dissolved by the acid secretion of that canal, and its coagulating property destroyed. In others of these cases we find intermingled with the menstrual discharge, shreds, or strips, or distinct laminae of membrane, or even a small membranous sac, which is seen on careful examination to form a complete cast of the uterine cavity. This occurrence sometimes takes place only once, but oftener it reappears during a long succession of menstrual periods. The discharge of the membrane is generally associated with very considerable aggravation of the patient's suffering; sometimes with distinct periodical pains, like those of abortion ; and when to them profuse hemorrhage is superadded, an occurrence which is frequent, though not invariable, unfounded suspicions have in some instances been entertained with reference to the chastity of women who have had the misfortune to present this combination of symptoms. In the ignorance which till lately prevailed with reference to the real structure of the uterine lining membrane, it has been customary to speak of the dysmenorrhceal membrane as the product of inflammation, or of some process akin to it. We know, however, that during menstruation the epithelium of the uterine cavity is thrown off in greater or less abundance; while an examination of the membrane suffices to show that what has occurred in its formation and detachment is merely an exaggeration of the process which to a less degree takes place at every menstrual period. The membrane is smooth on one surface, rough, almost villous on the other, and presents the remains of numerous dilated uterine glands; characters that prove it to be the analogue of that decidua which, under the physiological stimulus of conception, passes through a more complete development to serve important purposes. 1 I scarcely need say that it is not a matter of indifference in a practical point of view, whether or no you entertain correct opinions with reference to the structure of this membrane. To regard it as a layer of plastic lymph similar to that which is poured out in croup, at once 1 This opinion as to the identity in character of dysmenorrhceal membrane and decidua is now almost universally entertained both in this country and on the continent. In this country the first to assert this identity were, I believe, Dr. Oldham, in Med. Gaz., April 16, 1846, and Dr. Simpson, in Edinb. Monthly Journal, Sept. 1846. 5 66 CONGESTIVE DYSMENORRHEA. suggests the employment for its removal of active antiphlogistic measures, such as experience would by no means justify. Reasoning, however, even independent of the actual observation to which I have appealed, would suffice to show the fallacy of this opinion. It is utterly inconceivable that a mucous membrane so inflamed as to become the seat of deposits of lymph, should in a few days return to a perfectly healthy condition, and yet periodically undergo the same intense inflammation, issuing in the same deposit; and this with no serious injury to its functions and no permanent change of its structure. Allied to this congestive dysmenorrhcea, are cases of painful menstruation dependent on constitutional causes, especially on the gouty or rheumatic diathesis; though I cannot pretend to say why in women this peculiar ailment should result from it so much more frequently than the ordinary forms of those disorders with which we are familiar in the male sex. Such cases, however, are by no means rare in any class of society; and wherever they occur, they are chronic in their course and difficult of cure.' A casual attack of cold is in some instances referred to as the occasion of the patient's illness, while in other cases the ailment comes on by degrees, and with no definite exciting cause. Menstruation begins to be more painful than was its wont, often more scanty; an unusual degree of constitutional disturbance attends each period; the pulse at those times is very frequent, the skin hot though perspiring, and lithates abound in.the urine. In the intervals, profuse leucorrhceal discharges take place; the pain, though less intense, is yet severe, and is aggravated by trifling causes, or without any obvious reason. The pain at one time is most severe in the back, at another is referred to one or other iliac region, shooting down the legs in the course of the crural nerve, or, like sciatica, affecting the back of the thighs; while occasionally, in addition to these abiding discomforts, the patient is kept in bed for a day or two at a time by slight feverish attacks, accompanied by wandering pains in the limbs, though seldom attended by inflammation and swelling of any of the joints. The seat of the pain in these cases is no doubt the muscular tissue of the uterus; and the suffering from this cause sometimes outlasts that time of life during which menstruation takes place, though the cessation of the periodical congestion of the womb, which occurs so long as the sexual system retains its activity, is followed by a great diminution of the patient's ills. In the worst cases of this disorder, the womb, though presenting no appreciable alteration, is so intensely tender, that the slightest movement causes intolerable pain ; and many instances of an affection which the late Dr. Gooch 2 described with all that graphic skill of which he was so great a master, and for which he proposed the name of the Irritable Uterus, may be referred 1 The observations of Dr. Todd on the subject in section ix. of Practical Remarks on Gout, Rheumatism, Fever, &c, 8vo., London, 1843 ; and those of Dr. Rigby, in his work on Dysmenorrhcea, published in 1844, have more especially called attention to this subject. i On the More Important Diseases of Women, 8vo., 2d ed., London, 1831, p. 332. 67 MECHANICAL DYSMENORRHCEA. to this category. I shall presently have a few remarks to make on the treatment of this ailment; just now, I will add only that relief for it is to be sought by measures directed to the constitutional cause, and not by any form of local medication. Such then are the two principal forms of dysmenorrhcea; the one the neuralgic, the other the congestive; while often we meet with cases presenting the mingled characteristics of both varieties. But there are, besides, instances in which the dysmenorrhcea is the effect of some organic malady of the uterus, such as fibrous tumor, or of some alteration in its position, such as anteflexion or retroflexion, or of some positive mechanical obstacle to the escape of the menstrual fluid, such as narrowing of the cervix, or mouth of the womb. The continuance of dysmenorrhcea for several months in spite of treatment calculated to remove it, calls for a careful vaginal examination, in order to ascertain whether the painful menstruation is not merely a symptom of some local ailment which it may be in our power to palliate, if not to remove. One form of dysmenorrhcea from a local cause has of late years excited much attention—namely, that in which the suffering is due to the narrow channel through which the blood has to flow. This mechanical form of dysmenorrhcea is said to be characterized not only by pain, but also by the slow escape and scanty amount of the blood discharged, which, also, for the most part, escapes in small, imperfectly formed coagula. The late Dr. Mackintosh, of Edinburgh, 1 was, I believe, the first person who, in the year 1823, directed his attention to this source of difficult menstruation, and who, in 1826, advised the mechanical dilatation of the os uteri by bougies for its relief. The impediment may exist either at the external os uteri, or at some limited part of the cervix, especially at the internal os, where the body and neck of the womb communicate, or it may involve the whole of its canal. It appears, in some instances, to be attributable to inflammation, and probable ulceration of the cervical canal, as in the case of a woman once under my care, the canal of whose cervix was at one point so nearly obliterated as not to allow the passage of the finest cat-gut bougie, and who referred her sufferings to the effects of a labor twelve years before. In other instances, the dysmenorrhcea is habitual, and the narrow cervix is a congenital condition, or one due at least to some defect of uterine development, and this latter I believe to be the more frequent form of the affection. An impression has of late years been gaining ground that this form of dysmenorrhcea is very common, and mechanical means of treating it have accordingly come very much into vogue; to the neglect, it is to be feared, in many instances, of those internal remedies, by which painful menstruation is in general much more appropriately treated. One circumstance, which I believe to have much contributed to the support of this opinion, is the fact, that on introducing the uterine sound an obstacle is very often encountered at the internal os uteri to the passage of the instrument into the cavity of the womb. That this 1 In his Practice of Physic, 4th ed., 8vo., London, 1836, vol. ii. pp. 431—436. 68 MECHANICAL DYSMENORRHCEA. obstacle, however, is in reality perfectly natural, can be readily ascertained on the dead subject, since even after the removal of the uterus from the body, a bougie which passes with ease along the* cervical canal will then encounter a resistance such as can often be overcome only by considerable effort, or, perhaps, not at all, though a smaller bougie will pass at once with perfect facility, and the uterus, when laid open, will be found to be perfectly healthy. The constriction in this situation which is found to be so considerable even after death, was doubtless in these and many other instances far more considerable during life, and yet in spite of it, the history of such persons often gives no account of difficult or painful menstruation. 1 Nor, indeed, need this surprise us, for the discharge takes place during menstruation, not in a continuous stream as the urine flows from the bladder, but oozes from the interior of the womb, the blood escaping drop by drop from the os uteri. If the aperture be so small as scarcely to allow this to take place, menstruation no doubt may be rendered very painful; and just as when stricture of the urethra exists, the bladder, and ureters, and kidneys, become irritated, and disturbed in the performance of their functions, so it is quite conceivable that a similar state of the cervix uteri may exert the same influence on the function of that organ, and render the menstrual flux scanty in quantity and morbid in character, as the consequence of the difficulty in its discharge. A slight amount of unbiassed observation, however, will teach you that such a contraction of the os or cervix uteri as to impede the discharge of the menses guttatim is very unusual; while it will further show that in the majority of cases in which this condition really exists, the narrow cervix is only a part of the evil, that the neck of the womb is small because the organ is altogether very undeveloped. And this brings me to notice the treatment of dysmenorrhcea, which must vary just as its forms are various. In the dysmenorrhcea of young girls in whom menstruation is not yet completely established, our efforts must chiefly be directed to bringing about the regular performance of the function as speedily as possible, and there is reason to hope, that in proportion as this is effected, the pain will by degrees diminish. If, however, the suffering be so severe as to require the employment of remedies specially directed to its mitigation, they will in the majority of instances be such as are applicable for the relief of nervous dysmenorrhcea. One of the most serviceable of these is the hot hip-bath, which may be had recourse to on the first threatening of pain, and even twenty-four or thirty-six hours before the date at which the commencement of the menstrual discharge is expected. To obtain the full benefit from it the patient should remain in it for half or threequarters of an hour; the temperature of the water being maintained during the whole time at 96° or 98°; while the bath may often be advantageously rendered more stimulating by the addition of mustard 1 The fact of the natural constriction of the uterine canal at the situation of the internal os, was very clearly asserted by Dr. Henry Bennet in his work on Inflammation of the Uterus. See page 12 of the third edition. 69 TREATMENT OP DYSMENORRHCEA. to the water. If pain again returns with severity, the bath may be repeated twice or three times in the twenty-four hours, while after its employment the patient should always retire to bed, and remain there until, with the establishment of the menstrual flux, the pain has in great measure subsided. It will, however, still be wise for the patient to remain during the whole period in her apartment, and to avoid all exertion, as well as all changes of temperature. If the pain be very severe, some sedative or narcotic will probably be indispensably necessary, and this will be likely to produce the best effect if taken immediately on the patient coming out of her bath. Opium, in some of its various preparations, is of course the most powerful remedy; but there are many reasons why it is undesirable to have recourse to it, unless the milder sedatives have been tried and found inefficacious. In many instances opium deranges the digestive functions seriously, and inflicts on the patient a very distressing headache for hours after its first soothing influence has passed off; but a still more serious objection to its use is furnished by the fact that young women not seldom become habituated to the drug from having had recourse to it as a sort of domestic remedy for deadening the pain of menstruation. In many instances of the purely neuralgic dysmenorrhcea, ether alone suffices to remove the pain, or at least greatly to mitigate it, and when this is so, its transitory influence and the circumstance that it in no way interferes with the digestive functions, render it far preferable to any of the more direct narcotics. A draught containing half a drachm of the compound spirits of ether, and fifteen minims of chloric ether, will generally answer the purpose very well, while in cases where the patient, as sometimes happens, has an insuperable objection to the taste of ether, the eau de luce, or tinctura ammonia) composita of the pharmacopoeia, forms a very good substitute for it. 1 A single dose of any of these remedies will often suffice, but if not, they may be repeated frequently, and at short intervals. Some years ago, the Sumbul, an Indian remedy, was introduced into practice as applicable to the relief of neuralgic pains, as well as of other ailments. It certainly seems to possess a measure of that compound stimulant and anodyne property which characterizes ether, though in a far inferior degree. You will, however, always find it useful in the management of the diseases of women to have numerous expedients at hand for the relief of minor ailments in addition to being well acquainted with the great remedies for more serious ills. Should none of the above-named simpler means suffice, henbane is that one of the more decided narcotics of which you may make a trial with the least risk of its disagreeing with the patient. Forty minims of the tincture, or five grains of the extract, are an average dose, and the quieting action of the remedy seems to be much increased, espe- 1 (No. 8.) Re. —Tinct. ammonias composite Tnjvj. Tinct. aurantii 3j> Syrupi simplicis gj. Inf. aurantii co. giv. Mist, camphorse 3 v j-—M. ft. haustus. 70 TREATMENT OF DYSMENORRHCEA : cially in the case of uterine pain, by combining it with camphor, five grains of which may be given with each dose of the henbane. Another remedy extremely serviceable in controlling neuralgic pain, and free from many of the inconveniences of opium, is the Indian hemp, or Cannabis Indica. There are two drawbacks, however, from its use. The one is, that owing to the absence of any officinal preparation of the drug, the medicine, as ordered from different druggists, varies much in strength; the other is that the susceptibility of different persons to its influence varies much more than in the case of opium. For these reasons, it is expedient that it should always be procured at the same place, and also that it should always be ordered in a minimum dose at first, until you have ascertained its effect on your patient. The inhalation of chloroform or ether, though its effects are but transitory, yet sometimes exerts a permanent influence in mitigating uterine pain. The remedy, however, is too hazardous to be intrusted to the patient or her friends, but the local application of chloroform to the hypogastric or pubic region is not only free from risk, but is also often serviceable. If none of these means give relief, opium becomes our last resource, and Dover's powder, morphia, the sedative solution of opium, and the black drop, are all of them, in these cases, to be preferred to the simple tincture, because they generally occasion less sickness or headache, and are less apt to produce constipation of the bowels. Sometimes medicines given by the mouth seem unavailing, or the severity of the pain induces us to seek for a remedy that shall be more rapid in its action, and in these circumstances an opiate suppository, or an opiate enema, the bulk of which must of course be very small, will often afford speedy relief. I do not think it will be out of place if I here very strongly advise you to look on every case of dysmenorrhcea in young women as of importance, and not to content yourself with giving a few general directions, or with writing a prescription for your patient, if the pain from which she suffers should chance to be very urgent. There is always much greater risk of the attacks becoming habitual, and thus rendering your patient's future life miserable, than there is reason for expecting the popular belief to be realized, and that the ailment of the girl will spontaneously cease when she attains to full womanhod. Every precaution which 1 have suggested is of the greatest moment; the confinement of the patient to her room, the absolute rest, the repose in bed during the early part of the menstrual period, are indispensable with each return of menstruation, so long as the tendency to dysmenorrhcea continues, and I believe are much more important, as far as eventual permanent recovery is concerned, than is the employment of remedies to relieve pain on any single occasion. Your care, moreover, must not «ease with the cessation of the attack, but your attention must be most watchful during the menstrual intervals, to correct anything wrong in the general health, and to invigorate the patient's system, which in these cases is almost always feeble. One other caution you must allow me to add: there is a popular impression that when the highest functions of the sexual system are brought into play, many ailments, previously troublesome, are likely 71 OF THE CONGESTIVE FORM. to cease, and it is beyond a doubt that, in some instances, marriage, and pregnancy, and child-bearing, are followed by these desirable results. I fear, however, that the chances are the other way; that the girl who suffers from dysmenorrhcea will be likely to suffer more from it after marriage than she did before; that the extreme sensitiveness of her uterine organs will render marriage in all sexual respects, a very painful condition; that conception will be less likely to occur than in another woman, and that if it should, pregnancy and labor will be attended by far more than the usual amount of distress. If this be so, however, you must see how cogent the reasons are for treating dysmenorrhcea more gravely than may at first sight appear necessary. Good taste and good feeling will not fail to guide you in selecting the best way of conveying your opinions to your patient and her friends, and you will most likely find a ready acquiescence in your directions so soon as the grounds on which they rest are clearly understood. In the congestive form of dysmenorrhcea, anodynes no longer furnish the ready resource for the relief of present suffering which they supply in the neuralgic variety of the affection. The uterus and the pelvic viscera generally are overloaded with blood, and it is only by its abstraction that we can relieve the patient. Cupping to the sacrum, or the application of leeches to the hypogastrium, the anus, or the uterus itself, are the means by which this end is to be accomplished. It is not in general, however, that the abstraction of so large a quantity of blood as seems implied in the application of the cuppingglasses is necessary or desirable. The great benefit of leeching the hypogastric or iliac region seems to be confined to those cases in which the pain, referred especially to the sides of the pelvis, indicates the ovaries to be its seat; but in other cases it is decidedly inferior in efficacy to the application of leeches to the anus. These modes of abstracting blood can be resorted to at any time, even just before menstruation or during the presence of the discharge; leeches cannot, however, be applied to the uterus itself within three or four days of an expected menstruation without considerable risk of disturbing the regularity of its return. When depletion has been resorted to, the tepid hip-bath will generally afford some relief, while afterwards the patient should remain in bed, and take some diaphoretic saline, such as the liquor ammonias acetatis, combined with small doses of henbane or of opium, the efficacy of which remedy will in these cases be much increased by combining it with nauseating doses of tartar emetic. In some cases of this description the direct narcotics in any form or combination are ill borne, exciting much constitutional disturbance, and relieving the pain but little or not at all. Ipecacuanha in grain or half-grain doses, every hour till a decided nauseating effect is produced, is in these circumstances sometimes of very great service, affording much relief to the pain, and also lessening the amount of discharge, which otherwise not unfrequently becomes over-profuse about the second or third day of menstruation. The treatment of the patients at the menstrual period comprises, 72 TREATMENT OF however, only a small part of what is needed to bring about their cure. Though relieved for a season by the flow of blood, as is generally the case, the symptoms by degrees return before the next period comes on. It is during this interval that so much is gained by local depletion of the uterus; a proceeding which, although abundantly simple, I may, perhaps, as well stop for a moment to describe to you. Leeches, when applied to the womb, generally produce a much greater flow of blood than follows their application to any external part; and four, or at the most six, are therefore as many as it is desirable to put on at one time. Metallic tubes, perforated with holes at one end, and capable of being closed by a plug at the other, and some other similar contrivances, are sold in instrument makers' shops, and are very useful for servants or nurses, whenever they are intrusted with the operation of leeching the womb. I prefer, however, to employ a speculum, and generally use one of Fergusson's reflecting glass speculums, by which you can both ascertain more exactly the part to which to apply the leeches, and also, if the os uteri be at all open, have the opportunity of inserting into it a little bit of cotton wool, in order to prevent the leeches biting within the canal of the cervix; since that accident always gives most acute pain, though otherwise the operation is attended by very little suffering. The speculum, being introduced and adjusted as the patient lies upon her left side, the leeches are put into it, and then pushed up to the uterus by means of a little cotton wool or lint, which may be withdrawn in five or ten minutes, the leeches having generally bitten by that time. Now and then a leech, crawling out of the speculum, will make its way down between the instrument and the vaginal wall, and, fixing on the external parts, will cause much pain: but a little care will enable you to guard against any such mischance. I would not have taken up your time with details which may seem so trivial, if it were not that in the country you may be unable to command the services of a class of women who in London get a very good living by leeching the uterus under medical direction. After the leeches have come away, a warm hip bath is generally a comfort to the patient; and, unless the bleeding has been very profuse, is desirable as a means of promoting it, on the same principle as we often put on a poultice after the application of leeches externally. The evening is generally the best season for applying leeches to the womb, in order that the rest and sleep of the coming night may relieve the patient, jaded and wearied by the discomfort of the operation. I may just add, that it has been advised, as a more expeditious and less irksome mode of depleting the uterus, to scarify its lips through a speculum by means of a sharp lancet affixed to a long handle. Such scarifications are by no means painful, and in some instances where the mucous membrane covering the lips of the uterus is the seat of undue vascularity, and presents a peculiar granular, abraded appearance, I have seen much benefit result from it, just in the same manner as scarification of the palpebral conjunctiva sometimes does much good in strumous and other forms of ophthalmia. "We cannot, however, abstract by this means any considerable amount of blood, and CONGESTIVE DYSMENORRHCEA. 73 whenever there is much congestion of the vessels of the uterine substance, which we are anxious to relieve by depletion, leeches to the part are always to be preferred. Depletion, attention to the bowels, a nutritious but unstimulating diet, and all those little precautions which come under the somewhat vague denomination of attention to the general health, must in all of these cases engage our care during the intervals between each menstrual period. When to this I add, that the back-ache, if not relieved by a plaster, generally yields to a croton oil liniment, sufficiently weak not to produce a troublesome pustular eruption, and that small blisters in one or other iliac region usually mitigate the pain referred to the situation of the ovaries, I think I have given you all the special directions which are applicable to cases of this description. I have, however, referred to some instances in which the painful menstruation is associated with various evidences of a rheumatic or gouty diathesis, and such cases are both peculiarly painful, and peculiarly intractable. Colchicum is often of much utility, and during the paroxysm twenty or thirty minims of the tincture in combination with small doses of laudanum and of antimonial wine, will often give more relief than any other remedies, and prove especially useful when large doses of narcotics will be of no service. The treatment during the menstrual intervals is of particular importance to this class of patients, and yet so various are the symptoms in different cases, that it is impossible to lay down any definite plan as applicable to all. So long as the bowels are very constipated, as the tongue is foul, and the urine loaded with lithates, colchicum may be given two or three times a day, combined with the sulphate and carbonate of magnesia, and a small dose of blue pill or gray powder with the extract of poppy or of henbane at night. When the constipated state of the bowels has been overcome, the acetous extract of colchicum may still be continued at night, while during the day some mild tonic is given, such as the nitromuriatic acid with extract of taraxacum, or the liquor cinchona; and taraxacum; for with the disposition to local plethora and congestion there is almost always associated a general want of power iu the system. While the tonic plan is generally pursued, any increase of pain, or irritability of the bladder, or an increased deposit of lithates in the urine, will call for a return to the use of the colchicum, and its employment with greater frequency. The persistence of the symptoms and the presence of a profuse leucorrhceal discharge, as well as of an habitual excess of lithates, indicates the employment of the iodide of potassium, which is often of great service when the colchicum has already disappointed our expectations. The dysuria in these cases is frequently much relieved by the patient drinking Vichy water instead of spring water; while the form of tonic that in general suits best is the citrate of iron in doses not exceeding five grains twice a day, for which the Vichy water, sweetened with a little syrup of orange-peel, is a very agreeable vehicle. Lastly, when this condition has existed for years, it becomes, I fear, almost incurable. The waters of Carlsbad and of Wiesbaden do, indeed, effect something towards the alleviation of the patient's sufferings, sometimes, perhaps, even 74 TREATMENT OP RHEUMATIC SYMPTOMS; bring about a cure, but at the best slowly, uncertainly, and leaving behind a great disposition to relapse. Hence the wealthy lose heart at what seems to be a never-ending treatment, requiring to be renewed year after year, and imposing, as the price of even moderate success, strict self-denial, and precautions which almost exclude from society those who observe them. The poor, unable to afford the luxury of illness, are at least as unfortunate, and endure a life of wearing pain, all the more intolerable, perhaps, from its depending on no dangerous disease, and tending but little to shorten an existence which it yet renders extremely miserable. With reference to the last form of dysmenorrhcea—namely, that dependent on the narrowness of the os and cervix uteri, and the consequent mechanical impediment to the escape of the menstrual fluid, I have already expressed my conviction of its rare occurrence. In some instances in which this was supposed to be the cause of painful menstruation, the result of careful examination has been to show that the cervix was small, and its canal narrow, just because the sexual organs generally were undeveloped. Such cases, I need not say, are not cases of mechanical dysmenorrhcea, nor to be relieved by any attempt at dilating the cervix. Neither, indeed, is the proceeding to be resorted to, on speculation, if I may so call it, and with no better warrant than the fact that the dysmenorrhcea is habitual or of long standing, and that other means have not been successful in effecting its cure. To judge, indeed, by the multiplicity of contrivances which of late years have been employed for the purpose of dilating the cervix uteri, you would be led to a different conclusion from that which I believe to be the right one; and would suppose that the existence of a narrow cervix uteri was of great frequency. In addition to ordinary bougies, such as were employed by Dr. Mackintosh, and to bougies of flexible metal, which have been found in some respects more convenient, metallic stems with bulbous ends have been introduced, and left in the cervical canal for an hour or two at a time; and these stems have been recently modified by constructing them of two different metals with the view of obtaining some kind of galvanic action in the interior of the uterus. These ingenious contrivances are the inventions of Professor Simpson, of Edinburgh. I apprehend, however, that as in the case of the galvanic rings, which some time ago were sold about the streets for the cure of neuralgic and rheumatic affections, so in the case of the stems, the amount of galvanic action set up must be too slight to exert any real influence; while independent of the difficulty which there always is, especially if the vagina be narrow, in their introduction, the effect of allowing metallic bougies to remain for any considerable time in contact with the interior of the uterus, has almost always appeared to me to be that of producing very considerable suffering. Besides the gradual dilatation of the os and cervix uteri by bougies, instruments not unlike the speculum matricis of the ancients have been devised for forcibly widening it, literally screwing it open, and others for incising it by means of a bistoire cache. I am perfectly at a loss as OF MECHANICAL DYSMENORRHEA. 75 to the principle upon which these instruments are recommended. If the cervix uteri be wide enough to admit them, I do not see how its narrowness can offer a mechanical impediment to the escape of the menses. I can, however, readily understand that the uterus may suffer severely from the violence offered to it, and indeed have known pelvic abscesses succeed to some of these manipulations. These proceedings are, I believe, much less frequently resorted to now, since the mischief to which they are likely to lead has become more evident, than they were a few years ago. I cannot, however, refrain, now that the opportunity presents itself, from warning you against plausible errors such as led to this practice; errors into which you are all the more likely to fall, from their being of a kind to receive speedy currency among our patients. Non-professional persons cannot understand the reasons which induce us to adopt one course of medical treatment instead of another; but they can quite understand the popularized pathology which tells them that they menstruate with pain because the passage of the womb is too narrow, and in the hope of a cure will submit with readiness to almost any amount of mechanical treatment; and will perhaps draw comparisons between the doctor who is resorting to very needless interference and the less officious person who did no more than the necessities of the case required; comparisons, I scarcely need say, very unfavorable to the latter. If now, after taking all possible care to avoid mistakes, you still come to the conclusion that the painful menstruation is, in part, if not altogether, due to the narrow cervical canal, I think you will find a set of flexible metallic bougies the best and most convenient means for dilating the passage. Those which I use correspond in size with the sounds employed by surgeons for examining the bladder; but I have had a notch made at two-and-a-half inches from the extremity, in order to be able to tell how far the instrument has been introduced. Five or ten minutes are, I think, as long a time as it is desirable to allow the bougies to remain; but they should be introduced daily, and their employment should not be discontinued until the canal admits one corresponding to the ordinary No. 9 bougie. If after frequent attempts the bougie can be introduced only a short distance, a prepared sponge tent, such as Professor Simpson was the first to bring into use, should be introduced, and then a larger, and still larger, till in the course of a couple of days the cervix will be widely dilated throughout; or else we shall find the point at which a decided impassable contraction exists. In the only case in which I discovered this state of things, the patient's sufferings dated from a severe confinement, and the stricture close to the internal os uteri would not allow the passage of the smallest cat-gut bougie. In this instance I employed Stafford's instrument for dividing impermeable urethral stricture; and the result of this proceeding, and of the subsequent introduction at first of sponge tents, and afterwards of metallic bougies to keep the passage pervious, was in the highest degree satisfactory. In no other case, however, has the employment of a cutting instrument for widening a narrow cervix uteri appeared to me either necessary or proper. 76 DISEASES OF THE UTERUS. LECTURE VI. DISEASES OF THE UTERUS. Immediate results of pregnancy and delivery not treated of, though their remote effects are numerous and important. Inflammation, and kindred processes. Hypertrophy of the Uterus from deficient involution after delivery, or abortion ; — from uterine irritation. Illustrative cases, and treatment. Partial hypertrophy, affecting the cervix; its effects. Treatment, removal of enlarged cervix, dangers of hemorrhage. Inflammation. Acute Inflammation ; its rarity, its causes, symptoms, and results. Treatment. A course of lectures on the diseases of women, in which it is not proposed to include the ailments either of the pregnant or of the puerperal state, must needs present much that is defective in arrangement and incomplete in execution. These defects, appear to me to be a smaller evil than would be the occupying much of your time with the reconsideration of subjects such as puerperal fever, or phlegmasia dolens, which have already come before your notice in the lectures on midwifery, and which besides have engaged, and to such good purpose, the attention of many writers both in this country and on the continent. 1 Sacrificing, therefore, accuracy of nosological arrangement to practical convenience, I shall leave unnoticed alike the special diseases of pregnancy, and the morbid conditions which follow immediately on delivery. We shall find, however, over and over again, that conception, pregnancy, and delivery, are among the most frequent exciting causes of disorder of the sexual functions, and of diseases of the sexual organs, and also that many ailments which come under our care, days, or weeks, or even months afterwards, admit of being traced back uninterruptedly to their commencement in a miscarriage, or a severe confinement, or in some interruption to the changes that should occur in the puerperal state. This is especially the case with all the diseases which are the result of inflammation, or of kindred processes, such as pelvic abscesses, hypertrophy of the uterus, induration of its cervix, or tilceration of its orifice, with all the varied forms of menstrual disorder and of leucorrhceal discharge which attend upon them. The active forms of inflammation of the sexual organs, which threaten life soon after delivery, are not, however, those whose sequelae most frequently present themselves to our notice in hospital practice, or call for our attention in private. In many of these the local mischief is but a part of the disease, one of the consequences of that altered con- INFLAMMATION A CAUSE OF UTERINE DISEASE. 77 dition of the blood in which the essence of puerperal fever consists, and contributes only in a secondary degree to imperil or destroy the patient's life. In such cases, if the patient survive the constitutional malady, the local mischief is slowly but surely repaired during the course of her tedious convalescence, and the sexual organs, restored to their integrity, resume in time the healthy performance of their functions. In other instances, where the affection has been from the commencement purely local, the severity of the attack and the intensity of the suffering usually lead to corresponding activity and decision in the treatment, while the sense of past danger inspires in the patient and her friends the observance of most minute precautions until her health is completely re established. Hence it results that the great majority of cases of inflammation and enlargement of the womb, of inflammation of the uterine appendages, or of suppuration in the pelvic cellular tissue, which date back to pregnancy, miscarriage, or delivery, weeks or months before, are not only chronic in their course, but were attended from the very outset by symptoms of comparatively slight severity, and manifested themselves by a state of ailing rather than of serious illness; or succeeded to a sort of imperfect convalescence, for the incompleteness of whose character no adequate cause appeared for some time assignable. One result of inflammation succeeding to miscarriage or delivery is to check that process of involution by which the womb ought lo be restored in a few weeks to the size and condition which it presented before pregnancy began. If you examine the body of a woman who died of uterine inflammation after delivery, one of the first things to arrest your attention will be the large size of the womb, which, after the lapse of four or five days, will be found to be as large as the healthy womb when only twenty-four or thirty-six hours have passed since the completion of labor. This increased size of the uterus, too, is not due simply to its natural contractions being arrested, nor to the unusual afflux of blood towards it, nor to the effusion of the products of inflammation into its substance, though possibly all of these causes may in various degrees contribute to it; but is in a great measure owing to the mere suppression of those changes which ought to occur after delivery, and with whose nature the microscope has made us in some measure acquainted. In a perfectly healthy condition, a large amount of the blood previously supplied to the uterus is at once cut off by the powerful contractions which either completely close the vessels distributed through its substance, or at any rate greatly diminish their calibre. Its tissue having performed the functiomfor which it was raised during pregnancy to so high a degree of development, undergoes, as other tissues do previous to removal, a process of degradation or fatty degeneration; and having thus become more readily susceptible of removal, is either absorbed, or is discharged with the lochia from the interior of the womb. For some three or four weeks, little else goes on besides this process of degradation and removal, and this is much more active during the second week 1 after delivery, than 1 According to Heschl, "Wiener Zeitschrift, and Schmidt, Jahrbucher, vol. lxxvii. 1853, p. 341. 78 UTERINE DISEASE either before or after that period. There next, however, begins a process of reconstruction of the organ; and nuclei, and caudate cells, and elements of new fibres are formed, which await only the stimulus of a fresh conception to attain the same perfection of structure as was manifest in the former uterus. Observers are not altogether agreed as to how soon this reparative action begins; whether it is quite secondary to the removal of the elements of the old uterus, or whether, as seems indeed most likely, removal of the old and construction of the new go on actively at the same time. The interior, of the uterus undergoes changes as considerable as those which take place in its substance; and it is not until its lining membrane, with the exception of that of the cervix, has been several times reproduced and then cast off in a state of fatty degeneration, that it resumes the same condition as before impregnation. 1 The occurrence of inflammation appears to interrupt these processes, for though fatty degeneration of the tissues takes place, yet the removal of the useless material is but imperfectly accomplished, while the elements of the new uterus are themselves, as soon as produced, subjected to the same alteration, and the organ remains, long after all active mischief has passed away, increased in size, and at the same time composed of a tissue inapt for all the physiological processes of conception, pregnancy, and child-bearing. I cannot pretend to tell you the intimate nature of the changes which the uterine substance in these cases may afterwards undergo, for the microscope here leaves us for the present at fault, and many circumstances will always render the investigation of the effects of inflammation, and of its kindred processes when seated in the womb, particularly difficult. It must, however, be at once apparent, that after inflammation has passed away, its effects may remain in the larger size and altered structure of the womb, and that the very nature of these changes will be such as to render the repair of the damaged organ both unlikely to occur, and slow to be accomplished, and must leave it in a condition peculiarly liable to be aggravated during the fluctuations of circulation, and alternations of activity and repose, to which the female sexual system is liable. It must also be obvious that for these results to be produced, it is by no means necessary that the inflammation be very severe in character, but that a degree of inflammatory action far short of what is requisite to endanger life or to occasion much suffering, may yet interpose a great obstacle to the complete involution of the womb. The importance of this condition is due less to the symptoms to which it gives rise, so long as it remains uncomplicated, than to the circumstance, that complications of some kind or other are very apt to occur; that the heavy uterus is very likely to become prolapsed, or the enlarged uterus to become the seat of permanent congestion, 1 The, best microscopic observations on this subject are those of the late Franz Kilian, in Henle's Zeitschrift, vol. viii. p. 53, and vol. ix. p. 1, with which those of Heschl, loc. cit., generally correspond, though there are some differences between their statements in points of detail. Dr. Simpson was, I believe, the first to call attention to the practical bearings of the subject. See his Contributions to Obstetric Pathology, vol. i. p. 26. 79 FROM DEFECTIVE INVOLUTION. or to be attacked by chronic inflammation. A sense of weight in the pelvis, more or less bearing down, and a disposition to excessive and over-frequent menstruation, are, however, seldom absent when any considerable uterine enlargement exists, and in general the size of the womb and the severity of the symptoms are in direct proportion to each other. One of the best marked instances of this deficient involution of the uterus which I have met with, occurred in the person of a woman aged thirty one, who had been married twelve years, and had given birth to five children at the full period, and had also miscarried three times. Her last abortion occurred at the third month, six weeks before her admission into St. Bartholomew's Hospital. Since this abortion she had suffered from shooting pains at the lower part of the back and in the abdomen, from bearing-down pain during every effort at defecation, and from a constant sanguineous discharge by which she had been much exhausted. The medical man under whose care she had been, told her that she had a tumor in the womb. On examination the uterus was found low down, completely retroverted, the os uteri being directed forwards, and only a short distance from the vulva. Almost immediately behind the os, the uterus swelled out into a globular tumor of the size of a small apple, elastic to the touch. The canal of the cervix was open so as to admit the finger without difficulty. On introducing the uterine sound, it passed, with the concavity turned backward, for a distance of five inches and three-quarters, and on turning it round, the tumor previously distinguished completely disappeared. 1 The patient was kept quiet in bed, was allowed a little wine and meat diet, and the hemorrhage ceased, and the canal of the cervix contracted under the use of the ergot of rye, though no sensible uterine action was excited by the remedy. She afterwards took preparations of iron, and began the employment of the cold douche to the uterus, by which she was already much benefited, though the uterus was not much diminished in size, when the outbreak of smallpox in the ward compelled me to discharge her eighteen days after her admission. 1 saw her three months afterwards; her health was still much improved, but she complained of profuse menstruation, returning every fortnight, and her womb was still retroverted, though it was much smaller than before. At the end of rather more than three years she again came under my notice, having in the interval miscarried several times at an early period of pregnancy. Her uterus was still retroverted, and the abortions were probably due to the organ having been bound down by adhesions in this unnatural position. It 1 Dr. Matthews Duncan has described, in Edinb. Monthly Journal, June, 1856, p. 1057, some cases in which he believes that, independently of any disease of the uterus, there existed a state of unnatural patency of the Fallopian tube on one side, admitting of the passage of the uterine sound along it for several inches. Such a state, however, which is probably one of considerable rarity, is not likely to be confounded with instances of enlargement of the womb itself, since an ordinary vaginal examination would at once inform us whether or no that organ is larger and heavier and less movable than natural, conditions which were absent in the instances that he relates of dilated Fallopian tube. 80 ENLARGEMENT OF THE UTERUS had, however, greatly diminished in size, and was now little if at all larger than the healthy womb. Besides this form of uterine enlargement from defective involution, there is another, occasionally, though much less frequently met with, in which the enlargement of the icomb takes place independent of previous pregnancy, and is the result of a more genuine hypertrophy. Cases of this kind, which I have met with exclusively in women who have lived for a longer or shorter time in childless marriage, present themselves in most instances without any definite clue to their history; a sense of weight in the pelvis, pain usually of a burning character, and hemorrhages having gradually come on and forced themselves by their slowly increasing severity (sometimes not till after the lapse of years) on the patient's notice. Excessive or intemperate sexual intercourse does not produce it, though that leads to its own train of evils; but there has in many instances seemed good reason for associating the condition with the imperfect performance of that function, and sometimes the evidences of that being the case have been conclusive. Some years ago I saw a lady, aged forty-three, who, during thirteen years of married life, had never been pregnant. . She had always menstruated painfully, and rather profusely; and both these ailments had by degrees grown worse, and this especially during the last few months. She complained of sense of weight and dragging immediately on making any attempt to walk, and induced even by remaining long in the sitting posture. The bowels were constipated, and defecation was difficult. Menstruation was very profuse, accompanied by discharge of coagula, while at uncertain intervals during its continuance most violent paroxysms of uterine pain came on. On examination, the enlarged uterus was distinctly felt above the symphysis pubis as large as the doubled fist, and per vaginam the whole organ was found much enlarged and much heavier than natural; the cervix large and thick, but not indurated; the os uteri small and circular; and the hymen was entire. Rest, attention to the bowels, local leeching every fortnight, continued for several months, together!)— 20f> of his work on the Diseases of Women, so clearly, that no better rules can be laid down for the use of the ligature. 244 RULES FOR THE EXCISION OF POLYPI. The division of a large polypus, and its extraction piecemeal, has been proved by experience to be unattended by any of those risks of hemorrhage which were once apprehended frflm the employment of cutting instruments in any way for the extirpation of these tumors; while various practitioners have invented curved knives or cutting hooks for the divison of the pedicle of polypi which could not be drawn down with facility. Thus M. Velpeau 1 employs a knife eight or ten inches in length, curved at its point, which is blunt, and has a cutting edge only on one side. With this instrument he divides the pedicle of the polypus, which is kept on the stretch by an assistant grasping it with a pair of Museux hooks. A very ingenious, though perhaps rather complicated knife, the blade of which is fixed at right angles with the handle, and is introduced defended by a sort of sheath, like that of a hiatorie cache, was invented and used in a case where the polypus was very large, and its pedicle very thick and solid, by Dr. llerrich, of Ratisbon, 2 while more lately Professor Simpson, of Edinburgh 3 has employed an instrument not unlike the sharp hook employed by midwifery practitioners for decapitating the foetus. The instrument seems in his hands to have answered very well, though one might have feared that the sharp edge being on the same plane with the handle of the instrument, it would have cut too obliquely for the ready division of the pedicle. By whatever means a polypus is separated from the uterus (polypi of a malignant character of course excepted), the pedicle withers, and the growth is not reproduced. This fact, which was once regarded as suggesting a problem of difficult solution, is not hard to understand, if we bear in mind that the pedicle is formed of uterine tissue. On the removal of the growth, the stimulus to hypertrophy of the uterus is withdrawn, the whole organ returns by that process of involution of which we see so many illustrations, to its natural dimensions, while the pedicle of the polypus, having no longer any office to perform, is completely removed. Other modes of getting rid of fibrous polypi have been occasionally resorted to, but it is scarcely necessary to do more than enumerate them. Torsion is but rarely applicable, for the pedicle is usually too thick and too firm to admit of the growth being thus removed. If the polypus be small, and its stem slender, there can, however, be no objection to it, while it unquestionably has the great advantage of doing away almost completely with all risk of bleeding. The forcible tearing away or avulsion of the growth has nothing whatever to recommend it; it is uncertain, painful, and hazardous. The destroying the vitality of the polypus by forcible compression, either of the whole mass, or by an instrument strangulating its pedicle, as practised by M. Gensoul, of Lyons, 4 appears open to all the objections that may be alleged against the ligature, without any compensating advantage. 1 Bull. Gen. de Therapeutique, vol. xiv., Paris, 1838, p. 156, and Meissner, op. cit., vol. i. p. 864. 2 Ueber Gebarmutter Polypen und deren Ausrottung, 8vo., Regensburg, 1846. 3 Ed. Monthly Journal, Jan. 1855, and Obstetric Works, vol. i. p. 150. 4 Nouveau Procede pour operer les Polypes de Matrice, 8vo., Lyons, 1851, p. 11. 245 MANAGEMENT OP LABOR COMPLICATED WITH POLYPUS. Some reference ought, perhaps, to be made to the occasional complication of pregnancy or labor with polypus of the uterus, before we take a final leave of this subject. 1 There seems to be good reason for believing tljat polypi participate in the general development of the uterus during pregnancy, and that a growth previously very small may attain to a very considerable size during gestation. They do not, however, in general produce marked symptoms during pregnancy, nor do they tend to interfere with its natural progress. After the commencement of labor, their injurious effects become manifest, since they sometimes present a mechanical obstacle to the passage of the child, and at other times give rise to untoward consequences after its expulsion. Of these, one of the most frequent is hemorrhage; the polypus within the uterine cavity interfering with the due contraction of the organ, just as the portion of adherent placenta does in cases of its disruption. The other risk is that of violent and uncontrollable uterine action being excited, and exhausting the patient by its severity and continuance, as, for instance, in the remarkable case related by Dr. Gooeh, 2 in which, after delivery, a polypus weighing three pounds fifteen ounces was expelled beyond the external parts, and the patient died while her medical attendants were still uncertain as to what her ailment was, and what should be done for her cure. In spite of these contingencies, however, the general rule, and one concerning the wisdom of which there can be no doubt, is not to meddle with an uterine polypus either in labor or after delivery, unless the symptoms are so serious as to leave us no alterative. The ground for this rule is furnished by the risk of hemorrhage if the polypus be excised, and of phlebitis from the absorption of decaying animal matter if the growth be removed by ligature; while the vascularity of the polypus, and probably its size, will rapidly diminish as the involution of the uterus goes on, and the whole organ grows less and less susceptible as the date of delivery becomes more distant. It is, therefore, better during labor to extract the child, and afterwards to check hemorrhage, and by opiates to still any violent uterine efforts, if possible, rather than by attempting the immediate removal of the polypus, to expose the patient to hazards so serious and so difficult to obviate. If, however, interference became urgently necessary, I think that I should, even in these cases, prefer the excision of the polypus, with the present risk of hemorrhage, to the somewhat tardier, but, I apprehend, graver dangers attendant on the use of the ligature. There still remain a few varieties of uterine disease, concerning which something should be said, before we pass to the study of those malignant affections of the womb that constitute the most painfully important of all the ailments of the female sexual system. To a brief notice of these I propose devoting the remainder of this lecture; and first, I will describe a very rare form of tumor of the womb which resembles in its character what has been termed the Recurrent Fibroid tumor. 1 A very able essay on the subject, which will well repay perusal, was published by Dr. Oldham in the Guy's Hospital Reports, 2d series, vol. ii. 2 On Diseases of Women, &c, p. 2S1, case vli. 246 RECURRENT FIBROID TUMOR. In the eighth volume of the Transactions of the Pathological Society* there are recorded by Mr. Hutchinson the particulars of a case in which a tumor formed within the uterine cavity of a middle-aged unmarried woman, and gave rise to floodings large in amount and frequent in their return. At the end of twenty-three months an attempt was made to remove the tumor, which sprang from within the uterus by a pedicle as thick as the wrist, whence a mass as large as*three fists projected into the vagina, while the uterus itself was felt as large as a child's head above the pubes. The soft texture of the tumor prevented it from being firmly grasped, and the operation was discontinued after only a comparatively small portion of the mass had been detached. The bulk of the tumor, however, subsequently sloughed away, and at the end of a month no trace of it could be discovered, nor any enlargement of the womb detected. For the next three months the patient continued so to improve that it was hoped a perfect cure had been effected; but at the end of six months the growth was reproduced, though it had not quite regained its former size. A second operation was now performed, and the hand introduced into the uterine cavity broke down the tissue of the tumor, which it was found possible only very imperfectly to remove. Temporary improvement again followed, but in three months more the tumor had grown again, and was attended by its old symptoms. Attempts to destroy its tissue by caustic injections caused much suffering and did little good, and death took place two years and ten months after the commencement of the patient's illness. The uterus was about the size of two fists, and contained a white soft growth, attached by a very broad base to the fund us and posterior surface, its free extremity hanging down in a polypoid shape close to the os. The mucous lining of the cervix, though congested, was healthy. The uterine walls were much thickened in those parts to which the tumor had no attachment, but were thinned, evidently by its infiltration, at the base of the growth. On a microscopic examination the tumor was found to be composed of a fibroid tissue, and of a softer material made up of round nuclear bodies, of transparent molecules, and of some fusiform cells. Both its microscopic character as well as the history of the disease seem to remove the tumor from the class of malignant growths, and Mr. Hutchinson's own interpretation of its nature as belonging to the class of recurrent fibroid tumors is doubtless correct. In his paper on the enucleation of fibrous tumors, Mr. Hutchinson refers to a case of Dr. Atlee's, as probably belonging to the same category with the one just related. The account given by Dr. Atlee, 2 however, is too vague to enable one to form any very accurate judgment of the structure of the growth, though its rapid reproduction after removal renders his opinion in the highest degree probable. A case has also come under my observation, that belongs to the same class, and the details of which, as will be seen, harmonize very closely with the history of Mr. Hutchinson's patient. 1 Page 287. 2 Transactions of American Medical Association, vol. vi. p. 579, case iii. 247 RECURRENT FIBROID TUMOR. A young unmarried woman, aged twenty-three, who had always had good health, and since her fourteenth year had menstruated scantily, but without pain, every three weeks, was kicked on the lower part of her back during a menstrual period in July, 1852. This kick was followed by frequent abundant discharges of blood from the vagina, and towards the end of September by pain referred to the loins and Jiypogastrium, and by a sense of bearing down, which, however, was not aggravated by moderate exertion, nor relieved by the recumbent posture. The discharges, which had reduced her to a state of great weakness, were described at the time of her admission into the hospital on October 1st, 1852, as being habitually offensive, consisting sometimes of fluid blood, often intermixed with large coagula, but being at other times greenish and watery. On examination the os uteri was found widely open, and a polypus, apparently of the size of a pigeon's egg, protruded through it, but the finger could not be passed high enough up to reach the point of its insertion. The hooked forceps introduced to draw it down, tore out from its substance, which was found to be remarkably soft: but a portion as big as an egg having been removed, a large mass was still left behind in the uterus. No hemorrhage followed this first operation, which was attempted on October 4th ; on the 10th, the ergot of rye having been given in the interval in the hope of forcing the tumor lower down, the sound passed four and a half inches, and the finger detected a rough mass not unlike placenta or very old clot, firmly adherent to the walls of the uterus, which was perfectly movable in the pelvis. On November 11th a second attempt was made to remove the tumor, the patient having in the interval suffered much from hemorrhage, and having also experienced considerable pain. The attempt, however, issued in the removal of but a very small portion of the tumor, whose texture again broke down, while its attachment to the posterior and lower part of the uterus was too broad to allow of a ligature being placed around it. On December 20th, a third operation was attempted; a fourth on January 5th; a fifth on February 21st; and a sixth on March 8th ; the growth being partly torn away by the fingers, in part scraped from the interior of the uterus by a blunt knife, whose blade was fixed at right angles to its handle. After each operation masses of the tumor came away, and it was estimated that altogether the quantity removed in and after the several operations amounted to about six ounces. On April 11th, the sound still entered three and a half inches, showing that though the size of the uterus was diminished, it yet had not returned to its natural dimensions; while, though the os was closed so that the exact state of things could not bo ascertained* I yet feared the reproduction of the tumor, for I had been struck by the circumstance that in spite of its laceration and of the forcible avulsion of portions of it at each operation, it yet on every repetition of the proceeding presented the same smooth surface. Microscopic examination of the portions of the tumor showed its texture to be made up of imperfectly formed fibres, and of an aggre- 248 RECURRENT FIBROID TUMOR. gation of cells resembling those of inflammatory lymph, or granulation cells. In April the patient left the hospital, but at the end of June she had a most alarming hemorrhage, during which large portions of the tumor were discharged, intermixed with coagula. At the beginning of August she was readmitted, and the enlarged uterus was now felt distinctly over the pubes, while on a vaginal examination* its lower segment was felt much distended. The os uteri was dilated with sponge tents, and as much of the tumor as could be removed in fragments was extracted, though the quantity did not much exceed six drachms. The muriated tincture of iron was now injected into the broken-down tissue, in the hopes of thus expediting its destruction, and this was repeated thrice between that time and the 17th of October. The patient, however, dreaded these injections very much on account of the severe pain which they occasioned; while chloroform produced so much and such abiding sickness and depression, that it was not possible to have recourse to its use. Iu December, 1858, an attack of hemorrhage was accompanied by the expulsion of six ounces of the tumor; and on the loth of that month a large portion was removed; and on February 20th, 1854, a ninth and last operation was performed. The suffering caused by each operation, not so much at the moment of its performance as subsequently, when much abdominal tenderness was always experienced, and a great degree of constitutional disturbance was produced, coupled with the necessarily incomplete character of each operation, and the extreme rapidity with which the growth was reproduced, led me from this time to abstain from all interference. It would be tedious to relate minutely the subsequent history of the patient, who in the autumn of 1857 was still able to follow a sedentary occupation, and to walk half a mile in order to show herself to me at the hospital. She had had many attacks of profuse hemorrhage, one of which, in May, 1856, very nearly proved fatal, and was followed for weeks by alarming depression, with severe abdominal pain, which was kept under only by large doses of morphia, and by profuse, extremely offensive watery discharge. The outline of the abdominal tumor, too, could be felt above the umbilicus, the abdomen measuring at that point thirty-two and a half inches; while per vaginam a lobulated soft growth extended through the widely dilated mouth of the womb. In spite of the decided increase of the abdominal tumor, however, the patient's condition steadily improved after her recovery from the hemorrhage in May, 1856, since which time no considerable loss of blood occurred, though the abdomen remained extremely tender; and the patient, in spite of added strength, remained pale as a marble statue. On December 20,1857, she re-entered the hospital for the last time, not suffering indeed from any return of her uterine symptoms, but from pain, which she conceived to be rheumatic, in her neck, and from cough brought on by exposure to cold a week before. Some swelling was perceptible on the right side of the cervical vertebrae, and light was thrown on its probable nature, in the course of a few days, by the occurrence of numbness of the right arm and leg, and difficulty in RECURRENT FIBROID TUMOR. 249 moving them. Next, power over the left arm and leg became similarly impaired; and the urine was voided involuntarily as well as unconsciously. The respiration, too, was labored to an extent which auscultation did not account for; and the strength daily declined, though without suffering, and death took place quietlv on the 3d of January, 1858, nearly six and a quarter years from the commencement of the patient's illness. The following account of the appearances after death is from the notes of my friend and colleague, Mr. Callender. The rarity of the case furnishes my excuse for relating it in such detail. On opening the sac of the peritoneum, a large oval tumor, in front of which lay several coils of small intestine, was seen occupying the left iliac fossa, and extending upwards to about the level of the middle of the left kidney. It was invested by a thin transparent membrane, which dipped in between the convolutions that divided the tumor into lobes of unequal size. The tumor was of a white or pale straw color, slightly vascular, a few large bloodvessels ramifying over its surface. It grew from the posterior wall of the uterus, to which it was connected by means of a broad base, two inches and a half thick, by one and a half in length. The tumor itself measured five and a half inches in breadth. The uterus occupied the entire pelvis, and rose to some height above the level of its brim. Its walls were only a quarter of an inch in thickness, and the os uteri was so dilated by a tumor which projected through it, that it was impossible to determine exactly where the uterus ceased and the vagina began. The uterus, thus attenuated, was stretched over a large tumor which occupied its interior. This tumor was attached by a broad base to the posterior uterine wall, where it was continuous with the growth which projected into the iliac fossa, while anteriorly and at the sides it was perfectly free. Independently of this, a few isolated nodules were connected wijh the right side of the uterus, and projected upon its inner aspect, involving the mucous and submucous coat. The lobed surface of the tumor was free from any irregularities such as might have been expected from the previous operations. The lobes were more marked and more irregular on the anterior and lower portion of the tumor than elsewhere. It measured seven and a hall' inches in length, by five inches in breadth. These tumors presented throughout the ordinary characters of recurrent fibroid growths, being composed of narrow, elongated, caudate, and oat-shaped nucleated cells, with some detached nuclei and granular matter. The lumbar glands were the seat of a similar deposit; and nodules of a similar kind were imbedded in the lungs, and connected with the parietal layer of the pericardium. A mass of the same kind was seen projecting from the body of the sixth cervical vertebra, and the same deposit being infiltrated into the substance of the bone had expanded it, both anteriorly and posteriorly, compressing the anterior columns of the spinal cord, and producing the symptoms which at length proved fatal. 1 1 This case will probably be described at length by Mr. Callender, in vol. ix. of the Transactions of the Pathological Society. 250 FATTY TUMORS OF TH-E UTERUS. I have related this case at length on account of its rarity, and because its duration of more than six years brings into stronger prominence, than did the history of Mr. Hutchinson's patient, the differences between this kind of growth and those of a truly malignant character. No cancer cells were detected in the uterine tumor either during the patient's life, or when the parts were removed after her death; and though the nodules in the lungs were thought by some who examined their structure to contain cells resembling those of ordinary scirrhus, yet Mr. Callender did not discover any, while every one agreed as to the abundance of fibroid material. I know of no other cases resembling these. Our experience is at present too small to warrant our arriving at very positive conclusions respecting the disease which they illustrate. It may, however, be doubted whether our wiser course is not to let the disease alone; for while its complete removal seems impossible, its partial extirpation appears to be followed by an increased rapidity in its reproduction. Two instances of Fatty Tumors of the uterus are reported in the German medical journals; and though nothing of the kind has ever come under my notice, it might seem an omission if I failed to refer to them. The patients in whom this growth was observed were of the respective ages of fifty aud fifty-three.' The former of these women, after suffering for eleven years from leucorrhoea, expelled from the vagina a tumor the size of the first, which was ascertained to be made up of fat, closely resembling cholesterine, though not quite identical with it. In the other case the tumor, which was of the size of a child's head, projected beyond the external parts, but was connected by a pedicle three fingers broad with the whole margin of the os uteri. It was removed by ligature, and the patient, who had been subject to menorrhagia for a year previously, recovered. The tumor, which weighed three pounds and a half, is said to have been an ordinary fatty tumor, having an investment of dense cellular tissue, septa of which dipped down into its substance. The patient in the first case continued after the expulsion of the tumor liable to periodical discharges of very offensive slimy, watery fluid, in which were now and then small 'flat masses similar to the larger substance. The state of the cervix was quite natural, and I suppose that in this case the deposit of flat had taken place upon the free surface of the diseased mucous membrane of the womb, and had by degrees accumulated in the cavity of the organ until it stimulated its muscular fibres to contract upon and expel it. In conclusion, I will add a few words concerning tubercular deposit in the uterus, though it ought not, perhaps, in strict propriety to be noticed here, but should rather be referred to a separate category. Convenience, however, may be allowed to overrule strictly scientific arrangement. It happens occasionally that on examining the uterus, although its exterior may appear quite healthy, and the canal of the 1 The cases are related by Dr. W. Busch, in Miiller's Archiv. 1851, p. 358, and Dr. Seeger in Wiirtemb. Zeitschr. vol. v. 1852, and Schmidt's Jahrb., Dec. 1852, p. 335. 251 TUBERCLE OF THE UTERUS. cervix also be free from disease, the whole of its cavity is found occupied by a matter of a dirty yellow color, closely resembling both in its aspect and its consistence the substance of a tubercular bronchial gland when just beginning to soften. This deposit is generally about an eighth of an inch in thickness, is easily scraped away with the back of the scalpel, but on its removal it is found that all trace of the lining of the uterus has disappeared too, or if anywhere a portion of it remains, that is seen to be opaque, more vascular than natural, and to present beneath it small yellow spots, looking like distant tubercular deposits, which, in fact, they have been ascertained to be by careful microscopic examination. In cases where the disease is only beginning, the separate yellow deposits in the mucous membrane are alone apparent, while when the disease is far advanced (and it was so in the two instances which came under my own observation) not only is the mucous membrane completely destroyed, but the deposit encroaches on the substance of the womb, its cavity is enlarged by the abundance of the morbid substance, and its walls are thickened ; changes that in some instances have been known to occur to a very considerable extent. In the great majority of cases the tubercular deposit does not extend beyond the cavity of the uterus, though sometimes a similar matter is found distending the Fallopian tubes, and tubercular degeneration of the ovaries now and then coexists with the disease of the interior of the womb. Either of these occurrences is, however, more frequent than the extension of the disease to the cervical canal, and Rokitansky 1 denies that it ever appears there as a primary deposit. Occasionally one sees in the living subject, on the surface of one or both lips of the uterus, deposits of a yellow color, of the size of a split pea, or smaller, having altogether the appearance of small deposits of yellow tubercle, and which on being pricked give issue to a small quantity of matter of the consistence of pus, or rather firmer, and having a granular appearance under the microscope. These deposits have been alleged to be tuberculous; and the high authority of the late Professor Kiwisch 2 may be adduced in support of that opinion. I am familiar with the appearance, but am not altogether convinced of its tuberculous character; and am rather inclined to consider it as due to hypertrophy of some of the Nabothian follicles, with obliteration of their orifices and alteration of their contents. At any rate, though small slightly excavated ulcers are now and then left behind, I have never been able to trace any connection between this appearance and any form of destructive ulceration of the cervix. The disease seems to be always secondary to tubercular deposit elsewhere, and even then to be of rare occurrence, though perhaps less so than it was believed to be by Louis, 3 who did not estimate its frequency higher than one and a half per cent, of all cases of tubercle iu general. M. Kiwisch 4 states, that at Prague it was met with once in every forty cases, or, in other words, with a frequency of two and 1 Pathol. Anatomie, vol. iii. p. 550. 2 Op. cit., vol. i. p. 558. 3 RCcherches sur la Phthisis, 2d ed., Paris, 1834, p. 142. * Op. cit., p. 559. 252 TUBERCLE OF THE UTERUS. a half per cent.: and I know of no other statistics bearing on the subject. The following table deduced from data furnished by Kiwisch and a recent very painstaking writer on the subject, Dr. Geil, 1 furnishes some information not without its value. Tubercular deposit in the uterus was met with— In 6 subjects between 10 and 20 years " 22 " " 20 — 30 " " 15 " " 30 — 40 " " 10 « " 40 — 50 " « 7 « " 50 _ GO « « 6 " " 60 — 70 " " 2 " " 70 — 80 « Total 68 In forty-five of the cases collected by Dr. Geil, the seat of the affection is distinguished— Uterus alone affected 1 case „ 1,1 j ¦with affection of peritoneum . . 19 cases ancttuoes j without « « § § 12 u Uterus, tubes, and j in form of an aphthous process . 2 " vagina . . . | " true tuberculous ulcers 1 case Tubes alone affected 8 cases liight tube alone . 2 " Total 45 Amenorrhcea or dysmenorrheca, often associated with leucorrhceal discharges, are the symj)toms which are ordinarily observed in connection with uterine tuberculosis. In them there is nothing pathognomonic of this special form of uterine disease, nor do they call for any particular mode of treatment. Indeed, if we bear in mind that tuberculous affections of the womb appear to be always secondary to extensive deposit of tubercle in other organs, we are led to the practical inference that, in cases where phthisical symptoms are present, there is every reason for interfering as little as possible for the removal of amenorrhcea, or other irregularities of the menstrual function, and especially for abstaining from much local treatment of any other uterine ailment that may occur. 1 In an inaugural dissertation, published at Erlangen in 1851, and of which an abstract is given in Schmidt's Jahrbiicher, March, 1852, p. 324. 253 MALIGNANT OR CANCEROUS DISEASES OF UTERUS. LECTURE XIX. MALIGNANT OR CANCEROUS DISEASES OF THE UTERUS. Hopelessness of the subject, but importance of questions involved in its study ; erroneous opinions formerly held concerning it. Definition of Cancer ; its varieties. Scirrhus extremely rare; its anatomical characters. Medullary Cancer; its nature, mode of occurrence of ulceration, its rapid progress; abortive attempts at cure, and advance of the disease. Hypertrophy of uterus in its course ; changes in its walls ; its interior; on its surface. Extension of disease to vagina and bladder. Exceptional cases ; cancer of body of uterus ; cancerous polypi. Alveolar cancer. Epithelial Cancer ; its general characters, its relation to medullary cancer; essential identity with Cauliflower Excrescence. Ulcers of the os uteri; the so-called Tuberculous Ulcer; Corroding Ulcer. Frequency of secondary affections in cases of uterine cancer. In the study of the diseases which have hitherto engaged our attention, we have never entirely lost a sense of hopefulness. Either medicine might cure the ailment, or surgery might remove it; or at the very worst, so much might be done to retard its progress, and to alleviate the sufferings which it occasioned, that life was in many instances but little, if at all shortened; was sometimes even scarcely embittered by its presence. In passing now, however, to the investigation of the malignant diseases of the womb, of cancer and its allied disorders, we shall find but few of those mitigating circumstances which lessen the darkness of the picture in the case of many other incurable affections. Pain, often exceeding in intensity all that can be imagined as most intolerable, attended by accidents which render the sufferer most loathsome to herself and to those whom strong affection still gathers round her bed; the general health broken down by the action of the same poison as produces the local suffering, and all tending surely, swiftly, to a fatal issue, which skill cannot avert, from which it can scarcely take away its bitterest anguish : such are the features in the picture which I must now call on you to contemplate, and that not hurriedly, nor for a moment, but most carefully, and deliberately, and in all its various aspects. There are indeed many reasons which prevent our passing over the subject of uterine cancer (as we might be glad to do) with but a passing notice. The frequency of the disease forbids it, for scarcely any age is free from its attack, while it is doubtful whether any other form 254 VARIETIES OF CANCER. of organic affection of the womb is met with so often, and it is certain that there is no other so fatal. The dread most naturally felt, lest this symptom or that symptom should portend the onset or imply the existence of cancer, forbids it; for we are called on over and over again to remove the apprehensions of women whose fears have been excited by some uterine ailment, perhaps of no great moment, but out of which they have shaped to their affrighted fancies all the hideous features of an incurable, an almost unbearable disease. Need I say, then, how much it imports that we should be able to remove such apprehensions when causeless, not by holding out vague hopes or uncertain expectations, but by positive assurances founded on large and accurate experience, and as far as may be on certain knowledge? To those practitioners and writers, both English and foreign, who have taken the most active part in the study of the inflammatory affections of the neck of the womb, and whose investigations have led them (as some believe, and I confess myself to be of that number) to an exaggerated estimate both of their frequency and of their importance, we yet owe a debt of gratitude for the light which they have thrown on this disease, which outweighs many overstatements and cancels many errors. Cancer of the uterus used before their time to be described as a disease slow in progress, continuing in its first quiescent stage of scirrhus not only for months, but for years, and then, excited by one knows not what cause to activity, passing into the state of ulcerated carcinoma, and thus at its close quickly destroying the patient. It sufficed, then, for the neck of the womb to be hard and painful, and somewhat enlarged, for the suspicion of malignant disease to be entertained, and for years of causeless anxiety to be entailed upon the patient. Such and such-like were the results which followed from confounding the consequences of inflammation and of kindred processes, with the changes which the deposit of the elements of cancer brings about in the affected part. It is scarcely necessary to define cancer, but if some definition must be adopted, I know of none better than Muller's: 1 "Those growths may be termed cancerous which destroy the natural structure of all tissues, which are constitutional from their very commencement, or become so in the natural process of their development, and which, when once they have infected the constitution, if extirpated, invariably return, and conduct the person who is affected by them to inevitable destruction." Taking this definition, however, as, on the whole, the best that can be given, we must still bear in mind that morbid anatomy and chemical research have both, within the sixteen years that have passed since it was framed, tended to show great diversities between the different forms of carcinoma, and to show also that many of those which affect the womb are local in their origin, and continue so through much of their progress; and that probably if we could always discover the existence of the disease early, we often need not despair of its cure. No form of carcinoma seems to be peculiar to the uterus, though 1 On Cancer, &c, English Translation, 8vo., London, 1840, p. 28. 255 SCIRRHOUS CANCER. they do not all occur with anything like the same frequency. Fungoid or medullary carcinoma is by far the most common ; next in frequency may be classed the epithelial varieties of the disease, if indeed it be not more correct, as some men of high authority believe, to refer them to a separate category distinct from genuine cancer. Next to them, but divided by an interval which widens in exact proportion as fresh evidence is brought to bear on the subject, may be classed scirrhus, or hard cancer; while almost as rare, or, perhaps, even more uncommon, stands the colloid, or alveolar variety of the disease. The only attempt with which I am acquainted at a numerical estimate of the comparative frequency of scirrhus or hard cancer, and other varieties of malignant disease of the womb, is the statement by the late Professor Kiwisch, 1 that about three of every ten cases of cancer of the womb are scirrhus. This estimate, however, in all probability much overrates the frequency of scirrhus; and I cannot but think that many instances of firm medullary cancer have been regarded as scirrhus, and this not only by less competent observers, but even by Kiwisch himself. He goes on to say "that with the commencement of the softening of fibrous carcinoma, the peculiar characters of the growth progressively disappear; it grows like medullary cancer, becomes more vascular, and is easily broken down; contains a pultaceous, brain like substance, and the ulcer which forms upon it presents precisely the same external appearance, and the same characters as those which result from the breaking down of medullary cancer." The great authority of Bokitansky' may further be adduced in support of the opinion that " fibrous cancer is of extreme rarity;" while, on the other hand, "medullary carcinoma occurs with the greatest frequency." To say after this that I have not met with any example of genuine scirrhus of the uterus, considering hovt few comparatively are my opportunities for observation after death, may seem almost an idle impertinence. It is more to the purpose, however, to add that my friend Mr. Paget informs me that he has not met with any instance of it, while any one who carefully examines the preparations in our anatomical museums will find that this disease, once said to be so common, is in reality but seldom met with. It is perhaps not irrelevant to mention, that of a hundred and thirty-six cases of uterine cancer of which I have a record, the disease appeared from an examination during the patient's life to be of the medullary kind in a hundred and twenty-one, epithelial in thirteen, and colloid in two, while in not a single instance did I recognize the characters of scirrhus, though I have seen some cases of alleged scirrhus in which the history of the patient, and the result of long-continued observation, plainly showed the name to have been misapplied, and the enlargement and induration to be due to causes of a perfectly innocent kind. Before describing from my own somewhat scanty materials, the anatomy of uterine cancer, I will quote liokitansky's description of the scirrhous variety of the disease, deduced, as he informs us, from a 1 Op. cit., vol. i. p. 518. 2 Pathologische Anatomie, vol. iii. p. 550. 256 CHARACTERS OF MEDULLARY very few observations. He says :* " On a careful examination, one may discover in the midst of the tissue of the portio vaginalis, another structure recognizable by the different shade of white of the fibres composing it, and which, though closely packed, intersect each other in every imaginable direction ; while the small interstices between them are filled by a transparent matter of a pale, yellowish-red, or grayish color. This new structure is infiltrated into the uterine substance without any distinct limits ; extending further in one part than in another, and here and there heaped up in greater quantity, thus producing the enlargement of the portio vaginalis, the uneven nodulated character, and the well-known induration of its substance." In spite of differences on other points, all observers are agreed that the neck of the womb, or rather that part of it which projects into the vagina, the portio vaginalis, is the point at which cancer generally commences, and to which for a season it is confined. Its mode of commencement differs, according as the disease belongs to the epithelial or to the medullary form. In the first case, the papilke of the os uteri seem to be the point of departure of the evil, and a large, granular, sprouting outgrowth not un frequently projects into the vagina, while still the subjacent tissue is but little involved. In the second case, the morbid deposit takes place in the substance of the part, enlarging, butthickening far more than lengthening it, increasing the size of the lips of the uterus, rendering them hard and tense, though still not without a certain elasticity, and at the same time irregular and nodulated; while as they enlarge they usually gape, and leave the mouth of the womb and the lower part of its cervical canal more widely open than in a state of health. On making an incision into the parts which have thus lost their ordinary characters, the place of the natural structure of the uterus is found to be more or less occupied by a white, firm, semi-transparent deposit, which in some parts seems infiltrated into the proper tissue of the womb, in others, has entirely taken its place. This deposit is always more abundant near the mucous surface of the organ than towards its outer wall; and a thin layer of muscular substance may often be detected beneath the peritoneal investment of the uterus, even when the conversion of its tissues into cancerous structure has been most complete. It is very seldom that after death one finds nothing more than this substitution of cancerous deposit for the proper tissue of the womb. In the great majority of cases softening takes place, even while the part involved is but a comparatively small portion of the womb; softening is soon followed by death of the mucous membrane of the os uteri; an ulcer forms, a ragged uneven sore, with raised, irregular, hardened edges; and a dirty putrilage covering its uneven, surface, takes the place of the smooth but enlarged lips of the organ. Or, if the disease go on still further, the lips of the womb and its cervix are altogether destroyed, and a soft, dirty white flocculent substance covers 1 Loc. cit., p. 550. CANCER OF THE UTERUS. 257 the uneven, granular, and hardened substance, which alone marks their former situation. These ulcerations, when once formed, increase with great rapidity, a fact of which I have more than once seen remarkable illustrations. A patient, aged forty-nine years, was admitted under my care into St. Bartholomew's Hospital, whose symptoms consisted of hemorrhage, at first profuse, afterwards occurring frequently and without cause, though in less abundance, and with it some pain in the back had of late been associated. The uterus was low down, quite movable in the pelvis, and not much enlarged. The posterior lip was thin, and seemed healthy, the anterior was thick, hard, and nodulated, though the mucous membrane covering the surface of both appeared healthy under the speculum. Twelve days afterwards the examination was repeated, and the advance of disease within this short time was very remarkable. The posterior lip was now no longer thin and natural, but thickened, puckered, and uneven, and the inner surface of the anterior lip was irregular, as if from ulceration, while the introduction of the speculum showed the surface to be uneven, ragged, black, and bleeding. I have seen other similar cases, but none in which the occurrence of ulceration was so sudden, or its subsequent progress so rapid as in this instance. It is not easy to account for the occurrence of ulceration in all instances. Commonly it is preceded by softening of the morbid deposit, but this is by no means constant, for in the very instance which I have related, and in others too, in which it has been possible to fix the date of the ulceration, and to trace its subsequent progress, the cancerous substance round the ulcer has been, and has still continued firm. Mere rapidity of growth, too, does not of itself produce ulceration, for some instances of rapidly growing medullary cancer of the womb excite our suspicion; and yet obscure our diagnosis by the absence of ulceration even up to a late period. All that we can venture to assert with reference to the subject is, that in all forms of cancer of the womb (with the exception, perhaps, of that of its body), ulceration and the formation of an open sore take place sooner or later; and further, that this ulceration may occur in either of two ways, 1 either proceeding from within outwards, in which case it is preceded by softening of the cancerous ti-ssues, or from without inwards; the vitality of the investigating membrane of the uterine lips being destroyed first, just in the same way as the vitality of the skin is sometimes destroyed over a cancerous tumor of the breast. A few days often suffice to give to the ulceration the dimensions and even the depth which it may be found to retain for months subsequently. The patient, indeed, grows worse, the discharges continue, composed of pus from the ulcerated surface, fetid from the admixture with it of dead and decaying materials, tinged with blood from the giving way of some of the vessels distributed to the granulations, while every now and then abundant hemorrhages break forth, profuse enough, perhaps, to excite apprehensions even for the patient's present safety. 1 See, with reference to this subject, Paget, op. cit., vol. ii. p. 334. 17 258 ULCERATION OF MEDULLARY CANCER. If we examine, we find sprouting granulations or a positive fungous outgrowth from the surface, and, then, after a time, the fungus disappears, the surface feels less uneven, the edges less unhealthy, and we can almost persuade ourselves that here and there a process of cicatrization has begun. And yet healing does not take place. " The cancer sore does not heal, because its base, the cancer substance, is not cicatrix tissue, and consequently can form no scar, and the apparent scars which now and then form are never lasting. It does not heal, because the outgrowth is constantly going on ; it does not heal, because no skinning takes place upon its surface; and, lastly, it does not heal, because the new-formed tissue speedily dies again." 1 New formation and death of the newly-formed tissues go on in constant succession; a series of abortive attempts at cure, such as prevent the rapid extension of the ulcer, such as cheer the patient with delusive hopes of recovery, such as sometimes mislead the unwary, even among members of our own profession; and such as, I blush to say it, furnish the wretched charlatan with a fair pretext for the most despicable of all falsehoods; for those with which, for his own behoof, the doctor dares to impose on the credulity of his patients. Slowly, however, though the disease may sometimes seem to advance, it yet does advance, cancerous deposits extending from the cervix into the substance of the body of the uterus; the new-formed tissues dying, and dying on the whole to a greater extent than they are reproduced, until at length the lips of the os are quite destroyed, the portio vaginalis of the cervix is destroyed too, and a widely gaping opening, with thick, hard, and irregular edges, is all that is left to mark the point where the womb begins, and the canal leading to it ends. Often, though not invariably, a step preliminary to this occurrence is the formation of adhesions between the lips of the uterus and the contiguous surfaces of the vagina. Sometimes these adhesions are limited to one lip, often they involve both, and to them is in a great measure due that apparent shortening of the vagina which is very marked in many cases of uterine cancer, and which does not at all imply the previous occurrence of any descent of the womb. In the softer kind of medullary cancer, in which this condition is met with most frequently, and in the greatest degree, the surface of the portio vaginalis and the walls of the vagina become sometimes so completely fused together that a mere thickened ring is all that indicates the situation of the mouth of the womb. Even this, at length, becomes indistinct, owing to the extension of the cancerous disease along the vaginal walls, and the finger at last discovers no distinction between the uterus and vagina, but finds only that the uneven walls of the canal end in a cavity filled with a dirty putrilage. Sometimes, indeed, this fusion between the two surfaces does not take place, but nevertheless the vagina becomes almost always implicated in the advance of the disease. Cancerous deposit takes place in its cellular tissue, confined at first pretty much to the roof of the vagina, where it produces that thickening, hardness, and resistance, 1 Bruch, Ueber die Diagnose der biisartigen Geschwiilste, 8vo., Mainz, 1847, p. 454. 259 CHANGES IN THE UTERUS: ADVANCE OF CANCER. which render the cancerous womb less movable than natural. With the lapse of time the deposit both becomes more considerable at its original seat, and also extends further and further along the canal, shortening as well as thickening it, while general hypertrophy of the tissues tends to the same result. Nor is the disease confined to the substance of the vagina, but it affects the mucous lining in almost every instance, and this, as might be expected, most remarkably in the immediate vicinity of the womb. The whole mucous membrane, indeed, is often red and inflamed, but as the neck of the uterus is approached it is also found softened and thickened. Small spots of whitish cancerous deposit, from the size of a pin's head to that of a barley-corn, not infrequently beset the upper part of the canal, and unhealthy, superficial ulcerations, usually irregular in form, and having a transverse direction, are often present. These ulcerations are said by M. Lebert 1 seldom to have a cancerous base, and are probably due in great measure to the acrid nature of the discharge in which the upper part of the canal is almost constantly bathed. What renders this opinion the more probable is, that in cases of epithelial cancer in which this discharge is often absent, the ulcerations are also commonly wanting. It is almost needless to say that while disease advances at the lower part of the uterus, the rest of the organ is not left in a healthy state. If life is sufficiently prolonged, the deposit by degrees extends further and further upwards, till even as high as the ligaments of the ovaries, or sometimes higher still, the walls of the organ are thickened by infiltration of cancerous matter, or are completely converted into it. This, however, is not the only cause of that enlargement of the whole uterus which is met with in almost ever}'' case of carcinoma. In other organs of the body, the advance of cancerous deposit, and the wasting and disappearance of the proper tissue of the part, go on simultaneously and in equal proportions. In the case of the uterus, however, that disposition to growth and development of which we have seen so many illustrations, shows itself even during the progress of malignant disease. The walls thicken in parts which the cancer has not yet reached, for the increased afflux of blood brings with it an increased activity of growth, and even in those situations where the malignant deposit is abundant, there remains up to a late period a layer of muscular fibre bounding it externally; the product, as I imagine, of new formation, not simply the residue of the original parietes of the organ. 13ut though the cancerous disease, either for the reason which I have assigned, or on some other account, as yet inexplicable, seldom reaches to and involves the external surface of the womb, its mucous lining has no such immunity from disease. Its condition, however, is very variable. Sometimes nothing more is apparent than a general and intense redness of the interior of the womb; but much more frequently the uterine lining membrane is covered by a dark offensive secretion, and is beset here and there by small white deposits of cancer. If disease is more advanced, the mucous membrane is absent, at any » Op. cit., p. 230. 260 CHANGES ON EXTERIOR OF UTERUS rate from the lower part of the uterine cavity, and the surface is uneven and granular from the infiltration of cancerous deposit into the uterine tissue. On one occasion,, too, I found the whole interior of the womb lined by a Avhite membraniform layer of cancerous deposit, beneath which its substance was irregular and granular, as if ulcerated. This partial destruction of its mucous lining, and this granular state of its interior, occasion that roughness which the finger so constantly perceives when introduced within the orifice of the cancerous womb. There is, however, besides, in many instances of uterine carcinoma, a distinct, polypoid, cancerous outgrowth, which springs from low down in the cavity of the womb, or from the upper part of its cervix, seldom attaining any considerable size, but varying from month to month, and usually disappearing altogether as ulceration advances, and as the uterine structure is with its advance more and more extensively destroyed. Besides these, which are usually but temporary phenomena, there are distinct malignant polypi, concerning which I must say more presently, but about which it may suffice now to mention that they occur independently of disease of the os or cervix uteri, though they too become almost invariably involved in the progress of the cancer. If now from the substance of the womb and its interior we pass to the study of the alterations which cancerous disease brings about on its external surface, we shall find occasion to notice many important changes, though none perhaps so striking as those which we have already observed. Many circumstances concur to produce that firm fixing of the uterus in the pelvic cavity which is observable in almost every instance of carcinoma of the medullary kind, except in its very earliest stages. It is partly brought about by a chronic form of peritonitis, which is generally, though not constantly, limited to the parts in the immediate vicinity of the pelvis, and which glues the womb to the rectum and bladder. This, however, is not its only cause, but infiltration of cancerous matter between the uterus and adjacent parts, and between the folds of the broad ligament, tends to fix it in the pelvis, and to form it and the parts connected with it into one immovable mass. These deposits usually take place on the visceral surface of the peritoneum, and are sometimes so extensi ve as to be the apparent occasion of a degree of wasting of the womb itself, which I have once or twice found in the midst of abundant medullary deposit, small and shrunken, and its outer surface rough, as if partially eroded or destroyed by the morbid structure. While these deposits are but inconsiderable, they may still be seen in small patches beneath the peritoneum; but with their increase the peritoneum too becomes involved, and at length is undistinguishable in the midst of the large mass of cancerous disease which conceals the uterus and its appendages from view. In cases where these deposits are most abundant, it is by no means unusual to find softened cancerous matter in the pelvic cavity, or between the folds of the broad ligaments; while sometimes the intestines are matted together above the pelvic brim, so as to form the upper wall of an irregular cavity lined with cancerous matter; while now and then a real fecal abscess is produced by the extension of the disease to the intestines, and their consequent perforation. WITH THE ADVANCE OF CANCER. 261 More frequent than the actual destruction of the peritoneum by deposits of cancer beneath it, is the occurrence of numerous small masses of the same substance on its outer surface. These are sometimes flat and sessile, like small tubercles distributed over it, at other times they are connected with the serous membrane by a small and slender membranous pedicle, similar to that by which small fibrous outgrowths are not infrequently attached to the fundus and adjacent parts of the womb. On two occasions I have also found in the midst of the cancerous substance which enveloped the uterus serous cysts of the size of a filbert, containing a rather deep straw-colored, transparent serum, their walls thin, their outer surface free, their inner connected with the uterus itself by the interposition of a layer of cancerous substance of uncertain thickness. In one instance, five cysts were present, and the material which surrounded them, and which also had matted together the uterine appendages, was intermingled fat and cancer substance. In the other case, there was only one cyst, but it also was surrounded by a very abundant deposit of cancer. These cysts showed no sign of endogenous growth in their interior, but appeared to be simple serous cysts, such as sometimes form on the exterior of the uterus, independent of any other disease. I am therefore uncertain in what relation they stood to the cancerous deposits, whether in that of mere accidental complication, or whether the connection between the two was more intimate. 1 Iieference has already been made to the formation of adhesions between the uterine lips and the vaginal walls, and it is obvious enough that when this takes place the extension of disease to the substance of the vagina is almost sure to follow. It is matter of observation, however, that the anterior vaginal wall and the bladder are much more frequently involved by the advance of uterine cancer than are its posterior wall and the rectum. It has been attempted to explain this occurrence by the assumption that cancer oftcner attacks the anterior than the posterior lip of the uterus; but facts do not bear out this assertion, and my own experience, indeed, would rather lead me to the conclusion that cancer is oftcner limited to the posterior, and that certainly the disease of the posterior lip is often further advanced than that of the anterior. The intimate connection between the neck, of the womb and the bladder, parts which are separated only by the intervention of a fold of the pelvic fascia, while posteriorly the peritoneum descends even below the level of the commencement of the portio vaginalis, accounts much more satisfactorily for the more speedy infiltration of cancerous matter into parts contiguous with the front than with the back of the organ, and consequently for the frequency of vcsico-vaginal fistula, and the comparative rarity of communication between the vagina and rectum. 1 In all the cases of serous cysts of the uterus described by Huguier in his very valuable Essay in vol. i. of the Memoires de l'Academie do Chirurgie, chap. ii. pp. 295—325, and plates iv. and v., the cysts were sub-peritoneal. Those which I observed in the two cases above described was similar to the cysts delineated by Doivin and Duges, in plates xiv. and xxxiii. fig. 1 of their Atlas, but of which they give no particular description. 262 AFFECTION OF THE BLADDER IN CANCER. Though, perhaps, not strictly in place, it will yet be convenient to add a few words more about the affection of the bladder in cases of uterine cancer. It is by no means unusual, independent of any trace of cancerous deposit in the organ, to find the mucous membrane of the bladder intensely congested and of a deep red color, sometimes inflamed, even ulcerated, pus covering its rugae, and all the coats of the organ thickened, showing, what indeed the dysuria during the patient's life but too constantly announces, how close the sympathy is between the bladder and the womb. The mode in which the first anatomical evidence of positive disease of the bladder appears is not constant. Sometimes the mischief seems entirely to proceed from without inwards, and then at one spot, where the bladder and vagina are closely united, the mucous membrane of the former viseus may present a slightly flocculent appearance. If touched, it will be found to be softened ; if pressed on with a probe it will give way ; the cancerous deposit has gradually destroyed all the intervening tissues, and a few days more would have sufficed for the production of a fistulous opening. In other instances, disease attacks the bladder, secondarily indeed, but independently of mere extension to it by continuity of tissue. Deposits of cancer, in the form of small flat whitish tubercles, take place beneath its mucous membrane; not limited to that part where the uterus or the vagina and bladder are in immediate contact, though generally much more abundant there than elsewhere. These tubercles enlarge somewhat, though they do not coalesce nor attain any considerable size, but they destroy the mucous membrane above them, while that of the rest of the organ is generally inflamed, thickened, and sometimes even ulcerated. When the fistulous opening has once formed, the bladder undergoes all those changes which attend a vesico-vaginal fistula, however produced, only aggravated by the constant advances of the disease by which the fistula was occasioned. But, to return to that more special study of cancer of the womb itself which is our present business, I may observe that though the description of the disease already given holds good to a great extent of all forms of uterine cancer, there are some varieties of lite disease in which deviations occur from its most common course. It has been stated as a general rule, that cancer begins in the neck of the womb, and this statement is open to almost as few exceptions as the directly opposite one with reference to the exclusive seat of fibrous tumors in the body of the organ. In three, however, out of one hundred and thirty-six cases of uterine cancer, the disease occupied the body of the organ, and ran its course to a fatal issue without the occurrence of ulceration of the os uteri, or of any change in its condition, such as during life could lead to the suspicion of its being the seat of malignant disease, though its tissue was found after death infiltrated with cancerous deposit. In all of these cases the enlargement of the uterus was very considerable; in one it measured five inches in length, in a second six inches, and in the third was nearly as large as the adult head. This increase of size was due in two of the cases to the extreme thickening of the uterine walls by infiltration of cancerous deposit, 263 CANCEROUS POLYPI. which in one had converted the whole organ into a tolerably uniform mass of soft, indistinctly fibrous tissue, of a dirty grayish-white color, soaked in a dirty serum, very soft, but tearing most readily in a longitudinal direction, while no trace of mucous membrane was discoverable, nor any remains of uterine cavity beyond half an inch from the orifice of the womb, which was small and circular, and outwardly presented no evidence of disease. In the other case, the walls of the uterus were similarly thickened, though in a less degree, and the uterine cavity was not obliterated, but a mass of soft medullary cancer, of the size of a walnut, projected into it, springing from a little above the situation of the internal os uteri. Externally, the lips of the os uteri were healthy, their surface perfectly smooth and of a vivid red color. This character continued to just within the cervix, but there the mucous membrane at once became roughened, of a red color, with dead white spots of cancerous deposit showing through it everywhere 1 A similarly healthy state of the os existed in the third instance, in which the uterus measured five inches in length. The organ in that case was surrounded by a mass of softening carcinomatous matter, but its walls were not infiltrated with malignant deposit. The increased size of the womb, indeed, was due to expansion of its cavity; not at all to thickening of its walls; but their inner surface presented a very remarkable appearance, being everywhere beset by small warty growths, or irregularities, among which were one or two rather larger than the rest, but even these did not exceed the size of a pea. These granulations were quite sessile, and the surface altogether looked more like that of a chronically ulcerated bladder than of a part the seat of morbid deposit. In the substance of these granulations no distinct cancer cells were found, but at the fundus of the uterus, where the walls were generally very thin, there was an aperture of communication large enough to allow the finger to pass between the cavity of the womb and the mass of carcinoma which surrounded it. Here, too, the uterine wall was softened and disintegrated, and seemed infiltrated with the same kind of matter. Besides these cases, two others out of the total one hundred and thirty-six presented a great preponderance of disease in the interior of the womb, though the lips were not in a healthy condition. It was clear, however, in both instances, that the mischief had proceeded from within outwards, not in its usual course; and I am disposed to think that the commencement of cancerous disease in the interior of the womb, instead of about its orifice or in the substance of its neck, is not of that extreme rarity which is generally supposed. Lastly, in connection with these cases in which the os uteri escapes the cancerous deposit, or becomes affected only secondarily, some mention must be made of those rare instances in which polypi of malignant structure grow from the interior of the uterus, independent of previous disease of its orifice. Eeference has already been made to the frequent formation of polypoid outgrowths of malignant structure 1 A brief but interesting account of several cases of this description is given by Dr. Simpson in his Obstetric Memoirs, &c, vol. i. p. 193. 