■*Mf ' — -o NLM 0DSSMST1 7 =dicine national library of MEDICINE NATIONAL ll Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn 3nidiq3w do Aavaan ivnoiivn 3nidici3w j ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL L U.S. NATIONAL LIBRARY OF MEDICINE (ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL Aavaan ivnoiivn SNiDiasw do Aavaan ivnoiivn 3nidic]3w do Aavaan ivnoiivn snidiosw 1 / ?ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn aNOiaaw do Aavaan ivnoiivn 3Nioia3w NLM005545917 Fsy | \^ i jess | T ' ^ J OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR ian ivnoiivn 3NiDia3w do Aavaan ivnoiivn 3nidio3w do Aavaan ivnoiivn 3Nma3w do a»> k. - J ,-$?>&■ OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY ian ivnoiivn 3nidio3w do Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn 3noio3w do asm OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY an ivnoiivn 3Nma3w do Aavaan ivnoiivn snoiqsw do Aavaan ivnoiivn 3NiDia3w do a«x OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR ian ivnoiivn 3NIDIQ3W do Aavaan ivnoiivn snidiqsw do Aavaan ivnoiivn 3Ni3ia3w do Air OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR | V aan ivnoiivn snidicisw do Aavaan ivnoiivn 3nidio3w do Aavaan ivnoiivn aNmaaw do a» ^xW IS'/ r A CLINICAL HISTORY ,, MEDICAL AND SURGICAL DISEASES OF WOMEN. BY ROBERT BARNES, M.D., Lond. J*r- ENSOR OF THE ROYAL COLLEGE OF PHYSICIANS, LUMLEIAN LECTURER (1 873) ; LATE EXAMINER IN OBSTETRICS AND THE DISEASES OF WOMEN AT THE UNIVER8ITY OF LONDON AND THE ROYAL COLLEGES OF PHYSICIANS AND SURGEONS; OBSTETRIC PHYSICIAN AND LECTURER ON OBSTETRICS AND THE DISEASES OF WOMEN TO ST. GEORGE'S HOSPITAL. SECOND AMERICAN FKOM THE SECOND AND REVISED LONDON EDITION WITH ONE HUNDRED AND EIGHTY-ONE ILLUSTRATIONS. PHILADELPHIA: HENRY 0. LEA. 1878. wp IS72 PHILADELPHIA: COLLINS, PRINTER. Dear Dr. FORDYCE BARKER, I rejoice at my good fortune in being allowed to place this book under your protection. Your imprimatur will help me to bear more lightly the burden of its many faults. And let me here express through you, in whom are so happily com- bined the genial heart and the scientific spirit which animate our American brethren, my gratitude for the unbounded kindness which made my visit to them an epoch of pleasant memories. Yours ever truly, ROBERT BARNES. To Fokdyce Barker, M.D., LL.D., First President of the American Gynaecological Society. AS THE CONDITION OF THIS VOLUME WOULD NOT PERMIT SEWING, IT WAS TREATED WITH A STRONG, DURABLE ADHESIVE ESPECIALLY APPLIED TO ASSURE HARD WEAR AND USE. PREFACE. The First Edition of this work has been long exhausted. I have not on that account hurried the preparation of this Second Edition. The book has been subjected to conscien- tious revision. It is hoped that some of its defects have been either removed or lessened. By pruning redundancies, and by re-arrangement, space has been gained for the addition of new matter. The size of the book is not increased; yet room has been found for a new Chapter on the Belations of Bladder and Bowel Disorders to the proper subject-matter of the book. Many new illustrations have been added. I think it not unimportant to state, that I have given under every borrowed illustration the source whence it was taken. The illustrations contributed by myself are indicated by my initials. Although the work is essentially the fruit of my expe- rience and study as a practitioner, teacher, and examiner, I have earnestly sought to correct my own observations, and to enrich the book by drawing from other sources. I have, as a rule, specified in the text the titles of the works consulted. The opportunity is thus afforded to my readers of controlling m}' citations, and of extending their informa- tion, by appealing to the original sources. The instances are rare in which I have failed to consult directly the Vi PREFACE. authors cited. The copious index of authors will bear testimony to my diligence in this way. This index and the titles of the works referred to will supply a fairly com- prehensive bibliography of the subject. For useful aid in correcting the press, and in otherwise lightening the labor incidental to the preparation of a work of this kind, I am indebted to my son Dr. Fancourt Barnes. ROBERT BARNES. lf>, Hakley Street, London, June, 1878. CONTENTS. CHAPTER I. PAGE Introductory: Anatomy of Pelvic Organs : the Ovaries ; Fallopian Tubes ; Uterus; Douglas's Pouch; Axis and Movements of Uterus; Changes under Menstruation; Vagina; Vulva . . . . . . .17 CHAPTER II. Conditions indicating Necessity for Local Examination : Disorder of Function— Distant and Constitutional Reactions—the Subjective Signs, of Local Dis- ease indicate Appeal to Objective signs—Comparison of Study of Disease of Pelvic Organs with that of Skin and Eye—Disturbance of Functions of Ovaries, Uterus, and Vagina—Amenorrhcea, Real and Occult; Menorrha- gia ; Dysmenorrhoea—Abortion—Discharges: Leucorrhoea, Mucous, Albu- minous, Watery, Gaseous, Purulent, Hemorrhagic, Fleshy, Membranous— Nervous Phenomena: Pain, Lumbo-Dorsal, Inguinal, Pelvic; Irritable Ovary; Irritable Uterus ; Mastodynia ; Neuralgia, Spinal Irritation, Para- plegia, Mental Disorder, Reflex Nervous Phenomena, Vomiting, Convul- sion, Epilepsy, Hysteria—Dyspareunia, Vaginismus—Sterility . . . (!') CHAPTER III. Significance of Symptoms Connected with Bladder and Urinary Disorders in relation to Uterine and Peri-uterine Affections :— Retention of Urine ; Ischuria; Partial Retention; Incontinence; Cystitis; Abnormal Matters in Urine:—Blood, Pus, Faeculent Matter, Hair, Fat, Bones, Albumen— Significance of; Malignant Disease of Bladder, Primary and Secondary; Dysuria. Significance of Symptoms connected with Rectum and other Bowel-disorders in relation to Uterine and Peri-uterine Affections, Hemor- rhoids, Fissure, Dyschezia, Constipation, Retention of Faeces; Coprasmia; Blood, Pus, Mucus in the Faces ; Hair, Teeth, Bones, Foetal Elements in the Fasces............12<» CHAPTER IV. The Instruments Serving for Diagnosis and Treatment ..... 140 Vlll CONTENTS. CHAPTER V. PAOK The Diagnosis of Diseases of the Pelvic Organs. The Touch—The Sound— The Speculum . . . . . . . . . . . l.">7 CHAPTER VI. The Pathology of the Ovaries—The History of Menstruation and its Disorders 17>, Barnes's Whalebone Sound (R. B.) .... Kiichenmeister's Metrotome Scissors Simpson's Metrotome . Simpson's Tenaculum Hook . Improved Wire Ecraseur (R. B.) .... Barnes's Instrument for Introducing Laminaria or Sponge-tents into the Uterus (R-B.)....... Barnes's Nitrate of Silver Cautery .... Barnes's Tube for Depositing Fused Sticks of Sulphate of Zinc in Uterus (R. B. Barnes's Uterine Ointment and Nitric Acid Positor (R. B.) Higginson's Vaginal Syringe .... Barnes's Speculum for Application of Medicated Cotton Wool in Vagina (R. B.) 56. Skeleton Diagrams for Recording Alterations of Size, Position, and Relations of Pelvic and Abdominal Organs (R. B.) .... 158,159 Diagnosis of Early Pregnancy (R. B.) ...... 164 Showing Reversal of Sound in utero (R. B.) ..... 165 60, 61. Diagrams showing High Tension preceding Menstruation, High Tension in Ninth Month of Gestation, and Ordinary Tension after Menstruation (Fan court Barnes) ........ Dilated Uterus and Vagina from Retained Menses (R. B.) Complete Occlusion of Vulva (Radcliffe Museum) (R. B.) Atresia of Vagina (R. B.) ....... Conical Vaginal-Portion (R. B.) ...... Common Form of Narrow Os Uteri in Dysmenorrhoea and Sterility (R. B.) Section of Conical Cervix with Small Os Externum (R. B.) . . . 223 Section of Uterus made at Os Internum (R. B.) ..... 226 Action of Kiichenmeister's Scissors (R. B.) . . . . 