264 ALVEOLAR AND EPITHELIAL CANCER. during the course of general uterine cancer, but these outgrowths are for the most part of inconsiderable size, constitute but a small part of the general mass of disease, and disappear with the advance of the carcinoma. Now and then, however, at a time when the lips of the os are still unaffected, an outgrowth of cancerous tissue, generally of the medullary kind, springs from the interior of the womb, and descends into the vagina. The point of origin of such malignant polypi is usually low down in the cavity of the womb, or actually within the canal of the cervix, but occasionally they spring from its fundus. Of this a remarkable illustration is given by Boivin and Duges, and an instance of it came under my own observation some years since at the Middlesex Hospital, into which institution a woman came to die, apparently of ascites. An abundant and very offensive vaginal discharge attracted attention to the state of her womb, when a polypus considerably larger than the fist was discovered in the vagina. After her death, in addition to extensive cancerous deposits in various abdominal viscera, the walls of the uterus were found thickened by medullary deposit, and its cavity distended by the polypus, which sprang by a pedicle half the size of the wrist from the fundus of the womb. The polypus was of a very soft texture, and possessed of considerable vascularity. One other case of cancerous polypus has come under my observation. The outgrowth was of much smaller size, and, as well as could be ascertained, sprang from low down in the body of the womb. It projected but a short distance into the vagina, and the lip3 of the os uteri looked healthy, though there was some degree of thickening and induration of the posterior lip. I believe, indeed, that though the formation of the malignant polypus may precede other disease in the womb, yet the cancer before long extends to the uterine walls, and I am not aware of malignant outgrowths having ever been found in an otherwise healthy uterus. I believe that I have twice met with alveolar cancer of the womb, but in one instance only have I had the opportunity of corroborating my opinion by an examination after death. In that case the lips of the os uteri were nearly destroyed, and a layer of dense medullary carcinoma formed the base from which projected numerous semi-transparent warty granulations, occupying the whole interior of the uterus, and filled with a rather firm semi-transparent gelatinous matter, such as Lebert, 1 who appears to have met with this condition several times, speaks of as its characteristic. The epithelial cancer of the uterus presents itself under two forms: either assuming the character of a granular outgrowth from the lips of the uterus, or else of an intractable ulceration of their surface. In its most characteristic form, the first variety is the cauhjlotaer excrescence of Dr. John and Sir Charles Clarke; but of far more common occurrence are cases which, though essentially the same, present points of difference approximating them to ordinary medullary cancer. In its very early stages, epithelial cancer 2 of the womb has only 1 Traito des Maladies Cancereuses, 8vo., Paris, 1851, p. 217. 2 I have retained the term cancer as applied to these varieties of malignant disease of the uterus, because I do not feel myself competent to form an independent opinion 265 CHARACTERS OF EPITHELIAL CANCER. once come under my observation ; for the comparatively trifling symptoms to which it at first gives rise seldom force themselves upon the attention of our patients. In the instance where I had the opportunity of seeing the disease of the uterus at its commencement, it was secondary to the same affection in the vagina. On the surface of the posterior uterine lip was a patch of the size of a shilling, somewhat raised above the surrounding surface, of a vivid red color, bleeding readily, and with a papillary structure so fine that it closely resembled the pile of red velvet. Usually, however, when I have first seen it, the cervix of the womb has been already somewhat increased in size, the os uteri not open, but its lips flattened and expanded, so that their edge, which felt a little ragged, projected a line or two beyond the circumference of the cervix, while their surface was rough and granular to the touch. On introducing the speculum, this irregularity was seen to be produced by the aggregation of numerous small, somewhat flattened papillae or granulations, of a reddish color, semi-transparent appearance, and often bleeding very readily. Sometimes these granulations continue for many months, scarcely at all increasing in size or altering in character; and then on one or other lip an ulcer forms, with irregular, excavated edges,, and the case, if then seen for the first time, would scarcely be suspected to have been other than one of ordinary uterine cancer. Generally, however, the small sessile papilhe increase in size, and form a distinct outgrowth from the whole circumference of the os uteri, of the size of an egg, an apple, or even of a greater magnitude. These growths are split up by deep fissures into lobules of various sizes, all of which, however, seem to be connected together at their base, though the fissures are so deep and their directions so various, that it is seldom possible, when the growth is of any size, to distinguish between them and the os uteri itself. The dimensions of these growths are not in general the same throughout, but they spring from the surface of the os uteri by a short thick pedicle or stem, the elongated and hypertrophied cervix, and then expand below into that peculiar cauliflowerdike shape from which their name has been derived. Even the most careful examination generally breaks down some of the tissue of the growth, and produces hemorrhage; but if in spite of this the finger be carried down to its base, the substance will be found to become much firmer, and at the same time to bo possessed of a degree of sensibility which, though but low, is much greater than that of the more depending part of the tumor. Sometimes the outgrowth is confined, at any rate at its commencement, to one lip, and may attain a considerable size before the other is involved in the disease 1 This is more likely to occur if the posterior than if the anterior lip is affected, and for the obvious mechanical reason which accounts for every large polypoid outgrowth being flattened on its with reference to what is still a moot point between the highest authorities; and because the general tendency of epithelial and cancroid diseases of the womb is to become associated during their progress with medullary cancer; often, indeed, they lose their own distinctive features completely, merging them in those of ordinary uterine carcinoma. 1 Of which there is a very characteristic drawing in Boivin and Duges' Atlas, plate xxiv. fig. 1. 266 CAULIFLOWER EXCRESCENCE. anterior surface, spheroidal on its posterior. The hollow of the sacrum allows more room for the development of any outgrowth than is afforded by the comparatively flattened anterior half of the pelvic cavity bounded by the rami of the pubes. Though the vagina does not by any means escape from a participation in the disease, and a granular or papillary structure may be felt sometimes extending over its roof, and for some distance along one or other wall, yet this is by no means constant; and so long as the disease retains its original characters well marked, the disposition to involve adjacent parts is far less than in ordinary uterine cancer. The tendency, however, to pass into ordinary medullary cancer, or to become associated with it, is very strong; while we find that the tumor itself undergoes the same processes of alternate partial death and partial reproduction, as we have noticed in other forms of malignant disease. Usually the outgrowth in the course of time disappears in part, and the irregular, sharp-cut edge of the os whence it grew is at first felt granular and uneven within, but afterwards grows thicker and nodulated, assuming by degrees all the characters of a part which has from the first been the seat of medullary cancer, while the walls of the organ and its interior likewise undergo just the same changes. Between this disease and genuine cauliflower excrescence the differences appear to be of degree rather than of kind. In the latter, indeed, the epithelial cells which compose it are of the cylindrical form, but its more obvious peculiarities consist in the larger size of its vessels, in the greater delicacy of their walls, and in their being covered by a thin investment, not bound together into a comparatively solid mass by connecting tissue, but "hangingin fringes almost like a mass of uterine hydatids j" 1 while the base of cancer substance, which in the more solid growths is deposited very early, in the delicate and vascular cauliflower excrescence is not formed till a much later period, or even not at all. - Their intimate structure, however, and their microscopic elements are just the same, and both consist of hypertrophied papillae, composed of epithelial cells richly supplied in their interior with large aud delicate vessels, and covered with a thickened layer of epithelium. The enormous looped capillaries of the cauliflower excrescence explain the abundant hemorrhages and the profuse serous discharges that attend it, while the absence of that solid structure which is found in other forms of epithelial cancer accounts for the peculiarly favorable results that have followed its extirpation, and also for the fact that after its removal a few shreds are all that remain of what had seemed to be a large and firm tumor. Difference of opinion exists as to the exact nature of those intractable ulcerations of the os and cervix uteri, which, in accordance as I be- 1 This not inapt comparison is made by Virchow in his description of the microscopic structure of these growths, in the Verhandl. der Phys. Med. Gesellschaft in Wiirzburg, vol. i. p. 110, which harmonizes with and completes previous observations. Very good representations of the general aspect of these growths are given by Sir C. Clarke in vol. ii. pi. i. of his work on Diseases of Women; by Dr. Simpson, at pp. 165 and 166 of his Obstetric Works; and by Dr. Mayer, in vol. iv. of the Verhandl. der Oes. f. Geburtsh. in Berlin, which also contains a drawing of the appearances presented under a low magnifying power. 267 INTRACTABLE ULCERATIONS OF THE UTERUS. lieve with the preponderance of authority on the subject, I have referred to epithelial carcinoma, but which are alleged by some very competent observers to be tuberculous. When speaking of uterine tubercle, I made mention of numerous small deposits of a yellowish color sometimes met with on the surface of the os uteri, and which, if punctured, or if their contents escape spontaneously, sometimes leave behind small slightly excavated ulcers. Their tuberculous character did not, however, appear to me to be clearly substantiated, since I had never observed any general fusion of the deposits, and consequent breaking down of the tissue of the cervix. M. Lisfranc, 1 however, has described a condition which has never come under my own notice, but which has been seen and described by M. Robert," M. Pichard, 3 and others, who relate cases illustrative of its character, and who refer it to the breaking down of tubercular deposits in the substance of the cervix. " These tubercular ulcerations of the cervix uteri," says M. Robert, 4 " may be recognized by their excavated base, their grayish appearance, and the presence of a caseous matter in the midst of the mucopurulent discharges which come from the interior of the cervix. They may also be known by the presence in the cervix of tumors of uncertain size, of a rounded form, at first firm and with no change of color, afterwards soft, whitish, yielding to the pressure of the ringers, and giving an indistinct sense of fluctuation. These tumors are formed by the tubercular matter still in a crude state, or in course of softening. " It is, moreover, to be observed that these scrofulous ulcerations are almost always accompanied by considerable engorgement of the cervix uteri, a condition which is due either to the presence of masses of tubercle still unsoftened, or to some tubercular infiltration still remaining, or lastly, to that inflammatory process which accompanies the softening and elimination of this kind of morbid product. This last circumstance may obscure the diagnosis of the case, and lead to the belief that the engorgements or the ulcerations are of a malignant character, an error which Lisfranc confesses that he fell into several times." These appearances, however, receive a different interpretation when the microscope is called in to aid our researches. The softened matter is found not to consist of the elements of tubercle, but of epithelial cells similar to those of the uterine mucous membrane, while the indurated, callous structure which forms the base of the ulcer is formed of a mixture of fibro-plastic and epidermoid materials. In short, as M. Kobin 5 says, this kind of ulcer is to the uterus what lupus or can- 1 Clinique Chirurgicale, &c, vol. iii. pp. 548—553. 2 Des Affections, &c, du Col de l'Uterus, 8vo., Paris, 1848. 3 Des A bus de la Cauterization, &c, dans les Maladies de la Matrice, 8vo., Paris, 1840, pp. 124—132. 4 Op. cit., p. 48. 5 The conjoint testimony of Robin, Archives de Medecine, August, 1848, pp. 407— 411 ; of Lebert, Maladies Cancereuses, p. 218 ; and of Hanover, Das Epithelioma, 8vo., Leipsig, 1852, p. 120, may be taken as decisive on this point. It is, I think, extremely doubtful whether Dr. Gibbs's case of alleged extensive tuberculous ulceration of the uterus and bladder, described at p. 209 of vol. vi. of Transactions of the Pathological Society, ought not rather to be referred to this category. 268 SECONDARY DEPOSITS OF CANCER. croid ulcers are to the face, the chief differences between them depending on the constant exposure of the latter to the air, and the constant contact of the other with the mucus and other secretions of the vagina. One affection still remains to notice, which, though less strictly deserving to be ranked with cancer than were those varieties of malignant disease which we have just now been studying, yet will find here perhaps its fittest place. The late Dr. John Clarke was the first writer who described under the name of corroding ulcer a peculiar form of destructive ulceration of the os and cervix uteri, beginning at the mucous membrane which covers it, involving the whole circumference of the os, and utterly destroying both it and the subjacent parts, but differing from carcinoma, in the absence of any thickening, hardness, or deposit of new matter in its vicinity. Not to dwell on certain differences between its symptoms, and those of ulcerated carcinoma, the fact that the corroding ulcer may continue for several years without causing any very formidable symptoms, while death takes place speedily as well as inevitably in ulcerated cancer, points to some essential difference between the two diseases. Tts real nature has given rise to much difference of opinion, and the rarity of the affection has been a great obstacle to the thorough understanding of its nature. There can be no doubt, however, but that it ought to be classed with rodent ulcers, as indeed it has been by all recent microscopic observers, for, like them, its aspect, rate, and mode of progress are unlike those of cancer, while neither cancer cells nor epithelium formations are present in the adjacent tissues. 1 One point only connected with the morbid anatomy of uterine cancer still remains for notice, and that concerns the frequency with which other organs become affected in the course of the disease. I apprehend the number of cases to be very few indeed in which cancer has not extended before the death of the patient by continuity of tissue from the uterus itself to some of the parts immediately adjacent. Thus, for instance, it is certainly very unusual for a patient to die of uterine cancer, in whom there does not exist some degree of cancerous infiltration into the upper part of the vagina; and, as we shall see hereafter, the frequency of this occurrence, even at a comparatively early period of medullary cancer, is one of the circumstances which most of all interferes with the success of operative proceedings for its cure, and which oftenest contrainclicates any attempt at their performance. There does, however, seem to be reason for believing that carcinoma of the uterus is oftener at its commencement confined to one part, and that it continues so for a longer period than does cancer when situated in any other organ of the body. M. Lebert 2 states that the evidence of general infection of the system, as manifested by secondary deposits in other organs, existed in only a third out of fortyfive cases of uterine cancer, but in twenty-four out of thirty-four, or in five-sevenths of the number of cases of cancer of the breast. These results, however, are more favorable than those which the late Professor Kiwisch deduced from seventy-three post-mortem examinations of 1 Hanover, op. cit., p. 12S. 2 Op. cit., pp. 239, 310, 394. 269 MALIGNANT OR CANCEROUS DISEASES OF THE UTERUS. uterine cancer made in the hospital at Prague. Lie found cancer of the bladder in forty-two per cent, of his cases; Lebert 1 only in thirteen per cent.; of the ovaries in nineteen; and of the lungs in 7.5 per cent.; while Lebert met with each of them only in the proportion of 4.4 per cent. These discrepancies, which I am not able from personal observation to explain, are yet probably due to the different forms of cancer having occurred in different proportions at Paris and at Prague; possibly to the greater frequency of epithelial cancer in the former city, and of medullary cancer in the latter. In any future statistical table showing the frequency of cancerous infection of the system, it will obviously be necessary to refer the cases to different categories according to the character of the primitive disease. In the mean time the knowledge of the fact that such infection of the system occurs less invariably and less early in cancer of the womb than in other forms of the disease, may serve to throw a feeble ray of hopefulness over the gloomy prospect which we have now to contemplate from other points of view. LECTURE XX. MALIGNANT OR CANCEROUS DISEASES OF THE UTERUS. Their frequency; causes influencing the occurrence of cancer, as age, state of the menstrual function, its mode of establishment, child-bearing, influence of child-bearing accounted for ; hereditary tendency. Symptoms of cancer; mode of onset, and first symptom. Fain, its character, and causes. Hemorrhage, its import; frequent as a first symptom, and why. Discharges ; cause of their offensive character, and of variations in this respect. Cancerous cachexia ; its characters. Two exceptional forms of cancer, the latent and the acute. Influence of cancer upon labor. Diagnosis of uterine cancer. Duration of the disease. One of the reasons which at the commencement of the last lecture I assigned for occupying much of your time with the study of carcinoma of the uterus was the frequency of its occurrence. Our tables of mortality, indeed, do not at present enable us to learn with complete accuracy how often it is met with, but they furnish data from which it is not difficult to make a tolerable approximation to the truth. It appears from the Seventeenth Report of the Registrar-General, 2 that the mortality from cancer throughout England, in the year 1851, amounted to 1754 males, 4072 females. The whole of this excess of female mortality from cancer may be confidently attributed either to 1 Op. cit., vol. i. p. 511. 2 See p. 124. 270 FREQUENCY OF CANCER. cancer of the breast or of the womb. According to Tanchou's tables, 1 however, deduced from the mortuary registers of Paris, cancer of the womb was more frequent than cancer of the female breast, in the proportion of 2996 to 1147, or.as 2.6 to 1. Neither this statement, however, nor the assertion which he also makes, that uterine cancer was the cause of 1.6 per cent, of all female deaths during the decennial period to which his calculations refer, can be received as absolutely correct, though it is my impression that neither the one nor the other deviates much from the truth. I have already referred more than once to the circumstances which render the statistics of a large hospital inconclusive as evidence of the comparative frequency of different diseases. The sufferings that generally attend cancer in some of its stages, and the costly nature of the remedies by which these sufferings are best assuaged, induce a very large number of patients afflicted with that disease to seek relief at a wealthy institution like St. Bartholomew's Hospital, and I have no doubt but that my own experience there would, without allowing for these causes, lead me to suppose cancer of the womb to be even more common than is actually the case. 2 But though this be so, the disease still remains, of all organic affections of the womb, alike the most frequent and the most terrible. We light at once upon surer ground if, from the attempt to determine its exact frequency, we pass to the inquiry into the circumstances that favor its development; the influence of age, of marriage, childbearing, &c, upon its production. Dr. Walshe, 3 whose erudite work on cancer will always continue to be, with reference to many points, the best authority on the subject of which it treats, was the first to show that there is a progressive increase in the frequency of cancer with the advance of age. I hardly need observe that the frequency of any disease at different ages can be rightly estimated only by a comparison of the number of cases in which it occurs, with the total population at the same age; though from neglecting this obvious condition erroneous conclusions have sometimes been drawn with reference to this and other similar questions. Taking the population of England, however, at decennial periods, it seems, and Mr. Paget's researches lead to the same result, that with every ten years of additional age after the age of twenty, the liability to cancer steadily increases. A fact this of great interest, showing how a disease of constitutional degeneracy grows more and more common with the enfeebling of the powers of nutrition, and attains its 1 Recherches surle Traitement Medicate des Tnmeurs Cancereuses du Sein, 8vo., 1844, p. 258. 2 Dr. Lever, on Diseases of the Uterus, 8vo., London, 1843, p. 1G5, states that among the out-patients of Guy's Hospital, the proportion of cases of uterine cancer to other uterine diseases was nearly as 1 in 7, or 13.5 per cent. At Bartholomew's I find the proportion to be 1 in 18.2, or 5.4 per cent. ; numbers wich I mention merely as showing how unsafe it would be to draw any inferences as to the comparative frequency of that, or, indeed, of any other disease, from such data as are afforded by the out-patient books of a hospital. J Op. cit., p. 140. INFLUENCE OF AGE ON ITS PRODUCTION. 271 greatest frequency when nature's alchemy has well nigh reached its end, and the power to transmute the rough material into the highly organized and wonderfully complex tissues of the body is almost gone. But it is scarcely less interesting to find that when a part has outlived its uses it often begins to die, and that the greatest frequency of cancer of the breast and of the womb is not governed by the same law as prevails with reference to the disease in other parts, but occurs long before the ordinary period of human life has been attained. "The age of most frequent occurrence of scirrhous cancer of the breast," says Mr. Paget, 1 " is between forty-five and fifty years. Nearly all records, I think, agree in this. The disease has been seen before puberty, but it is extremely rare at any age under twenty-five; after this age it increases till between forty-five and fifty, and then decreases in frequency ; but at no later age becomes so infrequent as it is before twenty." This statement, too, he illustrates, not simply by the absolute numbers of cases which he has collected, but likewise by comparison with the population at different ages. Much the same fact holds good with reference to uterine cancer, as is shown by the subjoined table of the ages of the patients in 412 cases, 2 collected from various sources. 3 To whole population at respective Actual ages: the number being re- Number. uuco 2 4 Arnott 8 2 ... 2 Scanzoni 7 4 4 Dorrington 8 ...... 1 1 Kiwisch 9 4 4 Menzies" 20 10 10 Spiegelberg" ...... 1 ... 1 75 41 34 1 As in Dr. Menzies' very remarkable case recorded in Glasgow Medical Journal, vol. i. p. 129, July, 1853. 2 De Tumorlbus in Pelvi, &c, 8vo., 1840, cap. iii. and iv. 3 London Journal of Medicine, 1851, p. 204, and Guy's Hospital Reports, 2d series, vol. vii. p. 427. 4 London Journal of Medicine, 1851, p. 212. 6 Op. cit., p. 648. 6 Med.-Chir. Trans., vol. xxxi. p. 37. 7 Lehrbuch der Geburtshulfe, vol. ii. p. 258. 8 Prov. Med. Journal, Oct. 7, 14, 21, 1843. 9 Op. cit., vol. ii. p. 540. 10 Menzies, loc. cit. In Menzies' table of 27 cases are included those of Denman contained in Puchelt's table, and some cases of Oldham and Simpson, which are separately referred to by me. Those being omitted, 20 cases remain. Monatschrift f. Geburtsk., Feb. 1858, vol. xi. p. 110. 286 LABOR COMPLICATED WITH CANCER. In Seventy-two Cases the Fate of the Children is mentioned. Authority. Total Cases. Dead. Born alive. Puchelt 30 19 11 Oldham 5 4 1 Cormack ...... 1 ... 1 Simpson 6 2 4 Arnott 2 2 twins 1 Scanzoni 4 4 Dorrington ...... 1 1 Kiwisch. 4 4 Menzies 18 11 7 Spiegelberg 1 ... 1 72 47 26 Hereafter we must return to the subject, in order to inquire into the means which will give us the greatest chance of carrying the mother and her child safely through these dangers. For the present it is enough to have adverted to them, and to have shown their nature and extent. In the foregoing lectures I have occasionally noticed the main distinctions between innocent and malignant diseases of the womb, and it may at first sight appear needless to enter into details concerning the diagnosis of uterine cancer, since its characteristics are so wellmarked as seldom to leave room for doubt, or to allow the possibility of error except to the grossly ignorant, or the wilfully careless. But though this is usually the case, yet it does sometimes happen that error is fallen into by persons who can neither be charged with want.of knowledge, nor with want of care, and such error most frequently takes the form of regarding an innocent disease as one of malignant character,, and thus entails much needless anxiety on the patient and her friends. At a time when induration of the cervix uteri was commonly supposed to be due to scirrhous deposit, this mistake was much more frequently committed than it is at the present day; but even now the practical error survives, as is its wont, the pathological blunder in which it originated. Hence it becomes by no means superfluous to lay it down as a rule, so far as I know without any exception, that long-standing induration and hypertrophy of the cervix uteri, with or without superficial abrasion, but unaccompanied by thickening of the roof of the vagina and by diminished mobility of the uterus, is due to chronic inflammation, not to cancerous deposit. So great is the importance of distinguishing between these two conditions, that it may be worth while, even at the risk of being tedious, to contrast them with each other: — IN INFLAMMATORY INDURATION. The history of the patient's ailments generally goes back for a period of several years, and her symptoms have come on gradually. IN UTERINE CANCER. The average duration of cancer does not exceed eighteen months, and the first symptoms are generally sudden in their occurrence. 287 DIAGNOSIS OF UTERINE CANCER. A tedious labor, or an imperfect convalescence from labor or miscarriage, is very frequently referred to as the commencement of the patient's ailments. Pain is a more constant and an earlier symptom than hemorrhage. Menstruation is often scanty; hemorrhage, if it occurs, observes a monthly or sometimes a fortnightly type, is very seldom persistent, and is almost always attended by much suffering. The cervix uteri is always tender, often exquisitely so; the mobility of the uterus is but little modified ; the enlarged lobules of its lips radiate from the orifice. Ulceration of the os uteri is either a simple abrasion of the epithelium, or a red surface of a finely granular, velvety texture, sometimes raised a little above the level of the adjacent part, never depressed beneath it. The margins of the ulceration are always smooth and regular, and the discharge is sometimes purulent, oftener glairy, occasionally a little blood-streaked, hardly ever offensive, and furnished more from the interior of the uterus than from the ulcerated surface. Though cancer occasionally develops itself out of labor or miscarriage, yet such cases are usually so rapid in their course as to render mistake impossible. Hemorrhage is an earlier, and in the first stages usually a more urgent symptom than pain. It is causeless, sudden, often persistent, not governed by the menstrual type, and the season of flooding is generally one of mitigated suffering. The cancerous cervix is often but little sensitive; the mobility of the uterus is early interfered with; the enlarged lobules of its lips are irregular in their position, and not divided by fissures radiating from the orifice. Cancerous ulceration is never a simple abrasion, but either a sprouting, coarsely granular outgrowth with everted edges, or an excavated ulcer with a dark, surface, and jagged margins; often partially covered by a dark-grayish slough. The discharge, which is furnished from the diseased surface, rather than from within the uterus, is either thick, yellow, purulent, highly offensive, or thin, serous, often blood-stained, never transparent and albuminous. Attention to these distinctions will, I believe, suffice almost invariably to prevent the confounding of mere chronic induration and hypertrophy of the uterus with malignant disease. I have, however, met with two instances in which the diagnosis between the two conditions was extremely difficult, and in which time alone removed suspicions that had appeared but too well founded. Both of these cases presented considerable resemblance to each other; and the symptoms, which came on in both some months after delivery, were probably due in reality to a condition of imperfect involution of the uterus. In both instances profuse hemorrhage burst forth suddenly, endangering the patient's life, and being in one case restrained only by the use of the plug. The uterus was in both cases greatly enlarged, its lips were swollen and everted, and its orifice was open, so that its condition closely resembled that of the womb affected by fungoid 288 DIAGNOSIS OF UTERINE CANCER. cancer, while the serous discharge which flowed in the intervals between the attacks of hemorrhage gave out that offensive odor commonly regarded as almost pathognomonic of malignant disease. The nature of the case, too, was, with one of the patients, rendered the more doubtful by the circumstance that she being turned forty years of age, having given birth to her last child eighteen months before, and having weaned it seven months, had yet had no return of menstruation, while her health was failing, and she had suffered much from dull lumbar pains. In this case, which I had frequent opportunities of watching, the hemorrhage recurred at regular intervals for between two and three months, when it ceased, leaving the patient completely exhausted; slowly she regained her strength; and at the end of another three months the menses returned naturally. After having twice recurred at their proper periods, the menses once more disappeared; their cessation, however, was accompanied by the signs, not of disease, but of pregnancy, which have now continued for four months, and which give every promise of a happy termination. In this instance I was not alone in the unfavorable opinion which I entertained of the patient's prospects; but looking back upon the case now that time has corrected my judgment, I can recall to mind that there was a uniformity in the enlargement of the uterine lips, and in the degree of their hardness, which is not usual in fungoid cancer, and that there was an absence of that nodulated character which is generally obvious in the uterus affected by malignant disease. Between fibrous tumors of the uterus and malignant disease of the organ, a vaginal examination usually enables us readily to discriminate. Still it must not be forgotten that in those comparatively rare cases in which the body of the uterus is affected by cancer while its orifice is free from disease, we may find a tumor perceptible in the abdomen, coupled with marked increase in the dimensions of the uterine cavity, and sometimes with irregular thickening in the substance of one or other uterine wall, closely resembling that produced by the presence of a fibrous tumor, while sometimes a distinct outgrowth is perceptible through the os. Our diagnosis, however, will usually be directed aright, by the health being more impaired, and the local suffering more persistent than is usual in a case of fibrous tumor; by the loss of mobility of the uterus being more considerable than even its increased size would account for; and by the extreme vagueness in the outline of any tumor proceeding from the uterine walls. Reference has already been made 1 to the possibility of mistaking a fibrous tumor just passing through the os uteri for cancerous disease of the organ; and I have known the disintegrated sloughing surface of a pedunculated fibrous tumor or polypus hanging down into the vagina to be taken for advanced ulcerated carcinoma of the neck of the womb. Such an error, however, ought not to be committed, for on a careful examination, the absence of the os uteri from the lower end of the tumor —its oval or pyriform shape, its smooth and uniform surface at those parts which are not in a state of ulceration, and the 1 See p. 217. 289 DURATION OF UTERINE CANCER. possibility in almost every instance of reaching one or other lip of the os if the finger is carried high up along the tumor —will reveal the real nature of the case. * One point only still remains to be noticed in order to complete our history of cancer of the womb, and that refers to its duration, which seems indeed to be shorter instead of longer than that of many other forms of the same disease. In twenty-one instances I was able to fix accurately the duration of uterine cancer, and found that it was:— Under 4 months in 1 case "6 " " 3 " u Q It II | (i (i 9 " "1 " "12 " " 3 " Exactly 1 year " 2 " Between 1 and 2 years ... " 5 M m 2 — 2} " ..." 2 " u 21 3" " " 1 " Exactly 3£ " .' .' .' " 1 " Said to be 5, but doubtful ... "1 " 21 Average duration, 17.3 months. The average of thirty-nine cases, as given by Lebert, 1 is sixteen months and a fraction, a result very nearly approaching to my own, and less than the average duration of all forms of cancer, which is stated by the same authority at eighteen months, the progress of the disease being slower in the mammary gland, the testis in the male, the eye, the bones, the lymphatics, and the intestinal canal; though even in the breast and the testis, in which its advance is most tardy, the average duration of the disease does not exceed three years and a half. 2 In the next lecture we shall pass to the investigation—I wish we could do it with brighter prospects —of the remedial means, whether medical or surgical, by which we may hope to retard the course, to alleviate the sufferings of cancer, sometimes to obtain for the patient a brief respite, now and then perhaps to accomplish her cure. 1 Op. cit., p. 270. 2 Ibid., p. 122. 19 290 MALIGNANT OR CANCEROUS DISEASES OP THE UTERUS. LECTURE XXI. MALIGNANT OR CANCEROUS DISEASES OF THE UTERUS. Treatment ; various opinions entertained at different times concerning it. Palliative Tkeatment of the hemorrhages ; of the pain ; of the discharges ; management of the general health, and of symptoms of cancerous cachexia. Pregnancy and labor complicated with cancer; question of induction of premature labor ; management of the labor itself. Curative Treatment ; extirpation of the whole uterus ; results of the operation, and reasons for rejecting it. Excision of the neck of the womb ; errors which brought it into discredit; cases suited for it; modes of performing the operation ; dangers ; that of hemorrhage the chief. Comparative advantages of ligature and excision considered. Other means supposed to be remedial; employment of cold, of caustics, and of the actual cautery ; observations on each. Very numerous have been the fluctuations of opinion with reference to the management of cancer of the womb. When knowledge concerning it was most imperfect, alleged remedies abounded, and various medicines had the reputation of eliminating the cancer poison from the system, and, acting thus through the medium of the constitution, of removing the local disease. Next came a period of adventurous surgery, of attempts to root out the whole evil, over which it became evident that internal means had but little influence. Soon, however, practitioners were affrighted at the difficulties and the dangers of such operations, and then resorted to a combination of local and general treatment; and believing that between cancer and inflammatory induration there was some close bond of affinity, they endeavored by depletion, and by other means calculated to retard the changes which inflammation produces, to keep at bay the advances of cancer. An attempt was made, too, to vindicate to surgery its share in the removal of this disease, even when medicine was of no avail, and for a time the amputation of the scirrhous neck of the womb was vaunted as a mode of almost infallibly arresting the otherwise inevitable danger. Time and increased knowledge, however, have led us to unlearn much in which our predecessors had an unfaltering faith. We have renounced all credence in the specific remedies once believed in; we have abandoned, as too hazardous to be warrantable, the extirpation of the whole uterus; we have found out that there is no relation between inflammation and cancer—that antiphlogistic means which remove the effects of the former have yet no power to control the progress of the latter; and, moreover, that the supposed triumphs of surgery in cutting short the disease, by removing that small part of the organ whence, if let alone, it might have spread to surrounding tissues and TREATMENT OF UTERINE CANCER. 291 neighboring viscera, were, for the most part, purely imaginary; and the trophies once displayed in our museums are now generally put out of sight, as the mementoes of a pathological blunder and a needless operation. It seems, then, that, in the greater number of instances, our duty in the treatment of uterine cancer, is the very humble one of mitigating sufferings which we cannot remove; of depriving death of some of its terrors, though we may feel ourselves powerless to delay its steps. Carefully to study, religiously to carry out this duty, calls for much care, for much and most untiring patience. But there are some few cases concerning which we must admit the possibility of a better issue being attainable, and we shall advance all the more steadily in our quest of means of cure, now that we have learned with greater certainty than before to distinguish the different varieties of the disease; to know the cases in which recovery may be possible from those in which we shall assuredly err if we aim to do more than palliate the more urgent symptoms. I propose, therefore, first to pass in review the different means by which we/, can minister present relief to the patient laboring under cancer of the womb; and then to consider the exceptional cases in which we may attempt something more, and the merits of the various proceedings by which a radical cure of the disease has been attempted, has sometimes even been achieved. In cases of cancer generally, our attention is divided between the relief of the local symptoms, and the maintenance, as far as possible, of the general health. I know of no means by which the progress of cancer can be arrested in its first stage, and the disease kept stationary; a source, indeed, of constant apprehension, but the occasion of little present discomfort, and of no immediate danger. Almost all the vegetable, almost all the mineral poisons have been tried, extolled, and rejected in turn; tonics have been administered; and, again, the patient has been placed under the so-called hunger cure —that is to say, her food has been reduced to the smallest quantity on which life can be maintained; and this with the result which the empirical trial of remedies almost always merits, almost always attains. The hemorrhage is usually the first symptom which so excites the patient's alarm as to induce her to seek for medical aid. But, unfortunately, ere then the disease has often made considerable advances, and its nature is already but too evident. The hemorrhage at the outset of the disease being, as already explained, due to congestion of the womb, our first endeavor must be by every means to abate it, and thus to prevent, if possible, the return of the bleeding. It is selfevident that, with this object in view, every direct excitement of the sexual organs must be injurious, and hence there can be no exception to the rule which interdicts marital intercourse whenever there is the least suspicion of cancerous disease. The state of the bowels is the next point to attend to, and they must be kept freely open, if possible, by mild saline aperients, which unload the hemorrhoidal vessels, as well as prevent the accumulation of feces in the intestinal canal. A mild, stimulating diet is equally important; and I have no doubt but 292 TREATMENT OF HEMORRHAGE IN UTERINE CANCER. that, in the early stage of cancer, an opposite plan is injurious to the patient's general health, and indirectly accelerates the advance of the disease. When to these precautions are added the avoidance of all active exertion, and the most absolute rest at the return of each menstrual period, I fear there is little more within our power. The local employment of depletion, which has been recommended in the early stages of cancer, is very rarely admissible, and I am not disposed to advise that the blood should ever be drawn from the uterus itself, but rather from the hypogastrium or the groin, since I have known very serious difficulty occur in arresting the bleeding from leeches applied to the neck of the womb in these cases. At a later period of the disease, the hemorrhage may be so profuse as to call for direct restraint, and the necessity for immediately cheeking it, is, of course, urgent in proportion to the degree of anaemia which already exists. The gallic acid is of all astringents that which has least often failed me; but, in order to obtain decided effects from it, it should be given in doses of six or eight grains every four hours. The infusion of matico, as a local application, is also of much use in some of these cases, but the management of the injection can never be safely intrusted to the patient, who either employs it ineffectually, or else causes herself much suffering by striking the neck of the womb in her endeavors to introduce the instrument far enough into the vagina. There are obvious difficulties in the way of plugging the vagina in cases of ulcerated carcinoma; and, indeed, the mode in which the profuse bleedings usually take place, by sudden outbursts of hemorrhage, followed by a long pause, is that against which such a proceeding is least of all calculated to guard. In some cases of soft medullary cancer, or of epithelial cancer, when the continuance of hemorrhage becomes a very serious source of danger to the patient, we may break down the tissue with the finger, and then inject into the midst of it the tincture of the sesquichloride of iron. The bleeding vessels are thus destroyed, and the coagulation of the extravasated blood by the chemical agent prevents the occurrence of any further hemorrhage, while the whole mass which has been thus treated sloughs away in the course of a few days, leaving behind a healthier surface, or one at any rate less disposed to bleed. This proceeding, which was, to the best of my belief, first recommended by Kiwisch, 1 is not accompanied by pain, nor has it in my experience ever been followed by serious constitutional disturbance, while the improvement which for a time succeeds the checking of the previous drain upon the system is often very remarkable. 2 Kiwisch also speaks of the em- 1 Op. cit., vol. i. p. 547. 2 In the Lancet for December 20, 1855, is a very remarkable case related by Dr. Boulton, of Horncastle, in which the breaking down of the tissue of a large epithelial cancer of the cervix uteri, and the arrest of the subsequent bleeding by caustics, of which the muriated tincture of iron appears to have answered best, had heen persevered in for live years, not only with great improvement in the patient's condition, but, as would seem, with the final result of completely destroying the disease, of which for sixteen months previous to his communication the os uteri had presented no trace. In a subsequent report, dated Oct. 1857, Mr. Boulton adds, that after the lapse of three years from the last operation the patient continued perfectly well, that for twelve months all discharge had ceased, and that the state of the os and cervix uteri was perfectly normal. 293 TREATMENT OF THE PAIN. — CHOICE OF ANODYNES. ployment of the actual cautery as a very efficacious means of restraining bleeding, in cases where the surface is of too firm a texture to be broken down. I have not tried the actual cautery specially for this purpose, though I believe that in some cases of uterine cancer I have obtained by it much temporary improvement both in the general health of the patient and in the condition of the ulcerated surface. Of this, however, more hereafter. The pain is, of all the symptoms, that from which the patient most earnestly prays for relief, while, unfortunately, we are often but little able to afford it. There is a permanent pain, or at least a permanent sense of discomfort, which most women experience, and besides, there are occasional paroxysms of severe suffering from which some are fortunately exempt. The backache, the pain in micturition, and the distress in defecation, are usually to be relieved rather by attention to the function of the bladder, and the state of the bowels, than by direct anodynes. The Vichy water as a drink, the extract and decoction of uva ursi, with small doses of liquor potassae and tincture of henbane, often give much relief to the irritable bladder which troubles the patient in the early stages of cancer, while, at a later period, when organic mischief has commenced there, and the urine is loaded with phosphates, small doses of hydrochloric acid, with the extract and decoction of pareira, will, in turn, be of service. The establishing a habit of regular action of the bowels will save the patient from many of the distressing bearing-down sensations from which she had previously suffered. Mild laxatives, such as the confection of senna, or very small doses of castor oil, are generally best fortius purpose; enemata are not in general expedient, for their administration is often very painful, owing to the presence of haemorrhoids, while the pressure of the distended rectum against the womb sometimes brings on very severe suffering. Plasters of belladonna, or opium, applied to the back or above the pubes, sometimes relieve the permanent pain in those situations, while any casual aggravation of it is often mitigated by the local application of chloroform, or of cotton wool soaked in a liniment of equal parts of chloroform and oil, and covered over with oiled silk to prevent evaporation. The longer the patient can dispense with the habitual employment of anodynes, the better is it for her general health. In time, however, they are sure to become necessary, and the need for them is usually first experienced at night, for almost always at that time the pain becomes more severe than it had been during the day. Whether employed at night, however, or given more frequently, it is always desirable to begin with the mildest form of narcotic, and to pass only by degrees, and as each in turn ceases to be efficacious, to those which are more potent, and to the preparations of opium. I usually begin with camphor and henbane in the form of pill, giving five grains of each at bedtime, and find in most cases that henbane is a more certain and more efficient medicine than hemlock. If the anodyne begins to lose its power, it is not always necessary at once to increase its strength, but the same dose will often continue to act if it be combined with a draught containing ether, or some other diffusible stimulant. Twenty 294 TREATMENT OF THE PAIN. minima of the compound spirits of ether, and fifteen of the chloric ether, will often, when added to the anodyne, lull the pain which had previously been importunate, or procure the rest which the patient had before been unable to obtain. The same fact holds good through the whole course of the disease, even at a time when opiates in large and frequently repeated doses have become absolutely necessary. After henbane, I generally make trial of the Indian hemp, for though it is an uncertain medicine, and one the effect of which seems to be much modified by the idiosyncrasies of the patient, it does not in general either constipate or produce headache, or disorder the digestion to so great an extent as opium. Belladonna does not constipate, but it occasions headache, arid if given in doses sufficiently large to control the pain of cancer, it is sometimes followed by an alarming degree of depression. We come then to opium and its different preparations, and of all of these the tincture is generally borne for the longest time, and with the greatest relief. There are peculiarities in different cases, however, which lead us sometimes to prefer one form and sometimes another of this remedy. The black drop, I think, causes on the whole less sickness than the other preparations of opium, morphia not excepted, while, in spite of the many recommendations of the latter medicine, we are sometimes compelled to abstain from giving it, in consequence of the extent to which it aggravates the irritability of the skin, and the disposition to urticaria, which are not very unusual attendants upon uterine cancer. I have not found any such advantages from the employment of opiate suppositories or of opiate enemata as to induce me to prefer that mode of giving opium to its administration by the mouth; and I may further add, that the local employment of the vapor of chloroform by means of Dr. Hardy's very ingenious contrivance, has hardly ever proved sufficiently powerful to give much relief to the patient. Another anaesthetic, of which I have hitherto had but slight experience, is furnished by directing a stream of carbonic acid gas against the ulcerated surface. This agent has been used at various times within the past thirty years for the purpose of allaying uterine pain, but the isolated instances of its employment attracted little notice till attention was recently directed to the subject by Professor Simpson, of Edinburgh. 1 lie speaks of its results as uncertain; since in some cases it completely failed, while in others the success that followed its use was striking and immediate, but his paper contains few definite details with reference to its employment. Some trials have since been made of it in Paris, 2 the action of the remedy still appearing to be uncertain, and its effect now and then to be that of aggravating instead of mitigating suffering, while in a few instances headache, drowsiness, and depression followed its employment, though not to a serious degree, and subsiding spontaneously in a few hours after the discontinuance of its use. According to M. Bernard, who has written most fully on the subject, the unpleasant symptoms were less frequently produced and in a slighter degree in cases of uterine carcinoma, than in those in which the vapor was applied for the miti- ' Obstetric Works, vol. ii. 709. 3 See the papers of M. Follin, in Arch. Gun. de Medecine, Nov. 1850, p. G08, and M. Bernard, ibid. Nov. 1857, p. 529. 295 TREATMENT OF THE PAIN, gation of pain consequent on congestion or inflammation of the womb. In some instances the continued employment of the gas for some ten minutes twice a day during several weeks was followed not only by a great mitigation of suffering, but also by a great improvement in the state of the womb itself and by a partial cicatrization of the ulcer. In other cases, however, the local condition remained unchanged, though for a time the health improved in proportion as the previously severe pains were lessened. Nothing can be simpler than the mode of applying the gas. In a glass vessel capable of containing a pint, and such as is used for the disengagement of gases, either carbonate of soda and tartaric acid, or chalk and sulphuric or muriatic acid, or carbonate of soda and bisulphate of potass may be placed, and water being added in quantity sufficient to cover them, the gas may be conducted through an elastic tube into the vagina, while a cloth applied to the external parts will prevent its too rapid escape. M. Bernard, who uses 25 grammes of bicarbonate of soda, and 20 grammes of bisulphate of potass, or about 5vi of the former to 5v of the latter, estimates the quantity of gas disengaged from these materials at about four pints, which is given out in a period of from ten to fifteen minutes. 1 My own experience of the use of the carbonic acid gas in cases of cancer is confined to four cases, in three of which temporary relief followed its employment, while in one the patient'.s. sufferings seemed rather increased by it, and it was therefore discontinued. In the other three instances the relief was not striking: certainly was not greater than a comparatively small dose of an anodyne would procure; nor was the condition of the patient otherwise more improved than might be expected from the quiet and the comfort of an hospital. On the other hand, no inconveniences due to the poisonous influence of the gas were produced, and my own feeling is that any additional means of assuaging pain in a malady so grievous as uterine cancer deserves a more extended trial than this has yet received. The idea of employing the inhalation of chloroform to relieve the violent paroxysms of uterine pain, naturally suggests itself to our minds. It is not, however, of as much service practically as might have been anticipated. Sometimes the pain is of such intensity that chloroform scarcely mitigates it; not infrequently sickness and vomiting come on before the patient is fully under its influence; while in a large number of cases so much depression follows its use, and such long-continued irritability of the stomach, that the patient herself is unwilling to purchase at so dear a rate a very short, and sometimes very imperfect immunity from suffering. Still it is one of the means which we may try, and in some few cases it is well borne, and gives much temporary relief. The discharges which occur in the course of uterine cancer call for 1 One case of death from the injection of carbonic acid gas into the cavity of the uterus is recorded by Scanzoni at p. 181 of vol. iii. of his Beitriige zur Geburtskunde und (Jyniikologie, 8vo., Wiirzburg, 1S58. The case, however, was not one of cancer, and the whole circumstances attendant upon it, are of so exceptional a kind that no inference can be drawn from them beyond the proof which they afford of the possible death of a person from the use of this agent. 296 TREATMENT OF THE DISCHARGES. medical interference, either to restrain their excess, or to correct the offensive odor that attends them. In the absence of these indications, no interference is desirable beyond such as mere attention to cleanliness dictates, and for which tepid water is preferable to any kind of medicated injection. Direct astringents, such as the matico or tannin, or the decoction of oak bark, are useful in restraining the profuse serous discharges which occur in some cases of epithelial cancer, and are, I think, generally preferable for this purpose to lotions of lead, or zinc, or alum, which more frequently produce pain, while they are of less efficacy in checking the superabundant secretion. Sometimes the discharge, though of a mucous or muco-purulent character, is extremely profuse, and this is often diminished, and the condition of the ulcerated surface secreting it is improved by a very weak acid lotion, such as 5j of dilute nitric acid to Oj of water; while more decided astringents will either fail altogether of the intended effect, or will produce an increase of pain. Sometimes, however, an abundant secretion from an irritable ulcerated surface is checked, and the sensibility of the part diminished by the use of an injection of 5j of sulphate of iron and 5i'j of extract of conium to a pint of water. Now and then the extreme sensitiveness of the ulcerated surface is diminished by a lotion of Jsa of opium to a pint of lead-wash, but as a general rule, the local application of anodynes to the diseased surface is by no means efficacious; and much more relief is afforded by agents of greater power, and which tend directly to alter the state of the part. In this way great relief is sometimes given by strong solutions of caustic, which at the same time are a most powerful means of destroying the horribly offensive odor that attends upon the sloughing and detachment of portions of cancerous outgrowth. A solution of 9j to 5ss of nitrate of silverin oj of water injected immediately into the diseased tissue, has the effect both of destroying the bad odor, and also of hastening the separation of the slough. The employment of this daily for one or two days generally suffices, but at the same time a weak solution of chloride of lime, such as would be formed by Jij ( >f the solution to Oj of water, may be used several times a day with the effect both of diminishing the fetor, and of improving the condition of the ulcerated surface. In far-advanced carcinoma these remedies may cease either to be useful or to be admissible, but then the creasote lotion, made with 3j of creasote to Oj of some mucilaginous fluid, will have a remarkable influence in removing the offensive smell which adds so much to the distress of the patient and of those about her. When the bladder or rectum has been injured by the advance of the disease, we are unfortunately reduced to mere ablution, and the use of lotions of tepid water. When this accident does not happen, it fortunately occurs, as has already been mentioned, that the disease of the womb often remains stationary for months together, and that the patient is spared at the close of life many of the painful local symptoms which distressed her during the earlier period of her disease. And this brings me last of all to consider the management of tho cancerous cachexia; of those symptoms of general constitutional disorder, which, springing from an irremediable cause, are sure at length 297 TREATMENT OF CANCEROUS CACHEXIA. to baffle our skill. Most, and the most distressing, of the patient's symptoms, are referable to the state of her digestive functions. She not only loses strength with the loss of blood, but digestion itself becomes generally impaired. In some cases, indeed, as in those of epithelial cancer, in which the most prominent symptoms are those of mere anaemia, iron is often well borne, and is then of much service. I usually employ the ammonio-citrato of iron in five-grain doses, three times a day, giving it in some effervescing medicine, such as the citrate of ammonia. The stronger chalybeate preparations, or large doses of the milder, often disagree, producing headache and feverislmess. The failing appetite is sometimes for a time restored by the preparations of bark ; but rather by the infusion or by small doses of the liquor cinchonas in combination with acids, than by quinine, which, in many instances, is not borne. A combination that often suits is the nitromuriatie acid in the infusion of cloves or of orange-peel; while throughout the whole treatment of the disease, our remedies must be not only gentle in kind, but must be given in small doses. In most cases the stomach after a time grows irritable, and the tongue becomes raw and red, and aphthous. The irritability of the stomach is relieved by all food and drink being taken cold, by sucking small morsels of ice, by very small quantities of effervescing drinks, or of effervescing wines, such as Champagne or the sparkling Moselle. Sometimes, too, a mustard poultice or a slight vesication over the epigastrium will give relief, or even the application of a piece of lint soaked in the accturn opii. The hydrocyanic acid may be tried, and sometimes it gives relief, but its benefits are usually more marked when combined with ether than when given alone. The sense of sickness and faintness, unaccompanied by actual vomiting, which often becomes very distressing as the disease advances, is in many instances relieved by sal volatile, in doses of forty to sixty drops, or by the compound tincture of ammonia. 1 The soreness of the mouth, however, sometimes precludes the administration of stimulants, and even renders the taking food a source of extreme suffering. This state is often much relieved by the chlorate of potash, of which a quarter to half an ounce may be taken in the course of the day, in a pint of barley-water flavored with a little orange or lemon-peel; but the unpleasant soapy taste which it leaves behind, often disgusts the patient, and compels us to discontinue its use. In some of these cases the soreness of the mouth and the dry burning sensation in the throat are relieved by a spermaceti draught, 2 which also furnishes a convenient vehicle for opiate preparations in cases where diarrhoea is present. The diarrhoea is usually a temporary symptom only, and yields for the most part to aromatics and opiates tolerably readily, though when it occurs at a very advanced stage of the disease, and when the vital powers are much weakened, it sometimes carries off the patient. The disposition to constipation is a 1 See Formula No. 8, p. G9. 2 (No. 10.) —Cetacei, l'ulveris tragaoantb.se, aa Syrupi papaveris albi gj. Aqua? destillatee gxi.—M. f. haustus. 298 QUESTION OF INDUCTION OF LABOR. much more frequent source of distress; and it is of great moment not to allow the bowels to remain many days without being acted on. From neglect of this precaution, I once knew constipation to continue for eighteen days, when the patient died with an enormously distended abdomen, and ill-marked symptoms of peritonitis. There was no mechanical obstacle to the passage of the feces, but they had been allowed to accumulate till the feeble muscular power of the intestines was insufficient to propel their contents; medicine irritated the stomach, and caused vomiting, without producing any action of the bowels, and peritoneal inflammation at length came on, just as it does in a case of strangulation of the intestines. I know no other ordinary incident in the course of uterine cancer which calls for special notice now; but I would have you bear in mind that when there has long been no hope of cure, it is yet often within our power to minister very largely indeed to the comfort of the patient, to soothe distress, and mitigate suffering which otherwise would be utterly intolerable. Eeference was made in the last lecture to the dangers which attend on pregnancy and labor when associated xoith cancerous disease of the neck of the womb. In not a few instances of this complication, abortion or premature labor occurs, owing to the disease not allowing of those changes which with advancing pregnancy ought to take place in the lower segment of the uterus. In such circumstances greater suffering, and more considerable hemorrhage than ordinary, usually attend the miscarriage. I have indeed known the loss of blood to be so considerable as to occasion the patient's death in a few clays; while though she should survive this danger, and the subsequent risk of peritoneal inflammation, the cancerous disease generally advances more rapidly than before. Still the dangers which attend upon the miscarriage are not to be put in comparison with those that accompany labor at or near the full period of pregnancy. In some instances labor pains have come on, but the os uteri not yielding, the contractions of the organ have again subsided, and the patient has at length died painfully after gestation protracted for months beyond the full period. More commonly, either the womb gives way during the labor, or the violence inflicted on it during the passage of the foetus or its instrumental extraction, proves immediately, or speedily fatal; and on this account it is laid down as a general rule that abortion or premature labor should be induced in cases of this description. The rule is doubtless a sound one, though something of its applicability must depend on the extent of the disease, and the stage of pregnancy at the time of the patient coming under our observation. If the mischief should appear to be already so far advanced as to preclude an}' reasonable expectation of life being prolonged by medical or surgical treatment, while at the same time there does not seem to be any insuperable obstacle to the passage of the child, it would be the better plan to allow pregnancy to go on without interruption; inasmuch as while the life of the child might be thereby preserved, the mother herself would be more likely to retain comparatively good health during the remainder of gestation, and the disease to make less rapid progress than during an equal space MANAGEMENT OF LABOR WITH CANCER. 299 of time after the womb had been emptied of its contents. In some instances, too, the disease is found to be so extensive as to offer an apparently insurmountable obstacle to the rupture of the membranes, or to any other mode of bringing on miscarriage, and here the great immediate peril of interference must be allowed to counterbalance the remoter risks of delay. When labor actually comes on, it is often the case that free incisions into the os uteri and the cervical canal are the only means by which such a dilatation of the passages can be obtained as will allow of the birth of the child. Still it is important not to be premature even in these cases in resorting to operative interference. I remember, years ago, when a student in Paris, a patient was received into the Clinique des Accouchemens in an advanced stage of pregnancy, and suffering at the same time from extensive cancerous disease of the womb. Professor Dubois mentioned her case to the class, and spoke with considerable certainty of the necessity for incising the neck of the womb when labor should come on. Contrary to all expectation, however, the os uteri dilated readily to admit of the passage of the child, and the labor was but of a few hours' duration. That which happened in this case, I myself observed in another instance, where the comparatively small part of the lower segment of the womb which was not implicated in the disease stretched beyond what might have been supposed possible, and in spite of the unyielding condition of the bulk of the cervix, thus made room for the passage of the child. But so soon as labor has advanced far enough for us to be really satisfied of the necessity for interference, and to determine the direction in which incisions should be made, and the extent to which they should be carried, any further delay would add to the patient's clanger, without any corresponding advantage. The question has been raised, whether in eases where the disease is very extensive, and the impediments to the passage of the child, or to the employment of instruments for its extraction very great, it might not be less hazardous to remove the child by the Cesarean operation? Dr. Oldham, 1 however, is, to the best of my knowledge, the only person who has carried out the idea in practice; and the favorable result of his case, as far as the issue of the labor was concerned, proves the wisdom of the choice which he made. Desperate, however, must be the state of a patient, when of two alternatives the Ceesarean section is the less hazardous. And now, having considered the indications which, in the great majority of cases of uterine cancer we may have to fulfil, and the best mode of accomplishing them, we come, in conclusion, to the examination of different proceedings that have been recommended either for the extirpation of the diseased organ, or for the removal of the diseased portion of it, or for retarding by various local measures the rapid progress of the evil. First among these proceedings we must consider the removal of the ivhole uterus, though in spite of one or two temporary successes which have followed its performance, the unanimous voice of the profession 1 Guy's Hospital Reports, 1851, second series, vol. xi. p. 420. 300 RADICAL CURE OF CANCER. has pronounced it to be overbold, and has rejected it from among the legitimate operations of surgery. The only instance with which I am acquainted of permanent recovery after the complete extirpation of the cancerous uterus, is that in which the elder Langenbeck removed the long procident organ from a woman, who lived free from disease for twenty-six years afterwards. 1 In the first place, however, it is by no means certain that the induration and ulceration were due to anything else than the irritation of the organ from long exposure to external injury, and even though it were, you will yet remember that the sensibilities of the womb become so lessened by long residence out of the pelvis, that no inference can be drawn as to the danger of operations on the organ when in situ from the results obtained when it has been long procident. So favorable a conjuncture as that met with in Langenbeck's case, and which, no doubt, much facilitated the difficult task of shelling out the organ from its peritoneal investment, must be of extreme rarity, and few, indeed, are the instances in which it has existed. 2 Attempts have been made artificially to produce a state of prolapse of the womb, and thus to approximate the conditions of the operation to those which existed in Langenbeck's case, but with little success; while some have removed the organ through the vagina without any attempt at altering its position, and once the abdominal cavity was laid open, and the womb removed through the incision. I need not enter into a long critique of these different proceedings, when I have told you that of 25 cases, 22 terminated fatally in consequence of the operation, and tha£ two months, four months, and a year, were the respective periods during which the patients survived in what are termed the successful cases. 3 1 The particulars of which are detailed, and drawings showing the appearances after death are given, together with much important information concerning the operation, by the present Professor Langenbeck, in his inaugural dissertation De totius uteri extirpatione, 4to., Gottingee, 1842. a A case is on record of the successful extirpation of the uterus, said to be cancerous, by means of the ligature and knife, performed in the year 1783, by M. Marschall, of Strasburg, and reported in Salzb. Med. Zeitung, 1794, vol i. p. 13(i, and another recently by Bellini, in Omodei Annali Universali, for 1828, vol. xlvii. p. 35"). In the latter case, however, the removal of the uterus was only partial. Paletta's case, in which the patient died on the third day, reported in Omodei Annali, 1822, vol. xxiv. p. 43, cannot with propriety be included among these cases, inasmuch as the removal of the uterus was unintentional, and the disease seems to have been rather a large fibrous tumor dragging the uterus beyond the external parts, than any form of cancerous affection. Itecamier removed the procident cancerous uterus by ligature, Archives de Med., vol. xxx. The patient recovered, but died of dysentery in three months. 3 The subjoined table gives, I believe, a tolerably accurate account of all recorded cases of total extirpation of the uterus on account of cancerous disease. Successful Cases. Period during Operator. Reference. which Patients survived. Recamier \ RGcherches sur le Traitement du Cancer, 1829, j 2 th [ vol. i. p. 519 ) Sauter { Extirpation d. Care. Gebarmutter, | 4 monthg f Lancet, Oct. 1828, Med. Gazette, vol. ii. p. 2941 Blundell j vo *" ' arK * 110 * e a * commence ~ I 1 year all but a 1 1 ment of his Researches, &c, in Royal College of f few days [ Surgeons J 301 CANCEROUS UTERUS. — ITS EXTIRPATION. Of the 22 fatal cases, 4 terminated within six hours, and 4 more in twenty four hours, 7 in two days, 2 in three days, 2 in four days, 1 in a few days, 1 in ten days, and in 1 the duration of life is not stated, though the patient is said to have died from the effects of the operation. In 21 cases the cause of death is stated, and appears to have been the pain or shock of the operation in 8 instances, hemorrhage in 3, hemorrhage and shock in 2, peritonitis in 6, peritonitis and shock in 1, and a so-called nervous fever in another instance. But while facts such as these amply justify the general verdict of the profession, as to the impropriety of attempting the complete extirpation of the cancerous womb, no such general verdict of condemnation can be passed on that less hazardous operation which aims at the cure of the disease in an earlier stage by the removal of the affected part. Not to lose ourselves in fruitless antiquarian investigations, we may date the introduction of the amputation of the cancerous neck of the ivomb among the operations of surgery from the year 1802, when it was successfully performed by the late Professor Osiander, of Gottingen. Between that time and the year 1816, Osiander amputated the neck of the womb in twenty-three instances, 1 and so striking an Unsuccessful Cases. Operator. Reference. DeaMiafter A1 'f 1 " Operation. ' Blundell Lancet, Nov. 22, 1828, vol. xv. p. 255 2\ hours Shock " Ibid 9 hours " " Ibid. ' 39 " " Langonbcck Langenbeck, jun., Dissertation, p. 52 . 24 " Peritonitis " Ibid. p. 55 2 days " " Ibid. p. 58 10 " Nervous Fever , T , , f Graefe u. Walther's Journal, vol. vi. p.") 0 . , . C1 . Holscher < nna 1 > 24 hours Shock Wolff Ibid. vol. vii. p. 47S . . . . 2 days Peritonitis Siebold Journal f. Geburtshiilfe, vol. iv. p. 507 . 65 hours " M Ibid. vol. vii. p. 600 .... 2 days " Banner Lancet, Oct. 11, 1828, vol. xv. p. 57 4 " " Lizars Ibid. Nov. 2!), 1828, vol. xv. 269 . . 22 hours / iremo '' rha S e ' ' (_ and Shook t, f Archives Gen. de Medecine, Oct., 1829,1 OQ ,, c , , Roux < „ noo ' > 33 " Shock (. p. Zoo . . . . . . J Ibid. p. 241 24 » {" emor S a S e e* \ Pain, Shook Reuamier Journal Hebdom., vol. vi. p. 120 . . 2 days Hemorrhage Doubled Ibid. vol. viii. p. 123 .... 22 hours " Dieffenbach Operative Chirurgie, vol. ii. p. 800 . 4 days | n iti 8 er ' t0 Delpech { Bo ;;j n * » n g n > Maladies de l'tTterns, j 3 M paln> ghock v. Walther I Uperationslehre, &c, vol. iii. ) Immediate (. 2d ed., p. 261, note . . • • J Warren MUd '. Scie " CeS ' > 182! ''} 3d day Hemorrhage Bodenstab i Neue Zeitsohrift f. Geburtskunde, vol. \ Imme(liate ghock ( xvm. p. 2J2 J Fabri { N ° tizeU / V01 ; XH - N °- f °' P ; } Not stated 1 So stated in Langenbeok, op. cit., p. 20, note 5, from sources there indicated. 302 EXCISION OF THE CERVIX: innovation as this proceeding not unnaturally excited much attention in Germany. The operation did not, however, meet with much encouragement among Osiander's countrymen, for the sometimes formidable, and, in some instances, fatal hemorrhage which often succeeded it, not unnaturally deterred many from attempting it, while it was further alleged that even in its originator's hands the operation failed more frequently than it proved successful. There were also personal defects of character which always stimulated into activity numerous hostile critics of all of Osiander's doings and sayings; and hence, until quite recently, the cases were very few indeed in which the amputation of the neck of the womb was had recourse to in Germany. In France, however, where no such causes were in action, the operation met with numerous advocates, and it received the sanction of Dupuytren, who performed it on several occasions. The remarkable results obtained by M. Lisfranc, who alleged that he had performed the operation ninety-nine times, and in eighty-four instances with lasting success, obtained for a time great notoriety, both for the proceeding itself, and for the surgeon who has constituted himself its most clamorous champion. Before long, however, doubts but too well founded were thrown on the accuracy of Lisfranc's statements, and his former pupil, M. Pauly, published a book in which he asserted, and his assertions have never been disproved, 1 that M. Lisfranc overstated the number of the operations he had performed, and falsified their results; and further, that in many of the cases in which he had removed the cervix, the disease was not cancer at all, but mere induration of the neck of the womb. Though not altogether abandoned, yet both in France and in this country, where it had been occasionally performed, this operation fell into comparative disuse, till it was recently revived with better knowledge of the subject, and a juster appreciation both of the cases which are suited for it and of those for which it is not lifted. There can be no doubt but that formerly in many instances in which the neck of the womb was amputated, no cancerous disease existed, and I have myself seen the cervix uteri excised and the patient exposed to the present risk of hemorrhage and to the subsequent dangers of uterine inflammation, for the removal of mere induration of the organ. On the other hand, the excision of the neck of the womb was not infrequently had recourse to in cases of fungoid carcinoma of the organ; a form of disease which, beginning in the substance of the part, has already made extensive progress when it reaches to the surface, and does not in general give rise to any obvious symptoms of its presence, till it has advanced so far that any attempt at the extirpation of the part must be worse than useless. Such were the two opposite errors by which this operation was brought into discredit; by the one it was performed when needless, by 1 Those who wish to pursue the particulars of this quarrel, not creditable to either party, but least so to Lisfranc, will find the materials in Pauly, Maladies de l'Uterus, 8vo., Paris, 1836, pp. 427—481 ; and Lisfranc, Clinique Chirurgicale, 8vo., Paris, 1843, vol. iii. pp. 033—057. Lisfranc's feeble defence amounts almost to a plea of guilty on his part. 303 MODE OF OPERATING. the other when useless. I have, however, described a variety of malignant disease to which it is applicable, and in which its performance has been found to be most salutary. Cases have long been on record in which the complete removal of cauliflower excrescence of the uterus has been followed by the patient's complete recovery, and you know that there are other forms of disease of more solid texture, and endowed with smaller vascularity, which present the same character of beginning on the surface of the os uteri, and only by degrees extending to deeper tissues. Now precisely these epithelial cancers of the uterus are they which have been cured by the removal of the affected part, and to such cases I believe the operation ought to be almost exclusively limited. It is to be feared, however, that the conditions which even in this form of the disease warrant the performance of the operation, are comparatively seldom to be met with, for though for the past twelve years I have been constantly looking out for cases suitable for it, but one instance has come under my observation in which my surgical colleagues have considered it justifiable, and not above two or three more in which, in my own opinion, it might have been attempted. The patient whose cervix uteri was removed, was operated on by Mr. Arnott in the Middlesex Hospital. There existed in her case perfect mobility of the uterus, so that but little difficulty was experienced in drawing the organ down beyond the external parts; while the neck of the womb was of sufficient length, and seemed sufficiently unaltered at its upper part, to warrant the expectation that the incision might be carried through healthy tissues, and that the disease miglit be completely eradicated. The hemorrhage in this case was very formidable, a large arterial trunk pouring out blood in great abundance, and this was restrained o»ly by the employment of the actual cautery, while on the separation of the slough a second outburst of hemorrhage rendered it necessary to plug the vagina. These dangers surmounted, the patient's subsequent recovery was very rapid; she regained flesh and strength, and for nearly six months continued in the enjoyment of perfect health. Symptoms of her disease then reappeared, and she died in the course of two months, eight months after the performance of the operation. Even six months of life, of hope, of freedom from pain, of health and happiness, cannot, however, be thought dearly purchased by an operation which, even without the aid of chloroform, is by no means very painful, and whose one great danger, that of hemorrhage, can generally be controlled, if not averted, by the use of the plug. The operation has been performed in two ways: either by drawing the uterus down with hooks so as to bring the diseased part beyond the vulva, just as in the excision of polypi; or, without displacing the organ, by simply cutting through the cervix, either with or without the previous introduction of the speculum, with a curved bistouri, a pair of scissors, or an instrument specially contrived for the purpose, of which the most ingenious is Cojombat's hysterotome. 1 It is very 1 For a description and drawing of this instrument, see Meigs' Translation of Colombat's work on Diseases of women, 8vo., Philadelphia, 1845, p. 351. 304 MODE OF AMPUTATING THE CERVIX UTERI. doubtful, indeed, whether any speculum could embrace the really cancerous cervix, and yet leave room for the dexterous manipulation of a bistouri or a pair of scissors. All complex instruments, such as Colombat's, are found in practice to be open to objections which their inventor never anticipated, and, in spite of the obvious advantages of meddling no more than is absolutely necessary, I should prefer, whenever it is not attended by much difficulty, and can be accomplished without violence, to draw down the uterus before dividing the cervix. 1 This is to be done by means of hooked forceps inserted into the neck of the womb, just as they are inserted into a polypus which we are about to extirpate, and the parts may be divided by strong probepointed scissors, curved in the direction of their shank, not in that of their cutting edge, as is the case with Osiander's scissors, which have been much used for this purpose. The position in which the patient is placed is that usually adopted for lithotomy; but Dr. Simpson 2 recommends that she be placed on her face, with the legs hanging over the edge of the couch, as in operations for haemorrhoids. The reason which he assigns for it is a weighty one, and is probably the same as induced Lisfranc to cut from behind forwards 3 —namely, that as the peritoneum descends much further behind the neck of the womb than in front of it, there is much more risk of wounding it in an incision carried from before backwards than if it were made in the opposite direction. I should imagine, however, that if this danger is borne in mind, it will not be difficult to avoid it without placing the patient in this very constrained attitude, which, among other inconveniences, has that of preventing the safe administration of chloroform. Though the hemorrhage after the operation is sometimes very formidable, and has been known indeed in several'instances to prove fatal, I am yet disposed to think that the actual risk to life from loss of blood has been over-estimated, and that the danger of the supervention of phlebitis or inflammation of the peritoneum is in reality the more serious. Something of the risk of bleeding, too, may be referred to the inefficient way in which the simple operation of plugging the vagina is not unfrequently performed. Except during labor, it cannot be thoroughly done without the use of the speculum. The comparatively narrow vulva and entrance of the vagina render the introduction of the tow or cotton wool a very tedious process; and the lower part of the canal is already filled, while its wider and extensile upper portion is so little distended that ample room is left for the accumulation of a large quantity of blood between the uterus and the 1 In dragging down the uterus, however, much caution must be observed ; since, as Scanzoni mentions, op. cit., p. 254, it is by no means unusual for adhesions, the result of peritonitii, to form between the uterus and adjacent parts, even in the early stages of cancerous disease of the womb. If these adhesions were torn or violently stretched, fresh inflammation of an acute kind would not fail to be set up; and Scanzoni even relates an instance in which a rent in the peritoneum behind the uterus, two inches in length, was produced during the efforts to draw down the womb in order to remove its cancerous cervix. * Obstetric Memoirs, p. 180. 3 Pauly, op. cit., p. 473, asserts that hemorrhage proved fatal within twenty-four hours to three out of nine cases in which he assisted M. Lisfranc. Such a result, however, is quite out of proportion to the general experience in this matter. AMPUTATION OF THE CERVIX UTERI. 305 plug, until at length under some effort at vomiting or some sudden movement, an enormous coagulum and the plug are expelled together, and the bleeding breaks out afresh. The question is not, however, whether the excision of the neck of the womb in these cases is unattended by immediate risk, but whether such risk is greater than would attend any other operation performed for the same purpose ? That dread of hemorrhage which has led some practitioners to prefer the ligature to the knife for the removal of polypi, has also had much influence in preventing the excision of the cervix, and has consequently led to the restriction of attempts at cure to those softer varieties of epithelial cancer in the removal of which, as of true cauliflower excrescence, the ligature is available. In the only case in which I saw the ligature employed for this purpose, the patient died of phlebitis ; and Dr. E. Watson, 1 who has collected such scanty statistics as can be brought to bear on the subject, gives the following result of his inquiries. Of seven patients operated on by ligature, one died four months after of inflammation of the womb, which threatened to prove immediately fatal, and probably would have done so but for the removal of the ligature on the sixth day after its application. In every one of the others the disease speedily reappeared, but the life of one of the number was saved by the excision of the remainder of the cervix, an operation which was performed by Dr. Montgomery, of Dublin. Of nine patients in whom the cervix uteri was excised, none died from the immediate effects of the operation; the disease returned in three; in five the cure was permanent; and the condition of one patient was doubtful, since her history was not brought down later than the eleventh day. Excision of the part seems to me the preferable proceeding, because it is applicable to cases where the ligature cannot be employed, because the present risk which attends it is, to say the least, not more considerable, while the prospect of a permanent cure is far greater. This opinion seems, too, to be that of the profession generally ; for while, as far as I am aware, no fresh instance has been recorded since the publication of Dr. Watson's paper of the employment of the ligature, there are many additional cases of the removal of the diseased cervix by excision. On a few occasions the operation has been performed with the ecraseur, but one almost fatal objection seems to attach to its use, and to more than counterbalance the safeguard which it affords against hemorrhage. The instrument appears so apt to draw within its chain parts not involved at the time of its first application, that the peritoneum has on several occasions been wounded in the attempt to amputate the neck of the womb. This objection was recently urged against it at a meeting of the Berlin Obstetrical Society by Dr. Mayer, who referred to an instance in which this accident had occurred to a patient of Professor Langenbeck ; and Dr. Biefel on the same occasion mentioned a case of fatal injury to the bladder and peritoneum by the instrument. 2 A case of injury to the vagina, and protrusion of the intestine through 1 Monthly Journal, Nov. 1849, p. 1183. 2 Monatsohr. f. Gieburtsk., March, 1858, p. 1G9. 20 306 LOCAL EMPLOYMENT OF COLD. the opening, is likewise related by Dr. Breslau, 1 but his patient happiby survived, as also did another whose case came to my knowledge, and in whom a portion of the peritoneum behind the uterus was removed with the diseased cervix. The cases in which auy of these proceedings are applicable, must obviously be comparatively few and exceptional; since the disease admits of being extirpated only when comparatively limited in extent, and at a comparatively early stage of its progress. Is there, then, no resource in these circumstances but to watch the daily advance of the evil; or can anything be done to retard, if not to cure, to alleviate the patient's sufferings, and to postpone for some weeks or months the inevitable result? Dr. James Arnott, 2 to whose ingenuity we owe many very important suggestions in medicine and surgery, believes and adduces evidence to show that by the systematic application of a very low temperature to parts affected with cancer, the pain of which they are the seat may be greatly diminished, the advance of the disease may be considerably retarded, and ulcerations of their surface may even be made to assume a comparatively healthy character. Practical difficulties in the way of applying the freezing mixtures so often as might be desirable, have interfered with the trial of his plans upon a large scale in our hospitals, while some degree of disappointment has been experienced in consequence of the proved inadequacy of cold to annul the pain of surgical operations in other than a very few instances, and those of the very simplest kind. Notwithstanding a very kind letter of explanation which Dr. Arnott was so good as to send me, I have yet found very great difficulties in the attempt at employing freezing mixtures in cases of uterine carcinoma. The necessary removal from bed to a couch, the discomfort of the position, the almost impossibility of preventing the patient's person from becoming wet, and the tenderness of the vagina and external parts produced by the frequent introduction of a large speculum, which even when of great size seldom embraces the hypertrophied cervix completely, have precluded my making such a number of trials of the agent as would alone warrant me in speaking with any measure of confidence as to its powers. Other agents more potent, and more easily applied, have been used in cases of uterine cancer, but with results so indecisive that opinion is still much divided with reference to the propriety of their employment. In coming to a conclusion with reference to the use of any of these remedies, the object with which in each instance it has been had recourse to must not be lost sight of. I have already mentioned, that a strong solution of nitrate of silver applied to a cancer of the womb, in some stages of the disease, both diminishes the excessive fetor of the discharge, and also expedites the separation of sloughs from its surface, aiding in this manner the attempts at a cure, which though abortive as far as permanent recovery is concerned, are yet most 1 Scanzoni's Beitrage, vol. iii. Wiirzburg, 1858, p. 80. 2 On the Treatment of Cancer by the regulated application of an anaesthetic temperature, 8vo., London, 1851. APPLICATION" OF CAUSTICS AND CAUTERY IN CANCER. 307 welcome pauses in the course of the disease. For this purpose, I believe a strong solution is of greater service than the solid nitrate of silver, probably because in this form the remedy penetrates more thoroughly into the affected tissue. I have also sometimes employed the acid nitrate of mercury to check those granulations which in cases of uterine cancer not infrequently sprout from the interior of the cervix, and I think that in both of these ways the use of caustics has been advantageous as a palliative, not as a curative proceeding. There are some forms of external carcinoma, in which the employment of the more powerful escharotics, as the chloride of zinc, has been of great service; but I need scarcely remind you that the benefit derived from such agents has depended almost entirely on the possibility of completely destroying the affected tissue, and that as a general rule, its partial destruction has been followed by a more rapid development of the disease than before. Now, in the case of the uterus, it is obvious that the thorough application of any deliquescent substance is impossible ; that the risk of injuring adjacent parts must lead to the inefficient employment of the caustic, and consequently to the aggravation instead of the amendment of the disease. This circumstance leaves us no alternative but to resort to the actual cautery in any case in which it is intended to do more than modify the state of the surface of the affected parts. The idea of the operation is much more formidable than its reality, for it is not very painful in itself, while it can always be performed under chloroform; and the only real danger attending it, that of injuring adjacent tissues by the radiation of the heat, can always be effectually guarded against by the use of a boxwood speculum. I have not myself used it, or seen it used sufficiently often to have formed a very decided opinion with reference to the amount of benefit which may be anticipated from it; but I feel satisfied that there is no danger to be apprehended in its employment, and that it does not tend to make matters worse. Generally there is a very decided, though often temporary mitigation of the patient's previous sufferings, an improvement which has seldom outlasted the separation of the eschar. A diminution in the quantity and fetor of the discharge has generally continued for a longer time, but I cannot say that as yet I have been able to attribute to it any delay in the progress of the evil, partly, perhaps, from not having repeated it sufficiently often, and in still greater measure probably from the disease being already far advanced when the patients first came under my care. I believe, however, that like other proceedings intended to effect the real cure of cancer, the actual cautery is seldom indicated except in cases of the epithelial form of carcinoma, for in that alone is the mischief at all likely to be confined within limits which we can hope to reach by any local treatment. These remarks are, I know, anything but detailed enough to furnish a safe and sufficient guide as to when and how, and how often, this kind of interference is likely to be useful, or may even by good fortune prove actually curative. They are merely suggestive of the direction which your observations should take, and in which your 308 DISEASES OF PARTS CONNECTED WITH THE UTERUS. efforts should be made. Your duty and mine is, not to sit down in apathetic indifference, doing nothing, trying nothing for a patient's cure, because her disease is one which hitherto has proved almost invariably mortal; but rather, patiently, carefully, with much mistrust of our own powers, much watchful scrutiny of our own motives, to apply ourselves to the trial of every means by which suffering may be mitigated or life prolonged, To this our common humanity prompts, our obligations as medical men compel us. It is to misinterpret both very grievously, if we not merely content ourselves with doing nothing, but take shelter under noisy censure of the conduct, and uncharitable construction of the motives, of those who read their duty differently. LECTURE XXII. DISEASES OF PARTS CONNECTED WITH THE UTERUS. INFLAMMATION AND ITS RESULTS. Inflammation of Uterine Appendages:— of the Cellular Tissue. Causes of affection ; generally consequent on delivery or abortion ; its various seats, and modes of termination ; general tendency to end in suppuration. Morbid appearances. Relation cf this affection to inflammation of the ovaries ; its analogy to other inflammations of the cellular tissue. Symptoms; mode of attack twofold. Formation of abdominal tumor; occurrence of suppuration, but chronic character of the abscess ; various outlets by which it discharges itself. Characters of intra-pelvic tumor ; its similarity to uterine hsematocele. General sketch of symptoms and course of affection. There are many phrases which, though still daily used in medical writings, express not merely the opinions but also the errors of a bygone time. It is thus with the term Uterine Appendages, long applied to parts connected with the womb, some of which, indeed, are secondary to it in importance, and subsidiary to its functions, but others are physiologically of higher moment than the uterus itself, and originate those acts to whose due performance the womb does but minister. I have no fear, however, lest by retaining the phrase Appendages of the Uterus, or by speaking to you about their diseases, I should be suspected of ignoring the office of the ovaries, or of implying that they are of less importance than the womb in the sexual system of the woman. I shall be understood to use the term merely as a convenient epithet, expressing without waste of words the broad ligaments of the uterus and all the various parts and structures contained within, or intimately connected with them; parts whose physiological import just now concerns us less than do the ailments to which they are liable. When speaking of the diseases of the uterus itself we considered first, those which are the result of inflammation; and it will, I think, INFLAMMATION OF THE UTERINE APPENDAGES. 309 be convenient still to retain the same arrangement, and before passing to other subjects to study the inflammatory affections of the appendages of the womb. These admit of being classed under two heads, according as the inflammation attacks the ovaries themselves, or as it is chiefly limited to the cellular tissue in the immediate neighborhood of the womb. In the latter case the symptoms are of course modified according to the precise seat of the mischief, which, though most frequently involving the cellular tissue between the folds of the broad ligaments, sometimes attacks that which intervenes between the womb and the adjacent viscera, or extends to that lining the pelvic walls, or even to that which lies between the outer surface of the peritoneum and the abdominal muscles. Inflammation of the cellular tissue in the neighborhood of the womb takes place as a consequence of abortion or of delivery much more frequently than from any other cause. The great tendency that it has, too, to terminate in suppuration, familiarized practitioners of midwifery from a very early period with it; or at least with the abscesses to which it gives rise, though misconception long prevailed with reference to their nature. They were generally imagined to be secondary deposits, the result of a supposed metastasis of the milk, or of an outpouring of its elements when present in too great abundance in the blood. It was imagined, too, that this occurrence sometimes took place in one situation, sometimes in another, and the most various sequeke of delivery were attributed to this as their remote occasion ; a theoretical error, which, as Puzos' essay, "Sur les Depots Laiteux," 1 abundantly proves, did not at all interfere with the most accurate description of some of the most important ailments of the puerperal state. With advancing knowledge the erroneous theory was discarded, but the inflammatory affections of the uterine appendages ceased to attract attention, or were passed over as occasional complications of puerperal fever, until attention was once more drawn to them quite recently by the essays of Doherty, Churchill, and Lever, in this country 2 and by those of Grisolle, Marchal de Calvi, 3 and others, in France. Even at the present time, however, and in spite of the recognition of these ailments as attendants on the puerperal state, their occurrence, independent of pregnancy and its consequences, has scarcely been appreciated as generally as it deserves, and it is this circumstance which is my chief reason for bringing the subject now under your notice. An attempt has been made by some writers to discriminate between inflammation of the uterine appendages occurring after delivery, and the same affection when coming on in other circumstances. I do not think, however, that this distinction is called for either by the symptoms of the disease, or by the treatment which it requires in the puer- 1 In his Traite des Accouchemens, 4to., Paris, 1759. See especially pp. 35(!—360. 2 Dublin Journal, vol. xxii., 1843, p. 199; Ibid., vol. xxiv., 1844, p. 1; and Guy's Hospital Reports, Second Series, vol. ii. 1844, p. 1. 3 Archives Gen. de Medecine, Third Series, 1839, vol. iv. pp. 34, 137, 293; and Des Abces Phlegmoneux Intra-Pelviens, 8vo., Paris, 1844. 310 CAUSES OF INFLAMMATION peral state, though the peculiar condition of the uterus at that time often imparts to disease in its vicinity a more acute character than would be presented by the same ailment at another season. The subjoined table shows very clearly the influence of labor and its consequences in giving rise to inflammation of the appendages of the womb, and of the cellular tissue in their immediate vicinity. It shows, too, that almost invariably, even when labor did not precede the attack, some accident induced it, which acted immediately on the womb—such, for instance, as miscarriage, or disorder of the catamenia; while the cases were only 6 in 52, or 11.5 per cent., in which the attack was not brought on by some local ailment of the sexual system. Occurred after delivery in .... 27 cases. " " abortion 10 " " " disorder of catamenia . . 7 " " " seduction, and some probable violence to uterus . . 1 " " " ulceration and inflammation of uterus 1 " " M no ailment of uterus . . 6 " 52 In 9 of the 27 cases in which the affection succeeded to delivery the patients were primiparas; or, if to my own cases those of Lever and Marchal de Calvi be added, 27 out of 51 cases were those of women who had been delivered for the first time. The supposition, however, which this fact might seem to suggest, that protracted or difficult labor specially predisposes to this ailment, is scarcely borne out by further inquiry ; since in 18 of my 27 cases, and in 7 out of 8 of those recorded by Dr. Lever, labor was in all respects natural. In 4 of my cases it was protracted, though in none was instrumental interference necessary; in Lever's case turning was performed on account of arm-presentation; in 1 case of mine extensive laceration of the perineum seemed to have been the point of departure of the whole of the subsequent inflammatory mischief, and in the remaining 4 labor was attended by profuse hemorrhage, an accident which also complicated one of the cases of tedious labor. From these data all that we can venture to affirm is the preponderance of frequency with which the accident occurs in primiparas, and an increase of liability to its occurrence when labor is more than usually protracted, or when it is accompanied by hemorrhage. M. Grisolle expresses his belief that the omission on the part of the mother to suckle her infant is one of the most powerful predisposing causes of the disease, and this opinion is in the highest degree probable; but in this country it is so universally the practice for women, especially among the poor, to suckle their children, that none of my observations bear at all on that point. The nature of the influence of abortion, of disorder of the catamenial function, or of other accidents which directly interfere with the sexual organs, is too obvious to call for explanation. Why, under the influence of such causes, a woman should be seized in one case by violent 311 OF UTERINE APPENDAGES. general peritonitis, in another by an ailment chronic in its course, and seldom dangerous to life, it is perhaps impossible to explain. In so far, however, as this disease is a consequence of labor, it must be borne in mind that it is essentially different from any of the complications or sequelae of puerperal fever. Puerperal fever is a disease of the whole constitution, associated with important changes in the circulating system, probably with other alterations, too, which we have not at present the skill to discover; but the local mischief which may be found after death was no more its occasion than are the ulcerations of Peyer's glands the occasion or the essence of typhoid fever. In puerperal fever there may be evidence of injury to the uterus, or to its appendages, or to its vessels, or to the peritoneum, but there is this and something more; and this something more, the divinum aliquid, the to Onov of Hippocrates, has puzzled our philosophy, eluded our research, and outwearied the speculations of the most ingenious theorists, who have labored vainly to unriddle its nature. Hence it is, however, that these inflammations of the uterine appendages, or of the adjacent cellular tissue, do not usually come before us in cases where puerperal fever has threatened life, for that disease either destroys the patient speedily, or with the abatement of the general disturbance of the system, the local evil, unless the mischief done was irreparable, abates too, and soon disappears completely. This ailment, on the other hand, begins as a local affection, its early symptoms are often so slight that it is overlooked for days or weeks together, the constitution sympathizing just in proportion to its extent and intensity, and general health returning as the consequence of the mitigation or of the cure of the local disease. There does not seem to be any rule that determines absolutely either the part which shall be the seat of inflammation, or the course which that inflammation shall run, and whether it shall issue in suppuration, or may by good fortune terminate in resolution. The cellular tissue anywhere in the neighborhood of the womb may be the seat of the mischief, though that contained within the folds of the broad ligament is attacked, as the subjoined table shows, far more often than the same structure in any other situation, or 34 out of 52 times. Next in frequency are the cases where the cellular tissue between the uterus and rectum is the seat of the affection, and which were met with 14 times; while those in which the tissue between the uterus and bladder is attacked are much rarer, and occurred only in 3 of the 52. Inflammation of the cellular tissue between the abdominal muscles and the peritoneum, the external peritonitis of some writers, is of very rare occurrence as an idiopathic affection, but far from unusual as a complication of inflammation of the cellular tissue contained within the folds of one or other broad ligament. The mischief is not, I believe, in the great majority of these cases, confined to the situation where the external tumor and abscess eventually form; but the cellular tissue covering the iliacus internus having been the original seat of the disease, the inflammation extends by degrees round to the front of the abdomen, though the matter which may form in that situation is by no means invariably discharged through the abdominal walls, but CAUSES, SEAT, AND COURSE 312 Tabic of Cases of Inflammation of Cellular Tissue in the neighborhood of the Womb. j After in- Independent _, , After After ,. , r , After flammation of causes Tnml FARTs AFFECTED. delivery. abortion. ' 0 seduction. and acting spe- T ° taL catamema. ulceration cially on the of uterus. uterus. Right side, without abdominal tumor 2 2 ... ... ••• 2 6 " with " ... 1 ... ... ... — 1 " " " and suppurating . . 1 ... ... ... ... ... 1 u " " suppurated, and with) external peritonitis j Left side, without abdominal tumor ....... 6 1 1 ... ... 1 9 " " " but suppurating . . 1 ... 1 ... ... ... 2 ¦ with " 2 ... ... ... ... ... 2 " " " and suppurating . . 1 ... 2 l ... ... ... 3 " " " suppurated, and with \ . _ .5 external peritonitis j Both sides, without abdominal tumor 1 1 ••• ... ... 1 3 " " " suppurated, and with \ i i 1 abscess in glutseus j Tissue between uterus and rectum 2 ... ... ... ... 1 3 " " « and suppurating ... 2 3 ; 2 1 1 1 1 10 Tissue between uterus and bladder ... 1 ... ... ... ... 1 " " " and suppurating . . 1 ... ... ... ... ... 1 " " " suppurated, and with) external peritonitis j External peritonitis alone, suppurated I 2 ... ... ... j ... ... 2 27 | 10 7' 111 6 52 1 One case is included under both of these categories, which makes the real total under this heading 6, and the gross total 52. OF INFLAMMATION OF CELLULAR TISSUE. 313 escapes in the majority of cases through some communication formed with the intestinal canal. The tendency to suppuration, and to the discharge of pus externally in all of these cases, seems to be very great, since it occurred in 27 out of 52 instances. This mode of termination of the inflammation appears also to be as frequent in case3 independent of previous delivery or miscarriage as in those which are due to puerperal causes, since it happened in 9 out of 15 instances of the former kind, as well as in 18 out of 37 of the latter. I apprehend, too, notwithstanding the conflicting statements which have been made by different writers 1 with reference to this point, that the occurrence of suppuration, or, at least, of oedema, with infiltration of sero-purulent fluid, is in all these cases the rule rather than the exception, and this even though no discharge of matter should at any time take place externally. The extreme rapidity with which a tumor forms so as to be detected through the abdominal walls, or to be felt in other cases in the vagina is explicable only by the sudden pouring out of fluid into the loose cellular tissue; while its varying extent, its ill-defiued edges, its occasional disappearance from one side, and reappearance on the opposite, all serve to show that the mischief does not generally involve the substance of any solid organ such as the ovary, and consequently explain the completeness of the patient's recovery, and the subsequent integrity of all her sexual functions, even when the attack has been most severe and the symptoms have appeared most formidable. It is comparatively so seldom that the disease terminates fatally that the opportunity of observing the nature and seat of the mischief while still in active progress rarely occurs. Some years ago, however, I was present at the post-mortem examination of a young woman who died twenty-one days after delivery. I had not seen her during her lifetime, but I learned that labor had come on prematurely after frequentlyrecurring hemorrhage, that the placenta was found presenting, and that within a day or two after delivery she began to suffer from deep-seated pains in the back and pelvis, which extended by degrees over the abdomen, and which were accompanied by very distressing bearing-down efforts. The nature of her disease was not thoroughly understood during her lifetime; but after death her uterus was found pushed upwards and to the right by a collection of more than eight ounces of chocolate-colored grumous pus, which had formed in the loose cellular tissue to the left side and back of the organ; the upper part of the abscess reaching to about an inch and a half above the level of the os uteri. There was here no general peritonitis, no disease of the uterus itself, and both ovaries were perfectly healthy, death having taken place from inflammation and suppuration of the cellular tissue about the uterus just as it takes place from the same affection of the 1 M. Grisolle, in his paper already referred to, states that suppuration occurred in 16 out of 17 cases which succeeded delivery, and in 38 out of 51 cases that occurred independent of puerperal causes ; while M. Gallard, in a recent very carefully written dissertation, Du Phlegmon Peri-uterin, 4to., Paris, 1855, alleges that suppuration took place only in 4 out of 53 cases, when the inflammation was independent of delivery. I scarcely need add that my experience inclines me to the opinion of M. Grisolle. 