230 Uterine Mucous Membrane shed entire (R. B.) ..... 242 Exfoliated Mucous Membrane of Vagina (R. B.) ..... 245 Blood Coagulum in a Cyst of Ovary (R. B.) ..... 269 Fibrous Tumor of Ovary (R. B.) ....... 270 Early Stages of Cystic Disease (R. B.) . . . . . .286 Incipient Cystic Enlargement of Graafian Follicles (R. B.) . . . 287 Fibrous Stroma of Compound Cystic Tumor of Ovary (H. Arnott) . . 290 Epithelial Lining of a Compound Ovarian Cyst (H. Arnott) . . . 291 Section of Ovarian Tumor showing Alveolar Structure (R. B.) . . . 292 Ovaries Affected with Proliferating or Papillary Disease (R. B.) . . 293 Dermoid Cyst of Ovary (R. B.) ....... 296 Hook to Extract Hair, etc., from Dermoid Cysts (R. B.) . . . 299 Gestation in Left Fallopian Tube (R. B.) . . . . . .304 Gestation in Rudimentary Horn of Uterus (Luschka) .... 306 Tubo-Uterine Gestation (Poppel) ....... 326 Inflammation of Fallopian Tubes (Hooper) ..... 332 Dropsy of Fallopian Tube (R. B.) . . . . . . . 337 Ovarian Tumor and Pregnancy (R. B.) ... ... 358 89, 90. Diagrams : Diagnosis of Ascites and Ovarian Dropsy (R. B.) . 364, 365 Microscopic Character of Ovarian Fluid (Thomas M. Drysdale) . . . 374 Uterus Strongly Developed to Right (Tiedemann) .... 405 Double or Bicornute Uterus (St. Thomas's) (R. B.) .... 405 Bicornute Uterus (R. B.) ........ 406 Bicornute Uterus. Septum dividing Cavity (Guy's) (R. B.) . . . 407 Double Uterus and Vagina (Guy's) (R. B.) ..... 408 Transverse Section of Vaginae of preceding figure (R. B.) . . 409 Atrophy of the Uterus and Ovaries (Carswell) ..... 411 Stenosis; Atresia; Dilatation of Uterus (R. B.) ..... 412 LIST OF WOOD ENGRAVINGS. XV FIG. 100. Representing Bulk of Uterus arrested in its Involution after Pregnancy, and also the Bulk it ought to attain (Simpson) .... 101. Congestion of Vaginal-Portion of Cervix after Labor (R. B.) . 102. Showing Loss of Epithelium, leaving Villi of Os Uteri bare (Hassall and Tyler Smith) ......... 103. Epithelial Abrasion after Labor (R. B.) . 104. Marion Sims's Curette ....... 105. Recamier's Curette ........ 106. Collar of Hard Inflammatory Effusion encircling Cervix Uteri (R. B.) 107. Remains of a Retro-Uterine Haematocele (Guy's) (R. B.) 108. Retro-Uterine Haematocele from a Diseased Ovary (R. B.) 109. Retro-Uterine Haematocele (R. B.) ..... 110. Sectional View of the Parts in Retro-Uterine Haematocele (R. B.) 111. Illustrating Relative Position of the Uterus and Rectum and Intervening Cyst (R-B.)......... 112. Complete Procidentia Uteri (R. B.) ..... 113. Illustrating Successive Stages of Prolapsus of Uterus (R. B.) . 114. Prolapsus Uteri (R. B.) . 115. One Form of Hypertrophy of Vaginal-Portion of Cervix Uteri (R. B.) 116. Appearance of same after Complete Cicatrization from Amputation by the Gal- vanic Cautery (R. B.) ....... 117. Eversion of Mucous Membrane of Cervix Uteri (R. B.) . 118. Prolapsus of Uterus, with Hypertrophic Elongation and Complete Eversion of Vagina (London Hospital) (R. B.) ..... 119. Hypertrophy with Procidentia of Vaginal-Portion of Cervix Uteri (R. B.) 120. Early Stage of Hypertrophic Elongation of the Cervix Uteri (R. B.) . 121. Advanced Hypertrophic Elongation of Cervix Uteri (R. B.) 122. Hypertrophic Elongation of both Supra and Infra Vaginal-Portions of Cervix Uteri (King's College) ....... 123. Great Hypertrophic Elongation of Supra Vaginal-Portion of Cervix Uteri (St. Bartholomew's) (R. B.) . 124. Hypertrophic Elongation of Uterus (St. Thomas's) (R. B.) 125. Diagram showing how Hypertrophic Elongation of the Anterior Lip of the Os Uteri is caused by Pressure under Retroflexion (R. B.) 126. The Cup-and-Stem Pessary (R. B.) ..... 127. Scott's Pessary ........ 128. Diagrams Illustrating Versions and Flexions of the Uterus (R. B.) 129. Graily Hewitt's "Cradle-Pessary" (R. B.) .... 130. Extreme Anteflexion of Uterus (R. B.) ..... 131. Anteflexion of Uterus (R. B.) ...... 132. Diagnosis of Anteflexion of Uterus (R. B.) .... 133. Mode of applying Hodge or Lever Pessary for Retroversion or Retroflexion (R-B.)......... 134. Second Stage in Application of the Hodge (R. B.) 135. Third and Final Stage in Application of the Hodge (R. B.) . 136. Extreme Retroflexion of the Uterus (R. B.) 137. Diagnosis of Retroflexion by the Vaginal Touch (R. B.) 138. Diagnosis and Reposition of the Retroflected Uterus by the Sound (R. B.) 139,140. Reduction of Retroflected Uterus by Finger (R. B.) . . 613, 614 141. Reduction of Retroflected Uterus by Sound (R. B.) . . . .615 142. Occasional Vicious Action of the Hodge in Extreme Retroflexion of Uterus (R-B.)......... 143. Combined Action of Intra-Uterine Pessary and the Hodge (R. B.) 144. Illustrating Three Degrees of Inversion of Uterus (Crosse) 145. Extreme Inversion in Section (Crosse) ..... LIST OF WOOD ENGRAVINGS. 146. Specimen of Inverted Uterus (Crosse) 147. Barnes's Operation for Inversion of Uterus (R. B.) 148. Barnes's Elastic Pessary for Reduction of Chronic Inversion of the Uteru (R-B.)...... 149. Structure of Fibroid of Uterus (H. Arnott) 150. Conglomerate of Fibroid Tumors of Uterus (St. Thomas's) (R. B.) 151. Sub-peritoneal Fibroid Tumor of Uterus (London Hospital) (R. B.) 152. Fibroid Tumor of Uterus (R. B.) .... 153. Uterus with two large Fibroid Tumors (St. George's) (R. B.) 154. Fibroid Tumors of the Uterus (St. George's) (R. B.) 155. Fibroid or Muscular Tumor of Uterus (St. Thomas's) (R. B.) 156. Erectile Tumor of Uterus (Carswell) 157. Ossified or Cretified Fibroid Tumor of Uterus (St. Thomas's) (R. B.) 158. Large Fibroid Tumors, one in the Anterior, the other in the Posterior Wall of Uterus (St. George's) (R. B.) . . . 159. Fibroid Polypus filling Cavity of Uterus (College of Surgeons) (R. B.) 160. Fibroid Polypus extruded from Uterus (College of Surgeons) (R. B.) 161. Mucous or Glandular Cervical Polypus (R. B.) .... 162. Section of a " Channelled" Glandular Polypus (Arnott) 163. Uterus with Fibroid Polypus attached to Upper Wall and ligatured (St. Bar tholomew's) (R. B.) . 164. Operation for removing Polypus Uteri by Wire Ecraseur (R. B.) 165. Tubercular Disease of Uterus (Guy's) (R. B.) .... 166. Phthisis Uteri (Carswell) . . . . . 167. Cancer of Uterus (St. Bartholomew's) (R. B.) .... 168. Uterus enlarged from Infiltration with Encephaloid Matter (St. Thomas's (R-B.)......... 169. Uterus lower two-thirds destroyed by Ulceration (St. Bartholomew's) (R. B/ 170. Cancer eating away lower half of Uterus (St. Thomas's) (R. B.) 171. Pavement-Epithelioma of Uterus (Lancereaux) . 172. Malignant Disease of Uterus (St. George's) (R. B.) 173. Cauliflower Growth of the Cervix Uteri (Arnott) 174. Spindle-cell Sarcoma (Arnott) ...... 175. Intra-Uterine Speculum (R. B.) . 176. Cicatricial Band Binding Os Uteri of Vagina (R. B.) 177. Showing the Relations of Ureters to Vesico-Vaginal Fistula (St. Thomas's (R-B.)......... 178. Diagram representing " Perineal Body" (modified after Thomas) (R. B.) 179. Representing the Split Sphincter Ani and the Course of the Suture necessary to bring the ends of the Sphincter together (Thomas) 180. Showing the Ring of Sphincter Ani nearly restored by drawing up Suture passed as in preceding figure (Thomas) . 