314 POST-MORTEM APPEARANCES. tissue between the rectum and bladder after the operation of lithotomy in the male subject. Sixteen weeks after her second labor, a poor woman, aged twentyfive, died of exhaustion consequent on inflammation and suppuration in the cellular tissue adjacent to the uterus; on examination of the body after death two abscesses were found. One, the larger in size, situated in the cellular tissue in front of the right sacro iliac synchondrosis, and extending for some distance behind the psoas muscle; the other to the left side of, and somewhat behind, the rectum, containing a small quantity of discolored pus, lined by a slightly rough, ash gray membrane, bounded by walls of at least half an inch in thickness, reaching downwards to about two inches from the anus, upwards to a little below where the sigmoid flexure passes over into the rectum where the abscess communicated with the bowel by an opening about a third of an inch in its longest direction, which was transverse. There was no general peritonitis nor any fluid in the peritoneum; but bands of old adhesions about half an inch long connected the uterus and rectum, and retained the womb completely in the posterior part of the pelvis. There was no trace, however, of any intra-peritoneal cyst or sac containing pus, nor of anything more than the old adhesions just described. The original seat of the mischief in the cellular tissue immediately adjacent to the uterus is further illustrated by the subjoined case, in which I had the opportunity of observing after death the process by which nature had effected the cure of an inflammation of the cellular tissue contained within the folds of the left broad ligament. The person on whom this observation was made was a young woman who died of abscess of the liver fourteen months after her recovery from inflammation of the uterine appendages of the left side. The results of examination when she was originally admitted into the hospital, six weeks after her delivery, were as follows: The abdomen generally was soft and painless, but immediately over the symphysis, extending about two inches above its level, and about the same distance transversely, was a firm, globular enlargement, very slightly movable, tender on firm pressure. The vagina was hot, its anterior wall from about half an inch from the orifice of the urethra was swollen into a distinct elastic tumor, which gave the sensation of containing fluid, and projected so as to contract to half its ordinary dimensions the calibre of the canal. In this tumor, which was not modified by the introduction of the catheter, the anterior lip of the uterus was lost, while the posterior lip was small and natural. The right side of the uterus was free from any unnatural condition, the swelling existing to the left and anteriorly. The uterus and tumor, when pressed on, moved together, but their mobility was very small. In a few days the tumor felt per vaginam was greatly lessened after a profuse discharge of pus, and when the patient, after six weeks' sojourn, left the hospital, there was said to be no other morbid condition than a thickening at the left side of the uterus, by which it was almost completely fixed in the pelvis. The appearances found after death explained this thickening, and 315 NATUKE AND ANAI OGIES OF THE AFFECTION. accounted for the non-mobility of the womb, for the folds of the broad ligament, from the upper part of the vagina to the lower surface of the ligamentum ovarii, inclosed a mass of dense cellular tissue of almost cartilaginous hardness, crying under the knife; dense white bands intersecting each other in all directions, and having a firm, yellow fat between them. This mass was closely adherent along the whole left side of the uterus, though the uterine tissue was in no respect implicated in it. The left Fallopian tube was tied at two or three points by long adhesions to the ovary and its ligament, and the ala vespertilionis on that side was thickened and uneven, as if from old deposits of lymph. The Fallopian tubes were pervious, and the ovaries were quite healthy, and contained several Graafian vesicles. 1 Between the affection we are now studying and inflammation of the substance of the ovaries themselves the differences are obvious and manifold. The extreme rapidity with which matter is formed, and the large quantity of it which is secreted in so short a time, are not compatible with the seat of the disease in the substance of an organ furnished as is the ovary with a dense fibrous capsule, which, though elastic and admitting of vast expansion in the course of time, is yet not capable of yielding so as to allow of the accumulation of a large quantity of matter in a few days. The termination of ovaritis by suppuration is, I believe, quite exceptional. In the puerperal state it is the peritoneal investment of the ovaries which is usually affected; while when inflammation, even of the acutest kind, attacks the substance of those organs, and ending in the formation of matter proves speedily fatal, it does not lead to any great increase of their size, but to softening and complete disintegration of their tissue. When, in other circumstances, large collections of matter form within the ovary, their origin is usually traceable to some cyst in whose wall inflammation has been accidentally set up ; and such ovarian abscesses generally remain for a long time as distinct, well-circumscribed tumors, whose contents are very slow in making their way outwards. Generally, indeed, ovaritis is not only a far more chronic evil than inflammation of the cellular tissue about the womb, and is attended by pain of a very different character, but the enlargement of the organ is always inconsiderable, and its situation is often inferred from pain produced 1 I have related these details of post-mortem appearances more at length than I otherwise should have done, because in the Archives de Medecine, for March and April, 1857, M. Bernutz has thrown doubt on the reality of the supposed inflammation of the cellular tissue in the neighborhood of the uterus. He suggests, on the strength of three observations, that these cases are in reality cases of inflammation of the peritoneum lining the pelvis ; that the supposed abscesses are nothing else than circumscribed collections of matter, produced by the cohesion of convolutions of intestines to each other ; or by their connection with some part of the wall of the pelvis ; or with some of the organs contained within it. That such cases occur no one can doubt; that some of the largo collections of matter forming tumors of considerable size felt through the abdominal parietes, have this origin must also be admitted; but I do not think that the majority of instances of what French writers call phlegmon pMuterin are in reality misinterpreted peritonitis. I believe the affection of the cellular tissue to be by far the more frequent occurrence, and generally the primary ailment, and am of opinion that M. Bernutz has fallen into the error of stating as the rule what is indeed the somewhat rare exception. 316 SYMPTOMS OF THE A.FFECTION. by pressure at one spot rather than clearly pointed out by any considerable increase of its dimensions, while the thickening and hardening of the vaginal walls, scarcely ever absent from that side of the canal on which the affection of the cellular tissue is situated, is never met with in cases of simple ovarian inflammation. The analogies of this affection are, I believe, rather to be found among those inflammations of the cellular tissue which, succeeding to operations, advance with great rapidity, and terminating soon in the formation of enormous quantities of matter, constitute one of the most untoward of those accidents by which the skill of the surgeon is disappointed of best-merited success. The rapid formation, and occasional rapid disappearance, of the swelling show, if further proof were wanting, that it is not due to changes in the solid tissues of any organ, but rather to oedema or the infiltration of a loose tissue with fluid. This fluid, too, like that which is formed in other inflammations of cellular tissue, is not at first genuine pus, but a thin sero-purulent matter, and often still retains this character long after it has been formed in quantity sufficient to impart to the fingers a most marked sense of fluctuation. These characters then correspond to those of diffuse cellular inflammation, or "acute purulent oedema," as it has been well termed by the distinguished Russian surgeon. Pirogoff. 1 If we take this view, which, he indeed suggests, even the most anomalous features of the affection will become comparatively easy to understand. We shall not be surprised that the disease should occur in the weakly rather than in the strong, that previous hemorrhage, or other debilitating influences should favor its development, that whde often attended by comparatively little local suffering, it should yet run rapidly through its earlier stages; but still now and then come suddenly to a stand still, and that all trace of it should then quickly disappear. Since we know, too, that the seat of the mischief is not in the sexual organs themselves, but only in their connective tissue, we shall find nothing difficult of explanation in the re establishment of menstruation, or in the recurrence of pregnancy, or in the regular performance of all the generative functions, even after symptoms which had seemed most formidable, and had appeared as though they imply that injury had been done passing the power of nature to repair. In those cases in which the affection succeeds to delivery or abortion, its mode of attack seems to be twofold. Either it sets in with well-marked symptoms of constitutional disorder, such as general feverishness and heat of skin, sometimes, though not often, preceded by shivering, and accompanied by abdominal pain, which is seldom very intense; or else it comes on gradually, the local evil being developed almost imperceptibly out of a state of incomplete convalescence; while it is quite an exceptional occurrence for severe puerperal peritonitis to precede the inflammation of the uterine cellular tissue. In the majority of instances the tenderness and pain, though referred chiefly to the lower part of the abdomen, are not at first distinctly limited to one or other 1 Klinische Chirurgie, Drittes Heft, 8vo., Leipzig, 1854, pp. 36—54. TENDENCY TO EARLY OCCURRENCE OF SUPPURATION. 317 side, and not infrequently the discovery of swelling, induration, or even of a definite tumor in one or other iliac region by the medical attendant, is the first circumstance which directs the patient's notice to one spot as the special seat and source of her sufferings. The symptoms of general constitutional disorder, even when most marked at the onset, very rarely go on increasing in severity with the progress of the local mischief, but, having set in on the second or third day after delivery, subside at the end of a fortnight or three weeks. This subsidence of the symptoms too often takes place quite independently of the employment of any medical treatment; but the apparent convalescence thus established is not only imperfect from the first, but becomes every day more and more interrupted, as the local ailment advances, and now, if not earlier, distinctly manifests itself by abdominal pain, by painful micturition or defecation, or by some other symptom which clearly points to its situation. It depends upon the situation of the affected parts, whether or no any tumor is perceptible externally, for while always more or less manifest in cases where the parts contained within the broad ligament are the seat of inflammation, it is generally absent when the mischief is limited to the cellular tissue between the uterus and bladder, and always when it is confined to the parts in or about the recto-vaginal septum. The somewhat vague character of the symptoms in many of these cases, and the too common neglect of vaginal examinations, lead in cases of this description to very frequent mistakes as to the nature of the patient's ailment, and mistakes all the less excusable since there are few ailments whose diagnosis is more simple if the investigation is properly conducted. It is not easy to say at how early a period after the commencement of the attack a swelling forms, so as to be detectable on examination; but my impression is, that though often not discovered till after the lapse of many days, it usually occurs very speedily. Careful examination even two or three days after the symptoms began, will generally ascertain the existence of fulness in one or other iliac region, will find that on pressure there the complaint of pain is greater than elsewhere, and that percussion in that situation yields a dull sound, and conveys a sense of solidity not perceptible on the other side. In such circumstances, local depletion will not only afford immediate relief to the patient's sensations, but that relief will be accompanied by a disappearance of the swelling so complete and so speedy as to raise a momentary doubt in our minds as to whether the impression of its existence was not a mistake. The doubt, however, would be unfounded; the swelling was very real, due to oedema of the cellular tissue, in which, but for our treatment, suppuration would soon have taken place, as indeed it does in the great majority of cases, and then condemns the patient to a tedious illness, and a tardy convalescence. The same rapid formation, and rapid disappearance of the swelling, receive another illustration in cases where a sort of metastasis of the inflammation takes place, or where, to speak more correctly, the mischief, originally situated on one side, attacks without apparent cause the other also; and the new complaints of pain in a different situation are accompanied by tumefaction there, which may 318 CHRONIC COURSE OF THE AFFECTION. be very temporary; or may, if the inflammation there advance, become as solid, and prove as permanent as that on the other side. It is not possible to fix the precise limits of time within which resolution of the swellings may take place. My impression, however, is that the period is very short, and that after the lapse of a few days at furthest; the changes are far too considerable for any rapid cure; and that pus is early formed, though the processes by which it makes its way to the surface are generally very tardy, and those are slower still by which, without any escape of matter generally, its complete absorption is now and then effected. The formation of matter is by no means invariably followed by any marked increase in the sufferings of the patient; and it is surprising how the constitution bears its presence even in considerable quantities, the mechanical inconveniences produced by the pressure of the abscess being not unfrequently those from which the patient suffers most, and which drive her at length to seek for medical assistance. Thus, a young woman, aged twenty-five, was admitted in the year 1849 into St. Bartholomew's Hospital, having been ill since her delivery seven months before. On the ninth day after her confinement she was attacked by abdominal inflammation, the more acute symptoms of which subsided under depletion, and she attained a state of imperfect convalescence. She went about some of her household duties, though with difficulty, and even cohabited with her husband in spite of the pain by which sexual intercourse was attended. When she sought for admission into the hospital it was on account of increased difficulty in micturition, and frequent desire to pass water. On examination of her abdomen an oval tumor was discovered in the mesial line reaching midway between the symphysis pubis and the umbilicus, and produced by a collection of pus in the cellular tissue between the uterus and bladder, ten ounces of which escaped on a puncture being made into it through the vaginal wall. The patient alleged that the tumor had existed only for three weeks; a statement which can scarcely be received as correct, since she had never thoroughly recovered from the illness which followed her delivery; but which may be accepted as evidence that the abscess had produced no special effects, till by its increased size it began mechanically to occasion discomfort, and to interfere painfully with the functions of her bladder. Another illustration of the same fact may be adduced in the person of a young woman in whom constipation from the fourth to the eighteenth day after her first confinement was followed by inflammation of the cellular tissue behind the rectum. The action of her bowels was from this time attended by great pain, and costiveness alternated with diarrhoea, the evacuations being not infrequently intermixed with pus. In spite of these symptoms, however, she gradually regained her general health, and menstruation returned, though not regularly. Seventeen months after her confinement she had been visiting the Crystal Palace, in Hyde Park, and while returning home in an omnibus, the jolting of the vehicle occasioned the sudden bursting of an abscess, and the discharge of about three pints of matter streaked with blood per anum. For the next three mouths from that time more ITS DIAGNOSIS. 319 or less copious purulent discharges took place from the bowel, behind which the abscess whence it proceeded was situated, forming there a tumor of about the size of a small apple. Occasional local leeching, and the most sedulous attention to the state of the bowels were succeeded by the cessation of the discharge, and the ultimate complete disappearance of the tumor, of which six years afterwards no trace existed. The presence of any collection of pus so considerable as that which existed in these two cases is decidedly unusual, for the mischief is generally more circumscribed, and a wall of condensed cellular tissue surrounds the collection of matter, and prevents the extension of suppuration. But though the size of the abscess is not usually very great, it not infrequently passes into a chronic state, and emptying itself, usually through some narrow passage of communication, into the bowel, the patient continues for months or years liable to occasional discharges of pus per anum, the commencement of which dates back to some attack of inflammation of the cellular tissue years before. In the case of a poor woman who died after long suffering from ulceration of a quasi-malignant character about her urethra and rectum, a collection of matter was found in the midst of the thickened and condensed cellular tissue by the side of the rectum, and between it and the uterus. This abscess, too, was lined by a membrane so distinct, so smooth and polished, as for a moment to raise the question whether it was not a distinct cyst in which suppuration had been accidentally excited. A patient was some years ago under my care in whom inflammation of the cellular tissue between the uterus and rectum having gone on to suppuration, it was considered expedient to puncture the tumor which was found in the vagina. Not more than two ounces of sero-purulent fluid were evacuated by this proceeding, but from the puncture flowed for the ensuing seven weeks many ounces of pus daily, its quantity, however, diminishing, and the discharge at length completely ceasing as the patient advanced towards recovery, and as the swelling behind her womb diminished. In another instance, occasional discharges of matter took place from the bowel, and pus was often intermixed with the feces, live years after the first symptoms of inflammation of the cellular tissue about the uterus, the chronic results of which were still evident in a tumor which was closely connected both with the rectum and the womb. These chronic abscesses generally contract, and the fistulous passages which lead to them become by degrees obliterated, but exceptions to this now and then occur, two of which have come under my own notice, and Dr. Simpson 1 has reported some very interesting cases in which permanent fistulous communications have formed between the abscess succeeding to inflammation of the pelvic cellular tissue, and the bladder, uterus, or intestinal canal. Often, though perhaps not always, the formation of abscesses having so chronic a character as those to which reference has just been made, might be prevented if the nature of the ailment were recognized as the 1 Obstetric Memoirs, vol. i. p. 232. 320 DIAGNOSIS OF DIFFERENT commencement. The diagnosis, too, is not attended by much difficulty, if only it is borne in mind that whenever after delivery or miscarriage ill-defined febrile symptoms occur, accompanied by abdominal pain, inflammation of the cellular tissue in the vicinity of the uterus is probably present, and this even though the constitutional disturbance should not be considerable, nor the pain experienced by any means severe. If now the inflammation is seated in that part of the tissue which lies between the folds of the broad ligament, there will at first be found in one or other iliac region a vague sense of fulness; percussion in that situation yielding a dull sound, and pressure being painful; and afterwards a more definite swelling. At no time, however, is this swelling so circumscribed that its border can be distinctly traced, nor is it movable like a fibrous tumor of the womb, or an enlarged ovary, but it is felt like a hard mass, extending laterally to the inner surface of the pelvic wall, and firmly adherent to it, reaching down into the pelvic cavity so that its lower border cannot be felt, while its upper and inner margin are both but vaguely marked; the thickening in those situations seeming rather to pass away by degrees than suddenly to cease. The dimensions of this swelling are always much more considerable from side to side than from below upwards; differing in this respect from tumors of the uterus or ovaries; its surface is even, but extremely hard ; it seems very superficial; the abdominal walls are not readily movable over it, but often seem as though they were adherent to it. This, too, they doubtless are in some cases, but the same sensation is very often communicated to the hand in instances where there is no reason whatever for supposing that adhesion has taken place between the opposite surfaces of the peritoneum, while further, the rapidity with which in some cases the apparent union is dissolved, shows that it must have depended on some cause of a much more temporary nature. My impression is, that it is due to oedema of the cellular tissue between the abdominal muscles and the peritoneum; a condition which not unfrequently terminates in suppuration, and thus constitutes what has been termed external peritonitis, but which in many cases is but an attendant on inflammation of the more deeplyseated tissues, increasing as that advances, remaining stationary when that comes to a stand-still, and rapidly disappearing as that begins to subside. An obvious lessening of the general fulness of the abdomen, and a sense of mobility of the abdominal walls over the tumor is one of the first signs of the patient's amendment, and one which often long precedes any alteration in the size or contour of the swelling; while next, as its size lessens, the previous adhesions between it and the pelvic wall become less firm, and its chief connection is felt to be not with the side of the pelvis, but with some body at its centre ; in other words, with the uterus itself. Up to the last, the indistinctness of outline which has been already noticed as characteristic of these swellings continues to distinguish them, and a vague sense of fulness in the iliac region remains long after all other evidence of their presence has ceased. When suppuration takes place, the matter makes its way outwardly through the vagina, or through the intestinal canal, in almost all cases 321 FORMS OF THE AFFECTION. in which the inflammation is limited to the parts contained within the broad ligaments. In those cases, however, in which the pelvic cellular tissue is implicated, the matter not unfrequently makes its way round between the muscles and the external surface of the peritoneum, and the abscess points and discharges itself through the abdominal walls somewhere in the course of Poupart's ligament, or a little below that situation. It sometimes happens, however, that even after fluctuation has become distinctly perceptible through the abdominal walls, the abscess eventually bursts either through the vagina or the rectum, and in one instance a communication formed apparently about the situation of the sigmoid flexure of the colon; and after the escape of matter by the bowel, air was for many days distinctly perceptible in the sac of the abscess. In cases of uncomplicated external peritonitis, and also in those where inflammation in this situation occurs simultaneously with that of more deep-seated purts, the tendency naturally is to the escape of matter externally. The swelling in cases of external peritonitis is harder and tenser than when the mischief is more deeply seated, the integuments become red, shining, and brawny, and this condition extends lower down than when the inflammation is seated in the parts within the fold of the broad ligament, and reaches quite into the inguinal region. The quantity of matter formed in these cases usually amounts to several ounces; the abscess pointing at one spot, and the whole of its contents escaping at a single aperture. Sometimes, however, in cases where inflammation of the uterine or pelvic cellular tissue is present, the tissue external to the peritoneum becomes affected secondarily: not by direct extension of the mischief to it, but rather by a sort of sympathy, and in this case two or three small circumscribed collections of matter are not unfrequently formed, each of which may require to be separately evacuated. An examination per vaginam throws additional light upon the case, except of course in those instances in which the external surface of the peritoneum is alone affected. The vagina is hot, and puffy, and tender; and, according to the seat of the inflammation, either its anterior or its posterior wall is felt to be thickened, and hard like brawn; and the uterus itself is fixed by this thickening of the vagina more or less completely in the pelvis, and at the same time is carried by means of it higher up than natural, so as not to come as readily as usual within reach of the exploring finger. As the cellular tissue within the folds of the broad ligament is oftener affected than that in any other situation, so it is at the roof of the vagina, towards one or other side, and commonly extending somewhat round behind the uterus, these characters are most marked. Soon, too, a distinct tumor is perceptible in addition to the general thickening, swelling, and hardness of the vaginal wall, and the swelling, if considerable, pushes over the uterus towards the opposite part of the pelvis. If seated at the side it does not in general dip down deeply into the pelvic cavity, and though it may be seized between the hand externally, and the fingers in the vagina, the state of the abdo?ninal integuments, and the thickening of the roof of the vagina interfere with the accurate deter- 21 322 DIAGNOSIS OF THE AFFECTION. mination of its size and contour. If the mischief extends, as often happens, either in front or behind, a definite swelling is very likely to be formed, and this swelling is usually larger, and more distinctly circumscribed when situated behind the uterus than when occupying the cellular tissue in front of the organ. If the cellular tissue between the uterus and bladder, and along the anterior vaginal wall is the seat of the inflammation, we may then find the hardened, thickened, tumefied state of the vagina reaching down to its very outlet, and the os uteri pushed quite out of reach by a swelling in front of it, not distinctly circumscribed, but passing over into the substance of the thickened anterior vaginal wall. If any large quantity of pus is formed in this situation, it does not commonly seem to increase very much the size of the pelvic tumor, but forms a distinct, well-defined swelling between the uterus and bladder, which rises up out of the pelvic cavity, and may be felt through the abdominal walls, occupying the situation, and having much the contour of the half-distended bladder. It is when seated behind the uterus, on the other hand, that the occurrence of suppuration is apt to give rise to the most definite pelvic tumor; for there is in this situation a greater obstacle than elsewhere to the extension of the swelling upwards out of the pelvis, while the cellular tissue in the recto-vaginal septum is looser and more abundant than anywhere else in the immediate vicinity of the uterus. Here then matter very speedily forms, and gives rise to a swelling which occupies the whole posterior part of the pelvis, bulging out into it, just as an ovarian tumor is apt to do when seated in the recto-vaginal pouch, but more elongated in form, less globular, and while generally tense, yielding usually at one spot, perceptible through the vagina or through the rectum, a peculiar boggy sensation, suggestive of a thinning of its covering having taken place there, and of matter being likely to escape in that situation. The os uteri, too, will be found to be carried out of reach more completely than it would be by an ordinary ovarian cyst of equal dimensions, and the tumor itself to reach lower down, nearer to the orifice of the vulva, since it is not a mere swelling seated in the recto-vaginal, but is formed in the substance of the septum itself, where the matter naturally gravitates lower and lower. I do not know of any error which with moderate care can be committed as to the nature of these swellings, except in the rare cases of extravasation of blood into the cellular tissue behind the uterus, uterine hcematocele, as it has been called ; and in them the tumor very closely resembles that produced by suppuration in the same situation. The suddenness of the attack of uterine kasmatocele, its independence of delivery or abortion, and the general absence of thickening and hardening of the vaginal wall around the swelling will, I should imagine, usually enable us to discriminate between them; while happily there is no serious practical error to which a mistaken diagnosis would give occasion. It is scarcely necessary to trace the further progress of these swellings, except, perhaps, to add two cautions : first, that the sense of fluid being contained within them is not infrequently deceptive, so far at least ITS ORDINARY COURSE. 323 that it would seem to imply in many instances the existence of a state of general oedema of the cellular tissue, and not such a definite collection of matter as could be evacuated by the trocar; and, second, that even after the actual evacuation of pus, there is seldom that immediate and great diminution of the swelling which we might beforehand anticipate ; but the thickening of the cellular tissue which remains behind is not only considerable, but is many months before it is entirely removed. The symptoms of the disease, even after it is fully established and after the formation of a distinct tumor has taken place, are not in general of a very definite character. The patient's condition is one of weakness, illness, feverishness, with evening exacerbations, restless nights, and morning remissions, rather than one either of very great local suffering or very urgent constitutional disturbance, though when the affection has lasted very long, and is telling severely on the patient's powers, diarrhoea not infrequently comes on, and the fever assumes a marked hectic character. The local suffering varies much, according to the part which is chiefly affected ; the sense of bearing down being most distressing when the recto-vaginal tissue is involved, and the frequent need of micturition most troublesome when the tissue between the uterus and bladder is the seat of inflammation. In all instances, however, the bladder sympathizes more or less with the inflammation in its vicinity, and some degree of dysuria and overfrequent micturition are symptoms scarcely ever absent. While in all cases, be the exact seat of the mischief what it may, there is more or less pain referred to the pelvis, more or less tenderness on pressure upon the abdomen, the amount of severe suffering varies very considerably, and varies, too, without any very obvious cause. A dull pain, a sense of weight, and a burning sensation seem to be constant, while very severe suffering is often produced by the attempt to stand or even to sit up. Sometimes, too, independent of any exciting cause, paroxysms of pain occur, of extreme violence, which last for an hour or two, and then subside, returning the next day or sooner, being equally violent, and passing off again on their own accord. The severest suffering generally takes place before the presence of matter in the swelling has become distinct, while afterwards during the long period which often elapses previous to the contents of the abscess rinding an outlet, though the constitutional disorder may become more serious, the local pain generally abates. With the escape of the matter the relief obtained is usually far more decided, though this seldom occurs in a sudden gush, so as to give instant ease, but the aperture of communication with the abscess being very small, the matter for the most part escapes only in small quantities; or being poured out into the rectum, collects there till a few ounces have accumulated, and are expelled during some effort at defecation ; while for days or weeks afterwards pus is intermingled with the feces, or a small discharge of it precedes their passage. In cases where the cellular tissue between the folds of the broad ligament is the seat of the inflammation, as well as in those where the tissue behind the uterus is affected, the escape of the matter generally takes place through the rectum ; very rarely 324 ORDINARY COURSE OP THE AFFECTION. indeed through the vagina. The aperture of communication with the bowel is usually low down, though above the internal sphincter, and though commonly too minute to be detected, its situation may be guessed with tolerable accuracy, as the finger discovers some spot in the swelling where its parietes are soft and yielding. Once an iliac abscess on the left side, in which fluctuation was distinctly perceptible, while the redness of the abdominal integuments, and their firm connection with the swelling led one to expect that it would discharge itself externally, burst into the intestine, and the communication was free enough to allow of the entrance of air into the sac of the abscess, in which situation crepitation continued for days to be distinctly felt. In the mean time suppuration went on in the tissue beneath the abdominal muscles, and a distinct abscess formed there, which was afterwards evacuated by the knife. Twice also I saw an abscess discharge itself through the bladder, though this occurrence was not final in either case, for in the one an abscess formed externally, and in the other it burst likewise into the intestinal canal, and the patient suffered for several weeks from diarrhoea, with discharge of pus per anum. In these cases, however, and also in others, in which after an abscess has pointed or has actually burst in one situation, matter afterwards makes its escape in another, it is, I think, very doubtful whether both discharges took place from the same source, or whether there have not been two distinct abscesses perfectly independent of each other, and the one anterior to the other in the date of its formation. The disposition of this affection not simply to extend by direct continuity of tissue, but also to attack similar structures even when not immediately connected, is a feature of the complaint to which reference has already been made, and one which adds much to its gravity, and imposes on us the necessity of watching our patients most sedulously for a long time after they have seemed to be fairly in the way to convalescence. The gradual progress of the patient towards recovery during the continuance of discharge from the abscess, and the slow processes by which the thickening and induration of the affected parts are by degrees removed, are unattended by symptoms calling for special description. Their history is one of a convalescence as irksomely slow in some instances, as in other cases where the mischief having been seen and understood, and appropriate treatment having been early adopted, it is surprisingly rapid. The disposition to relapse, too, to the reproduction of fresh mischief in its old seat, or to the kindling of inflammation in some part previously unaffected, is never to be lost sight of, both as governing our prognosis and as regulating our treatment. 325 DISEASES OF PARTS CONNECTED WITH TIIE UTERUS. LECTURE XXIII. DISEASES OF PARTS CONNECTED WITH THE UTERUS—INFLAMMATION AND ITS RESULTS, AND KINDRED PROCESSES. Inflammation of Uterine Appendages : of the Cellular Tissue. Exceptional cases, consequent on peritonitis without special uterine disorder; important, but apt to be overlooked. Treatment in recent stage, care during convalescence. In chronic stage ; question of puncture ; treatment of sequelae. Hemorrhage about Uterus, or Uterine Hematocele. Seat and causes of extravasation of blood. Symptoms and course; case in illustration. Diagnosis ; from extra-uterine pregnancy, from retroversion of the uterus, from pelvic abscess, from ovarian tumor. Prognosis. Treatment; comparative merits of interference and expectancy. In all the cases of inflammation of the cellular tissue in the vicinity of the uterus which engaged our attention in the last lecture, the disease was spoken of as succeeding to delivery or miscarriage. In such cases the disorder of the puerperal processes by which it is accompanied usually gives to the attentive observer early notice of its occurrence. The affection may, however, come on quite independently of puerperal causes, and may sometimes, though I believe rarely, be wholly unconnected with any previous disorder of the uterus, or with any previous disturbance of its functions. In cases of this last description, the local ailment seems usually to develop itself out of the symptoms of a general peritonitis of no very great severity, which, though relieved by treatment, have not altogether disappeared, but have become limited in extent, and have been referred to the uterus and the pelvic region, where a careful examination discovers just the same changes to have taken place as succeed to inflammation in the puerperal state. A woman aged thirty-nine, married twenty-one years, thrice pregnant, her youngest child being eleven years old, was attacked while following her occupation at a mangle by sickness, retching, and pain in the abdomen, severest at its lowest part. She kept her bed for a week, then attended at the out-patient room of the hospital for ten days, during which time leeches were applied to the abdomen; and being afterwards admitted as an in-patient, she was further depleted, and subjected to a mercurial ointment, by which her mouth was made slightly sore. Her severer symptoms were relieved by these means, but as she was not cured she was transferred to my care at the end of ten days more, or just a month from the commencement of her illness. 326 EXCEPTIONAL CASES. At this time she complained of very severe pain at the lower part of her abdomen, extending to her back, and increased in paroxysms that came on causelessly; as well as of constant sickness after taking any food or drink, and of troublesome diarrhoea. Her abdomen was distended and generally tympanitic, but percussion yielded a dull sound in the right iliac region, though there was no distinct tumor to be there discovered. The uterus was found on a vaginal examination carried forward, and to the right side, by a tumor of stony hardness, smooth surface, and globular form, extending from near the left sacroiliac synchondrosis, pushing the rectum before it and to one side, and occupying a great part of the pelvic brim. Tenesmus and pain accompanying the frequent efforts at defecation were for a time very distressing, but the appearance of pus in the evacuations, and its occasional discharge by the bowel unmixed with feces, were followed at the end of a week by much relief. At the end of six weeks the patient left the hospital, the tumor being much diminished, and the uterus having returned more nearly to its natural position, though being still firmly fixed in the pelvis, as indeed it continued thirteen months afterwards. In this case the opportunity was afforded of watching the evil while still in progress, but accident sometimes bring cases before us where though the mischief already done is extensive, we can gather but little information as to the circumstances in which it originated. Inquiry may perhaps elicit a vague history of fever, or of an illness accompanied by disorder of the bowels, or by abdominal pain, but unattended as far as the patient knows by uterine ailment; and yet the womb may be firmly fixed in the pelvis, and thickening of the adjacent parts may plainly show that at some distant period the cellular tissue in its vicinity had been the seat of serious inflammation. In such cases there is no reason for doubting our patient's veracity; the symptoms of the slighter ailment were masked by those of the more grave disease, or perhaps were really by no means urgent in their character, and were regarded as only the ordinary discomforts of a tedious convalescence. They are of great practical importance, as illustrations of the necessity for watching very carefully the convalescence of patients who have been the subject of any illness in the course of which abdominal inflammation may by possibility occur. The mischief may possibly not entirely pass away, but with few signs to betray its existence, may become limited to parts within the pelvis. It may then be confined to the peritoneal -surface of the viscera, matting the different organs together by firm adhesions, which interfere with the elevation of the uterus out of the pelvic cavity, and thus in the event of pregnancy occurring give occasion to its premature termination, though absolute sterility is by no means an infrequent consequence of the attack. Or, instead of being limited to the peritoneum, the inflammation may chiefly affect the cellular tissue in the vicinity of the uterus, and may issue in suppuration, or in deposit and permanent thickening, which may remain long after the acute disease is over, sometimes even after the memory of it has almost passed away. It behooves us then to bear these risks in mind, not to take the decline of TREATMENT OF THE AFFECTION. 327 the symptoms in such cases as a certain pledge of their complete disappearance; but so long as there is any pain or discomfort referred to the lower part of the abdomen or the neighborhood of the uterus, to have our suspicions alive to the possible occurrence either of circumscribed peritonitis, or of inflammation of the cellular tissue connected with the womb or its appendages. In considering the treatment of this affection, we must bear in mind the difference between the results likely to be obtained before suppuration has taken place and after it has occurred. In the former case, a few days will suffice for the complete removal of all traces of disease; in the latter, weeks or months will often issue in but a very incomplete recovery. Whether treated in its acute or in its chronic stage, indeed, our prognosis may almost always be favorable as for as the life of the patient is concerned. When the disease, however, is of long standing, it is idle to attempt any reply to inquiries as to the probable duration of the patient's illness, or as to the time that must elapse before the pelvic organs return to their previous state, and to the regular performance of their wonted functions. It is not a heroic plan of treatment, however, which is necessary when we see the disease at its onset, in order to cut short its further progress. A dozen leeches applied to whichever iliac region is the seat of pain; a warm poultice, frequently renewed, and continued for thirty-six or forty-eight hours; a gentle aperient, some mild febrifuge medicines, and opiates to subdue pain and to insure for the patient quiet rest at night, with a generally mild and unstirnulating diet, are the simple, and, as I believe, the fully sufficient means by which the symptoms may be combated. Should the pain and tenderness not be removed by the first depletion, half a dozen leeches ought to be reapplied within the next twenty-four hours; but the frequent abstraction of blood is undesirable. The tenderness and pain which sometimes remain even after blood has been drawn to as great an extent as seems expedient, and which are often accompanied by considerable fulness of the affected side, are generally much relieved, often altogether removed, by the application of an ointment composed of two drachms of extract of belladonna, and six drachms of mercurial ointment, which may be thickly spread on lint, covered with oiled silk, and renewed every twenty-four hours. The relief, too, is obtained quite independently of the production of any specific mercurial influence on the system. If, in addition to the pain at one or other side of the abdomen, there should be difficulty in micturition, or tenesmus, or bearing down, or much pelvic pain or discomfort, it is probable that a vaginal examination will discover the mischief not to be limited to the uterine appendages, but to involve the cellular tissue between the uterus and rectum, or between that organ and the bladder. In this case the application of four or six leeches to the uterus itself, by means of the speculum, will often afford an amount of relief that would be vainly sought for by the employment of four times their number if put on externally. After all general febrile disturbance has subsided, and when nothing remains but a little local pain and tenderness, and perhaps some stiff- 328 TREATMENT OF THE AFFECTION. ness in the limb of the affected side, the application of a small blister, so as scarcely to vesicate, will often yield great relief, and this may be repeated two or three times, at intervals of as many days, its situation being varied just sufficiently to obviate the production of a troublesome sore. In many instances, however, if the case is seen quite at the outset, the symptoms disappear at once after a single application of leeches, and our chief difficulty then consists in persuading our patient to submit to those restrictions and to observe those precautions which may seem to her to be dictated by our over-carefulness rather than by the actual necessities of her case. The avoidance of fluctuations of temperature, and of premature exertion of any kind, is indeed a matter of the greatest possible importance during the whole period of convalescence. So long as there are any considerable remains of pain, or as there is much tenderness on pressure in the iliac region, or over the pubes, it is unsafe for the patient to leave her bed, or even to move much from the recumbent posture; for there is risk, not simply of a very slight cause producing an exacerbation of the inflammation at its original seat, but also, as has been already explained, of mischief attacking the opposite side. Now and then, too,'phlegmasia dolens has come on under my observation in cases where all active symptoms had already passed away, and where no special cause could be assigned for its occurrence. Even after complete recovery, the return of menstruation, or even of the period at which the menses ought to occur, calls for fresh solicitude, and any recurrence of pain, or even of uneasiness, any rekindling of febrile disturbance, must be at once met by a repetition of local bleeding, and a renewal of former precautions and former treatment. Unfortunately, in the great majority of cases, the evil, before it attracts attention or receives appropriate treatment, has advanced further, and there is not merely a general sense of fulness at one side of the abdomen where the patient complains of pain, but a distinct tumor is already perceptible on external or internal examination. In these circumstances a speedy recovery can no longer be anticipated, but something may still be done to prevent any abundant formation of matter, to favor the absorption of the sero-purulent •fluid already poured out, and to bring about the resolution of the tumor. The application of leeches is as appropriate here as in the earlier stages of the complaint, though, as it will probably be expedient to repeat them several times, it is seldom desirable to apply more than six or eight at once. The warmth of the poultice is as grateful as at the outset of the affection, while, if the pain is very severe, the use of laudanum instead of water in mixing it will render it a very powerful local sedative, aud its employment need not at all interfere with the use of the belladonna and mercurial ointment of which I spoke just now. I am not, however, accustomed, in cases which have already advanced to the formation of a definite tumor, to rely exclusively on the effects of depletion and of general hygienic measures, but usually give small doses of some mild mercurial preparation, and continue their use sufficiently long to produce slight soreness of the mouth. A five-grain pill, composed of equal parts of Dover's powder and gray powder, TREATMENT OF THE' AFFECTION. 329 given twice a day, usually has this effect in a week or ten days, and, thus employed, it seems to have the twofold result of preventing the extension of mischief on the one hand, and of promoting the absorption of the products of inflammation on the other. If the symptoms are urgent, I sometimes give the pill every six hours, but am not in the practice of giving calomel, nor even of persevering with the more frequent doses of gray powder if they should appear to irritate the bowels. As in most local inflammations, the night is usually the time of the greatest suffering, and an anodyne is generally needed towards evening; camphor, in five-grain doses, being a very useful addition to any opiate which may be employed. It is seldom that any rigorously antiphlogistic plan is suitable in this stage of the affection. Good beef-tea is indispensable, wine and tonics are generally needed ; I think I may say always, when any even vague sense of fluctuation shows that matter in some considerable quantity is already present. A disposition to irritability of the bowels frequently contraindicates the use of quinine, and I therefore generally prefer the liquor cinchona), as being free from any of those objections which maybe alleged against most other preparations of bark. Slowly, almost imperceptibly, in proportion as the symptoms of constitutional disorder abate, the swelling itself in some instances diminishes in size, till at length an indistinct thickening is all that is left behind. But still this is a more favorable issue than we often meet with, or than we can ever venture to count upon, where a distinct tumor has formed. Often, though some abatement of the general symptoms takes place, the tumor enlarges, becomes tenser, and feels more elastic; a vague sense of deep-seated fluctuation is communicated to the finger, and may continue for weeks without growing more perceptible, till at length the abscess begins to discharge itself through one or the other of the channels which were described in the last lecture. The question now naturally suggests itself, whether, when suppuration has once occurred, we cannot expedite the escape of the matter, and thereby hasten the recovery of the patient? I believe that as a general rule it is safer to leave the emptying of the abscess entirely to nature, rather than to attempt the evacuation of its contents by puncture; those cases always excepted in which the inflammation has attacked the cellular tissue external to the peritoneum, and where the abscess consequently points in the abdominal wall. In those cases the very tardy advance of the matter towards the surface may sometimes be accelerated by the application of a blister; for even here it is not expedient to make an incision so long as any considerable thickness of parts intervenes. In the far more frequent instances in which the seat of the mischief is within the pelvic cavity, the pus tends to escape either per vaginam or per rectum, and the attempt to anticipate by puncture the exact course which it may take is very frequently unsuccessful, and not always safe. The natural relation of parts is much changed by the effects of the inflammation ; the swelling and tension of the vaginal walls extend far beyond the limits which circumscribe an}' actual collection of matter, and it is "very likely that the trocar may be merely thrust through hardened textures, and, though passing 330 QUESTION OF PUNCTURE OF ABSCESS CONSIDERED. very near to the collection of matter, may entirely fail to enter it. The extent and relations of the tumor can be most accurately determined, and puncture can consequently be most safely performed, when the cellular tissue between the vagina and rectum has been the seat of the inflammation ; and a Pouteau's trocar introduced by the vagina will generally reach the matter, if the indications of its presence have been distinct. In one case, where inflammation of the cellular tissue between the uterus and bladder had issued in suppuration, the escape of Ix of pus on puncture being made proved the expediency of the interference. In a few days, however, the vaginal tumor had reacquired almost its former size; the puncture was repeated, but no pus followed, for the trocar had at once entered the bladder through the firm and cedematous vaginal wall; an accident which fortunately was not followed by any bad consequences. The previous introduction of a silver catheter into the bladder in the one case, and examination made simultaneously with one finger in the rectum and the other in the vagina in the other case, will suffice to prevent a mistake which otherwise is more easily committed than might be supposed possible. The management of the patient after the discharge of the contents of the abscess calls for no special rules. The chief difference indeed between those cases in which the discharge of pus takes place, and those in which it is either not secreted or is absorbed, consists in the greater degree of debility to which in the former circumstances the patient is reduced; a debility which is often extreme if the suppuration has been extensive, or if the discharge of pus is of long continuance. Even then, however, and in spite of well-marked hectic fever, and of sweats alternating with colliquative diarrhoea, by which, and by the exhaustion produced by continued suffering, life seems sometimes to be seriously threatened, the disease terminated fatally only in two out of the fifty-two patients on whom these remarks are founded, and death in one of these instances was due not to the affection of the cellular tissue between the uterus and rectum, but to the rupture into the abdominal cavity of a large intra-peritoneal abscess. With reference to the thickening left behind after the cessation of all active inflammation, I do not think that we can do much more than trust to time for its gradual, often indeed for its partial removal. Blisters, indeed, occasionally applied in the iliac region do something to relieve the pain and uncomfortable sensations which may long outlast the other symptoms; and they may, perhaps, somewhat accelerate the removal of thickening in the substance of the broad ligament. I have little faith, however, in the external application of iodine, or in its introduction as an ointment into the vagina; nor do I think that the subjecting a patient to a course of mercurial remedies or of preparations of iodine is likely to effect any local good at all equivalent to the impairment of the constitutional powers which such remedies can scarcely fail to produce. Within the past few years attention has been directed, chiefly by French writers, to cases in which tumors have been formed in the immediate vicinity of the uterus* by the effusion of blood either into the cellular tissue around the womb, or into the peritoneal cavity in the cul-de-sac 331 EFFUSIONS OF BLOOD BEHIND THE UTERUS. between the uterus and rectum. 1 In both instances the hemorrhage is generally associated with some previous disorder of the menstrual function, often with its temporary suppression; the congestion of the sexual organs relieving itself by a profuse outpouring of blood, for which effusions the name of uterine, retro-uterine, or peri-uterine hcematocele has been proposed. When the hemorrhage takes place into the peritoneal cavity, its source has probably in the first instance been the lining membrane of the uterus itself and the B'allopian tubes, whence escaping at their fimbriated extremities it collects in the cul-de-sac behind the uterus. In one post-mortem examination this process was seen in actual course of occurrence, both tubes being distended with blood, and a partially decolorized coagulum hanging from the extremity of one of them. The blood thus poured out speedily excites inflammation, and adhesions forming between the adjacent coils of intestines shut it out 1 Cases of pelvic tumor, giving issue not to matter but to more or less altered blood, are scattered here and there through our medical records, and some of them may be found referred to by M. Huguier, in a lecture on uterine hematocele, which he gave before the Surgical Society of Paris, on May 28, 1851. As early as 1843, M. Velpeau, at p. 125 of his llecherches sur les Cavites Closes, gave an account of one instance in which he evacuated the sanguineous contents of one of these swellings, and afterwards injected a solution of iodine into the cavity. He seems, too, to have entertained a correct idea as to the nature of the affection ; but the mistake into which M. Malgaigne fell in the year 1850, who, thinking to enucleate a librous tumor of the posterior uterine wall, opened one of these collections of blood behind the womb (an operation which was followed by fatal hemorrhage), shows that the subject, even down to this time, had attracted very little attention. In the year 1851, M. Nelaton gave some lectures on the subject of uterine, or as he termed it, from its usual situation, retro-uterine haematocele, which were published in the Gazette des Hopitaux, Dec. 11 and 13, 1851. In them he refers to 15 cases, namely, 6' of his own, 2 reported by Bourdon as occurring in the practice of M. Hecamier, 1 reported by M. Laugier in vol. v. of the Dictionnaire en 30 volumes, 2 cases which Nelaton saw in the practice of M. Beau, 1, Malgaigne's unfortunate case, 1 of M. Dufraigne, 1 of M. Latis, 1 of M. Huguier. He has since recorded another case in the Moniteur des Hopitaux, August 23,185(J, and has made additional remarks on the affection in the Gazette des Hopitaux, 1855, No. 23, in which he advocates an expectant mode of treatment. Other cases are recorded by M. Gallard, Union Medicale, 1855, and Gazette Hebdomadaire, Oct. 9, 1857, Laborderie, Gazette des Hopitaux, 1854, No. 149 ; Bernutz, Archives de Medecine, June, 1848, p. 133 ; Piogey, Bull, de la Societe Anatomique, 1850, p. 91; Robert, Bull, de la Societe de Chirurgie, May 22, 1851, p. 130", and Gazette des Hopitaux, May 1, 1855, p. 204; Follin, Gazette des Hopitaux, 1855, June 5, p. 260; Laborderie, ibid., 1854, No. 149 ; Monod, Bull, de la Societe de Chirurgie, June 4, 1851, p. 154; and Marotte, ibid. p. 152; and Engelhard, Archives de Medecine, June, 1857. There is besides much valuable information to be gathered from the discussion on the subject which took place in the Societe de Chirurgie, May 14, 21, and June 4, 1851, and which is reported at pp. 132, 154, and 151 of the Bulletin, and in the inaugural thesis of M. Vigues, Des Tumours Sanguines de l'Excavation Pelvionne choz la Femme, 4to., Paris, 1850, with which, however, I am acquainted only through an abstract in Schmidt's Jahrbiicher. Besides these communications, all of which are of a directly practical character, one of a theoretical kind, was addressed by M. Laugier to the Academie des Sciences, and is published at p. 455 of vol. xl. of the Comptes Rendus. Its object is to connect the occurrence of these effusions witli the escape of the ovule at or about the menstrual period. In Germany but few cases have hitherto been recorded : by Credo, Monatschrift f. Geburtskund, vol. ix. p. 1; Breslau, ibid., p. 455 ; and Hirtzfelder, ibid., vol. x. p. 312 ; and in our own country Dr. Tilt is the only writer who has noticed it. The second edition of his work on Diseases of Women, p. 261, contains the particulars of one case which came under his own notice, and a detailed account of most of the observations of French writers ou the subject. 332 SYMPTOMS AND COURSE from the cavity of the abdomen. It here undergoes within the artificial cyst that incloses it the same changes as are incidental to sanguineous effusions elsewhere. Sometimes the blood is altogether removed by absorption, and adhesions between the uterus and adjacent viscera remain the only evidence of the bygone mischief. At other times an aperture of communication forms with the rectum, or more rarely with the vagina, and the decomposed blood is expelled, the patient either altogether recovering, or the sac remaining a pussecreting surface, and pelvic abscess succeecjing to the hematocele, as in a case which came under my own observation. In cases which have a fatal issue this is due either to the recurrence of hemorrhage exhausting the patient, or more commonly to the irritation extending beyond its original seat, and at length involving the whole of the peritoneum in a general inflammation. In two out of eight post-mortem examinations of which I have found a record, the hemorrhage seemed to have been furnished entirely from the uterus and Fallopian tubes; in one the vessels of the ovaries had given way under a more than usually intense congestion of those organs. In one it appeared to have had a twofold source, being derived in part from the tubes, in part from the vessels of the broad ligament, into the tissues of which blood was effused. In two of the remaining four cases the blood was poured out behind the uterus but beneath the peritoneum ; in one beneath the peritoneum in the iliac fossa, and in the fourth between the folds of the broad ligament. 1 We learn, then, from these observations the existence of a previously unknown hazard attendant on disorders of the sexual system in women: that not merely may intense congestion lead to profuse and dangerous floodings, or functional disturbance issue in inflammation of parts in the vicinity of the uterus, but also that vessels may give way, and hemorrhage take place inwardly, in situations where it is hard to discover, and still harder to suppress. As might be expected, the accident is one which takes place only during the period of sexual vigor, it having occurred in 21 women at the following ages:— Under 20 in 2 Between 20 and 25 " 2 " 25 " 30 " 7 30 " 35 " 5 " 35 « 40 " 4 At 40 « 1 21 Of the above 21 patients 15 were married, 3 were single, and the civil state of the other 3 is not mentioned. The affection has scarcely been observed often enough or with sufficient minuteness to allow of its features being sketched with complete exactness, though in all the cases of it there is a sort of general family 1 The post-mortem observations are those of MM. Malgaigne, Monod, Marotte, Robert, Follin, Bernutz, Piogey, and Engelhard. 333 OF UTERINE HEMATOCELE. likeness which I think would enable the attentive observer usually to recognize it, or which at least would arouse his suspicions as to its possible character. Of the four cases that came under my own notice, one was that of a young unmarried woman, aged twenty-two, who having long suffered from attacks of pain of a paroxysmal character in the left iliac region, was surprised at the age of nineteen by a profuse discharge of a dirty reddish brown color from the vagina, which continued in varying quantity for many weeks, and was then succeeded by a puriform discharge occurring in gushes, which continued down to the time of her coming under my care. A tumor in the iliac region, and another felt behind the uterus fixing that organ in its place, were the evidences of some bygone inflammation; of an old pelvic abscess in short, the origin of which in an effusion of blood was rather inferred from the patient's previous history than actually demonstrated. Puncture of the abscess and the injection of a solution of iodine into its cavity were followed by its complete cure. In the other cases the accident was of recent occurrence, and its symptoms were sufficiently characteristic to remove all doubts as to its nature. The patients were married women of the respective ages of 33, 24, and 25 years. In the first, exertion on the second day after miscarriage at the sixth week was followed by great increase of the sanguineous discharge, which continued for twelve weeks. At the end of this time a vaginal examination detected a tumor behind the uterus of the size of an apple. On being punctured it gave issue to a reddish-brown discharge, the continuance of which for three weeks was followed by the complete disappearance of the swelling. In the second patient, who for five years had lived in sterile marriage, the symptoms gradually developed themselves during the persistence for two months of a discharge supposed to be menstrual. Here, too, a tumor behind the womb gave issue when punctured to a black offensive discharge, which evidently consisted of decomposed blood, and the patient having surmounted an attack of peritonitis perfectly recovered. The third case so well illustrates the symptoms and the dangers of the affection, that it seems to me deserving of relation somewhat in detail. A tall, stout, and tolerably healthy-looking woman, twenty-five years old, who had been married for seven years, had been pregnant four times, and had given birth to three living children, of whom the youngest was twelve months old, was admitted into St. Bartholomew's Hospital on February 22d, 1851. Her general health had been good, her labors had been natural, and after all of them she had menstruated regularly during the whole period of lactation. After her third labor matters went on as usual until Christmas, when she menstruated naturally, but ever since that time a sanguineous discharge, neither very profuse nor intermingled with coagula, had been constantly present. For a month she had had pain of a bearing-down character, aggravated by exertion, but not notably relieved by rest, nor by any particular position; and she had also for the same time suffered from occasional fainting fits. Micturition was frequent and painful, and her urine was reported to be both scanty and high-colored. A medical man whom she had consulted told her that " her womb was down." 334 SYMPTOMS AND COURSE OF UTERINE HEMATOCELE. The abdomen was large and somewhat tense, its enlargement being d ue to the presence of a tumor, the surface of which was slightly uneven, occupying the whole of the left side, extending three inches above the umbilicus, reaching about three inches across the mesial line, though gradually sloping downwards, so that on the right side its upper margin was an inch and a half below the umbilicus. The tumor was firm, non-fluctuating, very tender to the touch, especially in the left iliac region. The finger on being introduced into the vagina came almost immediately on a somewhat firm, elastic tumor, of an oval shape, of about the thickness of the wrist, and which had pushed before it the posterior vaginal wall. This tumor seemed to pass over into the substance of the uterus about half an inch behind its orifice, the whole organ being so misplaced that the os uteri was felt lying horizontally immediately behind the symphysis pubis. The finger passed up in the front and right side of the pelvis without encountering any resistance; but at the left side and posterior part of the pelvis a firm tumor was felt apparently continuous with that immediately behind the uterus. The vessels of the tumor pulsated very forcibly. About three ounces of a bloody fluid were drawn off on the tumor being punctured with a grooved needle through the vagina. The microscope discovered nothing but blood corpuscles in the fluid, and with the view of emptying the tumor if possible, and of thereby relieving the painful pressure on the rectum, which occasioned much distress, a Pouteau's trocar and canula were introduced, but only about four ounces of fluid of the same character as before were let out. The tumor was not thereby much diminished in size, nor was the patient's discomfort much alleviated. On February 27th no fresh interference having been resorted to, she was seized with peritonitis, during the course of which there was manifest increase of the tumor, which extended more towards the right side of her abdomen. By the 3d of March all active symptoms were subdued, and on that day the patient passed two copious evacuations, which were perfectly black, and apparently consisted entirely of altered blood. The same afternoon, too, she experienced a sensation as of something giving way internally, and this was immediately followed by an abundant gush from the vagina of very fetid fluid, resembling coffee-grounds in appearance. This fluid flowed at first very abundantly, afterwards more scantily till morning, when it ceased, though another gush of it took place on the following day, and afterwards recurred occasionally for several days, acquiring by degrees a lighter color, and becoming at last a dirty sero-purulent matter. Very slowly the patient's general health improved, while at the same time her abdomen diminished in size, and having measured forty-six inches on her admission had shrunk to forty inches on March 24th. The tumor in the left hypogastric region at the same time manifestly diminished in size and became more mesial in its position ; and on April 5th the uterus had nearly regained its natural situation ; there was no longer any distinct tumor behind it, but a hard, semicartilaginous thickening, ill-defined as to its extent and relations. On April 17th all discharge from the vagina finally 335 SYMPTOMS OF THE AFFECTION. — ITS DIAGNOSIS. ceased, and on May 5th all trace of abdominal tumor had completely disappeared, the position of the uterus was quite natural, the thickening behind it was much lessened. A year afterwards I again saw the woman ; she was in perfect health, menstruating regularly; there was no trace of abdominal tumor, the uterus was perfectly movable, and there was scarcely any thickening to be felt behind it, or to its left side. In its main features this case corresponds very closely with the description of uterine hasmatocele given by M. Nelaton and others. Though some form of disorder of the menstrual flux usually precedes the attack, the suppression of that discharge does not seem to be so constant as might on theoretical grounds have been anticipated; for sometimes irregularity has been observed both in its return and in the quantity of blood lost; at other times actual menorrhagia, and at others again a flow of blood, not alarming in its quantity, but at length causing anxiety by its continuance. 1 In most cases, too, even though the menses had been previously suppressed, a somewhat profuse flow of blood, sometimes for a few days, sometimes for a few weeks, precedes the actual occurrence of the internal hemorrhage ; but the development of the acute symptoms generally follows a temporary diminution or cessation of the sanguineous discharge. The acute symptoms scarcely ever appear till after the sanguineous discharge has either ceased completely, or has become much diminished in quantity. The symptoms are those of general febrile disturbance, seldom, however, very severe, accompanied by abdominal pain, and usually by enlargement of the abdomen. Even of their own accord, these febrile symptoms usually subside, and the pain also diminishes; a sense of weight in the pelvis, bearing down, difficult micturition, and still more difficult defecation remaining behind, and leading by the distress which they occasion to a vaginal examination, and to the discovery of the pelvic tumor. When matters have reached this stage, the subsequent progress of the case seems to depend on circumstances. Puncture of the tumor may be followed by the complete evacuation of its contents, and the rapid recovery of the patient; or an expectant mode of treatment may be succeeded by the slow absorption of the blood, and by gradual convalescence. But events may follow a different course, and one far less auspicious: peritonitis may come on as the result perhaps of some fresh effusion of blood, or in the course of nature's efforts to eliminate it; and this peritonitis occurring in a patient already weakened by the hemorrhages may prove fatal. Or, after more or less suffering, the blood may find a passage by the bowel, or by the vagina, or as in the case just related, by both at once; and with its discharge the 1 In 13 out of 20 cases, suppression of the menses, or the irregularity of their return, ¦which was postponed beyond its proper time, preceded the development of the symptoms of the effusion ; in o', on the contrary, there was menorrhagia, or a constant sanguineous flow, and in one instance abortion was followed for two months by constant, though not profuse hemorrhage. In six of the cases, or in rather less than a fourth, pain preceded the acute symptoms, but neither suppression of the menses nor any other form of menstrual disorder. 336 DIAGNOSIS OF UTERINE HEMATOCELE. swelling may disappear, and the patient eventually regain perfect health; her whole illness having extended over a period of from' two months to six or seven. There are four conditions with which this uterine hcematocele may be confounded; viz., extra-uterine pregnancy, retroversion of the pregnant uterus, inflammation of the cellular tissue between the uterus and rectum, and ovarian tumor; and the points of similarity between each of these are quite sufficient to lead very readily into error. The suppression of the menses, the abdominal or pelvic discomfort, and the sense of bearing down backwards, are symptoms common to eff usion of blood behind the uterus, and to an extra-uterine fcetation between the second and fourth months; while the general contour of the tumor is very similar in the two cases, and there is the same remarkable pulsation of the vessels distributed to it in both. The attacks of pain in the extra-uterine fcetation are, however, usually more intense and more paroxysmal, while the discomfort in the intervals is less; the sanguineous discharge is absent, and the uterus, if examined with the sound, is ascertained to be increased in size; and even without it the condition of the os uteri and portio vaginalis of the cervix, with the puffy lips, the closed orifice, and the swollen tissue differs widely from the completely undeveloped state of those parts in cases of hemorrhage about the womb. The effusion when considerable may cause, as it did in the case which I have related, complete retroversion of the womb, a condition which, when associated as it is sometimes with suppression of the menses for two or three months, may raise the suspicion of pregnancy, and lead to the tumor being taken for the fundus of the enlarged and misplaced uterus. Professor Cre'de, of Berlin, relates an instance in which these very circumstances led him for a moment into error, and which he endeavored vainly to replace what he supposed to be the pregnant and retroverted womb. Further observation soon led him right, and the same considerations as rectified his diagnosis may keep us from error. The cervix and os uteri presented none of the changes of pregnancy; the bladder was not affected; and the uterine sound, which entered readily in the natural direction, could not be turned round with its concavity backwards, nor be made to enter the tumor, intimately though it seemed connected with the womb. The characters of the tumor in cases of inflammation of the uterine cellular tissue very closely resemble those of uterine hamnatocele, and the history and symptoms present a very near analogy in the two affections. There are, however, some points of difference between them which are generally sufficiently marked to preserve the attentive observer from error. Pelvic abscess is very generally the consequence of delivery or of abortion, while it is scarcely ever associated, with any other form of menstrual disorder than its sudden suppression; the inflammatory symptoms developing themselves directly out of that accident. Uterine haematocele, on the contrary, is seldom the immediate consequence of a single suppression of menstruation; it is not infrequently preceded by menorrhagia, and is often accompanied, at any rate for a time, by a copious sanguineous discharge, a symptom DIAGNOSIS OF UTERINE HEMATOCELE. 337 which never attends upon inflammation of the cellular tissue in the vicinity of the uterus. Moreover, the tumor consequent on inflammation is at first very firm and resistant, and becomes soft only by degrees with the advance of suppuration. The tumor of uterine hasmatocele, on the contrary, is soft at first, and becomes more resistant in time, as'the fluid elements of the blood are partially removed, while at no period are there the same thickening and induration about it which are so remarkable in that part of the vaginal wall adjacent to any collection of matter. Ovarian cysts occupy when small the same situation as uterine haomatocele; they are not, however, so sudden in their occurrence, nor so rapid in their increase; while though their development-is often associated with menstrual irregularity, they are not attended by any constant sanguineous discharge. The ovarian tumors, too, do not descend equally low into the recto-vaginal pouch, and consequently do not produce the same difficulty in defecation, while, further, they are not so intimately connected with the uterine wall, and the womb can usually by means of the sound be completely isolated from the adjacent swelling. The number of instances of this affection hitherto observed is scarcely sufficient to enable us to determine accurately the degree of danger attaching to it, any more than the comparative frequency of the intra and extra-peritoneal variety of the hemorrhage. Including the four cases which came under my own observation, I can find some account, though often very meagre, of 41 instances of uterine H;ematocele, 33 of which terminated in recovery, 8 in death; or, in other words, the deaths were in the proportion of 19.5 per cent, of the total number of cases. In one of the fatal cases death took place from phthisis, and was therefore the indirect rather than the immediate result of the affection, twice it resulted from loss of blood, which, however, was in one of the instances due to the accidental wounding of a vessel of the cervix uteri, once it took place under the symptoms of pyemia, and in the remaining four instances was produced by peritonitis of a rather chronic kind ; the patient surviving a month in one case, forty-five days in another, four and a half months in the third, and seven and a half months in the last. There can, I apprehend, be little doubt but that the real fatality of this affection is considerably less than would appear from our present imperfect data. On the one hand, some of the cases, such as that of M. Bernutz and of M. Piogey, have been reported as pathological rarities ; and, on the other, many which have had a favorable issue have been unrecorded. Many, too, have unquestionably passed unrecognized ; for the disposition to the spontaneous absorption of the effused blood, unless the quantity poured out has been enormous, seems to be very great, and menstrual disorder and abdominal pain have probably often passed away without a suspicion having arisen of their connection with hemorrhage around the uterus, or into the cavity of the peritoneum. Still, every allowance being made for the influence of these circumstances, uterine hematocele must, I imagine, be always regarded as an accident of a much graver kind than mere inflamma- 22 338 TREATMENT OF UTERINE HEMATOCELE. tion of the cellular tissue in the neighborhood of the uterus, or of its appendages. In the treatment of this affection two different modes of procedure have been advocated, of which one is the expectant plan; while early interference and complete evacuation of the sac are the principles of the other. The statistics of the two methods yield th*e following results : — Treated on the expectant plan 14 Eecovered 11 Died 3 " by puncture.... 27 " 22 "5 41 33 8 but from such slender data I should hesitate to draw any conclusion. I imagine, indeed, that neither plan can be regarded as absolutely the best, but that the special circumstances of each case must guide us. In three of my cases, that alone excepted in which the effusion had already become a chronic evil, the puncture was followed by peritoneal inflammation, which was once of great severity; and the existence of an opening in the vagina did not in that instance prevent the establishment of a communication with the bowels and the discharge of a large quantity of blood per anum. In some instances, too, the fibrin of the blood forms, by its coagulation, a thick layer within the sac, and prevents'the escape of the fluid contents after puncture with the trocar; while the enlarging the opening with a bistoury seems to be free neitheV from the dangers of hemorrhage on the one side, nor from those of inflammation of the cyst on the other. The complete emptying of the cyst, its subsequent washing out with water, and the injection of a solution of iodine into it, as practised by M. Velpeau and advocated by M. Eobert, appear to me hazardous proceedings, except when resorted to quite in the chronic state of the affection, when all disposition to hemorrhage has ceased, and the susceptibilities of the cyst wall have become blunted by the lapse of time. In the earlier stages of the affection, absolute rest, local depletion, and the ministering to each symptom as it occurs, are the indications which we should endeavor to fulfil; while the presence of a tumor even of considerable dimensions, or even its increase to some extent after its first discovery should not, I venture to think, lead us to puncture it, apart from some very serious ill, or suffering clearly attributable to it. In the event of puncture being obviously necessary, a Pouteau's trocar would appear to be the safest and most manageable instrument to employ, and was used in all of my cases. In none of these, however, it must be admitted, was the escape of the blood immediate; but I should imagine that the use of a curved trocar and canula of the thickness of one's finger, such as I have employed to puncture ovarian cysts, per vaginam, would obviate the inconvenience with less risk than would be incurred by the use of the knife. After puncture, the great hazard seems to be that of the supervention of inflammation, and my own experience leads me to regard this as very considerable, though it was controlled in each instance by active treatment. Further experience may very possibly modify some of the views I 339 DISEASES OF PARTS CONNECTED WITH THE UTERUS. have just now expressed, and may show that the balance inclines greatly in favor of very early interference in these cases. I may just add, however, that the opinions of M Nelaton appear to lean even more decidedly than at first they did towards the adoption of an expectant plan of treatment, and to leaving to nature alone the removal of the blood, even though poured out in great abundance. LECTURE XXIV. DISEASES OF FARTS CONNECTED WITH THE UTERUS—INFLAMMATION AND ITS RESULTS, AND KINDRED PROCESSES. Inflammation of Uterine Appendages : of the Ovaries. Inflammation of the ovaries, imperfect state of our knowledge. Morbid appearances, frequency of inflammation of their peritoneal surface ; inflammation of their substance rare. Changes produced by inflammation in the Graafian vesicles; suppuration, and ovarian abscess. Symptoms of ovarian inflammation ; of its acute form ; of abscess of the ovary ; cases in illustration. Chronic inflammation of the ovary, its frequency probably overrated; neuralgic character of symptoms attributed to it. Occasional occurrence of subacute ovaritis ; relation to it of the so-called displacement of the ovary. Note on Hernia of the Ovary, and on Serous Cysts of Uterus. Over and over again in the course of these lectures I have had occasion to lament the incompleteness of our knowledge, the imperfection of the evidence on which we are compelled to act; and have been fain to content myself with hints and suggestions; with communicating mere fragments of information, where yet I felt that definite statements and positive rules were most needed. Much of the subject of to-day's lecture can, I fear, be treated by me only after this imperfect fashion, unless I widely overstep the limits of my own knowledge, and assume a positive air where yet my convictions are far from settled. Some facts indeed are well known and universally admitted, such as the frequency of acute ovarian inflammation as a complication of puerperal peritonitis, its rarity in other circumstances; but the frequency, the symptoms, and the importance of the more chronic forms of inflammation of the ovaries are questions which have received very discordant replies, and for whose final decision data appear to me to be still wanting. The difficulties to which I have referred do not indeed arise from the rarity with which morbid appearances are discovered in the ovaries, but rather from the uncertainty which prevails as to their nature or as to their importance. In 21 out of 66 instances in which I examined the uterus and its appendages in the adult, the ovaries themselves, or 340 CHANGES IN THE OVARIES parts immediately connected with them, presented changes more or less obviously due to inflammatory action. In 10 of the 21 cases the main, evidence of inflammation consisted in traces of old peritonitis of the uterine appendages, and in 5 of the number there was no evidence of other or of more recent mischief. The amount of this peritonitis varied exceedingly. In some instances it was confined to one side, and its results were nothing more considerable than a thin and partial layer of false membrane on the surface of one or other ovary, and long, filamentous adhesions between the ovary and Fallopian tube. In other cases a complete web of false membrane enveloped the ovaries, thickened the broad ligaments, and by its contraction shortened the ovarian ligaments, thus drawing the ovaries much nearer than is natural to the sides of the uterus, while at the same time they and the Fallopian tubes were firmly and inextricably matted together. Now and then, too, the ovaries were not merely drawn nearer to the uterus, but their position was in other respects changed, they being tied down behind it; as in the following .notes of the examination of the body of a woman wno died at the age of thirty-seven, of chronic bronchitis and emphysema, and all of whose four labors were alleged by her husband to have been perfectly natural. The uterine appendages on either side were doubled back behind the uterus, and matted together in that situation by firm old adhesions, in the cellular tissue of which a good deal of firm granular fat was intermingled. The Fallopian tubes of either side were convoluted, dilated to the size of the little finger, by the presence in them of a thick red secretion, like a mixture of blood and mucus. Each was firmly adherent to its corresponding ovary, so that it was almost impossible to dissect them apart. Though twisted round as above described, they did not pass the mesial line, but wound about on either side of the uterus. On opening them they presented the appearance of a number of freely communicating sacculi, not unlike a section of the Fucus Marimis, and the right, which was the larger of the two, measured at its widest part, which was one inch from the uterus, just an inch and a line when laid open. This enlargement continued, though diminishing till about a quarter of an inch from the uterus, where it ceased; the short remainder of the tubes, though pervious, not being wider than natural. The walls of the tubes were very dense; their muscular structure remarkably distinct, and their lining membrane stout, tough, easily detached from the subjacent tissue, and presenting somewhat of a polished surface. The left ovary was much atrophied, and was with difficulty distinguishable in the midst of the thickened cellular tissue and the fat which abounded on either side of the uterus and within the folds of the broad ligament. The right ovary was much larger than natural, though very little of its proper tissue was distinguishable. Its size, which was that of an unshelled walnut, was chiefly due to a cyst, lined by a smooth, polished membrane, and filled with thick, grumous blood, as well as containing some old coagulum, which required a little force for its detachment. In other cases I have met with a less degree of the same condition of the uterine appendages, and have found the ovary wasted, appa- 341 PRODUCED BY INFLAMMATION. rently as the result of its compression by the formation of false membrane around it, an occurrence to which must probably be attributed the sterility that frequently follows an attack of peritonitis, and the permanent suppression of the menses that occasionally, though less often, succeeds to the same cause. More important than the changes produced by inflammation on the exterior of the ovary are those alterations which it causes in their substance, and especially in the Graafian vesicles. The mere substance of the ovaries does not, indeed, except in the puerperal state, often present appearances indicative of inflammation or of its results. The softening of their tissue, the infiltration with pus —which is sometimes poured out so suddenly and in such abundance as to produce rupture of the organs—or that sloughing of their tissue occasionally observed in the bodies of women who have died during epidemics of puerperal fever, are conditions which, to the best of my knowledge, are not met with in the unimpregnated state. Affections of the ovarian tissue, apart from the puerperal condition, ace, I believe, almost always secondary and subordinate to those of the Graafian vesicles themselves. Thus, when the functions of the ovaries are no longer exercised, and ovules are not in course of production and maturation, we find the substance of the organs shrunken, dense, and frequently intersected by white lines of firm cellular tissue; and just in a similar way do we find it swollen, congested, and infiltrated, in conjunction with a turgid state of the Graafian vesicles, and with the presence of evidences of inflammation about their coats. In these circumstances indeed we may find the whole of the ovary considerably increased in size; but my own experience corresponds with that of Kiwisch, who says that it is extremely unusual for the organ in the unimpregnated condition to be enlarged by any inflammatory affection of its stroma to more than double its natural size. 1 It is in the Graafian vesicles themselves that we find, as indeed might be anticipated, the most important results of inflammation ; and such inflammation is of great moment, from the circumstance that in some instances it is probably the first step in the production of ovarian dropsy. In the case of women who have died during or soon after menstruation, it is, as you know, very usual to find a state of general turgescence of one or other ovary, with great prominence of some of the Graafian vesicles, and minute injection of their external membrane, while a large clot occupies the cavity of that one of the vesicles from which the ovule has escaped. Such appearances of the ovary are physiological, and pass away with the subsidence of the periodical congestion that produced them, the clot itself being gradually removed, and the contracted vesicle disappearing by degrees. Appearances of a somewhat similar kind are met with, however, independent of menstruation, and in circumstances that point directly to inflammation as their cause. Thus, in the case of a prostitute, twenty years of age, who was suffering from severe gonorrhoea at the time of her death from pleuro-pneumonia, the whole interior of the cavity of the uterus was 1 Op. cit., vol. ii. second edition, p. 47. 342 CHANGES IN OVARIES PRODUCED BY INFLAMMATION. covered by a copious puriform secretion, the surface beneath being of a bright red, just like red velvet. This condition ceased abruptly where the plicated structure of the cervix uteri began, but was continued along the whole tract of the Fallopian tubes. They were pervious at their uterine ends, obliterated at their fimbriated extremities, filled with thick pus, which had distended the fimbriae into little pouches, while their lining membrane was of a finely flocculent appearance, and of the most vivid red. The ovaries were rather large; they were somewhat congested, the Graafian vesicles were both numerous and turgid, and their membrane presented a most beautiful appearance, being traversed by very minute vessels, and looking as if the finest vermilion injection had been thrown into them. I do not know exactly what the subsequent stage of the disease would have been if the patient's life had not been cut short by the pneumonia. Probably, however, the contents of the vesicles would next have been obviously changed, and in all likelihood would have eventually become purulent. Such at least were the contents of many of the Graafian vesicles in the right ovary of a girl who died of very acute peritonitis; and in whom there was found a cyst distended with pus, of the size of an orange, connected with that organ, while many of the Graafian vesicles contained little drops of pus, though there was no suppuration of its general tissue, and the other ovary was quite healthy. The large cyst in this case had probably existed for a long time before the commencement of the patient's fatal illness, and the supervention of inflammation in it was very likely the point of departure of all the subsequent mischief. As we shall have occasion hereafter to observe, the occurrence of inflammation and suppuration in an ovarian cyst is an accident by no means unusual, and one which sometimes takes place without giving rise to symptoms so severe as might have been anticipated. Such cases, however, are perfectly distinct from those of primary ovarian abscess, which latter are also, I believe, of much greater rarity. For the most part the increase of such abscesses generally goes on rather slowly, and their development is usually attended with symptoms of far more serious constitutional disturbance than accompanies the growth of an ordinary ovarian cyst; though after a time they not seldom become stationary, and remain so even for years. Thus, in the case of a patient who died twelve years after her first attack of inflammation of the uterine appendages, and four years after her second and last seizure of a similar kind, the right ovary was beset with numerous yellow dots of a matter which looked like softened cheese, probably the result of some change in the contents of the Graafian vesicles, while the left ovary, to which the corresponding tube was firmly adherent, formed an abscess the size of an orange and full of pus. The jcavity of this abscess was sinuous, as if several collections of pus had eventually been fused by the removal of their septa into one, and at its lower part there was a mass of cretaceous matter of the size of a chestnut. There are, besides, some appearances of no great rarity presented by the Graafian vesicles, which have been supposed, and with con- ACUTE OVARITIS. 343 siderable probability, to be the results of a chronic, or, at any rate, of a by-gone inflammation. Such is the loss of transparency of the coats of the vesicles, and especially their entire conversion into firm, whitish, or yellowish-white, shot-like bodies, of the size of a small pea, and of a homogeneous, somewhat friable, texture. In some instances the stroma of the ovaries has appeared unaltered around these bodies, but at other times I have found it also the seat of a 3'ellow matter like fibrin, either infiltrated into the centre of the organ, or deposited in striae which intersected its tissue. This condition, too, has always been associated with considerable thickening of the ovarian capsule, and with a dead white color of its surface ; and the ovary generally has been small and shrunken, and contained few Graafian vesicles, and sometimes none but those which had been the subject of this change. It is not, however, as might be supposed, a result of mere wasting, from the advance of age and the cessation of the generative function, for I have met with this state in the body of a woman who died at the age of twenty-five, and in whose ovaries there were not merely other healthy Graafian vesicles, but also in one a large menstrual clot, and other evidences of recent menstruation. Acute inflammation of the substance of the unimpregnated ovary is of such rare occurrence that no case has come under my own care, and but one has presented itself to my observation. To that case I have already referred, as affording an instance of suppuration in the Graafian follicles themselves, but the cause of death was the supervention of general peritonitis. The patient's history afforded no clue to the cause of her illness, for she was a young unmarried woman, eighteen years old, living in comfort as a domestic servant, and never having had any disorder of her catamenia, or any uterine ailment. Her illness had come on spontaneously four or five days before her admission into the hospital, and not at a menstrual period, with pain in the back and abdomen, fever and languor, for which, however, no treatment was adopted before she entered the hospital. Her symptoms were just those of general peritonitis; a dry skin, a small pulse of 120, urgent thirst, and constant sickness, great headache, a full, tense, and tender abdomen, and much pain in the abdomen and back. Her Condition did not seem to admit of active treatment, and the next day the pulse had risen to 160, the sickness was incessant, the matter vomited being of a dark greenish color; the abdomen was more tense, its tenderness undiminished, but the pain now recurred in paroxysms, between which were intervals of comparative ease. In eighteen hours more she died ; about forty hours from her admission into the hospital. There was universal peritonitis; two pints of purulent fluid were present in the abdominal cavity; and inflammation had extended to the diaphragmatic pleura. The uterus and the left ovary were perfectly healthy. Connected with the right ovary was a cyst filled with pus, which reached as high as the brim of the pelvis, and pus coated the outer surface of the ovary as well as occupied the Graafian vesicles. So rapid a course of the disease, and so serious a termination of it, are of great rarity. Inflammation commencing about the uterine 344 ABSCESS OF THE OVARY. appendages on either side seldom exteuds beyond the peritoneum in the immediate vicinity of the uterus; and even when the substance of the ovary is affected, and inflammation ends in suppuration, it is for the most part from a slow and wasting illness that the patient suffers; the abscess attaining a very large size, and possibly even persisting for years. Such at least is the experience of Kiwisch, 1 and my own more limited observation leads me to the same opinion. He notices the disposition of the symptoms to come to a stand still, so that sometimes the patient suffers chiefly from the mechanical inconvenience of the tumor, while in other instances the arrest of the symptoms is of a more imperfect kind : the patient continues to lose flesh ; occasional febrile attacks come on, till at length a condition of hectic manifests itself, indicative in many instances of decomposition of the contents of the abscess, and death takes place either before or soon after it has discharged itself. All of these occurrences have come under my observation in cases of ovarian cysts in which inflammation has supervened, converting their contents into purulent matter; but I have only once met with an instance in which there was reason to believe that the tumor had been from the commencement an abscess, and had not originated in the inflammation of the cyst wall of a dropsical ovarium. In this instance the patient's illness commenced with suppression of the menses five months after marriage, she being at that time twenty-six years old. The suppression of her menses was followed by pain in the right side of the abdomen, about the situation of the crista ilii, but extending to the opposite side, aggravated by motion or exertion, and confining her by its severity, and by the general constitutional disorder which accompanied it, almost constantly to bed during the six months which preceded her admission into the hospital. Very soon after the commencement of her illness a tumor appeared in the right iliac region, which was said by her medical attendant to be an abscess. A month after the swelling was first perceived a discharge of pus took place from the urethra, which continued at intervals for some weeks, though without any marked change in the swelling. The discharge then ceased for a time, but at the end of three months it again recurred, and continued to take place occasionally until the patient came under my care, though, in spite of this, the tumor had gone on slowly increasing in size. On her admission the patient looked very ill, her countenance was anxious, her pulse frequent, her tongue red at the tip and edges, thickly covered with aphthae. Her abdomen measured twenty-eight inches in circumference at the umbilicus, its enlargement being due to a pyriform tumor in the mesial line, which occupied the hypogastric, umbilical, and lower parts of the epigastric regions, and extended laterally to the lumbar and lower part of the hypochondriac regions. The tumor yielded a distinct sense of fluctuation, and was 1 Kiwisch, op. cit., vol. ii. p. 67, mentions having seen an abscess of the ovary which contained sixteen pints of pus. I have seen thirty five pints of pure pus evacuated from an ovarian cyst; but this was in a case of dropsy, in which inflammation of the cyst wall had supervened, an accident to which further reference will be mado in another lecture. 345 CHKONIO OVARITIS. very tender on pressure, especially in the hypogastric region. The uterus was low down, and carried forwards nearer than natural to the anterior pelvic wall. It did not seem to be altered or enlarged, neither was it fixed in the pelvis, nor was there any thickening of the vaginal walls. The movements of the organ were, however, impeded by some tumor, which, though not dipping down into the pelvic cavity, nor presenting any distinct outline, was yet to be felt, as offering a general resistance on pressure being made in any direction against the roof of the vagina. Three weeks after the patient's admission pus began to be discharged from the bowel, and in the course of a little more than a fortnight under the continuance of these discharges the tumor almost entirely disappeared, though much pain continued to be felt in the right iliac region, and a little pus occasionally re-collected in the sac of the abscess, and was from time to time discharged per rectum. The progress of her recovery was retarded by an attack of phlegmasia dolens of the left leg; but about two months after her reception into the hospital she was discharged perfectly well, and no trace of the tumor was to be detected anywhere. In this case the suddenness of the attack, the acute character of the symptoms which attended its onset, and the rapid formation of the tumor, are alike incompatible with the supposition that the case was one of dropsy of the ovary. On the other hand, the situation of the swelling in the abdomen, the mobility of the uterus, and the absence of thickening by the side of the womb, or at the roof of the vagina, clearly show that the case was not one of pelvic abscess, or of inflammation of the cellular tissue within the folds of the broad ligament. We thus arrive at the conclusion that the matter was secreted from an abscess in the ovary due to inflammation excited in all probability by the sudden suppression of the menses which marked the commencement of the patient's illness. I do not know that practically there is very much to gather from the details of a case such as the preceding beyond the knowledge of the fact that acute ovaritis, ending in suppuration, may come on without apparent cause, and that the tumor thus formed may acquire a great size, and may present all the characters of a dropsical ovary. As far as treatment is concerned, it would I think in the case last related have been the wiser course to have punctured the tumor and have evacuated its contents soon after the patient's admission. It is not from the observation of cases such as have hitherto been related, and which are confessedly as rare in their occurrence as they are formidable in their character, that has arisen the general impression of the importance and the frequency of ovarian inflammation. The ovaritis which is chiefly dwelt on by medical writers is said for the most part to be either subacute or chronic in its character. It is an affection supposed to be capable of lasting for many years without leading to any grave alteration of structure, though occasioning much functional disorder, and producing much local suffering. Disturbance of menstruation of various kinds, sterility, and pain in the abdomen, more especially pain referred to one or other iliac region, are tho 346 OVARIAN PAIN OFTEN symptoms commonly assigned to this chronic ovaritis: and, indeed, a very large proportion of the ailments that have been referred by some observers to inflammation of the cervix uteri, and ulceration of its orifice, have been attributed by others equally confidently to chronic inflammation of the ovary. My own impression is that a larger share has been assigned to chronic inflammation in the production of these symptoms than can be proved to be really due to it. In no class of ailments is pain so incorrect an index to the nature and importance of the morbid process which gives rise to it as in the disorders of the sexual system of women. On the one hand, diseases of the most formidable character sometimes run their course without the production of any suffering till they reach a stage utterly beyond remedy, while, on the other hand, pains of the severest kind recur in some instances for weeks or months, or even for years, aud yet neither during life nor after death can any adequate explanation be discovered of their occurrence or their persistence. It seems, indeed, as if the sorrow which women are peculiarly heirs to were not confined to the time of parturition, but as if the sentence extended in a measure to the performance of all the sexual functions. Pregnancy and menstruation as well as childbearing are very generally times of suffering, and sexual intercourse itself is not unfrequently attended or followed by the same kind of pain as has been referred to ovarian inflammation. Pain in the ovarian region is a very general attendant on prolapse of the womb, and it suffices but to introduce the sound into the cavity of the uterus in order to produce, and often with great intensity, pain referred to the situation of the ovaries. But while such symptoms are of frequent occurrence, are sometimes as causelessly persistent as in others they are causelessly evanescent, the researches of morbid anatomists do not make us acquainted with such changes in the ovaries as can be supposed to occasion them. We often indeed find the evidences of circumscribed peritonitis about the ovaries, but we find them in cases where there have been no symptoms of an urgent character during life, often indeed where no symptom of any kind has existed. But with the exception of those evidences of inflammatory action on the serous surface of the ovaries, the signs of a morbid process, too, which must soon have run its course, there are but few changes in those organs which an examination after death reveals, and those limited, or nearly so, to the Graafian vesicles, and usually to a few only of their number. In many of the instances, too, where such appearances are discovered, it has been matter of absolute certainty that during life all the sexual functions were performed with complete regularity, and without any suffering. I could not acquiesce in the opinion that almost all the numerous ills of womanhood are due to inflammation of the neck of the womb. I can as little see in them the evidence of ovarian inflammation, and I believe that in M nineteen cases out of twenty in which the ovarian regions are the seat of deep, dull, aching pain, and appear tender and rather swollen, there is no actual ovarian disease whatever." 1 I cannot 1 Dr. H. Bennet, op. cit., p. 222. 347 INDEPENDENT OF INFLAMMATION. finish the sentence by saying with the author whose words I have quoted, that the symptoms are almost invariably the result of some uterine lesion, for I believe that in many cases the symptoms are purely neuralgic in their character, independent of any local lesion, and curable less by local treatment than by remedies addressed to the general state of the constitution. My opinions on this subject, indeed, correspond very closely with those expressed by Dr. Churchill, 1 of Dublin, who has described this class of affections as the result of ovarian irritation. To this term, for my own part, I see no kind of objection, though, if preferred, the simpler designation of ovarian pain will answer every purpose, and serve equally well to impress upon your mind the fact that mere suffering does not of necessity imply either the presence or the previous existence of inflammation. Pain is in itself the patient's ailment, and this even varies greatly in different persons, and causelessly and within very short intervals in the same person, both in its character and intensity. It is ordinarily dull and aching, is accompanied by tenderness in the iliac region, in which situation a degree of fulnes may often be detected, though careful percussion will discover that this fulness is due rather to the presence of flatus in the intestines than to the existence of any solid tumor. Though this pain seldom subsides completely, it is apt to be increased in paroxysms; walking, riding, exertion of any kind, and sometimes even the remaining for a short time in the erect posture, considerably aggravating it. Menstruation almost always adds greatly to its severity, and sexual intercourse nearly invariably increases it, sometimes even induces a paroxysm of great violence. The extent of the pain is very variable. Always severest in the situation of one or other ovary (and, for some unexplained reason, generally in the situation of the left), it is sometimes limited to that spot; but in other cases extends more or less to all of the pelvic viscera; difficult, frequent, and painful micturition is then always experienced, and defecation is likewise often attended or followed by severe suffering. While pressure in the iliac region is always painful, a vaginal examination sometimes causes little inconvenience. In other cases, however, it is productive of pain which lasts for several hours, and this even though no trace of disease may be detected. In some instances, indeed, in which the suffering produced by examination was most severe, the uterus was smaller than natural, a condition which, when coupled with the sterility of the patient, seemed to indicate an imperfect development of the whole sexual system. In those instances where the patient's sufferings were severest there were almost always unmistakable signs of the hysterical temperament, often very obvious symptoms of hysteria; while even when this was not the case, the sudden aggravation or sudden cessation of the pain was sufficiently characteristic of its neuralgic character. Though frequently independent of actual disease, pain, such as has been described, is also in a very largo number of cases, a concomitant or sequela of various uterine ailments. Of course when disease of any 1 Dublin Medical Journal, vol. xii., August, 1851, p. 82. 