181. Showing Wound and Application of Sutures in Restoration of Perineum (Thomas) ..... . , THE DISEASES OF WOMEN. CHAPTER I. introductory : anatomy of pelvic organs: the ovaries; fallopian tubes; uteri's; dougus's pouch; axis and movements of uterus : changes under menstruation; vagina; vulva. It may seem superfluous to state that a clear knowledge of anatomy is the antecedent condition of a correct understanding of disease, diagnosis, and treatment. All sound medicine is based upon this proposition. But it is more strictly true of the diseases of women than it is of disease in general. For example, it is quite possible to imagine a satisfactory diagnosis to be made of a fever and to treat it successfully, without any precise knowledge of anatomy ; but in the diagnosis and treatment of morbid conditions of the female pelvic organs it is hardly possible to move a step without precise knowledge of their anatomy and physiology ; that is, without imminent risk of falling into error in practice. It therefore becomes especially desirable to introduce the study of the medical and surgical diseases of women by an adequate description of the organs specially concerned. It might be thought to be sufficient to refer the reader for this to any one of the many admirable works on anatomy which we now possess ; but this, it would quickly be found, would very imperfectly answer the purpose. Anatomical text-books teach pure anatomy only, certainly as far as the diseases of women are concerned. "What we want is the applied anatomy of the sexual system. Almost every physiological or pathological condition of the pelvic organs is attended h\ variations more or less marked either in their tissues, in their shape, size, or in their relative positions, and often in all. Hence the necessity of keeping constantly before us the normal standard by which we may estimate the abnormal deviations and understand how these are to be corrected. The principal organs we are concerned with are all contained within, the true pelvis. They are further inclosed or packed between the peri- toneum above and the perineum below. These organs are the ovaries, the Fallopian tubes, the uterus, the vagina, and vulva. The rectum and bladder, also contained within the 2 18 ANATOMY OF PELVIC ORGANS. same region, are indirectly important, in consequence of their physio- logical and pathological relations to the genital organs. The pelvic organs are all related to each other by position, by con- necting tissues, and by a system of bloodvessels common in their source, and intimate in their mutual play. The organs of the pelvis in their relative positions are displayed in section in Figs. 1 and 10, and from above in Fig. 2: 1 is diagrammatic, and Broisky's is taken from nature from a frozen body. Fig. 1. Showing the Pelvic Organs in Section—(after Sappey). ' 1, body of uterus ; 2, its cavity ; 3, the vaginal portion ; 4, canal of cervix ; 5, os uteri externum ; 6, the vagina ; 7, orifice of the vulva; 8, interior of bladder; 9, urethra; 10, vesico-vaginal soptuni; 11, rectum ; 12, its cavity ; 13, anus ; 14, recto-vaginal septum ; 15, perineum: 16, vesico-uterine sac of peritoneum ; 17, recto-vaginal, or Douglas's sac of peritoneum ; IS, os pubis ; 19, labium minor; 20, labium majus. The connective tissue being distributed everywhere at the points of union of the organs, carries the bloodvessels, nerves, and lymphatics to the organs. In certain parts this connective tissue is limited by fascise. In addition to these organs, we have to remember that the pelvis is traversed by bloodvessels and nerves, which are not strictly related to the genital organs, but which are liable to be implicated in various wavs, as by pressure, during gestation and labor, by tumors, or displacement of the ovaries or uterus. These vessels and nerves lie in close contact with the walls of the pelvis, and have their exit at the sacro-sciatic notches, at the brim under Poupart's ligament and the obturator foramina. Then there are muscles all cushioned by fat and cellular tissue. ANATOMY OF OVARY. 19 The strictly genital organs consist of—1st, two glands, the ovaries, in which the ova are formed: 2d, the uterine tubes, called Fallopian, which are true excretory ducts to the ovaries ; 3d, the uterus, a muscular organ in which the fecundated ovum is received and is developed, and Fig. 2. Transverse Section just above Pelvic Brim, showing the Relative Position of the Organs as seen from above—(after Savage). m, pubes ; a, a, (in front) remains of hypogastric arteries ; a, a, (behind) spermatic vessels and nerves ; B, bladder ; l, l, round ligaments ; u, uterus seen by its fundus ; t, t, Fallopian tubes ; o, o ovaries; r, rectum; g, right ureter resting on the psoas muscle; c, utero-sacral ligaments forming the lateral borders of Douglas's pouch ; v, last lumbar vertebra. which is the principal agent in the expulsion of the foetus; 4th, the vayhui, a canal which connects the uterine cavity wTith the exterior, and serves in copulation ; 5th, the vulva, an assemblage of organs placed around the entrance of the genital organs. Associated with the genital organs are the breasts, whose function it is to secrete the milk, the first nourishment of the infant. THE OVARIES. 1. The ovaries are so called from their containing small vesicles or ova. They are two; they are placed in front of the rectum, from which they are often separated by convolutions of the small intestine, on either side of the uterus, behind the Fallopian tubes, and in that portion of the broad ligaments which is called the posterior wing or fold. They are maintained in position by the broad ligaments, which make for them a kind of mesentery, and by a special ligament, the liyameut of the ovary. The situation, however, varies according to the age and the condition of the uterus. In the foetus, they are placed in the lumbar region, like the fundus of the uterus. In mature women, the ovaries lie nearly on a level 20 OVARY AND FALLOPIAN TUBE. with the fundus of the uterus. If enlarged or increased in weight, they tend to fall, and thus to drop into the Douglas's pouch behind the lower segment of the uterus. During pregnancy they rise in the abdomen with the body of the uterus, to the sides of which they are applied. Imme- diately after delivery, they occupy the internal iliac fossne, where they sometimes remain throughout life, fixed bv accidental adhesions, or adhe- sions may bind them to the rectum. Frequently they are found turned backwards and adhering to the posterior surface of the uterus. Some- times an ovary is found in the sac of an inguinal, a femoral, or even of an umbilical hernia. Cases have been met with in which no ovaries were found. It must be very rare that organs so essential are absolutely wanting ah initio. There is a preparation in University College Museum from a girl, aged 20, who had never menstruated. The uterus presents the features cha- racteristic of early childhood, and no ovaries are manifest. When not discovered, the ovaries may have disappeared by atrophy, the result of some morbid process. The size of the ovary varies according to age, the condition of the uterus, and health or disease. In the adult it measures an inch or two inches in length, an inch in breadth, and half an inch in thickness. The average weight is 87 grains. It is proportionally larger in the foetus; it diminishes after birth, it enlarges considerably, becoming softer and more vascular at the epoch of puberty, and becomes atrophied and hard in old age. It enlarges during menstruation; and if an ovule be impregnated, the ovary may acquire double or treble the size of the ordinary state. Adult Parovar'um, Ovary, and Fallopian Tube—(after Kobelt). n, n, tubules of the original Wolffian body or i arovarium ; b, remains of the upper set which occa- sionally become distended by collections of fluid, and constitute one form of dropsy of the broad liga- ment: c, middle set of tubules ; d, lower set atrophied ; e, atrophied remains of the excretory duct of Wolffian body ; /, terminal bulb of the same, converted here iuto the hydatid often seen attached to the broad ligament; h, the former duct of Miiller, now the Fallopian tube, with its infundibulum from which hangs i, the terminal bulb, now converted intj a pedunculated hydatid ; I, generative gland now the ovaiy. The shape is that of an ovoid, a little flattened from before backwards ; the outer extremity, that looking towards the fimbriated end of the Fal- ANATOMY OF OVARY. 21 lopian tube, is rounder and thicker than the inner extremity, which looks towards the uterus. The anterior surface, like that of the uterus, is flatter than the posterior, which is gibbous. The upper border is convex; the lower one is straight or concave. The color is whitish. The surface is smooth during childhood (as seen in Fig. 3) ; after puberty it becomes scarred by the repair of the rents made in the tissues to afford escape to the ova at the menstrual periods (as seen in Fig. 4) ; but in young women smooth interspaces may still be seen. The ovary is free in front, Right Fallopian Tube laid open. From an Adult who had not b.irne Children—(after Richard). a, funnel-shaped canal, leading from the uterus to 6, uterine portion of the tube ; c, point at which the large plicae commence ; d, infundibulum covered by plicae, continuous with those lining the canal; e, tubo-ovarian ligament and fringes ; /, ovary ; g, round ligament; h, ligament of the ovary. above, and behind ; it floats in the pelvic cavity, fastened, 1st, by its lower border to the broad ligament which is furnished with a peritoneal investment, and represents the hilum of the gland. Along this border bloodvessels penetrate and emerge; 2d, it is fastened by its outer extremity to the pavilion of the Fallopian tube (see Fig. 4) ; and 3d, by its inner extremity to the corresponding side of the uterus, a little below the superior angle of this organ, by a cord named the Uyanient, of the ovary (see h, Fig. 4). This cord is fibrous and muscular, and is simply a prolongation of the proper tissue of the uterus. The ovary is usually described as composed of an investment and paren- chyma ; the investing structure consisting of the peritoneal or serous coat, and of an inner fibrous coat called also the tunica albuyinea. The two, however, are so intimately blended that it is impossible to separate them; nor is it easier to separate a fibrous coat from the parenchyma. Indeed, Sappey denies the existence of peritoneal coat and fibrous coat alike. The peritoneum is represented only by a simple layer of epithelium ; and of tunica albuginea there is not even a vestige.1 When the ovary is divided perpendicularly to its surface, it is seen to consist of two very different parts: 1st, a superficial part, white, of firm consistence, of homo- geneous aspect: 2d, a central part, reddish, spongy, clearly formed of various elements. The superficial or peripheral part is the exclusive seat of the ovarian vesicles. The deep or central part is essentially made up 1 Sappey, Anatoniie Descriptive, 1874. oo OVARY. of vessels, muscular fibres, and laminar fibres. The first part Sappey calls the glandular or ovigenous, and the second the vascular or lulling part. Direct observation and anatomical analysis establish very pre- cisely the line of demarcation between them, the glandular portion is only 1 mm. thick, sometimes less. It assumes the aspect of a bark which covers both faces, both ends, and the free border of the ovary. It is this which, its nature and uses alike misunderstood, has been especially de- scribed under the names, proper tunic or fibrous tunic. The central por- tion forms nearly the whole mass of the organ. We will first examine the bulbous portion. Upon this is spread, so to speak, the ovigenous layer. It comprises smooth muscular fibres, con- nective tissue, vessels, and nerves. The muscular fibres, described in 1858, by llouget, very numerous, are disposed in bundles. They pro- ceed from the ligament of the ovary, from the ligament of the Fallopian tube, the posterior round ligament, and the posterior winglet of the broad ligament. The fibres arising from these sources are directed from below upwards, radiating in all directions, and partly crossing. The fibres of connective tissue especially follow the track of the vessels, binding them together, and to the muscular bundles. With these fibres are mingled a large number of fibro-plastic fusiform bodies. The arteries proceed from branches of the utero-ovarian. They are numerous and of large relative size. All penetrate the gland by its ad- herent border, and thence radiate towards the periphery. These arteries are extremely flexuous; most of them twine around a fictitious axis, describing a spiral, the turns of which approach so closely that, strongly compressed between two laminae of glass, they still preserve the shape of a corkscrew'. This spiral character is manifested in injected specimens even before the arteries enter the ovary. The arterial divisions in their course anastomose, and ultimately form a network, the meshes of which become smaller and smaller as they approach the surface of the gland. The veins are remarkable alike for their number and their size. They therefore constitute a large proportion of the bulbous part. They begin, as all veins do, by radicles continuous Avith the capillaries. But they rapidly get larger, become knotty, as if varicose at points, and form by anastomoses a plexus with singular meshes. From this plexus emerge trunks which run parallel to the arterial divisions and terminate in the utero-ovarian vein. The lymphatic vessels are also remarkable for their size. Their origin has not been made out. From the convergence of their radicles result six or eight trunks which run towards the hilum of the gland to join the lumbar ganglia. M. His points out that the lymphatics in the hilum are often filled with pus, the consequence of puerperal peritonitis, which is often complicated with ovaritis and inflammation of the lymphatic vessels. The nerves come from the ovarian plexus which, passing beneath the adherent border of the ovary, gives up to it the greater number of its tAvigs. These penetrate Avith the arterial divisions into the interior of the organ. M. His1 is of opinion that the entire interstitial tissue of the ovaries is 1 Beobachtungen viber den Ban des Saugethiereierstocks. Max Schultze's Archiv f. inikrosp. Auat., 1SG5. OVARY. 23 nothing but a peculiarly modified and confused mass of muscular tissue, and he proposes for it the name " fusiform mass." Rouget regards the arrangement by which these muscular fasciculi accompany the vessels in the form of sheaths, as analogous to that which obtains in erectile tissues. But Sappey points out this distinction, that erectile tissue is especially formed of big capillaries, very short and anastomosing, supported by muscular scaffolding, and into which the ultimate divisions of the arteries open ; whilst in the ovaries it is not only simple capillaries that Ave see, but true veins exhibiting their usual arrangement. There are no dilated capillaries, no areolae, no frameAvork. And Waldeyer observed1 that at present avc cannot be said to possess any direct observations on the erec- tion of the OA'aries. The uses of the bulbous portion are to support the ovarian vesicles and the ovules by offering them to the contact of the pavilion of the Fallo- pian tubes ; and to supply the vesicles and ovules with the elements of nutrition. The peripheral or cortical or ovigenous portion constitutes the essential part of the ovary, that in Avhich the ovule is formed. It is the first part formed in the embryo. In it are