348 OVARIAN PAIN. kind exists, its removal forms our first duty; but even when this has been effected, the pain often outlasts the cause which first excited it; or, when it seems to have completely disappeared, may return during menstruation, or be rekindled by any imprudent exertion, or by sexual intercourse. Just like that backache which bears so large a part among the minor ills of women, so this ovarian pain, while easy to mitigate, is very hard to cure. Leeches do not relieve it, or if they give any ease, it is only for a few hours, and the pain then returns as severely as before. Blisters sometimes afford ease, though not often in those cases where the pain is most severe, while sometimes they seem rather to aggravate discomfort by the soreness of the surface which they occasion. Chloroform applied to the side generally gives temporary relief, even when the paroxysms of pain are most severe; while a piece of lint soaked in a mixture of equal parts of chloroform and oil, and covered with a piece of oiled silk, is an application which, while in bed, the patient may employ constantly with much benefit. The camphor liniment, with extract of belladonna, is another external application which I have found advantageous; and when these means have been fruitless, I have employed the tincture of aconite with advantage, applying the undiluted tincture by means of a brush, or laying a piece of lint soaked in it over the seat of pain. These symptoms sometimes wear themselves out; the pain by degrees subsiding as the patient's general health improves; but I have never been able to trace the permanent cessation of suffering to the unaided use of any local measures. Some caution, too, is necessary in their employment, for as with many neuralgic and almost all hysterical pains, so here any kind of local treatment which directs the patient's attention very much to the seat of her sufferings is apt to defeat its own object, and to perpetuate the evil instead of removing it. Attention to the general health must always go hand in hand with the local treatment, must indeed, I think, hold the first place. It would be useless to endeavor to go into long detail here with reference to this subject. I will only observe that there are two tonics which in cases of this kind generally do the most service. One of them is the sulphate of quinine, which, when tolerated by the patient, does the same kind of good as in other cases of neuralgic pain, though not so certainly, nor to the same extent. The other is the valerianate of zinc, to which I generally have recourse, wherever quinine is contraindicated or cannot be borne. I know of but one drawback from its employment, and that is the permanent taste which it is apt to leave in the mouth, and the unpleasant eructations with which patients are sometimes troubled hours after it has been taken. There are indeed some cases, though I believe their number to be inconsiderable, in which the existence of inflammation of the ovaries is less questionable. The attack in these cases is usually definite in its onset, and for the most part succeeds either to sudden suppression of the menses, or follows at least some considerable disturbance of the menstrual function, or occasionally comes on not very long after a miscarriage, though once or twice I have met with the affection without being able to 349 DISPLACEMENT OF THE OVARY. assign any probable cause for its occurrence. General febrile disturbance, usually of no great intensity, and by no means invariably ushered in by shivering, is accompanied by pain referred to the hypogastrium, or to one or other iliac region, and by frequent desire to pass water, which is usually high-colored and deposits lithates. In the main, indeed, the symptoms are such as attend an attack of uterine inflammation, except perhaps that they are less severe. A vaginal examination suffices to show that the uterus is not the part affected, for though the heat of the vagina may be somewhat increased, the womb is neither enlarged nor tender, nor are its lips puffy; while, at the.same time, pressure against the roof of the vagina, at one or other side of the womb, not only produces considerable pain, but very often detects the indistinct outline of the enlarged ovary. Sometimes, indeed, the ovary may be very clearly felt, especially if, as is sometimes the case, it occupies the cul-de-sac between the uterus and rectum. Almost always, too, the finger introduced into the bowel distinguishes the ovary much more clearly than can be done by any mere vaginal examination, though I do not think an examination per rectum so essential to the recognition of the ailment as it has been alleged to be by Dr. Lowenhardt, 1 who a few years since drew the attention of medical men to its occurrence. The general symptoms, combined with the absence of affection of the uterus, and the pain on pressure at its side, suffice to point to the ovary as the seat of the patient's sufferings. When the tumor can be distinguished, as it may be recognized as the ovary by its oval shape, its smooth surface, its elasticity, a certain degree of mobility, of which it is found susceptible, as well as by the peculiar sickening sensation which pressure upon it produces. These symptoms for the most part have a sufficiently active character to enforce the patient's attention, while the employment of local leeching, of the tepid hip-bath, the use of anodyne and mild antiphlogistic remedies, and the observance of absolute rest; the same remedies, in short, as would be applicable in cases of inflammation of the uterus itself, generally suffice for their removal in the course of a few days. Some exceptional cases are, however, occasionally met with in which in a somewhat mitigated form the above-mentioned symptoms continue for months or years, and are found to be associated with the presence of the enlarged and congested ovary in the cul-de-sac between the uterus and rectum. Dr. liigby? was, I believe, the first person who drew attention to this condition under the name of displacement of the ovary, and the cases of it" which have come under my notice bear out the accuracy of his description; except that I have not observed the paroxysms of pain to have anything like that intensity which they assumed in some of his cases. The condition seems to be one of considerable rarity, for I have a record of but four instances of its occurrence, though I remember seeing one or two other cases of which I have failed to preserve an account. The patients in all my cases were married women, of whom the eldest 1 Diagnostisch-praktische Abhandlungen, &c, 8vo., Prenzlau, 1S5G, p. 207. 2 Medical Times, July 6, 1850. 350 OVARIAN DISPLACEMENT. was thirty-two; the youngest twenty-three years of age; but Dr. Rigby relates an instance in which he met with the condition in an unmarried girl only eighteen years old. Two of my patients were sterile, the other two had given birth to children, and both of these latter dated their symptoms from their last delivery. In all of them the severe pain attendant upon sexual intercourse had by degrees compelled its discontinuance, and had much to do with the application of the patients for medical aid. Besides this, however, there were complaints of pain referred to the lower part of the abdomen, though severest on one side, aggravated by exertion, by menstruation, often induced with great intensity by defecation, and generally being severer at night than in the daytime, thus preventing sleep, or causing the rest to be very disturbed. In one patient menstruation was natural, except that it was attended by unwonted suffering; but in the other three the discharge was both excessive in quantity, and anticipated the proper period of its return. Pressure in one iliac region always aggravated the pain; but the paroxysms of suffering which were every now and then superadded to the abiding discomfort, and which were attended by a sense of darting and shooting referred to the womb, lasting sometimes for several hours, came on without any assignable cause. These symptoms were present with considerable uniformity in all the cases, and in all on an examination per vaginam there was found behind and rather to one side of the uterus, or else quite in the cul-desac between the uterus and rectum, an oval body, slightly movable, elastic, intensely tender to the touch, and immediately recognized by the patient as the point whence all her suffering proceeded. In all of these cases, rest, abstinence from sexual intercourse, and the application per vaginam of leeches to the neighborhood of the painful part, were followed by the gradual cessation of suffering, the diminution in size of the swollen ovary, and the almost complete removal of the tenderness. In no instance, however, was there any such disappearance of the tumor felt through the roof of the vagina as to suggest the idea that the main element in the production of the patient's illness had been the displacement of the organ, or that the improvement in her condition was attributable to the ovary having regained its natural position. My own impression is, that cases of this kind are to be regarded as instances of a chronic congestion of the ovary and slow increase of its size, rather than as illustrations of any mere change in the position of the organ. The enlarged ovary almost always descends in the pelvis, and in the early stage of ovarian dropsy the organ may often be felt per vaginam at a time when no tumor is perceptible in the abdomen. But though the organ may by growth thus apparently change its situation, and though besides its ligament elongates readily enough, as we see in cases where the ovarian cyst has already ascended into the abdominal cavity, we should yet, I think, be in error if we fancied the organ so loosely tethered in its place that without any other alteration it could fall down into the cul-de-sac between the vagina and rectum, and be made to resume its proper position merely by the patient placing herself in a prone posture. I imagine whatever relief a patient 351 CYSTS ON EXTERIOR OF UTERUS. may experience from assuming this attitude may fairly be referred to the removal from the congested and tender organ of the weight of the superincumbent intestines, to which, either in the sitting or in the recumbent posture, it is subjected. 1 1 There are two conditions which I do not like to pass over entirely without notice, though neither of them has come under my own observation. One of them is Hernia of the, Ovary, of which the best account is still that given by Deneux, in his Recherches sur la Hernie de l'Ovaire, 8vo., Paris, 1813, who has there collected the particulars of all cases recorded down to the time of the publication of his essay. The compilers of the Bibliotheque du Medecin-Practicien ; Maladies des Femmes, vol. i. p. 043, have a long article on the subject, for which, however, they are chiefly indebted to Deneux ; while Meissner's laborious work, vol. ii. p. 240, contains additional references to cases of ovarian displacements. The other affection is one for our knowledge of which we are entirely indebted to M. Huguier, who describes in the Memoires de la Societe de Chirurgie, vol. i., 1847, p. 295, Serous Cysts on the exterior of the uterus. In the lecture on Cancer, p. 353, I described productions of a similar kind which had occasionally come under my own notice, though their relation appeared to be somewhat different from those of the cysts of which M. Huguier speaks. According to him, they are sometimes developed immediately beneath the peritoneum ; at other times in the sub-peritoneal cellular tissue ; or, lastly, are subjacent to that layer of fibro-cellular tissue which connects the serous investment of the uterus with the substance of the organ. Their most frequent seat seems to be the posterior surface of the uterus, since they were found occupying that position in seven out of thirteen cases, while they were situated only four times on its anterior wall, and twice on its fundus. Though generally sessile, they are now and then connected with the uterus by a narrow neck, which sometimes has shrunk to a slender pedicle of cellular tissue. Their size varies from that of a millet-seed to the bigness of an egg, or even of an orange; and the larger cysts might, especially if pediculated, be readily taken for cysts of the ovary. The diagnosis between the two would seem, indeed, to be scarcely possible, though no practical evil would arise from an error. M. Huguier connects their occurrence with previous attacks of uterine congestion, or of peritoneal inflammation ; accidents, however, which are so common in comparison with the cysts to which they are supposed to give rise, that their influence must, I think, be regarded as very doubtful. The symptoms which they produce, judging from the two cases in which they were discovered during the patient's life, would appear to be entirely mechanical, and to result from their pressure on adjacent organs. In one instance the cyst was punctured per vaginam ; about 3i j of transparent serum were evacuated, and the cyst wall was lightly touched with the nitrate of silver. The fluid did not re-collect, and no serious symptom followed the puncture. The chief importance of these cysts is, perhaps, from their introducing a new element of uncertainty into the diagnosis of ovarian tumor in an early stage. 352 OVARIAN TUMORS AND DROPSY. LECTURE XXV. OVARIAN TUMORS AND DROPSY. Special disposition to formation of cystio growths in the ovary. Variety of cysts —the simple cysts ; cysts of the Wolffian bodies ; cysts truly ovarian ; their relation to dropsy of the Graafian vesicles; their structure and contents ; modification of their form when several were present. Questions as to their cause. Compound, or proliferous cysts: possible development from simple cysts. Structure and contents of compound cysts, and,of cysto-sarcomatous growths. Alveolar or colloid growths of the ovary. Cutaneous or fat cysts : their peculiarities of structure and their contents Comparative frequency of affection of one or both ovaries, and of different forms of ovarian tumor. I have had occasion in the course of these lectures to make frequent incidental reference to enlargement of the abdomen as an attendant upon various ailments of the sexual system; the consequence and one of the signs of their presence. To-day, however, we are about to enter on the examination of a class of diseases whose most important and most frequent characteristic is that they bring with them enlargement of the abdomen, that this is often the first symptom of their existence, and that to it is due no small share of the patient's sufferings. But, while they have this one symptom in common, Tumors of the Ovaries differ most widely in all other respects. They occur in the young and the aged, in the single and in the married, in the sterile and in women who have given birth to many children. They are formed sometimes by simple cysts containing serous fluid, at other times they are composed of solid matter, while in very many instances their structure is identical with that of growths which morbid anatomists have unanimously designated malignant. Their rate of increase is sometimes quick, at other times slow, and the disease which had seemed in course of rapid development becomes occasionally stationary, and so remains for months or years; while now and then nature herself interferes, and excelling all that the most skilful physician could do, completely takes away the ill which medicine is usually impotent to cure. Their diagnosis, in some cases most easy, is in others attended by extreme difficulty; and yet there are scarcely any ailments in which so much is involved in a right decision. The determination that the supposed disease is in reality due to the existence of pregnancy, or that the suspected pregnancy is but the evidence of disease, often has moral consequences which touch more nearly the 353 SIMPLE OVARIAN CYSTS. profoundest sources of human happiness or misery than any which would follow the mere assurance, though never so positive, of coming health, or the admission that the future has no other prospect than that of a lingering and painful death. The prognosis to be formed, and the treatment to be adopted, bring with them, too, their own peculiar difficulties. Recovery, when there seemed small ground for hope; death, when little had appeared to call for apprehension; medical treatment rejected because it has been proved inefficacious; surgical proceedings shrunk from because they are known to be hazardous; additional facts scarcely seeming to widen our experience, or serving only to detect the fallacy of some loudly vaunted plan of cure; such are the uncertainties, and such the difficulties that meet us when we propose to ourselves the inquiry—What shall we do ? In short, there are no diseases whose pathology is more imperfect, whose symptoms are more fluctuating, whose diagnosis is more obscure, or whose treatment is founded on more uncertain data, than those very diseases of the ovaries which are yet so important, and to whose study I must now beg to call your most patient attention. In each of the different organs of the body we find a disposition more or less marked to diseased formation similar to its own proper, healthy structure. This peculiarity is observable in tumors of bone, of muscle, of nerve, or of fibrous tissue, and even in the case of those formations which, from their non-identity with healthy structures, have received the name of heterologous, something of the same disposition is still perceptible. Thus the cancerous tumor of bone, while interfering with and destroying the structure of the part in which it is formed, is yet itself built up upon a bony skeleton or fabric; and I have already pointed out to how, even in cancer of the womb, the bulk of the organ is increased, not merely by the morbid deposit in its substance, but also by the development of its natural structure. It is in accordance with this law that, in the ovary especially (as to a less degree in all glandular organs, such as the thyroid body, the testicle, and the mamma), there exists a peculiar liability to cyst-formation ; and that nineteen out of twenty of all ovarian tumors are cystic grovjths. Very various classifications of ovarian cysts have been proposed according as they have been regarded simply from a practical point of view, or as the minuter differences in their anatomical structure have also been taken into consideration. It is, however, so desirable to avoid multiplied divisions and subdivisions, that I propose to conform to the arrangement adopted by Mr. Paget, 1 and to speak first of Simple or Barren Cysts, and, secondly, of Compound or Proliferous Cysts. This arrangement, too, will I think be found not simply anatomically correct, but also practically convenient. The first kind of Simple Cyst is one which, though in the immediate vicinity of the ovary, is strictly speaking not connected with it; but which I mention here because until comparatively recently its 1 Surgical Pathology, vol. ii. p. 26. 23 354 CYSTS OF THE WOLFFIAN BODIES. nature was misapprehended, and erroneous conclusions based on this misapprehension have been applied to real ovarian cysts. In examining the bodies of female infants, and less often of female adults, we may sometimes notice hanging from the under surface of the Fallopian tube, nearer to its fimbriated than to its uterine extremity, small delicate cysts, varying in size from the bigness of a pea to that of a cherry, furnished with a slender pedicle from one to three inches in length, and containing a transparent, serous, or slightly gelatinous fluid. Now and then a similar cyst may be seen bearing the same relation to the Fallopian tube, with the exception of being sessile instead of pediculated. Sometimes, too, a cyst of larger size may be observed within the folds of the broad ligament situated between the ovary and the Fallopian tube, but obviously not originating in either; and the cysts of this latter kind, unlike the others, are observed in the grown subject. The difference of their seat seems to be the only point of dissimilarity between them, for the wall of both is composed of a thin, structureless membrane, incapable of division into layers, often, though by no means constantly, furnished with a lining of nucleated epithelium; while their contents, though usually serous and colorless, are sometimes reddish and gelatinous. The delicacy of the cyst-wall, the absence of any support, and the slenderness of its footstalk, are doubtless, as has been suggested by M. Verneuil, 1 the reasons why the pendent variety of cyst is seldom met with after early infancy, while the support which the peritoneum on either side furnishes to the sessile cyst which is situated between the folds of the broad ligament, allows of its readier enlargement and of its attainment of a greater size. An examination of the pedicle of those cysts which hang from the Fallopian tube furnishes the clue to the understanding of the real nature of these growths. This pedicle is often found to be hollow, though in the course of its gradual elongation and attenuation it becomes converted into a slender cord. The canal, however, sometimes even communicating with the cyst, points to its origin in the dilatation of one of the small csecal tubes which make up the Wolffian bodies in the foetus, and the slight remains of which, difficultly discernible in the adult, have received from their deseriber the name of the Corpus Rosenmulleri. The size of an egg, an apple, or an orange, is the greatest magnitude to which these cysts have yet been proved to attain; and the pendent cysts very rarely indeed reach dimensions sufficient to make them recognizable during life. With the exception, too, of the giving way of the pedicle of the pendent cysts, and the probable rupture of the delicate walls of both kinds of these growths, there are no changes which have been observed to take place in them; and in no instance has cyst formation occurred in their walls or into their cavity, though several distinct cysts, especially of the pediculated kind, are by no means unfrequently seen in the same subject. Before proceeding to examine the other and more important cysts 1 By far the best account of these cysts, which contains also a notice of the observations of previous writers, is that of Dr. Verneuil, Recherches sur les Kystes de l'Organe de Welff, in the Memoires de la Societe de Chirurgie, 1854, vol. iv. p. 58. 355 SIMPLE CYSTS OF THE OVARY ITSELF. which really spring from the ovary itself, we must for a moment notice a circumstance which has given to these cysts of the broad ligament, as they have generally been termed, a greater pathological value than really attaches to them. It has been very customary for medical men, whenever they met with a simple cyst tolerably movable, and of moderate size, to assume that such a cyst was not ovarian, and to console their patients with the assurance that it is a less serious disease, and one much less likely to increase. Now, while it is of great moment to give to our patients every legitimate comfort, and to encourage all reasonable hope, it is yet no less important, in the interests alike of science and of humanity, that we should not make large promises, or give positive assurances without adequate grounds. A visit to any of the large museums of this metropolis will suffice to convince any one that cysts of the Wolffian bodies of size sufficient to be distinguishable during life are of very great rarity, while the same evidence will also prove that for such cysts to exceed the dimensions of an apple is rarer still. Whenever then a tumor is discovered in the abdomen which has attained a greater size than that of the doubled fist, that circumstance may be taken as in itself affording almost conclusive proof that the cyst is not extraovarian, nor of that kind concerning which it can be predicated that its tendency will be to remain stationary, rather than to increase in size. , But we may now pass to the study of those various kinds of cysts and cystoid growths which have their origin in the ovary itself. The simplest of these, the least dangerous, I fear, however by no means the most frequent, are those which are produced by the dropsy, or over-distension with fluid of one or more (Jraafian vesicles. The structure of these simple ovarian cysts plainly indicates their origin. They are furnished with three coats: the first, the peritoneal investment of the ovary; the next, the capsule of the organ, on whose surface ramify the vessels that supply it; and the third, the wall of the Graafian vesicle itself, which is usually much thickened, generally divisible into several layers, and has a lining of tessellated epithelium. This laminated structure of the ovarian cyst is, as we shall hereafter see, not without its practical importance, inasmuch as it sometimes increases the difficulties of the operator, who cannot, if adhesions exist, always distinguish readily whether his finger is breaking down the connection between the enlarged ovary and the peritoneum, or whether it is separating the layers of the cyst-wall. The surface of these cysts is generally white and glistening, and their anterior smooth and polished; sometimes of a dead white color, or even of a mother-of-pearl lustre; unless the growth has been the seat of inflammation, when it will in many parts be dull, roughened on its interior by old deposits of lymph, and its walls will be found to present various degrees of firmness, density, and thickness. Even independently of previous inflammation the thickness of the cystwalls often varies at different parts, and is by no means most considerable in all cases close to the pedicle of the growth. 356 STRUCTURE OF The vessels of these, as indeed of all ovarian cysts, are usually of considerable size; while their distribution is uncertain beyond the fact that all converge towards the pedicle of the cyst. They almost all present a venous character, or, as Cruveilhier aptly says, in describing the structure of a large ovarian "They are venous sinuses analogous to those of the dura mater," and, ramifying immediately beneath the peritoneum, their delicate outer wall seems wholly formed by that membrane. The large size of these superficial veins is to be borne in mind as an occasional source of danger in tapping; while their convergence towards the pedicle of the tumor constitutes one of the principal objections to the operation of tapping per vaginam. The branches which pass from these trunks towards the interior of the cyst, and which ramify, sometimes very abundantly on its inner wall, are small in size, but still retain their venous character, and this preponderance of the venous over the arterial system is the great peculiarity of the vascular supply of these growths. Be their size what it may (and this is liable to very wide variations; for while sometimes no larger than a pea, they contain in other cases a gallon or a gallon and a half of fluid), their contents are usually of the same description, namely, serum, often of a rather low specific gravity, and very seldom exceeding 1020, highly albuminous, of a slightly greenish color, and though generally transparent, yet occasionally more or less stained with blood. Sometimes, indeed, the fluid contains a large admixture of pus, and now and then 1 presents characters but little distinguishable from those of healthy matter. This, too, may be the case even when few local symptoms of inflammation have been present, so that it is not possible to foretell with any certainty the nature of the fluid which even a simple ovarian cyst may be found to contain; or to infer the absence of inflammation from the absence of pain. The circumstance which imparts to this fact its practical importance is that inflammation of the interior of the cyst is in very many instances accompanied with inflammation of its peritoneal surface, of extent and intensity sufficient to produce very considerable adhesions with adjacent viscera, while even this peritonitis may give rise to no severe pain. The feasibility of various surgical proceedings for the cure of ovarian dropsy depends entirely on the absence of adhesions. The want of any certain means by which to determine their presence or absence is one of the most serious of the difficulties which beset all operations for the extirpation of diseased ovaries. I have described this affection hitherto as it presents itself to our notice when confined to a single Graafian vesicle. It is, however, seldom that the disease is so strictly limited, but usually other vesicles, sometimes in both ovaries, show a disposition to the same dropsical condition. Not infrequently, too, we meet with cases in which the affection of several vesicles has appeared to have commenced simultaneously, all being equally enlarged; and the ovary containing as many perhaps as ten or fifteen small cysts no bigger 1 Anatomie Pathologique Generale, 8vo., Paris, 1856, vol. iii. p. 408. 357 SIMPLE OVARIAN CYSTS. possibly than a large pea. As these cysts increase in size, they lose by their mutual pressure the regularly globular form which at first they present, becoming flattened,or somewhat wedge-shaped, with their broader end outwards. When, however, the ovary has attained to dimensions greater than those of an unshelled walnut, or of an egg, the development of one or two of the cysts generally goes on at the expense of the others, and a multilocular tumor is thus produced, made up of a number of simple cysts, of very various sizes, from that of the adult head to that of an apple or an orange. The contents of these cysts, too, may vary as much as their size, for while some are filled with transparent serum, others may contain fluid deeply tinged with blood, and others again a sero-purulent secretion, according as hemorrhage or inflammation has occurred in one and has not occurred in another, even though immediately adjacent. These varieties in the same tumor have sometimes given occasion to the opinion that a growth is a compound cyst, when in reality it is only an aggregation of simple cysts in which morbid processes of various kinds have been going on. It is by no means an unusual occurrence, too, with tumors of this description, for their pressure on each other to produce absorption of the dividing septa, and for a multilocular tumor to be thus in the course of time converted into a single cyst. The openings of communication between the different cysts are usually of a circular form, with smooth edges, as if a portion of the wall had been removed by some cutting instrument, and while small at first, the advance of the process of absorption by degrees enlarges them; till at length a slight irregularity in the external contour of the tumor remains as the only evidence of its original structure. The circumstances that regulate the process are, however, by no means clearly understood; for while the absorption of the septa sometimes takes place at a time when none of the cysts are larger than a marble, it is far from unusual to find the partitions still entire when some of the cysts have reached the size of the adult head, or have even attained still larger dimensions. It is perhaps needless to say that dropsical enlargement of the Graafian vesicles is by no means the only source whence simple ovarian cysts may be produced. There can indeed be no doubt but that the development of cysts may go on in the ovary just as it does sometimes in the kidney, not by any enlargement of pre-existing cavities, but by a process which is one of new formation from the very beginning. Still the whole tendency of pathological research is to increase the number of instances in which cysts are formed by the enlargement of pre-existing cavities ; and besides the question has been set at rest as far as the occasional production of ovarian dropsy from enlarged Graafian vesicles is concerned by Rokitansky's discovery of the ovule within the cyst in a case of incipient cystic disease of the ovary. 1 1 Wiener Wochenblatt, 1855, No. 1, as quoted by Scanzoni, Lehrbuch der Krankheiten der Weiblicben Sexual Organe, 8vo., Wien, 1857, p. 354. The question is one of so much moment with reference to the prognosis of ovarian dropsy, aud the opinion of so high an authority as Dr. Bright (See Guy's Hospital Reports, vol. iii. 1838, pp. 181 and 193), is so decidedly unfavorable, that one rejoices at obtaining any evidence which enables us to soften the very dark hues of the picture which he has drawn. 358 MODES OF ORIGIN OF SIMPLE OVARIAN CYSTS. The preeise mode in which the dropsical condition of the vesicles is produced, is indeed, and probably will always remain, to a great degree unknown. It seems, however, to be very likely that in some cases at least a state of congestion of the vesicle, and hemorrhage into its cavity, are the first steps towards the production of the subsequent effusion. In the museum of Guy's Hospital, to which I was most courteously admitted, are a series of preparations which appear to illustrate this mode of origin of ovarian dropsy. In some of them a clot alone is seen within the vesicle; in others the clot occupies only a portion of the cyst, adhering to its wall by a sort of pedicle, while the remainder of the cavity is occupied by a serous fluid ; the relative proportions of the clot and the fluid varying much in different specimens. Now, just as hemorrhage into the sac of the arachnoid is followed in many instances by the subsequent effusion of serum, so far exceeding in quantity that of the blood originally extravasated as to produce one form of chronic hydrocephalus, so there can be no reason for doubting but that hemorrhage into the sac of a Graafian vesicle may in like manner be followed by a similar hypersecretion. A theory, indeed, has been propounded, the very opposite of this, by Professor Seanzoni, 1 who suggests that the dropsical condition of the Graafian vesicles may be due to the flow of blood to the ovary at a menstrual period having been insufficient to produce the rupture of the sae and the escape of an ovule, but sufficient only to occasion a certain degree of congestion, terminating in an increased effusion of fluid into its cavity. This theory is based chiefly on the alleged frequency of amenorrhcea, or of scanty menstruation, as a precursor of ovarian dropsy; an allegation, which, as we shall see hereafter, is scarcely substantiated. I know of no other facts, nor of any other plausible theory bearing on the production of dropsy of the Graafian vesicles ; and I fear that I must confess my inability to determine the proportion of instances in which simple cysts of the ovary are due to the enlargement of these cavities, and of those in which the cysts are themselves of new formation. That simple cysts may arise here, however, as in other parts, by the mere collection of fluid in the parenchyma of the organ, and the gradual formation of a cyst around it, I see no reason to doubt. 2 Possibly some of the very delicate and thin-walled ovarian cysts which we occasionally meet with may have this origin; but my conviction is, that this is not the general mode of production of simple cysts, but that most are formed by the distension of a pre-existent cavity. Another question of greater practical moment is whether single cysts always remain single, or whether they may not become proliferous "This case," says he, loc. cit., p. 193, "adds to the doubt I have already expressed of having met with any very distinct case of dropsical accumulation in the Graafian vesicles, as distinguished from the disease which runs into the malignant ovarian tumor." 1 Op. cit., p. 353. 2 A mode of cyst-production most fully illustrated by Professor Bruch, Zur Entwicklungs-geschichte der Pathologischen Cystenbildungen, in Zeitschr. f. Rationale Medizin, vol. viii., 1849, p. 91. 359 STRUCTURE OF COMPOUND OVARIAN CYSTS. or compound cysts in the course of their development. Here, too, it is to be regrettQfl that our data do not suffice for a satisfactory answer to this inquiry. The practical consequences involved in the decision of this point are very obvious; for it is apparent that if at any period a simple cyst is capable of passing into an active state, and of enlarging not by mere distension of its cavity, but by growth in its interior, or by cyst-formation in its walls, the expediency of having recourse to early and very decided therapeutical proceedings becomes far greater than it otherwise would be. My belief, though I cannot adduce absolute proof of its correctness, is that such a change may take place; and that a cyst originally barren may become proliferous; that its continuing simple is rather a happy accident than a condition on the permanence of which we can calculate with any certainty. Without the stimulus of impregnation, a Graafian vesicle does, we know, sometimes produce hair, fat, teeth, cartilage, and bone, and the proliferous power of which these are the highest instances, does also, I believe, exert itself in lower forms in the production of endogenous growths in its interior; and, though possibly less often, in exogenous cellformation from its walls. In some of the cases of endogenous cell-development the growths that occupy the interior of the cyst spring universally from its walls, and consist of an immense number of small pedunculated cysts or vesicles, multiplied apparently by the same simple process of growth as has been so well studied in the hydatid disease of the chorion. Such growths may, too, be so numerous as to fill nearly the whole of the interior of a very large cyst. 1 In other cases the endogenous growth, though similar in its character, does not arise from the whole of the interior of the cyst, but is connected with it by a pedicle, from which a pyriform mass of cystic growths proceeds. Besides these forms of endogenous growth, there is another in which the cavity of the parent cyst is more or less completely occupied by others of a smaller size, but springing from it by a broad base, 2 and containing within themselves others of a third order, of smaller size, and with thinner walls. As these cysts grow, some probably empty themselves completely into the parent cyst, and collapsing become adherent to its walls; thus giving to them that thickness and resistance which in some cases, even of large ovarian cysts, are very remarkable. At the same time, the progressive increase of the smaller cysts, and the constant formation of new cysts, help to make up that enormous mass to which ovarian tumors sometimes attain. But while there is perhaps room for doubt as to the nature of the original growth whence these forms of complex cysts arise, there can be no question but that some cysts assume the complex character from their very commencement, and are not developed out of any transformation of the Graafian vesicles. In these cases we find the ovary converted into a tumor of irregular form; its firm, fibrous capsule, some quarter or third of an inch in thickness, inclosing a 1 As in a very remarkable preparation, No. 2245 04 in Guy's Hospital Museum. -' As No. 2(>22 in the Hunterian Museum. 360 COMPOUND OVARIAN CYSTS. number of cysts or cells, one or two of which may greatly exceed the dimensions of the others, and be capable of containing»many quarts of fluid, while the remainder vary in size from the bigness of a marble to that of a pigeon's egg, or an apple. While some of them may appear as separate cysts, adherent to the others, but apparently developed independently of them, others have obviously been formed in the thickness of the cyst-wall itself, and project, sometimes inwards, at other times towards its exterior. When the growths have attained to any considerable size, inflammation generally roughens their originally smooth internal membrane, and deposits of lymph thicken it; or the collapse of some of the smaller cysts, and their incorporation with the dividing walls of the different cavities, thicken as well as otherwise alter the septa. At the same time, too, similar causes modify their contents; so that while one cyst is filled with a serous fluid, another contains a glairy, albuminous matter, or its contents are deeply tinged with blood, or are of a dark chocolate color; while others contain pus, or sero purulent fluid, or a liquid in which scales of cholesterine sparkle like the brilliant particles in Dantzic eau de vie. It is usually towards the pedicle of these tumors, where the smaller cysts are mostly situated, that their structure can be best studied. They are then seen to be formed by a smooth, polished membrane, tough and resistant, though thin, scarcely semi-transparent, but of a white color, and supplied by long slender bloodvessels, which ramify on their outer surface. Their general form is oval, but as they increase in size, this is much modified by their mutual pressure on each other; while besides, irregular spaces exist here and there, partly produced, perhaps, by the fusion of two or more cysts together, partly by the intervals left between several adjacent cysts. The smaller size of the cysts near the pedicle of the tumor is apparently due to their being subjected to a greater degree of compression than the others; for sometimes a large cyst will develop itself downwards into the pelvic cavity ; while again, where the increase of the tumor has been very rapid, a number of small cysts may sometimes be found towards its upper part, where apparently the resistance offered by the transverse colon, the liver, stomach, and diaphragm, has also prevented their increase. 1 The amount of solid matter which enters into the composition of these cystic tumors of the ovary varies exceedingly. In many cases, as in those just described, the whole mass is but a collection of cysts whose walls, even when thickest, bear but a small proportion to the quantity of fluid which their cavities contain. In other instances, however, these proportions are reversed, and the bulk of the solid matter far exceeds that of the fluid. This is the kind of tumor to which the name of Gystosarcoma has been applied by Muller, 2 who describes it as principally composed of a more or less firm, fibrous, or vascular mass, but invariably containing solitary .cysts in its 1 A very good drawing of a compound ovarian cyst is given by Dr. Bright, op. cit., pi. v. p. 270. * On Cancer, &c, English translation, London, 8vo., 1840, p. 170. 361 COLLOID TUMORS. substance. The fibrous masses consist of an albuminous substance, and sometimes contain granules scattered between their fibrils, and the fibrous tissue forms the stroma in which the separate cysts are imbedded. I do not feel myself competent to decide how far these growths really require.to be referred to a separate category. The structure of the cysts, and their various contents are analogous to what one observes in other compound ovarian cysts. Perhaps, however, it should be added that fat cysts, or cysts containing hair, teeth, or other products of cutaneous tissues, when not existing alone, are most frequently associated with cystosarcoma; and further, that these comparatively solid growths do not attain to the enormous dimensions of other compound ovarian cysts, and very seldom exceed the size of the adult head. Another form of compound ovarian cyst, allied to the preceding kinds, but I believe essentially different from them, is that in which the organ is the seat of alveolar or colloid cancer, a disease 1 whose precise relations to other varieties of carcinoma are as yet undetermined. The grand characteristic of colloid degeneration of any part is, as you know, the development in its substance of innumerable cells, containing a tenacious, gummy secretion, which vary from a size too small to be discerned by the naked eye, to an inch or rather more than an inch in diameter. These cells increase, though by no means exclusively, by endogenous growth, and the presence of a countless number in the same stage of development shows that the formation of very many occurs simultaneously. If their contents are washed out so as to leave behind only as it were a skeleton of the growth, it is then perceived that very many of the cells or sacculi communicate with each other; the whole mass having a honeycombed appearance, or resembling, perhaps, more closely a section of the lung of a reptile. The septa between the cells are in general of a somewhat firm, though delicate fibrous tissue, of a whitish, sometimes of a dead-white color; though while the cells are very minute, their walls or the septa between the areola) are semi-transparent, and their jelly-like contents shining through, they look not unlike grains of boiled sago. In the ovaries this colloid disease assumes many different forms. Sometimes several rounded masses make up an irregular tumor, which is solid to the touch, and firm on section, presenting no trace of the proper tissue of the part, but a structureless substance in which are imbedded countless semi-transparent grayish cells, scarcely any of which are larger than the head of a large pin. Again, in other cases the cell walls generally are very delicate, while large spaces are left between, of irregular form, and filled with the characteristic gelatinous secretion, which may be collected to the amount of several ounces or of a pint, or more. Such spaces, however, do not appear to be cysts enlarged beyond the dimensions of those which surround them, but to be mere interspaces of irregular form produced by the absorption 1 A good representation of alveolar cancer of the ovary is given by Cruveilhier, Atlas, etc., Livr. v. pi. 3. 362 FAT CYSTS OF THE OVARY. or liquefaction of the cell walls, and the consequent escape of their contents into a common receptacle. 1 Besides the instance in which colloid disease exists alone, cases are by no means unusual of its association either with compound cysts of the ovary, or with fungoid or medullary cancer of the organ. In the former case it is far from uncommon for one or two of the cysts to have attained to a very great magnitude; and the colloid matter may be in part poured into them from some of the adjacent cells, so as to give to their contents almost the same degree of tenacity as is observed in the secretion within the small cells of alveolar cancer. Even though this should be the case, however, and though there should be very close juxtaposition of the two structures, the differences between them will, I think, be sufficiently obvious. In the case of the association of genuine fungoid cancer with the colloid disease, it is usually about the pedicle of the tumor, and near its base, that the great mass of cancer is situated. It is not, however, limited to this part, and sometimes a mass of soft brain-like substance is found in the midst of the tumor, surrounded by the delicate cysts and gelatinous substance of alveolar cancer; while at other times the medullary matter seems altogether fluid, and on cutting through the tumor it issues forth from some of the irregular cavities which have been already spoken of. The peculiarities of the matter contained in the cells of colloid cancer have been frequently referred to; and even in growths of considerable magnitude these characters are s6metimes still present in a marked degree. Often, however, they are more or less modified by the same causes as influence the contents of other forms of ovarian cysts, and the viscid secretion is often dark from the admixture of blood ; sometimes even of a dark chocolate color, sometimes grumous; but I do not think that it becomes purulent, as is not infrequently the case with the secretion of the other ovarian cysts. One form of ovarian cyst still remains for notice, and it is one concerning which some problems still remain unsolved. Cysts are sometimes formed in the ovary, either alone, or associated with cystosarcoma of the organ, containing fat, hair, teeth, or other products of cutaneous tissue. The presence of scales of cholesterine, or of small quantities of fat, is indeed often observed both in simple and in compound ovarian cysts, and is due to the formation and rapid desquamation of their epithelial lining, and to the alterations which the corpuscles undergo. In these cysts, however, fat is present in much larger quantities, so that it forms a layer on the surface of the fluid removed by tapping as 1 Remains of the septa may in these cases be discovered by means of the microscope, in the midst of the colloid material. It was the observation of this fact which led Virchow, Verhandlungen der Gesellschaft f. GeburtshUlfe, vol. iii. p. 197, to the assumption that all compound ovarian cysts are in reality instances of colloid disease of the organ in which this liquefaction and disappearance of the septa has taken place. This theory, however, in the extension given to it by Virchow, is now generally regarded as untenable. Indeed, it is by no means unusual to meet with compound ovarian cysts which present no similarity either in their structure or in the nature of their contents to alveolar cancer; and I believe that the microscope fully bears out the verdict which observation without its aid would induce us to return. STRUCTURE OF FAT CYSTS OF THE OVARY. 363 firm as lard, or even firmer; or collects perhaps into large irregular flakes or masses, or else into a number of small balls like marbles, of a yellow color, and of the consistence of tallow, shaped into these symmetrical forms by mutual attrition in the fluid which partly filled the c}'sts, of which there is a remarkable specimen in the museum of Guy's Hospital. 1 Sometimes the cyst contains no fluid, but a matter of the appearance and consistence of putty, possibly intermingled with hair. Hair, indeed, is often met with in these cysts, sometimes in shapeless, tangled masses, but more frequently rolled together into round balls; and teeth, bone, and bone cartilage are also all found in many instances. When it had been clearly ascertained that these structures existed independently of impregnation, it was next assumed either that they were the relics of some imperfectly developed germ included by accident within that ovule which had gone on to perfection, and that they were therefore congenital formations, or else that the ovule itself was capable of a certain imperfect attempt at growth independent of its appropriate vivifying power, and thus produced incompletely, and with no orderly arrangement, some of the materials of the foetus. In a measure, too, both of these theories are probably correct, though cutaneous cysts are found in circumstances which do not seem to admit of either of these solutions. In all such cysts there may be found any of the products of dermoid tissue regularly formed, as though growing in their natural situations; the hairs implanted in a perfectly normal manner into the cutaneous tissue, which is found to be supplied with perspiratory and sebaceous follicles, while the teeth, in different stages of development, are imbedded in tooth sacks. We owe the observations which have removed cases of this kind from the domain of the wonderful, and have shown how method and order reign, where a more imperfect knowledge could discover nothing but mere freaks of nature, to the acuteness of a German physician. 2 Another of his countrymen has done much to complete our information, and I will briefly state to you the results at which he has arrived. Dr. Steinlin, 3 on examination of the body of a young woman from whom seventy-eight pounds of pus were removed in four successive tappings, found that while the left ovary contained several small cysts, none of which exceeded the size of a hazel-nut, the right ovary was the principal seat of the disease. It was made up of many cysts, all of which, with the exception of one large sac containing several pounds of pus, were fat cysts, varying from the size of a grain of linseed to three or four inches in diameter. The fat was in different conditions in different cysts, and in the older cysts was often intermixed with hairs intertwined into a mass. All the contents being removed, the greater part of the cyst-walls was seen to be smooth and shining, but there were one or more round islands, of a dull whitish color, with a wart-like prominence in their centre, overgrown with hair; and other 1 No. 2237 2 \ Rokitansky also relates a remarkable case of a somewhat similar kind, op. cit., vol. iii. p. M7. . 2 Dr. Kohlrausch, in Muller's Archiv., 1843, p. 3G5. 3 Zeitschrift. f. Rationelle Medizin, vol. ix. p. 14b'. 364 STRUCTURE OP FAT CYSTS OF THE OVARY. similar spots without the wart-like prominence, and without the growth of hair, but with several teeth or portions of bone more or less buried under their surface. The cyst-walls admitted of division into several layers. Of these the outermost was composed of loose cellular tissue, beneath which was a denser layer made up of fibres, which, though interlaced, had on the whole a parallel arrangement; under this was a layer of elastic tissue, and innermost of all a coating of epithelium. The epithelium was everywhere of the tessellated kind, and at the polished parts the cells were round and regular, but at the dull parts the superficial layer was arranged irregularly, though round cells were regularly disposed beneath. On denuding the wart-like prominences of their epithelium, the subjacent surface exactly resembled that of the true skin, having well-developed papillae, and the whole of the cyst-wall beneath the unpolished islets had a similar structure. The hairs growing here sprouted from a regular bulb, and there were sebaceous glands and perspiratory follicles in varying number. The quantity of hairs is accounted for by their being deciduous, though formed in the natural manner, and the fat is not secreted by the whole interior of the cyst, but by the sebaceous glands, just as the vernix caseosa is in the foetus. The presence of teeth is explained by their being true products of dermoid tissue, so that wherever that tissue is found there always exists the possibility of teeth being developed; and their presence in the jaws is a sort of accident by no means essential to their formation. Dr. Steinlin concludes that the development of the cyst is but a secondary occurrence; that the first step in these cases is the formation of a tissue exactly identical with the external skin, the accumulation of its secretions by degrees distending the investing membrane. The earliest appearance of one of these tumors is as a small, fleshylooking mass, of the size of a grain of linseed, in the situation of a Graafian follicle, and surrounded by a small sac. In the course of time this small body becomes detached from the sac except at one point, where its stem remains, and where vessels having a looped arrangement enter it. Next, a thin layer of fat is found between the small lump and the sac, and on careful examination of the former the sebaceous follicles are now seen developed. With the increase of their number the fat increases, and the sac becomes distended, while the perspiratory follicles modify by their secretion the contents of the sac. If to this description one adds that the intimate relation between pus and fat globules may be taken as explaining the general presence of pus in fat cysts of any considerable size, I think that the description of this, as of the other forms of cystic ovarian tumor, may be regarded as complete, in so far at least as the practical object of these lectures is concerned. Two points, however, still remain which require a brief notice: namely, the comparative frequency of disease of one or other, or of both ovaries, and the comparative frequency of the different varieties of ovarian disease. With reference to the first of these questions, the general evidence FREQUENCY OF DIFFERENT FORMS OF OVARIAN TUMOR. 365 of statistics, as the subjoined table shows, goes to prove the preponderating frequency of affection of the right ovary. Right Ovary. Left Ovary. Both Ovaries. Total. Cases collected by S. Lee 1 50 35 8 93 Chereau 2 109 78 28 215 " observed by Scanzoni 3 14 , 13 14 41 " the Author 28 22 16 66 201 "l48 66 ~415 This table, however, can be regarded only as a very rough approximation to the truth in this matter, since it is mainly deduced from observations made during the life of the patient, while it is often a matter of considerable difficulty to determine whether a tumor is formed by the right or by the left ovary; and harder still to decide that the disease is limited to one ovary, and that the organ on the opposite side is healthy. In two instances, indeed, in addition to those enumerated in the table, I found myself quite unable to determine which ovary occasioned the tumor, and very likely in some other cases the conclusion which I did come to was erroneous. This difficulty, too, arises not simply from the mesial position of the tumor at the time when the case comes under observation, and from the inattention of the patient to her own early symptoms, though that is very frequent, but also from the circumstance that the ligamentum ovarii becomes twisted occasionally as the organ increases in size, so that a tumor of the left ovary sometimes produces enlargement of the right rather than of the left half of the abdomen. Observation after death, too, fails to bear out the alleged greater frequency of the disease on one side than on the other, while it shows that the affection tends far oftener than would appear from the former table to involve both ovaries. Scanzoni's figures were deduced from post-mortem examinations, and if to them be added 19 of my own, and 15 of Dr. R. Lee's cases, 4 a total is obtained of 75 cases, in 26 of which the disease occupied the right side, in 23 the left, and in 26 both ovaries. This result, too, tallies with that which we might reasonably anticipate beforehand, for to the best of my knowledge there is no ground for the special liability of one ovary, or for the special immunity frorn disease of the other. Professor Scanzoni is, I believe, the only writer who has attempted any numerical estimate of the comparative frequency of the different varieties of cystic disease of the ovaries. 5 His 41 cases and my 19 yield the following results: — Simple cysts in 15 cases. Fat cysts " 1 " Compound cysts, and cystosarcomata . " 23 " Colloid, or alveolar tumors . . " 19 " Cancer with cyst-formation . . " 2 " Total 60 1 On Tumors of the Uterus, etc., 8vo., London, 1847, p. 120. 2 As quoted by Scanzoni, op. cit., p. 305. 3 Ibid. 4 On Ovarian and Uterine Diseases. London, 1853. 6 Op. cit., p. 364. 366 OVARIAN TUMORS AND DROPSY. It must be reserved for the next lecture to consider what becomes of these tumors; to examine how nature endeavors, too often fruitlessly, to effect their cure, and how the disease tends too generally and too inevitably to increase, and as it increases to bring added suffering, and to hasten the approach of death. LECTURE XXVI. OVARIAN TUMORS AND DROPSY. General course of the affection ; exceptional character of the cysts of the Wolffian bodies—their disposition to remain stationary. Occasional arrest of growth of simple cysts usually temporary—their complete removal very rare. Cyst sometimes discharges its contents through Fallopian tube, vagina, intestine, externally, or into peritoneum. Changes in cysts, their gradual softening. Inflammation of cysts. Disorder of health from pressure of cyst on viscera ; cachexia attending the increase of cyst. Various modes of death. Causes predisposing to ovarian dropsy—influence of age, marriage, and child-bearing. Alleged exciting causes of the disease. The study of the anatomy of ovarian cysts and tumors which occupied us at the last lecture, has enabled us now to advance a step further in our investigations, and to inquire what is their course, and what their tendency, what efforts nature makes to effect their cure, and what are the different ways in which they prove fatal? It has been already stated that pnietitioners, though ignorant of their real nature, were long familiar with the occasional presence of thin-walled cysts between the folds of the broad ligament, which, unlike other cysts connected with the substance of the ovary, had no disposition to increase beyond comparatively small dimensions. Not unnaturally, however, they indulged the favorable anticipations which were justified only in the case of a peculiar and infrequent affection, with reference also to a great number of simple ovarian cysts. Utterly unfounded expectations of the disease eventually becoming stationary have thus on several occasions within my own knowledge deterred patients from justly estimating their own condition and prospects, and from consenting while there was yet time to the adoption of any curative measures. It is therefore of importance to bear in mind that the only cysts concerning which the disposition to remain stationary can be predicated as their general characteristic are the cysts of the Wolffian bodies; and, further, that these cysts have scarcely ever been met with exceeding the size of an orange, while even such dimensions are unusual, and in by far the greater number of instances they reveal themselves by no symptoms during life, and present themselves to the CYSTS OF WOLFFIAN BODIES OFTEN STATIONARY. 367 anatomist far oftener than to the physician. One case, indeed, and but one, has come under my own notice, concerning which I could feel justified in assuming that the cyst was not ovarian, but was connected with the remains of the Wolffian body. The patient, who, when she first came under my notice, was fifty years old, has now for eight years been under my observation; and the tumor which was connected with the right uterine appendages continued during the whole time of the same dimensions, being rather smaller than the foetal head until six months ago, when, without any symptom, it suddenly disappeared, its thin walls having doubtless given way, and its contents having escaped into the peritoneal cavity. The tumor was extremely movable, floating loosely just above the pelvic brim, but occasionally sinking down into its cavity, and then producing discomfort of various kinds, by its pressure on the parts situated there, and especially by the obstruction it offered to emptying the bladder, symptoms which with its disappearance have completely ceased. This, however, is in my experience a solitary instance of a cyst connected with the uterus remaining quite stationary at a small size for years; so that I fear we must regard the chances as being against the more hopeful view of the nature of any of these tumors, and must further look upon the mere fact of the cyst having attained a greater size than that of a large orange, or of the foetal head, as decidedly negativing it. The arrest of the disease may indeed still be hoped for as a lucky accident; it can no longer be counted on as a probable occurrence. I said that the arrest of the disease may in any case of simple ovarian cyst be looked for as a lucky accident; and, indeed, 1 do not know how more fitly to designate it, for the nice adjustment of the balance between exhalation and absorption depends on conditions which remedies cannot bring about, which diagnostic skill cannot even predicate. It is not in general while in the pelvic cavity that this arrest occurs; for though the growth of the tumor may then be slow, it is while situated there liable to be pressed on, irritated, excited by the varying condition of the adjacent viscera. Alter it has arisen above the pelvic brim this fortunate occurrence sometimes takes place, though it takes place but very rarely, for though the cyst is no longer irritated as it was before, its increase is not now restrained by unyielding boundaries, and hence it frequently enlarges with greater rapidity. As a general rule, the enlargement goes on, not continuously, indeed, but by fits and starts, till at length the size of the abdomen causes distress, and necessitates interference. The exception is met with in instances where the cyst having attained a size somewhat less than that of the adult head, begins, to the patient's surprise and pleasure, to diminish, becomes notably smaller than it once had been, though it scarcely ever entirely disappears, but remains for years, possibly even for the remainder of the patient's life, a source of apprehension and an occasion of some discomfort, but not of much actual suffering, or of serious injury to the health. In March, 1853, I saw a single woman, aged 31, in whom the development of an ovarian cyst had succeeded to a heavy fall on the nates three years before. Her abdomen on admission measured thirty seven 368 OCCASIONAL ARREST OF SIMPLE OVARIAN CYSTS. and a half inches at the umbilicus, and its increase was alleged to have been going on with rapidity; and the patient was anxious even to undergo some risks for the chance of being cured of an ailment now threatening to become the source of much suffering. She was ordered to keep her bed for a few days, in order that a careful examination of her abdomen and of the relations of the tumor might be made. In a week the abdomen measured only thirty-five inches; and in another fortnight only thirty-four. I need hardly say that in these circumstances the patient was advised neither to be tapped nor to have any other operation attempted. She returned to the country, and to her occupation as a village schoolmistress. In April, 1855, her abdomen measured little more than thirty-five inches; and I am sure that I should have heard if it had subsequently increased. To a slighter degree, and for a shorter time, the partial absorption of the contents of an ovarian cyst is by no means uncommon ; and no one can have seen much of ovarian dropsy without having been struck by the different degrees of tension which the tumor at different times presents. Sometimes it is so tense and firm as to seem almost solid, and, indeed, if the growth be but small, this extreme tension of its walls may so obscure the sense of fluctuation as to lead the observer, unless very carefully on the watch, into error. At other times not only is fluctuation most distinct, but the cyst-wall is so flaccid that if the tumor is large it may not be very easy to distinguish between an encysted dropsy and ascites. 1 It is not easy to determine the cause of such fluctuations in the condition of the cyst. A connection may now and then be observed between the approach of a menstrual period and an enlargement and increased tension of the cyst, while it once more grows smaller, and its walls become flaccid as menstruation passes off. In the majority of cases, however, no approach to regular periodicity in these changes crfn be observed, though even when the disease goes on tolerably uninterruptedly from bad to worse, there are yet almost always seasons during which it remains stationary, followed by times of rapid increase. The increase of the tumor, too, sometimes takes place noticeably in the course of twelve or twenty-four hours; the suddenness of the enlargement showing it to be due to a rapid effusion into the cavity of the cyst, not to the comparatively slow process of growth. If the contents of an ovarian cyst may then vary from time to time, there certainly can be no reason why in some instances the process of absorption may not go on so as to effect the entire removal of the fluid and the complete cure of the patient. Such an occurrence, however, appears to be of extreme rarity, and some most competent authorities ! Cruveilhier, Anatomie Pathol., vol. iii. p. 400, speaks of a variety of ovarian cysts, as kystes uniloculaires flasques, and describes them as retaining a remarkable flaccidity of their walls in spite even of having attained a very considerable size. He further gives the details of a case in which these characters led two very distinguished physicians into the error of mistaking an ovarian dropsy for ascites. These flaccid cysts seem to cause comparatively small discomfort, to interfere but little with the general health, and to give rise to no symptoms such as to justify tapping. One such case I saw quite recently, in which it was not till after I had carefully examined the abdomen several times that I came to the decision that the fluid was encysted. OCCASIONAL SPONTANEOUS CURE OF OVARIAN DROPSY. 369 have even discredited it altogether. 1 In one case I believe that I witnessed it in the person of a young married woman, who had vague symptoms of discomfort about her uterus for nine months, and had been aware of the existence of a tumor for four months before her admission into the hospital. The tumor, which was connected with the left ovary, was tapped per vaginam, and sixteen ounces of highly albuminous fluid were withdrawn. It was determined that so soon as the cyst had regained its former dimensions, tapping should be repeated, and a solution of iodine be injected, in order to prevent the reaccumulation of the fluid. On the forty-second clay after the first tapping this operation was to have been clone; but "it then struck some who were present that the tumor had seemed larger a day or two previously than it was then. The operation was postponed ; and day by day the tumor shrank, not suddenly as if from rupture of its walls, nor with any discharge per vaginam suggestive of a communication existing between it and the Fallopian tube, but by degrees, as if its contents were gradually absorbed. Fourteen days afterwards, or on the fifty-sixth day from the first tapping, all traces of the tumor had disappeared. Another case has come to my knowledge of the disappearance of an ovarian tumor in a lady from whom seven pints of deep amber-colored glutinous fluid were removed by tapping five weeks before the birth of her fourth child. Her labor was quite natural, but nineteen days afterwards, while seated on the sofa, she was attacked by sudden violent pain, with great faintness, and symptoms of rupture of the cyst followed by those of general peritonitis, for which she was treated very actively. Her abdomen at this time became swollen to double the size which it had presented when she was tapped. In the course of two months, however, this general enlargement subsided, disclosing a distinct elastic tumor occupying the hypogastric and right iliac regions. This next shrank gradually, so that at the end of nine months from the patient's confinement I could scarcely find any trace of it; and after a natural pregnancy she was confined of her fifth child, two years and a month after her former labor. On this occasion, the medical man who attended her, and who had watched her through all her previous illness, searched in vain for any traces of the tumor. In this second case there can be little doubt but that some connection existed between the attack of peritoneal inflammation in which the cyst itself was involved and the subsequent complete disappearance of the tumor. In the former instance, however, no symptom whatever attended the removal of the fluid; but though we do not understand the means by which it was effected, still the removal of the fluid is scarcely more inexplicable than the permanent cure which occasionally follows a single tapping, in cases where yet neither constitutional disturbance nor local suffering has followed the operation. 2 1 Kiwisch and Scanzoni, two of the most recent, and of the highest authorities, most completely discredit its occurrence. 1 A case of gradual disappearance of a well-marked ovarian cyst is related by Dr. Huss in Monatschrift f. Geburtskunde, Feb. 1S57, vol. ix. p. 143. 2-1 370 OVARIAN CYSTS EMPTY THEMSELVES The simple absorption of their contents is, indeed, the rarest of all the changes which take place in ovarian cysts. A much more common occurrence, and one by which their increase is for a time arrested, and their complete cure now and then effected, is their rupture, and the escape of their contents through various channels, the empty cyst ceasing, perhaps for a time, perhaps forever, to perform its secretory function. An ovarian cyst may empty itself through the Fallopian tube, the most fortunate, but by no means the most frequent, its contents; through the vagina, or through the intestine; or it may burst into the cavity of the perineum, or, forming adhesions with the abdominal walls, may pour out its contents at or near the umbilicus. Each of these outlets needs a moment's notice; and, first, of that which is formed by the dilated Fallopian tube. Cases are sometimes met with in which, on examination of the body after death, the fimbriated extremity of the Fallopian tube is found adherent to an ovarian cyst, and expanded over it, Avhile the tube itself is distended at its abdominal extremity, and presents all the characters of dropsy. On pressure upon the cyst, however, it is found that the fluid can pass readily from it into the tube, while in most instances, and quite contrary to what might be expected, no mechanical obstacle is found closing the uterine end of the canal. The communication between the cyst and the tube is, however, free enough to admit the point of the index finger, a slight contraction marking its situation, and the longitudinal arrangement of the fibres indicating the commencement of the tube. The mere tonicity of the parts prevents the ready escape of the fluid at the uterine end of the tube. It collects in the canal, distending by degrees its abdominal extremity, and at length escaping through the womb only when it has dilated the whole length of the tube, and overcome the natural resistance of its walls. A gush of fluid then takes place by the vagina, and the cyst is partly or even completely emptied, though such discharges do not in general effect a permanent cure, but the cyst refills, the tube becomes redistended, and the same process may be several times repeated. Such at least appears to be the opinion of M. Adolphe Richard, 1 who has described these cases very minutely, and who suggests, and with much plausibility, that many of the instances of alleged communication of ovarian cysts with the vagina were in reality instances of their opening into the Fallopian tube. No opportunity of studying this process has presented itself to me after death, and indeed I am disposed to believe that it is a rare occurrence, since I have met with but one instance, out of the total of sixtyeight cases on which my remarks are founded, where the cyst appeared 1 Memoires de la Societe de Chirurgie, vol. iii., 1853, p. 121. The absence of any evidence of past inflammatory action about the communication between the ovary and the tube, leads M. Richard to suppose that the origin of the condition dates back to a bygone menstrual period; that the Graafian vesicle having discharged its ovule did not collapse and wither as it usually does, but, still retaining its communication with the tube, enlarged, became dropsical, and thus formed what he proposes to term a tuboovarian cyst. THROUGH VARIOUS CHANNELS. 371 to empty itself in this manner. The patient in that case was a married woman, thirty-six years of age, whose abdomen first began to enlarge six years before her admission into the hospital. After having acquired a considerable size, the swelling suddenly disappeared during a profuse watery discharge from the vagina; and the same occurrence took place afterwards eight or ten times. The fluid thus discharged was colorless; it escaped with a gush, amounted sometimes to several quarts, and the suddenness of its flow not unfrequently produced faintness or actual syncope. Sometimes it escaped during the effort at defecation, but most commonly its flow was independent of any such exciting cause. I myself ascertained the presence of a distinctly fluctuating tumor, its sudden disappearance fourteen days afterwards, and then the slow return of abdominal enlargement during the ensuing three weeks, when I lost sight of the patient. The symptoms, however, were so characteristic, that I imagine one is perfectly justified in assuming the case to have been one of communication of the cyst wiih the Fallopian tube. The uterus itself was perfectly movable, rather high up in the pelvis, no aperture existed in the vagina, nor, indeed, was the tumor to be distinctly felt through it; but it evidently floated in the abdominal cavity loosely tethered, as an unadherent ovarian tumor often is, by the elongated uterine appendages. How the communication is brought about between the ovary and the tube in these cases is uncertain; but it has been suggested with considerable plausibility that the process is one of a physiological rather than of a pathological character. In the other instances, however, inflammation, the formation of adhesions, and the absorption of the wall both of the cyst and of the adjacent viscus, are all implied in the escape of the fluid. Many instances are on record 1 of a cyst emptying itself 'per vaginam; and this, too, even if we exclude those concerning which it is doubtful whether they do not more properly belong to the class described by M. Richard. Far more frequent, however, is the formation of a communication between the cyst and the intestinal canal. Generally, though not invariably, this communication takes place quite low down, and seems to be due to the pressure of that portion of the cyst which occupies the pelvic cavity upon the rectum, and the consequent absorption of the walls, both of the intestine and of the tumor. Not long since a communication took place in this manner, in the case of a patient of my own, between a large sac which formed part of a compound ovarian cyst and the rectum a little above the internal sphincter. Through the opening, which was of the size of a crown-piece, many quarts of a dark grumous fluid escaped during the last few days of the patient's life, with much alleviation of her sufferings, and with complete removal of the-obstinate constipation that for a long time previously had been maintained by the mechanical pressure of the tumor on the intestine. The observation of this and of similar cases suggests the expediency of attempting to tap the tumor per vaginam whenever 1 Meissner's Frauenkrankheiten, vol. ii. p. 318, contains numerous references illustrative of this subject. 372 OVARIAN CYSTS EMPTY THEMSELVES serious inconvenience is produced by its pressure upon the intestine, and paracentesis through the abdominal walls has either proved unsuccessful, or has afforded but partial relief. In the instance just referred to very little fluid was obtained by puncture of the abdomen, while, had a trocar been introduced into that part of the growth which projected into the pelvis, the principal cyst would have been emptied, and the patient's sufferings, which nature mitigated but too tardily, would long before have been assuaged. Sometimes, however, communications form between an ovarian cyst and the intestinal canal in other situations, and are not attributable to the direct effects of pressure, though their real cause is very obscure. Thus, in the museum of Guy's Hospital there is a preparation of an ovarian cyst, at whose upper part an opening has formed into the bowel. A patient of mine, too, in whom an ovarian cyst had developed itself with much rapidity in the course of two months, and who experienced much abdominal pain and tenderness, suddenly felt a sensation as if something had given way within he?, and was immediately attacked by violent diarrhoea. In the course of ten hours the bowels were purged twenty times; the evacuations not being feculent, but consisting of a dark bloody fluid, which, under the microscope, was found to contain many blood globules, and also many pus corpuscles, as well as some crystals of cholesterine. The tumor was now found to have completely disappeared, and five weeks afterwards there was still no trace of it discoverable, though I am unable to say whether the cure was permanent. Openings in the abdominal parietes are another channel through which ovarian tumors sometimes empty themselves. In one instance which I saw the cyst haft dilated the umbilical ring, and projected, like a hernia covered by the thinned integument, some inches beyond the surrounding abdominal walls. In this thin integument an opening formed, through which on several occasions the cyst partially discharged itself. It is, however, more usual for the opening to take place below the navel, adhesions first forming between the cyst and the integuments. The opening sometimes continues long fistulous, though I have known it to close, and discharges from it permanently to cease without any special change taking place either in the condition of the tumor or of its contents. To the best of my knowledge a permanent cure less often follows the discharge of the contents of the cyst through the abdominal walls than their escape through some other channel. The rupture of an ovarian cyst into the peritoneal cavity is, however, an accident of far more frequent occurrence than the discharge of its contents through any other channel, and was met with in 6 out of 68 cases of which I have a record. In one of these cases, a fall on the abdomen produced the bursting of the cyst, but in by far the greater number of instances on record its rupture has been independent of external violence. Sometimes the delicate cyst gives way from overdistension, and this is probably the explanation of its sudden disappearance in the case which I referred to some time ago, as being probably an instance of a tumor connected with the remains of the 373 THROUGH VARIOUS CHANNELS. Wolffian body; as also in another instance where a tumor half the size of the adult head suddenly disappeared, the same accident having occurred to the patient eighteen months before. In other cases inflammation and softening of the cyst-wall have preceded its rupture; and an examination after death discovers it red and congested, and the edges of the rent soft, irregular, and jagged. Sometimes the sac, once ruptured, does not refill, and a permanent cure is obtained, though, usually at the expense of an attack of peritonitis; and I much fear that there is no direct or constant relation between the severity of the inflammation which follows the rupture of the cyst and the non-accumulation of the fluid afterwards. One of my cases was that of a young lady, aged twenty-six, in whom an ovarian cyst gave way twice, and whose life on each occasion was in the greatest jeopardy, but who did not gain thereby the slightest delay in the rapidity with which the fluid re-collected. In two other cases of mine the rupture of the cyst proved fatal; the wall having in both instances given way at the posterior part of the tumor, where it was closely pressed against the pelvic brim, and extensive ecchymosis around the rent attested in one case the mechanical obstacle which had existed to the course of the blood in that situation. In the other case decomposition was too far advanced to allow of any observation as to the state of the cyst-wall. The mortality of 2 cases out of 6 agrees very nearly with that which Dr. Tilt 1 deduces from a collection of 34 cases, in 10 of which death followed the rupture of the cyst. In 20 of the cases, however, the fluid did not re-collect, but I feel very doubtful whether a more numerous collection of facts would be found to bear out the conclusion that in 2 cases out of 3 the escape of the cyst contents into the abdomen is followed by the permanent cure of the patient. 2 For the very various results that have followed the escape of the fluid of ovarian dropsy into the abdomen an explanation has been suggested by Dr. Simpson, 3 and adopted by Scanzoni. 4 It is supposed that the different characters of the fluid in the cyst determine the occurrence or non-occurrence of peritonitis; that the pure serum gives rise to no ill effects, while dangerous peritonitis follows the escape of fluid mixed with blood or with the products of inflammation. Still, this is only a hypothesis, probable, indeed, but not proven, and wholly insufficient to form the basis of any therapeutical proceedings. Other changes take place in ovarian cysts, tending for the most part less to the cure than to the aggravation of the evil. Some of these changes seem accidental to the process of growth, as for instance the removal of the septa between the cysts, the gradual liquefaction of the solid matter, and the consequent conversion of a firm into a distinctly fluctuating tumor. This alteration is in one sense of bad omen, since I believe its occurrence is generally contemporary with the more 1 Lancet, Aug. 5, 1848, vol. ii. p. 146. 2 In vol. v. p. 226, of Transactions of Pathological Society, a case is related by Dr. Bristowe of rupture of an ovarian cyst into the abdomen, the aperture remaining permanent, the cyst still continuing to secrete, and ascites resulting from the accumulation of the secretion within the peritoneal cavity. 3 Op. cit., vol. i. p. 247. 4 Op. cit., p. 392. 374 DISORDER OF GENERAL HEALTH rapid increase of the growth; on the other hand, however, it often places within our reach the means of mitigating the patient's sufferings by tapping, which in the earlier stages of the affection was impracticable. With the rapid growth of the tumor there is in all cases of compound ovarian cysts a corresponding increase in the vessels which supply it, and a consequently greater disposition to hemorrhage into its cavity. Sometimes, indeed, the admixture of blood with the fluid of the cyst is so considerable as no doubt to have had a large share in the production of that anaemia, and that extreme exhaustion of strength which are often observed in patients suffering from large ovarian tumors. Of all the morbid processes, however, of which these growths are the seat, inflammation is the most common and the most important. Few cysts attain any considerable size without having been attacked by it, and this inflammation is of all the greater moment since it is seldom limited to the interior of the cyst, but generally affects its outer surface likewise, producing adhesions between it and adjacent organs, and thus forming great, often insuperable obstacles to the success of various operations which have been proposed for the cure of ovarian dropsy. In a practical point of view, too, this inflammation is the more important from being often unattended by local suffering, sometimes, indeed, accompanied by a comparatively small amount of constitutional disturbance, so that it is almost impossible to determine anything with certainty concerning its occurrence or non-occurrence from the patient's history. Of this no better proof can be given than is afforded by the observation of cases where on tapping a cyst, instead of the transparent serum which it was supposed to contain, a turbid fluid largly mingled with pus has been let out, or of other cases in which, the extirpation of the tumor having been resolved on, universal adhesions have been found connecting it with the viscera, and with the abdominal walls. In many instances the inflammation issues in the exudation of lymph as well as in the outpouring of pus, and the lining membrane of the cyst is found roughened and thickened by its deposit, which is sometimes so abundant that it may be stripped off just as may the false membrane deposit on an inflamed pleura. Multilocular cysts are, I think, more liable than simple cysts to this occurrence; and often, even where the different cavities intercommunicate, inflammation and the outpouring of lymph may be found in one cyst, and no trace of any such occurrence be»observable in another immediately adjacent. With the increase of the tumor, and the failure of the patient's powers, the liability to inflammation of the cyst appears to increase also, and its occurrence contributes to hasten the fatal event. It is but seldom, however, except after tapping, or some other operation, that cyst-inflammation of itself proves fatal; but many causes in general combine by slow degrees to destroy the patient. First among these causes may be mentioned the disorder of the functions of other viscera, as the tumor by its increasing size presses upon and disturbs them. The pregnant uterus, as you know, even when it has attained its largest size, interferes but little with the func- 375 FROM OVARIAN DROPSY. tions of other organs. The intestines find room on either side of it, while the direction of its fundus forwards in the axis of the pelvic brim obviates all interference with the descent of the diaphragm, and usually prevents all disturbance of the stomach or liver. The ovarian tumor, on the other hand, as it increases in size, so completely fills the lateral regions as to leave no room for the intestines except behind and above it, where they are often compressed into a very scanty space. No such law governing the direction taken by the tumor as regulates the enlargement of the pregnant womb, the descent of the diaphragm becomes earlier impeded, and respiration is thereby rendered labored. The liver is at the same time pressed on and disturbed in the performance of its functions, and this just at a time when the active discharge of its duties is rendered all the more necessary by the congestion of the abdominal vessels which the pressure of the tumor occasions, and the scanty urinary secretion that is its attendant and its consequence. 1 In a great proportion of cases this abdominal congestion relieves itself by the effusion of fluid into the peritoneum, and in some instances the amount of this effusion is very considerable; enlargement of the superficial veins attests the obstruction to the circulation, and the ascites becomes the occasion of more distress than the original disease to which it is superadded. of the lower extremities is less frequent than in pregnancy, probably because the peculiar state of the blood which favors its occurrence in the latter condition is absent. Where it exists, it is often confined to one limb, being the direct result of mechanical pressure. This is not invariably the case, however, for ovarian dropsy is sometimes associated with albuminous urine, whether as the result of its accidental complication with granular disease of the kidneys, or of congestion of those organs produced by the pressure of the tumor, I do not feel myself able to determine. While the enlarging tumor thus tends to trouble all the functions of the body, the patient's strength is further exhausted by the determination to the growth of a large quantity of that blood which ought to minister to the general nutrition of the body. Nor is this all; but a state of cachexia, the consequence and the evidence of the deteriorated condition of the blood, occurs frequently in the course of this, as of other forms of malignant disease, with which, if not actually identical, many tumors of the ovary are at any rate closely allied. In the simple ovarian cysts it is true that this latter source of suffering and of peril does not exist, and the prospects of the patient are accordingly far less dark than in other varieties of the disease. These simple cysts, too, as has already been mentioned, now and then remain stationary for many years, life being not at all shortened, scarcely even embittered by their presence. Such, however, are exceptional cases, and exceptions of but rare occurrence; for generally the accumulation of fluid even in a simple cyst sooner or later necessitates the performance of tapping, while, when once done, its repetition is speedily required, 1 Two drawings given by Dr. Bright, loc. cit., pi. vii. ix., are extremely instructive illustrations of the manner in which tumors of the ovary press on and displace the viscera. 376 PREDISPOSING CAUSES OF THE DISEASE. and the patient is thus worn out by the frequent collection and frequent evacuation of the contents of the cyst. A certain risk, too, of cyst-inflammation accompanies every tapping, and is, when it occurs, a hazard of a very serious kind. The liability to its occurrence appears to be greatest either after the first performance of the operation, or else in the case of patients who have been exhausted by the long continuance of the disease, and the frequent repetition of the tapping. In much debilitated patients, especially in those who are suffering from malignant or quasi-malignant forms of ovarian disease, the spontaneous supervention of cyst-inflammation, or of a low form of peritonitis, is of no very rare occurrence, and not infrequently puts out the life whose flame had burnt but flickeringly for weeks or months before. We have now completed our examination of the structure of cystic tumors of the ovary, and have also studied the different modes whereby in some rare instances nature effects their cure, as well as those far more numerous ways by which the patient is usually conducted from bad to worse, and the fatal issue is but too surely brought about. Before we proceed to the investigation of the symptoms of these diseases, and to the inquiry as to what' either medicine or surgery can do for their alleviation or their cure, there are still some questions concerning their causes, and the circumstances that favor their occurrence to which we must endeavor to furnish a reply. It may be asked, when do these affections commonly occur; what is the influence of the exercise of the sexual functions upon their development; whether does sterility or fecundity predispose to them; and does a disordered state of the uterine health commonly precede them; or are they as likely to befall the person whose health has been previously good as her who for years has been a valetudinarian ? To these inquiries as to the causes of ovarian dropsy, it would seem that very definite and conclusive answers might be given, and yet, strangely enough, the replies are most contradictory. The young and the aged, the single and the married, the sterile and the mother of many children, the robust and she whose uterine functions have been performed with pain and difficulty, have all in turn been asserted to be specially liable to the occurrence of ovarian disease. With reference to the age of patients in whom the disease occurs, there seems to be no period of life that enjoys an absolute immunity from it; though it is of extreme rarity before puberty, and its commencement after the cessation of the menstrual function, if not equally uncommon, is at least very unusual. Professor Kiwisch mentions 1 a preparation of cystic disease of the ovary in a child only a year old in the museum at Prague, and refers to a similar one at Wurzburg, in which the affection involves both ovaries in the fcetus. He states, however, that fourteen years is the earliest age at which he himself has observed it; and a girl died recently in St. Bartholomew's Hospital, under the care of Dr. Burrows, from malignant disease of the ovaries, with cyst-formation in their substance, who had not attained her fifteenth year. One of my patients died of rupture of the cyst 1 Op. cit., vol. ii. p. 79, § 36. CAUSES PREDISPOSING TO OVARIAN DROPSY. 377 when in her sixteenth year, and the enlargement of her abdomen, which was very considerable at her death, was alleged to have been first observed when she was thirteen years old; menstruation not having occurred till the age of fourteen years and six months. In another of my patients the disease began in her seventeenth year; menstruation having occurred once at the age of fifteen and a half; but it did not reappear till after she was tapped at the age of eighteen. These, however, are exceptional occurrences, and in nearly half of all cases of ovarian dropsy the commencement of the disease dates from between the ages of thirty and forty. This result at least is what I arrive at from a comparison of 68 cases of my own with 97 of Seanzoni's, 1 which are thrown into the following table. I employ Seanzoni's figures in preference to those of any other writer, because he alone has taken as its basis the ages at which the first symptoms of the disease appeared, while many writers have constructed their tables according to the age at which the patients first came under their observation. Table showing the age at which, in 165 Women, the symptoms of Qvarian Dropsy were first perceived. Author's Scanzoni's Total ¦ Ag0 at Proportion per cent, cases. cases. ' symptoms. at different ages. 14 5 19 from 13 to 25 years 11.5 13 12 25 " 25 " 30 " 15.1 14 21 35 " 30 " 35 « 21.2 14 32 46 " 35 « 40 " 27.8 7 14 21 " 40 " 45 " 12.1 4 6 10 " 45 " 50 " 0.0 2 2 4 " 50 " 55 " 2.4 0 5 5 " 55 " 60 " 3.0 68 97 165 The next question concerns the influence of the exercise of the sexual functions in predisposing to the disease; an influence which you may remember was very decided in the case of uterine cancer, since only 3 out of 134 patients affected by it were single women, and only 8 out of the 131 who had been married were sterile. Of 68 cases of ovarian disease, however, 19 occurred in single women, 10 in widows, and 39 in the married; a statement which refers to their condition at the time when the disease commenced. This proportion is not very materially altered by the employment of higher numbers, since, adding to my own cases those collected by Mr. Lee and those observed by Scanzoni, 2 we obtain the following result:— Single women 89 or 29.5 per cent. Widows 28 " 9.3 Married women 184 " 61.1 " 301 » Op. cit., p. 365. 8 Op. cit., p. 365. I have included in his list of married women, seven, who though single, had given birth to one or more children. 378 CAUSES PREDISPOSING TO OVARIAN DROPSY. or, in other words, considerably more than a third of all cases of ovarian disease began at a time when the sexual functions were not in active exercise; and more than a fourth occurred in women in whom those functions had never been exerted at all. That the exercise of the sexual functions does not predispose to ovarian disease, but that, on the contrary, some connection subsists between their imperfect performance and the development of this affection is evident from the low rate of fecundity among married women in whom ovarian dropsy occurs. Of 49 of my patients, either married or widows, there were 16 sterile; and of Seanzoni's 52 cases, 18 who had likewise never been pregnant; or, in other words, in 34 of 101 women who became the subjects of ovarian dropsy, marriage had never been followed by conception, while among my patients generally at St. Bartholomew's Hospital the proportion of sterile marriages was only 11.7 per cent. Even those marriages, too, that were followed by conception showed less than the average fecundity; for of my 49 cases, the 33 in which the women were not sterile yielded only 105 pregnancies; of these 83 terminated at the full time, 22 ended in miscarriage. These numbers yield an average of 3.1 pregnancies to each marriage, or less than half the number which occurred in persons in whom cancer of the womb took place. It may perhaps as well be added that in 13 of the total 33 cases pregnancy occurred but once, and terminated in 3 instances prematurely, in the other 10 at the full period of gestation. One question still requires an answer, namely, what connection, if any, subsists between the ordinary state of a joatienfs uterine health, and the subsequent development of ovarian disease ? Now nothing can seem more probable than that she who has menstruated irregularly, painfully, or scantily, shall be more liable to suffer afterwards from disease of the ovaries than the person whose menstruation has always gone on quite regularly. This, too, appears from Seanzoni's statement really to be the case ; though my own observations do not corroborate his assertion, and probably neither his facts nor mine are sufficiently numerous to decide the question. Of my own 68 cases, there were 54 in which the ordinary uterine health was quite good ; 3 had had puerperal inflammation, but had quite recovered from its effects ;*1 was still weak from hemorrhage after delivery; in 5 menstruation was always painful; in 3 menstruation was always scanty; 1 was chlorotic, and had bad uterine health in all respects; 1 had suffered for years from great hypertrophy of the neck of the womb, and much consequent discomfort. On the other hand, Scanzoni says that there were but 20 of his 57 cases in which menstruation was always healthy; while 19 patients had suffered more or less from chlorosis, 12 from dysmenorrhcea, 5 had always menstruated very profusely, and 1 patient, in whom ovarian disease came on in her forty-first year, had never menstruated at all. Be the truth concerning this matter what it may, I cannot but think that Seanzoni's figures overstate the frequency of menstrual disorder, as a precursor of ovarian disease, as much as mine perhaps err on the opposite side. 379 EXCITING CAUSES OF OVARIAN DROPSY. We find that in the case of most diseases onr patients like to assign some cause for the commencement of their ailment, a cause often indeed quite fanciful, sometimes absurd. It is so in the case of ovarian diseases, while if all mere phantasies are rejected, the instances will turn out to be comparatively few and exceptional in which any plausible ground can be assigned for the beginning of the affection. 1 In 21 of Seanzoni's 97 cases, and in 16 of my 68, or in 37 out of 165 instances, the following were with some probability alleged as the exciting causes of ovarian dropsy :— Began within a year after marriage in 6 Came on daring pregnancy "2 Followed not long after delivery "14 Succeeded to abortion "4 " metritis from cold "3 " suppressed menses from cold . . " 2 " violent blows on the pelvis ... "2 " strains or over-exertion .... "3 Occurred simultaneously with ascites and anasarca from exposure to cold " 1 37 From all these facts, then, we may conclude that the immediately exciting cause of ovarian dropsy, when any cause can be assigned for it, is usually connected with some disorder of the uterine functions, or with the recent excitement of their highest forms of activity. Nevertheless, too wide an inference must not be drawn from this fact, since in the great majority of instances the disease comes on independently of any cause to which it can be reasonably attributed ; while further, it occurs in the unmarried oftener than most other organic diseases of the sexual organs; and the married who suffer from it are remarkable for their low rate of fecundity, and for the frequency among them of absolute sterility. In the next lecture we shall leave these incomplete and inconclusive details for the more important practical inquiry into the symptoms and diagnosis of tumors of the ovary. 1 Of 36 instances collected by Mr. Leo, op. cit,, p. 118, there were 28 in which the alleged causes had reference to the uterine functions, being in 5 marriage, in 9 labor, in 2 abortion, in 7 sudden suppression of the menses, in 2 cessation of menstruation, and in 3 irregularity of its performance. 380 OVARIAN TUMORS AND DROPSY. LECTURE XXVII. OVARIAN TUMORS AND DROPSY. Symptoms op the disease occasionally absent in early stage; generally referable to five heads—of functional disorder of ovaries, pain, the effects of pressure, cachectic symptoms, and the symptoms consequent on interference. Diagnosis, its difficulties; diagnosis from inflammation of broad ligament and its effects, from fibrous tumor of uterus, misplacements of uterus, ascites, distension of bladder, pregnancy, tumors of spleen or liver, &c. Note on floating tumors of the abdomen. Many uterine ailments in their early stage present a puzzling resemblance to each other. Pain and menstrual disorder are common to most, and accompany as well the slight as the more serious affections, while it is often not until after some time that the distinctive features of the disease show themselves, and enable us to determine its nature, and to estimate its importance. This is especially true with reference to ovarian disease, which at its onset commonly attracts but little notice, owing to the vagueness of its early symptoms ; while not infrequently, just as is the case with fibrous tumors of the uterus, its existence is not suspected till accident all at once reveals the presence of a growth of considerable size. On a comparison of the 68 cases on which these observations are chiefly founded, it appears that the first symptom of ovarian disease was— Suppression of the menses 6 cases Irregular menstruation 4 " Pain in the abdomen, more or less distinctly referred to the side where the disease began . .24 " Suppression of urine, or difficult micturition . . 6 " The unexpected discovery of a tumor .... 28 " 68 The want of attention to their own condition implied in the very considerable size to which abdominal tumors sometimes attain before they attract the notice of patients is so remarkable as to be scarcely credible if it were not of every-day occurrence. Not very long since I saw a young lady in whom an ovarian cyst of the size of the adult 381 EARLY SYMPTOMS OF OVARIAN DROPSY. head was only accidentally discovered in consequence of her suffering from a severe attack of abdominal pain while staying in the house of a medical man. If tumors so large can escape notice, it is less to be wondered at that those of smaller size should frequently be found out only when they become the seat of pain, or when they'cause inconvenience by pressure on surrounding viscera. It is not easy to say on what the frequent absence of symptoms in the earlier stage of ovarian dropsy depends. The immunity from suffering then is also far from constant, and in many instances much more pain and discomfort are experienced while the enlarged ovary still remains within the pelvic cavity, than are felt subsequently, or at least than are experienced till its size begins to interfere with the functions of the abdominal viscera. While in the pelvis the large ovary presses on the rectum, the uterus, and the bladder, and maintains a constant congestion of the pelvic vessels, all of which inconveniences are diminished, or completely removed when once it rises higher, and floats as it were loosely tethered by the ovarian ligament. When pains are experienced, too, they generally tell plainly of some cause seated within the pelvis. They are usually of a throbbing or burning character, referred chiefly to one or other iliac region, and are liable, like all ovarian pains, to exacerbation in paroxysms. More frequently, too, in this affection than in any form of uterine disease, pain is experienced extending down the leg of the affected side, being sometimes a mere numbness or sense of weariness, aggravated, however, and rendered positive suffering by walking or exercise; at other times it is severe and neuralgic in character. Besides this, too, painful defecation and micturition, especially the latter, are frequent; and occasionally the necessity for the introduction of the catheter is an early symptom of the disease; though while the dysuria often persists for a considerable time, retention of urine is a rare accident, and may even not occur a second time. Though generally more severe than the same class of symptoms when they accompany fibrous tumors of the uterus, they are at the same time usually of shorter duration, since an ovarian cyst tends more certainly and at an earlier period to rise out of the pelvic cavity than does the fibrous tumor whose growth is slower, and whose close connection with the womb confines it longer to its original position. My own observations do not show such frequent disorders of menstruation as might be expected either among the precursors of ovarian disease or among its earlier symptoms. Few, however, indeed, are the cases in which the disease runs to its fatal termination without the uterine functions being altogether deranged. I have not the data to show the influence of the disease from its commencement to its close in this respect. The following table represents the state of 08 patients, in all of whom the disease was fully established; but the majority were only a few weeks or months under observation. In 3 cases menstruation had ceased before the disease began. " 2 " disease began during pregnancy. " 26 " menstruation had continued quite undisturbed. 382 SYMPTOMS OF THE LATER STAGES In the remaining 39 Menstruation was painful in 1 " M profuse " 5 " " anticipating " 4 M " irregular " 7 ; in 2 was the first symptom. M " postponing " 3; " 1 was the first symptom. u " scanty " 5 " " suppressed " 14; "6 was the first symptom. 39 The general tendency of the disease then is to impair the activity of the ovarian functions, no doubt by the disorganization of their tissue. Hence the persistence of menstruation is always a favorable sign in cases of ovarian dropsy, warranting the hope that the disease is simple in kind, and that one ovary only is involved. Complete amenorrhcea, however, is more to be dreaded as an unfavorable sign than is even tolerably regular menstruation to be hailed as evidence of the simpler forms of disease, or of its being limited to one side. It is not possible to give any general description of the symptoms which attend the later stages of ovarian dropsy. They are modified by very many causes, and differ according to the nature of the tumor, the rate of its increase, the age of the patient, and even her civil state, and general condition. They may, however, be referred to some of the five following heads, which have already been briefly touched upon when I was endeavoring in the last lecture to point out the various modes in which the fatal issue of ovarian dropsy is prepared for or actually brought about. 1st. There are the various evidences of derangement of the function of the ovaries, showing themselves in different forms of menstrual disorder, of which the irregularity, or the total suppression of the discharge are the most common; its over-frequent, or too profuse occurrence are the rarest. Menorrhagia, however, does now and then for a season accompany ovarian dropsy, so that we cannot place unqualified reliance on the state of the menstrual function as enabling us to discriminate between uterine and ovarian tumors. 2d. Pain and other symptoms are experienced indicative of changes in the tumor itself. In simple cysts, the degree of fulness and tension of the cyst seems in great measure to determine the presence or absence of pain. Variations in this respect often take place with great rapidity, and increased pain will be found almost invariably associated with increased tension, and an abatement of suffering with a flaccid state of the cyst. The occurrence of actual inflammation is almost always accompanied with tenderness of the tumor, though, unless the peritoneal surface is affected, there is not usually much pain except on pressure. Vague constitutional disturbance usually attends this process, and though it is seldom very well marked, yet indefinite febrile attacks, shivering, loss of flesh, and hectic may generally be regarded as indicative of this occurrence, and the more certainly provided the abdominal tumor is found to be tender on pressure. The malignant OF OVARIAN DROPSY. 383 forms of ovarian tumor are often associated with pain during their growth quite independently of tension of their walls, or of any attack of inflammation. This, however, is by no means constant, and no inference as to the simple character of the disease can be drawn from the painlessness of its development. 3d. With the increase of the growth various disorders are produced by its pressure on the different viscera, and a class of symptoms appear, whose causes I dwelt on fully in the course of the last lecture. Difficult breathing, impaired, digestion, obstinate constipation, frequent and painful micturition, diminished secretion of urine and the effusion of fluid into the abdominal cavity, are but so many different results of this mechanical pressure. The difficulty in micturition, however, that occurs in the more advanced stage of the disease is produced in a different manner from that which accompanies its commencement. While the tumor is still within the pelvic cavity, it interferes with micturition by pressing directly against the bladder; afterwards, as it rises out of the pelvis, it drags the uterus and bladder upwards, and thus interferes with the function of the latter organ, while the presence of a portion of the outgrowth behind the bladder in most cases prevents its distension in the antero-posterior direction. Scanzoni mentions also another occasional result of the pressure of the tumor on the under part of the bladder. 1 lie states that it sometimes prevents the passage of the urine from the ureters, and thus produces great distension both of them and of the pelvis of the kidneys, and in illustration of this relates the case of a "patient who was tapped twentyone times in the course of three years, which operation, during the last year of her life, was rendered necessary chiefly by the circumstance that the rapid accumulation of fluid in the tumor was always accompanied by complete retention of urine, which could not be relieved by the catheter, since the pressure of the tumor prevented the escape of the urine from the ureters into the bladder. For the first few days after each tapping the function of the bladder was undisturbed, but by degrees the flow of urine became more and more scanty, and in the course of five or six weeks complete retention of urine was once more produced. On examination of the body after death, a cysto-sarcornatous tumor was discovered, twice the size of the adult head, the lower, solid part of which pressed on the neck of the bladder, and had produced, by the obstacle to the outflow of the urine, so great a dilatation of both ureters that the right was two inches, the left an inch and a half in diameter." The pressure on the stomach sometimes causes a serious impediment to the patient's taking food, since not only does the organ become unable to retain more than extremely small quantities at a time, but in some instances obstinate vomiting occurs, which no medicine can in the least degree relieve, and which is arrested only by tapping the cyst, and thus removing the pressure. Still more distressing symptoms sometimes follow the compression 1 Op. cit., p. 370. 384 DIAGNOSIS OF OVARIAN DROPSY. of the rectum. Not only is most obstinate constipation thus induced, but even the escape of flatus is in some instances prevented; the whole colon becomes distended by it to the thickness of the arm ; and every now and then violent attacks of colic pains come on, during which the movements of the bowels are distinctly visible through the thinned abdominal parietes, and, as in ileus, or in strangulated hernia, stercoraceous vomiting adds from time to time to the patient's sufferings. 4th. To this class belong a large array of symptoms of the cachectic kind, due in some instances to the nature of the disease of the ovaries; in others, to the mere diversion to the tumor of a large quantity of blood which ought to minister to the general necessities of the body. They are symptoms of the same kind as we see towards 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 for are given up; then those for cleanliness, and lastly, those for comfort; till at length one position is maintained all day long in spite of the cracking of tender skin, it sufficing for the patient if in that respiration can go on quietlj'-, 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 false brightness, 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. 5th. May here be reckoned all those incidents which are inseparable from every attempt at alleviation or at cure. The exhaustion which follows after repeated tappings, the cyst-inflammation which sometimes succeeds to its first performance, the hemorrhage from vessels divided in the extirpation of the tumor, or the more frequent, and therefore more serious attacks of peritonitis that are induced even by attempts at its removal, all belong to this category. Their study, however, will find its fittest place when we come to consider the treatment of the different forms of the disease, and the comparative dangers either of letting it alone, or of endeavoring by one or other of the numerous means which had been devised, either to delay its progress, to mitigate its evils, or to accomplish its entire removal. But before we pass to this subject, there comes the inquiry as to the diagnosis of ovarian tumors; an inquiry the importance of which it is impossible to overrate, while, though sometimes attended by no difficulty, it is at others exceedingly obscure, and calls for large experience and well-schooled observation to return a quick reply. 385 DIAGNOSIS OF OVARIAN DROPSY. The difficulties which we encounter in the diagnosis of tumors of the ovary vary according to the size of the growth, and the situation that it occupies. So long as it remains principally within the cavity of the pelvis, it for the most part yields but an indistinct sense of fluctuation, even though its contents should bo entirely fluid, and it may then be hard to distinguish between it and the results of inflammation of the broad ligament, or between it and a fibrous tumor of the womb, or the retroflected uterus itself, especially if the organ is enlarged by pregnancy. When the growth has ascended into the abdomen, the distended bladder, the pregnant uterus, the enlargement produced by ascites, by tumors of the uterus itself, or by tumors of other organs, as the liver, spleen, omentum, or mesentery, present so many separate sources of error, against which we need to be on our guard, while last of all the caution is not superfluous which warns us to be on the watch against imaginary tumors such as are produced, by flatus in the intestines, or by fat in the integuments, or loading the omentum, or by feces in the large intestine, or against those still more unreal swellings which have no existence at all save in the disordered fancy of the patient. It sometimes happens that the earlier stages of ovarian dropsy are accompanied by a good deal both of general febrile disturbance and of local suffering. In such cases doubt may for a time be entertained as to whether a swelling which is discovered by the side of the uterus is the result of inflammation, or whether a more serious view must be taken of its nature. If the disease be ovarian, it will generally be found on close investigation that some slight discomfort, referred to the affected side, had for a considerable time preceded the more acute symptoms, or that those symptoms themselves had been of longer duration than are commonly such as betoken inflammation of the broad ligament. At the same time, however, it must be borne in mind that an attack of inflammation is sometimes the first evidence of the presence of ovarian tumor, and that this is especially the case with hair and fat cysts of the ovary. Still even then the inflammation does not in general extend to the adjacent tissues, so that the ovarian tumor is very often still movable; or if it be pressed so closely between the uterus and the pelvic wall as to have lost this characteristic, yet we miss that thickening and induration of the roof of the vagina which are such constant attendants on inflammation of the broad ligament, and of parts therewith connected. The tumor, too, whether felt per vaginam, or with the hand over the ramus of the pubes, presents "a much more definite outline than is yielded by the swelling formed by the inflamed broad ligament, while, lastly, in many instances the uterine sound enables us to isolate the womb from the tumor by its side. Even when at first there is most room for doubt, observation continued for a comparatively short time almost always dispels the uncertainty. Often the inflammation attacks the side opposite to that first affected, while it is rare for both ovaries to be involved within so short a time of each other. But even though this should not occur, the inflammation will nearly certainly issue in suppuration and the discharge of matter, though perhaps by no perceptible channel. The 25 386 DIAGNOSIS OF OVARIAN DROPSY. swelling will then diminish, though for a time possibly increasing in hardness, till at length it slowly disappears; while the ovarian tumor, on the contrary, will increase, and with its growing bulk the presence of fluid within it will become more and more perceptible. The distinction between fibrous tumors of the uterus and tumor of the ovary is far from being as easy as might beforehand be anticipated; especially when the tumor grows from the posterior uterine wall. The facts that fibrous tumors are seldom developed at as early an age as tumors of the ovary, that they are seldom solitary, and that they are usually accompanied by menorrhagia are always worth bearing in mind, though far enough from being conclusive in any doubtful case. But, besides, their surface is often uneven or nodulated, they present a greater degree of hardness than an ovarian cyst, though it must not be forgotten that when small and tense the cyst may yield no distinct evidence of fluctuation. The circumstance of the tumor being felt at both sides of the pelvis, on which stress has been laid by some writers as indicative of fibrous tumors of the uterus, is in reality of no great worth, since, as stated in the last lecture, both ovaries are involved in the disease in about a third of all cases. Fibrous tumors not unfrequently somewhat retrovert the womb, while tumors of the ovary do not produce that effect, but merely drive it forwards and to one side. We are very apt, however, to be misled with reference to this point if we examine the patient in the ordinary position on her left side; since the weight of the tumor will be likely to drag or to push the womb towards the side on which the woman lies; and on this account the examination with the view of ascertaining this fact should be made with the patient lying on her back. The sound, too, often helps to clear up doubt; sometimes by distinctly isolating the uterus from the ovarian tumor, in other cases by ascertaining the cavity of the womb not to be elongated, and thus leading to the conclusion that the growth does not spring from its walls. Valuable, however, as the evidence thus obtained unquestionably is, two circumstances detract from its worth. Elongation of the uterine cavity is met with in cases of ovarian disease either by the tumor as it rises out of the pelvis dragging out the corresponding horn of the uterus, instead of merely lengthening the ligaments of that side; or, as the result of adhesions having formed between the uterus and the tumor, when the cervix becomes of necessity greatly stretched by the rapid increase of the growth. In both of these cases the measurement by means of the sound would suggest an incorrect conclusion; and hence we are justified in attaching greater weight to the evidence which the small uterine cavity affords of the disease being ovarian than to that which the large uterine cavity yields of the disease being seated in the womb. The grooved needle ought perhaps to be mentioned as assisting in doubtful cases, by affording proof either of the solidity of a tumor or of the presence of fluid within it. The failure to discover fluid in a tumor does not, however, by any means disprove its being ovarian; while further, with reference to this aid to diagnosis, I would add that its use is not always harmless, but that symptoms of serious inflamma- 387 DIAGNOSIS OP OVARIAN DROPSY. tion are sometimes excited even by the simple puncture with the needle of a tumor which had not seemed to be endowed with any high degree of sensibility. The tumor formed by the retroverted or retroflected uterus is scarcely likely to be mistaken for an ovarian tumor. In the first place, as has just been mentioned, the tumor of the ovary does not alter the direction of the os uteri, but merely carries it forwards towards the anterior pelvic wall, while, in the next place, the small size, the solidity, and the comparatively slight mobility of the retroflected fundus of the uterus, and the direct transition of the cervix uteri into its substance, suffice, independently even of the information afforded by the sound, to preserve us from error. In one instance, however, where retroflection of the uterus had persisted down to the end of the sixth month of pregnancy, I fell into the error of mistaking the tumor for ovarian disease. There were, it is true, many circumstances which in this case tended to throw one off one's guard; but I would remind you, first, that just such exceptional cases are those for which habits of observation are to be cultivated, and diagnostic skill is to be acquired; and second, that in every instance of doubtful pelvic or abdominal tumor, before we attempt to determine what it is, we must first thoroughly satisfy ourselves that it is not the result of pregnancy. When the tumor has increased in size, so as to occupy the abdominal cavity, there are other affections with which it may be confounded. In many of these cases, too, we are compelled to judge exclusively from what comes under our personal observation, for the patient is often unable to give other than a most imperfect account of her previous condition, or of the symptoms which attended the development of her disease. In the case of all abdominal tumors whose nature is at all obscure, it is therefore prudent to take certain precautions before we attempt to establish their diagnosis. It is always useful to keep the patient in bed for twenty-four hours; and if the abdominal distension is at all considerable, to apply a bandage lightly, as well as to take care that the bowels are freely relieved some hours before our examination is made. The difference between the morning and afternoon measurement of the abdomen in the case of a person following her ordinary pursuits is often as much as an inch and a half; and this increase in the after part of the day appears to be almost entirely due to the presence of flatus in the intestines. On the other hand, the good effects of a day's stay in bed are often very striking in the diminution of abdominal distension, and the consequently increased facility with which the relations of any tumor are examined, while at the same time the tenderness of the abdominal walls is much lessened, and they become far more tolerant than they otherwise would be of the pressure of the hand. The general tendency of ovarian tumors as they increase in size is to 3'ield with more and more distinctness the sense of fluctuation; and many growths which, when small, had seemed to be solid, become evidently in the course of time large simple cysts with fluid contents. This change is brought about either by the tension of the cyst diminishing as it grows larger, in consequence of which fluctuation becomes 388 DIAGNOSIS FROM ASCITES. more manifest; or by the removal of the septa which had previously divided it into many chambers; or lastly, by the growth of one cyst at the expense of the others, which remain with whatever solid matter enters into the composition of the tumor, at its lower part, near to its pedicle; where they cannot readily..be, detected. It is due to the influence of some or all of these causes that we occasionally find the abdomen so much enlarged and the fluctuation in all directions so uniformly distinct as to render it doubtful whether the patient suffers from ascites or from encysted dropsy. The grounds of diagnosis, and which in the great majority of cases suffice for the ready distinction between the two conditions, are the following: Ascites is generally preceded and accompanied by considerable disorder of the general health, usually of a febrile character; it is comparatively acute in its development, is often associated with anasarca, almost always with very scanty secretion of urine; in many cases with albuminuria, in all of which respects it differs essentially from ovarian dropsy. Examination, too, yields a different result in the two diseases. The enlargement of the abdomen is symmetrical in ascites; while in ovarian dropsy one side is often manifestly more prominent than the other. In ascites the abdomen is flattened, spreading out at either side : in ovarian dropsy the tumor is distinctly most prominent towards the mesial line, somewhat as is the case in pregnancy, while when the size of the tumor is very considerable, it spreads out the floating ribs, and imparts a conical form to the thorax, which is not produced by mere ascites. Percussion over the front of the abdomen almost invariably yields a dull sound in ovarian dropsy, for it scarcely ever happens that any coils of intestine are interposed between the enlarged ovary and the abdominal walls. In ascites, on the other hand, the intestines float as near the surface as the mesentery to which they are tethered will permit; and hence percussion over the front of the abdomen gives out a clear sound; or should there at first be dulness, owing to the presence of a large quantity of fluid, it suffices to press a little firmly, so as to displace some of the fluid, and bring the hand nearer to the intestines in order to elicit a clear sound, or at least a semiresonance, which is equally characteristic. As the patient with ascites lies upon her back, percussion yields a dull sound in either lumbar region ; while, if she turns upon her side, resonance is at once perceived on that side which is uppermost. When to this is added that ascites seldom exists long without being attended by some obstruction of the abdominal circulation, and by an attempt at compensating for it by enlargement of the superficial abdominal veins; and, lastly, that some trace of the outline of the tumor can usually with care be made out in case of ovarian dropsy, I have enumerated all the customary signs of each affection. Various causes, however, complicate a question which seems so simple, and one might almofet console one's self for one's own errors of diagnosis in these cases by finding how many and how eminent are the men who have confessed to the like mistakes. Cruveilhier 1 men- 1 Auatomie Pathologique, vol. iii. p. 400. 389 DIAGNOSIS FROM ASCITES. tions seeing a lady in whom an encysted dropsy to the ovary had been taken by two very experienced practitioners for ascites, and it was not until after a second very careful examination of the patient that they were convinced of the error of their opinion, and of the correctness of the view adopted by the Cruveilhier; while Boinet confesses 1 that he on one occasion injected the peritoneum with a solution of iodine under the impression that the case was one of ovarian dropsy. Most of the mistakes which are committed are of this latter kind, and many circumstances contribute to render this the form of error to which practitioners are most liable. Now and then, indeed, we meet with exceptions to the development of ovarian dropsy during a comparatively good state of the general health. A patient, aged forty-two, was admitted in St. Bartholomew's Hospital, in whom the formation of an ovarian tumor exactly coincided with an attack of general dropsy and albuminuria produced by exposure to cold. Greatly impaired health, and a scanty secretion of urine, which was loaded with albumen, still persisted at the time of the woman coming under my notice five months afterwards; but the characters of the tumor were fortunately too well marked for its nature to be overlooked. The opposite error is especially likely to be committed in those cases in which ascites, depending on some obstacle to the portal circulation, such for instance as occurs in cirrhosis of the liver, comes on without any active symptoms or any important disturbance of the general health. Such a case was that of a woman, aged thirty-four, who was received into St. Bartholomew's Hospital, suffering from urge fit dyspnoea, owing to the enormous distension of the abdomen, which measured forty-four and three-quarter inches in circumference. Tapping was at once performed, and thirty-one pints of serum were evacuated with great and immediate relief to her symptoms. The patient then stated that after experiencing vague pains in her limbs, her abdomen eighteen months before began to enlarge, and as her menstruation, previously regular, had now become suspended, she at first fancied herself pregnant. After an interval of three months, however, the menses returned, and had subsequently become much more profuse than formerly. This weakened her; but until her respiration began to be interfered with by the enormous enlargement of the abdomen, no grave symptoms of ill-health had appeared. The skin was not icteroid, and a day or two after the tapping the patient expressed herself as feeling quite comfortable; her tongue was clean, her bowels were regular, her appetite was good, and she slept well. The history of the patient and her general condition might have misled one; but the following circumstances abundantly guarded against error. 1st. The fact that no tumor or cyst had been distinguished after the first tapping, and that on the reaccurnulation of the fluid no distinct limitation of the swelling in any direction could be discovered. 2d. The existence of distinct resonance on percussion, in spite of the enormous distension of the abdomen, while at the same time there was 1 Iodotherapie, etc., 8vo., Paris, 1855, p. 206. 390 ASCITES MISTAKEN FOR none of that bulging outwards of the floating ribs which a solid tumor of such dimensions would occasion. 3d. The procident condition of the uterus, while that organ is commonly though not invariably drawn upwards by an ovarian tumor. 4th. The enlargement of the superficial abdominal veins, and the presence of a very obvious irregular, nodular enlargement of the liver. The signs that in this instance kept from error may be almost entirely absent; and then, as in the painful case which I will next relate for your warning, a little oversight, a little want of vigilance and care may suffice to lead us grievously wrong. A young girl, aged seventeen and a half years, was sent up from the country, alleged to be suffering from ovarian dropsy, which her appearance and history confirmed. Her abdomen measured forty-one inches; it was generally dull on percussion, except in both lumbar regions, where there was semi-resonance on the right side, and a clear sound more marked and more extended on the left. Her history was, that having begun to menstruate at fifteen, the catamenia continued regular for twelve months, when they ceased in consequence of a fright at a menstrual period. Her health, however, still remained pretty good, but about five months before she came under my notice the abdomen began to enlarge, and for a month this enlargement had been going on with great rapidity, and her respiration had become impeded, while some swelling of the legs had taken place within a week. There was no enlargement of the superficial abdominal veins; the generally dull sound on percussion, with the resonance in the lumbar regions, the patient's age, her history, all tallied so exactly with the opinion said to have been expressed by her previous medical attendant, that no doubt was for a moment entertained as to her disease being ovarian dropsy. Twenty pints of clear, yellowish serum were let out with great relief, a bandage was applied to the abdomen, and no bad symptoms followed. In eleven days, the fluid having re-collected, seventeen pints were once more let out, and fx of a solution of iodine were thrown in through the canula, and so completely was the nature of the case taken for granted, that this was not preceded, as it ought to have been, by a repetition of careful examination of the abdomen. The injection caused some pain and alarming faintness, and until the patient's death in sixteen and a half hours great faintness was the prevailing symptom. There was but little pain, no anxiety of countenance, no restlessness, nor jactitation ; and though the pulse was very feeble, yet for eight hours the heart's action was good and regular, the patient dozed occasionally, and awoke sensible. After that time, however, more marked collapse came on, the surface became cold, vomiting occurred frequently, and sinking thus, she died with very little suffering, and retaining her intellect unclouded almost to the last. Examination of the body discovered intense congestion of the peritoneum, a few adhesions between the coils of intestine in the upper part of the abdomen, and more numerous adhesions lower down, but no effusion into the abdominal cavity, nor any general deposit of lymph on either surface of the peritoneum. The uterus and its appen- OVARIAN DROPSY. 391 dages were healthy, there was no tumor anywhere, but the liver was shrunken to half its natural size, and in a state of very far advanced cirrhosis. Both of these cases are instructive, but the latter is especially so. It teaches the sleepless watchfulness which alone can guard from error, the importance of not taking anything upon trust, nor of allowing our judgment to be swayed by any previously expressed opinion as to the nature of the disease, when once a patient comes under our care, and we assume the responsibility of her management. It shows the need, too, of not taking the previous history upon any other person's authority, but of cross-examining both the patient and her friends ourselves. In this instance it was ascertained after the patient's death that her sister had died of disease of the liver, and that the fright, which was followed by suppression of the catamenia, was succeeded also by severe pain in the right hypochondrium, and by great sallow* ness of the complexion, which subsequently passed away. These facts would doubtless have awakened attention to the possibility of the fluid in the abdomen being dependent on some visceral disease, though the existence of advanced cirrhosis of the liver in so young a person is undoubtedly an exceptional occurrence. The case shows, moreover, that enlargement of the superficial abdominal veins is not a constant attendant on obstruction of the portal circulation, while it further proves that resonance in the lumbar region is not so trustworthy an evidence of encysted dropsy as is commonly supposed. The presence of a considerable amount of flatus in the large intestine may cause percussion to yield a clear sound, and this is especially the case on the right side, where the varying relations of the caecum greatly modify the results which we obtain. Lastly, we may deduce the rule, that the distinct perception of the outline of the tumor is a condition indispensable to any attempt at operation, and further, I may add, that this must have been perceived not simply on a previous occasion, but also at the very time at which the operation, be it what it may, is attempted. In the cases which I have related, no solid tumor existed, or at least none whose situation at all corresponded with that which would be occupied by the enlarged ovary. Ascites and ovarian tumor may, however, coincide, but the tendency of any error in diagnosis in such a case will be rather to overlooking the existence of the tumor, than to misinterpreting the ascites. Sometimes, indeed, the solid tumor is not perceptible until after the removal of the fluid by tapping, while in other instances it is found on careful examination of the abdomen, that the hand displacing the superjacent fluid conies down here and there upon a solid body, whose exact dimensions anil form it may yet not be possible to determine. It is chiefly as influencing our prognosis that the detection of the solid tumor is of importance. The presence of a small quantity of fluid in the abdominal cavity adds little or nothing to the gravity of the prognosis of ovarian dropsy. On the other hand, the presence of a large amount of fluid in the peritoneum associated with a small, solid tumor is always a matter of great moment. Such a tumor is seldom ovarian, for ovarian tumors r 392 DIAGNOSIS OF OVARIAN DROPSY. though when large they disorder the circulation through the abdominal vessels, seldom so far interrupt it as to produce any considerable effusion. Solid tumors so situated as to have this effjct are often malignant in character, are very likely to increase, and are scarcely at all within reach of any kind of interference. , The distended bladder has been taken for a dropsy of the ovary, but this is an error which ought not to be committed. The exactly oval form of the tumor, its mesial situation, its tension as ascertained by external examination, the unchanged position of the uterus, the absence of any tumor felt per vaginam, or if any be discovered, its situation in front of the uterus instead of behind it, are characteristic, even if no history of the case were obtainable. It is almost needless to remind you that in every instance where the nature of a tumor admits of doubt, the catheter should be introduced in order to obviate the possibility of this cause of error. The mistake of dropsy of the ovary for pregnancy is impossible so soon as the case is submitted to a thorough examination, though it is far from rare for idle whispers to be raised prejudicial to a patient's character before she has come under medical observation. Examination per vaginam, and the discovery of the unaltered state of the os and cervix and lower segment of the uterus, as contrasted with the closure of the os, the softening of the cervix, and the expansion of the lower segment of the womb which accompany pregnancy, cannot but remove all doubt. In those cases, however, in which a mistake would be most serious in its consequences, namely, in unmarried women, we are often precluded from giving to any one the slightest hint of our doubts or suspicions, and are consequently unable to suggest the expediency of making a vaginal examination. So long, too, as an ovarian cyst does not exceed the size of the womb at the fifth month of pregnancy, it is by no means unusual for it to be elastic rather than distinctly fluctuating, while the position of the tumor is often so nearly mesial that its situation does not afford any means of discriminating between it and the gravid uterus. The absence of the mammary sympathies, and also of any sound like the uterine souffle can both in general be ascertained, and deserve great reliance, as strong negative evidence against the existence of pregnancy. There are still some rare conditions productive of enlargement of the abdomen which may be mistaken for ovarian tumors. Such, for instance are those large accumulations of fluid which have been found in the substance of fibrous growths of the uterus, 1 and such the almost equally uncommon ones of encysted dropsy of the abdomen, where the fluid collects in the sub-peritoneal cellular tissue, or between the layers of the omentum. 2 One instance of this latter occurrence has 1 See a reference to these cases in a note at p. 201. 2 On the subject of cysts of the abdominal cavity seo Abeille, Traite des Hydropsies et des Kystes, 8vo., Paris, 1852, pp. 519 —587 ; Copland's Dictionary, article Dropsy ; and the references at p. 6G0; S. Lee on Tumors of the Uterus, p. 123 ; the cases of Sir B. Brodie, Med. Gazette, vol. i. p. 3)54; Dr. Thomson, Ibid., p. 4GS ; Cruveilhier, Traite d'Anatomie Pathol., vol. iii. p. 518 ; and the papers of Mr. C. Hawkins, Med.-- Chir. Trans., vol. xviii. p. 175 ; and M. Chantourelle, Archives de Med., 1831, vol. xxvii. p. 218. FLOATING ABDOMINAL TUMORS. 393 come under my own observation, in which between four and live quarts of a dark fluid were found collected between the folds of the omentum, and during the patient's lifetime frequent discharges of a similar fluid had taken place from the umbilicus. The dropsy had during the life of the patient been supposed to be ovarian ; but though malignant disease of both ovaries was discovered, yet neither of them contained fluid at all similar in character to that which was found in the omentum; nor, indeed, could either be detected till after the fluid in the omental cyst had been let out. I am aware of no means by which such cases are to be discriminated from ovarian dropsy; as far as I know, their nature has scarcely ever been suspected during the lifetime of the patient. The only conditions in which large tumors of the spleen or liver are likely to be taken for growths of the ovary, are when they are of very long standing, have acquired a very large size, and have occurred in persons who are either incapacitated by illness from telling their own history, or who have been so unobservant as not to notice the beginning, and scarcely to attend to the progress of their disease.. Still even in these circumstances the prominence of the tumor at the upper part of the abdomen, the dulness in the hypochondriac region, and the fact that at some part, if not at all, the lower edge of the growth can be detected, will keep the moderately careful observer from error. And here, I think, we may take leave of the diagnosis of ovarian tumor. 1 That feces in the large intestine have been taken for them ; 1 I know no place more fitting than the present for a brief reference to those floating abdominal tumors which all practitioners have probably occasionally met with, though I believe that no one has offered a thoroughly satisfactory explanation of their real character. All of these tumors bear a very close resemblance to each other, both in size, shape, and situation. They are oval in form, usually about the size of a turkey's egg, and are generally situated in the hypochondriac or lateral region, their lower margin seldom descending below the level of the iliac crest. In most instances one tumor only is present, but sometimes there are two in opposite sides, and for the most part symmetrical in all respects. They generally admit of displacement inwards towards the mesial line much more readily than outwards, and upwards to a far greater extent than downwards, so that they can sometimes be pushed up out of reach under the floating ribs, but seldom downwards into the iliac region, and never into the pelvic cavity. They are firm, though not without a certain degree of elasticity; their surface is smooth and regular ; no sound can be detected in them by means of the stethoscope, and they yield a dull sound on percussion, modified only by the presence of a coil of intestine distended with air behind them, when they may yield a sort of semi-resonance. Pressure on them is painful, but the pain, which is of a peculiar sickening character, usually passes off when they are no longer handled. Sometimes, however, they are the seat of a constant wearing pain, which conies on causelessly, and continuing for hours, days, or weeks, subsides equally without occasion, though it may be said, as a general rule, to be aggravated by exertion and mitigated by rest. They have either been accidentally found out on examination of the abdomen for some other purpose, or the pain experienced in them has led to the discovery of their presence by the patient. Their rate of increase must be slow, for though patients affected with them have for years been under my occasional observation, I have never ascertained that their size has undergone any modification. 1 know of one instance, too, in which a tumor of this description had existed for more than twenty years in a lady of sixty, unchanged in shape, size, or situation. This lady had been seen by the late Dr. Warren, by Sir Astley Cooper, and Sir Benjamin Brodie, and it may illustrate the obscurity which prevails with reference to their nature if I mention that each of theso eminent men gave a different opinion with reference to it, one of them regarding it as 394 FLOATING ABDOMINAL TUMORS. that fat and flatus have raised a suspicion of their presence; that the abdomen even has been opened to remove a tumor which was found to have no existence, proves only how large is the possibility of error, how vigilant must be our care if we will avoid a danger which the wisest have not always been so fortunate as to escape. connected with the mesentery, another as a floating kidney, and a third believed it to be ovarian. I have a record of ten cases, of which the chief particulars are represented below in a tabular form:— . I I 8> Years Married, j Seat of Tumor. Period it had existed. Symptoms. r Accidentally dis- "] covered when 26 2 Right Hypochondrium -j under treatment I None. for another [ ailment. J 27 4 " " One year Pain and dyspepsia, on a i t *i tt i i • u P am which came on 29 8J Left Hypochondrium after exertion. 30 6, sterile .Right Hypochondrium Eighteen months Pain and dyspepsia. 35 Married | Both Hypochondria j RighMhreeweeks} Pain> 38 14 !Right Hypochondrium One year " 47 Married Left Iliac Seven years Pain, occasional. {Twice mar- "} ried, now [ Right Iliac Twenty years Slight occasional a widow J j pain. 38 j 17 I Right Hypochondrium Six months Occasional pain. 30j 5 J " " Three years and a half Dull pain. In 7 cases, then, the tumor was seated on the right side, in 2 on the left, and in 1 on both sides, its position having in 8 out of the 10 been distinctly in the hypochondrium, twice only in the upper part of the iliac region, and in those two instances allowing of displacement upwards, but not at all in a downward direction. The connection of dyspeptic symptoms with the tumor in the right hypochondrium on two occasions may suggest the probability of its being sometimes formed by the scirrhous pylorus, a hypothesis which, in the case of a patient under the care of Dr. Burrows, was confirmed by a post-mortem examination. The hypothesis of the tumor being a floating kidney may probably be applied to explain many other of these tumors, and perhaps would even account for their occasional sudden appearance after exertion. Cruveilhier 1 has noticed them ; has observed that it is almost always the right kidney which is thus displaced, and that the accident, while very rare in the male subject, is far from being uncommon in the female. He attributes it to the pressure of tightlylaced stays upon the liver. "The kidney,"says he, "is then compressed between the liver, which is in front, the lower ribs and the vertebral column, which are behind; and is squeezed, as it were, out of the sort of bed in whioh it lies without being adherent to it, just as a plumb-stone would slip from between the fingers." Some may possibly be tumors connected with the mesentery, and some doubtless admit of the explanation which I have been informed that the late Dr. Abercrombie, of Edinburgh, proposed. He thought that a sort of spasmodic constriction of some of the fibres of the colon inclosed a small collection of flatus, sufficient to form a swelling distinctly perceptible by the hand of the physician, but distinguishable by its resonance on percussion from all solid tumors. I cannot say, however, that 1 have met with any condition clearly answering to this description. Whatever be the doubt that may still be entertained with reference to these tumors in some cases, I feel quite satisfied that they are not connected with the uterus or ovaries, that they consequently do not come within the scope of our present inquiries, except inasmuch as they have been occasionally taken on inadequate grounds for ovarian tumor. 1 Anatomie Pathologique Generale, vol. ii. p. 723. OVARIAN TUMORS AND DROPSY. 395 LECTURE XXVIII. OVARIAN TUMORS AND DROPSY. Treatment ; difficulty of estimating its results. Duration of life in ovarian dropsy. Cases divisible into three classes : some must be let alone, some may be, some require interference. Prophylactic measures, and medicinal agents. Operative proceedings. Tappinu, when absolutely necessary. Opinions as to danger of its performance, statistics of the subject, bad results possibly over-estimated, circumstances in Which early tapping may be admissible. Mode of performing the operation ; danger of exhaustion and of cyst inflammation ; their symptoms and treatment. There is some fallacy as well as much truth in almost all popular sayings. Even the adage that a "doubtful remedy is better than none," is not of universal application, for doubtful remedies are often dangerous, and if they fail to cure they frequently aggravate the disease. The danger of the disease itself is an element never to be lost sight of in our estimation of the expediency of interfering with its progress, and if the present suffering it occasions is but small, if its advance is likely to be slow, if it may be interrupted by occasional pauses, we should hesitate to advise any proceeding by which, though perfect cure may possibly be wrought, yet, on the other hand, life may be cut short suddenly. The chances of complete recovery will by few persons be felt to overbalance the risk of immediate death, and I do not think it becomes us to throw the weight of our influence into the scale. Considerations of this kind are nowhere more in place than in an inquiry into the treatment of ovarian tumors and dropsy; a class of diseases which indeed tend progressively from bad to worse, which often bring them much suffering ; but in which, nevertheless, the suffering is not invariable, nor the downward tendency constantly progressive, so that we cannot limit their possible duration, or, from the date of their commencement, calculate with any approach to certainty the time which will elapse before they reach their close. The reasons for this uncertainty are so obvious as scarcely to need that I should insist upon them here. I may, however, remind you that in many instances we are unable to fix the time at which ovarian disease began; so imperceptible are often its advances, so few the symptoms that accompany its earlier stages, that not infrequently the growth has attained a considerable size before the attention of the patient, or of her medical attendant, is drawn to its presence. Even 396 UNCERTAINTIES OF PROGNOSIS IN OVARIAN DROPSY. after it has been discovered it is often as difficulty to foretell the future progress of the disease as to determine its past duration. The cyst may long remain stationary, its flaccid walls announcing that absorption goes on more rapidly than secretion, or it may possibly disappear altogether. On the other hand, just the opposite course may be run ; the barren cyst may become proliferous, or the compound cyst may suddenly, and apparently causelessly, pass into a state of active development, or evidences of malignancy may manifest themselves in a growth presumed for a long time previously to be innocent; while to all these contingencies must be added those inseparable from the various kinds of interference which the mere palliation of the evil in most instances requires. Advocates of the most opposite views with reference to the dangers attendant on ovarian disease are not without ample support for their opinion : cases are to be found of life continuing for years in very tolerable comfort, and even of the sexual functions being duly performed, and pregnancy and labor occurring in spite of it; the patient dying at length of some other perfectly different ailment. Illustrations of just an opposite kind are still more numerous, telling of the rapid development of the growth, of speedy impairment of the general health, of death occurring in one, two, or three years from the commencement of the evil, or of life being cut short even sooner in consequence of some attempt at giving temporary relief, which it was not possible any longer to delay. The endeavor has been made indeed to arrive at more definite results, and the late Mr. Salford Lee 1 collected with characteristic diligence the particulars of 323 cases:— In 88 of which the disease lasted 1 year m 25 " " 2 " (i 17 u u 3 i< tt io u u 4 « " 3 " "5 " " 14 " " 5 to 10 years. « 6 « u 10 ii 12 a ii 5 ii « 12 u 16 i. ii 4 ii ii 9'0 " 25 " ii i ii ii 50 ii 123 Now from this table it appears that 90 out of 123 cases, or 3 out of 4, or 73.9 per cent., terminated fatally within five years, and more than a third of this number within one year from the observed commencement of the disease. But, on the other hand, between the observed and the real commencement of the disease, there is, as has already been stated, a wide difference, and while the numbers doubtless understate the duration of the evil in many cases where the disease appeared to be most rapid, they probably by no means truly represent the degree to which life was often prolonged in spite of it. 1 On Tumors of the Uterus, p. 117. 397 OVARIAN DROPSY. — CASES TO LET ALONE. Even as they stand, however, the numbers show that in 16 out of 123 cases, or nearly 1 in 7, life continued for a period of from ten to fifty 3 r ears; and it must not be forgotten that when a disease has been long quiescent the patient learns to think but little of it; she speaks of it still less; even her medical attendant is perhaps scarcely aware of its presence; and when she dies either of that or some other affection, it is doubtful whether he who sees the end had also seen the beginning of the malady. One other point there is, concerning which there can be no doubt, and which invalidates all the statistics on the subject wherewith hitherto we have been furnished ; and that is the wide disparity between the results that different cases yield. One year and fifty years cannot both truly represent the time occupied by the same disease in running its course. We can fix the duration of uterine cancer with tolerable accuracy, and find the disease when seated in the womb to obey the same laws as govern it in other parts. We know, too, that the slow-growing fibrous tumors of the uterus have in themselves no tendency to destroy life, though in their course some accident may occur to compromise it, and many others to render it painful. The discrepancy between the results of different cases of ovarian dropsy, on the other hand, plainly shows, what indeed the study of its morbid anatomy has taught us, that under this name several different diseases have been included, having different tendencies, warranting a different prognosis, and calling for different modes of treatment. In any inquiry into the treatment of the disease these facts must not be lost sight of, but we must consider it with reference to the special form of the affection with which in each separate case we have to do. The question cannot be propounded as to whether this or that plan of treatment is suitable for ovarian dropsy ; but, given a certain form of ovarian disease, is this or that proceeding expedient or allowable; or is it wiser to do nothing, or to palliate; or is the attempt to do more, justifiable; and when at length the necessity for interference of some kind becomes absolutely unquestionable, are the risks even of palliative proceedings so considerable as to warrant a greater hazard being run for the chances-of a perfect cure ? All cases of ovarian dropsy and tumor may for the purposes of therapeutics be considered as belonging to one or other of three classes, according as they are, either— 1st. Cases which may be let alone. 2d. Cases which must be let alone. 3d. Cases justifying or absolutely requiring interference. All cases of ovarian dropsy, or of tumor undistinguishable from it, may be let alone in which the growth does not exceed the size of two fists, in which its position does not seriously disturb the functions of the pelvic viscera, in which it is unaccompanied by severe suffering, and, as far as can be ascertained, is not in course of rapid increase. Further, in proportion to the small size of the tumor, to the smoothness of its surface, to its elasticity when pressed upon, and to its mobility, will be the amount of encouragement which we shall be able to afford to the patient, since there will be the more reason for hoping 398 TREATMENT OF OVARIAN DROPSY. either that the tumor is one of those cysts of the Wolffian bodies, which never exceed certain comparatively small dimensions, or that it may possibly be a mere dropsy of the Fallopian tube, which, though not equally limited in the size to which it attains, has in it nothing'of the serious character that belongs to ovarian dropsy. Even in cases, too, in which neither of these hypotheses is correct, it may still be remembered that an ovarian cyst while small is far more likely to remain stationary than when it has attained a considerable size. The mere size of the tumor, however, provided it does not by its bulk disturb the general health, cannot be taken as an indication for interference. The old maxim, "Quieta non movere," is at least as applicable in medicine as in politics, and you will remember the instance which I mentioned to you, 1 where a tumor considerably larger than the adult head has remained for many years stationary, or rather with a slight tendency to diminish in size. Still, when it is said that such tumors are to be let alone, I do not wish to iniply that no precautions should be observed, or that nothing can be done to retard their growth. These precautions, however, are comparatively few, and abundantly simple. They may be summed np as consisting in the endeavor to maintain the general health, and to prevent congestion of the pelvic viscera. The first indication, I conceive, implies the avoidance of all such proceedings as courses of mercury, of iodine, of iodide of potass, or of liquor potassa), agents of whose power in retarding the development of ovarian cysts there is scarcely any evidence, while of their injurious influence on the constitution when long continued there is the most abundant proof. To carry out the second object, we should certainly dissuade a person affected with this disease from contracting any matrimonial engagement; though between that and the non-fulfilment of an engagement already formed, or the separation of a married woman from her husband's bed there is a wide difference, and moral considerations enter into the question which more than counterbalance mere medical rules. Besides this, too, it is I think very doubtful whether in the mysterious influence of the mind over the body, disappointed affection, or the removal of a wife from her husband's bed, would not act more injuriously even on the sexual system itself than the physical causes which alone our restrictions can control. Sexual intercourse, however, should be moderate, and inasmuch as the influence of pregnancy and labor is often, though by no means always unfavorable, giving rise in many instances to irritation of the cyst, to a more rapid increase of its growth, to inflammation of its peritoneal surface, and the formation of adhesions; or of its interior, and to consequent outpouring of pus, it is desirable that intercourse should not take place at those seasons, just before or just after a menstrual period, when conception is most likely to occur. The condition of the bowels must always be most carefully watched, and every attention must be paid to insure the perfectly regular performance of the me,nstrual function. If the menstrual period is at- ' Lecture XXVI. p. 367. CASES TO LET ALONE. 399 tended by any febrile disturbance, or by any increase of pain in the tumor, the patient must be kept strictly in bed, and four or six leeches must be applied over the painful spot, and repeated every second or third day so long as the pain continues; a warm poultice, or fomentations with spongiopiline being constantly employed in the intervals. As soon as the tumor has risen completely into the abdomen, a welladapted bandage should be worn, partly for the comfort which it seldom fails to afford to the patient, partly because a cyst fills far less rapidly when moderate compression is made upon it than when no counterpressure is employed to resist the accumulation of the fluid. It has, I know, been alleged that the power of medicine over this disease is much more considerable than I have represented. So great, too, is the influence of a name in determining the conduct of nroat of us, that almost all the remedies of known efficacy in ascites have been assumed to be beneficial in ovarian dropsy. There can be no doubt, too, but that under the influence of such remedies very appreciable diminution in the size of the abdomen has taken place—a diminution, however, which I believe to be due to the absorption of the fluid poured out into the peritoneal cavity, and not to any modification of the contents of the cyst. Some ovarian tumors it was said might, others must be let alone. The latter are all those eases, for the most part of rather rapid growth, whose irregular nodulated surface and whose solid non-fluctuatinp; mass suggests the idea that they are not mere compound cysts, but productions of a malignant character. In most of such cases, too, we find in the patient's history other grounds still more cogent than the anatomical peculiarities of the tumor for avoiding all interference. Such are the facts that the general health has failed simultaneously with the development of the tumor, and that loss of flesh and loss of strength have been early attendants on its progress, and have not first appeared when the different functions of the body had been disordered by its bulk, or when nutrition might be supposed to be impaired by the tax levied on the system for the supply of the mass. Unhappily the eases which seem most to call for help are those in which it is least possible to afford it, while it is in precisely those which may most safely be let alone that interference has the best chance of success. Between these two classes, however, there is a third in which present relief is called for, and in which it is in our power to afford it. It is just in these eases that we encounter the inquiry as to the comparative risks and comparative merits of different proceedings, whether it is much more hazardous to attempt to remove the evil than to palliate it for a time with the almost absolute certainty that again and again it will return, and that on each occasion our power to palliate it will diminish? Nor is the question altogether confined to these cases. The uncertain tenure of health and life, even in instances where the evil seems quiescent, suggests the importance of discovering some proceeding which entails no greater hazard than we can conscientiously advise our patient to encounter for a reasonable prospeet of obtaining 400 TREATMENT OF OVARIAN DROPSY. so great a good, and of freeing herself from danger ever impending, like the fabled sword which hung over the guest at the banquet. Very numerous, indeed, are the solutions which have been proposed to these inquiries. It is our duty carefully to examine their merit, and carefully to scrutinize the different surgical proceedings that have been recoinmende(| for the relief or the cure of ovarian dropsy. The first of these proceedings which we must notice, the simplest, the least hazardous, and at the same time the most generally applicable, is the operation of tapping. Simple as it is, however, opinion is much divided with reference to the circumstances that warrant its performance; for while some practitioners look upon it as too dangerous to be justified by anything short of most absolute necessity, others consider it to be attended by little risk, and to be a palliative all the more valuable since it is sometimes followed by a perfect cure. Two questions then come before us. The first of these concerns the circumstances which by unanimous consent justify the performance of tapping as a palliative in cases of ovarian dropsy. The second refers to the amount of hazard attendant on the operation, and the consequent expediency or inexpediency of having recourse to it when not actually compelled by the urgency of the patient's symptoms. The operation is absolutely indicated in all cases where the bulk of the tumor is so considerable as seriously to interfere with the patient's health, or to occasion her very severe suffering; and this, be the supposed nature of the tumor what it may. In proportion as the contents of the tumor are fluid will the relief obtainable by the operation be considerable; but even though its great bulk should be solid, still the diminution obtained by letting out even some ounces may afford considerable temporary relief to the patient, and will fully justify the experiment. The state of things which calls thus imperatively for interference varies considerably in different patients, and is far from being absolutely connected either with a*certain duration of the disease, or with a certain size of the abdomen. A slowly-increasing growth will often attain to a very large size indeed before it causes serious disorder, and a tumor whose contents are entirely fluid commonly produces less distress than one even of smaller size, into the composition of which solid matter enters in large proportion. One reason of this probably is, that solid tumors more frequently press upon the abdominal vessels, interfering with the circulation through them, producing effusion into the peritoneal cavity, aud disturbing the kidneys in the performance of their function. Orthopncea, habitual shortness of breath, even when no exertion is made, complete loss of appetite, or sickness, owing in part to the stomach being mechanically prevented from retaining food, pain referred to the liver, and obstinate constipation, with frequent colicky pains independent of the action of the bowels, a very scanty secretion of urine, and a very feeble aud thready pulse, with, perhaps, irregularity of the heart's action—such are the symptoms which, when they begin to occur, indicate the immediate necessity for tapping. Mere unwieldiness in moving about, or discomfort from the tension of INDICATIONS FOR TAPPING. 401 the abdominal integuments, though perhaps very painful to bear, cannot be regarded as absolute indications for the operation; and time not infrequently habituates a person to a state of things which at first seemed almost intolerable. Even the circumstance that a tumor is steadily on the increase cannot be taken as necessarily calling for the operation, since ovarian cysts, though large, sometimes come to a standstill, and to decide in favor of interference when it is possible for a short time longer to delay it, implies that we have answered to our own satisfaction the second question as to the amount of risk attendant upon simple tapping. In the cases hitherto referred to, the dangers of the operation scarcely enter as an element into our consideration, but tapping takes its place in the same category with various other operations of necessity, such as amputation performed in consequence of injuries, which, how serious soever might be the risk attendant on them, would still be most legitimate, because the only resources at our command. It would, however, be unreasonable to expect that an operation performed in these circumstances should be free from danger, and this danger arises chiefly from two sources. Great as the relief often is to the patient, a certain amount of shock follows the evacuation of a large quantity of fluid, and patients previously much exhausted sometimes sink in two or three days after tapping. In spite of the warning given to the patient that tapping will in this way probably shorten her days, the choice is not infrequently made to submit to a proceeding which brings at least present ease; nor have I thought myself failing in my duty if, when our art was almost powerless, I tried to secure the last boon our patients ask of us—an euthanasia. The other danger is one of inflammation of the cyst-walls, issuing in the effusion of lymph and pus into its interior, and not infrequently associated with peritonitis, which often proves fatal in the course of two or three days. This latter occurrence, too, seems to be of greater frequency after first tappings than in those cases where the operation has been frequently performed, while death from mere collapse is, as might be supposed, more likely to occur where recourse has often been had to tapping. Besides these two risks, which not unnaturally have led practitioners to shrink from this operation, another objection has been urged to it on the ground of the increased rapidity with which after each time of its performance the fluid reaccumulates within the cyst. Expressed in various ways, the opinion is almost unanimous that tapping is but the beginning of the end, and patients are commonly advised, even at the expense of great inconvenience and discomfort, to put up with the present ill, and not to purchase prematurely a brief respite from suffering at so high a price. The result of the general impression as to the danger of tapping has been not only to postpone its performance in all cases to as late a period as possible, but also to lead to the endeavor to devise some other proceedings, which, if not in themselves less hazardous, should at least afford the chances of a greater good, and offer, by their great prize which they hold out to the fortunate few, some amends for the hazards that all must run, and in the encounter with which many, 26 402 RISKS ATTENDANT ON TAPPING. perhaps most, must fail. Such endeavors are but the expression of a feeling deeply rooted in the breasts of all, and I see nothing to reprobate either in the surgeon who advises, or in the patient who encounters some great present risk, when in the one scale is placed the expectation of perfect health, death, indeed, in the other; but still a death which does but anticipate by a few months the certain issue of her present suffering existence. To judge at all fairly, however, on such a question we must not overcharge either side of the picture: and that which it now concerns us to determine is whether the colors in which the results of tapping have been drawn are faithful, or whether they are not somewhat darker than the facts of the case altogether warrant. The chief, indeed almost the only numerical data of which we are possessed bearing on this subject, are derived from a table of 20 cases compiled by Mr. Southam, 1 of 46 collected by the late Mr. S. Lee, 2 and of 64 the results of which are given by Professor Kiwisch. 3 Of these 130 cases, 22 terminated fatally within a few hours or days after tapping, and 25 more in the following six months, or, in other words, 34.7 per cent, of the cases ended in the patient's death in the course of half a year after the performance of tapping. In 114 of the 130 death is stated to have taken place. In 22 within a few hours, or in less than ten days after tapping. " 25 " six months. M 22 " one year. " 21 " two years. "11 " three " " 13 after a period exceeding three, and sometimes amounting to several years. 114 In 109 of these cases we are further informed how often the patients had been tapped. It appears that 46 died after the first tapping. M 10 " second " " 25 " from three to six tappings. " 15 " " seven to twelve M " 13 " more than twelve " 109 The greater absolute mortality attendant upon first tappings of course does not represent an equal amount of greater relative danger. Still, when it appears that only 49 of the total 130 cases were instances of the first performance of tapping, and further, that all the 22 patients who died within a period of ten days from the operation had undergone it for the first time, we are, I think, compelled to admit that the first paracentesis is accompanied by perils which are greatly lessened on its repetition. Of 31 patients of mine who ' Med. Gazette, vol. xxx. p. 237, Nov. 24, 1843. 2 Op. cit., p. 176. . 3 Op. cit., vol. ii. p. 115. 403 RISKS ATTENDANT ON TAPPING. underwent the operation of paracentesis abdominis on account of ovarian dropsy, two died of inflammation of the cyst within a few days after its first performance, and one sank exhausted thirty-six hours after the second tapping. The others all survived the operation, which in one instance was not repeated on account of the large amount of solid matter that entered into the composition of the tumor, and the serious symptoms which had followed its first performance. In one patient the fluid has never re-collected, and now, after the lapse of three years, during which time she has given birth to her fifth child, all traces of the tumor have disappeared, and recovery may be looked on as complete. In a second the cyst, having refilled, spontaneously subsided, and to the best of my knowledge the patient continues free from disease. Two died subsequently after attempts at the extirpation of the cyst, four sank under the progress of the disease, in the course of which tapping was had recourse to more than once, one died of apoplexy, and the remaining patients were still living when I last heard of them, tapping in many having been subsequently repeated on several occasions, and the injection of a solution of iodine having in eight instances been resorted to with results concerning which I shall have more to say hereafter. Unfavorable, however, as are the conclusions to which we are irresistibly led by facts such as those which have just been mentioned with reference to the ultimate issue of tapping, it is yet very questionable whether they represent the whole of the truth concerning this matter. Some of the data from which the tables were constructed were not collected originally with the view of illustrating the operation of tapping, while the majority of others are deduced from observations in hospitals, and must therefore, for reasons obvious to all, yield a very high average of unsuccessful results. The cases that seek admission to those institutions are almost always the least hopeful, generally the most far advanced, not infrequently those of persons who have sought out a place where death may come to them with less suffering than if they awaited it in their own homes. If relieved, such patients quit the hospital, and are often lost sight of; so that while the failures are known, the instances are frequently undiscovered in which life has been prolonged or rendered comparatively comfortable. Almost in proportion as experience concerning this operation is derived from hospital practice, or from observation in private, does the estimate of its danger appear to be increased or lessened, a circumstance which seems to show that the hazards of the operation depend at least as much on the conditions that surround the patient, as on anything inherent in the proceeding itself. 1 1 In the American Journal of Medical Sciences, vol. xix., New Series, April, 1850, p. 334, are some observations on the mortality attendant on tapping, by Dr. W. Atlee, showing that, even tried by such evidence as that adduced by Mr. S. Lee, the tendency of the operation is, on the whole, to prolong life, not to shorten it. M. Velpeau, too, in the recent discussion at the Academie de Medecine (Journal Hebdomadaire, Nov. 28, 1856), demurs to the accuracy of the generally received opinion of the great mortality arising from simple tapping. He admits that in one year he lost four patients after tapping; but these were exceptional cases of large compound cysts, which it was 404 RULES FOR THE PERFORMANCE OF TAPPING. It is, moreover, a question quite open to debate whether the period at whieh the operation is generally performed has not contributed largely to its fatal issue? The delay, commonly continued until the different functions are seriously disordered, and the patient's sufferings from mere mechanical causes have become urgent, may on the whole be expedient; but it can scarcely be doubted that it must lessen the prospects of recovery when at length the operation is resorted to. Besides, the favorable results which are said to have followed the early performance of tapping in some of those instances where tight bandaging was associated with it, renders it probable (due allowance being made for the exaggeration by which many of the published reports of cases where this proceeding was resorted to are vitiated) that the mere act of tapping in certain selected cases of ovarian dropsy is unattended by any considerable hazard. The whole of this subject needs a much more searching investigation than it hitherto has received; but in default of this I will venture to give my own impressions, and I do so as mere impressions, which further experience may modify or completely change. My present belief, however, is that the dangers of the operation of tapping have on the whole been over-estimated; and further, that while in cases where the amount of solid matter in the growth is considerable, the rule which prescribes the postponement of the operation to the latest possible period is a sound one, it will probably be more expedient in the case of simple ovarian cysts to tap early, before the growth has acquired a large size, and before the constitutional powers of the patient have seriously suffered. The early tapping, too, will most likely become more extensively resorted to if experience should confirm the safety of injections of iodine solutions into the cavity of the cyst. The operation of tapping, as it was generally practised until within the past few years, whether for ascites or for ovarian dropsy, used to appear a very formidable proceeding. The patient, seated on the edge of the bed or of a sofa, was supported in that position by a couple of assistants, while a bandage was placed round her abdomen, which was tightened in proportion as the fluid escaped, and was adjusted and firmly fastened before she was replaced in her bed. In spite of these precautions, however, very distressing faintness was often induced by the operation, and actual syncope was not very uncommon. It had, indeed, been customary in some exceptional cases, as, for instance, when the patient was very feeble, to tap in the recumbent posture; but to the best of my knowledge Dr. Simpson 1 was the first person who publicly recommended the general performance of the operation in this posture, and for the past five years all my patients have been tapped while lying on their side, by my colleague, Mr. Paget. found possible to empty only very partially. With these exceptions he has performed the operation 312 times, on about 98 patients, without any serious results either immediate or remote, and many of the patients survived its first performance, ten, fifteen, or twenty years. 1 Ed. Med. Journal, Oct. 1852, and Obstetric Works, vol. i. p. 239. EXHAUSTION AND CYST-INFLAMMATION AFTER TAPPING. 405 The selection of this attitude avoids all the fuss and preparation which are inseparable from tapping the patient in the sitting posture, and which are so suggestive of the idea that some formidable operation is about to be performed. Nothing more is necessary than to bring the patient to the edge of the bed so as to allow of her abdomen projecting somewhat beyond it. The bladder should then be emptied by the catheter (a precaution for which the voluntary efforts of the patient are but a very imperfect substitute), and it having been clearly ascertained that fluctuation is distinct, and that no great thickness of solid matter is situated at the point selected for puncture, the skin may be divided for a quarter of an inch or less with a lancet, and the trocar introduced. It has in some rare instances happened that a large venous trunk ramifying on the surface of the cyst has been wounded by the trocar, and that the hemorrhage has had a fatal issue. 1 Such an accident, however, is scarcely to be guarded against by any foresight, while the risk of wounding the epigastric artery is pretty certainly avoided by the selection of the linea alba instead of the linea semilunaris as the situation of the puncture. If there were obviously considerable thickness of solid matter in the former situation, it would no doubt be our duty to puncture in the linea semilunaris, or at some other part where there seemed to be a less thickness of intervening substance. It is, however, quite as easy to empty the cyst through a puncture made in the former situation as in the latter; if the patient incline a little more over towards her face, and its greater safety renders it therefore generally preferable. All pressure of the abdomen in order to get rid of the fluid as completely as possible appears to me inexpedient, and I think I have seen inflammation of the cyst excited by such manipulations when rather roughly performed. The application of a flannel bandage afterwards, though not in general necessary, is usually a comfort to the patient; and, in cases where any considerable portion of the growth is solid, can scarcely be dispensed with, since, unless supported by external pressure, the mass is apt to fall from side to side with every movement of the body in a manner to occasion much distress. I have always been accustomed to keep my patient in bed for a day before tapping, and for three or four days afterwards, and to select for the operation a time as distant as possible from a menstrual period. These precautions indeed may not in every case be necessary ; but, in spite of histories such as that of the patient who every three weeks used to come by omnibus a distance of some five or six miles to Paris, and having been tapped, immediately returned by the same conveyance, I believe them to be always expedient. In every instance of first tapping, where we can have no data to guide us as to the probable results of the operation, it is scarcely possible to err on the side of caution. The dangers attendant on the operation of tapping are twofold: that of exhaustion on the one hand, of cyst-inflammation on the other. 1 A remarkable instance of fatal hemorrhage from a wound of the vessel of the omentum which adhered to a large ovarian cyst is related by Scanzoni, op. cit., p. 400. 406 CYST-INFLAMMATION AFTER TAPPING. The previous state of the patient's health has, as might be expected, much to do with the former occurrence, but nothing seems to furnish a guarantee against the latter. It sometimes happens that cyst-inflammation runs its course with scarcely any symptoms other than those of exhaustion, or, rather, I imagine that in patients previously much debilitated, a diseased state of the blood is apt to supervene, and death takes place from pya3rnia, of which the cyst inflammation is the consequence, not the cause. In other instances, however, the sinking of the patient is independent of any recent morbid process, but the slight shock of the operation suffices to disarrange the frail machinery, and to bring it to a stand-still. It is well to bear this risk in mind in all cases where the patient is very weak, and to dissuade from tapping unless most urgently called for by the difficulty of respiration, or the inability to retain food on the stomaeh, which the mere mechanical distension of the abdomen sometimes produces. The precaution of letting the fluid out very slowly, of lowering the head and shoulders as it escapes, and of only partially emptying the cyst, are the means by which the danger from exhaustion is best guarded against, while, after the operation is over, careful watching and judicious nursing are more needed than what is strictly called medical treatment. The cyst-inflammation is a still more serious accident, and all the more from its occurring when least expected, though it is certainly much less likely to attack simple serous cysts than growths of a more compound character, and those especially whieh partake of the nature of alveolar carcinoma. Its symptoms are seldom very marked at the outset, and the pain whieh attends it is by no means proportionate to the danger of the attack. Tenderness on pressure over the tumor is indeed always evident, and sometimes, when the inflammation has extended to the peritoneum, there is likewise severe pain independent of pressure; but a quickened pulse, a general febrile condition, unpreceded, however, by shivering, and sickness, are the signs which should at once excite our apprehension. Of all the symptoms, indeed, vomiting and an irritability of stomach, which rejects all medicine, all food, all drink, though the thirst is usually considerable, are of the greatest moment, since they are almost pathognomonic of this affection. It seldom comes on within the first thirty-six hours, often not until the third day after tapping; while the rate of its progress in fatal cases is variable; death sometimes taking place in three days from its commencement, in other instances not till after the lapse of a week. "Whether quick, or slow, however, in its advance, symptoms of an acute character are at no time well marked; the pulse seldom has much power, the intense pain often attendant on peritonitis is absent, the bowels, though constipated, answer tolerably readily to medicine, and death usually takes place under the symptoms of depression which accompany pyemia. When allowed to go on unchecked for twenty-four or thirty-six hours, the cyst-inflammation is I believe an almost hopeless affection, though if treated quite at the outset, and in women not exhausted by the previous ovarian disease, it yields tolerably readily to treatment. Depletion is the great remedy on which I rely, and local depletion OVARIAN TUMORS AND DROPSY. 407 usually answers every end; though, on one occasion, when the symptoms set in with much severity, and indeed more nearly resembled those of acute peritonitis than of mere inflammation of the cyst, I abstracted twelve ounces of blood from the arm with great benefit. Twelve or eighteen leeches, however, applied over the tender part, and followed by a warm poultice frequently renewed, or by perpetual fomentation by means of the spongio-piline, often remove the pain, abate the fever, and stop the sickness. So long as the last-named symptom continues, no amount of improvement in other respects can be considered satisfactory, and whether the tenderness seemed to call for it or not, I should repeat the depletion if the sickness had not ceased, or, at least, were not greatly mitigated. A single large dose of calomel, as ten grains given in powder, sometimes arrests the irritability of the stomach, and obtains the action of the bowels with the smallest amount of general disturbance; but I have never found that there was time in these cases for obtaining the specific action of mercurials. The less, too, that the irritable stomach is teased with medicines the better, and iced water in small quantities, or little pieces of ice given to the patient to suck, are by far the best means of relieving the sickness and of quenching the thirst. When the more serious symptoms are passing off, a few spoonfuls of cold beef-tea, or of cold chicken-broth, will be found to be the most appropriate food, and that which the stomach will best support. To see the patient early, to watch her carefully, so as to be ready with a timely repetition of the depletion if the symptoms do not yield to its first performance, such are the essentials for saving the patient from this disease, in the management of which no time is afforded for elaborate treatment, nor any chance given for retrieving lost opportunities. LECTURE XXIX. OVARIAN TUMORS AND DROPSY. Treatment continued. Measures proposed for the radical cure of ovarian dropsy. Tapping and pressure. Subcutaneous puncture of the cyst. Tapping per vaginam. Tapping followed by some contrivance for keeping the wound permanently open; incision and partial excision of the cyst- Tapping, with injection of iodine. Although in the last lecture I assigned some reasons for doubting whether the perils attendant on tapping in ovarian dropsy had not been overrated, it must yet be allowed that the operation very rarely indeed proves curative, that the fluid generally re-collects, and that a reprieve, and commonly but a very brief reprieve, is all that it affords to the patient. 408 PROCEEDINGS FOR PERMANENT Hence have arisen various modifications of the operation of tapping, each of which has had for its object the favoring the contraction of the cyst, and the retarding, if not the preventing, the reaccumulation of the fluid. These consist of— 1st. The employment of tight bandaging after the evacuation of the contents of the cyst. 2d. The subcutaneous puncture or incision of the cyst, with the view of allowing of the escape of its contents into the peritoneal cavity, and of thus imitating the occurrences which take place when the cyst bursts spontaneously. 3d. The puncture of the cyst per vaginam, in order to insure its more thorough evacuation, and thereby to increase the chances of its permanent contraction. 4th. The keeping the cyst constantly empty, either by allowing a tube to remain permanently in its cavity, or by rendering the opening into it fistulous. 5th. The employment of medicated injections into the cavity of the cyst, of which solutions of iodine appear to be the least hazardous as well as the most frequently successful. Each of these proceedings must be considered in succession. I. Tight bandaging after the evacuation of the contents of the cyst. The probable utility of tight bandaging as a means of preventing the reaccumulation of the fluid of an ovarian dropsy after tapping was suggested by Mr. Benjamin Bell : J and the late Dr. Hamilton, 2 of Edinburgh, was accustomed to apply a bandage moderately tightly round the abdomen as an adjunct to that plan of percussion of the cyst from which he believed that in some instances he had obtained very remarkable results. Mr. Baker Brown, 3 however, was the first who proposed its systematic employment as a means of preventing the growth of ovarian cysts or their refilling after tapping. In his original communications on the subject he proposed to combine the free usp of mercurials and of active diuretics with the local treatment, but subsequently abandoned their use, and has since restricted himself to the application of firm pressure over the tumor. His mode of applying it will be best described in his own words. 4 " First of all, compresses of linen or lint should be so arranged as to present a convex surface, adapted as nicely as possible to the concavity of the pelvis. Over these compresses straps of adhesive plaster should be applied, so as to embrace the spine, meeting and crossing in front, and be extended from the vertebral articulation of the eighth rib to the sacrum. Oyer this strapping either a broad flannel roller, or, still better, a band with strings and loops which tie in front, may be applied; or a well-made bandage, which, by lacing in front, may be gradually tightened, as made at my suggestion by Mr. Spratt, 2, 1 System of Surgery, vol. v. p. 246. 2 Practical Observations on Midwifery, 8vo., 2d ed., Edinburgh, 1840, p. 62. 3 At first in the Lancet, and afterwards in his work on Diseases of Women, etc., Svo., 1854, p. 213. ? Op. cit., p. 212. 409 CURE OF OVARIAN DROPSY. Brook Street. These bandages must be prevented from slipping upwards by a strap around each thigh. Both the compresses and the bandages will require watching and adjusting from time to time, lest by unequal pressure the bowels or bladder be subjected to inconvenience. Also the crest of the ilium should be guarded with thick buffalo skin or amadou plaster." This proceeding is recommended as especially applicable for cases of simple ovarian cysts, free from adhesions, with clear and not albuminous contents, and when time and the condition of the patient admit of its persevering employment. Such, however, are the very cases in which there is the greatest probability of the spontaneous cure of the disease, of which two instance after a single tapping have come under my own observation. If to this fact we likewise add the s,rnall number of the reported cures effected by this means, and the circumstance that the reality or, at any rate, the permanence of some of them is more than doubtful, we can, I think, come to no other conclusion than that the curative powers of compression of the cyst either before or after the evacuation of its contents is not all established. At the same time, however, there can be no doubt but that the enlargement or the refilling of an ovarian cyst may be much retarded by the patient constantly wearing a well-adjusted bandage, though it is obvious that no kind of compress and bandage, how well soever they may be adjusted, can do more than interfere with its rising above the pelvic brim, that they cannot press upon it at all until it has acquired a certain magnitude, whieh, if not considerable, is yet quite sufficient to render the mere mechanical obliteration of its cavity almost or altogether impossible. In some instances it is probable that inflammation of the cyst may be excited by very firm pressure, and that thus adhesion between its walls and a permanent cure may be effected; but such cases must be exceptional, are probably very rare, and no such result can be calculated on as at all likely to take place from mere compression. II. It has been suggested that an attempt should be made by the subcutaneous puncture of the dropsical ovarium to imitate nature's own proceedings when the cyst gives way and pours out its contents into the peritoneal cavity. This is, however, a suggestion on theoretical grounds, rather than a mode of treatment which has been brought to the test of actual experiment. 1 Its expediency turns in part on the answer (at present by no means an encouraging one) to be given to the inquiry as to the danger to life attendant on the spontaneous rupture of ovarian cysts. But it must also not be forgotten that while very often fatal, the accident has in a large proportion of the cases where the patients survived, been followed by the speedy re-collection of the fluid. Moreover, by the subcutaneous puncture of the cyst we should empty into the peritoneal cavity fluid of the nature of which, and the probability of its exciting serious inflammation, we must be almost entirely ignorant. 1 Dr. Tilt, indeed, Lancet, Aug. 5, 1848, p. 140, mentions an instance in which it was adopted with success under the direction of M. Recamier, but I am not aware of any other case in which this proceeding was attempted. 410 PROCEEDINGS FOR PERMANENT The direct puncture of the cyst through the abdominal walls in order to ascertain this point, would at once deprive the operation of what has been alleged as its chief recommendation, namely, the avoidance of any communication between the interior of the cyst and the external air. Iff. The puncture of the cyst through the vagina instead of through the abdominal walls has been advocated as a means of insuring the more complete evacuation of the fluid, and consequently of increasing the probabilities of a permanent cure. The question of the advantages of this proceeding turns, I apprehend, very much on the view taken of the expediency of early tapping. In the case of an ovarian cyst which, though still small, though smooth, elastic, and as far as can be ascertained, simple in its character, is yet obviously increasing, tapping per vaginam appears to me to have the advantages of completely emptying the cyst, of excluding the admission of air, and of wounding the peritoneum in a situation where, as far as I have seen, wounds are less often resented than when inflicted higher in the abdominal cavity. On the other hand, for the following reasons I do not think the proceeding expedient in cases where the tumor has attained any considerable size. 1st. Because the cyst when large sometimes prevents the bladder from rising out of the pelvic cavity. The organ consequently becomes much altered in shape, and it is spread out laterally in such a way as to expose it with no very great unskilfulness on the part of the operator to the risk of injury by the trocar. 2d. In the case of all compound cysts, the larger are commonly those which are distinguishable in the abdominal cavity, the smaller cysts and the greater proportion of solid matter are to be found near its pedicle. Hence a puncture per vaginam is likely in these circumstances to prove less efficacious than tapping the cyst through the abdominal walls. 3d. The risk of hemorrhage from wounding some large vessel is greater when the puncture is made near the pedicle of the tumor. Except in those cases, therefore, where the cyst is very small, or where it is proposed to follow up the puncture by some further proceeding, it is not desirable to deviate from the ordinary mode of tapping. IV. It has been recommended to keep the cyst constantly empty, either by means of a tube retained permanently in its cavity, or by rendering the opening into it fistulous. As one of the great drawbacks from the simple puncture of an ovarian cyst consists in the rapidity with which the fluid re-accumulates, so nothing would seem a more obvious means of preventing this evil than keeping the opening permanent. The idea, indeed, is as old as Celsus, 1 who gives very detailed directions for fixing a leaden or copper tube in the wound, and, after partly evacuating the fluid, closing its orifice, and then allowing the daily escape of about half a pint at 1 De Medicina, lib. vii. cap. xv. See page 362 of Milligan's edition, Edinburgh, 1831. My attention was called to this passage by Fock's extremely able paper on the operative treatment of ovarian cysts, in Monatschrift f. Geburtskunde, vol. vii. p. 332, which contains a good critique on the comparative merits of various proceedings. 411 CURE OF OVARIAN DROPSY. a time till it is entirely drained away. The directions of Celsus apply, indeed, to cases of ascites, for the distinction between it and encysted dropsy was not then understood ; and to this circumstance it is probably in some measure to be attributed that like many other suggestions of the old writers, it remained unnoticed. In the middle of the eighteenth century, however, the celebrated French surgeon, Le Dran, 1 adopted a somewhat similar proceeding. His operation, indeed, was a much more formidable one than that of Celsus, inasmuch as he enlarged the opening into the ovarian sac to the extent of four inches, then introduced into it a leaden tube of considerable size, and at length, after a hazardous suppuration had continued for some time, the patient recovered, though in all cases but one a permanently fistulous opening into the cyst was left behind. Isolated instances are to be found from that time in the medical journals, in which purposely or by accident the opening into an ovarian cyst had remained unclosed, and the consequent suppuration had been followed by the contraction, or even by the complete obliteration of its cavity. It is, however, only within the past twenty years that any systematic attempts have been made to carry this idea into practice, as a means of effecting the radical cure of ovarian dropsy in cases not amenable to other modes of treatment, or in which their employment is shrunk from as being too hazardous. There are three different modes by which it has been endeavored to obtain the contraction or obliteration of the cyst. 1st. By leaving a tube in the aperture formed after tapping through the abdominal walls, or by stitching the edge of the cyst wound to that of the integuments so as to keep the opening permanently fistulous. 2d. By tapping per vaginam, and securing a tube in the opening. 3d. By excising a portion of the cyst wall, either with or without subsequent closure of the external wound. All these proceedings have this in common : that the inflammation, and more or less complete destruction of the cyst, or at least of its secreting membrane, is the condition of their success, while their common danger arises from the difficulty of restraining that inflammation within safe bounds. None of them have been resorted to sufficiently often to furnish any trustworthy body of statistics illustrative of their results ; but the cases related by Mr. Baker Brown, 2 who is an advocate of their performance, plainly show the nature and amount of the hazard to which the patient is exposed. My own experience of the first of these operations is derived from two cases, in both of which an exploratory incision had been made with the intention, had not the unexpected presence of adhesions prevented it, of extirpating the cyst. The cases had a fatal issue, which took place in one instance in the course of ninety-six hours, the patient dying apparently exhausted by the profuse sero-purulent discharge. No tube was introduced either in this or in the other case; but the edges of the cyst were simply 1 Memoires de l'Academie Royale de Chirurgie, tome vi., 12mo., Paris, 1753, pp. 51 and 73. 2 Op. cit., pp. 227 and 237. 412 TAPPING PER VAGINAM: stitched to those of the integuments in the first case, while in the second the opening remained fistulous of its own accord. In that instance the cyst was multilocular with a considerable amount of solid matter. Life was prolonged for seventeen days, during which the symptoms were those of exhaustion, gradually increasing, but unattended by any apparent suffering. The discharge from the cyst was horribly offensive, and the washing it out on several occasions with tepid water had no influence in modifying this condition. After death the same kind of morbid appearances was observed in both cases, namely, cyst-inflammation, with great softening of its wall, a deposit of lymph on its interior, and some peritonitis which, however, in the first case was not of recent date. In neither instance was there more than a very small quantity of pus within the cyst, and I suppose that if the opening be moderately free the pressure of the surrounding viscera will keep the sac nearly empty. It has, indeed, been proposed, in order to obviate all risk of the accumulation of the contents of the cyst within its cavity, that the patient should, as far as possible, observe the prone position, or that the incision into the cyst should be made in the linea semilunaris, a practice adopted by Mr. Brown, or in the lateral region in the situation of a line drawn from the last rib to the iliac crest, as very strenuously urged by the late Dr. Biihring, of Berlin. 1 The danger of the proceeding does not appear to be of a kind which any modification in the seat of the opening would remove, or perhaps even much lessen. Still this point is one not altogether to be lost sight of, since to the circumstance of the more eligible situation of the opening in cases where the puncture is made per vaginam must be attributed in part the more favorable results whieh have followed that operation. The great advocate of the puncture per vaginam was the late Professor Kiwisch, 2 whose colleague and successor, Professor Scanzoni, of Wurzburg, speaks of the proceeding in terms scarcely less eulogistic. The former, indeed, gives no data from which the exact proportion of successes to failures can be arrived at (an omission which in many other instances detracts from the value of his statements), but Professor Scanzoni 3 gives a very clear account of the results which he has obtained, and they are wonderfully favorable. He sa} r s that in 8 out of 14 cases a perfect cure followed the operation, that in two the fluid re-collected.in the course of a few weeks, that 1 died of typhus fever two months afterwards, and that 3 patients were lost sight of, but that in no instance did death take place from the immediate effects of the operation. At the same time, however, he admits the possibility of such an occurrence, and mentions the case of a } r ou.ng woman, aged nineteen, who died of extensive peritonitis a few days after the performance of this operation on her by Professor Kiwisch. It always appeared to me that an unnecessary degree of violence was 1 Die Heilung der Eierstockgeschwiilste, 8vo. Berlin, 1848. 2 At first in the Prager Vierteljahrschrift, vol. x. p. 87; and afterwards in his work, to which reference has so often been made. See vol. ii. p. 102. ¦ Op. cit., p. 400'. 413 AND WOUND KEPT OPEN. inflicted on the cyst by the operation as practised by that physician. He tapped the cyst per vaginam once in order to ascertain that the cyst was a simple one, a proceeding which, though it involves a delay of some weeks, is certainly expedient in every case of ovarian dropsy, since, now and then, the fluid does not re-collect, and it is always desirable to give the patient that chance, even though it be but slender. So soon as the fluid had re-collected sufficiently to allow of the repetition of the puncture, the patient being placed in a semi-recumbent posture, her feet resting on two stools, and her knees separated by assistants, a small canula, curved so as to correspond with the axis of the pelvis, was carried along the fingers and introduced through the roof of the vagina into the cyst. When but a small quantity of fluid had escaped, a grooved director, curved so as to correspond with the canula, was introduced through it, and the canula then withdrawn. A narrow probe-pointed bistoury was then carried along the director, and the wound enlarged so as to admit the index finger to examine the interior of the cyst, and to allow of the ready escape of its contents. A metal tube of the thickness of the thumb, terminating in a rounded, slightly bulbous extremity, was next introduced into the cyst, and retained there by a J bandage. Professor Scanzoni adopts a similar plan, though he employs a straight trocar instead of one curved like that of Kiwisch, and leaves the silver canula in the wound, which he does not enlarge, unless the contents of the cyst are too thick to flow out readily, in which case he enlarges the opening by a long handled knife with a blade an inch and a half long, which he introduces through the canula for this purpose. , In the three cases in which I performed this operation I employed a trocar and canula having a curve like that of a Kiwisch's instrument, and nearly as big round as the little finger. Through the canula a long elastic tube of the size of a No. 12 catheter was introduced, and the canula was withdrawn over it, while the tube was easily retained in the cyst by carrying it through a little silver collar in which it was fixed by a screw, the collar itself being attached to a framework such as used to be employed for retaining the uterine supporter in its place, and secured in a similar manner by tapes passing round the pelvis and thighs of the patient. My belief is that the operation thus modified in its details is attended by less discomfort and also by a smaller amount of risk than when an incision is made into the cyst and a heavy metallic tube afterwards fixed in the opening. Be this as it may, however, the proceeding has appeared to me to be attended by much more hazard than would be inferred from the language of Kiwisch or Scanzoni. The death of one of my patients was, indeed, not due to causes necessarily connected with the operation ; but in the other two, who eventually recovered, the symptoms of inflammation beginning in the cyst and extending to the peritoneum were so formidable that their life was for some thirty-six hours in most imminent danger, and most active local depletion was needed to subdue the mischief. Scanzoni, indeed, says that in some of his cases no symptoms of reaction followed the operation, nor any signs of local inflammation, but the tumor gradually 414 DANGER OP CYST-INFLAMMATION diminished in size, and in the course of a few days all discharge had ceased, so that the canula was sometimes withdrawn as early as the eighth or tenth day, or even sooner. Both he and Kiwisch, however, speak of the general occurrence of severe cyst-inflammation, during the continuance of which a thin or sanious discharge is poured out, and the local tenderness is extreme. Kiwisch speaks of the gradual subsidence of these symptoms in from ten to twenty days, and of the discharge then gradually assuming a puriform character, but not finally ceasing until from five to seven weeks, previous to which it is not prudent permanently to withdraw the tube. During this time the cyst should be often syringed out gently with tepid water, and I believe the direction that this should be done twice a day is very judicious. I may also add that if an elastic tube be employed, that will require to be changed every five or six days, and I have been compelled by the contraction of the opening to dilate it by means of a sponge tent introduced for a few hours, before it would readmit a tube as large as that which had previously been placed there. The one great peril of this operation seems to be the cyst-inflammation, and this surmounted, the risk of the hectic symptoms occurring, of pyaomia and its consequences, does certainly seem to be much smaller than when the puncture is made in the abdominal walls. The most energetic antiphlogistic and depletory treatment afford the only chance of subduing the cyst-inflammation, and if very formidable, and not yielding at once to treatment, it would of course be our duty to withdraw the tube and to postpone the attempt at curing the disease the more pressing necessity of preserving the patient's life. I ought to add that the results of the operation were on the whole satisfactory in the two patients who survived its performance. I lost sight of one, however, within two months after her discharge from the hospital, though up to that time the fluid had not re-collected. The other patient continues now, after the lapse of six years, in very tolerable health, and stands all day to serve in a confectioner's shop. Her case was one of fat cyst of the ovary, consequently not one in which its complete obliteration was likely to occur. Nor, indeed, has this happened, but an opening into the cyst has remained permanently fistulous, and from §iij to svi of purulent matter escape thus every day, while if, as occasionally happens, the discharge for a day or two becomes very scanty, headache occurs, and the patient feels various discomforts, which again cease on the reappearance of the wonted secretion. Whatever may be thought of the advantages of this operation, it is not possible to adopt it in a very large number of cases, since the ovarian cyst often rises at a comparatively early period out of the pelvic cavity. In many others, also, it is clearly inexpedient, since in none but simple cysts is cure by this method possible. In the case of a small simple cyst, however, it appears to me more than doubtful whether we are justified in exposing a patient to a danger so very formidable as that of the cyst inflammation which this operation almost invariably provokes. At any rate, we cannot, I think, rest satisfied with a proceeding, the indications for which must be furnished by some 415 FROM THESE PROCEEDINGS. purely exceptional conditions, but must carry our inquiries further after some measure more certain, or more safe. The dangers which attend on the incision of ovarian cysts, or on any attempt to keep the puncture made in tapping permanently fistulous, accompany in a still greater degree the excision of a portion of the cystwall. No instance of the performance of this operation has come under my own notice, but several cases are reported in the medical journals both of its successful and its non-successful employment. In some instances it was had recourse to in consequence of unexpected adhesions preventing the complete removal of the tumor; as in the patients operated on by Martini, 1 Biihring, 2 Poland, 3 Prince, 4 and Atlee, 5 of whom 4 died and 3 recovered. But it has also been selected in cases of thin-walled cysts, uncomplicated with adhesions, and existing in patients whose health was but little impaired, on the supposition that partial excision might be found to be a less hazardous operation than total extirpation of a cyst. In such, or such-like conditions, the operation has been performed by Mr. Wilson, of Bristol, 8 Mr. Brown, of London, 7 and Mr. Crouch, 8 and of these 6 cases 2 terminated fatally, 4 had a favorable issue. One of the patients died from hemorrhage, the other from exhaustion, and the effusion of purulent matter from the cyst into the peritoneal cavity ; while so alarming were the symptoms of inflammation in one of Mr. Brown's cases, that it was considered necessary to bleed the patient from the arm four times in the first forty-eight hours after the operation. The existence of adhesions such as prevent the complete extirpation of an ovarian cyst may possibly justify the incision into it, aud the allowing the escape of its contents, though it is doubtful whether the risks of this proceeding do not outweigh the probabilities of success. The excision of a portion of the cyst and the return of the remainder into the abdominal cavity rest for their justification on the assumption that the fluid, unchanged by the grave injury inflicted on the cyst, will be absorbed by the peritoneum, that the cyst itself will continue for but a short time to secrete, and will then become altered in character and probably calcified. We need, however, some guarantee of the probability of this occurrence usually taking place, some evidence that the excision of a large portion of the cyst is not likely to be followed by very acute inflammation of that which is left behind, that the secretion from it will not become sanious or purulent, and consequently will not be likely to excite violent peritonitis. At present we have no grounds for such expectations, and consequently no encouragement to imitate this proceeding. 9 1 Rust's Magazin, vol. xv. p. 430. 2 Op. cit., cases vii. and viii., pp. 37 and 43. 3 Guy's Hospital Reports, 3d series, vol. i. p. 63. 4 American Journal, July, 1850, vol. xlv., p. 267. 6 Ibid., April, 1855, p. 387. Nos. 9, 12, and 13 in his table. 6 Provincial Medical Journal, 1851, p. 33. 7 Op. cit., p. 235. 8 Association Medical Journal, p. 60. In this case, unlike the others, the cyst-wall was of very considerable thickness. It is worth notice, too, that no fewer than seventeen small arteries required ligature. 9 A judgment still more unfavorable to this proceeding has been passed by Fock, in his able critique, pp. 362—367 ; and in even more unqualified terms by Scanzoni, op. cit., p. 412. 416 CURE OF OVARIAN DROPSY V. The employment of iodine injections into the cavity of the cyst with the view of preventing tjie reaccumulation of the fluid. In many of the cases to which reference has hitherto been made, injections into the cyst were employed either for the purpose of more completely evacuating its contents, or with the view of exciting such a measure of active inflammation of its walls as should lead more quickly or more surely to the obliteration of its cavity. In all these instances the injections were but subsidiary measures, neither much relied on by the operators, nor to which any great share in producing the patient's recovery (where recovery did take place), could be attributed. Of late years, however, the attempt has been made to destroy the secreting power of the cyst by the injection into it of a solution of iodine, a practice suggested by the success of a similar mode of treating hydrocele first adopted by Mr. Martin, late of Calcutta, and M. Velpeau. The first reported cases of the employment of iodine injections in ovarain cysts were published by M.Thomas in 1851 ;* though M. Boinet, 2 who is so strong an advocate of the measure, first put it in practice in the year 1848. Since that time it has been repeatedly had recourse to both in this country and the continent, and the results hitherto obtained lead to the hope that in a very large proportion of cases it will be found to check the reaccumulation of the fluid, and in many instances to prevent it completely, while it appears to be attended by less serious danger than any other operation for the radical cure of ovarian dropsy. Some of the advocates of its employment, indeed, represent the injection of iodine as being less hazardous than tapping unaccompanied by it; but we may hesitate to accept this conclusion till the statements concerning it are more definite than the alleged results of "twenty or thirty" cases. 3 The only statistics with which we are yet furnished sufficient in number and in apparent exactness to warrant any conclusion being drawn from them, are those of M. Boinet, 4 who has published the results of 45 operations on 44 patients, one having had two cysts, which were tapped and injected at different times. Age of Patients. Cases. Cures. Failures. Deaths. From 15 to 20 years 2 110 " 20 « 30 " 7 5 1 1 " 30 " 40 " 17 16 0 1 " 40 " 50 " 116 2 3 " 50 " 60 " 5 2 0 3 " 60 " 78 " 3 1 1 1 45 31 5 9 In 34 of the cases the cysts were simple; in 11 compound. All the successes occurred where the cyst was simple ; but 3 deaths also fol- 1 Revue M6d.-Chir., Feb. 1851, and Schmidt's Jahrb., 1851, No. vi. p. 327. 2 Iodotherapie, etc., 8vo., Paris, 1855, p. 429. 3 Dr. Simpson, in Lancet, March 21, 1857, says that only one death occurred in twenty or thirty cases in which he had used the injection of iodine. Singularly enough, this statement appears in a paper devoted to a defence of statistics. 4 Gazette Hebdomadaire, Nov. 21, 1850, p. 828. 417 BY IODINE INJECTIONS. lowed the injection of simple cysts. All the operations on compound cysts failed; and 6 of them were followed by the patient's death; though certainly in many of these cases death would have taken place as soon, possibly even sooner, if interference had not been resorted to. In 19 of the 45 cases the puncture and injection were employed only once, and in 16 of the number a permanent cure was obtained. 19 injected once, 16 were cured, 2 failures, 1 death. 7 " twice 5 " 1 " 1 " 6 " thrice 4 " 1 " 1 " 41 it four 2 " 1 " 1 « 4 " six 2 " 0 " 2 " 2 " seventeen 1 " 0 " 1 " 2 " nine 0 " 0 " 2 " The whole of M. Boinet's paper deserves an attentive perusal; for even after every allowance has been made for the over-estimate of success into which the advocate of any peculiar mode of treatment is almost sure to fall, these results still remain far more favorable than have been obtained by any other mode devised for the radical cure of ovarian dropsy. The injection which he employs is a mixture of equal parts of distilled water and the tincture of iodine of the Paris Pharmacopoeia, which contains more than twice as much iodine as the compound tincture of the London Pharmacopoeia; the proportion being one part to in the former, one in 29 in the latter. From 3iv to Sviii, or sx of this mixture, to whieh some iodide of potass has been added to insure the complete solution of iodine, are thrown into the cyst, and after being allowed to remain there for from seven to ten minutes, during which time the cyst is kneaded with the hand, in order to bring every part of its wall in contact with the liquid, it is allowed to run out, the tube is withdrawn, and the wound closed. At first he was accustomed to leave in the tube, combining the attempt at cure by keeping the tapping wound fistulous with the use of the injection; but he has now almost entirely discontinued this practice, and proposes its adoption only when frequently-repeated tapping and injection have failed to effect a cure. Although in many instances a considerable quantity of tincture of iodine has remained behind in the cyst without any bad symptoms resulting, M. Boinet always prefers allowing of its escape after the lapse of some minutes. No one can read the particulars of Mr. Teale's cases, 2 of which one proved fatal, while the other two remained unconscious for fifteen and fourteen hours respectively, without feeling that the hazard is greatly increased by allowing the fluid to remain. The same symptoms of most formidable depression are also noticed in the report of a case under Mr. Brown's care 3 in St. Mary's Hospital. That gentleman appears usually to allow the solution of iodine to remain in the cyst, and to combat the formidable symptoms which result from the practice by the liberal administration 1 In one of these cases, though the tumor was punctured four times, it was injected only thrice, and in another only twice. ' Reported by Mr. Hardwick in Medical Times, Jan. 31 and Feb. 7, 1857. 3 Lancet, March 21, 1857, p. 290. 27 418 CURE OF OVARIAN DROPSY. of wine and brandj r . Among my patients at St. Bartholomew's Hospital, in whom the injection has never been allowed to remain more than ten minutes in the cyst, serious depression only once followed its employment; and I very much doubt the propriety of adding to the patient's risks those of poisoning by iodine, when there seems good reason for the belief that the peculiar curative influence of the agent is exerted even after a very short contact with the cyst-walls. The nature of this influence is still but little understood. It is clear that cyst-inflammation is not a necessary condition for success ; for in several instances where no reaccumulation of fluid has taken place no pain has followed the operation, nor any constitutional disturbance, but the cyst once emptied has not refilled, and recovery has not been purchased by the suffering or the peril which seem inseparable from all other modes of cure of ovarian dropsy. We have at present no account of the appearances found on dissection after the successful employment of this proceeding in ovarian disease. Observation, however, has already taught us that the radical cure of hydrocele by no means of necessity implies the formation of adhesions between the opposite surfaces of the sac. Such adhesions, too, appear to occur less often after the use of iodine injections than after any of the other usual surgical proceedings for the cure of hydrocele, 1 and if the opposite surfaces of the comparatively small cyst in that case fail to become adherent, it is little likely that union should take place between the sides of a large sac which has been distended by many quarts of fluid. It is possible that something is lost of that security against relapse, which enhances so much the value of any cure; it is certain, however, that much is gained in safety if we can avoid the risks of a disease so formidable, so difficult to control, as cyst-inflammation. My own experience of the use of iodine injections is at present very limited, though what I have seen of its results makes me most anxious to give the method a further trial. Hitherto I have employed it only in eight cases, the results of which are shown in the subjoined table. 1 See the observations of M. Hutin on the cure of hydrocele, quoted by M Boinet, op. cit., p. 270. IODINE INJECTIONS. 