distinguished the ovisacs or Graafian vesicles, destined to secrete and expel the ovum. Immediately beneath the serous epithelium the stroma is found com- posed of bundles of connective tissue variously crossed; near the bulbous substance it presents the irradiations of the connective fibres of this part. What distinguishes the connective tissue is the enormous quantity of interstitial nuclei revealed by acetic acid, described by Rouget as fusi- form fibro-plastic bodies. BetAveen these tAvo layers of connective tissue is a layer, the variable thickness of Avhich mainly determines the differ- ences in size Avhich the ovary presents. It consists essentially of fusiform nucleated cells, strongly compressed against each other, and sometimes furnished Avith filiform prolongations, very short and penetrating into the interstices of the adjoining cells. The Graafian vesicles or follicles are scattered in the stroma of the cortical substance, chiefly in the most super- ficial layer. The limitation of the ovules to the peripheral portion is most marked in infancy. After puberty they are apt to invade the bulbous portion. TWards puberty the follicles are found close together. Their number is very great. To give an approximate idea, Henle makes the folloAving calculation : In the ovary of a person eighteen years old an antero-posterior section, forming about a sixth of the periphery of the organ, showed 20 follicles ; in the entire section there Avould be 120 follicles; and as it would be possible to divide the ovary into 300 sections, it fol- lows that each ovary contained 300 times 120 or 36,000 follicles, or 72,000 for each Avoman. Sappey makes a much higher estimate. The OAraries, he says, contain on an average (300,000 to 700,000 germs. Woman possesses already in the embryonic state all the ovisacs she is ever to have. The number remains Avhat it Avas, subject to diminution by maturation, by atrophy, by the cicatricial process, by inflammations, and other influences. A great number of vessels spread out in the ovigenous layer. They 1 Strieker's Manual of Histology, N. Sydenham Soc. 1ST2. 24 OVARY. form by anastomoses a very rich netAvork. Most of the capillaries end at the periphery of the ovary forming arches and irregular loops. The minute arterioles Avhich are lost in this capillary network preserve the spiroid direction Avhich they had in the bulbous portion. Their last divi- sions are spread around the ovarian vesicles. The veins are remarkable for their size, and by the frequent swellings observed in their course. The lymphatics spring from the peripheral layer. Sappey says that it is not rare to find in the alar mesentery, especially round about the ovary, several cystic ovules, some of them the size of a pea. They may be re- garded as stray ovules, which have failed to become incorporated in the ovary. They may possibly be the germs of some of the cystic tumors observed in the broad ligament. Fig. 5. B a i A, a, ovary enlarged under menstrual nisus ; B, ripe follicle projecting on surface; a, a, a, traces of previously burst follicles—(after Raciborski). The follicles, at first microscopic, rapidly groAV after puberty when they are destined to mature. They form a hemispherical bulging on the surface of the ovary. This ripening appears to take place rapidly, since only a small number of follicles is usually made out by the naked eye ; that is, in process of development; yet it is certain that every month one follicle, at least, arrives at complete maturation. When ripe, the follicle, or vesicle, or ovisac, consists of an investing membrane and contents. 1. The investing membrane presents an outer or fibrous tunic, a middle or proper tunic, and an inner or epithelial or granular layer. The first is thick, very vascular, and very retractile ; it is united to the stroma by a loose cellular tissue: hence it is easily isolated. It is formed of compact bundles of connective tissue arranged in poncentric layers. The tunica propria is also composed of connective tissue ; but this is in a more embryonic state, and contains a multitude of nuclei and fusiform cells. This tunic is also much less retractile than the fibrous tunic. The epithelium which lines the membrane of the fol- licle inside is composed of one or more layers of polygonal cells, inclosing a large nucleus and some fatty granules. The epithelium is much thicker at the part which surrounds the ovum. At the level of this part the GRAAFIAN FOLLICLE. 25 accumulated cells form a warty SAvelling, Avhich bulges into the cavity of the follicle. This SAvelling is the cumulus or discus proligerus. The ovum is situated in the middle of the cells of the proligerous disk, part of Avhich it carries along with it, Avhen, after the dehiscence of the fol- licle, it leaves the ovary to enter the oviduct. The ovum is a spherical vesicle ; it may be represented as a simple cell. The membrane of the cell is called the vitelline membrane; it is very thick, perfectly hyaline and transparent, resisting and very elastic. The contained matter is called the vitellus; this is a \dscous liquid of yelloAvish color, in Avhich are seen a multitude of granulations. A large vesicular nucleus, called the germinal vesicle, is situated excentrically in the vitellus, and itself contains a small nucleolus, the germinal spot. It is rare to find tA\o ova in the same follicle. The follicle contains a transparent, yelloAvish fluid, resembling serum ; at first this is Aery small in quantity, but increases gradually as the fol- licle approaches maturation, until the tunics, swollen and thinned by this Fig. 6. Showing Menstrual Corpus Luteum and Ovary—(after Raciborski). B, cavity of Graafian sac from which ovum has escaped ; b, clot of blood in sac. accumulation of liquid, burst at the culminating point, and discharge their contents. Corpora Lutea.-—When the follicles haAre burst, and the ovum has escaped, a process takes place Avhich results in the formation of the so- called yelloAv bodies. On the bursting of the follicle, its membranes collapse. The retraction is due entirely to the fibrous membrane ; the internal membrane and the granular layer having no elasticity simply folloAv the movements of the fibrous tunic, and form folds, just as the mucous membrane of the stomach does under the influence of the con- traction of the muscular coat. The cavity of the follicle is thus greatly contracted ; a small quantity of blood, escaped from some ruptured ves- sels, is retained, but only as an exception, according to Coste, in the cavity, Avhich is early invaded by a plastic and gelatinous secretion fur- nished by the inflamed part. Soon the cellular and granular layer, a 26 CORPUS LUTEI'M. part of Avhich has been expelled Avith the ovum, undergoes a kind of hypertrophy, Avhich gives it an enormous size. Every cell becomes about six times as large as before ; this groAvth is especially due to the accumulation, in the inside of the cells, of a multitude of vcIIoav granules of albuminous nature, giving to the Avhole follicle the color Avhich sug- gested the name of yellow body, Owing to this hypertrophy and to the folding of the inner membrane, the cavity of the follicle is at last com- pletely closed. The circumvolutions of the inner membrane coming into contact groAV together ; and even after having obliterated the cavity they continue to groAV, and thus, not finding room in the retracted external tunic, they often project as a hernia through the rent of the follicle, and are seen outside resembling luxuriant fleshy granulations. At this stage Fig. 7. Bulb of Ovary—(after Savage). The venous erectile system