419 Table showing the Result of Iodine Injections in eight cases of Ovarian Dropsy. - . Civil Durati °Ji Previous Ovary Nature of Quantity 1 Immediate ~- p PS ,,it a I dig f ase tappings. affectcu. cyst. effects. ReSUU8 ReSUU8-1 26 years Single 4 years Four. Cyst rup- Right Single 5 pints j Cyst inflamma- At end of 13 mouths abdomen larger than be- Possible retured into abdo- tion. Iodism fore tapping, hut cyst had not ruptured again, tardation of * men twice. I nor had tapping been needed. disease 2 39 " Married 2 " None Right Single Ij " Active inflam- Symptoms yielded to depletion readily. Atend Cure ! matory symp- I of 2 years fluid not re-collected, toms. 3 29 " Single 1 " One Both Multilocular 8 " : Iodism, extreme Gradually rallied; but fluid re-collected, and No benefit j partly solid j depression has been thrice tapped in ensuing 12 months. 4 22 " Single 2 " One Right Supposed 8 " No symptom For 2 years continued perfectly well; in Cure of the single years tumor formed, with a distinct mass, first cyst and possibly the remains of former cyst on its consequent wall. Tapped again, and injected, but fluid retardation I immediately re-collected. \ of disease 6 31 " Married 2 " One Right Supposed 5% " Inflammatory The symptoms yielded readily. At end of 18 Cure of first single symptoms mouths cyst not refilled, but on its wall two cyst; disease I masses were felt, the size of an orange. i retarded 6 21 " Single 4 " One Left Single 3% " Immediate 'Awatery solution of iodine was employed. The None: intense pain ; I cyst was successfully removed some months operation operation after by Mr. Humphry, of Cambridge. It unfinished discontinued I was quite unadherent. 7 35 " Married 4 " Once, and twice Left Malignant 16 pints on each No symptom iThe quantity of pus in the fluid was much di- Slight emptied itself at of three occa- 1 minished after first injection, and ameuilment improvement umbilicus. sions in course' after it seemed considerable. The other two of 3 months I had no effect. Death from exhaustion and phlegmasia dolens 21 days after 3d injection. •8 j 17 " Single 6 months Three Right Compound, si'j pints on oc-' No symptom Between 1st and 2d tapping, in'erval Marked re(probably) I Much solid casion of first j months ; between 2d and 3d, \% month ; be- tardation of Both" matter injection; 5Jj on j tween 3d and 4th, 3Jf months; iodine then disease jtwo subsequent j injected; between 4th and oth, 8 months;! occasions j between 5th aud 6th, 20'i months. 420 RESULTS OF IODINE The first thing, perhaps, which strikes one in looking over this table is the fact that in no instance did the injection 1 have a fatal result, while in three cases no constitutional disturbance whatever was produced by the proceeding; and, further, it is worth notice that no connection seemed to subsist between the severity of the symptoms that were produced in some cases, and the permanent cure of the patient. Cyst-inflammation, indeed, appeared to be excited on several occasions, though it yielded tolerably readily to moderate depletion. Its signs were in most instances partly masked, partly exaggerated by the symptoms of iodism, as those phenomena have been termed which are produced by the absorption of large quantities of iodine into the blood. Great abdominal pain, usually, however, speedily abating, extreme depression, cold extremities, a very frequent and very feeble pulse, which sometimes becomes altogether imperceptible at the wrist for a few hours, a sense of sickness, often accompanied by actual vomiting, drowsiness without sleep, thirst, and a metallic taste in the mouth, are the symptoms which occasionally follow immediately, or within the course of a few hours after the injection of the cyst, and suggest a peril even more imminent than in all probability really attends them. Coupled with this condition, which usually loses its more formidable features in the course of twentyfour hours, there is a very scanty secretion of dark claret-colored urine, loaded with iodine; and a diminution of the amount of iodine, an increase in the quantity of urine, and an abatement of the symptoms take place simultaneously. In the case where the symptoms of iodism were most alarming, an aqueous solution of iodine was employed, and one of the benefits of the admixture of a certain quantity of spirit with the fluid appears to be that it retards the absorption of the iodine. I have, however, found traces of iodine in the urine fourteen days after the injection of the solution that I usually employ, and which contains a third part of spirit, and this although the fluid was allowed to remain in the cyst only for ten minutes. The observation of these facts renders me very decidedly opposed to the practice either of employing very strong solutions of iodine, or of allowing the injection to remain permanently in the cyst —a practice to which the formidable symptoms and the fatal results which have occurred in some English cases appear to me in great measure attributable. The uncertainty as to the cases which will bear the iodine injection well, as distinguished from those in which cyst-inflammation or profound iodism will be excited by it, is a drawback from its value which this operation shares with every other proceeding for the cure, or even for the temporary relief, of ovarian dropsy. It is hard to say how long a lapse of time is necessary to establish 1 The injection which I have been accustomed to employ is a solution prepared at the time, as recommended by M. Guibourt of Paris (see Boinet. op. cit., p. 101), and •which consists of 5 parts of iodine, 5 of iodide of potass, 50 of spirit, and 100 of water. The quantity of iodine which this mixture contains does not differ materially from that which would be present in a mixture of equal parts of compound tincture of iodine of the London Pharmacopoeia, and distilled water. 421 INJECTIONS ESTIMATED. the permanence of a supposed cure of this disease. At the end of two years after the injection of a cyst with the solution of iodine no recollection of fluid had taken place in one case, and it is perhaps fair to regard that as an instance of its cure. In two other cases, however, the obliteration of the first cyst was followed at the end of eighteen months in the one, and of two years in the other, by the development of others, which showed that the tumor was not of that simple kind which it had at first been supposed to be. Such occurrences point out, indeed, the incompleteness of the success obtained by this proceeding as compared with the really radical cure effected by the extirpation of the ovary. But, on the other hand, even they are not without an encouraging feature, since they show that the presence of solid matter in the tumor does not contraindicate the injection, nor the compound character of the cyst render the operation dangerous, but that from it we may expect retardation of the disease in cases where yet we must abandon the hope of effecting a permanent cure. The real value of this proceeding still remains to be definitely determined by larger trials than have yet been made, and it seems almost idle to bring forward an array of names to settle a question which as yet is not ripe for a decision. In this country, Dr. Simpson is the only person who has often had recourse to iodine injections in ovarian dropsy, and I have already mentioned the extremely favorable conclusions at which he has arrived. In France, too, the weight of evidence at the recent discussion of the subject before the Academy of Medicine was decidedly in support of the proceeding. M. Velpeau, indeed, estimated that out of 130 instances in which iodine injections had been employed, 30 terminated fatally ; only 6-1 were permanent cures, while the fluid reaccumulated in 36. In 20 of the 30 fatal cases, however, the opening into the cyst had been maintained fistulous, and to this proceeding, which he characterizes as bad and detestable, M. Velpeau is disposed to attribute the patient's death rather than to the mere employment of the iodine injections. In Germany, Scanzoni is the only writer of authority 1 who pronounces an opinion decidedly unfavorable to the employment of iodine injections. His objection to it appears to rest in part on theoretical grounds, in part to apply to the combination of iodine injections with the maintenance of a tube in the wound. The objection founded on the intractable nature of cystinflammation, while it comes somewhat strangely from the advocate of the practice of keeping the cyst wound fistulous, will lose much of its force if experience should confirm the opinion that the iodine acts not by exciting cj'st-inflammation either necessarily or generally, but by suspending or altogether destroying the secreting power of its surface. The grand objection to most proceedings hitherto devised for the cure of ovarian dropsy is not only that they often fail to accomplish that object, but still more that they frequently destroy the patient who submits to them. A comparatively low average of successes may be more than counterbalanced by an equally low rate of mortality; but a very high probability of perfect cure is needed to outweigh a great 1 Op. cit., pp. 40S—410. 422 OVARIAN TUMORS AND DROPSY. risk to life. It will, I apprehend, be found that the comparative safety of the iodine injection will be its great recommendation. For my own part, I confess that I shrink from playing a game with heavy odds against success when human life is the stake. How far this objection applies to the last great remedy, the removal of the diseased organ, must be the subject of inquiry at the next lecture. LECTURE XXX. OVARIAN TUMORS AND DROPSY. Treatment continued. Extirpation of the diseased ovaries. History of the operation, its two varieties, the major and the minor. General results of the operation ; its mortality undiminished ; date and cause of death. Circumstances modifying its hazards ; existence of adhesions, age of patient, extent of incision, character of tumor. Unfavorable opinion pronounced, and why ; its results and those of Csesarean section compared, but operation to be judged by its own merits, not by comparison with operations for other purposes. It still remains for us last of all to examine the great radical cure of ovarian dropsy, the extirpation of the diseased organ. The history of the operation has been so often related, that I need not occupy much time in repeating its details. Performed for the first time in the year 1809 by Dr. Macdowell, of Kentucky, and repeated by him five times in the subsequent ten years, it yet did not attract much attention nor find many imitators even among his countrymen for nearly five-and-twenty years. Neither on the continent nor in this country were the results of the few. instances of its performance at all encouraging, and down to the year 1810 it had been attempted in its original form, which consisted in the making a long incision from the sternum to the symphysis pubis, only twenty five times. 1 In 14 of these cases, 2 the ovary was removed, 9 patients survived the operation, 5 sank under its effects; in 11 either no tumor was discovered, or 1 The diligence of M. Fock, loc. cit., p. 3G7, has discovered the mention of a case where, more than 150 years ago, the cyst was drawn through the wound made in tapping, by a sort of unintentional anticipation of Mr. Jeaffreson's operation, and he refers also to a similar occurrence having happened to the late Mr. Howship. These, however, are not instances of the intentional extirpation of the diseased ovarium, and cannot be taken into our consideration here, any more than L'Aumonier's case (Memoires de la Societe Royale de Medecine, 1782, 4to. p. 296), in which with a barbarous surgery, he removed the ovary distended with pus in consequence of inflammation after delivery. 2 A notice of these earlier cases of the operation by the large incision will be found in the British and Foreign Medical Review, Oct. 1843 ; and three cases not noticed there, are referred to in the Report on Midwifery, etc., for 1842-3, published in the same journal for April, 1844. OVARIOTOMY: ITS MORTALITY. 423 adhesions prevented its removal, and of these patients 8 survived the exposure of the abdominal cavity, 3 were destroyed. Matters stood thus when Dr. Clay and Mr. Walne, by the publication of several cases, a good proportion of which had had a favorable issue, excited the attention of the profession to the subject; and though it was some time before the operation was generally regarded as a legitimate proceeding, and though it is still denounced by some surgeons in unmeasured terms, we yet can reckon now some 200 cases in which it has been resorted to, and are therefore in a position to form some opinion of its advantages and its dangers. The operations, indeed, have not all exactly resembled those first performed, for in the year 1833, Mr. Jeaffreson, of Framlingham, in Suffolk, endeavored to lessen the formidable character of the proceeding by tapping the cyst, and then withdrawing it through as small an opening as possible. This has been called the operation by the small incision in contradistinction to the other, or operation by the large incision. The advocates of each of these proceedings are very strenuous in insisting upon the merits of that of which they approve, and as we shall presently see, each has its peculiar advantages. In many respects, however, they stand upon common ground, and we may class them together for the present while we seek to ascertain what rate of mortality is to be apprehended, and what measure of success may be hoped for from the attempt to extirpate the dropsical ovary. Several writers have collected with much diligence the statistics of this operation, of which there are now more than 200 instances on record. This last is the number arrived at by Fock, in his very valuable paper on the subject, 1 and though the past eighteen months have furnished a few additional cases both of success and of failure, it is yet so convenient to deal with round numbers that I prefer adopting his figures as they stand. Now these 200 cases of actual extirpation of the ovary yield 111 recoveries to 89 deaths; or, in other words, the mortality is 44 \ per cent., or not very far short of half the number of persons in whom the operation is completed die from its effects. But, 1 The first of these tables, and the foundation of all subsequent ones, was published by Dr. W. L. Atlee in the American Journal for April, 1845, and was copied, without quite adequate acknowledgment, by Mr. S. Lee, in his very useful work on uterine tumors. Had he lived, the omission would have been rectified, but justice to Dr. Atlee compels me to refer to it here. Dr. Robert Lee has collected in his Clinical Reports, etc., the particulars of 102 cases in which ovariotomy was either attempted or actually performed in this country; while Kiwisch's table, in vol. ii. of his Klinische Vortiiige, supplies some additional cases, chiefly contributed by continental practitioners. In the American Journal for April, 1850, Dr. Atlee gives the general results of 179 cases, though not with the same detailed references as in his former table ; and in the same journal for April, 1855, he contributes a synopsis of 30 cases of ovariotomy occurring in his own practice. Dr. Clay, of Manchester, who has performed the operation more frequently than any other person, published in the British Record of Obstetric Medicine the particulars of 40 cases that came under his own care, and his papers on this subject were collected and published by him at Manchester, in 1M48. In March, 185(J, he sent a letter to Dr. Simpson, which appeared in Ed. Med. Journal for that month, in which he briefly states the results of 29 additional cases. From all these sources, as well as from others either overlooked by former writers, or which have occurred subsequently to their investigations, Dr. Fock has collected a total of 292 cases, on which he bases his conclusions, and I have availed myself of his labors. 424 PERFORMANCE OF OVARIOTOMY besides these, there are 92 cases in which the operation could not be completed on account of the presence of adhesions, or of the tumor having some other situation or other attachments than was supposed beforehand, or in which some even greater diagnostic error was committed, and the very existence of the tumor was found to be a mistake. Of these 92 patients, 31 died, or 33.6 per cent., or 1 in every 3; but 9 of those who survived, after passing through great perils, are reported to have been more or less completely cured of the disease. Putting all the cases together, it seems that of 292 recorded instances of the operation being attempted, 120 ended in death, and 92 in failure; or, in other words, the chances are two to one that the operation will be accomplished; but, if it succeeds, they are nearly equal that the patient will die, and if it fails the prospect of her surviving the fruitless interference is only double that of her sinking in consequence of it. The belief was expressed by the advocates of the operation that the mortality attendant on its performance was in course of diminution, and that with the perfecting of our diagnostic skill the proportion of unfinished operations was also lessening. "The rate of mortality," says Dr. Atlee, in the year 1850, " has very much diminished since the publication of my table in 1845. Then there was 1 death in every 2~£ cases of gastrotomy, or 37.62 deaths in every 100 cases. Since the publication of that table 78 cases have occurred, in which there was 1 death in every 3| cases, or 26.92 deaths in every 100 cases. There has also been a diminution in the proportion of unfinished operations .... hence diagnosis has also improved." 1 Unfortunately, as we have seen, it needs but to increase the number of observations in order to do away with the correctness of this very natural, though too sanguine expectation. One death in every 2ff of those cases in which the operation was completed, or 1 in 3 T 4 5 of all cases, those included in which the operation was abandoned, such are the results of the most recent data; while the number of instances in which the ovary could not be extirpated has risen from 1 in at which Dr. Atlee estimated it in 1850, to 1 in 8A six years afterwards, according to the calculation of Dr. Fock. This last category of cases, too, would, I doubt not, be swelled far beyond its present dimensions if every instance in which an exploratory incision sufficed but to discover the impossibility of any further proceeding were placed upon record. Besides the cases '88, 101, and 103, in Dr. Lee's list, the first of which occurred during my connection with the Middlesex Hospital, while the other two were patients of my own, I have had two other cases at St. Bartholomew's Hospital, in which the attempt was made with my full concurrence to remove the ovary, but was made unsuccessfully. One of the patients, a girl about twentytwo, survived the operation four months, but after having struggled through an attack of cyst-inflammation, which followed within thirtysix hours after it was attempted, she sank into a state of hectic, which, after death, seemed to be accounted for by the extension of the 1 American Journal, April, 1850. OFTEN IMPRACTICABLE. 425 inflammation to another cyst that was found distended by more than a quart of pus. The other case was that of a married woman, fortyseven years old, in whom the disease had been of very rapid development, but the cyst was apparently single, while the absence of any history of peritonitis, and the extreme mobility of the tumor seemed to warrant the tolerably confident expectation that no important adhesions existed to interfere with its removal. This hope was found, however, to be illusory, and death took place from cyst-inflammation with all the symptoms of pyeemia seventeen days after the operation. The examination after death illustrated a source of difficulty which no wisdom could have foreseen. There were, indeed, adhesions to the abdominal peritoneum, and these it may be conceded (though I am by no means convinced of the fact) that the well-skilled tact of some one else might have detected. But the upper and posterior wall of the cyst adhered to the intestines, while from its upper part there passed off a pyriform prolongation, which reached up as high as the eighth rib, and, dividing into three separate branches or diverticula, adhered to the intestines, to the pancreas, and to the capsule of the left kidney. It happens then that my personal experience of ovariotomy is made up of the observation of five cases, in every one of which the operation was undertaken after much consideration, with the approval and under the direction of surgeons of large experience and undoubted skill, but who, in every instance, were baffled in their attempt. Two of these cases are now published for the first time, and go to swell the list of unsuccessful operations. They were not withheld before except as the mention of many an unsuccessful operation is withheld, because it teaches no now fact, and serves only to illustrate some well-known danger. I have no doubt, however, but that very many other cases of the same kind must have occurred which are still unpublished just as mine were ; but which, could they be collected, would bring out the dark side of the operation, not so much perhaps in proving the mortality from completed ovariotomy to be so much greater than the present estimates, as in showing failures to accomplish it to be much more common, and those failures to be much oftener attended by danger and followed by death. Some details as to the circumstances in whieh death takes place from this operation, and the conditions which favor its occurrence may help us to a more correct estimate of its value. In 68 cases the date at which death occurred is mentioned. It was immediate, or within six hours in 4 " soon " 1 " on the 1st day "6 " « 2d " "14 " 3d " "12 " 4th " "4 " 5th " "6 " " 6th " "6 " " 7th " " 1 " 10th " "2 " 11th " " 1 426 CAUSES OP MORTALITY It was on the 12th day .... in 2 " 17th " « 1 " " 21st " "2 " » 22d " j- Decoct, uvse ursi, ad j$vj.—M. ft. mist., cujus sumat cochl. 2 ampla 4ta quaque hora,. 2 (No. 12.) R. —Extracti pareira gr. xlviij. Acid, hydrochlor. dil. tTLxl. Morphias hydrochlor. gr. ss. Decoct, pareinc 5vj.—M. ft. mist., cujus sumat 4tain partem (ita quaque hora. 440 TREATMENT OF CHRONIC CYSTITIS. in bed; the uniform temperature of the surface being thus maintained prevents any sudden demand being made on the function of the kidneys, while the disposition to congestion.of the pelvic viscera is much lessened by the maintenance of the horizontal posture. Throughout the whole course of one of these cases opium in some form or other is the remedy on which our greatest dependence must be placed, and its value far exceeds that of any medicine supposed to exert a specific influence on the bladder. Of these medicines, two of the most useful, the uva ursi and the pareira, have already been alluded to. When these remedies fail in the forms which I have already suggested, I have seen benefit result from the combination of the pareira either with small doses of copaiba or with the benzoic acid. Sometimes, too, especially where the secretion of urine is scanty, the benzoin alone has proved serviceable; though a not infrequent drawback from any of these medicines is that they nauseate the stomach, and the alleviation of local suffering is then too dearly purchased at the expense of the patient's general health. I have on several occasions made trial of injections into the bladder in cases Avhere the condition of the urine was very unhealthy, and where it contained a large quantity of ropy mucus. For this purpose I have, in accordance with Sir B. Brodie's suggestion, employed the decoction of poppies, to which I have but very rarely added a few drops of dilute nitric acid. The instances, however, in which this proceeding was at all tolerated were quite exceptional, and almost always such severe and such abiding pain was excited as to compel me to desist from a repetition of the experiment. Even when borne for two or three times, and giving an earnest of effecting some lasting good by the improvement which it wrought in the state of the urine, pain has seldom failed to come on, and to preclude the continued employment of the measure. One reason of this failure (for I am not aware of any want of care either in the selection of the cases or in the application of the remedy) may perhaps have been that the persistence of chronic cystitis in the female subject for any considerable time generally, if not invariably, occasions irritation of the kidneys, and a sort of subacute pyelitis. There seems also to be a great tendency for the mischief in these cases to terminate in ulceration of the mucous membrane of the bladder, and not to stop short with the induction of that thickening which is so common in the male subject. One other proceeding which T have now and then resorted to in cases of chronic cystitis with much irritability of the bladder, has been the introduction of a seton just above the symphysis pubis. I have observed decided benefit from it, especially in those cases where the irritability of the bladder was out of proportion to the amount of obvious disease; though from its nature this remedy is one to which we cannot very often have recourse. It would perhaps scarcely be right to take leave of the subject of inflammation of the bladder without a word or two concerning those sad cases in which vaginitis following delivery terminates in the death of the tissues, and in the formation of a fistulous communication 441 VESICO-VAGINAL FISTULA. — MEANS OF PREVENTING IT. between the bladder and vagina. There can be no doubt but that in the great majority of instances this accident is due to the delay of instrumental interference in tedious labor, coupled with the omission to use the catheter. It is extraordinary how often this latter simple precaution is neglected, how often the statement of the patient or of her nurse is accepted as conclusive of her having emptied her bladder; while the practitioner, conscious perhaps of his own incxpertness in performing this little operation, is only too ready to frame an excuse to his own mind for not attempting to do that which he knows he should do but awkwardly, and fears that he might possibly fail to do at all. To this neglect of the catheter, and to the omission to interfere instrumentality as early as is necessary, is the occurrence of vesicovaginal fistula to be attributed far oftcner than to any direct injury inflicted by the instruments themselves. After labor is over, too, the same neglect to keep the bladder empty not only adds to the patient's distress, but greatly aggravates the perhaps inevitable cystitis, and renders the case to a great degree unfit for any attempt at cure by means of a plastic operation. Wherever from the protraction of labor, and from the long stay of the head in the pelvic cavity, there is any reason to fear the occurrence of inflammation of the vagina, its possible issue in sloughing and in the formation of a fistula must always be borne in mind, and attention must be closely directed to the local condition of the patient as well as to her general symptoms. The bladder must be regularly emptied by the elastic catheter every six hours, a warm poultice must be constantly applied to the hypogastrium, and poppy fomentations to the vulva; while the vagina must be carefully s} 7 ringed twice a day with lukewarm water, and local leeching must be at once employed on the first onset of symptoms of cystitis. The state of the parts must not be judged of from hearsay, but must be inspected every day; a precaution which though especially necessary when any laceration of the perineum has taken place, is yet always worth taking, since the appearance of the vulva furnishes no bad index to the general state of the vagina. If the secretion from the vagina assumed an unhealthy character, and if shreds of mucous membrane appear in it, we may be sure that sloughing has taken place, and though the sloughing may be superficial, yet of this we cannot be certain, while contraction of the canal, and the formation of cicatrices are its almost inevitable results. The soothing injection previously used must now be changed for others of a more stimulating kind, while, when the parts begin to heal, it will be expedient to introduce a large gum-elastic bougie into the vagina, and to allow it to remain for some hours every day, in order to prevent adhesions forming between the opposite surfaces of the vagina by which the orifice of the uterus is sometimes almost completely closed, or the vaginal canal itself is divided into two chambers, into the upper of which the uterus opens. Nor indeed are these the only possible consequences of sloughing of the vagina, but in proportion to the extent of the mischief the vagina is shortened; the edges of any fistula are permanently kept asunder, the space between the opening 442 VESICO-VAGINAL FISTULA. and the neck of the womb is diminished, while the cicatrix tissue on which the operator has to depend for the closure of the aperture is endowed with far feebler vitality than the unaltered structures of which if the mischief has been circumscribed he may hope to avail himself. Supposing all these points to have received due attention, the next question that suggests itself concerns the period after labor at which any operation for the cure of the fistula should be attempted. Now, I believe that nothing should be done within the first three months after delivery at the soonest, for the susceptibility to inflammation is greater in the woman who has recently miscarried or given birth to a child than in another, while not only are all plastic operations about the sexual organs attended by some hazard, but a degree of local inflammation quite inadequate to cause danger to the patient, may yet more than suffice to destroy the promise of the most dexterous operation. Another reason, too, for some delay is that within certain limits a fistulous opening is likely to contract; and it is well to obtain the full amount of improvement which nature can effect before having recourse to any surgical proceeding. Besides this, too, it is of the greatest importance that a person should be in the best possible health before the operation is undertaken, and no delay can be regretted which affords the opportunit} 7 for the amendment of her general condition, and the improvement of the state of her urine. The two generally keep pace with each other, and my own impression is that to operate at a time when the health is feeble, and the urine abounds in phosphatic deposits, is completely to throw away all chance of benefiting our patient. If the aperture in the bladder is comparatively small, so that the urine can be retained for an hour or so, in certain positions of the body, delay may be allowed a month or two longer, provided that the bladder tolerate the frequent introduction of the catheter; an operation which the patient will soon learn to perform for herself. I am not, however, disposed to recommend that a catheter be kept constantly in the bladder; for a few days are generally the utmost limit during which the patient can bear it; the bladder then becoming irritated by its presence, so as to compel the removal of the instrument. Still less would I advocate the use of the plug, or of any mechanical device for restraining the outflow of the urine. All such contrivances irritate, and are likely to interfere with that healthy condition of the parts which it is so essential to maintain. In all instances, therefore, where the aperture is large, and where no urine is retained, delay continued after the effects of the puerperal processes have subsided, answers no useful end; while when waiting for this we must content ourselves with the daily use of the tepid hip-bath, with the injection of warm water into the vagina, and with most sedulous ablution and scrupulous cleanliness, as means of preventing the irritation of the parts by the perpetual escape of the urine. It would be out of my province to go into detail concerning the operation for the closure of vesico-vaginal fistula. Two points only I may just refer to. One concerns the utility of the galvanic cautery, especially in the more chronic fistulas,, in those of small size, or whose 443 FUNGOUS TUMORS OF BLADDER. dimensions have been reduced by other operative proceedings. By its frequent application in one case, my colleague, Mr. Paget, effected a complete cure. The other point has reference to the great merit both of the mode of operating adopted by Dr. Sims, of Alabama, 1 and also of his curved catheter, which often remains in the bladder without any trouble or any adaptation of her posture on the part of the patient, and answers the purpose of preventing all escape of urine by the wound far more effectually than a catheter of the ordinary form. Even this, however, irritates in a few days, and requires withdrawal earlier than is quite satisfactory; an evil which perhaps its construction of some very light material might in some measure obviate. It is not necessary to say much about that rare accident intestinevesical fistula; for the circumstances in which it occurs have no necessary connection with the sexual ailments of women. I have met with it but thrice. In the first case, it was associated with malignant disease of the uterus; and dysuria and .painful defecation had existed for between two and three years, their occurrence being coincident with the appearance of an indurated tumor in the left iliac and inguinal regions; and the escape of fecal matter with the urine had taken place for four months previous to the patient's admission into the hospital. In the second case, the mischief succeeded to ulceration of the intestines during fever nine weeks before, which had issued in the formation of a pouch communicating above with the sigmoid flexure of the colon, and below with both rectum and bladder. This patient died in the course of a few weeks, but less in consequence of the local disease than of the progressive increase of the exhaustion which the fever had occasioned. The third case was that of a young lady in whom suppression of the menses from cold was succeeded by inflammation, which involved among other parts the uterine appendages on the right side, where a distinct tumor formed. This tumor, at first quite solid, afterwards grew softer, and then diminished in size. Its diminution was not attended by any very marked discharge of pus, but about the same time purulent and fecal matter began to appear in the urine, and continued to be intermixed with it for three weeks when she first came under my notice. In this case, as in the other two, the sensitiveness of the bladder was so great that all attempts at syringing it with tepid water were of necessity discontinued; but great relief followed the use of very simple means, such as the employment of the uva ursi, of hydrochloric acid and the pareira, and the administration of opium or morphia, to mitigate suffering and to relieve the irritability of the bladder. In the case of the young lady, too, concerning whom alone was there much room for hopefulness, the fistulous communication became closed in the course of two months, and after the lapse of a year I saw her in perfect health; slightly diminished mobility of the uterus being the only remaining evidence of the serious bygone mischief. 1 American Journal of Med. Sciences, Jan. 1852, and a pamphlet with the title Silver Sutures in Surgery, New York, 1858. His earliest and his latest suggestions present, indeed, many points of difference, but all seem tending to simplify the means of relieving this most grievous infirmity, and to increase the chances of its cure. 444 MALIGNANT DISEASE OF THE BLADDER. I am not aware of having ever met wij;h those soft fungous tumors, or polypoid excrescences from the bladder, whose true relation to malignant disease seems to be still undetermined. It is, indeed, possible that in some of the cases of dysuria which have come under my notice the symptoms may have arisen from this cause; but there is no sign actually pathognomonic of their existence, and though in all obscure cases I am accustomed to have recourse to the microscope for help, I have never yet succeeded by its means in the diagnosis of any outgrowth from the bladder. 1 In one respect, indeed, these growths conform to the same rule as decided malignant disease of the bladder, for while not very common in either sex, they are yet infinitely rarer in the female than in the male. Of eight cases of fungoid disease of the bladder recorded in the Transactions of the Pathological Society, 2 there were but two in which the subject was a female, and in like manner of the seven cases of carcinomatous disease of the bladder on which M. Lebert 3 founds his observations, six occurred in the male subject. In the only case of primary maligndnt disease of the bladder that has ever come under my notice, the patient was a widow woman, sixty-two years of age, who had suffered for a year previously from pain in the region of the bladder, aggravated after passing water, the calls to which became more frequent than natural, while at the same time her urine grew turbid, and deposited a thick sediment. Blood now frequently appeared in her urine, sometimes in small quantities, sometimes in clots, and about three months before I saw her she lost » large quantity at once. She had of late suffered from pain in the back, and for two months the urine had been always thick with a ropy sediment. No treatment had been adopted till three weeks before her admission into the hospital, when the patient applied to a surgeon, who introduced a catheter, an operation followed by considerable hemorrhage, which lasted for several days, though it was eventually suppressed by gallic acid. On being received into the hospital the patient's appearance was healthy, her pulse was 80, and soft, her tongue slightly coated, her bowels were regular. No tumor was perceptible in the abdomen, but firm pressure immediately over the pubes caused some pain. The uterus was high up, small, its tissue soft and perfectly healthy. In front of the uterus, pushing it into the posterior half of the pelvis, was a firm, somewhat irregular growth, reaching from the anterior half of the pelvis in the situation of the bladder, apparently extending round that organ on either side, but much more on the right. This growth was perfectly immovable, it seemed to be connected with the 1 The general opinion, and that adopted by Rokitansky, op. cit., vol. iii. p. 460, is that these outgrowths all belong to the class of malignant diseases. An opposite view is, however, maintained by Mr. Sibley, in Transactions of Path. Society, vol. vii. pp. 256 and 214, based on very careful microscopic observations. Gross, On the Urinary Organs, 2d ed., Philadelphia, 1855, p. 324, in his notice of these outgrowths, assumes their non-malignant character. 2 The two cases in the female subject are reported in vol. v. p. 200, and vol. vii. p. 256 ; the others in vol. ii. pp. 85 and 237 ; vol. iii. pp. 125 and 127 ; vol. v. p. 201, and vol. vi. p. 258. 3 Op. cit., p. 876. MALIGNANT DISEASE OF THE BLADDER. 445 pelvic walls, was somewhat tender on pressure. It was of such size as to occupy the whole anterior half of the pelvic brim, though not dipping down considerably into the pelvic cavity. The urine was pale, alkaline, depositing ropy mucus, and under the microscope crystals of the triple phosphate and cells of nucleated epithelium were perceptible. The patient derived considerable comfort from treatment during ten days' stay in the hospital; but returning home at the end of that time, and indulging in the intemperate habits to which she was addicted, she fell and injured her face, an accident that was followed by fatal erysipelas on the twelfth day after she left the hospital. The uterus and vagina were found on examination after death to be perfectly healthy; but the whole posterior half of the bladder was occupied by a medullary growth, with an irregular surface, which projected into the cavity of the organ, its substance being in part firm, in part almost semi-fluid. The anterior half of the bladder was quite healthy, as also was the substance of both kidneys, except that the right ureter being involved in the diseased mass was dilated to three or four times its natural size, and the infundibulurn of the right kidney was enormously enlarged. As far as it went this patient's history was exactly that of malignant disease of the bladder, and had not her life been prematurely cut short, the affection would no doubt have run its usual course. Hemorrhage would have returned again and again, and would have weakened the patient more and more, the increased growth would have produced increased difficulty in micturition, while the advance of the malignant disease would have been associated with the further development of the cancerous cachexia, till under these combined causes death would at length have taken place in circumstances far more painful than those by which it was actually attended. As in this case, so I believe in most instances of primary malignant disease of the bladder, there is but little tendency to the perforation of its walls and the extension of the disease into the vagina. The constant dribbling away of the urine which sometimes attends the more advanced stages of this disease by no means necessarily indicates the existence of any communication between the bladder and vagina, but is due in many instances partly to the encroachment of the evil on the cavity of the bladder, partly to its walls having been rendered unyielding by disease, and especially to the infiltration of the tissue of the neck of the bladder with carcinomatous deposit. The observation of Kiwisch 1 is also worth repeating here, "that the occurrence of incontinence of urine in the course of cancer of the uterus is not to be regarded as a certain evidence of the occurrence of perforation of the bladder, for this symptom is frequently only the consequence of carcinomatous infiltration of the neck of the bladder, and especially of that part corresponding to the sphincter, by which it is hindered in the performance of its functions, and thus, no'longer closing the ostium vesicas, admits of the constant escape of the urine." 1 Op. cit., vol. iii. p. 308. 446 MALIGNANT DISEASE OF THE BLADDER. Though the diagnosis of fungoid outgrowths from the bladder maybe obscure, yet the ordinary form of malignant disease of the organ appears to be too well marked to leave much room for uncertainty. The causeless pain and difficulty in micturition, coupled with the frequent desire to pass water; the occasional appearance of blood in the urine, sometimes in considerable quantity, and in the form of clots, while the secretion is habitually alkaline, unhealthy, and deposits a sediment, are of themselves strong evidences of the nature of the case, though scarcely conclusive unless associated with a firm, immovable tumor in front of the uterus. In the absence of the evidence obtained by vaginal examination, the extreme rarity of primary cancerous disease of the bladder always renders it the more probable supposition that the kidneys are the seat of the mischief. There is no treatment specially applicable to malignant disease of the bladder. The indications to be followed are very obvious, and within certain limits and for a certain time their fulfilment would not appear to be difficult. To relieve pain by opiates, to render the urine less irritating by the mineral acids, the pareira, and those other remedies to which reference has been made in the earlier part of this lecture, to keep the patient in bed, and thus to equalize as far as possible through the whole twenty-four hours the demands upon the functions of the kidneys, and to maintain the general health of good diet, and by the moderate use of stimulants, are the objects to aim at. When once the nature of the disease has been ascertained, the introduction of instruments into the bladder must be carefully avoided; while if it should become necessary to draw off the urine, an elastic catheter without its stilet must be employed with all possible gentleness. It is, however, I believe but seldom in the female subject that this disease produces actual retention of urine, though I remember a patient many years ago in the Middlesex Hospital in whom the urethra became implicated in the extension of the growth, so that it became eventually necessary to tap the bladder above the pubes, an operation which she survived only a very few clays. 447 DISEASES OF THE URETHRA AND VAGINA. LECTURE XXXII. DISEASES OF THE URETHRA AND VAGINA. Diseases of the Urethra. Congestion of the urethra, most troublesome as a chronic ailment; its symptoms and treatment. Vascular tumors of urethral orifice, their seat, nature, symptoms, and treatment. Ulceration of urethra ; doubts as to its syphilitic nature. Diseases of the Vagina. Acute vaginitis ; character of the discharge which attends it as distinguished from uterine leucorrhoea; its treatment. Chronic vaginitis. Granular vaginitis, its real nature. Cysts of vagina. Fibrous and fibro-cellular tumors of vagina. Cancer of vagina. From the study of the affections of the bladder, -vve pass next by a natural transition to the examination of those incidental to the female urethra, a class of ailments which, though comparatively trivial, are often attended by very serious discomfort, and are by no means easy of cure. Of these ailments, one of by no means unusual occurrence is a state of undue congestion of the urethra, which sometimes presents itself in an acute form, at other times has a chronic character. In the former case, it very generally accompanies a similar condition of the pelvic viscera, and hence is chiefly observed either in newly-married women, or at the commencement of a menstrual period, or is experienced during the first few weeks of pregnancy. It is then attended by a sense of itching and irritation about the urethral orifice, which is redder than natural, slightly swollen, and tender to the touch, while micturition is accompanied by a scalding or cutting sensation, the discomfort of which induces the patient to retain her urine longer than usual. This, however, is a temporary discomfort, lasting for the most part no longer than the cause which produced it, though its frequent recurrence may no doubt issue in the chronic form of the ailment which constitutes an abiding source of annoyance difficult to remove and very apt to recur. This chronic congestion of the urethra comes on with no apparent exciting cause in women who have given birth to many children, the interruption to the free circulation in the pelvic vessels having no doubt produced it, for which reason it also sometimes follows on attacks of uterine inflammation, or of pelvic abscess, or comes on during the growth of an uterine or ovarian tumor. It adds also in other instances to the distress produced by affections of 448 CONGESTION OP URETHRA, THICKENING ITS WALLS. the bladder, or is associated with disease of the kidney, and with morbid states of the urinary secretion. In this form of the disease there is very considerable thickening of the whole canal, which may be traced as a firm cord as thick as the finger, or even thicker, running under the symphysis pubis, somewhat tender upon pressure; while if the nymphaa are separated it may be seen as a large swelling at the upper part of the entrance of the vulva, looking almost like a distinct tumor growing from the anterior vaginal wall. 1 The long standing congestion has here been followed, as it is elsewhere, by overgrowth of the part, by hypertrophy of the cellular tissue of the urethra, and hence, though the swelling may vary in size, and the symptoms which it produces may admit of very great alleviation, yet they never entirely disappear, and very slight causes suffice to reproduce them. These symptoms consist in a sense of fulness and aching, accompanied by frequent desire to pass water, which is scarcely at all relieved by the act of micturition. The erect posture aggravates these discomforts, as do sexual intercourse and the approach of the menstrual period, while relief is obtained by rest and the recumbent posture. The natural tendency of the affection is, as can be readily understood, to grow more and more troublesome under the influence of those causes which first produced it; attacks of an acute kind coming on every now and then, during which the urethra becomes more swollen and more tender, and the pain in micturition extremely severe. In one instance I saw an attack of this kind issue in the occurrence of suppuration in the cellular tissue around the urethra, and on puncturing the abscess quite an ounce of pus escaped; but on all other occasions these attacks have subsided almost spontaneously, and without leading to any such result. There is no other condition with which, as far as I know, this state of the urethra can be confounded. The only caution, therefore, which seems to me necessary as to this point concerns the occasional dependence of this thickened state of the urethra upon the presence of one of those small vascular excrescences of its mucous membrane which, though usuall}' seated at its orifice, are yet sometimes so far within the lips of the canal as to escape a superficial examination. The acute form of urethral congestion is generally so brief in its duration as scarcely to call for treatment. A tepid hip-bath, the temporary discontinuance of sexual intercourse, if the symptoms have succeeded to marriage, the avoidance of all stimulants, mild diluent drinks, and slightly alkaline waters, such as the potass or the Vichy water, generally answer every purpose. In the chronic form of the evil, attended by more or less hypertrophy of the tissue of the urethra, complete rest is an essential, and the avoidance of any cause, such as sexual intercourse, by which congestion about the pelvic viscera can be excited or maintained. Generally, indeed, if the urethral hypertrophy is at all considerable, the act of intercourse is attended by so much discomfort as to lead to its discontinuance. One or two leeches 1 This condition was first described by Sir C. Clarke, Diseases of Women, vol. i. p. 309. VASCULAR EXCRESCENCES FROM THE URETHRA. 449 applied by means of a small glass leech-tube to the urethra itself, and repeated weekly or twice a week for a short time, generally afford very great relief. Frequent cold sponging, and the use of cold astringent lotions, or of cold hip-baths, confirms the improvement which depletion and careful dietetic measures had obtained. I have found, however, that any attempt at the employment of pressure, as suggested by Sir C. Clarke, was attended by more annoyance than advantage, and therefore content myself, as the removal of the hypertrophied tissue cannot be expected, with explaining to the patient the nature of her ailment, and the simple means by which, though she cannot expect a cure, she may always obtain for herself great alleviation. Under the name of Vascular Tumors of the Orifice of the Afeatus Urinarius, Sir C. Clarke described a very painful affection, which, though it had not altogether escaped the observation of previous writers, had yet received comparatively little notice. These tumors are hypertrophied papillae made up of elementary fibro-cellular tissue, covered by a layer of tessellated epithelium, the thickness of which varies much in different instances, and very richly supplied with vessels. 1 They grow from the lower, and often also from the lateral margin of the orifice of the urethra, but they scarcely ever involve the whole of its circumference, or spring from its upper border. Sometimes they are furnished with a pedicle, the bulk of the growth in that case projecting beyond the urethral orifice, but often they are sessile, and then distend its aperture, leaving a narrow passage at the upper part of the urethra, through which the urine flows, though not readily: the obstacle to its outflow occasioning considerable dilatation of the canal behind the excrescence. These growths vary much both in size, in vascularity, and in sensitiveness; but they do not in general exceed the bigness of a currant —are frequently smaller; and I have never seen one larger than a hazelnut, though instances are alleged of their attaining the size of a pigeon's egg, or even a still greater magnitude. Their vascularity and their sensitiveness are generally proportionate to each other; those whose color is most vivid bleeding the most easily, having apparently the most delicate epithelial covering and the most exquisite tenderness. The most vascular of these growths are of a bright cherry-red, while those which are least so are of the same color with the surrounding mucous membrane. Though frequently solitary, yet in many instances two or three separate growths are situated at the edge of the urethra, or just within its orifice; and it is by no means unusual to observe several small excrescences of a similar character, but generally of a much smaller size, springing from different points of the vestibulum. Sometimes, indeed, they are scarcely larger than the head of a blanket pin, but of a vivid red color, and most exquisitely tender. Those growths which occupy the urethra seldom extend above a sixth or a fourth of an inch along its canal, but now and then they reach further, 1 Sir C. Clarke, Diseases of Women, Part I. p. 303. Paget, op. cit., vol. ii. p. 282, note ; Burford Norman, London and Ed. Monthly Journal, June, 1849, which contains an account of their microscopic structure by Mr. Quecket; and again in London Journal of Medicine, Feb. 1852, p.. 146. 29 450 VASCULAR TUMORS OF URETHRA. and cases are related in which almost the whols length of the urethra has been the seat of these excrescences, a condition the more unfortunate since it is almost impossible of cure. The symptoms to which these outgrowths give rise are, pain in micturition, sometimes of extreme severity, though in other cases in which the sensibility of the tumor is lowest, the sensation is one of discomfort rather than of severe suffering. Coupled with this, there is in many instances pain on any attempt at sexual intercourse, and this pain is often aggravated by the presence of the small outgrowths to which reference has been made about the vestibulum. The presence of these growths does not produce a frequent desire to pass water, but, on the contrary, it not infrequently happens that, on account of the pain which attends the effort at micturition, patients acquire the habit of retaining their urine for a longer time than natural. When, however, the long-continuance of the irritation has produced that thickening of the urethra which was spoken of a short time ago, its* characteristic symptoms manifest themselves in a constant sense of weight and aching, and frequent desire to pass water. It is not possible to say on what these outgrowths depend, though they have, in my experience, been much less common in the single than in the married, and in the young than in the middle-aged. Thus of 18 cases of which I have preserved a record, 15 occurred in married women, only 3 in those who were single. Four of the patients were upwards of 50 years old, 4 between 40 and 50, 5 between 30 and 40, 4 between 20 and 30, and one only was under 20 years of age. All the married women, too, with but one exception, had given birth to children, and in the case of some of the patients there was a history of previous vaginitis or gonorrhoea; a circumstance which favors the suggestion of Scanzoni, 1 that in some instances these outgrowths depend on a previous chronic urethritis. There is a condition in some respects allied to this, and productive of some of the same symptoms, in which a tumor occupies and obstructs the orifice of the urethra, formed apparently only by a hypertrophied condition of the otherwise unaltered mucous membrane, a fold of which nearly blocks up the canal, causing it to dilate behind the point of obstruction, and thus renders the act of micturition difficult and painful, though unattended by the acute sensibility which accompanies the genuine vascular tumor. In many instances this hypertrophy of the urethral mucous membrane, is associated with the presence of a number of small outgrowths of mucous membrane, fringing the orifice of the vulva, or growing from the outer edge of the lips of the urethra, and productive of some degree of irritation, and even of inconvenience in sexual intercourse. The treatment of those excrescences, of whatever kind, is abundantly simple, and consists in their complete removal, and in the application to the surface whence they sprang of some strong caustic, or of the actual cautery,-in order to prevent their reproduction, which is otherwise very apt to occur. I am accustomed always to apply the actual 1 Kiwisch, op. cit., vol. iii. p. 298. 451 CHRONIC ULCERATION OF URETHRA. cautery for this purpose, both because it most effectually arrests that flow of blood, which I have known in one or two instances where it was not employed to be so considerable as to excite alarm, and also because it has seemed to me to be more efficient than any form of caustic in preventing the reproduction of the growth. 1 The operation, though of very short duration, is so painful, that very few patients can dispense with the use of chloroform, and its administration is the more needed since it is essential that the patient should remain absolutely quiet lest the urethra should be injured. Care to avoid this accident is, indeed, the only precaution specially called for during the excision of these growths; this, however, is all the more necessary, since injury to the orifice of the urethra has. sometimes been followed by incontinence of urine, or by difficulty in its retention. If after the excision of these growths there should remain any one spot where their removal has not been quite complete, or if, though • no excrescence be present, a state of morbid vascularity of the urethra should continue, such as sometimes precedes or accompanies the formation of these little excrescences, either condition is generally capable of removal by the application twice a day, for two or three weeks, of the undiluted liquor plurnbi. There is a condition of chronic ulceration of the urethra of which I have met with a few instances, and which it may be worth while to refer to here, since, though I believe it to be of syphilitic origin, and therefore to lie, strictly speaking, beyond my province, I yet have found no mention of it in treatises on the venereal disease. The affection has come six times under my observation : twice in married women, who acknowledged to having suffered from venereal disease; and four times in women of unchaste life, one of whom was at the same time suffering from a secondary syphilitic eruption. Tn every instance the patients alleged either that they had been aware of the ulceration of the urethra, or that they had experienced difficult and painful micturition for periods varying from nine months to five years. Twice the disease was associated with an excrescence from the mucous membrane of the urethra, having the characters of the less vascular form of those outgrowths which have just been described. The ulceration appears to commence at the orifice of the urethra, and to extend thence inwards towards the bladder, producing as it extends a great widening of the canal, and a patulous state of its orifice, so that the finger tip can enter it with ease, while the surface is the scat of large, firm, indolent granulations, which secrete a small quantity of a muco-purulent fluid, are not in general very tender to the touch, but highly sensitive to the passage of urine. 1 have met with this ulceration of the urethra independent of any other disease of the sexual organs, but have also observed it in cases where previous ulceration had destroyed the clitoris and the nymphao, and have seen it associated 1 Dr. Medoro, of Padua, recommended some years ago in an Italian journal, whence it was extracted in Schmidt's Jahrbiicher, vol. xxxvii. p. 180', the use of the actual cautery, without previous excision for the removal of these growths. I have not tried it in this manner, but as an adjunct to excision I believe it to be most desirable. 452 CHRONIC ULCERATION OF URETHRA. —ITS TREATMENT. with unhealthy ulceration about the posterior commissure of the labia and the entrance of the vulva; as also with those small condylomatous growths about the vulva in cases of vascular tumor of the urethra, and these latter, indeed, are more commonly present than absent. When the disease has advanced far, or has been of long standing, the cellular tissue beneath the urethra usually becomes considerably thickened, and I have seen the lower wall of the urethra represented by a dense, cartilaginous substance, not unlike one of the lips of a hypertrophied, and partially procident cervix uteri; while on two occasions I have been able to carry my finger along the whole length of the canal into the bladder. Even when not very far advanced this disease causes difficulty in the retention, or actual incontinence of urine, while, when it has extended along the whole canal, and left its aperture permanently patulous, the patient becomes almost completely unable to retain her urine at all. One such case I saw in a young woman, aged 22, in whom*there was not the least power to hold the urine: an infirmity that she said had existed many months. I gave her an elastic pessary to wear, which, by pressing against and mechanically closing the urethra, rendered her more comfortable. Once, also, I saw a prostitute whose ulcerated urethra was so widely open that two fingers could be passed into the bladder with ease. She was constantly soaked with urine; but in spite of her loathsome condition still plied her trade, and no argument could induce her to abandon it. Whether these cases are truly syphilitic, or whether they deserve more properly to be classed with the rodent ulcer, or lupus exedens, I am at present unprepared to say. On the one hand their directly syphilitic origin may appear to be rendered doubtful by the circumstance that in only one instance was there any evidence of then existing venereal taint; while on the other hand the affection of the urethra differs from the other forms of rodent ulcer, lupus, or esthiomene, in being unattended by the same disposition to great thickening of the adjacent tissues, which, in the case of lupus of the vulva, approximates the affection at a first glance very closely to elephantiasis. In its less severe forms I have seen this condition greatly improve, the pain in passing water diminish, and the ulcerations cicatrize under the use twice a day of a lotion composed of 3j of oxide of zinc suspended by means of half an ounce of mucilage in an ounce of water, and injected into the urethra, while the surface was shielded from the irritation of the urine by the abundant application to it of the zinc ointment. At the same time the continued employment of the iodide of potass and syrup of iodide of iron have seemed to exercise a beneficial influence on the patient's general health, which in every instance has appeared to be indifferent. For the most part, however, these measures seldom prove more than palliatives; but in one case of very long standing, when other means had completely failed, the repetition three or four times of the actual cautery was of the most signal benefit. It was of course applied but lightly, so as not to destroy the tissues to any depth; and under its use the large granulations by degrees disappeared, leaving a healthy surface behind; the pain in ACUTE INFLAMMATION OF THE VAGINA. 453 micturition subsided ; the wide urethra contracted its dimensions; and the patient regained the power of holding her urine. I am not prepared, however, to say how far in this instance the amendment was lasting, or how far the most extreme cases would be amenable to the same treatment. As we approach the end of these lectures, the interest which I would fain persuade myself attached in some degree to the subjects that were brought before your notice diminishes, I fear, at almost every step. We have come now to the study of ailments purely local in their character, often indeed painful, always annoying, sometimes dangerous, but which yet afford small matter for investigation, and seems to yield little scope for the exercise of the higher qualities of the practitioner of medicine. But an observation which I made some years ago, when addressing the seniors of our profession, may perhaps be repeated without apology to those who are but beginning the exercise of medicine, and on whom it cannot be too deeply impressed that "the thousand smaller ills to which mankind is subject bring, in their frequent repetition, as much suffering, cause as much sorrow, and therefore are as worthy of our heartiest labor to understand, and of our best efforts to relieve, as those perilous visitants—inflammations, fevers, apoplexies, which threaten life only at long intervals, or on rare occasions.'" With this preface let us now pass to the study of the diseases of the vagina, and of the external organs of generation. And first among the ailments of the vagina we may notice, as we have done in the case of other organs, those affections which are the result of inflammation either in an acute or in a chronic form. The acute form of inflammation of the vagina, apart from those cases in which it occurs in the puerperal state, is probably oftenest due to impure sexual intercourse. Between gonorrhoea, however, and acute vaginitis dependent on any other cause, there does not seem to be any certain distinction furnished either by the character of the symptoms or by their severity, while a similar treatment is applicable to both. When dependent on the contagion of gonorrhoea, the symptoms generally commence within three days after the suspected intercourse; but vaginitis may be equally excited by exposure to cold or wet, and especially by getting wet-footed ; by local irritation of the sexual organs, by intemperate or unaccustomed sexual intercourse, and to this latter cause attacks of moderately severe vaginitis are not very rarely due in newly-married women. A disagreeable sense of fulness, heat and tenderness about the vulva, with frequent desire to pass water, and pain and scalding in the act of micturition, are the symptoms with which it sets in. Sometimes there is associated with these discomforts great swelling of the labia, which are so tender that the sitting posture can scarcely be borne, while a feeling of aching and weight extends along the perineum, and considerable tenderness of the hypogastrium announces that the bladder has become involved by the advance of the inflammation. For 1 Crooniau Lectures, 8vo., London, 1854, p. 04. 454 ACUTE VAGINITIS. the first twenty-four hours the customary secretion is suppressed; but a discharge then begins to be poured out in great abundance; yellow, acrid, purulent, occasionally streaked with blood, always of an offensive smell. This discharge is chiefly furnished from the lower extremity of the vagina, though the inner surface of the nymphaa, and the parts about the vestibulum also contribute to it, and sometimes the inflammation extends along the vaginal canal, the whole of which may then pour out the discharge. In a few instances the mischief extends even further; I have seen internal metritis supervene upon inflammation of the vagina, and two successive attacks of vaginitis, after an interval of eighteen months, were followed in the same patient by such severe peritonitis as to call on each occasion for the abstraction of blood. These, however, are purely exceptional occurrences; and in most instances the affection remains limited to the vulva and the lower part of the vagina. If the parts are examined during the acute stage of the affection, they appear of a bright red color, shining, and swollen, while if the finger is introduced into the vagina, the heat of the parts will be found to be greatly increased. The introduction of the finger even is almost always excessively painful, and the tenderness is so great as to render the employment of the speculum quite impossible. During the severity of the onset of the disease, an abscess sometimes forms in one or other labium, usually, if not invariably, having its seat in Cowper's gland ; but, supposing this not to be the case, the swelling and tenderness generally abate in four or five days, the discharge loses its acrid character and offensive odor, and except that its quantity is excessive, differs little from the muco purulent secretion which constitutes ordinary leucorrhoea. These changes in the character of the discharge appear to depend on the more or less abundant presence of pus-globules, and of the tessellated epithelium of the vagina; desquamation of which takes place so very abundantly in vaginal leucorrhoea that it furnishes us, as Dr. Tyler Smith 1 has shown, with a very valuable means of determining the source of the discharge from which a patient suffers. To a very great extent also similar information may be gathered from the discovery in the discharge of a small infusorial animalcule first described by M. Donne', and once supposed by him to be pathognomonic of gonorrhceal, as distinguished from simple vaginitis. He soon, however, found cause to renounce this opinion, though he still alleges that the Trichomonas is never observed in healthy vaginal mucus, but only in the secretion when containing a large admixture of pus-globules. This latter statement, too, is confirmed by the researches of Kolliker and Scanzoni, 2 who further add the remark that while never present in the cervical mucus, and by that circumstance plainly demonstrated to be something more than a mere cell of ciliary epithelium, as has been sometimes imagined, the Trichomonas 1 On Leucorrhoea, etc., chap. iv. pp. 51—79. a See with reference to these points, the very elaborate investigations of Kolliker and Scanzoni, on the secretion of the mucous membrane of the vagina and cervix uteri, in Seanzoni's Beitriige, etc., vol. ii., Wurzburg, 1855, pp. 128—146. CHRONIC VAGINITIS. 455 is on the one hand not constantly present in vaginal leucorrhoea, and on the other the existence of the disease in a grave form is by no means essential to its development, since it is found in some persons in apparent health, and in whom the admixture of pus-globules with the discharge though evident is yet not very considerable. It may perhaps be added, that as the microscope fails to furnish us with a means of distinguishing between gonorrheal and simple vaginitis, so no symptom or combination of symptoms is absolutely conclusive on this point. The amount of affection of the urethra certainly strengthens the suspicion of the gonorrhoea! origin of the disease; but urethral inflammation and discharge are sometimes present in cases where no suspicion of gonorrhoea can for a moment be entered, and, according to M. Rioord, are likewise absent in cases avowedly due to impure intercourse, about once in every three times. It is comparatively seldom, at any rate in private practice, that vaginitis or vaginal leucorrhoea comes under our notice in its acute stage. If it does, the employment of tepid hip-baths, of tepid vaginal injections, rest, and mild laxatives, usually suffice to afford relief, while as the inflammatory symptoms subside injections of cold water, of the diluted liquor plumbi, of solutions of sulphate of zinc, or of alum, will restrain, and in a week or two put a stop to the profuse discharge which for a season remains behind. Now and then, however, if the pain is very severe, the tenderness great, and the swelling of the labia considerable, it is expedient to apply eight or a dozen leeches to the vulva, to encourage the bleeding by a warm hip-bath, and a warm bread-and water poultice, and afterwards to keep warm fomentations of two parts of the decoction of poppy and one part of the diluted lead lotion constantly applied to the vulva. These measures will, in most cases, within less than twenty-four hours, reduce a state of previously intense suffering to one of very bearable discomfort. Sometimes, however, the difficulty and pain in passing water continue very distressing, and in that case the extract and decoction of uva ursi with small doses of liquor potassas and of the tincture of henbane seldom fail to afford very speedy and very marked relief. I am disposed to think, indeed, from my hospital experience, that the complication of vaginitis with some degree of inflammation of the bladder often fails to receive that degree of attention which it merits; for it has happened to me not infrequently to meet with patients in whom very distressing dysuria, the evident result of chronic cystitis was referred back to some acute attack pf leucorrhoea or gonorrhoea which had occurred months before. But it is, as I have stated, a more chronic form of ailment with which we oftener have to do, and this not only in cases where a leucorrhceal discharge has been left behind after the subsidence of the acute attack, but in a large number of instances where the ailment has been chronic from the outset. Such are many of the cases of leucorrhcea that occur in women exhausted by frequent child-bearing, or by prolonged lactation, or by menorrhagia. Such, too, are the instances in which leucorrhoea accompanies chlorosis, and of the same kind are those abundant 456 TREATMENT OF VAGINAL LEUCORRHCEA. discharges from the sexual organs which take place in strumous children, and which, sometimes assuming a subacute character, and being associated with much swelling of the external parts, have been erroneously supposed to be due to criminal attempts at intercourse. I may just add, however, that the discharge in the case of the child takes place almost entirely from the parts in front of the hymen, and is the result, therefore, rather of vulvitis than of vaginitis. Any condition which maintains or is dependent on habitual venous congestion of the abdominal viscera is apt to be associated with vaginal leucorrhoea. Hence the discharge is often observed not only in women who suffer from ovarian or other abdominal tumors, but also in patients liable to disorders of the liver, or to heemorrhoidal affections, or who suffer from habitual constipation. Uterine tumors, and uterine misplacements are, as it is almost needless to observe, apt to be associated with vaginal leucorrhoea, while even in those cases in which the larger proportion of the discharge is poured out from the interior of the uterus, there is almost invariably a large admixture of secretion furnished from the walls of the vagina. It is obvious that the chances of cure of this chronic vaginal leucorrhoea depend entirely on the uncomplicated character of the ailment, or on the diseases with which it is associated being of a kind to admit of removal. Thus, the leucorrhoea attendant on uterine tumors, while in itself it need not excite any solicitude, yet scarcely admits of cure, its restraint by astringent lotions being all that can be attempted. For the same reason, too, those vaginal discharges which are associated with abdominal tumors do not admit of cure, while in those instances in which they accompany hepatic disorder or abdominal congestion, as is not infrequently the case in women after the middle period of life, and in whom menstruation has ceased, the cure of the local ailment depends on the removal of the constitutional disorder. The leucorrhoea of the feeble and chlorotic obviously needs a tonic plan of treatment, and the administration of chalybeates, in addition to the employment of local remedies, while in the case of children it is always necessary to ascertain that the discharge from the vulva is not produced by the irritation of ascarides in the rectum. But, not to dwell upon points which are almost self-evident, I must just notice some of the more useful astringent applications; for to these local means we must chiefly trust, since they are no internal remedies that exercise a direct influence on vaginal discharges in the same way as cubebs and copaiba restrain uterine leucorrhoea. First among these means stands the abundant use of cold water, either for ablution, for vaginal injection, or in the form of the hip-bath ; for simple though it is, and therefore often too little had recourse to, it is not only very efficacious, but in many instances suffices of itself to arrest the discharge, and, if continued, to prevent its return. The water may be rendered more astringent by the addition of about a quarter of an ounce of alum to each pint of water used for injection, or by mixing half a pound of alum with the water used for the hip-bath, and which should be employed either on rising from bed, or at any rate during the morning hours, not just before going to rest at night 457 GRANULAR VAGINITIS. The alum both has the advantage of being one of the best astringents, and also of being one of those remedies with which a patient can always supply herself without the intervention of the chemist. If, however, it should fail, as all local applications, if long continued, are in turn apt to do, a more powerful injection may be obtained by the addition of a drachm of tannin to each two drachms of the alum, or by dissolving the alum in decoction of oak-bark instead of in water. Both of these lotions, however, have the disadvantage of staining the linen almost as indelibly as the nitrate of silver, though not of so dark a color. The lead lotion of various strengths, and lotions of sulphate of zinc, either alone, or in combination with alum, may also be employed if other means fail, but failures very often depend on the inefficient use of the injection rather than on any fault in the remedy itself, and it is therefore always of importance to ascertain that the patient employs a syringe of sufficient size, and that she uses the injection when in a recumbent and not in a sitting posture. It is also always desirable that cold water should be injected into the vagina so as to remove the discharge as much as possible before the medicated injection is employed. I have no personal experience of the use of nitrate of silver in solution or in substance in cases of chronic leucorrhoea. There can be no doubt, however, but that in instances of very obstinate discharge after acute gonorrhceal vaginitis, the remedy has proved of great service. 1 For very obstinate cases of vaginal leucorrhoea a plan of Seanzoni's will probably be found successful. 2 He introduces into the vagina a plug of cotton wool, the outer surface of which has been bestrewn with alum in powder; or if there be much sensitiveness of the parts, with a mixture of one part of alum and one or two parts of loaf-sugar. This plug should not be allowed to remain longer than twelve hours at a time, nor should its introduction be repeated oftener than every second or third day, injections of tepid water being employed in the intervals. The chief drawback from the adoption of this plan seems to be that unless carefully watched a very troublesome vaginitis may be induced by the remedy, which in that case may aggravate instead of arresting the discharge. For the majority of cases even of very chronic leucorrhoea, a safer, and at the same time a very efficacious mode of keeping the astringent in constant contact with the vaginal walls is furnished by the use of the alum or tannin pessaries of Dr. Simpson. 3 Attention was specially drawn some few years ago by M. Deville, of Paris, 4 to what he believed to be a previously unnoticed form of inflammation of the vagina, and to which, from its anatomical peculiarities, he applied the name of granular vaginitis. These peculiari- 1 Acton, on the Generative Organs, etc., p. 287. 2 Op. cit., p. 287. 3 Ed. Monthly Journal, June, 1848, and Obstetric Works, p !)8. Formulas are given there for various kinds of pessaries. The alum and tannin are made as follows : ty. —Tanninse 9ij ; Cerse albse 9v; Axungiae 3vi. Misce, et divide in Pessos quatuor. R. —Alum, sulph. 3j; Pulv. catechu 3j; Cera) flavse 3j ; Axungiae -jVss. Misce, et divide in Pessos quatuor. 4 Archives de Medecine, 1844, Quatrieme Serie, tome v. pp. 305,417. 458 CYSTS OF THE VAGINA. ties consist in the presence of numerous round, shot-like bodies, of a more vivid red color than the adjacent tissues, in the depressions between the rugae of the vagina, and especially abundant towards the upper part of the canal. These bodies were imagined to be the hypertrophied follicles of the mucous membrane, and were supposed to bear a large share in secreting the abundant thick yellow discharge which was poured out from the vagina. The affection was further observed to be connected very closely with the pregnant state, while it scarcely ever occurred in women who had not at some comparatively recent period given birth to children. The researches of minute anatomists, and especially those of M. Mandt, 1 have shown, however, that the vagina is singularly destitute of mucous follicles, and that those bodies are nothing else than hypertrophied papillae. This discovery, while it explains the association of granular vaginitis with the pregnant condition, at once deprives it of all claim to be regarded as a peculiar disease. It is nothing else than vaginitis, associated with hypertrophy of the vaginal papillae; a physiological condition in pregnancy; one which, independent of that state, may follow or accompany long-continued inflammation, irritation, or discharge. On two occasions I have met with cysts projecting into the vagina. In one instance their presence gave rise to no inconvenience, and the patient, who died of fecal abscess, was not aware of their existence, though they were so low down as partially to protrude through the vulva. Two, which were of the size of a chestnut, were connected with the posterior vaginal wall, and were so firm as to convey the impression of being solid fibrous growths. The anterior cyst was smaller, softer, and felt like a small vaginal cystocele. The surface of all three was of the same color with that of the adjacent vaginal wall. After death, these cysts were found to have firm, thick, fibrous walls, to be lined by a polished membrane, and to contain a perfectly clear, glairy, yellowish, and rather viscid fluid, not unlike synovia; the anterior cyst differing from the others only in its walls being rather thinner. Similar in kind to this was a cyst described by Scanzoni, 2 which had slowly developed itself till it had attained the size of a pigeon's egg. It had probably been many years in course of development, for the patient had long experienced pain in sexual intercourse, referred to the situation of the cyst, and this pain at last became so severe as to render the act impracticable. The tumor was seated at the right side and anterior part of the vagina; it was very sensitive, tense, but yet yielded a sense of fluctuation. The mucous membrane covering it and in its immediate neighborhood was very red, and there was abundant secretion from the vagina. The cyst was opened, and an ounce of transparent serous fluid was let out from its interior, which was felt to be lined by a smooth membrane. Injections of a solution of nitrate of silver were made into the cyst for fourteen days, in order to prevent any re-collection of the fluid, and apparently with good 1 Zeitschrift f. Rationelle Medizin, 1849, .vol. vii. p. 1. 2 Op. cit., p. 470. 459 CYSTS OF THE VAGINA. effect; for six months afterwards no trace of the tumor could be detected. Almost identical with this was the history of the patient in my second case. She was a married woman, aged thirty-three, who for some seven years had been aware of the presence of a swelling about the size of an egg, which, though not painful, was yet the cause of inconvenience in sexual intercourse, while besides she had more or less aching about the vulva, and for six months had suffered from frequent desire to pass water and from pain in micturition. The situation and appearance of the swelling were such as immediately to suggest the suspicion that it was a procident bladder, and it was only after the introduction of a catheter that this was ascertained not to be the case. It was of the size of an egg, projecting between the labia, and its surface from exposure had assumed much of the character of ordinary integument. It was elastic, evidently containing fluid, was situated at the upper part and rather to the right side of the vulva, springing from the under surface of the right nympha, and sufficiently movable to allow of its being pushed back entirely within the vagina. On puncture nearly an ounce of glairy fluid was evacuated, and the cavity was afterwards injected with equal parts of tincture of iodine and water. The previous uncomfortable sensations were greatly relieved by the proceeding, and for a time at least the tumor was got rid of; but I do not know whether the fluid re-collected. The only point of special moment connected with these cysts regards the distinction between them and those cases in which the vaginal wall itself is prolapsed, constituting a rectocele or a cystocele ; either of which conditions, when of long standing, is associated with thickening of the vaginal wall, and may on a superficial examination be mistaken for a cyst in these situations. The complete disappearance of the tumor formed by the prolapsed vagina under pressure, and its increase upon any effort at straining, coupled with the results of the introduction of the catheter, are simple and conclusive means of distinguishing between a swelling produced by mere vaginal prolapse and one dependent on the presence of a cyst in its walls. These cysts appear to have their origin in the substance of the muscular coat of the vagina; but M. Huguier, 1 to whom we owe an elaborate essay on this subject, speaks also of small superficial submucous cysts, seated quite low in the vagina, especially around the urethra, or at the lower part of the anterior vaginal wall. These cysts, which seldom exceed the size of a large pea, and are often smaller, appear to be merely obstructed mucous follicles, since their walls are always thin, and so transparent that their contents are visible through them. These cysts, with which I confess that I am not familiar, though Huguier speaks of them as being more frequent than the others, seem to produce no symptoms, but to burst spontaneously, or to give way during sexual intercourse, and are therefore of less importance even than the others. My knowledge of fibrous tumors of the vagina is equally fragmentary, and indeed I believe them to be still rarer than cysts connected with 1 Memoires de la Societe de Chirurgie de Paris, vol. i., 4to., 1847, pp. 326—394. 460 FIBROUS TUMORS OF THE VAGINA. its walls. In the only instance that I have met with, the tumor, which was spherical in form did not exceed the size of a cob-nut, gave rise to no symptoms, and remained quite stationary for more than two years, during which period the patient was under my observation. Sometimes, however, tumors having this origin acquire a very considerable size; and the late Professor Kiwisch 1 quotes from a German journal the history of a case in which a tumor weighing more than ten pounds sprang by a pedicle of two fingers' breadth from the posterior vaginal wall, two inches from the orifice of the canal. Tumors of this large size, however, are possibly fibro-cellular, rather than strictly speaking fibrous growths, and spring originally not from the substance of the vaginal wall so much as from the cellular tissue around it, but naturally grow as they increase in size, in that direction where they encounter the least resistance, and thus come at last to assume the appearance of pedunculated tumors of the vagina. Such is probably the nature, and will most likely be the progress, of a tumor in a patient who was under my care in June, 1857, in St. Bartholomew's Hospital. She was 33 years old, had been married eight years, and a year after marriage had given birth to her only child. She professed to have suffered habitually from some degree of dysuria, which had been aggravated after marriage; but in August, 1856, had suddenly become so much worse, after suppression of the catamenia, from catching cold, that the use of the catheter became necessary, and had at intervals been required since. Her urine on admission was turbid and mixed with blood, but general health was good, and the dysuria almost disappeared under the influence of rest and very simple treatment in the hospital. The cause of her symptoms seemed to be a tumor, about three fingers broad, somewhat oval in form, but with its larger end towards the uterus, and which lay in the direction of the urethra. This tumor was firm, but with some degree of elasticity; its surface was smooth, and it was not tender on pressure. Behind it, and driven quite into the posterior part of the pelvis, was the healthy uterus, which had no connection with it whatever. The introduction of the catheter was attended by some difficulty, and the instrument in entering the bladder passed much to the left side. Now, supposing this tumor to increase, as it doubtless will, it is in the direction of the vagina that it will encounter the least resistance; thither it will therefore grow; and there it will probably, in course of time, present itself as a polypoid tumor. Such, doubtless, was the history of the growth of a tumor which Mr. Paget 3 has described, and which I had the opportunity of seeing with him. It sprang originally from the right side of the vagina, and the patient had been aware of its existence for between three and four years, though she had sought for medical advice on account of it only within the previous twelvemonth. One physician whom she consulted took it for an abscess, and punctured it; another recommended the employment of some support. It had not protruded beyond the external parts till some ten days before its removal by Mr. Paget, at which time it hung beyond the vulva as a mass five inches in diameter, 1 Op. cit., vol. ii. p. 5G'0. 2 Op. cit., vol. ii. p. 115. 461 MALIGNANT DISEASE OF THE VAGINA. of a somewhat pyriform shape, connected by a pedicle an inch and a half long and of the same thickness, with the right wall of the vagina, and the tissues beneath, just behind the right nympha, which was as it were arched over the upper part and right side of the neck or pedicle of the tumor. Its removal was accomplished with very little loss of blood ; and the pedicle was found to pass by the outer wall of the vagina, in the loose tissue between it and the ramus of the pubes, and reached nearly two-thirds of the way to the uterus. The characters of the tumor, as minutely described in Mr. Paget's own notes, with a copy of which he favored me, were just those of the fibro-cellular outgrowth which is apt in all situations to attain a size such as the firm fibrous tumor less often reaches, and is always much slower in acquiring. The subject of malignant disease of the vagina has been, already in a measure anticipated in the remarks made upon uterine cancer. I am, however, inclined to think that the rarity of primitive cancer of the vagina has been to some degree exaggerated; and although the main features of the disease are the same as when it takes its point of departure from the womb itself, there are yet some reasons on account of which it deserves a separate notice. Cancerous disease of the vagina, consequent on similar affection of the uterus, begins for obvious reasons at the upper part of the vaginal canal, and travels thence downwards, involving in general the anterior more than the posterior wall. Primitive cancer of the vagina does not show the same predilection for the anterior wall; nor does it in general seem to begin at one spot, and thence extend; but, for the most part, cancerous infiltration takes place into the whole of one, or more often of both walls of the vagina simultaneously; and is at least as obvious near the vulva as in the neighborhood of the uterus. To this rule, which obtains in all instances of fungoid cancer of the vagina (and they are by far the more numerous, since to that class may be referred 1(3 out of 13 cases of which I have a record), the epithelial variety of the disease forms an exception; for in that the mischief seems to begin at one circumscribed spot, not in the vicinity of the uterus, and, as far as my experience goes, in the posterior wall; and to extend to the subjacent tissues and to pass into the state of ulceration, while as yet the womb is quite unaffected, and apparently healthy tissue is to be found both above and below the seat of mischief. The following statements embody the chief results whieh are deducible from the cases to which I have referred. In 10 instances the disease was fungoid ; in 3 epithelial. In 1 case only the disease, which was fungoid, was limited to the anterior wall. In 4 cases, of which 1 was fungoid and 3 were epithelial, the disease was limited to the posterior wall. In the fungoid case the posterior uterine lip was also affected; in the epithelial, the uterus was free, though in one instance the os uteri began to be red, spongy, abraded, and bleeding, yet I think not cancerous. In 8 cases, all of which were instances of fungoid disease, both vaginal walls were involved. In one, however, the anterior wall was chiefly affected. 462 MALIGNANT DISEASE OF THE VAGINA. In 2 of these cases the contraction of the vagina prevented the uterus from being reached. In 1 case there was an outgrowth from the interior of the uterus, and in 1 a granular state of the anterior lip, the nature of which was doubtful. Or, in other words, in 6 cases the uterus was perfectly healthy; in 2 it could not be reached; in 2 the affection of the uterus was slight, and its nature not quite certain; in 3 it was the seat of decided cancerous disease; which consisted once in an outgrowth from its interior, and twice in affection of its posterior lip. With reference to the circumstances whieh favor its occurrence, cancer of the vagina seems to conform to the same rules as influence the development of uterine cancer; except, perhaps, that it appears to come on at a later period of life than cancer of the womb; for only 5 of the 13 cases were observed between the ages of 35 and 50; and the remaining 8 between the ages of 50 and 66. As with cancer of the womb, so also with that of the vagina, marriage and child-bearing apparently favor its production; for only 1 of the 13 patients was unmarried; while the remaining 12 had been pregnant 71 times, and had given birth to 64 children; or, in other words, there were nearly 6 pregnancies, and 5.4 labors at the full period to each marriage. Beyond the evidence furnished by these data of the general conformity of vaginal cancer to the same laws as govern the development of cancer of the uterus itself, I do not know that the conclusions are of much moment. The same similarity, however, between the two forms of disease, obtains also between its symptoms whichever be the situation that it occupies, and the duration of the affection appears to be about the same in both instances. The early symptoms very closely resemble, as this table shows, those which attend the commencement of uterine cancer. The first symptom was pain in 8 cases. " " hemorrhage without pain u 3 " M u II W itH « M 4 " " " pain and discharge " 1 case. " " discharge without pain " 2 cases. 13 Pain seems to be rather more frequent as an early symptom than when the disease begins in the uterus ; and pain referred to the'back, increased by defecation or micturition, is also of very common occurrence throughout the disease. The pain seems of a more abiding kind than that of uterine cancer, though in a large proportion of instances the severe paroxysms of suffering, due no doubt in great measure to uterine action being excited by the advance of disease in the womb, are absent. The reason for this is furnished by the fact that vaginal cancer may run its course to its fatal issue without the womb being at all implicated, though there is unquestionably a general disposition both to the extension of mischief by contiguity to the 463 CANCER OF THE VAGINA. uterus, and also to the occurrence of secondary though independent affection of that organ. Perforation of the rectum or of the bladder is not of such frequent occurrence in this disease as might beforehand be anticipated, though the action both of the bowels and of the bladder is commonly more or less difficult and painful, and the affection of the urethra which sometimes takes place in fungoid cancer of the anterior vaginal wall may render the evacuation of the bladder not only difficult but impossible. The practical conclusions to be drawn with reference to this form of disease are somewhat of the following kind. That it occurs, though less often, yet in the same circumstances as uterine cancer, showing the same predilection for the married over the unmarried, and for those who have been frequently pregnant over the sterile. Its general symptoms seem also to be similar, except that mere painless hemorrhage is somewhat rarer than in uterine cancer, a circumstance for which the seat of the disease in vaginal cancer probably affords a sufficient explanation. The progress of the disease appears in both instances to be analogous; the cancerous cachexia is developed in the one case as in the other, the advance of the evil is equally rapid, and the disposition to secondary deposits at least as decided in fungoid disease of the vagina as in fungoid disease of the womb. There is but little to observe with reference to treatment, except that the topical palliatives which are of use in uterine cancer are obviously of more difficult application when the disease is seated in the vagina. The only gleam of Ijope that brightens the case of a patient with malignant disease of the vagina is afforded in those instances where the affection is of the epithelial kind. The similarity of structure between the vagina, vulva, and external parts shows itself, as has been so well pointed out by M. Huguier, 1 in the similarity of the diseases by which they are attacked. There is, therefore, some hope that ulcerated growths of the epithelial kind about the vagina may be found to belong to the class of lupus, or rodent ulcer, rather than to the more utterly hopeless category of diseases which are intimately allied with cancer, and that local treatment may not be so thoroughly fruitless as experience has too amply proved it to be in the case of malignant disease of the womb. But hope even derived from this source is, I fear, but too often doomed to be illusive; for, on the one hand, the position of the disease not only renders surgical interference extremely difficult, but in all the cases which have come under my notice the mischief had extended too deep into the submucous tissue for it to be possible to dissect off the diseased structure from the subjacent tissues. On the other hand, the pain attendant on the introduction of the speculum generally renders any attempt at the continuance of local treatment abortive. Some time since a case was under my care that seemed favorable for local treatment. A long strip of raised, red, large granulations extended for nearly an inch in breadth and two in length along the left and posterior wall of the 1 Memoires de l'Academie de Medecine, vol. xiv., 1849, p. 500. 464 DISEASES OF EXTERNAL ORGANS OF GENERATION. vagina up to its roof, but leaving some quarter of an inch of healthy tissue between it and the neck of the womb. Mr. Paget, who was good enough to see the patient with me, was in hopes, from the absence of thickening about the parts, that the disease might be classed rather with rodent ulcer than with true carcinoma, and accordingly we determined to apply the nitrate of mercury to the affected surface. The results of this proceeding were for a time most encouraging, and though the introduction of the speculum caused pain which lasted for many hours, yet the patient gladly submitted to a plan of treatment, the benefits of which she experienced in the diminution of the previously profuse, offensive, blood-stained discharge, in the mitigation of the backache, and the improvement of her general health. Three or four applications of the acid produced the complete cicatrization of all but just that part of the disease which affected the roof of the vagina. In that situation, however, the application of the caustic was extremely difficult, and there the mischief spread. Deposits took place, thickening the vaginal wall, the granulations grew larger, bled more readily, and extended close up to the side of the cervix uteri, between which and the diseased structures an interval no longer existed; and thus treatment was baffled, hope was lost, and we were driven once more to recognize the very narrow limits that circumscribe our power to heal. The patient left the hospital, and died painfully a few months afterwards; and I do not know that her life could be said to have been prolonged by the local treatment, though unquestionably it was for a short time brightened by a hope which, though illusive, yet cheated her.only of some suffering and some sorrow. LECTURE XXXIII. DISEASES OF THE EXTERNAL ORGANS OF GENERATION Inflammatory affections. Inflammation of the labia, its connection with obliteration of duct of Cowper's gland ; description of the gland ; mode in which inflammation occurs in it. Furuncular inflammation. Eczema. Prurigo, its rarity. Pruritis generally independent of it; causes and treatment of pruritus. Inflammation of Follicles of Vulva. Ulcerative affections. Tertiary Syphilis, difficulties of its diagnosis. Lupus ; its characters, its relation to epithelial cancer. Case in illustration. Treatment. Malignant Disease, generally assumes form of Epithelial Cancer, its symptoms and course. Importance of early removal. The arbitrary line of demarcation which in this country separates the province of the physician from that of the surgeon, has limited my experience both in private and in hospital practice with reference to INFLAMMATION OF COWPER'S GLAND. 465 the diseases of the external organs of generation. If, indeed, we leave out of consideration such as are the result of syphilitic infection, the remainder of these ailments are by no means of frequent occurrence, nor in general of very great importance. Of inflammation of the labia, nymphoz, and external organs, except as an accompaniment of vaginitis, I have seen almost nothing, and of the unhealthy erysipelatous inflammation of those parts, which, occurring in the child, is apt to pass into a state of sloughing, I have seen very little. Indeed, notwithstanding that for nearly twenty years I have been connected with large institutions for the diseases of children, I have met with but three or four instances of its occurrence, and only one of diphtheritic inflammation of the labia and nymphas. The circumstances in which either of these affections occurs do not seem to be as commonly met with in this country as in some parts of the continent ; while they both appear to belong to the class of blood diseases rather than to be purely local ailments such as come more strictly within the scope of these lectures. The inflammation of the labia attendant on vaginitis, more particularly on that form of it which is dependent on gonorrhoea, sometimes extends to the cellular tissue on one or other side, and ends in the formation of abscess. For the most part, however, abscesses in the labia are not the result of diffuse inflammation, but of inflammation seated in one of those glands which are known by the name of Duverney's, Bartholin's, or Cowper's glands. 1 They are situated one on either side of the entrance of the vagina, in that triangular space bounded by the orifice of the vagina on the one side, the ascending ramus of the ischium on the other, and the transversalis perineal muscle on the third, and are covered by the superficial perineal fascia, and by some fibres of the constrictor vaginas. They are small conglomerate glands, of about the size of a bean, and open by a narrow duct some seven or eight lines in length just in front of the hymen, or of the carunculas myrtiformes, and secrete that albuminous fluid which is poured out abundantly in sexual intercourse. It happens sometimes that the duct of this gland on one or the other side becomes obliterated, and that the secretion then accumulates within it, causing it to form a small swelling of the size of a marble, a cob-nut, or somewhat larger, which projects at the lower part, and towards the inner surface of the labium. It may remain for some time in this condition producing little inconvenience, but in general 1 Like some old discoveries, so that of the existence of these glands, first found by Duverney in the cow, and afterwards by Bartholin in the human female, became forgotten after Haller had sought for them in vain. Mr. Guthrie, in his work on Diseases of the Bladder, refers to them, though without giving any exact description of their form or relations; but it is to the venerable Tiedemann, of Heidelberg, that we owe our present accurate acquaintance with them. His essay, Von den Duverneyschen Driisen, etc., was published at Heidelberg in 1840, his investigations having been begun the year previously. In 1850 M. Huguier published, in the Memoires de l'Academie de Medecine, a description of these glands, of which he believed himself to have been the re-discoverer in 1841; for like so many of his countrymen, he was unacquainted with what had been done even in his own field of investigation beyond the borders of France. 30 INFLAMMATION OF COWPER'S GLAND. 466 it becomes irritated in walking, or painful in sexual intercourse, and thus the case first presents itself to our notice. If now it be opened before inflammation has attacked it, a couple of drachms of a fluid like the white of egg will be let out, the swelling will disappear, and may perhaps never be reproduced, since in many instances the cyst after a free incision has been made into it becomes obliterated. Sometimes though no considerable annoyance has been produced by the swelling, inflammation has taken place in its interior sufficient to render its contents purulent, while in other cases the inflammation is not limited to the gland itself, but extends also to the adjacent tissue. The labium then becomes hot, swollen, and intensely tender and painful at its lower part, so that the patient is unable to move about, or even to leave the recumbent position without great suffering, while on its inner surface the gland forms an exquisitely painful prominence, and matter escapes on a puncture being made with great and usually permanent relief to the patient. It does, however, now and then happen that much suffering is produced by the successive re-formation of these tumors of Cowper's gland at intervals of two or three months, an annoyance which can only be prevented by laying the cyst freely open, and removing a portion of its wall, or probably by the injection of a solution of iodine into its cavity. The above condition has never come under my notice, except in comparatively young women, and who either were married or at least were accustomed to sexual intercourse. There are some other affections, however, which have no such relation, but which are perhaps more frequent in the middle-aged than in the young, and are at least as apt to occur in the single as in the married. Very troublesome boils, slow in their advance to suppuration, attended by much discomfort, occurring two or three at a time, or in rapid succession after each other, fresh crops of them frequently appearing at intervals of two or three weeks, sometimes show themselves on the outer surface of the labia. The patient's attention is usually first called to them by a disagreeable itching and smarting, and she then perceives a small pimple or two with a hardened base. The pimple by degrees enlarges, and the hardness around it extends both superficially and into the substance of the labium till it forms a mass as big as a small hazel-nut. It is not attended by much general swelling of the labium, and does not form a distinct head like an ecthymatous pustule, but its surface continues flat even at the time when suppuration having taken place in it, a small quantity of matter is discharged, after which the hardened spot gradually disappears. The only local treatment which has seemed of much service in this troublesome ailment consists in the free application of the nitrate of silver while the boils are still in the papular state. If done effectually this often prevents the further progress of the pimple, and spares the patient much of that suffering which fomentations, poultices, and all other surgical appliances at a later period do but very imperfectly mitigate. There is no general treatment which will prevent their formation any more than that of boils elsewhere, but as their occurrence seems sometimes connected with that irritation of the sexual system ECZEMA OF THE VULVA. 467 which often accompanies the final cessation of the menses, we are in such cases furnished with an indication to guide us worth bearing in remembrance. One of the most troublesome affections of the external organs is eczema of the vulva, which is apt to run a very chronic course, and to prove extremely intractable. For the most part the ailment appears in the flexures between the thighs and the labia, whence it extends to the labia themselves, and afterwards, as it becomes chronic, to the nymphae, while it is not infrequently associated with eczema about the margin of the anus, and extending along the perineum. In its acute stage it presents no difference from eczema in other parts of the body, but it seldom remains long in that condition, passing rapidly into a chronic state. In this state the labia are apt to lose the hair which naturally besets them, and they waste from removal of the fat which gives them their rotundity, while they and the nymphao become covered with a thick, hard, white epithelium, and the mucous membrane on their inner surface becomes dry, unlubricated, harsh, and unyielding. It is not usual for this disease to affect the vulva generally, but instances in which it has done so have come under my notice, the mucous membrane entirely losing its natural appearance, the dry, harsh, and thickened condition of the orifice of the vagina being associated with a marked narrowing of its calibre. In the worst cases, too, the disease involves the proeputium clitoridis to such a degree, that its thickened indurated tissue projects between the labia, while where the opposing surfaces are in contact they continue red, abraded, and just in the condition of parts affected by acute eczema. It is noteworthy also that in two instances of severe chronic eczema, a vascular tumor of considerable size grew from within the orifice of the urethra, but I do not know which of the two was of the longer standing. Those slight attacks of eczema to which some women are liable at the return of a menstrual period, from over-walking, or from similar causes, are often much relieved by the frequent application of a glycerine lotion, 1 while the parts where the eruption has been wont to appear may be afterwards rendered less irritable by the employment of pure glycerine or of zinc ointment. If the inflammation is severe, and the discharge from the surface abundant, the patient must remain in bed, and the continued application of an oxide of zinc lotion 3 will both restrain the secretion and abate the soreness, while afterwards the ablution of the parts with thin starch, and the keeping them constantly covered with the benzoated zinc ointment (a compound which has the advantage of not readily becoming rancid), seldom fails to bring about very speedy relief. It is, however, the chronic form of eczema, attended with the desquamation of dry scales of epidermis that is most troublesome to cure, or even to relieve. I have observed it in its severest forms only in hospital 1 (Formula No. 13.) R> —Glyc. purificati 3U« Aquae rosae |vj.—M. ft. lotio. 2 (Formula No. 14.) R. —Zinci oxydi gij. Mist, acaciae jj. Aquae rosae 3 v.—M. ft. lotio. 468 ECZEMA AND PRURIGO OP THE VULVA. patients, and these it was almost impossible to induce to remain long enough for more than some measure of alleviation of their ailment to be obtained. The distressing itching was iu most instances relieved for a time by smearing the parts with cod-liver oil. The relief which this afforded, however, was but temporary, and other unctuous applications answered the same end, also only for a time, and in general less effectually. Indeed nothing short of completely modifying the state of the skin by caustic applications seemed in these cases to hold out any prospect of cure. I have for this purpose employed the solid nitrate of silver, substituting for it, as fresh and more delicate epidermis was produced, a solution of twenty grains of the salt to an ounce of distilled water. Professor Scanzoni 1 uses with the same object a solution of half a drachm of caustic potass in an ounce of distilled water, which is to be lightly applied by means of a camel's hair pencil, and advises besides, as the disease abates, very copious and frequent ablution with cold water. I may just add that while attention is of course necessary to the state of the bowels, and any obvious indication for the use of internal remedies must not be neglected, the affection is essentially a local one, and is to be removed by the employment of local measures. Prurigo is often spoken of in connection with that distressing itching of the sexual orgaus from which women frequently suffer. While pruritus, however, is a common affection, prurigo is one of very considerable rarity; and I have never met with an instance in which the eruption was limited to those parts, though patients suffering from general prurigo are sometimes much distressed by the appearance of the eruption on the genitals, while others are driven by the irritation to scratch themselves to such a degree as to wound the skin, and thus produce little bloody points not unlike those which one sees on the top of the papilke of prurigo. In spite of this absence of any necessary connection between the painful itching of the sexual organs and the appearance of any eruption on their surface, this will perhaps still be the most convenient place for introducing what I have to say concerning it. Though commonly spoken of as pruritus of the pudenda or of the vulva, the sensation is by no means limited to one part, but is sometimes referred to the external organs, to the surface of the labia, or to the mons veneris; at other times it is experienced about the nymphas and the vestibulum, while sometimes it affects the vaginal canal, or even the os uteri. The circumstances in which it is met with vary as much as the situations to which the sensation is referred, and serve to show that in strict propriety the ailment deserves to be classed, as it is by some continental writers, among the nervous affections of the sexual organs. It is far from being an infrequent attendant on the earlier months of pregnancy, and likewise sometimes accompanies organic disease of the womb, especially carcinoma in its earlier stages. It sometimes attends, and still oftener precedes, the menstrual period, especially in women who menstruate scantily, irregularly, or painfully, while again 1 Op. cit., p. 495. 469 PRURITIS OF THE VULVA. it frequently occurs at the approach of the climacteric period, when menstruation has either finally ceased, or is about to disappear. It accompanies haemorrhoids, and is sometimes one of the discomforts produced by a varicose state of the veins of the labia; it attends the onset and decline of most cases of inflammation of the vagina, and in short is seldom altogether absent when any cause whatever produces a state of unnatural congestion of the sexual organs. Now and then it is associated with a sort of herpetic eruption of the inner surface of the labia, the vesicles of which are apt to assume on bursting something of the character of small aphthous sores; but my own experience does not lead me to regard this condition as at all of common occurrence. To describe a sensation is proverbially difficult; but it may be observed, that as this pruritus varies in degree, so it does also in kind. It is sometimes an unpleasant sense of creeping, or formication, at other times a feeling of smarting, while in other cases the positive itching is so distressing as to be almost unbearable. Warmth always aggravates it, and with some persons it suffices to come into a warm room in order to experience an attack of it, while in the case of most patients the nights are in great measure sleepless, because to lie down in bed is at once a signal for the commencement of the itching. Cold for a moment eases it, but this relief is but momentary, and patients are driven to scratch and rub themselves in order to obtain a sort of relief which consists in the substitution of a burning, smarting sensation for the less tolerable itching. This, however, not only does no real good, but the very rubbing of the parts both aggravates the patient's condition, and also helps to produce and to keep up a state of morbid sexual excitement, which in some of these cases constitutes by no means the least of her sufferings. The treatment obviously depends on the conditions with which this distressing symptom is associated. The empirical prescription of lotions, ointments, or other applications, without previous inquiry as to the state of the uterine functions, is worse than idle. One case I remember in which the application of the nitrate of silver to a long standing abrasiou of the os« uteri was followed by the almost immediate cure of a previously very distressing pruritus. When consequent on vaginitis the cure of the inflammation and the cessation of the itching take place almost simultaneously, while in general nothing relieves the irritation which accompanies the decline of the vaginitis more than the Goulard water and hydrocyanic acid, in the proportion of two drachms of the latter to eight ounces of the former. Whenever there is much evidence of congestion about the external parts, as shown either by their heat, swelling, or redness, and tenderness, a few leeches to the vulva, or to the margin of the anus, will generally give much relief, and the same local leeching is, as might be expected, of much service when the pruritus is associated with haemorrhoids. The herpetic eruption on which Dr. Dewees, of Philadelphia, laid so much stress as a cause of this ailment, is relieved—as indeed are other cases where without any disposition to the formation of vesicles or of little aphthous ulcers much heat and redness of the 470 FOLLICULAR INFLAMMATION parts exists—by a lotion of borax and morphia 1 , which indeed has proved more generally serviceable in my hands than any single remedy besides. In those cases in which there is any local inflammation, or considerable congestion present, unctuous applications do not in general do much good. In others in which this condition does not exist, or has been completely removed, the employment of a liniment of half a drachm of chloroform to an ounce of olive oil, both externally and to the vaginal walls, is often of great service. The pure cod-liver oil, also, often relieves the external irritation, though I suspect chiefly in those cases in which there is an approach to a state of chronic eczema; while Dr. Eigby, in his recent work, strongly advocates an ointment of equal parts of cod-liver oil and red precipitate ointment as successful in cases which have proved rebellious to other means. There still remains the employment of the nitrate of silver, either externally or to the vaginal walls, according to the seat of irritation, but I have not myself had recourse to it, for either other remedies have relieved the ailment, or it has ceased with the removal of its cause, as in cases where it occurred during pregnancy; or the patient has no longer heeded it, as in some instances of cancer, where other and worse suffering has made the former annoyance seem less intolerable. M. Huguier has described, with extreme minuteness, in the Memoirs of the Academy of Medicine of Paris 2 the diseases of the sebaceous and piliferous follicles of the vulva. He speaks of a condition of acne of the vulva, in which the contents of some of the sebaceous follicles accumulate without any obvious cause. The number of follicles so affected is not in general considerable, though like acne of the face, which in all respects it closely resembles, the affection is extremely chronic, and different follicles are apt to become diseased in succession. The accumulation of their contents, too, sometimes occasions inflammation of the follicles, and then that disease is produced which M. Huguier terms vulvar folliculitis, and which has occasionally come under my observation, though far less often than it and other ailments of the external organs present themselves to one who has so peculiar a field as is furnished by the Hojrital de Lourcine. This affection, which he states to be most frequent during pregnancy, may occur also at other times, induced by local irritation of any kind, and especially by habitual want of cleanliness. It is characterized by the appearance in the fold of the thigh, on the outer surface and free edge of the labia, on the nymphse, and on the base of the prasputium clitoridis, of little red rounded papilla), which at first scarcely exceed the size of a pin's head; some of them are distinct, while others are collected together into irregular patches. By degrees these follicles, at first merely congested and enlarged by the accumulation of their contents, become 1 (Formula No. 15.) R. —Sodse subboracis 5i v - Morphias hydrochlor. gr. viij. Aqua? rosse —M. ft. lotio. 2 Voi. xv. p. 527. AND TERTIARY SYPHILIS OF THE VULVA. 471 more inflamed, a little drop of pus may be seen at their apex; they then usually burst and shrivel, though sometimes they wither without having previously discharged their contents. The ailment, if left untreated, is chronic in its course, and the follicles take as long as twenty or thirty days, or even longer, to pass through the three stages of eruption, suppuration, and desiccation, while successive crops will run the same course, and protract the disease for weeks or months. It is, however, amenable to very simple treatment, such as rest, cleanliness, baths, the employment of mild astringents, such as the lead lotion, or of weak solutions of nitrate of silver. From these eruptive diseases of the external organs we pass now to the study of some other affections, not so superficial in their character, though still seated exclusively in the integument, and the subjacent cellular tissue. The correct classification of these diseases is very difficult, for while some are undoubtedly of syphilitic character, others belong to the same class with lupus, and are quite independent of venereal taint, and of these some pass by gradations difficult to seize into the same class with undoubted epithelial cancer. I do not pretend to say anything concerning the more usual varieties of syphilitic disease of the external organs. In truth my familiarity with them is but small. I have, however, occasionally met with what would seem to have been forms of tertiary syphilis, but which had been of such long-standing, and had proved so rebellious to treatment, that questions had been raised as to whether they were not really of a malignant character. Such a case was that of a patient aged forty-five, who was admitted under my care with ulceration of the external parts, of a year's duration, which appeared to have caused no other considerable inconvenience than occasional difficulty in retaining her urine. On the inner surface of her left labium, and extending on to the nympha, was a sore of a semicircular form, slightly irregular in its outline, its edges somewhat indolent, its surface covered by tolerably healthy granulations. The concavity of the sore was directed upwards, its convex edge downwards, beginning by a narrow edge about a quarter of an inch below the clitoris, and extending down to about three-quarters of an inch of the lower part of the left wall of the vagina. The cicatrix of a similar sore occupied the inner surface of the right nympha, and the right side of the entrance of the vagina, and a small portion of its lower edge was still unhealed. The orifice of the urethra was red and ulcerated, but it was not unnaturally open. The uterus was healthy, and there was no enlargement of the glands in the groins. In this patient there were no other venereal symptoms, though she confessed to having had sores accompanied by buboes, and by sore throat, fourteen years previously. Kecovery and complete cicatrization of the sores took place in three months, under the continued employment of the iodide of potass, with the black wash externally, and the occasional application of nitrate of silver. Other doubtful cases which have come under my notice have neither presented any evidence 472 TERTIARY SYPHILIS of syphilis, nor has it been possible to obtain from the patient's statements any proof of its previous existence. The clanger in such cases is scarcely of taking them for scirrhus, but rather of confounding them with some forms of epithelial carcinoma. The stony hardness of a scirrhous labium or nympha has in it something very characteristic, and the sore which forms on the mucous surface at the early stage when alone mistake is possible, is a mere superficial abrasion of epithelium, not a distinct ulcer with raised edges. Genuine epithelial carcinoma, beginning on the external parts, is less apt to extend up the vaginal canal, and does not show the same exclusive preference for the mucous surface of the labium; while when ulcerated its hardness uusally extends deeper, and its surface presents a more coarsely granular appearance. From rodent ulcer, or lupus, the diagnosis is more difficult. In that, however, the base of the ulcer is usually more indurated, and an indurated state of the integument extends beyond the limits of the ulcer, producing in very many instances a marked contraction of the orifice of the vulva; while, further, this disease is seldom limited to the inner surface of the labia, but in general affects their posterior part, the posterior vaginal wall for a short distance, and also, in many instances, the vestibulum; a greater extent of surface than syphilitic disease commonly involves, while lastly, in a large number of cases, there is associated with the ulceration a very remarkable disposition to hypertrophy of the labia and nymphae. This last peculiarity led M. Huguier, 1 who was the first person to give a minute description of this disease, to propose for one of its varieties the name of lupus hypertrophicus, designating its other forms lupus serpiginosus, and lupus perforans. In most instances, however, the characters are so blended as to render it doubtful whether there is any special advantage in these subdivisions. The affection may be briefly described as a form of ulceration, attended by little pain, which creeps all round the vulva, healing at one part while it advances at another, indolent in its progress towards healing, but also extending slowly; having irregular, usually rather overhanging edges, the tissue of which, and of the parts immediately around, is hard and cartilaginous. It is, moreover, attended by a disposition to hypertrophy of the parts not destroyed by ulceration, as, for instance, of the labia and nymphae, and by the formation of condylomatous growths about the entrance of the vagina, and the orifice of the anus, which growths themselves also become ulcerated. It is a further characteristic of this affection, that the ulcerations in healing tend to produce great contraction of the orifice of the vulva, by the formation of a firm cicatrix-like tissue, which also usually occupies a greater extent of surface than the ulceration had done which it succeeds. M. Huguier's essay contains an account of nine cases of this disease, and five have come under my own observation, making a total of 1 See his Memoir sur l'Esthiomene de la Region vulvo-anale, in Mem. de l'Acad. de Medecine, 1849, vol. xiv. p. 507. The engravings of the disease are remarkably characteristic of its peculiar features. AND LUPUS OP THE VULVA. 473 fourteen cases, all of which occurred in women who were either married or were known to have indulged in sexual intercourse, with the exception of one of M. Huguier's patients, concerning whom no mention is made on this point. Only two of M. Huguier's patients, and only one of mine, had had children; a peculiarity which seems scarcely accounted for by the impediment which, when the disease has reached an advanced stage, it may present to sexual intercourse. The influence of age in the production of this disease is shown in the following table:— Patients came under Disease said to notice at age of have begun. Years. Years. Months. 20 ... 18 6 21 ... 20 6 22 ... 20 6 24 ... 22 6 26 ... 21 0 26 ... 25 0 30 ... 29 0 Patients came under Disease said to notice at age of have begun. Years. Years. Months. 32 ... 30 4 32 ... 29 6 32 ... 31 4 33 ... 25 0 38 ... 28 0 47 ... 46 0 52 ... 45 0 Or in other words, the disease began, Under 20 years in 1 case. Between 20 and 25 " 4 " " 25 " 30 " 5 " " 30 " 35 " 2 " At 45 1 46 1 14 The duration of the disease, including the time during which the patients remained under observation, is shown in the following table: — Number. Duration. 1 under 1 year 3 " 18 months 3 "2 years 1 " 8 " 1 " 4 " 4 between 8 and 9 1 » 10 " 11 14 Results. i— ' Cured. Relieved. Not Relieved. Died. 1 2 1 2 l 1 1 1 3 1 1 4 6 1 3 It is quite evident that between this affection, which runs a course so uniformly slow, which admits of cure after the lapse of more than three years, and of great relief even after eight years, and any kind of malignant disease there must be an essential difference. Moreover, 1 This patient died under chloroform, and not from the advance of the disease. 474 LUPUS OF THE VULVA. when it runs a fatal course, it does not destroy life as cancer does, either by attacking some distant organ, or by involving as it extends all the tissues in one common morbid change, but death takes place from peritonitis consequent on the formation of fistulous communications between the vagina and rectum, and the contraction of the bowel whose walls have become implicated in the disease. The microscope, too, supports the distinctions which observation of the general features of the disease suggest. 1 With reference to the distinction between these ulcerations and such as are really of syphilitic origin, it deserves notice that in one case only of M. Huguier's did this disease appear to be grafted on syphilitic mischief ; while in the other thirteen cases, though one of the patients was a prostitute, and some of the others had undoubtedly exposed themselves to the risks of contagion, not one presented the slightest symptom of any venereal affection. The general character and progress of the disease will, perhaps, be best illustrated by the history of the case of a woman aged thirty, who was admitted under my care into St. Bartholomew's Hospital, in June, 1850. She had then been married four years, had given birth to one child at the full period, and had likewise miscarried from fright at the fifth month, a year before she came under my notice. She always had good health, though her menstruation was irregular, until after her labor, which was perfectly natural. She got about, however, too soon after her confinement, and to this indiscretion she attributed a leucorrhceal discharge, frequently streaked with blood, from which she had suffered ever since. This discharge had become more profuse since her miscarriage, but, with the exception of slight pain in the back, she had not experienced any other inconvenience until two months previously. Since that time, however, she had had a good deal of pain, both in micturition and in sexual intercourse, and the discharge had become yellow, thick, offensive, and escaped in gushes. The patient said that she had lost flesh, but she did not appear either emaciated or seriously out of health. The labia and nympha) were much swollen, but not diseased ; a very abundant, dirty puriform discharge escaped on separating them. A red, granular, bleeding ulceration, with a hard surface, slightly painful 1 The following memorandum was made by my friend Mr. Paget of an examination made by him after the death, under chloroform, of a young woman in whom a sore of this kind had existed for eighteen months. " In the material scraped from the free surface of the upper ulcer there were so many small epitheliform scales of various shapes, with well-marked nuclei and nucleoli, and various granular contents, that epithelial cancer might have been suspected. But all these cells and their nuclei were small, there were no laminated epithelial corpuscles, and (which was most significant) when I examined the substance of its base, taking it from beneath, and from immediately beneath its surface, I found nothing but the natural tissues of the mucous membrane with infiltrated, inflammatory, or reparative materials On the whole, the result of the microscopic examination was to show certainly that the characters of these ulcers are like those of common ulcers, having no new-formed structures of peculiar or specific form. If the materials taken from the surface of the ulcer had been examined during life, they would probably have led to a diagnosis of epithelial cancer. They were, however, I imagine, diseased epithelial cells from adjacent parts of the mucous membrane, or perhaps from the healing part of the surface of the ulcer." LUPUS OF THE VULVA. 475 to the touch, and bleeding readily, surrounded the urethra, while the ringer introduced into the vagina discovered a continuation of a similar condition extending upwards for about an inch in breadth, by an inch and a half in length. That part of the disease, however, which extended within the vagina was not entirely in a state of ulceration, but a thickening and infiltration of the tissues reached for some distance on either side, and the actual ulceration was of very limited extent. On the posterior vaginal wall, a little distance from the orifice of the canal, was a small, hard tubercle, the size of the top of the little finger, covered by unchanged mucous membrane. Six months later, the external parts were more tumid, and both they and the inside of the thighs were excoriated by the profuse discharge. The tubercle on the posterior vaginal wall remained unaltered, but a strip of ulceration was creeping up on either side. Five months later, or in the middle of May, 1851, the patient became again pregnant, and on February 19, 1852, she was delivered of a live female child, after a labor of little more than five hours' duration. The tubercle at the posterior wall of the vagina had somewhat increased during her pregnancy, and the perineum felt hard and brawny. It gave way during the passage of the head, but, nevertheless, the patient passed through the puerperal state without any bad symptoms, and on the 18th of March was again received into the hospital. The labia were then greatly swollen, but neither from anasarca, nor from inflammation. Their surface was pale and much wrinkled, like the hand when long soaked in water, while the whole of the integument felt thickened like that of a part affected with elephantiasis. The nympha} were also greatly enlarged, and projected between the labia, but otherwise their tissue did not appear to be much altered, except on their inner ulcerated surface. On separating the nyniphae an irregular ulceration was seen surrounding the urethra, which it seemed to have partially detached from its superior connections, and passing up under the symphysis pubis. The clitoris appeared to have been destroyed by the ulceration, which extended up quite to the superior commissure of the labia, whence it passed on to the inner surface of the nympha), while pale rose-colored warty granulations, exactly like those of the ulceration, surrounded the edges of the urethra, and formed a prominence about it almost of the size of a hazel-nut. The edges of the lacerated perineum were cicatrized to the extent of about a third of an inch, but the rest of the ununited margins of the labia, and the walls of the vulva and vagina as far as could be seen were of a harder texture than natural, semicartilaginous, of a pale rose red color, destitute of epithelium, but smooth and not granular-looking, but just like a section of a scirrhous mass, and pouring forth a copious sero-purulent secretion. A granulating ulceration extended for between half an inch and an inch along both walls of the vagina, that on its posterior wall ceasing at the base of the tubercle already mentioned as situated there. The removal of the nymphae was followed by great general amendment, and by partial cicatrization of the sore that surrounded the urethra. The granular outgrowth immediately at its orifice had by 476 LUPUS OF THE VULVA. the end of May lost nearly the whole of its preternatural redness, and was covered, as were the condylomatous growths, with pale mucous membrane. The inner surface of each labium, which looked before like sections of carcinomatous growths, was covered by healthy mucous membrane. On the 8th of July, 1852, just two years from the patient's first coming under my notice, there no longer existed any positive ulceration, though in other respects matters contiuued much as before, except that a vividly red, though but slightly sensitive excrescence, as big as the tip of the little finger, now sprouted from the wall of the urethra and quite filled up its canal, while the papillae which beset its margin continued as before. From this time I never saw the patient again; but this unfinished history displays the peculiarities of the disease, its slow progress, and its partial amendment. I wish it illustrated more favorably the results of treatment, though indeed the patient left the hospital better in many respects than when she entered it, and this in spite of its never having been possible to induce her to remain there for more than three months at a time. To a certain extent good diet, rest, cleanliness, the use of the hip-bath, and simple unirritating lotions improve the state of the ulcerations; and I have sometimes flattered myself that cicatrization would speedily take place. In a few weeks, however, the limit of this improvement has usually been attained, and the patient has passed from under my care benefited indeed, but by no means cured. In the only instance in which complete recovery took place, the patient was kept steadily on a course of mild mercurial medicine with small doses of the iodide of potassium for nearly two months. In this instance, however, the ulceration did not date from longer than seven months previously, and the amount of thickening and hypertrophy of the nymphaB was inconsiderable. In other cases I have employed preparations of mercury, iodine, and arsenic, without having been able to attribute to any one of them a special influence over the disease, and the experience of M. Huguier does not in these respects differ from my own. One point to which he refers is of great moment, namely, the expediency of removing the nymphae, or any of the adjacent parts, which may readily admit of extirpation, provided the ulcerations upon them appear indisposed to heal. I should indeed be inclined to advocate in every case the removal both of the ulcerated nymphae, and also of all those papillary or condylomatous excrescences which beset the orifice of the vulva as a preliminary step to any attempt at the cure of the disease. The opposing surfaces keep up mutual irritation, while the hardened tissues prevent any application being effectually made to the ulceration about the vestibule. The outgrowths, too, around the vulva are apt to become the seat of ulceration, and also to increase by their presence the probabilities of the occurrence of a relapse. I am unable to say to what extent the use of the stronger caustics, such as the acid nitrate of mercury, may be of service in those instances in which the ulcerations are most indolent, but I am inclined, though from very slight experience on the subject, to think that where its application is practicable, the influence of the actual cautery is more beneficial in CANCER OF THE VULVA. 477 modifying the state of the parts than that of any kind of chemical escharotic. Malignant disease of the external parts usually assumes, as might be expected, the form of epithelial cancer, though a case of scirrhus of the labium and one of fungoid disease of the vulva have both come under my notice. Epithelial cancer generally commences in the form of a little hard tubercle on the outer surface, but near to the edge of the labium, and without being the seat of positive pain, is yet in most instances a source of annoyance by the smarting and itching which it occasions. It may continue thus for an uncertain period—for several months, perhaps for longer, till at length its surface becomes abraded, a serous discharge exudes from it, and then completely losing its epithelium, it presents the appearance of a circular sore seated on a hard, somewhat raised base. It now spreads by ulceration, the ulcer always retaining somewhat of a circular form, while with its extension the induration base also reaches further and further beyond the limits of the ulceration. It constantly displays an indolent character, its edges being hard, and its surface depressed a little below the level of the surrounding integument. The granulations so distinctive of the ulceration of epithelial cancer are frequently kept in check by the constant attrition of the opposing surfaces of the labia, for it is worth notice that, though the disease usually commences at the edge of the labium, the ulceration generally advances inwards towards its mucous surface, and comparatively seldom spreads outwards on the integument. From the inner surface of the labium it next involves the nympha, the praeputium clitoridis, and the clitoris itself, which parts before they are attacked by actual ulceration generally become red, abraded, and finely granular on their surface. For some time even after the ulceration has taken place, the inguinal glands continue healthy and are not enlarged, and the general substance of the labium is not affected. Presently, however, the ulceration extends in depth; as it does so, it grows more irregular, and the granulations that beset its surface become larger, while the whole labium now looks red and swollen, feels hard, slightly irregular, and is very tender to the touch. There is little difficulty in filling up the picture, with the few dark touches needed to complete it. The disease sometimes destroys the labium, and then extends upon the integument of the thigh, as a deep, excavated, ragged ulcer, which yet does not in general discharge much, nor invariably occasion severe pain. At other times a gland swells, increases rapidly in size, the skin over it then dies, and a large cancerous ulcer is left behind, while as the disease advances, the patient loses health and flesh, and fades away, not destroyed by hemorrhage, as in ute'rine cancer, nor by any means constantly worn out by pain, for that is. usually tolerably amenable to opiate remedies. I should perhaps mention that I have seen one instance of the commencement of epithelial carcinoma, not on the cutaneous surface of the labium, but on the outer surface of the left nympha in a young married woman thirty-one years old. The disease had the form of a deep hole, with ragged edges m apparently about large enough to con- 478 CANCER OF THE LABIA, NYMPH J2, ETC. tain a nut, but the edges were so close together that it was impossible to see to the bottom of it, while any attempt to separate them in order to obtain a good view gave so much pain that it was forced to be abandoned. Its edges and surface were made up of small red, semi-transparent granulations of the size of a pin's head, and remarkably characteristic of epithelial cancer. The commencement of the disease was referred to a fall against the edge of a chair five months before, when the patient hurt the external parts very much, and suffered from profuse hemorrhage in consequence. She would not submit to an operation then, but returned to the hospital a year afterwards, when all interference was out of the question, for the ulceration had destroyed the labium, and extended to the thigh. The poor woman had followed her occupation as a weaveress almost to the time of hep admission, had suffered much, had fared ill, and had taken to opium-eating for relief. She was transferred to the workv house, but I do not know when she died. 1 Our data are hardly sufficient to determine satisfactorily the duration of this disease. I believe, however, that the tubercle which precedes the development of the carcinomatous sore may exist for a long period, even for several years, though I do not imagine this usually to be the case: but that when the process of ulceration has commenced it runs it course to a fatal issue within two years. In the treatment of epithelial carcinoma the one great question to decide concerns the possibility of its removal. If let alone, at any rate after ulceration has commenced, its progress is invariably to a fatal issue; and any of the local applications which may be tried in ulcerations of a doubtful character on other parts can never be efficiently employed in diseases of the external sexual organs of women. I have not experience enough to say in what proportion of cases the disease recurs, or how long a period of immunity may be hoped for after its extirpation. Of this, however, I am sure, that present comfort is promoted, that life is decidedly prolonged, and that a chance, if but a slender chance, at any rate the only one, is thereby afforded the patient of a permanent cure. The surgery of the operation lies beyond my province ; the only suggestion that I would venture to give concerning it is, that care should be taken to remove enough, and that the operator should not, through fear of making too large a wound, carry his incisions too near to diseased tissues. 1 I have also seen one instance, in a woman aged thirty-four, of the simultaneous occurrence of malignant ulceration of the interior of the labia and nymphae, and of epithelial carcinoma of the skin over the pubes. Death took place in twenty months. There was infiltration of cancerous matter in the body of the uterus, but its cervix was healthy, and no secondary deposits existed in any other organ. INDEX. Abdomen, encysted dropsy of, 392 floating tumors of (note), 393 Abortion, share of, in production of uterine ailments, 105 cause of inflammation of uterine appendage, 310 Amenorrhoea, from defective formation, 35 from mechanical causes, 37 in opposite states of the system, 40 from suppression of menses, 47 vicarious hemorrhages in, 46 treatment of, 44—49 Anteflexion of uterus, a natural condition, 153 comparative frecpaency of it and of retroflexion, 153 Anteversion of uterus, 150 Ascent of the uterus, its causes and import, 185% Ascites, diagnosis of, from ovarian dropsy, 388 Bladder, distended, diagnosis of, from ovarian dropsy, 392 prolapsus of, 125 its characters, and mode of production, 125 its effect on the uterus and kidneys, 126 its symptoms, 132 its treatment, 140 affections, often secondary to those of uterus, 433 inflammation of, 433 chronic, 434 relation of to diseases of kidneys, 436 treatment, 438 fungous tumors of, 444 malignant disease of, 444 Blood, alterations of, as cause of amenorrhoea, 41 as cause of monorrhagia, 52 Boils, affecting the labia, 466 Cancer of the vagina, 461 of the vulva, 477 of uterus, 253 definition of it, 254 scirrhous, 255 medullary, 256 ulceration of, 256 attempts at healing, 257 general changes in uterus, 258 on its exterior, 260 affection of the bladder in, 261 of body of uterus, 262 cancerous polypi, 263 alveolar, 264 Cancer of uterus— epithelial, 264 ulceration of, 206 secondary deposits in, 268 relation of to fibrous tumors, 205 diagnosis of from fibrous tumors, 217, 288 simple induration, 286 frequency of, 269 influence of age on, 271 uterine functions, 272 influence of pregnancy and labor, 273 hereditary predisposition, 275 symptoms of, 275 pain, 275 occasional absence of, 278 hemorrhage, 279 discharge, 280 cancerous cachexia, 282 sometimes latent, 284 acute, 284 complicating labor, 285 duration of, 289 treatment, 291 of hemorrhage, 291 of pain, 293 of discharges, 295 of cachexia, 296 of labor with, 298 extirpation of uterus, 299 excision of cervix uteri, 301 and ligature compared, 305 employment of cold, 306 of caustics and of actual cautery, 307 Carbonic acid gas, as local anaesthetic, 294 Cauliflower excrescence, 264 Caustics, mode of applying to os uteri, 114 Cellulitis, pelvic, 311 Cervix uteri, comparative physiological importance of it, and of body of uterus, 92 alleged importance of its ailments, 108 sometimes chief source of discharge, 115 hypertrophy of, 81 in cases of prolapsus, 121, 124, 126 excision on account of, 82 cyst-formation in, 115, 191 removal of, in cases of cancer, 301 Chloroform, vapor of, as local anaesthetic, 294 Chlorosis, 36 Corroding ulcer of uterus, 268 Cowper's gland, inflammation of, 465 Cretins, puberty late in, 39 Cysts of cervix uteri, 115, 191 diagnosis of, 193 480 INDEX Cysts of cervix uteri — treatment of, 195 on exterior of uterus (note), 351 of ovaries, varieties of, 353 their comparative frequency, 365 of Wolffian bodies, 353 of vagina, 458 Diabetes, a cause of pruritus of vulva, 19 Diagnosis, errors in, illustrated, 19 Digitalis, use of, in menorrhagia, 58 Diseases of women, study of, important, 18 errors committed in, 18 disturbance of function in, 20 sensibility in, 22 Dysmenorrhcea, 62 neuralgic, 63 its treatment, 69 congestive, 64 membrane expelled in, 65 its relation to gout and rheumatism, 66 its treatment, 71 treatment of rheumatic cases, 73 mechanical, 67 its treatment, 73 Eckaseur, for amputation of cervix uteri, dangers of, 82, 305 Eczema of vulva, 467 Emmenngogues, remarks on, 45 Enlargement of uterus, from defective involution. See Hypertrophy, 76 Enucleation of fibrous tumors, 229 Examination in diseases of women, rules for, 24 of abdomen, 25 vaginal, 26 by rectum, 27 with sound, 27 Excision of portion of wall of ovarian cyst, 415 External peritonitis, 320 Extirpation of uterus, when procident, 145 inverted, 179, 182 by ligature and knife compared, 180, . 183 in cases of cancer, 299 Fallopian tube, its unnatural patency (note), 79 discharge of ovarian cyst through it, 370 Fat cysts of ovary, 362 Fatty tumors of uterus, 250 cystic tumors of uterus (note), 201 polypi (note), 197 Fibroid (recurrent) tumors of uterus, 245 Fibrous polypus. See Polypus,237 Fibrous tumors of uterus, general characters of, 198 microscopic structure, 199 relations of, to uterus, 199 size and number, 201 containing large cysts (note), 201 spontaneous cure of, 201 softening of, 203 calcification of, 203 relation of, to malignant disease, 205 influence of age on, 206 of marriage on, 207 symptoms of, 207 influence of, on fecundity, 209 state of uterus in, 210 Fibrous tumors of uterus — diagnosis of, 213 from ovarian tumor, 213, 386 from abortion, 215 from flexions of uterus, 216 from cancer of uterus, 218, 288 associated with intense pain, 219 from pregnancy, 220 prognosis of, 222 complicating pregnancy, 223 treatment, 225 use of iodine, 227 use of the Kreuznach waters, 228 extirpation of, 229 of labor, complicated with, 229 Fibrous tumors of vagina, 459 Fistula, intestino-vesical. 443 vesico-vaginal, 440 Flexions of uterus, 152 how produced, 154 comparative frequency of ante and retroflexion, 153 anatomical results of, 154 congenital, 155 symptoms of, 156,161 their importance overrated, 159 symptoms of, accounted for, 160 diagnosis of, 164 treatment, 166 employment of mechanical means, 167 Follicular inflammation of vulva, 470 Formulae, aperient, chalybeate, 44 astringent, 57 antiphlogistic, sedative, 57 mucilaginous, 297 stimulant, 69 anodyne liniment, 111 for cases of cystitis, 439 sedative lotions, 467, 470 Gangrenous inflammation of vulva, 465 Gonorrhoea, its diagnosis not always possible, 455 a cause of acute metritis, 83 Granular vaginitis, 457 Hematocele, uterine, its nature, 331 its symptoms and course, 332 its diagnosis, 336 its dangers, 337 its treatment, 338 Hair in ovarian cysts, 362 Hymen, imperforate, 37 Hypertrophy of uterus, from defective involution, 76 from sterile marriage, 80 of cervix only, 81 partial, 188 Hysteria, peritonitis simulated by, 20 Idtots, puberty late in, 39 Inflammation of uterus, difficulties in its study, 83 acute, its causes and symptoms, 83 treatment, 85 chronic, 87 treatment, 110 of uterine appendages. See Uterus, appendages of, 308 Intra-uterine injections, in monorrhagia, 60 danger of, 113 481 INDEX Inversion of uterus, 172 its causes, 172 its symptoms at time of its occurrence, 173 its results, 175 spontaneous replacement of, 177 diagnosis of, when recent, 177 when chronic, 182 treatment, attempts at replacement, 178 extirpation of uterus, 180, 182 from polypus, 184 Involution of uterus, results of its interruption, 77 Iodine, injection of, into ovarian cysts, 416 its dangers and results, 420 Irritable uterus, 66 Kidneys, atrophy of, from prolapse of bladder, 126 in cancer of uterus, 277 disease of, producing svinptoms of cystitis, 436 Kreuznach, waters of, in cases of fibrous tumor, 228 Labia, inflammation of, 465 boils on, 466 Labor, share of, in production of uterine ailments, 105 cause of inflammation of uterine appendages, 310 complicated with polypus, 245 with fibrous tumor, 223, 234 with cancer, 285, 298 induction of, prematurely in fibrous tumor, 236 in cancer, 298 Leeches to uterus, how applied, 72 caution with reference to their use, 86 Leucorrhcea, cervix uteri, its alleged source, 108 treatment of, 112 cervical, treatment of, 116 vaginal, microscopic character of, 454 treatment of, 456 Lupus of vulva, 472 Malformation of sexual organs, a cause of amenorrhcea, 35 Menorrhagia, its causes twofold, 50 eonstitutional causes of, 51 from local causes, 53 occasional death from, 59 its treatment, 54 of cases requiring depletion, 56 use of astringents in, 57 use of digitalis in, 58 use of local measures in, 60 Menstruation, various causes of its disorders, 20, 33 disorders of, referred to three classes: 33 first, average date of, 33 tardy, usually difficult, 34 precocious (note), 51 Metritis, acute, 83 hemorrhagic, 56 Nabothian bodies, their nature, 115 enlarged, 190 cyst-formation from, 191 31 Obliquity, congenital, of uterus, 155 Ovaries, special function of, 20 defective development of, 36 displacement of, 349 hernia of (note), 351 inflammation of, 339 in cases of acute metritis, 86 rare in an acute form, 343 occasional occurrence of abscess, 344 most frequently chronic, 345 symptoms of chronic ovaritis, 346, 350 treatment, 348 cysts of, simple cysts of, connected with Wolffian body, 353 simple cysts of, often stationary, 366 from enlarged Graafian vesicles, 356 from other causes, 358 sometimes stationary, 367 disappear, 369 compound cysts, 359 cystosarcomatous, 360 colloid cysts, 361 cancerous, 362 fat cysts, 362 frequency of, in each ovary, 365 different kinds of, 365 cysts of, discharge of by various channels, 370 danger of rupture into peritoneum, 373 inflammation of, 374 Ovarian dropsy, disorder of health from, 374 predisposing causes of, 376 exciting causes of, 379 early symptoms of, 380 advanced symptoms of, 382 diagnosis of, 213, 337, 384 prognosis of, 396 treatment, 395 palliative, 398 tapping in, 400 radical, 408 tight bandage after tapping, 408 subcutaneous puncture, 409 puncture per vaginam, 410 maintenance of opening, 410 excision of portion of wall, 415 iodine injections, 416 extirpation of ovary, 422 Ovariotomy, 422 often impracticable, 424 two operations, 423 their results compared, 428 its mortality, 423 (note), 431 causes of, 426 and of Caesarean section compared, 426, 431 reasons for rejecting the operation, 430 Pelvic cellulitis, 311 diagnosis from uterine haematocele, 322, 336 Peritoneum, rupture of ovarian cyst into, 372 Peritonitis, hysterical, 20 Pessaries, their different kinds, 135 rules for their introduction, 139 Plug, in cases of monorrhagia, 60 operations on uterus, 304 482 INDEX Polypus of uterus. Mucous polypus, 189 glandular, 190 symptoms of, 191 source of hemorrhage in, 192 diagnosis of, 193 removal of, 194 fibrinous, 195 its nature, symptoms, and treatment, 196 fibro-cystic—its nature doubtful (note), 197 fibrous —structure of, 237 source of hemorrhage in, 192, 239 development of, 239 m inversion of womb, by, 184 symptoms of, 240 diagnosis, 241 and of inverted womb, 182 management of labor with it, 245 removal by ligature or excision, 241 malignant, 263 Pregnancy, share of, in production of uterine ailments, 105 obscured by fibrous tumors, 221 diagnosis of, from fibrous tumors, 220 ovarian dropsy, 392 rendered dangerous by fibrous tumors, 223 cancer, 285 Extra-uterine, diagnosis from uterine haematocele, 336 Procidentia of uterus, 122 its symptoms, 129 its treatment, 140 cautions in returning it, 141 operations for its cure, 142 extirpation of uterus for, 145 Prolapsus uteri, its different degrees, 118 anatomical arrangements which prevent its occurrence, 118 its causes, 120 mode of production, in the ag«d, 120 alterations in the uterus itself from it, 121 complete prolapse, or procidentia, 122 secondary to prolapse of vagina, 123 symptoms of its earlier stages, 127 complete prolapse. Sec Procidentia, 130 associated with pregnancy, 131 Its treatment, 133 mechanical support, when to be used. See Pessaries and Supports, 134 Prolapsus of vagina, 124 a cause of hypertrophy of oervix uteri, 125, 126 partial, of anterior or posterior wall. See Bladder, prolapse of, 126 symptoms of, 132 Pruritus of vulva, 468 attendant on diabetes, 19 Puberty, precocious (note), 51 tardy, from various causes, 35, 38 Puncture, subcutaneous, of ovarian cyst. See Tapping, 409 Rectum, prolapsus of, 127 its symptoms, 132 its treatment, 140 Recurrent fibroid tumors of uterus, 245 Retroflexion of uterus, comparative frequency of it, and of anteflexion, 153 Retroversion of uterus, 146 mode of its production, 147 causes of, 148 diagnosis from uterine hematocele, 336 ovarian tumors, 386 Rodent ulcer of uterus, 268 Rupture, spontaneous, of ovarian cyst, 370 Scarification of uterus ; its uses, 72 Scirrhus of uterus ; its rarity, 255 its structure, 255 Secretions, from sexual organs; their various sources, 21 Sensibility, disorders of, in diseases of women, 22 Sound, uterine ; by whom suggested, 27 Dr. Simpson's described, 28 mode of introduction, 28 Speculum uteri, invention of, 29 varieties of, 29 mode of introduction, 31 its value estimated, 32 Sterility, influence of flexion of uterus in producing it, 161 polypi, 193 fibrous tumors, 209 Support, mechanical, in prolapsus uteri, 134 internal, 135 externa], 138 Supporter, the uterine, 167 objections to its use, 168 Syphilis, tertiary, of vulva, 470 Tapping, in ovarian dropsy, 400 attitude in, 404 its dangers estimated, 402 exhaustion after, 405 cyst-inflammation from, 405 followed by tigbt-bandaging, 408 subcutaneous, 409 per vaginam, 410 and maintenance of opening, 410 injection of iodine, 416 Teeth in ovarian cysts, 362 Trichomonas, characteristic of vaginal leucorrhcea, 454 Tubercle of uterus, 251 ulceration said to be tuberculous, 266 Tumors, floating, of abdomen (note), 393 Ulcer, rodent, of uterus, 267 Ulceration of os uteri; its characters, 93 its alleged importance, 94 its importance doubted, 95 success of local treatment explained, 100 local treatment sometimes mischievous, 100 objections to frequent use of caustics, 102 local treatment, when necessary, 113 Urethra, congestion of, 447 vascular tumors of, 449 chronic ulceration of, 451 Urine, albumen in, from presence of leucorrhcea, 19 Uterine sound. See Sound, 27 Uterus, absence of, 37 knowledge of its structure and diseases formerly defective, 8S 483 INDEX Uterus— assumed constitutional origin of its diseases, 89 its special liability to disease accounted for, 90 inflammation of its cavity and body, 105 cancerous, extirpation of, 299 appendages of; inflammation of, 308 its causes, 310 tendency to suppuration, 313, 317 post-mortem appearances, 313 process of cure of, 314 nature and analogies of, 316 its symptoms, 316 its chronic course, 319, 323 its diagnosis, 320, 385 occasionally independent of puerperal causes, 325 its treatment, 327 puncture, when indicated, 329 Vagina, acute inflammation of, 453 its treatment, 455 chronic inflammation of, 455 its treatment, 456 Vagina, chronic inflammation — cysts of, 458 fibrous tumors of, 459 malignant disease of, 461 extension of cancerous disease of uterus to, 258 rupture of ovarian cyst into, 371 Vaginitis, 453 granular, 457 Vesico-vaginal fistula, 440 treatment previous to operation for, 441 Vulva, eczema of, 467 pruritus of, 468 follicular inflammation of, 470 gangrenous inflammation of, 465 tertiary syphilis of, 471 lupus of, 472 cancer of, 477 Wolffian bodies, cysts of, 353 often remain stationary, 366 Zwanck, his pessary described, 137 THE END. HENEY C. LEA'S (LATE LEA & BLANCHARD'S,) MEDICAL AND SURGICAL PUBLICATIONS. TO THE MEDICAL PROFESSION. The prices on this Catalogue are those at which these books can generally be furnished by booksellers, who can readily procure for their customers any which they may not have on hand. Where access to bookstores is not convenient, I will forward them at these prices, free by mail, to any post office in the United States. In all cases the amount must accompany the order, as accounts are opened only with dealers; I assume no risks of the mail, either on the money or the books, and can supply nothing but my own publications. Gentlemen desirous of purchasing will, therefore, find it more advantageous to deal with the nearest bookseller whenever practicable, or to send orders through their merchants visiting the larger cities. HENRY C. LEA. Philadelphia, February, 1866. %* Just issued, a revised Illustrated Catalogue of Medical and Scientific Publications, forming an octavo pamphlet of 80 large pages, containing specimens of illustrations, notices of the medical press, &c. &c. It has been prepared without regard to expense, and will be found one of the handsomest specimens of typographical execution as yet presented in this country. Copies will be sent to any address, by mail, free of postage, on receipt of nine cents in stamps. Catalogues of publications in miscellaneous and educational literature forwarded on application. EP* The attention of physicians is especially solicited to the following important new worka and new editions, just issued or nearly ready:— Ashton on the Rectum, new edition, See page 3 Brinton on the Stomach, " 4 Bennett on l he Uterus, sixth edition, " 4 Bowman's Medical Chemistry, fourth edition, " 4 Bumstead on Venereal, second edition, " 5 f Barclay on Medical Diagnosis, third edition, " 5 Brande and Taylor's Chemistry, " 6 Dal ton'8 Human Physiology, 3d edition, " 11 Dunglison's Medical Dictionary, a revised edition, 1865, 12 Ellis' Formulary, new edition, M 13 Erichsen's System of Surgery, a revised edition, „...." 14 Flint's Practice of Medicine, now ready, " 15 Gross's System of Surgery, third edition, M 16 Gray's Anatomy, Descriptive and Surgical, 2d edition, . • " Yl Hillier on Skin Diseases, " 18 Hamilton on Fractures and Dislocations, second edition, " 18 Hodge's Obstetrics, " *• Pereira's Materia Medica, condensed edition, preparing, . . . . " 24 Roberts on Urinary Diseases, nearly ready, " 24 Parrish's Practical Pharmacy, a new edition, " 25 Smith on Consumption, " 26 Stifle's Therapeutics and Materia Medica, second edition, " 27 Wilson on the Skin, filth edition, . " •» Winslow on the Brain and Mind, second edition " 32 West on Cnildren, fourth edition, " 32 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES AND THE MEDICAL NEWS AND LIBRARY, For FIVE DOLLARS per annum, Invariably In Advance. To avoid raising the price at which the " Medical Journal" has been published for nearly fifty years, subscriptions are now only taken payable in advance. The result of this policy during 1865 has been a largely increased subscription lift, which has exhausted the whole edition printed. No copies can be supplied for 1865, and subscriptions can now only be received for 1866 1 HENRY C. LEA'S MEDICAL 2 The publisher trusts to be sustained, by an enlarged circulation, in this course, which gives to the subscriber, notwithstanding the enormous advance in the cost of production, nearly fifteen hundred large octavo fages for the very moderate price of Five Dollars. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., is published Quarterly, on the first of January, April, July, and October. Each number contains about two hundred and seventy large octavo pages, handsomely and appropriately illustrated, wherever necessary. It has now been issued regularly for more than forty years, and it hat been under the control of the present editor nearly the whole of that period. Throughout this long period, it has maintained its position in the highest rank of medical periodicals both at homt and abroad, and has received the cordial support of the entire profession in this country. Its list of Collaborators will be found to contain a large number of the most distinguished names of the profession in every section of the United States, rendering the department devoted to ORIGINAL COMMUNICATIONS full of varied and important matter, of great interest to all practitioners. As the aim of the Journal, however, is to combine the advantages presented by all the different varieties of periodicals, in its REVIEW DEPARTMENT will be found extended and impartial reviews of all important new works, presenting subjects of novelty and interest, together with very numerous BIBLIOGRAPHICAL NOTICES, including nearly all the medical publications of the day, both in this country and Great Britain, with a choice selection of the more important continental works. This is followed by the QUARTERLY SUMMARY, being a very full and complete abstract, methodically arranged, of the IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES. This department of the Journal, so important to the practising physician, is the object ol especial care on the part of the editor. It is classified and arranged under different heads, thus facilitating the researches of the reader in pursuit of particular subjects, and will be found to present a very full and accurate digest ol all observations, discoveries, and inventions recorded in every branch of medical science. The very extensive arrangements ol the publishers are such as to afford to the editor complete materials for this purpose, as he not only regularly receives ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti. nent, thus enabling him to present in a convenient compass a thorough and complete abstract of everything interesting or important to the physician occurring in any part of the civilized world. To old subscribers, many of whom have been on the list for twenty or thirty years, tnt publisher feels that no promises for the future are necessary; but those who may desire for the first time to subscribe, can rest assured that no exertion will be spared to maintain the Journal in the high position which it has occupied for so long a period. By reference to the terms it will be seen that, in addition to this large amount of valuable and practical information on every branch of medical science, the subscriber receives, without further charge, THE MEDICAL NEWS AND LIBRARY, a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the current information of the day, while the ••Lubrary Department" is devoted to presenting standard works on various branches of Within a few years, subscribers have thus received without expense, many works of the highest character and practical value, such as " Watson's' Practice," "Todd and Bowman's Physiology," " Malgaigne's Surgery," "West on Children " " West on Females, Parti.," "Habershon on the Alimentary Canal," "Simpson on Females," &'c. The work at present appearing in its columns, to be completed in 18ob\ is CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS, C. Handfield Jones, M.D., F.R.S., &c. As a practical treatise on a class of frequent and intractable diseases, such as Paralysi* Eoilepsy, Neuralgia, Delirium Tremens, Chorea, Hysteria, ore. &c., the publisher believes that he could not lay before subscribers a more acceptable work. It will thus tie seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber will obtain a Quarterly aud a Monthly periodical, EMBRACING ABOUT FIFTEEN HUNDRED LARGE OCTAVO PAGES, Remittances of subscriptions can be mailed at my risk, when a certificate is taken from the Postmaster that the money is duly inclosed and forwarded. Address HENRY C. LEA, Philadelphia. AND SCIENTIFIC PUBLICATIONS. 3 ASHTON (T. J.), Surgeon to the Blenheim Dispensary, &c. ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, from the fourth and enlarged London edition. With handsome illustrations. In one very beautifully printed octavo volume, of about 300 pages. $3 25. (Now Ready.) The moat complete one we possess on the subject. Medico-Chirurgical Review. We are satisfied, after a careful examination of the volume, and a comparison of its contenta with those of its leading predecessors and contemporaries, | t hat the best way for the reader to avail himself of the excellent advice given in the concluding para- J graph above, would be to provide himself with a I cipy of the book from which it lias been taken, and diligently to con its instructive pages. They may 1 secure to him many a triumph and fervent blessing j Am. Journal Med. Sciences. ' 'Pa is iaanewand carefully revised edition of one of the most valuable special treatises that the physician and surtreon can have in hia library.— Chicago Mcdicil Examiner, Jan. 1866. The short period which has elapsed since the ar>pearance of the former American reprint, and the numerous editions published in England, are the best arguments we can offer of the merits, and of the uselessnesa of any commendation on our part of a book already so favorably known to our readers. — Boston Med. and Surg. Journal, Jan 25, 1666. ALLEN (J. M.), M. D., Professor of Anatomy in the Pennsylvania Medical College, &c. THE PRACTICAL ANATOMIST; or, The Student's Guide in the Dissecting. ROOM. With 266 illustrations. In one handsome royal 12mo. volume, of over 600 pages, extra cloth. $2 00. r 8 ' We believe it to be one of the most useful works upon the subject ever written. It is handsomely illustrated, well printed, and will he found of convenient size for use in the dissecting-room.— Med. Examiner. However valuable may be the " Dissector's Guides" which we, of late, have had occasion to notice, we feel confident that the work of Dr. Allen is superior to any of them. We believe with the author, that none is so fully illustrated as this, and the arrangement of the work is such as to facilitate the labors of the student. We most cordUlly recommend it to their attention.— Western Lancet. ANATOMICAL ATLAS. By Professors H. H. Smith and W. E. Horner, of the University of Pennsylvania. 1 vol. 8vo., extra cloth, with nearly 650 illustrations. See Smith, p. 26. ABEL (F. A.), F. C. S. AND C. L. BLOXAM. HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical; with a Recommendatory Preface by Dr. Hofmann. In one large octavo volume, extra cloth, of 662 pages, with illustrations. $4 50. ASH WELL (SAMUEL), M. D., Obstetric Physician and Lecturer to Guy's Hospital, London. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third American, from the Third and revised London edition. In one octavo volume, extra cloth, of 528 pages. $3 50. The most useful practical work on the subject in the English language. — Boston Med. and Surg, Journal. The most able, and certainly the most standard and practical, work on female diseases that we havs yet seen.— Medico-C kirurgical Review. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra tions. $2 25. BIRD (QOLDING), A. M., M. D., tec. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. Edited by Edmund Lloyd Birkett, M. D. A new American, from the last and enlarged London edition. With eighty illustrations on wood. In one handsome octavo volume, of about 400 pages, extra cloth. $3 25. BARLOW (GEORGE H.), M. D. Physician to Guy's Hospital, London, ice. A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Condie, M. D., author of" A Practical Treatise on Diseases of Children," &c. In one handsome octavo volume, extra cloth, of over 600 pages. $2 50. WerecommendDr.fiarlow'sManualinthe warm- I found it clear, eoncise, practical, and sound. Bosmut manner as a most valuable vade-mecum. We ton Med.and Surg. Journal. have had frequent occasion to consult it, and have | found it clear, eonciae, practical, and sound. Boston Med.and Surg. Journal. BUCKLER ON THE ETIOLOGY, PATHOLOGY AND TREATMENT OF F1BRO-BRONCHI TiS AND RHEUMATIC PNEUMONIA. Ii one 8vo. volume, extra cloth, pp. ISO. 8125. BRODIE'S CLINICAL LECTURES ON SUR GERY. 1 vol.8vo. cloth. 350pp. 8125 BLOOD AND URINE (MANUALS ON). BY J W. GRIFFITH, G. O. REKSK, AND A MARK WICK. One volume, royal 12mo., extra cloth, with platea. pp.460. $1 25. IKALK ON THE LAWS OF HEALTH IN KFLATION TO MIND AND BODY. In one v. L royal ISmo., extra cloth, pp. MM. do cent*. 4 HENRY C. LEA'S MEDICAL BUDD (GEORGE), M. D., F. R. •., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Third American, from the third and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beautifully colored plates, and numerous wood-cuts. pp. 500. $4 00. Has fairly established for itself a place among the classical medical literature of England.— British and Foreign Medico-Chir. Review. Dr. Budd's Treatise on Diseases of the Liver is now a standard work in Medical literature, and during the intervals which have elapsed between the successive editions, the author has incorporated into the text the most striking novelties which have characterized the recent progress of hepatic physiology and pathology: so that although the size of the book is not perceptibly changed, the history of liver diseases is made more complete, and is kept upon a level with the progress of modern science. It is the best work on Diseases of the Liver in any language.— London Med. Times and Gazette. BUCKNILL (J. C), M. D., and DANIEL H. TUKE, M.D., Medical Superintendent of the Devon Lunatic Asylum. Visiting Medical Officer to the York Retreat. A MANUAL OF PSYCHOLOGICAL MEDICINE; containing the History, Nosology, Dmte ription, Statistics, Diagnosis, Pathology, and Treatment of INSANITY. With a Plate. In one handsome octavo volume, of 536 pages, extra cloth. $4 25. The increase of mental disease in its various forms, and the difficult questions to which it is constantly giving rise, render the subject one of daily enhanced interest, requiring on the part of the physician a constantly greater familiarity with this, the most perplexing branch of his profession. Yet until the appearance of the present volume there has been for some years no work accessible in this country, presenting the results of recent investigations in the Diagnosis and Prognosis of Insanity, and the greatly improved methods of treatment which have done so much in alleviating the condition or restoring the health of the insane. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Sixth American, from the fourth and revised English edition. In one octavo volume, of about 000 pages, extra cloth. $3 75. {Just Issued.) This standard work, w hich has done so much to introduce the modern and improved treatment of female diseases, has received a very careful revision at the hands ol the author In his preface he slates : " During the past iwo years this revi. ion of former b bors has been my principal occupation, and in its present stute the woik may be considered to embody the matured experience of the many years 1 have devottd to the study of uterine diseape." BRINTON (WILLIAM), M. D F. R. S., Physician to St. Thomas's Hospital. LECTURES ON THE DISEASES OF THE STOMACH, with an introduction on its Anatomy and Physiology. From the second and enlarged London edition. With illustrations on wood. In one large and handsome octavo volume. $3 25. (Just R'ady.) The entire series of lectures embraced in the volume before us are well worthy of a Hose study on the part of every one desiious of ucquiring coricct views in relation to tne nature and treatment of the diseases of the stomach Nowhere can be found a more full, accurate, plain, und instructive history of these diseases, or more rational views respecting their pathology and tberapeutics — American Journal of the Mtd Sciences, April, 1865. This is no mere c< mpilalion, no crude record of oases, but the carefully elaborated production of un aecomplished physician, who, for many years, has devoted special attention to the symptomatology, pathology, and treatment of gustriu diseases.— Edinburgh. Med. Journal. Dr. Brinton'a position as a laborer in medical science and a medical author is fully established, and these lectures have only added to a reputation based on many solid grounds. The work is an important one, and we argue for it a great place in medical literature.— London Lancet, Dec. 3, labl. BOWMAN (JOHN EJ, M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L Bloxam. Fourth American, from the fourth and revised English Edition. In one neat volume, royal l2mo.,extra cloth withnumerousillustrations. pp.351. $225. Of this well-known handbook we may say that tt retains nil i>s < Id simplicity and clearness of airangement and description, whilst it hus received from the able edit ¦ *5 This favorite litt'e manual hus received a very thorough and careful revision at the hands of a competent editor,and will be lbund lolly brought up lo the present condiiiou ol chemical science. Many portions have- been rewrilttn, the subjects ol the blow-pipe und Volumetric analysis huve received speeiul attention, and an additional chapter has been appended. Siudents ol practical ohemmtry will therefore find it, as here ofore, a most convenient mtd condensed text-book and guide in the operations of the laboratory. AND SCIENTIFIC PUBLICATIONS. 5 BUMSTEAD (FREEMAN J ) M. D., Lecturer on Venereal Diseases at the College of Pnysicians and Surgeons, New York, Ac. THE PATHOLOGY AND TREATMENT OF VENEREAL DISEASES, including the results of recent investigations upon the subject. Second edition, thoroughly revised end much improved. With illustrations on wood. In one very handsome octavo volume, of about 700 pages. $5 00 (Just Issued.) Ky far the most valuable contribution to this par- ticular branch of practice that has seen the light Within the last score of years. His clear and accu- rate descriptions of the various forms of venereal dsease, and especially the methods of treatment he ffi'resoe lD ?« by ? re " m SI 2 S f Hnd Cofn 5 Uo » u ?h 8 U " sur l ,i,8^ a - 11 mI f l" ,f "- s "" n "/every praetitumer-CAteago Med. Journal. Nov. Ib6l. Tlie foregoing admirable volume comes to us, em bracing the whole subject of s> philology, resolving many a doubt, correcting and confirming many an entertained opinion, and in our estimation the best, completes!, fullest monog.aph on this subject in our language. As far as the author's labors themsel ves are concerned, we feel it a duty to say that helms not only exhausted his subject, but he has presented to us, without the ¦lightest hyperbole, the best di- tested treatise on these diseases in our language He. has earned its literature down to the pres. nt moment, aud has achieved his task in a manner wlnch cannot but redound to his credit.— British American Journal, Oct lb6l. VVe believe this treatise will come to be regarded as high authority in this branch of medico 1 practice, and we cordially commend it to the favorable notice of our brci.hren in the profession. For our own part. we candidly confess that we have received nnny ni'W id (as from its perusal, as well as modified many views which we have long, and, as we now think erroneously entertained on the subject ot syphilis. To sum up all in a few words, this book tsone which no practising physician or medical student can very well afford to do without.— American Med Times, Nov. 8, 18(11. T|]e wh|||p W(lr |. nr „ 8enfs „ e ( , mi) l P ,» historv of *-£j5 <™™> \S^\SS^S^^Si o?rnyS P e5^ ¦ubject-the' whole carefully digested by the aid of the author's extensive personal experience, and offered to the profession in an admirable form! Its completeness is secured oy good plates, which are ejpeeially full in the anatomy of the genital organs. We have examined it with great satisfaction, and congratulate the medical profession in America on the nationality of a work that may fairly be Jailed original.— Berkshire M'd. Journal, Dec 18(11. G ne thing, however, we are impelled to say, that we hiive m H wiu , no otner 0( ; ()k {,„ 8 yp|„|n, in the Bngii8 ,, huifuage, which gave so full, clear and i m ° a rtial views of the important, subj. eta on Which it , real8 . V Ve cannot, however, refrain Iron, expre8ejn - onr ea tisfaction with the full and perspicuoua mwnner |„ w hich the subject has been presented, and the careful attentiou to minute details, so useful-notto say indispensable—in a practical i realise. i„ conclusion, if we may be pardoned the use of a phrase now become stereotyped, but which we here employ in all seriousness and sincerity, we do not hesitate to express the opinion that Dr. Buinstead'g Treatise on Venereal Diseases is a u work without which no medical library will hereafter be considered complete."— Boston Med and Surg. Journal Sept. 5, IbtJl. BARCLAY (A. W.l, M. D., Assistant Physician to St.. George's Hospital, A.C. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Sign*and Symptoms of Disease. Third American from the second and revised London edition. In one neat octavo volume, extra cloth, of'451 pages. $150 (Jusi Issued ) The demand for another edition of this work *huws that ihe vacancy winch it attempts to sup- Kly has been recognized by the profession, and that the efforts of the author to meet the wunt have uen successful. The revision which it has enjoyed will render it better adapted than before to atlord assistance to the learner in the prosecution of his studies, and to tin; practitioner who requires a convenient and accessible manual for speedy reference in the exigencies of his daily duties. For this latter purpose it< complete and extensive Index renders it especially valuable, offering facilities for immediately turning to any class of symptoms, or any variety of disease. The task of composing such a work is neither an easy nor a light one; but Dr. Barclay has performed it in a manner which meets our most unqualified, approbation. He is no mere theorist; he knows hit work thoroughly, and in attempting to perform it. oas not. exceeded his powers.— British Med. Journal. We venture to predict that the work will be deservedly popular, and soon become, like Watson'i Practice, an indispensable necessity to the practitioner.—N. A. Med. Journal. An inestimable work of reference for the yount practitioner and student.— Nashville Med. Journal. We hope the volume will have an extensive Oilculation, not among students of medicine only, but practitioners also. They will never regret a faith• ful study of its pages.— Cincinnati Lancet. An important acquisition to medical liter iture It is a work of higli merit, both from the vast im> por ance of the subject upon which it treats, and also flom the real anility displayed in 't« elaboration. In conclusion, let us bespeak for tins Volume that attention of every student of our art which it so richly deserves - that place in ev.:ry meuical library which it can so well adorn.- P ninsular Medical Journal. BARTLETT (£l_ISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVBRB OF THE UNITED STATES. A new and revised edition. By Alonzo Clark M. D., Prof of Pathology and Practical Medicine in the N. Y. College of Physicians and Surgeons, say of bis work that it. it an important uddition to obstetrical literature. The operative suggestions and contrivances which Mr. Brown de- exhibit much pructicul sagacity and akiii, und merit the careful attention of every surgeooaeeoueheur.—Association Journal. We have no hesitation in recommending this hook to tlie careful attention of all surgeons who make ; female complaints a part of their study and practice, i -Uuoiin juurttrly Journal 6 HENRY C. LEA'S MEDICAL BRANDE (WM. T.) D. C. L., akd ALFRED S. TAYLOR, M. D., F. R. S. Of her Majesty's Mint, Ice. Professor of Chemistry and Medical Jurisprudence in Ouy's Hospital. CHEMISTRY. In one handsome 8vo. volume of 696 pages, extra cloth. $4 50. «' Having been engaged in teaching Chemistry in this Metropolis, the one for a period of forty, and the other for a period ol thirty years, it has appeared to us that, in spite of the number of books already existing, there was room for an additional volume, which sheuld be especially adapted for the use of students. In preparing such a volume lor the press, we have endeavored to bear in mind, that the student in ihe present day has much to learn, and but a short time at his disposal for the acquisition of this learning."—Authors' Preface. In reprinting this volume, its passage through the press has been superintended by a competent chemist, who has sedulously endeavored to secure the accuracy so necessary in a work of this nature. No notes or additions have been introduced, but the publishers have been favored by the authors with some corrections and revisions of the first twenty-one chapters, which have been duly inserted. In so progressive a science as Chemistry, the latest work always has the advantage of presenting the subject as modified by the results of the lutest investigations and discoveries. That this advantage has been made the most of, arid that the work possesses superior attractions arising from its clearness, simplicity of style, and lucid arrangement, are manifested by the unanimous testimony of the Engli.-h medical press. It needs no great sagacity to foretell that this book will be, literally, the Handbook in Chemistry of the student and practitioner. For clearness of language, accuracy of description, extent of information, and freedom from pedantry aud mysticism of modern chemistry, no other text-book comes into competition with it. The result is a work which for fulness of matter, for lucidity of arrangement, for clearness of style, is as yet withont a rival. And long will it be without a rival. For, although with the necessary advance of chemical knowledge addenda will be required, there will be little to take away. The fundamental excellences of the book will remain, preserving it for years to come, what it now is, the best guide to Ihe study of Chemistry yet given to the world.— London Lancet, Dec. 20, 1862. Most assuredly, time has not abated one whit of the fluency, the vigor, and the clearness with which they not only have composed the work before us, but have, so to say, cleared the ground for it, by hitting right and left at the affectation, mysticism, and obscurity which pervade some late chemical treatises. Thus conceived, and worked out in the most sturdy, common sense method, this book gives, in the clearest and most summary method possible, all the facts and doctrines of chemistry, with more especial reference to the wants of the medical student.— London Medical Times and Gazette, Nov. 29, 1862. If we are not very much mistaken, this book will occupy a place which none has hitherto held among chemists; for, by avoiding the errors of previous authors, we have a work which, for its size, is certainly the most perfect of any in the English language. There are soveral points to be noted in this volume which separate it widely from any of its compeers— its wide application, not to the medical student only, nor to the student in chemistry merely, but to every branch of science, art, or commerce which is in any way connected with the domain of chemistry.—London Mbd. Review, Feb. 1863. BARWELL (RICHARD,) F« R. C. S., Assistant Surgeon Charing Cross Hospital, &c. A TREATISE ON DISEASES OF THE JOINTS. Illustrated with engravings on wood. In one very handsome octavo volume, of about 500 pages, extra cloth; $5 00. At the outset we may state that the work is worthy of much praise, und bears evidence of much thoughtful und careful inquiry, and here and there of no slight originality. We have already carried this notice further than we intended to do, but not to the extent the work deserves. We can only add, that the perusal of it has afforded us great pleasure. The author has evidently worked very hard at his •subject, and his investigations into the Physiology and Pathology of Joints have been carried on in a manner which entitles him to be listened to with attention and respect. We must not omit to mention the very admirable plates with which the volume is enriched. We seldom meet with such strik- ing and faithful delineations of disease.— London Med. Times and Gazette, Feb. 9, 1891. This volume will be welcomed, as the record of much honest research and careful investigation into the nature and treatment of a most important class of disorders. We cannot conclude this notice of a valuable and useful book without calling attention to the amount of bona fide work it contains. It is no slight matter for a volume to show laborious investigation, and at the same time original thought, on •the part of its author, whom v e mav congratulate on tne successful completion of his arduous task.— London Lancet, March 9,1861. CARPENTER (WILLIAM B.), M. D., F. R. 8., See, Examiner in Physiology and Comparative Anatomy in the University of London. THE MICROSCOPE AND ITS REVELATIONS. With an Appendix containing the Applications of the Microscope to Clinical Medicine, &c. By F. O. Smith, M. D. Illustrated by four hundred and thirty-four beautiful engravings on wood. In one large and very handsome octavo volume, of 724 pages, extra cloth, $5 25. The great importance of the microscope as a means of diagnosis, and the number ot microscopists who are also physicians, have induced the American publishers, with the author's approval, to add an Appendix, carefully prepared by Professor Smith, on the applications of '.he instrument to clinical medicine, together with an account of American Microscopes, their modifications and accessories. This portion of the work is illustrated with nearly one hundred wood-cuts, and, it is hoped, will adapt the volume more particularly to the use of the American student. Those who are acquainted with Dr. Carpenter's i The additions by Prof. Smith give it a positive f previous writings on Animal and Vegetable Physio- claim upon the profession, for which we doubt not ogy, willfully understand how vustudtore of know- he will receive their sincere thanks. Indeed, we ledge he is able to bring to bear upon so comprehen- know not where the student of medicine will find sive a subject as the revelations of the microscope ; 1 such a complete and satisfactory collection of microsnd even those who have no pievious acquaintance ] scopic facts bearing upon physiology and practical with the construction or uses of this instrument, medicine as is contained in Prof. Smith't appendix; will find abundance of information conveyed in clear and this of itself, it seems to us, is fully worth the ud simple language.— Med. Times and Gazette, i cost of the volume.— Louisville Medica, tieview. The additions by Prof. Smith give it a positive claim upon the profession, for which we doubt not he will receive their sincere thanks. Indeed, we know not where the student of medicine will find such u complete and satisfactory collection of microscopic facts bearing upon physiology und practical medicine as is contained in Prof. Smith't appendix; and this of itself, it seems to us, is fully worth the cost of the volume.— Louisville Medica, Review. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM BJ, M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the last and revised London edition. With nearly three hundred illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsylvania Medical College, dec. In one very large and beautiful octavo volume, ol about nine hundred large pages, handsomely printed, extra cloth, $5 £0 For upwards of thirteen yeara Dr. Carpenter'sI work haa been considered by the profession generally, both in thia country and England, as the most valuable compendium on the subject of physiology in our language. This distinction it owes to the high attainments and unwearied industry of its uccoinpUshed author. The present edition (which, like the .ast American one, was prepared by the author himself), is the result of such extensive revision, that it may almost be considered a new work. We need hardly say, in concluding this brief notice, that while the work is indispensable to every student of medicine in this country, it will amply repay the practitioner for its perusal by the interest and value of its contents.— Boston Med. and Surg. Journal. Tins is a standard work—the text-book used by ali medical students who read the English language. it haa passed through several editions in order to keep pace with the rapidly growing science of Physiology. Nothing need be said in its praise, for its merits are universally known; we have nothing toI say of its defects, for they only appear where the science of which it treats ia incomplete.— Western Lancet. The most complete exposition of physiology which any language can at present give.— Brit, and For. Mtd.-Chirurg. Review. The greatest, the moat reliable, and the best book oi the subject which we know of in the English language.— Stethoscope. To eulogize this great work would be superfluous. We should observe, however, that in this edition the author has remodelled a large portion of the former, and the editor has added much matter of interest, especially in the form of illustrations. We may confidently recommend it as the most complete work on Human Physiology in our language.— Southern Med. and Surg. Journal. The most complete work on the acience in our language.— Am. Med. Journal. The most complete work now extant in our language.—N. O. Med. Register. The best text-book in the language on this ex tensive subject.— London Med. Times. A complete cyclopaedia of this branch of science. — N. Y. Med. Times. i The profession of this country, und perhapa also I of Europe, have anxiously undforaometimeawaited the announcement of this neweditionof Carpenter s j Human Physiology. His former editions have for i many years been almost the only text-book on Physiology in ull our medical schools, and itseirculaj tion among the profession has been unsurpassed by I any work in any department, of medical science. ft ia quite unnecessary for us to apeak of thia I work as its merits would justify. The mere an| uouncement of itsappearance will afford the highest ' pleasure to every student of Physiology, while its perusal will be of infinite service in advancing 1 physiological science.— Ohio Med. and Surg. Joum BY THE SAME AUTHOR. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIOLOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp.566 $4 00. In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of "Elements" is still retained as being more expressive of the scope of the treatise. BY THE SAME AUTHOR. PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New American, from the Fourth and Revised London edition. In one large and handsome octavo volume, with over three hundred beautiful illustrations, pp. 752. Extra cloth, $5 00 This book should not only be read but thoroughly studied by every member of the profession. None are too wise or old, to be benefited thereby. But especially to the younger class would we cordially commend it as heat fitted of any work in the English language to qualify them for the reception and coinprehension of those truths which are daily being developed in physiology.— Medical Counsellor. Without pretending to it, it is an encyclopedia of the aubject, accurate and complete in all respects— a truthful reflection of the advanced state at which the science haa now arrived.— Dublin Quarterly Journal of Medical Science A truly magnificent work—in itself a perfect physiological study.— Ranking'* Abstract. This work stands without its fellow. It ia one few men in Europe could have undertaken; it ia one no man, we believe, could have brought to so successful un issue as Dr. Carpenter. It required for its production a physiologist at once deeply read in the labors of others, capable of taking a general, critical, and unprejudiced view of those labors, ana of combining the varied, heterogeneous materials at his disposal, so as to form an harmonious whole. We feel that this abstractcan give the reader a very imperfect idea of the fulness of this work, and no idea of its unity, of the admirable marner in which material has been brought, from the most various sources, to conduce to its completeness, of the lucidity of the reasoning it contains, or of the clearness of language in which the whole is clothed. Not the profession only, but the scientific world at large, must feel deeply indebted to Dr. Carpenter for this great work. It must, indeed, add largely even to his high reputation.— Medical Times. by the same aothor. (Preparing.) PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC CHEMISTRY AND HISTOLOGY. With a General Sketch oi the Vegetable and Animal Kingdom. In one large and very handsome octavo volume, with several hundred illustrations.. BY THE SAME AUTHOR. A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTB AND DISEASE. New edition, with tt Preface by D. F. Con die, M. D., and explanation ol scientific words. In one neat 12mo. volume, extra cloth, pp. 178. 60 cents. 8 HENRY C. LEA'S MEDICAL CONDIE (D. F.), M. D., 4tc. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth edition, revised and cugmented fn one large volume, 8vo., extra cloth, of over 750 pages. $4 50. In presenting a new and revised edition of this favorite work, the publishers have only to state that the author has endeavored to render it in every respect "a complete and faithful exposition of the pathology and therapeutics of the maladies incident to the earlier stages of existence—a full and exact account of the diseases of infancy and childhood." To accomplish this he has subjected the whole work to a careful and thorough revision, rewriting a considerable portion, and adding several new chapters. In this manner it is hoped that any deficiencies which may have previously existed have been supplied, that the recent labors of practitioners and observers have been thoroughly incorporated, ar d that in every point the work will be found to maintain the high reputation it has enjoyed as a complete and thoroughly practical book of reference in infantile affections. A few notices of previous editions are subjoined. Or. Cnndie'B scholarship, acumen., industry, and practical sense are manifested in this, as in all his numerous contributions to science.— Dr. Holmes's Report to the American Medical Association Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the greatest satisfaction.— Western Journal of Medicine and Surgery. One of ttie best works upon the Diseases of Chil•iren in the English language.— Western Lancet. We feel assured from uctual experience that ni physician's library can be complete without a copy of this work.— N V. Journal of Medicine. A veritable psediatric encyclopedia, and an honoi to American medical literature.— Ohio Medical and Surgical Journal We feel persuaded that the American medical profession will soon regard it not only us a very good, but as the verv best "Practical Treatise on th< Pi senses of Children."— American Medical Journal In the department of infantile therapeutics, the work of Dr. Condie is considered one of the nest which has been published in the English language. -The Stethoscope. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has been published, we still regard it. in that light.— Medical Examiner. The value of works by native authors on the diseases which the physician is called upon to combat, will be appreciated by all; an 1 the work of Dr. Condie has gained for itself the character of a safeguide tor students, and a useful work for consultation by those engaged in practice.— N. Y. Med Times. This is the fourth edition of this deservedly popular treatise. During the interval since the last edition, it has been subjected to a thorough revision by the author; and all new observations in the pathology and therapeutics of children have been included in the present volume. As we said b< fore, we do not know of a better book on diseases of cmldren, and to a large part of its recommendations we yield an unhesitating concurrence.— Buffalo Med Journal. Perhaps the most full and complete work now beore the profession of the United States; indeed, we nay saj in the English language. It is vastly superior to most of its predecessors.— Transylvania Med. Journal CHRISTISON (ROBERT), M. D., V. P. R. 5. E., sVc. A DTSPENSATOliY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Actions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and improved, with a Supplement containing the most important New Remedies. With copious Additions, and two hundred and thirteen large wood-engravings. By R. Ehlesfeld Griffith, M. D. In one very large and handsome octavo volume,extra cloth, of over 1000 pages. $4 CO COOPER (BRANSBY BJ, F. R. S. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. in one very large octavo volume, extra cloth, of 750 pages $2 00. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty-five Miscellaneous and Surgical Papers. One large volume, imperial 8vo., extra cloth, with 252 figures, on 36 plates. $3 DO. COOPER ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS ULAND. One vol. imperial8vo., extra cloth, with 177 figures on 29 plates. $2 50. CLYMER ON FEVERS: THEIR DIAGNOSIS) PATHOLOGY, AND TREATMENT. In ons octavo volume, leather, of 600 pages. SI 7 j. COLOMBAT DE L'ISERE ON THE DISEASES OF FEMALES, and on the special Hygiene of their Sex. Translated, with many Notes and Additions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, leather, with numerous wood-cuts. pp. 720. S3 75. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 8YNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania Whli three Lectures on the Modus Operandi of Medicines. Third edition, revised. In one handsome octavo volume. $2 50. CURLING (T. BJ, F.R.S., Surgeon to the London Hospital, President of the Hunterian Society, ice A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMATIC CORD, AND SCROTUM. Second American, from the second and enlarged English edition. In one handsome octavo volume, extra cloth, with numerous illustrations pp.420. 52 00 AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American from the fourth revised and enlarged London edition. With Notes and Additions, by D. Francis Condie, M. D., author of a "Practical Treatise on the Disease- of Children," fee With 194 illustrations. In one very handsome octavo volume of nearly 700 large pages, extra clolb, 84 00. This work has been so long an established favorite, both as a text-book tor the learner and as a reliable aid in consultation lor the practitioner, that in presenting a new edition it is otilv necessary to call attention to the very extended improvements which it has received Having had the benefit of iwo revisions by the author since the last American reprint, it has been materially enlarged, and Dr. Churchill's well-known conscientious industry is a guarantee that every portion has been thoroughly brought up with the latest results of European investigation in all departments of the science and art of obstetrics. The recent date of the last Dublin edition has not left mucfr of novelty for the American editor to introduce, but lie has endeavored to insert whatever ha* since appeared, together with such matters as his experience hus shown him would be desirable lor the American student, including a large number of illustrations Wilh the sanction of the author he has added in the form of an appendix, some chapters from a little "Manual for Midwive- and Nurses," recently issued by Dr. Churchill, believing 'hat the details there presented can hardly fail to prove ot advantage to the. junior practitioner. The result of all these auditions is that the work now contains fully one-half more matter than the last American edition, with nearly one-half more illustrations, so that notwithstanding the use of a smaller type, the volume contains almost two hundred p;'ges more than before. No effort has been spared to secure an improvement in the mechanical execution of the work equal to that which the text has received, and the volume is confidently presented as one of the handsomest that has thus far been laid before the American profession; while the verv low price at which it isdflered should secure for it a place in every lecture-room and on every office table. A better book in which to learn these important points we have not met than Dr. Churchill's. Every pfige of it is full of instruction; the opinion of all writers of authority is given on questions of difficulty, as well as the directions and advice of the learned autnor himself, to which be adds the result, of statistical inquiry, putting statistic s in their pio per place and giving them their cue weight, and no more. We. have never read a book more free from professional jealousy than Dr. Churchill's. It appears to be written with the true design of a book on medicine, viz : to give all that is known on the sub ject of which he treats, both theoretically and practically, and to advance such opinions of hit own as he believes will benefit medical science, and insure the safety of the patient. We have said enough to convey to the profession that this book of Dr. Cnurcitill's is admirably suited for a book of reference for the practitioner, as well as a text-book for the student, and we hope it mny be extensively pur chased amongst our readers. To them we most strongly recommend it. — Dublin Medical Press To bestow praise on a book that has received such marked approbation would be superfluous. Weneed only say, therefore, that if the first, edition was thought worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much interee 1 and instruction in everything relating to theoretical and practical midwifery.— Dublin Quarterly Tournal o f Medical Science A work of very great merit, and such as we can confidently recommend to the study of every obstetric practitioner.— London Medical Gazette. Few treatises will be found better adapted as i text-book for the student, or as a manual for tin freqaent. consultation of the young practitioner.- American Mudical Journal. Were we reduced to the necessity of having hut me work on midwifery, and permitted to choose, vc would unhesitatingly take Churchill.— Western Vied, and Surg. Journal ft is impossible to conceive a more useful and legant. manual than Or. Churchill's Practice of Midwifery.— Provincial Medical Journal Certainly, in our opinion, the very lest work on le subject which exists.—/V. V. Annalist. No work nolds a Higher position, or is more deserving of being placed in the hands of the tyro, the advanced student, or the practitioner.— Medical Examiner Previous editions have been received wit) marked favor, and they deserved it; hut this, reprinted from a very late Dublin edition, carefull) revised and brought up by the. author to the present time, docs present an unusually accurate arid able exposition of every important particular embraced iu the department of midwifery * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, liave served to place it already in tite foremost rank of works in tins department of remedial science.— V O Me,,-i and Sura Journal In our opinion, it tonus one of the best if not t e very best text-book and epitome of obstetric science which we at r resent possess in the English language.— Monthly Journal of Vfedie.al Science. The clearness anu precision of style in which it is written, and the great amount of statistic;- 1 research which it contains, have served to place it in t lie first rank of works in this departmentof medical science. — N. Y. Journal of Medicine. This is certainly the most perfect system extant, it is the best adapted for the purposes of a text)ook, and that which i;e whose necessities confine lim to one book, should select in preference to all ithers.— Southern Medical and Surgical Journal BY THE SAME AUTHOR ON THE DISEASES OF INFANTS AND CHILDREN. Seoond American Edition, revised and enlarged by the author. Edited, with Notes, by W. V*. Keating, M. U. Id one large and handsome volume, extra cloth, of over 700 pages. $4 50. In.preparmg this work a second time for the American profession, the author has spared no labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, while every portion of the volume has been subjected to a severe scrutiny. The efforts of the American editor have been directed to supplying such information relative to matters peculiar to this country as might have escaped the attention of the author, and the whole may, therefore, be safely pronounced one of the most complete works on the subject accessible to the American Profession. By an alteration in the size of the page, these very extensive additions have been accommodated without unduly increasing the size of the work. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PECULIAR TO WOMEN. Selected from the writings ol British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pag\es $2 50. 10 HENRY C. LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. O., M. R. I. A., &.C. ON THE DISEASES OF WOMEN; including those of Pregnancy and Childbed. A new American edition, revised by the Author. With Notes and Additions, by D Francis Condik, M. D., author ot " A Practical Treatise on the Diseases of Children." With numerous illustrations. In one large and handsome octavo volume, extra cloth, of 768 pages. $4 00. This edition ol Dr. Churchill's very popular treatise may almost be termed a new work, so thoroughly has he revised it in every portion. It will be found greatly enlarged, and completely brought up to the most recent condition of the subject, while the very handsome series of illustrations introduced, representing such pathological conditions as can be accurately portrayed, present a novel feature, and afford valuable assistance to the young practitioner. Such additions as appeared desirable for the American student have been made by the editor, Dr. Condie, while a marked improvement in the mechanical execution keeps pace with the advance in all other respects which the volume has undergone, while the price has been kept at the former very moderate rate. It comprises, unquestionably, one of the most exact and comprehensive expositions of the present state of medical knowledge in respect to the diseases of women that has yet been published.— Am. Journ. Med. Sciences. This work is the most reliable which we possess on this subject; and is deservedly popular with the profession.— Charleston Med. Journal, July, 1857. We know of no author who deserves that approbation, on "the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and students as a masterpiece in its particular department. — Tht Western Journal of Medicine and Surgery. As a comprehensive manual for students, or a work of reference for practitioners, it surpasses any other that has ever issued on the same subject from the British press.— Dublin Quart. Journal. DICKSON (S. H.), M. D., Professor of Practice of Medicine in the Jefferson Medical College, Philadelphia. ELEMENTS OF MEDICINE; a Compendious View of Pathology and Therepeutics, or the History and Treatmenl of Diseases. Second edition, revised. In one large and handsome octavo volume of 750 pages, extra cloth. $4 00. The steady demand whieh has so soon exhausted the first edition of this work, sufficiently shows that the author was not mistaken in supposing that a volume of this character was needed —an elementary manual of practice, which should present the leading principles of medicine with the practical results, in a condensed and perspicuous manner. Disencumbered of unnecessary detail and fruitless speculations, it embodies what is most requisite for the student to learn, and at the same time what the active practitioner wants when obliged, in the daily calls of his profession, to refresh his memory on special points. The clear and attractive style of the author renders the whole easy of comprehension, while his long experience gives to his teachings an authority everywhere acknowledged. Few physicians, indeed, have had wider opportunities for observation and experience, and few, perhaps, have used them to better purpose As the result of a long life devoted to study and practice, the present edition, revised and brought up to the date of publication, will doubtless maintain the reputation already acquired as a condensed and convenient American text-book on the Practice of Medicine. DRUITT (ROBERT), M.R. C.S., See. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new and revised American from the eighth enlarged and improved London edition. Illustrated with four hundred ami thirty-two wood-engravings. In one very handsomely printed octavo volume of nearly 700 large pages, extra cloth, $4 00. A work which like Druitt's Surgery h«s for so many years maintained the position of a leading favorite with all classes of the profession, needs no special recommendation to attract attention to a revised edition. It is only necessary to stale that the author has spared no pains to keep the work up to its well earned reputation of presenting in a small and convenient compass the latest condition of every department ol surgery, considered both as a science and as an art; and that the services of a competent American editor have been employed to introduce whatever novelties may have escaped the author's attention, or may prove of service to the American practitioner. As several editions have appeared in London since the issue of the last American reprint, the volume has had the benefit of repeated revisions by the author, resulting in a very thorough alteration and improvement. The extent of these additions may be estimated from the fact that it now contains about one-third more matter than the previous American edition, and that notwithstanding the adoption of a smaller type, the pages have been increased by about one hundred, while nearly two hundred and fifty wood-cuts have been added to the former list of illustrations. A marked improvement will also be perceived in the mechanical and artistical execution of the work, which, printed in the best style, on new type, and fine paper, leaves little to be desired as regards external finish; while at the very low price affixed it will be found one of the cheapest volumes accessible to the profession. This popular volume, now a most comprehensive work on surgery, has undergone many corrections, improvements, and additions, and the principles and the practice of the art have been brought down to the latest record and observation. Of the operations in surgery it is impossible to speak too highly. The descriptions are bo clear and concise, and the illustrations so accurate and numerous, that the student can have no difficulty, with instrument in hand, and book by his side, over the dead body, in obtaining a proper knowledge and sufficient tact in this much neglected department of medical education.— British and Foreign Medico-Chirurg. Review, Jan. 1960 In the present edition the author has entirely rewritten many of the chapters, and has incorporated the various improvements and additions in modern surgery. On carefully going over it, we find that 1 nothing of real practical importance has been omitj ted ; it presents a faithful epitome of everything relating t > surgery up to the present hour. It is de: servedly a popular manual, both with the student i and practitioner.— London Lancet. Nov. 19, 1859. In closing this brief notice, we recommend as cordially as ever this most useful and comprehensive hand-book. It must prove a vast assistance, not only to the student of surgery, but also to the busy practitioner wh< may not have the leisure to devote himself to the study of more lengthy volumes.— London Mtd. Times and Gazette, Oct. 29,1859. In a word, this eighth edition of Dr Druitt'a Manual of Surgery is all that the surgical student or practitioner could desire. — Dublin Quarterly j Journal of Mtd. Sciences, Nov. 1869. AND SCIENTIFIC PUBLICATIONS. 11 DALTON, JR. (J. C), M. D. Professor of Physiology in the College of Physicians, New York. A TREATISE ON HUMAN PHYSIOLOGY, designed for the use of Students and Practitioners of Medicine. Third edition, revised, with nearly three hundred illustrations on wood. In one very beautiful octavo volume,of 700 pages, extra cloth, $5 25. (Just Issued.) The rapid demand for another edition of this work sufficiently shows that the author has succeeded in his efforts to produce a text-book of standurd and permanent value, embodying within a moderate compass all that is definitely and positively known within ihe domain of Human Physiology. His high reputation as an original observer and investigator, is a guarantee that in again revising it he has introduced whatever is necessary to render it thoroughly on a level with the advanced science of the day, and this has been accomplished without unduly increasing the size of the volume. No exertion has been spared to maintain the high standard of typographical execution which has rendered this work admittedly one of the handsomest volumes as yet produced in this coun'ry. It will be seen, therefore, that Dr. Dalton's best efforts have been directed towards perfecting his work. The additions are marked by the same features which characterize the remainder of the volume, and render it by far the most desirable textbook on physiology to place in the hands of the student which, so far as we are aware, exists in the English language, or perhaps in any other. We therefore have no hesitation in recommending Dr. Dalton's hook for the classes for which it is intended, satisfied as we are that it. is better adapted to their use than any other work of the kind to which they have access.— American Journal of the Med. Sciences, April, 1861. It is, therefore, no disparagement to the many books upon physiology, most excel len'. in their day, to say that Dalton's is the only one that gives us the science as it was known to the best philosophers throughout the world, at the beginning of the current year. It states in comprehensive hut concise diction, the facts established by experiment, or other method of demonstration, and details, in an understandable manner, how it is done, but abstains from thediscussion of unsettled or theoretical points. Herein it it unique; and these characteristics r*n der it a text-book without a rival, for those who desire to study physiological science as it is known to its most successful cultivators. And it is physiology thus presented that lies at the. foundation of correct pathological knowledge; and this in turn is the basis of rational therapeutics; so that path .dogy, in fact, becomes of prime importance in the proper discharge of our every-day practical duties. — Cincinnati Lancet, May, 1861. Dr. Dalton needs no word of praise from us. He ia universally recognizeo as among the first, if not ihe very fugt, of American physiologists now living. The fi rst edition of his admirable work appeared but two years since, and the advance of science, his own original views and experiments, together with a desire to supply what he considered some deficiencies in the firBt edition, have already made the present one a necessity, and it will no doubt be even more eagerly sought for than the first. That it ia not merely a reprint, will be Been from the author's statement of the foi'owing principal additions and alterations which he has made. The present, like the first edition, is printed in the highest style of the printer's art, and the illustrations are truly admirable tor their clearness in expressing exactly what their author intended.— Boston Medical and Surgical Journal, March 28, 1881. It is unnecessary fogive a detail of t he additions j suffice it to say, that they are numerous and important, and such as will render the work still more valuable and acceptable to the profession as a learned and ci iginal treatise on this all-import tint branch of meJicine. All that was said in commendation of the getting up of the first edition, and the superior style of the illustrations apply with equal fotce to this. No better work on physiology can be placed in the hand of the student.—Si. Louis Medical and Surgical Journal, May, 1861. These additions, while tes ifying to the learning and [nduatn of the author, render the book exceedingly useful, as the most complete expose of a science, of which Dr. Dal ton is doubtless the ablest representative on this side of the Atlantic.— New Orleans Med Times, May, 1861. A second edition of this deservedly popular work having been called for in the short space of two years, the author has supplied deficiencies, which existed in the former volume, and has thus more completely fulfilled his design of presenting to the profesjion a reliable and precise text- book, and one which we consider the liest outline on the subject of which it treats, in any language.— N. American Medico-Chirurg. Review, May, ibOl. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, Jre. &c. In four lurge super-royal octavo volumes, of 325-t double-columned pages, strongly and handsomely bound, with raised bands. Sl. r > 00. This work contains no less than (bur hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner. The most complete work on Practical Medicine sxtant; or, at least, in our language.— Buffalo Medical and Surgical Journal. For reference, it ia above all price to every practitioner.— Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal oj Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.— Medical Examiner. | The editors are practitioners of established reputation, and the list of contributors embraces many j of the most eminent professors and teachers of London. Edinburgh, Dublin, and Glasgow. It is, in| deed, the great merit ot t h is work t hat I he principal ] articles have been furnished by practitioners who j have not only devoted especial attention to the diseases about which they have written, but have (also enjoyed opportunitiei for an extensive practical acquaintance with them and whose reputation carries the assurance of their competency justly to appreciate the opinions o" others, while it stamps theirown doctrines will high and just authority.— I American Medical Journal. DEWEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings Twelfth edition, with the author's last improvements and corrections In oneoctavovolume, extra cloth, of600 pages .#3 50. DEWEES'S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD REN. The last edition In one volume, octavo, extra cloth, 548 pages S9 80 OEWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenlii edition In one volume, octavo extra cloth, 532 pages, with plates $3 00. 12 HENRY C. LEA'S MEDICAL DUNG LISON (ROBLEY), M . C., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia ENLARGED AND REVISED EDITION OF 1865— k Just Issued.) MEDIOAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation oi the various* Subjects and Terms of Anatomy, Physiology, Pathology, Hygienc ; Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence,and Dentistry. Notices of Climate and of Mineral Waters; Formulae for Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. Thoroughly revised and very greatly modified and augmented. In one very large and handsome royal octavo volume, of 1048 double-columned pages, in small type, strongly done up in extra cloth, $0 00; leather, raited bands, $6 75 Preface to the New Edition «' The author has again been required to subject his Medical Lexicon to a thorough revision. The progress of Medical Science, and the consequent introduction of new subjects and terms, demanded this; and he has embraced the occasion to render more complete the etymology and accentuation of tht terms. On no previous revision ha* so much time and labor been expended by him. Some idea may be formed of this, from the fact, that although the page has been augmented in all its dimensions, not lewer than between sixty and seventy pages have been added. "As the author has remarked on former occasions, it has ever been his ardent wish to make the work a satisiaetorvand desirable —if not indispensable—lexicon, in which the inquirer may search, without disappointment, for every term that has been legitimated in the nomenclature of the science; and he confidently presents this edition as having more claims on the attention of the practitioner and student than its predecessors. 'Once morethe auihor glad ! y seizes the opportunity afforded him to express his grateful acknowledgments for the vast amount of favor which has been extended to the Dictionary." January, 1S65. The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, under each a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand whica has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the position of a recognized and standard authority wherever the language is spolen. This has only been accomplished by the earnes'. determination to bring each successive edition thoroughly on a level with the most advanced condition of contemporary medical science, and on no previous occasion has tnis demanded a more patient and laborious effort than in rendering the present edition fully equal to the wanls of the student of the present day, and in no previous editions has the amount of few matter introduced been so large. While, therefore, the reader who merely de.