of the ovary, the anterior layer of the tubo-ovarian mesentery dissected off. u, uterus ; o, ovary and utero-ovarian ligament; t, Fallopian tube. 1. Utero-ovarian vein ; 2, Pampiniform venous plexus ; 3, commencement of spermatic vein. the burst follicle is a rounded tumor, bulging on the surface of the ovary, in size sometimes equal to or exceeding that of the rest of the organ. The process Avhich gives rise to the corpus hit earn begins soon after the escape of the ovule, and increases in activity up to the thirtieth or for- tieth day of pregnancy. The yelloAv bodies then remain stationary until near the end of the third month, and from that date they begin to decline ; the convolutions, united together by adhesions more or less intimate, atrophy and leave true fibrous bands; at the same time the yelloAv granu- lations are absorbed, the cells disappear, Avhilst the vessels retract and are atrophied. At the moment of labor the corpora lutea are large, but the process of absorption goes on after delivery, and ends by bringing about their complete disappearance. Then there remains on the surface of the ovary nothing but an irregular scar to mark the place of the rupture. There are considerable differences in the evolution of the corpora lutea. The most remarkable is that Avhich depends upon Avhether the discharge of the ovum has been folloAved by pregnancy or not. In the latter case the yelloAv bodies run through all their stages rapidly, ami never reach a great development; these have been called false corpora lutea. They Avither early; and, at the end of one or tAvo months, only traces of them are found on the surface of the ovary. Development.—The ovaries, like the testicles, are developed at the expense of a secondary blastema which forms upon the inner ed^e of the OVARY, DEVELOPMENT OF. 27 Wolffian body. They are relatively larger in the foetus than in the adult. This great proportional development is especially observed in the length; for, instead of being ovoid, they are thin and flattened. The surface is perfectly smooth and polished. Placed outside the cavity of the pelvis, in the lumbar region, it seems analogous in this respect to the testicle. But this appears to be due simply to the Avant of development of the pel- vis, the bladder and uterus being also as yet seated in the abdomen. At this period the ligament of the ovary is so little developed that the inner extremity of the ovary touches the corresponding border of the uterus. The ovarian follicles exist already in the foetus; and, at the moment of birth, they are seen in very compressed layers throughout the Avhole cor- tical substance of the ovary. They are composed of a small rounded mass of granular substance, surrounded by a simple layer of cells. The stroma divides them into groups, separated from each other by bundles of connective tissue, Avhich send finer prolongations betAveen the follicles of each group. An extremely fine membrane bounds the follicles ex- ternally. On the inner surface is a layer of epithelial cells, each of which contains an elongated nucleus. The contents of the follicles con- sist of a finely granular substance in Avhich is distinguished a spherical transparent vesicle. The ovaries are extremely small after birth, and undergo no change until the epoch of puberty. This epoch is more pre- cocious for the ovaries than for the other genital organs. In girls of o r"> C5 thirteen and fourteen years old, Avhose internal genital organs, and the uterus itself, still shoAved all the characters of the foetal state, the ovaries had already acquired their full development: they Avere ovoicl, soft, spongy, and full of blood. At the epoch of puberty very important changes take place in the ovary, the merit of pointing out which is due to Negrier,1 Gendrin,2 GirdAvood, Pouchet, Letheby,3 Bischoff,4 and Raciborski. From the facts brought to light by these observers it results: 1st. That every menstrual period is accompanied in the ovary by a particular process, Avhich appears to be limited to one Graafian follicle, Avhich increases remarkably in size, raises and thins the fibrous investment of the ovary, and finally ruptures it. 2d. That this rupture of the Graafian follicle has for its object to permit the passage of the ovule of Bae'r into the Fallopian tube. 3d. That hence there takes place in Avoman, at every menstrual period, independently of any special cause, something analogous to the spontaneous oviposition of the Oviparge. 4th. That the same phenomenon is effected in the females of the Mammalia at the time of heat. 5th. That the follicle of Graaf, immediately after its bursting, becomes the seat of a special process, which gives rise to the corpus luteum. 6th. That in consequence of the work of resorption in the corpus luteum, the follicle will be replaced by a slate-colored cicatrix, which penetrates more or less deeply into the substance of the ovary. 7th. Lastly, that the cicatrices or scars on the surface of the ovaries and the corpora lutea, are not the result of follicles 1 Recherches anatomiques et physiologiques stir les ovaires de I'espece humaine, etc. Paris. 1S40. 2 Traite philosopliique de Medeoine pratique. Paris, 1S39. 3 Philosophical Transactions. l'ST>2. * Zeitschrift fur rationelle Medioin. 1S53. 28 OVULATION* torn by the act of fecundation or of any erotic excitation, as llaller be- lieved. The ovaries maintain, throughout the period of menstrual life, the de- velopment acquired at the epoch of puberty. Throughout tins period, also, we meet with Graafian follicles in progress to maturation, so that the question arises : Do the vesicles, found in such multitude in the icetus, Showing Ovary in Old Age—(ad Nat.) (R. B.) continue without change until the time when they are roused to complete development, that is, from the age of fifteen to fifty? or are these first vesicles destroyed at the end of a certain time, to be replaced by others of more recent formation ? Another question, not less interesting, is whether a single vesicle arrives at maturity at each menstrual period, or whether several accomplish their full development at the same time ? These questions are not yet clearly solved. Sometimes several corpora lutea are found in the same ovary. If only a single vesicle Avere spent at each menstruation, it Avould take about 300 vesicles for the same num- ber of menstruations, Avhich, excluding the suspensions during pregnancy and suckling, take place during the reproductive period of life. Setting aside, therefore, the possibility of the neAV formation of vesicles, there exist in the ovary of the foetus infinitely more vesicles than are wanted for all the purposes of reproduction. After the critical epoch the ovary is deprived of follicles. It shrinks, shrivels, and in old age loses its ovoid form, becomes flattened, atrophied, rough, knotted, and seems reduced to its shell (see Fig. 8). Bischoff says that in eArery instance the full consequences of menstrua- tion are not necessarily carried out, but that a follicle may SAvell and the ovum ripen Avithout the bursting of the follicle or the escape of the ovum. Such a condition -will cause sterility notwithstanding menstruation. The ovaries, then, are the essential organs of generation. The destruc- tion of one ovary by disease, or its loss by extirpation, does not entail sterility ; but the destruction or loss of both condemns the Avoman to ab- solute sterility. In connection with the history of the ovary, it is convenient to describe an organ immediately contiguous—the organ or body of llosenmuUer. This body is placed in the thickness of the broad ligament betAveen the outer extremity of the ovary and the last convolution of the Fallopian tube (see Fig. 3, p. 20). It is a small tubular organ to which Kobelt1 gave the name of parovarium. It has been described with great care bv M. Follin.2 It is seen when the broad ligament is put on the stretch and 1 Der Nebenstock des Weibes. Heidelberg. 