-ire* a vocabulary explaining the terms in common use can satisfy himself wit! the smaller works, such as lloblyn's, the student and practitioner who wish a work to which they can at all times refer with unfailing confidence 'or ail which it is the province of such a book to supply, must still, as heretofore, keep the latest edition of " Ditnglison's Dictionary" within reach. The mechanical execution of this edition will be found greatly superior to that of previous impressions. By enlarging the size of the volume to a royal octavo, and by the employment of a small but clear type on extra fine paper, the additions have been incorporated without materially increasing the bulk of the volume, and ihe matter of two or three ordinary octavos has been compressed into the space of one not unhandy tor consultation and reference. A few notices of the previous editions are subjoined. This work, the appearance of the fifteenth edition of which it has become our duty and pleasure to announce,is perhaps the most stupendous monument of labor and erudition in medical literature. One would hardly suppose after constant use of the preceding editions, where we have never failed to find a sufficiently full explanat ion of every medical term, that in this edition " about six thousand subjects and terms have been added," with a careful revision and correction of the entire work. It is only necessary to announce the advent of this edition to make it occupy the place of the preceding one on the table of every medical man, us it is without.doubt the best And most comprehensive work of the kind which has ever appeared.— Buffalo Med. Journ., Jan. 1858. The work is a monument of patient research, skilful judgment, and vast physical labor, that will perpetuate the name of the author more effectually than any possible device of stone or metal. Dr. Dunglison deserves the thanks not only of the American profession, but of the whole medical world.— North Am. Medico-Chir. Review, Jan. 1858. A Medical Dictionary better adapted for the wants of the profession than any other with which we are acquainted, and of a character which places it far above comparison nnd competition.— Am. Journ. Med. Sciences, Jan. 1858. We need only say, that the addition of 6,000 new terms, with their accompanying definitions, ma) be 8aid to constitute a new work, by itself. We have examined the Dictionary attentively, and are most happy to pronounce it unrivalled of its kind. The erudition displayed, and the extraordinary industry which must have been demanded, in its preparation and perfection, redound to the lasting credit of its 'iiirhor, and have furnished nt with a volume indispensable at. the present day, to all who would find themselves au niveau with the highest standards of nedical information.— Boston Medical and Surgical T ournal, Dec. 31, 1857. Good lexicons and encyclopedic works generally, ire the most labor-saving contrivances which literary men enjoy ; and the labor which is required to produce them in the perfect manner of this example S something appalling to contemplate. The author tells us in nis pretace that ne aaa added about six thousand terms and subjects to this edition, which, before, was considered universally as the best work of the kind in any language Silliman's Journal, March, 1858. A complete and thorough exponent of medical terminology, without rival or possibility of rivalry. — Nashville .Tourn. of Med. and Surg., Jan. 1858. It is universally acknowledged, we believe, that this work is incomparably the best and most complete Medical Lexicon in the English language. Comment and commends tion are unnecessary, as no one at the present daj thinks of purchasing any other Medical Dictionary than this.— St. Louis Med. and Surg. Journ., Jan 1858. It is the foundation stone of a good medical library, and should always be included in the first list of books purchased by the medical student.— Am. Med. Monthly, Jan. 1858. It is scarcely necessary to remark that any medical library wanting a copy of Dunglison's Lexicon must be imperfect.— Cin. Lancet, Jan. 1858. The present edition we may safely say lias no equal in the world.— Peninsular Med. Journal Jan. 1858. AND SCIENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M. D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and extensively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, extra cloth, of about 1500 pages. $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled; the investigations which of late years have been so numerous and so important, have been carefully examined and incorporated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. We believe that it can truly be said, no more complete repertory of facts upon the subject treated, can anywhere be found. The author has, moreover, that enviable tact at description and that facility and ease of expression which render him peculiarly acceptable to the casual, or the studious reader. This faculty, so requisite in setting forth many graver and less attractive subjects, lends additional charms to one always fascinating.— Boston Med. and Surg. Journal. The most complete and satisfactory system of Physiology in the English language.— Amer. Med. Journal. The best work of the kind in the English language.—Silliman's Journal. The present edition the author has made a pcifcct mirror of the science as it is at the present hour. As a work upon physiology proper, the science of the functions performed by the body, the student will find it all he wishes.— Nashville Journ. of Med. That he has succeeded, most admirably succeeded in his purpose, is apparent from the appearance of an eighth edition, ft is now the great encyclopaedia on the subject, and worthy of a place in every physician's library.— Western Lancet. BY THE SAME AUTHOR. GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. With Indexes of Remedies and of Diseases and their Remedies. Sixth Edition, revised and improved. With one hundred and ninety-three illustrations. In two large and handsomely printed octavo vols., extra cloth, of about 1100 pages. $6 50. In announcing a new edition of Dr. Dunglison's General Therapeutics and Materia Medica, we have no words of commendation to bestow upon a work whose merits have been heretofore so often and so justly extolled. It must not be supposed, however, that the present is a mere reprint of the previous edition: the character of the author for laborious research, judicious analysis, and clearness of expression, is fully sustained by the numerous additions he has made to the work, and the careful revision to which he has subjected the whole.— N. A. Medico-Chir. Review, Jan. 1858. The work will, we have little douht, be bought and read by the majority of medical students; its size, arrangement, and reliability recommend it to all; no one, we venture to predict, will study it without profit, and there are few to whom it will not be in some measure useful as a work of reference. The young practitioner, more especially, will find the copious indexes appendid to this edition of great assistance in the selection and preparation of suitable formulx.— Charleston Med. Journ. and Review, Jan. 1858. BY THE SAME AUTHOR NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large oclavo volume, extra cloth, of 770 pages. $4 00. One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of reference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—JV«i* York Med. Gazette. The great learning of the author, and his remarkable industry in pushing his researches into every source whence information is derivable,have enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to examine the original papers.— The American Journal of Pharmacy. ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Eleventh edition, carefully revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one volume, 8vo., ofabout350 pages. $3 00. (Just Issued.) On no previous edition of this work has there been so complete and thorough a revision The extensive changes in the new United States Pharmacopoeia have necessitated corresponding alterations in the Formulary, to conform to that national standard, while the progress made in the materia medica and the arts of prescribing and dispensing during the last ten years have been carefully noted and incorporated throughout. It is therefore presented as not only worthy a continuance of the lavor so long enjoyed, but as more valuable than ever to the practitioner and pharmaceutist. Those who possess previous editions will find the additional matter of sufficient importance to warrant their adding the present to their libraries. 14 HENRY C. LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, &c. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. New and improved American, from the second enlarged and carefully revised London edition. Illustrated with over four hundred engravings on wood. In one large and handsome octavo volume, of one thousand closely printed pages, extra cloth, $6 CO. The very distinguished favor with which this work has been received on both sides of the Atlantic has stimulated the author to render it even more worthy of the position which it has so rapidly attained as a standard authority. Every portion has been carefully revised, numerous additions have been made, and the most watchful care has been exercised to render it a complete exponent of the most advanced condition of surgical science. In this manner the work has been enlarged by about a hundred pages, while the series of engravings has been increased by more than a hundred, rendering it one of the most thoroughly illustrated volumes before the profession. The additions of the author having rendered unnecessary most of the notes of the former American editor, but little has been added in this country; some few notes and occasional illustrations have, however, been introduced to elucidate American modes of practice. It is, in our humble judgment, decidedly the best book of the kind in the English language. Strange that just such books are notoftener produced by public teachers of surgery in this country and Great Britain. Indeed, it is a matter of great astonishment, but no less true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books for medical students, this is the only one that even ap proximates to the fulfilment of the peculiar wants of youngmen justenteringuponthe study ofthisbranch of the profession.— Western Jour .of Med. and Surgery. Its value is greatly enhanced by a very copious well-arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his novitiate of practice, we regard it the most serviceable guide which he can consult. He will find a fulness of detailleadinghim through every step of the operation, and not deserting him until the final issue of the case is decided.— Sethoscope. Embracing, as will be perceived, the whole surgi cal domain, and each division of itself almost com plete and perfect,each chapterfull and explicit, eac) subject faithfully exhibited, we can only express ou estimate of it in the aggregate. We consider it ar excellent contribution to surgery, as probably the best single volume now extant on the subject, and with great pleasure we add it to our text-books.— Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, profusely illustrated, are rich in physiological, pathological, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and surgeon, in the hour of peril.— N. 0. Med, and Surg Journal. We may say, after a careful perusal of some of the chapters, and a more hasty examination of the remninder, that it must raise the character of the author, and reflect great credit upon the college to which he is professor, and we can cordially recommend it as a work of reference hotn to students and p'ac'.itioners.— Med. Times and Gazette. We do not hesitate to say that the volume before us gives a veiy admirable practical view of the science and art ol Surgery of the present day, and we have no doubt that it will be highly valued as a surgical guide as well by the surgeon as bv the student of surgery. — Edinburgh Med. and Swg. Journal. FISKE FUND PRIZE ESSAYS — THE EF- I FECTS OF CLIMATE ON TUBERCULOUS DISEASE. By Edwin Lee, M. R. C. S , London, and THE INFLUENCE OF PREGNANCY ON I THE DEVELOPMENT OF TUBERCLES By Edward Warren, M. D.,of Edenton,N. C. Together in one neat 8vo. volume, extra cloth. SI 00. FRICK ON RENAL AFFECTIONS; their Diagnosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. 75 cents. FERGUSSON (WILLIAM), F. R. 3., Professor of Surgery in King's College, London, Ac. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $4 CO. FOWNES (GEORGE), PH. D., 4Vc. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. Edited by Robert Bridges, M. D. In one large royal 12mo volume, of 600 pages, extra cloth, $2 00. The death of the author having placed the editorial care of this work in the practised hands of Drs. Bence Jones and A. W. Hoffman, everything has been done in its revision which experience could suggest to keep it on a level with the rapid advance of chemical science. The additions requisite to this purpose have necesMtated an enlargement of the page, notwithstanding which the work has been increased by about fifty pages. At the same time every care has been used to maintain its distinctive character as a condensed manual for the student, divested of all unnecessary detail or mere theoretical speculation. The additions have, of course, been mainly in the department of Organic Chemistry, which has made such rapid progress within the last few years, but yet equal attention has been bestowed on the other branches of the subject—Chemical Physics and Inorganic Chemistry—to present all investigations and discoveries of importance, and to keep up the reputation of the volume as a complete manual of the whole science, admirably adapted for the learner. By the use of a small but exceedingly clear type the matter of a large octavo is compressed within the convenient and portable limits of a moderate sized duodecimo, and at the very low price affixed, it is offered as one of the cheapest volumes before the profession. Dr. Fownes'excellent work has been universally recognized everywhere in his own and this country, as the best elementary treatise on chemistry in the English tongue, and is very generally adopted, we believe, as the standard text-book in all i ur colleges, both literary and scientific.— Charleston Med. Journ. and Review The work of Dr. Fownes has long been before the public, and its merits have been fully appreciated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.— Lon don Journal of Medicine. AND SCIENTIFIC PUBLICATIONS. 15 FLINT (AUSTIN), M. D., Professor of the Principles and Practice of Medicine in Bellevue Hosp. Med. College, New York. Novo Ready, 1866. THE PRINCIPLES AND PRACTICE OF MEDICINE. For the use of Practitioners and Students. In one large and handsome octavo volume of over 850 closely printed pages, leather, raised bands, $7; handsome extra cloth, $6. The want has for some time been felt in this country of a volume which, within a moderate compass, should give a clear and connected view of general and special pathology and therapeutics in their most modern aspect. Re 'ent researches have modified many opinions which were formerly universally received on important points both of theory and practice, and these changes nave perhaps as vet scarcely received the attention due to them in the works accessible to the profession. The author's reputation as a teacher is a guarantee that the present volume will be fully up to the most advanced state of the science of the day, while his long and varied experience as a practitioner will insure that in all practical details his work will be a sound and trustworthy guide. the same author. (Preparing.) PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second edition. In one large and handsome octavo volume, extia cloth. THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. In one neat octavo volume, ol about 500 pages, extra cloth. $3 50. We do not know that Dr. Flint has written anything which is not first rate; but this, his latest contribution to medical literature, in our opinion, surpasses all the others. The work is moBt comprehensive in its scope, and most sound in the. views it enunciates. The descriptions are clear and methodical; the statements are substantiated by facts, and are made with such simplicity and sincerity, that without them they would carry conviction. The style is admirably clear, direct, and free from dryness. With Dr. Walshe's excellent treatise before us, we have no hesitation in saying that Dr. Flint's book is the best work on the heart in the English language. —Boston Med. and Surg. Journal. GRAHAM (THOMAS), F. R. S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applications of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, ot over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $5 ">1. Part II., completing the work from p. 431 to end, with Index, Title Matter, &c, may be had separate, cloth backs and paper sides. Price $3 00. From Prof. E. N. Horsford, Harvard College. It has, in its earlier and less perfect editions, been familiar to me, and the excellence of its plan and the clearness and completeness of its discussions, have long been my admiration. No reader of English works on this science can l afford to be without this edition of Prof. Graham's ! Elements.— Silliman's Journal, March, 1858. I From Prof. Wolcott Gibbs, N. Y. Free Academy The work is an admirable one in all respects, and its republication here cannot fail to exert a positive ; influence upon the progress of science in this country. GRIFFITH (ROBERT E.), M. D., «tc. A UNIVERSAL FORMULARY, containing the methods of Preparing and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu. tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo volume, extra cloth, of 650 pages, double columns. $4 00. It was a work requiring much perseverance, and i when published was looked upon as by far the besi Work of its kind that had issued from the American ! press. Prof. Thomas has certainly "improved," as well as added to this Formulary, and has rendered it additionally deserving of the confidence of pharmaceutists and physicians.— Am. Journal of Pharmacy. We are happy to announce a new and improved edition of this, one of the most valuable and useful works that have emanated from an American pen. It would do credit to any country, and will be found of daily usefulness to practitioners of medicine; it is better adapted to their purposes than the dispensatories.—Southern Med. and Surg. Journal. Itis one of the most useful books a country practitioner can possibly have.— Medical Chronicle. This is a work of six hundred and fifty-one pages embracing all on the subject of preparing and admi nistering medicines that can be desired by ihe physi cian and pharmaceutist.— Western Lancet. The amountof useful, every-day matter,for a prac ticing physician, is really immense.— Boston Med and Surg. Journal. This edition has been greatly improved by the re- vision and ample additions of Dr Thomas, and is now, we believe, one of the mosi complete works of its kind in any language. The additions amount to aboulseventy pages, and no effort has been spared to include in them all the recent improvements. A work of this kind appears to us indispensable to the physician, and there is none we can more, cordially recommend —IV. Y. Journal of Mediein*. Pre-eminent among the best and most useful compilations of the present day will be found the work before us, which can have been produced only at a very great cost of thought and labor. A short des--ription will suffice to show that we do not put too high an estimate on this work We are not cognizant of the existence of a parallel work. Its value will be apparent to our readers from tne sketch of its contents above given. We strongly recommend it to all who are engtiged either in practical medicine, or moreexclusively with its liteiature.— Load. Med. Gazette. A very useful work, and a most complete compendium on the subject of materia medica. We know of no work in our language, or any other, so comprehensive in all its details.— London Lancet. 16 HENRY C. LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, Ac. Enlarged Edition. Now Ready. A SYSTEM OP SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by over Thirteen Hundred Engravings. Third edition, much enlarged and carefully revised. In two large and beautifully printed royal octavo volumes, of 2200 pages; leather. $15 00. {Just Issued.) The exhaustion within five years of two large editions of so elaborate and comprehensive a work as this is the best evidence that the author was not mistaken in his estimate of the want which existed of a complete American System of Surgery, presenting the science in all its necessary details and in all its branches. That he has succeeded in the attempt to supply this want is shown not only by the rapid sale of the work, but also'by the very favorable manner in which it has been received by the organs of the profession in this country and in Europe, and by the fact that a translation is now preparing in Holland —a mark of appreciation not often bestowed on any scientific work so extended in size. The author has not been insensible to the kindness thus bestowed upon his labors, and in revising the work for a third edition he has spared no pains to render it worthy of the favor with which it has been received. Every portion has been subjected to close examination and revision; any deficiencies apparent have been supplied, and the results of recent progress in the science and art of surgery have been everywhere introduced; while the series of illustrations has been still further enlarged, rendering it one of the most thoroughly illustrated works ever laid before ihe profession. To accommodate these very extensive additions, the form of the work has been altered to a royal octavo, so that notwithstanding the increase in the mattei and value of the book, its size wi I be found more convenient than before. Every care has been taken in the printing to render the typographical execution unexceptionable, and it is confidently expected to prove a work in every way worthy ol a place in even the most limited library of the practitioner or student. Has Dr. Gross satisfactorily fulfilled this object? A caieful perusal of his volumes enables us to give an answer in the affirmative. Not only hashegiven to the reader an elaborate and well-written account of his o«vn vast experience, but he has not failed to embody in his pages the opinions and practice of surgeons in this and other countries of Europe. The result has been a work of such completeness, that it has no superior in the systematic treatises on surgery which have emanated from English or Continental authors. It has been justly objected that these have been far from complete in many essential particulars, many of them having been deficient in some of the most important points which should characterize such works Some ol them have been elaborate—too elaborate—with respect to certain diseases, while they have merely glanced at, or given an unsatisfactory account of, others equally important to the surgeon. Dr. Gross has avoided this error, and has produced the most complete work that has yet issued from the press on the science and practice of surgery. It is not, strictly speaking, a Dictionary of Surgery, but it gives to the reader all the information that he may require for his treatment of surgical diseases. Having said so much, it might appear superfluous to add another wird; but it is only due to Dr. Gross to state that be has embraced the opportunity of transferring to his pages a vast number ol engravings from English and other authors, illustrative ot the pathology and treatment of surgical diseases. To these are added several hundred original wood-cuts. The work altogether commends itself to the attention of British surgeons, from whom it cannot fail to meet with extensive patronage.— London Lancet, Sept. 1, 1860. Of Dr. Gross's treatise on Surgery we can say no more than that it is the most elaborate and com- Elete work on this branch of the healing art whicl as ever been published in any country. A systematic woik, it admits of no analytical review; but, did our space permit, we should gladly give some extracts from it, to enable our readers to judge of the classical style of the author,and the exhausting way in which each subject is treated.— Dublin Quarterly Journal of Med. Science. The work is so superior to its predecessors in matter and extent, as well as in illustrations and style of publication, that we can honestly recommend it as the best work of the kind to be taken home by the young practitioner— Am. Med. Journ. With pleasure we record the completion of this long-anticipated work. The reputation which the author has for many years sustained, both us a surgeon and as a writer, had prepared us to expect a treatise of great excellence and originality; but we confess we were by no means prepared for the work which is before us—the most complete treatise upon surgery ever published, either in this or any othtr country, and we might, perhaps, safely say, the most original. Then is no subject belonging properly to surgery which has not received from the author a due share of attention. Dr. Grois has supplied a want in surgical literature which has long been felt by practitioners; he has furnished us with a complete practical treatise upon surgery in all its departments As Amencins, we are proud of the achievement; as surgeons, we are most sincerely thankful to him for his extraord nary labors in our behalf.— N. Y. Review and Buffalo Med Journal. The great merit of the work may be stated as follows. It presents surgical science as it exists at the latest date, with all its improvements ; and it discusses every topic in due proportion. Nothing is omitted, nothing is in excess.— Chicago Med Examiner, May, 1860. We cannot close this brief notice of Dr. Gross's most valuable and excellent compendium of Surgery without again drawing attention to it, as we uid in our notice of his first edition, as an evidence of the progress our American brethren are making towards establishing a literature of their own.— Dublin Quarterly Journal, Feb. 1863. It has been characterized by the representative press and by individual surgeons of the highest eminence, both at home and abroad, as " the best systematic work on surgery ever published in the English language;" and that the profession at large have given substantial proofs of their agreement to this verdict, is sufficiently evident from the fact that translations into European languages have been called for, and that jo shortly after i's first appearance, and at a time most unfavorable to literary " enterprise," the Philadelphia puolishers have found il pay to issue a " second edition, much enlarged and carefully revised."— American Med. Monthly, May, 1862 We are much gratified to be able to announce a new edition of this Cyclopcedia of Surgtry. Considering the large size of the work and its expensiveness, the extremely rapid sale and exhaustion of an entire edition, not only proves the value of the work, and its adaptation to the wants of the profession, but it speaks well for the intelligence of American surgeons.— American Medical Times, May, 1862. A valuable and even necessary addition to every surgical library.— Chicago Med. Journ., Dec. 1859. A system of surgery which we think unrivalled in our language.— British American Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. 92 75. AND SCIENTIFIC PUBLICATIONS. 17 GROSS (SAMUEL D.), M. D. Professor of Surgery in the Jefferson Medical College of Philadelphia, Sec. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo volume, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings, extra cloth. $4 00.. The very rapid advances in the Science of Pathological Anatomy during the last few years have rendered essential a thorough modification of this work, with a view of making it a correct exponent of the present state of the subject. The very careful manner in which this task has been executed, and the amount of alteration which it has undergone, have enabled the author to say that " with the many changes aud improvements now introduced, the work may be regarded almost as a new treatise," while the efforts of the author have been seconded as regards the mechanical execution of the volume, rendering it one of the handsomest productions of the American press. THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER. THE PPOSTATE GLAND, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eightyfour illustrations. In one large and very handsome octavo volume, of over nine hundred pages, extra cloth, $4 00. Philosophical in 'ts design, methodical in its arrangement,ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so important a subject.— Boston Med. and Surg Journal Whoever will peruse the vast amount of valuable practical information it contains, will, we think agree with us, that there is no work in the English language which can make any just, pretensions to be. its equal.— N Y. Journal of Medicine ' A volume replete with truths and principles of the itmost value in I lie i n vest i gat ion of these diseases.— American Medical Journal. GRAY (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London, tea. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M. D.,late Demonstrator on Anatomy at St. George's Hospital; the Dissections jointly by the Author and Dr. Carter. Second American, from the sec >nd revised and improved London edition. In one magnificent imperial octavo volume, of over 800 pages, wiih 388 large and elaborate engravings on wood. Price in extra cloth, $'5 00; leather, raised bands, $7 00. The speedy exhaustion of a large edition of this work is sufficient evidence that its plan and execution have been found to present superior practical advantages in facilitating the study ot Anatomy In presenting' it to the profession a second time, the author has availed himself of the opportunity to supply any deficiencies which experience in its use had shown to exist, and to correct any errors of detail, to which the first edition of a scientific work on so extensive and complicated a science is liable. The>e improvements have resulted in*some increase in the size of the volume, while twenty-six new wood-cut* have been added to the beautiful series of illustrations which form so distinctive a feature of the work. The American edition ha* been passed through the press under the supervision of a competent professional man, who has taken every care to render it in all re-pects accurate, and it is now presented, without any increase of price, as fitted to maintain and extend the popularity which it has everywhere acquired With little trouble, the busy practitioner whose knowledge of anatomy may have become obscured by want of practice, may now resuscitate his former anatomical lore, and be ready for any emergency. It is to this class of individuals, and rot to the student alone, that this work will ultimately tend to be of most incal sulable advantage, and we feel satisfied that the library of the medical man will soon be considered incomplete in which a cony of this work does not exist.- Madras Quarterly Journal of Med. Science, July, 1861. This edition is much improved and enlarged, and contains several new illustrations by Dr. Westmacott. The volume is a complete companion to the dissecting-room, and saves the necessity of the stu dent possessing a variety of" Manuals."— The Lon don Lancet, Feb. 9, 1861. The work before us is one entitled to the highest praise, and we accordingly welcome it as a valuable addition to medical literature. Intermediate in fulness of detail between the treatises of S uirpey and of Wilson, its characteristic merit lies in the number and excellence of the engravings it contains. Most of these are original, of much larger than ordinary size, and admirably executed The various parts are also lettered after the plan adopted in Holden's Osteology. It would be difficult to over-estimate the advantages offend by this mode of pictorial illustration. 8 ones, ligaments, muscles, bloodvessels, and nerves are each in turn figured, and marked with their appropriate names; thus enabling the student to cm mprehend, at a glance, what would otherwise often be ignored, or at any ! rate, acquired only by prolonged and irksome application. In conclusion, we heartily commend the 1 work of Mr. Gray to the attention of the medical profession, feeling certain that it should he regarded is one of tlie most valuable contributions ever made to educational literature.— N. Y. Monthly Review. Dec. 1859. In this view, we regard the work of Mr. Gray as far better adapted to the wants of the profession, and especially of the student, than any treatise on matomy yet published in th is country. It is destined, we believe, to supersede ill others, both as a manual )f dissections, and a standard of reference to the student of general or relative anatomy. — N. Y. Journal of Medicine, Nov. 1859. In our judgment, the mode of illustration adopted in the present volume cannot but present many advantages to the studentof anatomy. To the zealous disciple of Vesalius, earnestly desirous of real improvement, the book will certainly be of immense value; but, at the same time, we must also confess that to those simplv desirous of " cramming" it will be an undoubted godsend. The peculiar value of Mr. Gray's mode of illustration is nowhere more markedly evident than in the chapter on osteology, and especially in those portions which treat of the bones of the head and of thsir development. The study of these parts is thus made one of comparative e ise, if not of positive pleasure: and those bugbears of the student, the temporal and sphenoid bones, are shorn of half their terrors. It is, in our estimation, an admirable and complete text-book for the student, and a useful work of reference for the practitioner; its pictorial character forming a novel element, to which we have already sufficiently alluded.— Am. Journ. Med. Sci., July, 1859. HENRY- C. LEA'S MEDICAL 18 GIBSON'S INSTITUTES AND PRACTICE OF SURGERY. Eighth edition, improved and altered. With thirty-lour plates. In two handsome octavo volumes, containing ubout 1,000 pages, leather, raised band$6 50 GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal 12mo. vol., cloth, pp. 306, with wood-cuts. 81, GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY Translated, with Notes and Additions, by Joseph Lkidy, M. D. in one volume, very large imperial quarto, extra cloth, with 320 copper- plate figures, pluin and eolored, $4 00. HUGHES' INTRODUCTION TO THE PRAC TICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS fN DISEASES OF THE LUNGS AND HEART Second edition 1 vol. royal Utmo., ex. cloth, pp. 304. SI 25. HOLLAND'S MEDICAL NOTES AND REFLECTIONS. From the third London edition. In one handsome octavo volume, extra cloth. S3 50. HORNER'S SPECIAL ANATOMY" AND HISTOLOGY. Eighth edition. Extensiv My revised and modified. In two large octavo volumes, extra cloth, of more than 1000pages, with over 309 illustrations. $6 00. HILLIER (THOMAS), M.D., Physician to the Skin Department of University College Hospital; Physician to the Hospital for Sick Children, &c. &c. HANDBOOK OF SKIN DISEASES, FOR. STUDENTS AND PRACTITJONEKS. In one neat royal 12mo. volume, of a'lout 300 pages, with two plates; extra cloth, price $2 25. (Now Ready ) From the Author's Preface. " My object has been to furnish to students and practitioners a trustworthy, practical, and compendious treatise, which shall comprise the greater part of what has long been known of cutaneous diseases, and of what ha< been more recently brought to light by English, French, and German dermatologists, as well as to embody the most important results of my own experience in reference to these diseases " The author's position both as a lecturer, wr'ter, and practitioner in this department of medicine, is n guarantee of his ability to accomplish his object in presenting a condensed and convenient manual, which shall comprise all that the general practitioner requires for his guidance. A text book well adapted to the student, and the information contained in it shows the author to be au niveau with the scientific medicine of the day— London Lancet, Feb. 25, 1865. HAMILTON (FRANK H.), M. D., Professor of Surgery in the Long Island College Hospital. A PRACTICAL TREATISE ON FRACTURES AND DISLOCATIONS. Second edition, revised and improved. In one large and handsome octavo volume, of over 750 pages, with nearly 300 illustrations, extra cloth, $5 25. The early demand for anew edition of this work shows that it has been successful in securing the confidence of the profession as a standard authority for consultation and reference on its important and difficult subject. In again passing it through the press, the author has taken the opportunity to revise it carefully, and introduce whatever improvements have been suggested by further experience and observation An additional chapter on Gun-shot Fractures will be found to adapt it still more fully to the exigencies of the time. Among the many good workersatsurgery ofwhom America may nowbonst rot the least is Frank Hastings Hamilton; and the volume before us is (we say it with a pang of wounded patriotism) the best und handiest book on the subject in the English language. It, is in vain to attempt a review of it; nearly as vain to seek for any sins, either of commission or omission. We have seen no work on practical surgery which we would sooner recommend to our brother surgeons, especially those of 1 the services," < r those whose practice lies in districts where a man has necessarily to rely on his own unaided resources. The practitioner will find in it directions for nearly every possible aciiuent, easily found and comprehended ; and much pleasant reading for him to muse over in the after confederation of his cases.— Edinburgh Med. Journ Feb. 1861. 1 This is a valuable contribution to the surgery of most, important affections, and is the more welcome, inasmuch as at the present time we do not possess a single complete treatife on Fractures and Dislocations in the English language. It has remained for our American brother to produce a complete treatise upon the subject, and bring together in a convenient form those alterations and improvements that have been made from time to time in the treatment of these affections. One great and valuable feature in the work before us is the fact that it comprises all the Improvements introduced into the practice of both English and American surgery, and though far from omitting mention of our continental neighbors, the author by no means encourages the notion—but too prevalent in some quarters— that nothing is good unless imported from France or Germany. The latter half of the work is devoted to the consideration of the various dislocations and their appropriate treatment, and its merit is fully equal to that of the preceding portion.— The London Lancet, May 5, I860. It is emphatically the book upon the subjects of which it treats, and we cannot doubt that it will continue so to be for an indefinite period of time. When we say, however, that we believe it will at once take its place as the best book for consultation by the practitioner; and that it will form the most complete, available, and reliable guide in emergenciesof every nature connected with its subjects; and sIbo thatthestudentof surgery may make it his textbook with entire confidence, and with pleasure also, from its agreeable and easy style—we think our own opinion may be gathered as to its value.— Boston Medical and Surgical Journal, March 1, 1860. HODGE (HUGH L.), M. D., Professor of Midwifery and the Diseases of Women and Children in the University of Pennsylvania, &c. ON DISEASES PECULIAR TO WOMEN, including Displacements of the Uterus. With original illustrations. In one beautifully printed octavo volume, of nearly 500 pages, extra cloth. $3 75. This contribution towards the elucidation of the pathology and treatment of some of the diseases peculiar to women, cannot fail to meet with a favor able reception from the medical profession. The character of the particular maladies of which the work before us treats; their frequency, variety,and obscuiity: the amount, of malaise and even of actual suffering by which they are. invariably attended; their obstinacy, the difficulty with which they are overcome, and their disposition again and again to recur—these, taken in connection with the entire competency of the author to render a correct account of their nature, their causes, and their appropriate management—his ample experience, his matured judgment, and his perfect conscientiousness— invest this publication with an interest and value to which few of the medical treatises of a recent date can lay a stronger, if, perchance, an equal claim.— Am. Journ. Med. Sciences, Jan. 1861. The illustrations, which are all original, are drawn to a uniform scale of one-half the natural size. AND SCIENTIFIC PUBLICATIONS. 19 HODGE (HUGH L.), M. D., Late Professor of Midwifery, &c, In the University of Pennsylvania, PRINCIPLES AND PRACTICE OF OBSTETRICS. In one large quarto volume of over 550 pages, with one hundred and fifty-eight figures on thirty two beautifully executed lithographic plates, and numerous wood-cuts in the text. $14 00. (Just Issued.) This work, embodying the results of an extensive practice for more than forty years, cannot fail to prove of the utmost value to all who are engaged in this department of medicine. The author's position as one of the highest authorities on the subject in this country is well known, and the fruit of his ripe experience and long observation, carefully matured and elaborated, must serve as au invaluable text-book for the student and an unfailing counsel for the practitioner in the emergencies which so frequently arise in obstetric practice. The illustrations form a novel feature in the work. The lithographic plates are all original, and to insure their absolute accuracy they have all been copied from photographs taken expressly for the purpose. In ordinary obstetrical plates, the positions of the foetus are represented by diagram* or sections of the patient, which are of course purely imaginary, and their correctness is scarcely more than a matter of chance with the artist. Their beauty as pictures is thereby increased without corresponding utility to the student, as in practice he must for the most part depend for his diagnosis upon the relative positions of the fietal skull and the pelvic bones of the mother. It is, therefore, desirable that the points upon which he is in future to rely, should form the basis of his instruction, and consequently in the preparation of these illustrations the skeleton has alone been used, and the aid of photography invoked, by which a series of representations has been secured of the strictest and most rigid accuracy. It is easy to recognize the value thus added to the very full detai's on the subject of the Mechanism of Labour with which the work abounds It may be added that no pains or expense have been spared to render the mechanical execution of the volume worthy in every respect of the character and vulue of the teachings it contains. HABERSHON (S. O.), M. D., Assistant Physician to and Lecturer on Materia Mediea and Therapeutics at Guy's Hospital, See. PATHOLOGICAL AND PRACTICAL OBSERVATIONS ON DISEASES OF THE ALIMENTARY CANAL, (ESOPHAGUS, STOMACH, CAECUM, AND INTESTINES. With illustrations on wood. In one handsome octavo volume of 312 pages, extra cloth. $2 50. HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. A new American edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the " Americun Journal of the Medical Sciences." In one large royal 12mo. volume, cloth, of over 500 double columned pages. $1 50. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation— Charleston Med. Journ. We know of no dictionary better arranged and adapted. Itisnotencumbercd with theobsoleteterms of a bygone age, but it contains all that are now in use; embracing every department of medical science down to the very latest date. — Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, Sec. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and seventeen illustrations. Third and revised American, with additions from the second London edition. In one handsome octavo volume, extra cloth, ol 455 pages. $3 V.5. Seven years having elapsed since the appearance of the last edition of this standard work, very considerable additions have been found necessary to adapt it thoroughly to the advance of ophthalmic science. The introduction of the ophthalmoscope has resulted in adding greatly to our knowledge of the pathology of the diseases of the eye, particularly of its more deeply seated lis>ues, and corresponding improvements in medical treatment and operative procedures have/been introduced. Ail these matters the editor has endeavoured to add, bearing in mind the character of the volume as a condensed and practical manual. To accommodate this unavoidable increase in the size ol the work, its form has been changed from a duodecimo to an octavo, and it is presented as worthy a continuance of the favour which has been bestowed on former editions. A complete series of M test-types" for examining the accommodating power of the eye, will be found an important and useful addition. JONES (C. HANDFIELD), F.R.S., 8c EDWARD H. SI EVE Kl N G, M.D., Assistant Physiciansand Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume.of nearly 750 pages, extra cloth. $3 50. As a concise text-book, containing, in a condensed form, a complete outline of what is known in the 1 domain of Pathological Anatomy, it is perhaps the I best work in the English language. Its great merit consists in its completeness and brevity, and in this j respect it supplies a great desideratum in our lite- | rature. Heretofore the student of pathology was | obliged to glean from a great numberof monograph's, and the field was so extensive that but few cultivated it with any degree of success. As a simple work of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.— Western Lancet. 20 HENRV U. LEA'S MEDICAL KIRKES (WILLIAM SENHOUSE), M.D., Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c. A MANUAL OF PHYSIOLOGY. A new American, from the third and improved London edition. With two hundred illustrations. In one large and handsome royal 12mo. volume, extra cloth, pp. 586. $2 25. This is a new and very much improved edition of Dr. Kirkes' well-known Handbook of Physiology. It combines conciseness with completeness, and is, therefore, admirably adapted for consultation by the busy practitioner.— Dublin Quarterly Journal. One of the very best handbooks of Physiology wt possess—presenting just such an outline of the science as the student requires during his attendance upon a course of lectures, or for reference whilst preparing for examination — Am. Medical Journal Its excellence is in its compactness, its clearness, and its carefully cited authorities. It is the most convenientoftext-books. Thesegentlemen, Messrs. Kirkesand Paget, have the gift of telling us what we want to know, without thinking: it necessary to tell us all they know.— Boston Med and Surg. Journal. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know.— Charleston Med. Journal KNAPP'S TECHNOLOGY; or,Chemistry applied to the Arts and to Manufactures. Edited by Dr. Ronalds, Dr. Richardson, and Prof. W. R. Johnson. In twohandsomi 8vo. vols .extracloth, with about 500 wood- engravings. $6 00. LAYCOCK'S LECTURES ON THE PRINCIPLES AND METHODS OF MEDICAL OBSERVATION AND RESEARCH. For the Use of Advanced Students and Junior Practitioners, In one royal 12mo. volume, extra cloth. PrieeSl. LALLEMAND AND WILSON. A PRACTICAL TREATISE ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. By M. Lallemand. Translated and edited by H enry J McDougall. Third American edition. To which is added ON DISEASES OF THE SEMINALES; and their associated organs. With special reference to the Morbid Secretions of the Prostatic and Urethral Mucous Membrane. By Marris Wilson, M. D. In one neat octavo volume, of about 400 pp., extra cloth. $2 75. LA ROCHE (R.), M. D., &c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. $7 00. We have not time at present, engaged as we are, by day and by night, in the work of combating this very disease, now prevailing in out city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malignant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but v penetrates country villages, plantations, and farmhouses; that it is treated with scarcely better success now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to knowledge in regard to the disease, and in view of the probnbility that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will be very generally read in the south.— Memphis Med. Recorder. BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E. Day, M. D., F. R. S., vc.ry page, that it, and every line, and every word lias been weighed and reweighed through years of preparation; that this is of all others the book of Obstetric Law, on each of its several topics; on all points eonnected with pregnnncy, to be everywhere received as a manual of special jurisprudence, at once announcing fact, affording argument, establishing precedent, and governing alike the juryman, advocate, and judge.— iV. A. Med.-Chir. Review. MEIGS (CHARLES D.), M. D., Lately Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Fourth edition, revised and improved. With one hundred and twenty-nine illustrations. In one beautifully printed octavo volume, of seven hundred and thirty large pages, extra eloth, $"00. From the Author's Preface. " [n this edition I have endeavored to amend the work by changes in its form ; by careful corrections of many expre>->imis, and by a few omissions and some additions as to the text. "The Student will find that I have recast the article on Placenta I'raevia, which I was led to do out of my desire to notice certain new modes of treatment which I regarded as not only ill founded as to the philosophy of our department, but dangerous to the people. " In changing the form of my work by dividing it into paragraphs or sections, numbered fro.n 1 to 951), 1 thought to present to the reader a common-place book of the whole volume Such a table of contents ought to prove both convenient and useful to a Student while attending public lectures." A work which hat- enjoyed so extensive a reputation and has been received with such general favor, requires only the assurance that the author has labored assiduously to embody in his new edition whatever has been found necessary to render it fully on a level with the most advanced stale of the subject. Both as a text-book for the student and as a reliable work of reference for the practitioner, it is therefore to be hoped that the volume will be found worthy a continuance of the confidence reposed in previous editions. BY THE SAME AUTHOR. WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Leetures to his Class. Fourth and Improved edition. In one large and beautifully printed octave volume, extra cloth, of over 700 pages. $5 00. In other respects, in our estimation, too much can I not be said in praise of this work. It a lounds with beautiful passages, and for conciseness, for originality, and for all that is commendable in a work on the diseases of females, it is not excelled, and probably not equalled in the English language. On the whole, we know of no work on the diseases of women which we can so cordially commend to the student ;>nd practitioner as the one before us.— Ohio Med. and Surg. Journal. The body of the book is worthy of attentive consideration, and is evidently the production of a clever, thoughtful, and sagacious physician. Dr. Meigs's letters on the diseases of the external organs, contain many interesting and rare cases, and many instructive observations. We take our leave of Dr. Meigs, with a high opinion of his talents and originality.— The British and Foreign Medico-Vhr rurgical Review. Every chapter is replete with practical instruction, and bears the impress of being the composition of an acute and experienced mind. There is a terseness, and at the same time an accuracy in his description ot symptoms, and in the rules for diagnosis, i which cannot fail to recommend the volume to the attention of the reader.— Ranking's Abstract. It contains u vast amount of practical knowledge. iy one who has accurately observed and retained the experience of many years.— Dub'.in Quarterly Journal. Full of important matter, conveyed in a ready and agreeable manner.— St. Louis Med. and Surg. Jour. There is an off-hand fervor, aglow, and a warmleartedness infecting the eff >rt of Dr. Meigs, which is entirely captivating, and which absolutely hurries the reader through from beginning to end. Besides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is presented. We know of no better test of one's understanding a subject than the evidence of the power ,>f lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and mnde to stand out in such bold relief, us to produce distinct impressions upon the mind and memory of the reader. —TA* Charleston Med. Journal. 22 HENRY C. LEA'S MEDICAL MEIGS (CHARLES D.) M. D., Lately Professor of Obstetrics, &c., in Jefferson Medical College, Philadelphia. ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. $2 Oo. The instructive and interesting author of this I work, whose previous labors have placed his coun- trymen under deep and abiding obligations, again challenges their admiration in the fresh and vigor- ous, attractive and racy pages before us. It is a de- 1 lectable book. * * * ThiB treatise upon childbed fevers will have an extensive sale, being destined, as it deserves, to find a place in the library of every practitioner who scorns tolag in the rear.— Nashville Journal of Medicine andSurgery. MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto ¦ With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Containing one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $14 00. These plates will be found of the highest practical value, either for consultation in emergencies or to refresh the recollections of the dissecting room. %* The size of this work prevents its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price $12 00. One of the greatest artistic triumphs of the age in Surgical Anatomy.— British American Medical Journal. No prnctitioner whose means will admit should fail to possess it.— Banking's Abstract. Too much cannot be said in its praise; indeed, we have not language to do it justice.— Ohio Medital and Surgical Journal. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.— Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a price.— Charleston Medical Journal Its plates can boast a superiority which places them almost beyond theraachof competition.—Medital Examiner. Country practitioners will find these plates of immense value—iv. Y. Medical Gazette. A work which has no parallel in point of accuracy and cheapness in the English language.—JV. Y. Journal of Medicine. We are extremely gratified to announce to ths profession the completion of this truly magnificent work, which, as a whole, certainly stands unrivalled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.— The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Anatomy that has come under our observation. W« know of no other work that would justify a student, in any degree, for neglect of actual dissection. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details of the dissecting-room perpetually fresh in the memory.— The Western Journal of Medicine and Surgery. MILLER (HENRY), M. D., Professor of Obstetrics and Diseases of Women and Children in the University of Louisville. PRINCIPLES AND PRACTICE OF OBSTETRICS, Ac. ; including the Treatmentof Chronic Inflammation of the Cervix and Body of the Uterus considered as a frequent cause of Abortion. With about one hundred illustrations on wood. In one very handsome octavo volume, of over 600 pages, extra cloth. $3 75. We congratulate the author that the task is done. We congratulate him that he hasgiven to the medical public a work which will secure for him a high and permanent position among the standard authorities on the principles and practice of obstetrics. Congratulations are not less due to the medical profession of this country, on the acquisition of a treatise embodying the results of the studies, reflections, and experience of Prof. Miller.— Buffalo Medical Journal. In fact, this volume must take its place among the standard systematic treatises on obstetrics ; a posi- tion to which its merits justly entitle it.— The Cincinnati Lancet and Observer. A most respectable und valuable addition to our home medica) literature, and one reflecting credit alike on the author and the institution to which he is attached. The student will find in this work a most useful guide to his studies; the country practitioner, rusty in his reading, can obtain from its pages a fair resume of the modern litera ture of the science; and we hope tosee this American production generally consulted by the profession.— Vm. Med. Journal, MACKENZIE (W.), M. D., Surgeon Oculist in Scotland in ordinary to Her Majesty, Ac. A,e. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EVE. To which is prefixed an Anatomical Introduction t xplunatory ol a Horizontal Section of the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and Enlarged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume, extra cloth, with plates and numerous wood-cuts $6 50. The treatise of Dr. Mackenzie indisputably holds I We consider it the duty of every one who has the the firstplace, and forms, in respect of learning aud love of his profession and the welfare of his patient research, an Encyclopaedia unequalled in extent by ! at heart, to make himself familiar with this the most any other work of the kind,either English or foreign, complete work in the English language upon the die—Dixon on Diseases of the Eye. | eases of the eye.— Med. Times and Gazette. We consider it the duty of every one who has the love of his profession and the welfare of his patient at heart, to make himself familiar wit h this the most complete work in the English language upon thediseases of the eye.— Med. Times and Gazette. AND SCIENTIFIC PUBLICATIONS. 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, to. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, extra cloth, ol 700 pages, with two hundred and forty illustrations on wood. $3 75. BY THE SAME AUTHOR. THE PRACTICE OF SURGERY. Fourth American from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume, extra cloth, of nearly 700 pages. $3 75. No encomium of ours could add to the popularity Of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which noconscientious surgeon would be willing to practice his&rt.—Southern Med. and Surg. Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the «< Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensible, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.— Kentucky Medical Recorder. By the almost unanimous voice of the profession, his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it as superior to all others.— St. Louis Med. and Surg. Journal. The author has in this and his " Principles," presented to the profession oneof the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, energetic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding theattention. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recommended.—Southern Journal of Med. and Physical Sciences. MORLAND (W. WJ, M. D., Fellow of the Massachusetts Medical Society, tec. DISEASES OF THE URINARY ORGANS; a Compendium of their Diagnosis, Pathology, and Treatment. With illustrations. In one large and handsome octavo volume, of about 600 pages, extra cloth. $3 50. Taken as a whole, we can recommend Dr. Morland's compendium as a very desirable addition to the library of every medical or surgical practitioner.— Brit and For. Mtd.-Chit. Rev., April, 1859 Every medical practitioner whose attention has been to any extent attracted towards the class of diseases to which this treatise relates, must have often and sorely experienced the want of some, full, yet concise rscent compendium to which he could refer. This desideratum has been supplied by I)r. Morland,and it has been ably done. He has placed before us a full, judicious, and reliable digest. Bach subject is treated with sufficient minuteness, yet in a succinct, narrational style, such as to render the worif one of great interest, and one which will prove in the highest degree useful to the general practitioner.— N. Y. Journ. of Medicine, BY THE SAME AUTHOR. THE MORBID EFFECTS OF THE RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. Being the Dissertation to which the Fiske Fund Prize was awarded, July 11, 1861. In one small octavo volume, 83 pages, extra cloth. 75 cents. MAYNE'S DISPENSATORY AND THERAPEUTIC A L REMEMBRANCER. With every Practical Formula contained in tlie three British | Pharmacopoeias Edited, with the addition of the Formulas of the U. S. Pharmacopoeia, by R. E Griffith,M .D 1 12mo. vol.ex.cl.,:l00on. tin. MALGAIGNE'S OPERATIVE SURGERY, based on Normul and Pathological Anatomy. Translated from the French by Frederick Brittan, A. B , M. D. Withnumerous illustrationson wood. In one handsome octavo volume, extra cloth, of oenrlv pix hundred pages. S2 50 NELIGAN (J. MOORE), M. D., M. R. I. A., fee. ATLAS OF CUTANEOUS DISEASES. Iu one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $5 50. This beautiful volume is intended as a complete and accurate representation ol all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the profession some years since. The publishers feel justified in saying that few more beautifully executed plates have ever been presented to the profession of this country. Neligan's Atlas of Cutaneous Diseases supplies a long existent desideratum much felt by the largest class of our profession. It presents, in quarto size, 16 plates, each containing from 3 to 6 figures, and forming in all a total of 9(1 distinct representations of the different species of skin affections, grouped together in genera or families. The illustrations have been taken from nature, and have been copied With such fidelity that they present a striking picture of life; in which the reduced scale'aptly serves to give, at a coup d'ceil, the remnrkable peculiarities of each individual variety. And while thus the disease is rendered more definable, there is yet no loss of proportion incurred by the necessary concentration. Each figure is highly colored, and so truthful has the artist been that the mostfastid ous observer could not justly take exception to the correctness of the execution of the pictures under his scrutiny.— Montreal Med. Chronicle. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Fourth American edition, in one neat royal 12mo. volume, extra cloth, of 334 pages. $1 50. 24 HENRY C. LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital,&c; and FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; forthe Use and Examination ol Students A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, ol about one thousand pages, with 374 wood-cuU, extra cloth, $4 00. Strongiy bound in leather, with raised bands. $4 75. This work is again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge of the changes and improvement in professional science, its reputation is permanently established. The best work of the kind with which we are acquainted.— Med. Examiner. Having made free use of this volume in our examinations of pupils, we can speak from experi•nee in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teachei much labor by enabling him readily to recall all of the points upon which his pupils should be examined. A work of this sort should be in the Hands of every one who takes pupils into his office with o view of examining them j and this is unquestionably the best of its class.— Transylvania Med. Journal In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non The one before us is, in most of the divisions, the most unexceptionable of all books of the kind that we know of The newest and soundest doctrines anil the latest improvements und discoveries are explicitly, though concisely, laid before the student There is a class to whom we very sincerely commend this cheap book as worth its weight in silver—that class is the graduates in medicine of more that: ten years' Standing, who have not studied medicine since. They will perhaps find out from it.that the science is not exactly now what it was when they left it off.— The Stetk*scope PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by ,Joux Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon tothe Pennsylvania Hospital, dec. In one very handsome 8vo. volume, extra cloth, of 780 pages, with 31b illustrations. $3 75. We know of no other surgical work of a reason- I able size, wherein there is SO much theory and prac- tice, or where subjects are more soundly or clearly taught.— The Stethoscope. ! Prof. Pirrie, in the work before us, has elabo- | rately discussed the principles of surgery, and a safe and effectual practice predicated upon them, Perhaps no win k upon this subject heretofore issued is so full upon the science of the art of surgery.— Nashville Journal of Medicine and Surgery. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRIMARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphilis, by a safe and successful method. With numerous Cases. Formula;, and Clinical Observations, From the Third and entirely rewritten London edition Id one neat octavo volume, extra cloth, ol 31b pages 92 50. PEREIRA (JONATHAN), M.D. MATERIA MEDICA AND THERAPEUTICS; being an Abridgment of the late Dr. Pereira's Elements of Materia Medica, arianged in conformity with the BriiHi Pharmacopoeia, and adapted to the use of Medical Practitioners, Chemists, and Druggists, Medical and Pharmaceutical Students, ore. By F. J. Farrk, M.D., Senior Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; assisted by Robert Benti.ey, M.R C. S., Professor of Materia Medica and Botany to the Pharmaceutical Society of Great Britain; and by Robert Wakington, F. R. S., Chemical Operator to the Society of Apothecaries. With numerous additions and references to the United Slates Pharmacopoeia, by Horatio C. Wood, M. D., Professor of Botany in the University of Pennsylvania. In one large and handsome octavo volume of about y00 pages, with numerous illustrations. (Preparing.) ROBERTS (WILLIAM) M. D., Physician to the Manchester Royal Infirmary, Lecturer on Medicine in the Manchester School of Medicine, &c. A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, including Urinary Deposits. Illustrated by numerous ca-es and engravings. In one handsome octavo volume of over 000 pages, extra cloth. (Just Rtady.) AND SCIENTIFIC PUBLICATIONS. 25 PARRISH (EDWARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE UN PHARMACY. Desigued as a Text-book for the Student, and as a Guide for the Physician and Pharmaceutist With many Formulae and Prescriptions. Third edition, greatly improved. In one handsome octavo volume, of 850 pages, with several hundred Illustrations, extra cloth. $5 00. (Just Issued.) Trough for some time out of print, the appearance of a new edition of this work has been delated for the purpose of embodying in it the results of the new U. S. Pharmacopoeia. The publication of this Intter has enabled the author to complete his revision in the most thorough maimer. Those who have been waiting for the work may therefore rely on obtaining a volume comp'etely on a level with the most advanced condition of pharmaceutical science The favor with which the work has thus Car been received shows that the author was not mistaken in his estimate of the want of a treatise which should serve as a practical text-book for all engaged in preparing and dispensing medicines. Such a guide was indispensable not only to the educated pharmaceutist, but also to that large class of practitioners throughout the country who are obliged to compound their own prescriptions, and who during their collegiate course have no opportunity of obtaining a practical familiarity wilh the neces-ary proeress.es and manipulations. The rapid exhaustion of two large editions is evidence that the author has succeeded in thoroughly carrying out his object. Since the appearance of the last edition, much has been done to perfect the science; the new Phamiacop and valuable service, no one. we think, who has had access to its pages will deny; doubly welcome, then, is this new edition, containing the added results of his recent and rich experience as an observer, teacher, and practical operator in thepharmaceutical laboratory. The excellent plan of the first is more thoroughly, — Peninsular Med. Journal, Jan. I860. Of course, all apothecaries who have not already a copy of the first edition will procure one of this; it is, therefore, to physicians residing in the country and in small towns, who cannot avail themselves of the skill of an educated pharmaceutist, that we would especially commend this work. In it they will find all that they desire to know, and should know, but very little of which they do really snow in reference to this important collateral branch of their profession; for it is a well established fact, that, in the education of physicians, while the science of medicine is genernlly well taught, very little attention is paid to the art of preparing them for use, and we know not. how this defect can be so well remeuied as by procuring and consulting Dr. Parrish's excellent work.— St. Louis Med. Journal. Jan. I860 We know of no work on the subject which would be more indispensable to the physician or student desiring information on the subject of which it, treats. With Griffith's " Medic il Formulary" and this, the practising physician would be supplied with nearly or quite all the most useful infor mation on the. subjict.—Charleston Med. Jour.and Review, Jan. I860. PEASLEE (E. R.), M. O., Professor of Physiology and General Pathology in the New York Medical College HUMAN HISTOLOGY, in its relations to Anatomy, Physiology, and Pathology j for the use of Medical Students With four hundred and thirty-four illustrations. In one handsome octavo volume, extra cloth, of over 600 pa<(es. $3 75. it embraces a library upon the topics discussed Within itself, and is just wliat the teaeherand Learner need. We have not only the whole subject ol Histology, interesting in itself,ably anil fully liseiissed, but wiiat is 01 infinitely greater interest to the student, because of greater practical value, are its relations to Anatomy, Physiology, and Pathology, which are here fully and satisfactorily set forth.— Nashville Journ. of Me.d and Surgery. We would recommend it as containing a summary of all that is known of the important subjects which it treats; of all that is in thfjjgreat works of Simon and Lehmann, and the organic chemists in genera!. Master this one volume, and you know all that is known of the great fundamental principles of medicine, and «ve have no hesitation in saying that it is an honor to the American medical profession.— St, Louis Mtd. and Surg. Journal. ROKITANSKY (CARL), M.D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, Ac A MANUAL UP PATHOLOGICAL ANATOMY. Four volumes, octav i, bound in two, extra cloth, of about 1200 pages. Translated by W. E. Swaine, Edward Sievjking, C. H. Moore, and G. E. Day. $7 50. The profession is too well acquainted with the reputation of Rokitansky's work to need our assuraace that this is one of the most profound, thorough, and valuable books ever issued from the medical press. It is sui generis, and bus no standard of comparison. It is only necessary to announce that it is issued in a form as cheap as is compatible with in size and preservation, "and its sale follows as a rnatter of course. No library can be called co n >lete without it.— Buffalo Med. Journal Au attempt to give our readers any adequate idea if the vast amount of instruction accumulated in tiese volumes, would be feeble und hopeless.— Wtstem Lancet KOYLE'S VlATEKlA MEDICA AND THERAPEUTICS; including the Preparation of the Pharmacopoeia* of London, Edinburgh, Dublin,and of the United States. vV nil many new medicines Edited by Joseph Carson, M. D. With ninety-eight illustration!. In one iargt: octavo volutin , extra cloth, of about 700 pages. S3 00. HENRY C. LEA'S MEDICAL 26 RIG BY (EDWARD), M.D., Senior Physician to the General Lying-in Hospital, dec. A SYSTEM OF MIDWIFERY. With Notes and Additional Illustrations. Second American Edition. One volume octavo, extra cloth, 422 pages. $2 50. BY THE SAME AUTHOR. ON THE CONSTITUTIONAL TREATMENT OF FEMALE DISEASES. In one neat royal 12mo. volume, extra cloth, of about 250 pages. $1 00. RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGER Y, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With Additions by W. V. Keating, M. D., Professor of Obstetrics, &c, in the Jeflerson Medical College, Philadelphia. In one large aud handsome imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty-four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly 200 large and beautiful figures. $7 00. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as beii g the best authorized exponent of British Midwifery. Its circulation will, 1 trust, be extensive th roughoi t our country. It is unnecessary to say anything in regard to the utility ot this work. It is already appreciated in oui country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the physician's library it is indispensable, while to the student as a text-hook, from which to extract the material for laying the foundation of an education on obstetrical science, it has no superior.— Ohio Med and Surg. Journal. The publishers have secured its success by the truly elegant style in which they have brought it out, excelling themselves in its production, especially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We km.w of no text-book which deserves in all respects to be more highly recommended to students, und we could wish to see it in the hundsof every practitioner, for they will find it invaluable for reference.— Med. Gazette. RICORD (P.), M. D. LETTERS ON SYPHILIS. Translated by W. P. Lattimore, M. D. In one neat oetavo volume, of 270 pages, extra cloth. $2 00. v SMITH (HENRY H.), M. D., AND HORNER (WILLIAM E.), M. D. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. »4 50. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artist.ical execution, 'iave been already pointed out VVe must congratulate the student upon tiie completion of this Atlas, as it is the most convenient work of the kind that hasyet appeared ; and we must add, the very beautiful manner in which it is " got up'' is so creditable to the country as to be flattering to our national pride— American Medical Journal. SMITH (EDWARD), M.D., LL.D., F.R.S. Assistant Physician to the Hospital for Consumption and Diseases of the Chest, Br< mpton, «fcc. CONSUMPTION; ITS EARLY AND REMEDIABLE STAGES. In one neat octavo volumejjpf 254 pages, extra cloth. $2 25. (Just Issued.) One-half of Dr. Smith's work is devoted to the treatment of Tuberculosis. We find in this portion of the work no occasion to join issue with the author ; but, on the contrary, much which we would commend to the reader's attention. Dr. Smith attaches tar greater importance to hygienic measures than to drugs in the treatment of the disease. In taking leave of the work, we would express the hope that the author will furnish occasions for the renewal of our intercourse as a reader, if not as a icviewer.— Am. Med. Journal, Jan. 1803. SHARPEY (WILLIAM), M.D., JONES QUAIN, M.D., AND RICHARD QUAIN, F. R. S., Sec. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large oetavo volumes, extra cloth, ol about thirteen hundred pages. With overSOO illustrations $6 00. SOLLY ON THE HUMAN BRAIN; its Structure,! Physiology, and Diseases. From the Second and much eniaiged London edition. In one octavo volume, extra cloth, of 500 pages, With 120 Wood- cuts #2 60. S'lEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. 9f325. SIMON > uENEJtAi, PATHOLOGY, as conduc ive t0 the Kstabiishmt-nt of Rational Principles for the prevention are Cure of Disease In one octavo volume, extra cloth, of212 pages. $125. AND SCIENTIFIC PUBLICATIONS. 27 STILLE (ALFRED), M.D., Professor of the Theory and Practice of Medicine in the University of Pennsylvania. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Second Edition, revised and enlarged, in two large and handsome octavo volumes, extra cloth. $10 00. (Just Issued.) This work is designed especially for the student and practitioner of medicine, and treats the various articles of the Materia Medica from the point of view of the bedside, and not of the shop or of the lecture-room. While thus endeavoring to give all practical information likely to be useful with respect to the employment of special remedies in special affections, and the results to be anticipated from their administration, a copious Index ol Diseases and their Remedies renders the work eminently fitted for reference by showing at a glance ihe different means which have been employed, and enabling the practitioner to extend his resources in difficult cases with all that the experience of the profession has suggested. The speedy demand for another edition of this work shows that it has acceptably filled an acknowledged want Noexertion of the author has been wanting to render it worthy a continuance of the favor with which it has been received, while an al eration in the typographical arrangement has accommodated the additions without increasing unduly the size of the volumes. Rarely, indeed, have we had submitted to us a i work on medicine so ponderous ia its dimensions us that now before us, and yet so fascinating in its contents. It is, therefore, with a peculiar gratih- j cation that we recognize in Dr. Stille the posses¦ion of many of those more distinguished qualifications which entitle him to approbation, and which justify him in coming before iiis medical brethren as an instructor. A comprehensive knowledge, tested by a sound and penetrating judgmeut, joined to a love of progress-which a discriminating spirit of inquiry has tempered so us to accept not hing new because it is new,and abandon nothing old because | it is old, but which estimates either accon ing to its [ relations to a just logic and experience—manifests itself everywhere, and gives to the guidance of the ; author all 'he assurance of safety which thedifficulties of his sabiectcanallow. In conclusion, we earnestly advise our readers to ascertain for themselves, by a study of Dr. Stille's volumes, the great value and interest of the stores of knowledge they present. We have pleasure in referring rather to the ample treasury of undoubted truths, the real und assured conquest of medicine, accumulated by Dr. Stille in his pages; and commend the sum of his labors to the attention of our readers, as alike honorable to our science, and creditable, to the zeal, the candor, and the judgment of him who has garnered the whole so carefully .—Edinburgh Med. Journal. The most recent authority is the one last men- i tioned, Stille. His great work on " Materia Medi'¦ ca und Therapeutics," published last year, in two 1 octavo volumes, of some sixteen hundred pages, j while it embodies the results of the labor of others ' up to the time of publication, is enriched with a j great amount of original observation and research. ! We would draw attention, by the way, to the very convenient mode in which the Index, is arranged in I this work. There is firstan " Index of Remedies ;' I next an "Index of Diseases and their Remedies." 1 Such an arrangement of the Indices, in our opinion, j greatly enhances the practical value of books of this | kind. In tedious, obstinate cases of disease, where | we have to try one remedy after another until our slock is pretty nearly exhausted, and we are almost ; driven to our wit's end, such an index as the second j of the two just mentioned, is precisely what we ; want.— London Med. Times and Gazette, April, 1861. We think this work will do much to obviate the j reluctance to a thorough investigation of this branch ; of scientific study, for in the wide runge of medical I literature, treasured in the English tongue, we shall | hardly find a work written in a style more clear and simple,conveying forcibly the facts taught,and yet free from tumidity and redundancy There isa fascination in its pages that will insure to it a wide popularity and attentive perusal, and a degree of usefulness not often attained through the influence of a single work. SIMPSON (J. Y,), M. D., Professor of Midwitery, &c, in the University of Edinburgh,&c. CLINICAL LECTURES ON THE DISEASES OF WOMEN. With numeious illustrations. In one handsome octavo volume, of over 800 pages, extra cloth, $-1 00. The principal topics embraced in the Lectures are Vesico-Vaginal Fistula, Cancer of the Uterus, Treatment of Care noma by Caustics, Dys nenorrhoea, Ainenorrhoea, Closures, Contractions, jrc, of tne Vagina, Vulvitis, Causes ol Death after Surgical Operations, Surgical Fever, Phlegmasia Doletis Coccyodinia, Pelvic Cellulitis, Pelvic Haeiiiaioma, Spurious Pregnancy, Ovarian Dropsy, Ovariotomy, Crnnioclasm, Diseases of the Fallopian Tubes, Puerperal Mania, Sub-Involution und Super-Involution of the Uterus, &c. &c. As a series of monographs on ihese important topics—many ol which receive little attention in the ordinary text-books—elucidated with the extensive experience and readiness of resource for which Professor Simpson is so distinguished, there are tew practitioners who will not rind in its pages matter of the utmost importance in the (realm ml of obscure uud dillicull cases. SALTER (H. H.), M. D. ASTHMA; its Pathology, Causes, Consequences, and Treatment. In one vol. 8vo., extra cloth (Just Issued.) $^50 The portion of Or. Salter's work which is devoted to treatment, is ol great practical inieresiand value. It would be necessary to loilow him step by step in his remarks, not only on the medicinal, but also on the dietetic and hygienic treatment of the disease, in order to convey aJust notion oi tne practical value of this part of his work. This our space forbius, and this we shall little regret, if, by our silence, wr. should induce our readers to possess themselves of the book itself; a book which, withou t uoubt, deserves to be ranked am >ng the most valuable of recent contributions to the medicui literature of this country. — Ranking'I Abstract, Jan., 1861. SLADE tO. D.), M. D. DIPHTHERIA: its Nature and Treatment, with an account of the History of its Prevalence in various countries. Second and revised edition. In one neat royal 12uio. volume, extra cloth. $125. (Just Issued.) Tne original essay of Uf. Slade, to which the Fibke Fund prize lor I86!» was awarded, appeared originally in this lournnl. lu the-edition before us lite essay has lieeu revised with ev.cent eare, wnile such addiiionshaveb.en made to it as were sug gested by the author's subsequent experience uud observation. In its present form, the work famishes to the student and young practitioner a very faithful and uselul exposition of Hit piincipal facts Mint are now known in respect to 'he nature of diphtheria, its causes and treatment.— Am luurn Mid Sciences, Jan. 1665. HENRY C. LEA'S MEDICAL 28 SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. New edition, with an additional chapter on Military Surgery. One handsome royal 12mo. vol., of nearly 400 pages, with 184 wood cuts. Extra cloth, $1 75. The value of this work as a handy and convenient manual for surgeons engaged in active duty, has induced the publishers to render it moie complete for those purposes by the addition of a chapter on gun-shot wounds and other matters peculiar to military surgery. In its present form, therefore, it will be found a very cheap and convenient vade-mecum for consultation and refereuce in the daily exigencies of military as well as civil practice. We consider that no better book could be placed in thehaiius of an hospital dresser, or the young surgeon, whose education in this respect has not been perfected VVt meist cordially commend this volume as one-which the medical student should most close ly study, to perfect himself in these minor surgical operations in which neatr.ess and dexterity are so much icquired, and on which a great portion of his re putation as a future surgeon must evidently rest And to the surgeon in practice it must preive itself a valuable volume, as instructive on many points which he may have forgotten.— British American Journal, May, 1862. The instruction given upon the subject of Bandaging, isulone of great value, and while the author modestly proposes to instruct the students of medicine, and the younger physicians, we will say that experienced physicians will obtain many exceedingly valuable suggestions by its perusal. It will be found one of the mott satisfactory manuals for reference in the field, or hospital yet published; thoroughly adapted to the wants of Military surgeons, and at the same time equally useful for ready and convenient reference by surgeon*, everywhere.— Buffalo Med. and Surg. Journal, June, 1862. SMITH (W. TYLERi, M. D., Physician Accoucheur to St. Mary's Hospital, Ac. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 50. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRHQKA. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. |3 00 TANNER (T. H.), M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS 'lo which is added The Code of Ethics of the American Medical Association. Third American Edition. In one neat volume, small ISmo., extra cloth. (Preparing.) TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital. MEDICAL JURISPRUDENCE. Filth American, from the seventh improved un> enlarged London edition. With Notes and References to American Decisions, by Edward Haktshokne. M. D. In one large 8vo. volume extra cloth, of over700 pages. $4 00. Tins standard work having had the advantage of two revisions at the hands of the aulhor since the appearance of the last American edition, will be found thoroughly revised and brought up completely lo the present stale of the science. As a work of auihonly, it must therefore maintain its position, both as a lext-beiok for the sludent, and a compendious treatise to which the practitioner ctm at all times leler in cases of doubt or difficulty. \o work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably j and none could be offered to the busy practitioner ol either calling, for the purpose ol casual or hasty reference, that would be more likely to afford trie aid desired. We therefore recommend it as the best and safest manual for daily aae.—American Journal oj Medical Sciences. It is not excess of praise to say that the volunii tiefore us is the very besl treatise extant on Medical Jurisprudence in saying this, we do not wish l< be understood as detracting from the merits of tht excellent works of Beck, Ryan, Traill, Ouy, am others; but in interest and value we think it must be. conceded that Taylor is superior to anything thai has preceded it.—iV. W. Medical and Surg, lournal It is at once comprehensive und eminently practical, and by universal consent t tunas at the head of . American and British legal medicine. It should be in the possession of every physician, as the subject is one of great, and increasing importance to the public as well as to the profession.— St. Louts Med. and Surg. Journal. This work of Dr. Taylor's is generally acknowledged to be one of the ablest extant on the subject of medical jurisprudence, it is certainly one of the most attractive oo iks that we have met with ; suppi) lOg so much both to interest and instruct, that we do not hesitate to affirm that after having once commenced its perusal, few could be prevailed upon to desist before completing it. In ihe lust Lonuon edition, all the newly observed and accurately recorded fucis have been insetted, including much that is recent of Chemical, Microscopical, and Pathological research, besidt ¦ papers on numerous subjects never before published Charleston Med Journal and Review. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Second American, from a second and revised London edition. In one large octavo volume, oi 755 pages, extra cloth. $5 00. Mr. Taylor's position as the leading medical jurist of England, has conferred on him extraordinary advantages in acquiring experience un these subjects, nearly all cases of moment being referred to him for examination, as un expert whose testimony is generally accepted as final. The results of his labors, therefore, as gathered together in this volume, carelully weighed and silted, and presented in the cleur and intelligible style for which he is noted, may be received as an acknowledged authority, and us a guide to be followed with implicit confidence. BY THE SAME AUTHOR AND WM BRANDS. CHEMISTRY. In one volume 8vo. See "Brahde," p. 6. 29 AND SCIENTIFIC PUBLICATIONS TODD (ROBERT BENTLEY), M. D., F. R. S., Professor of Physiology in King's College, London; and WILLIAM BOWMAN, F. R.S., Demonstrator of Anatomy in King's College, London. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume, of 950 pages, extra cloth. Price $4 75. 11 is more concise than Carpenter's Principles, and | more modern than the accessible edition of Mailer's Elements; its details are brief, but sufliciei.t; its descriptions vivid; its illustrations exact and copi- | ous; and its language terse and perspicuous.— Charleston Med. Journal. A magnificent contribution to British medicine, unu the American physician who shall fail to peruse it, wili have failed to read one of the most instructive books of the nineteenth century.—JV. O. Med. xnd Surg. Journal. TODD (R. B.) M. D., F. R. S., &.c. CLINICAL LECTURES ON CERTAIN DISEASES OF THE URINARY ORGANS AND ON DROPSIES. In one oetavo volume, 284 pages, extra cloth. $2 50 BY THE SAME AUTHOR. CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one neat octavo volume, of 320 pages, extra clotn. $2 50. TOYNBEE (JOSEPH), F. R. S., Aural Surgeon to, and Lecturer on Surgery at, St. Mary's Hospital. A PRACTICAL TREATISE ON DISEASES OF THE EAR; their Diagnosis, Pathology, and Treatment. Illustrated with one hundred engravings on wood, in one very handsome octavo volume, extra cloth, 44 CO. The work is a model of its kind, and every page and paragraph Ol it are worthy of the most thorough study. Considered all in all—as an original work, well written, philosophically elaborated,and happily illustrated with cases and drawings—it is by far the ablest monograph that has ever appeared on the anatomy and diseases of the ear, and one of the most valuable contributions to the art and science of surgery in the nineteenth century.— N. Arner. Medico- Chirurg Review, Sept. 1800. We are speaking within the limits of modest acknowledgment, and with a sincere and unbiassed judgment, when we affirm that as a treatise on Aural I Surgery, it is without a rival in our language or any j other.— Charleston Med Journ and Rev., Sept. I860. The work of Mr. Toynbee is undoubtedly, upon the whole the most valuable production of tne kind in any language. The author has long oeen known by his numerous monographs upon subjects connected with diseases of the ear, and is now regarded las the Highest authority on most points in his de| partment of science. Mr Toynbee's work, ne we have al really said, is undoubtedly the most reliable guide for the study of the diseases of the tar in any language, and should be in the library of every phy- I sician.- Chicago Med. Journal, July, 1860. WILLIAMS (C. J. B.i, M.O., F.R.S., Professor of Clinical Medicine in University College, Loudon, 4.0. PRINCIPLES OF MEDICINE. Au Elementaiy View of the Causos, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brie! remarks on Hygienics, or the preservation of health. A new American, from the third and revised London edition. In one octavo volume, extra cloth, ol about 500 pages. $3 50. (Now Ready.) WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under theauthority of the London Society for Medical Observauon. A new American, from the second and revised London edition. In one very handsome volume, royal 12mo., extra cloth. $1 00. To the observer who prefers accuracy to blunders and precision to carelessness, this little book isiu- valuable.—iV. H. Journal of Medicine. One of the finest aids to a young practitioner we have ever seen.— Peninsular Journal of Medicine. WALSHE (W. H.), M. D., Professor of the Principles and Practice of Medicine in University College, London, &e. A PRACTICAL TREATISE ON DISEASES OF THE LUNGS; including the Principles of Physical Diagnosis. Third American, from the third revised and much enlarged Loiuon edition. In one vol. octavo, of 4b8 pages extra cloth $3 00. The present edition has been carefully revised and much enlarged, and may be said in the main to be rewritten. Descriptions of several diseases, previously omitted, are now introduced; an effort has been made to bring tne description of anatomical characters to the level of the wants of the practical physician; and the diagnosis and prognosis ol each complaint are more completely considered. Tne sections on Treatment and the Appendix have, especially, been largely extended — Author's Preface. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DISEASES OF THE HEART AND GREAT VESSELS, including (lie Principles of Physical Diagnosis Third American, from the third revised and much enlarged London edition. In one handsome octavo volume of 420 pages, extra cloth. %-i 00. The present edition has been carefully revised ; much new matter has been added, and the entire work in a measure remodelled. Numerous facts and discussions, more or less completely novel, will be found in the description of tae principles oi physical diagnosis; bin theohiel additions have been made in the practical portions of the book. Several affections, of which little or no account had been given in the previous editions, are now treated of iii detail.— Author'* Preface 30 HENRY C. LEA'S MEDICAL New and much enlarged edition. WATSON (THOMAS), M. D., Stc, Late Physician to the Middlesex Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of "A Practical Treatise on the Diseases of Children," &c. With one hundred and eighty.five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type; extra cloth, $6 50; strongly bound in leather, with raised bands, $7 50. That the high reputation of this work might be fully maintained, the author has subjected it to a thorough revision; every portion has been examined with the aid of the most recent researches in pathology, and the results of modern investigations in both theoretical and practical subjects have been carefully weighed and embodied throughout its pages. The watchful scrutiny of the editor has likewise introduced whatever possesses immediate importance to the American physician in relation to diseases incident to our climate which are.little known in England, as well as those points in which experience here has led to different modes of practice; and he has also added largely to the series of illustrations, believing that in this manner valuable assistance may be conveyed to the student in elucidating the text. The work will, therefore, be found thoroughly on a level with the most advanced state of medical science on both sides of the Atlantic. The additions which the work has received are shown by the fact that notwithstanding an enlargement in the size of the page, more than two hundred additional pages have been necessary to accommodate the two large volumes of the London edition (which sells at ten dollars), within the compass of a single volume, and in its present form it contains the matter of at least three ordinary octavos. Believing it to be a work which should lie on the table of every physician, and be in the hands of every student, the publishers have put it at a price within the reach of all, making it one of the cheapest books as yet presented to the American profession, while at the same time the beauty of its mechanical execution renders it an exceedingly attractive volume. The fourth edition now appears, so carefully revised, as to add considerably to the value of a book already acknowledged, wherever the English language is read, to be beyond all comparison the best systematic work on the Principles and Practice of Physic in the whole range of medical literature. Every lecture contains proof of the extreme anxiety of the author to keep pace with iheadvuncing knowledge of the day One scarcely knows whether to admire most the pure, simple, forcible English— the vast amount of useful practical infonnation condensed into the Lectures- or the manly, kindhearted, unassuming character of the lecturer shining through his work.— Lond. Med. Times. Thus these admirable volumes come before the profession in their fourth edition, abounding in those distinguished attributes of moderation, judgment, erudite cultivation, clearness, and eloquence, with which they were from the first invested, but yet richer than before in the results of more prolonged observation, and in the able appreciation of the latest advances in pathology and medicine by one of the most profound medical thinkers of the day.— London Lancet. The lecturer's skill, his wisdom, his learning,are equalled by the ease of his graceful diction, his eloquence, and the far higher qualities ot candor, of courtesy, of modesty, and of generous appreciation of merit in others.— N A. Med-Chir Review. Watson's unrivalled, perhaps unapproachable work on Practice—the copious additions made to which (the fourth edition) have given it all the novelty and much of the interest of a new book.— Charleston Med. Journal. Lecturers, practitioners, and students of medicine will equally hail the reappearance of the work of Dr. Watson in the form of a new—a foui tk—edition. We merely do justice to our own feelings, and, we are sure, of the whole profession, if we thank him for having, in the trouble and turmoil of a large practice, made leisure to supply the hiatus caused by the exhaustion of the third edition. For Dr. Watson has not merely caused the lectures to be reprinted, but scattered through the whole work we find additions or alterations which prove that the author has in every way sought to bring up his teaching to the level of ,he most recent acquisitions in science.— Brit, and For. Medico-Chir.Review. New and much enlarged edition. WILSON (ERASMUS), F. R. S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and revised American, from the last and enlarged English Edition. Edited by W. H.Gobkecht, M. D., Professor of Anatomy in the Pennsylvania Medical College, &e. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, ol over 600 large pages; extra cloth, $4 00. The publishers trust that the well earned reputation so long enjoyed by this work will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to introducing everything which increased experience in its use has suggested as desirable to render it a complete text-book loi those seeking to obtain or to renew an acquaintance with Human Anatomy. The amount of additions which it has thus received may be estimated from the fact that the present edition contains over one-lburlh more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the lust, thus bringing distinctly before theeye of the student everything of interest or importance. It may be recommended to the student as no less distinguished by its accuracy and clearness of description ihun by its typographical elegance. The wood-cuts are exquisite.— Brit, and For. Medical Review. An elegant edition of one of the most useful and accurate systems of anatomical science which has been issued from the press The illustrations are really beautiful. In its style the work is extremely concise and intelligible. No one can possibly take up this volume without being struck with the great beauty of its mechanical execution, and the clearness of the descriptions which it contains is equally evident. Let students, by all means examine tne claims of this work on their notice, before they purchase a text-book of the vitally important science which this volume so fully and easily unfolds.— Lancet. We regard it as the best system now extant for students.— Western Lancet. it therefore receives our highest commendation.— Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS 31 WILSON (ERASMUS), F. R. S. ON DISEASES OF THE SKIN. Fifth American, from the Fifth enlarged London edition. In one handsome octavo volume, of nearly 700 large pages, with illustrations on wood, extra cloth $4 50. This classical work, which for twenty years has occupied the position of the leading authority in the English language on its important subject, has just received a thorough revision at the hands of the author, and is now presented as embodying the results of the latest investigations and experience on all matters connected with diseases of the skin. The increase in the size of the work shows the industry of the author, and his determination that it shall maintain the position which it has acquired as thoroughly on a level with the most advanced condition of medical science. A few notices of the last edition are appended. The writings of Wilson, upon diseases of the skin, are by far the most scientific and practical that have ever been presented to the medical world on this subject. The presentedition isa great improvement on all its predecessors. To dwell upon all the great merits and high claims of the work before us, seriatim, would indeed be an agreeable service; it would be a mental homage which we could freely offer, but we should thus occupy an undue amount of space.in this Journal. We will, howtver look at some of the more salient points witli which ii abounds,and which makeitincompurauiysuperior to all other treatises on the subject of dermatology No mere speculative views are allowed a place in this volume, which, without a doubt will, for a very long period, be acknowledged as the chief standard work on dermatology. The principles of an enlightened and rational therapeia are introduced on every appropriate occasion.— Am. Jour. Med Science. When the first edition of thiB work appeared about fourteen years ago, Mr Krasmus W ilson had already given some years to the study of Diseases of the Skin, and he then expressed his intention of devoting his future life to the elucidation of this branch of Medical Science In the present edition Mr. Wilson pr« Bents us with the results of his ma tured experience, and we have now before us not merely a reprint of bis former publications, but an entirely new and rewritten volume. Thus, the whole history of the diseases affecting the skin, whether they originate in that structure or are the mere manifestations of derangement of internal organs, is brought under notice,and the book includes a mass of information which is spread over a gieat part of the domain of Medical and Surgical Pathology. We can safely recommend it to the profession as the best work on the subject now in existence in the English language.— London Med. Times and Gazette No matter what other treatises may be in the library of the medical attendant, he needs the clear and suggestive counsels of Wil.sou, who is thoroughly posted up on all subjects connected with cutaneous pathology. We have, it is very true, other valuable works on the maladies that invade the skin; but, compared with the volume under consideration, they are certainly to be regarded as inferior lights iu guiding the judgment of the medical man.— Boston Med. and Surg. Journal, Oct. 1857. The author adopts a simple and entertaining style. He strives to clear away the complications of his subject, and has thus produced a book tilled with a vast amount of Information, in a form so agreeable as to make it pleasant reading, even to the uninitiated. More especially does it deserve our praise because of its beautiful and complete atlas, which the American publishers have successfully imitated from the original plates. We pronounce them by far the best imitations of nature yet published in our country. With Ihe text-book and atlas at hand, the diagnosis is rendered easy and accurate, and the practitioner feels himself safe iu his treatment. We will add that this work, although it must have been very expensive to the publishers, is not high priced. There is no reason, then, to prevent every physician from obtaining a work of such importance, aud oue which will save him both labor aud perplexity.— Va. Mtd. Journal. As a practical guide to the classification, diagnosis, and treatment of the diseases of the skiu, the bunk is complete. We know nothing, considered in this aspect, better in our language; it is a safe authority on all the ordinary matters which, iu this range of diseases, engage the practitioner's attention, and possesses the high quality — unknown, we believe, to every older manual, of being on a level with science's high-water mark ; a souud book of practice.— London Mud. Times. ALSO, NOW READY, A SERIES OF PLATES ILLUSTRATING WILSON ON DISEASES OF THE SKIN; consisting of twenty beautifully executed plates, of which thirteen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and containing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price in cloth. $5 50. In beauty of drawing and accuracy and finish of coloring these plates will be found equal to anything of the kind as yet issued in this country. The value of the new edition is enhanced by an additional colored plate. The plates by which this edition is accompanied leave nothing to be desired, so far as excellence of delineation and perfect accuracy of illustration are concerned.— Medico-Chirureical Review. Of these plates it is impossible to soeuk too highly The representations of the various forms of cutaneous disease are singularly accurate, and the coloring exceeds almost anything we have met with.— British, anil Foreign Medical Review. We have already expressed our high appreciation of Mr. Wilson's treatise on Diseases of the Skin. The plates are comprised in a separate volume, which we counsel till those who possess the text to purchase. It is a beautiful specimen of color printing, and the representations of the various forms of skin disease are as faithful as is possible in plates of the size. — Boston Med. and Surg. Journal, April 8, 1858. Also, the TEXT and PLATES done up in one hands ime volume, extra cloth, price $9 50. BY THE SAMB AUTHOR. THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, extra cloth, of 582 pages, with 154 illustrations $2 00. BY THE SAME AUTHOR. HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preservation and Management. Second American, from the fourth Loudon edition. One neat volume, royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00. HENRY C. LEA'S MEDICAL PUBLICATIONS. 32 WINSLOW (FORBES), M. D., D. C. L., &c. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS OF THE MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Prophylaxis. Second American, from the third and revised English edition. In one handsome octavo volume, oi nearly 600 pages, extra cloth. $4 25. (Just Ready.) We close this brief and necessarily very imperfect notice of Dr. Winslow's great and classical work, by expressing our conviction that it is long since so important and beautifully written a volume has issued from the British medical press.— Dublin Med. Press, July 25, I860. We honestly believe this to be the best book of the season.— banking's Abstract, July, 1860. The 'atter portion of Dr. Winslow's work is exclusively devoted to the consideration of Cerebral Pathology. It completely exhausts the subject, in the same manner as the previous seventeen chapters relating to morbid psychical phenomena left nothing unnoticed in reference to the mental symptoms premonitory of cerebral disease. It is impossible to overrate the benefits likely to result from a general perusal of Dr. Winslow's valuuole and deeply interesting work.— London Lancet, June 23,1860. It contains an immense mass of information.— Brit, anil For. Med.-Chir. Review, Oct. 1860. WEST (CHARLES), M. D., Aeconcheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF WOMEN. Second American, from the second London edition. In one handsome octavo volume, extra cloth, of about 500 pages; price $3 25. * # * Gentlemen who received the first portion, as issued in the " Medical News and Library," can now complete their copies by procuring Part II, being page 309 to end, with Index, Title matter, &c, 8vo., cloth, price $1 25. We must now conclude this hastily written sketch with the confident assurance to our readers that the work will well repay perusal The conscientious, painstaking, practical physician isapparenton every page.— N. Y. Journal of Medicine. We know of no treatise of the kind so complete and yet so compact.— Chicago Med. Jour. A fairer, more honest, more earnest, and more reliable investigator of the many diseases of women and children is not to be found in any country.— Southern Med. and Surg. Journal. We have to say of it, briefly and decidedly, that it is the best work on the subject in any language; and that it stamps Dr. West as the/act'/« vrincepi of British obstetric authors.— Edinb. Med. Journ. We gladly recommend his Leotures as in the highest degree instructive to all who are interested in obstetric practice.— London Lancet. Happy in his simplicity of manner, and moderate in his expression of opinion, the author is a sound reasoner and a good practitioner, and his book is worthy of the handsome garb in which it has appeared.— Virginia Med. Journal. We must take leave of Dr. West's very useful work, with our commendation of the clearness of its style, and the incustry and sobriety of judgment of which it gives evidence.— London Mid Times. Sound judgment and good sense pervade every chapter of the book. From its perusal we have derived unmixed satisfaction.— Dublin Quart. Journ. BY THE same author. (Just Ready.) LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Fourth American, from the fifth enlarged and improved London edition. In one handsome octavo volume, extra cloth, of about six hundred and fifty pages. $4 50. The numerous editions through which this work has passed on both sides of the Atlantic, are the best evidence that it has met a want felt by the profession. Few practitioners, indeed, have had the opportunities of observation and experience enjoyed by the author. In his Preface he remarks: '-The present edition embodies the results of 1200 recorded cases, and of nearly 400 post-mortem examinations, collected from between 30,000 and 40,0(0 children, who, during the past twenty-six years have come under my care, either in public or in private practice." The universal favor with which the work has been received shows that the author has made good use of these unusual advantages. The three former editions of the work now before us have placed the author in the foremost rank of those physicians who have tevoted special attention to the diseases of early life We attempt no analysis of thisedition, but may refer the reader to some of the chapters to which the largest additions have been made—those on Diphtheria, Disorders of the Mind, and Idiocy, for instance—as a prooi that the work is really a new edition; not a mere reprint. In its preient shape it will be tound of the greatest possible service in the every-day practice of ninetenths of the profession.—Med. Times and Gazette, London, Dtc. 10,1859. All things considered this book of Dr. West is by far the best treatise in our language upon such modifications of morbid action and disease as arc wijiussed when we have to deal with infancy and childhood. It is true that it confines itself to such disorders as come within the province of the physician, and even with respect to these it is unequal as regards minu terns* of consideration, and some diseases it omits to notice altogether. But those who know anything of the present condition of paediatrics will readily admit that it would be next to impossible to effect more, or effect it better, than the accoucheur of St. Bartholomew's has done in a single volume. The lecture (XYI.) upon Disorotrs of the Mind in chiluren is an admirable specimen of the value ot the later information conveyed in the Lectures of Dr. Charles West.— London Lancet, Oct. 22,1859. Since the appearance of the first edition, about eleven years ago, the experience of the author haa doubled; so that, whereas the lectures at first were founded on six hundred observations, and one hundred and eiginy dissections made among nearly fourteen thousand children, they now embody the results of nine hundred observations, and two hundred and eighty-eight post-mortem examinations made among nearly thirty thousand children, who, during the past twenty years, have been under his care.— British Med. Journal, Oct. 1, 1859. BT THE SAME AUTHOR. AM ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCERATION Of THE OS UTERI. In one neat octavo volume, extra cloth. $1 25.