1S47. 2 Recherches sur les Corps de Wolff. These inaug. Paris, 1850. FALLOPIAN TUBE?. 29 held up to the light; but is made out more clearly by removing the thin peritoneal lamina which covers it. It is situated in front of the ovarian vessels ; it is of triangular shape, the summit directed towards the ovary. It is generally composed of fifteen to tAventy small tubes, slightly flexuous, of unequal length, from 0.12 inch to 0.20 inch in diameter, and separated from each other by a variable space. In the adult Avoman this collection of tubes is attached to the outer half of the ovary; in the foetus at term, it corresponds to the upper border of this gland. One tube, that Avhich occupies the upper border of the body of Rosenmiiller, is distinguished from the rest as performing the part of a common excretory duct. In its middle it lies transversely ; its tAvo ends bend doAvmvards at right angles, and are directed toAvards the upper border of the ovary. The other tubes spring perpendicularly from the transverse portion of the marginal tube, and converge slightly towards the ovary. In this course they are flexu- ous, of unequal calibre, and sometimes the seat of cystic or hydatidiform enlargements. Their ovarian extremity ends in a cul-de-sac. The Avail of these tubes is composed of an outer investment formed of annular fibres; and of an inner tunic, having longitudinal fibres, and lined in its interior with a layer of vibratile epithelium. As an appendage to the organ of Rosenmiiller, Ave must mention a vesicle more or less peduncu- lated, situated at the outer extremity of the broad ligament, and often adhering to one of the fringes of the pavilion of the Fallopian tube. This is the analogue of the vesicle of Morgagni in man. M. Follin has searched the broad ligament in order to find something analogous to the duct of Gaertner which is seen in some animals ; but, like de Blainville, he has seen nothing resembling that which has been described by A. C. Baude- locque, Gardien, and others. It appears to be established that the organ of Rosenmiiller is the remains of the Wolffian body, a transitory organ Avhich very probably fulfils the functions of the kidney before the de- velopment of this gland. THE FALLOPIAN TUBES. The Fallopian or uterine tubes are truly oviducts. They are, in fact, the excretory ducts of the ovaries, differing, hoAvever, from all other excretory ducts in being entirely detached from their proper glands. They are situated in the thickness of the broad ligaments, and extend from the superior angles of the uterus to the sides of the cavity of the pelvis. Radiating from the same point spring tAvo other structures—the round ligament in front, the ligament of the ovary behind. The Fallo- pian tube lies betAveen at the highest margin of the broad ligament, occupying Avhat has been called the upper or middle Avinglet of this structure ; the round ligament occupies the anterior Avinglet, the ovarian ligament and ovary, the posterior winglet (see Figs. 2, 4, and 9). Floating in the pelvis betAveen the ovaries Avhich are behind, and the round ligaments Avhich are in front, the tubes occupy the middle Aving of the broad ligaments, of Avhich they form the upper border; they run at first transversely outAvards, and, just before terminating, bend doAvn- Avards, backAvards and imvards, to approach the outer end of the ovary, to Avhich they are connected by a remarkable prolongation (see Fig. 4, 30 FALLOPIAN TUBES. p. 21). For the inner half of their course they are nearly straight, but usually describe in the rest of their length great flexuosities resembling the sinuous disposition of that part of the vas deferens Avhich is nearest the epididymis. The broad ligament serves as a long mesentery to the oviduct, alloAving it to perform very extensive movements. It is not rare to find the tube doubled up, either before or behind, and bound doAvn by pathological adhesions. These accidental adhesions give to the pavilion of the tube a direction altogether different from the normal one. The tubes may be dragged into a hernia with the ovaries. And the uterus cannot change its position Avithout draAving at least the inner end of the tube along Avith it. From its form the tube Avas likened by Fallopius to a trumpet; it begins from the uterus as a canal of extremely fine bore (see Figs. 2 and 4), gradually enlarges, and ends by an extremity open- ing out like a funnel, named the pavilion of the trumpet. The internal orifice, very narroAV, leads into the uterine cavity ; the outer orifice opens into the peritoneal cavity, and here presents the solitary example in the human organism of a direct communication betAveen the mucous and a serous cavity. Around this free orifice, AAThich is a little more contracted than the portion of tube immediately behind it, the pavilion is developed. This is a membranous prolongation surrounding the orifice as the corolla of a floAver surrounds the stamens and pistils ; it is cut or divided into fringes or irregular and folded festoons, Avhence the name of fimbriated extremity, or the quaint metaphorical designation of morsus diaboli. The largest of the fimbriae are themselves subdivided or notched into smaller fimbriae. To see this disposition Avell the tube must be plunged into Avater. The inner surface of the fimbriae presents longitudinal or oblique folds, very prominent, and Avhich are prolonged into the interior of the oviduct. The number and dimensions of the fimbriae are very variable ; sometimes they scarcely exist: then the edge of the pavilion looks simply festooned ; sometimes they are very large, measuring as much as an inch in length, and are so numerous as to quite conceal the mouth of the oviduct. Often the base of the fimbriae is pierced Avith holes. One fim- bria is especially remarkable by its size ; it constitutes the posterior part of the corolla, arid numerous secondary fimbriae are developed on its borders. It is turned doAvn from Avithin outAvards, and is supported by a small ligament—the tubo-ovarian ligament—which extends from the pavilion to the outer extremity of the ovary, fixing the one to the other. A curious arrangement, described by Deville, is that this long and broad fringe is doubled up to form a channel open beloAv and behind. Accord- ing to Richard, the tubo-ovarian fringe is not constant. The oviduct may be divided into three portions : that Avhich is contained Avithin the uterine Avail; the free portion or body of the tube ; and the pavilion. The intra- uterine portion is about 0.4 inch long ; it is straight, or describes a slight curve Avith an inferior concavity. Its cavity is uniform and very narroAV ; it prolongs outwardly the kind of horn or funnel, which the uterine cavity presents at its upper part, on either side. The orifice of commu- nication betAveen the uterus and the tube—ostium uterinum—is usually filled with thick mucus, Avhich prevents liquid injected into the uterine cavity from passing into the cavity of the peritoneum. It forms a Avell- defined boundary betAveen the uterine and the tubal mucous membrane. FALLOPIAN TUBES. 31 The first is smooth, polished, rosy, and pierced with numerous glandular openings; the second is pale, Avhite, and folded in its longitudinal direction. The body of the oviduct springs from the summit of the superior angle of the uterus, and is immediately embraced in the middle Aving of the broad ligament; it is straight at its origin for about tAvo inches ; it then forms curves variable in degree and number, generally the more marked in proportion to the youth of the subject. These convolutions are inde- pendent of the peritoneal investment; they persist, even when the tube is inflated after being stripped. The inner or rectilineal portion of the tube is narroAver than the outer or undulating portion. The first, some- Fig. 9. The Three Winglets of the Broad Ligament—(after Sappey). 1, left side of the uterus ; 2, 2, ovary; 3, its ligament; 4, 4, Fallopian tube ; 5, 5, its pavilion ; 6, fringe by which the pavilion is continued to the ovary; 7, utero-ovarian vessels; 8, S, round liga- ment ; 9, vessels of the uterus ; 10, pediculated cyst attached to the fringe of the Fallopian tube. times called the isthmus, has a diameter of 0.8 in. to 0.12 in.; the second, which Henle calls the " ampoule,^ is slightly flattened from before backAvards, and measures 0.25 in. to 0.30 in. in diameter or more. Often it narroAvs a little near its termination. The transition betAveen the tAvo portions is commonly very abrupt. The most external convolu- tion of the tube presents a very constant arrangement; its convexity is directed upAvards and outAvards : in other Avords, the peripheral extremity of the oviduct is turned at first doAvmvards, then backAvards, so that the abdominal orifice looks backAvards and doAvmvards. Whilst the inner portion of the tube is scarcely large enough to admit a hog's bristle, the outer portion receives easily the extremity of a moderately-sized sound. The Avails of the oviduct are in contact, and the cavity, completely obli- terated, presents on transverse section the figure of a star, the rays of which penetrate betAveen the numerous longitudinal folds of the mucous membrane. In the uterine portion of the tube the bore is capillary, and it is only Avith great trouble that one succeeds in seeing the ostium uterinum with the naked eye. The tube expanding on the one side into the cavity of the uterus, and on the other into that of the peritoneum, it folloAvs that the tAvo cavities communicate, a disposition which has favored the development of peritonitis by permitting the passage of irri- 32 FALLOPIAN TUBES. fating matters from the uterus along the tubes into the peritoneal cavity. It is not rare to find the abdominal orifice obliterated. In such cases the tube is dilated in the form of a cone, with its base directed outwardly ; its inflexions then become very marked. The whole inner surface of the oviduct is of a pale-pink color, and is marked by longitudinal folds of unequal sizes, which touch by their surfaces, converting the channel of the tube into a series of capillary tubes. These folds, ahvays parallel to the axis of the tube, begin in the intra-uterine portion by tAvo or three small ridges, and become more numerous and prominent at the inner por- tion of the body of the tube, and are developed to the greatest extent in the expanded portion of the canal (see Fig. 4). They project in variable degree: some scarcelv rise above the level of the mucous membrane; others are 0.9 in. in height. On transverse section they sometimes resemble caecal glands; at others, arborescent villosities. In the latter case, the principal folds are provided on both surfaces Avith secondary folds, Avhich themselves may be covered Avith tertiary folds. Often, also, the surface of the folds presents linear reliefs, like projecting ridges, united together, and inclosing irregular spaces or pits. No valves are met with either in the course or orifice of the oviduct. In its narrow portion the tube is firm to the touch, inextensible, and much resembles the vas deferens; in its large portion it is collapsed upon itself, and its Avails are thin and extensible. Richard has observed small supernumerary pavilions, formed like the terminal pavilion by the mucous membrane of the tube cut up into fringes, and pierced by a hole opening into the canal. These are of interest in relation to the tubo-ovarian variety of ectopic gestation. The tube is composed of three coats : an external, or serous ; a middle, or muscular; and an inner or mucous coat. The peritoneum supplies the serous tunic, Avhich adheres but loosely to the tube, and only surrounds three-quarters of its circumference. The adhesion becomes closer at the level of the pavilion, the peritoneum of Avhich clothes the outer surface, and is continuous with the mucous membrane at the free edge of the fringes. In the very loose cellular tissue Avhich unites the serous coat to the muscular coat, small longitudinal muscular bundles are sometimes met Avith. The muscular coat of the oviduct forms a Avhite membrane of dense and close texture. Richard and Robin have doubted the muscular character of the middle coat. It is affirmed, however, by Kolliker. Dr. Arthur Farre has found Avell-marked, smooth, muscular fibres in the genera, Simia, Bos, Cervus, and in the pregnant dolphin, and also in the human female during middle life. It is composed chiefly of annular fibres : on its surface some bundles of longitudinal muscular fibres, Avhich seem to proceed from the muscular fibres of the uterus, are attached. Where the tube transverses the uterine Avail, the muscular coat of the oviduct preserves its own character quite distinct from that of the uterus. Sappey describes two muscular planes: one, longitudinal, a prolonga- tion from the fibres of the uterus ; it extends from the uterus to the fimbriated extremity. The other plane is circular; it is proper to the tube ; it surrounds the tube like a sphincter from end to end. The mucous coat, Avhich alone forms the numerous folds of the inner surface of the oviduct, presents a fundamental stratum formed by con- THE UTERUS. 33 nective tissue and longitudinal muscular fibres, and by a vibratile or ciliated ejn'thelium. It contains neither glands nor villi. The cilia Avhich cover the free surface of the cells execute movements the effect of Avhich is to carry on liquids and the ovum to the uterine cavity. This is one function of the tube ; the other is to receive and transmit tOAvards the ovary the fecundating principle of the male. If the tubes are closed by ligature or by disease, sterility is the consequence. The ovum may be fecundated and arrested in the tube, and be developed there, consti- tuting tubal gestation. The pavilion of the tube is charged Avith the duty of embracing the ovary at the moment of dehiscence of the Graafian fol- licle, and of applying itself closely to the point Avhence the ovum detaches itself. Hence it folloAvs that any adhesion of the ovary or of the tube which prevents this relation is a cause of sterility. The Fallopian tubes, like the uterus and vagina, result from the development of the canals of Muller, Avhich stretch over the surface of the Wolffian bodies, Avith Avhich they have no connection, and terminate at the pedicle of the allantois, uniting together in the median line. At first, the uterine tubes are rela- tively more developed than the body of the uterus ; so much so that they seem to be continuous one Avith the other at their uterine ends. They preserve this relative development until the epoch of puberty, gradually departing from the type of the loAver animals in Avhich the uterus is repre- sented by tAvo horns. THE UTERUS. The Uterus (iitrieulus, a bag~) is the organ of gestation and of partu- rition. It is a hollow organ possessing thick muscular Avails, destined to receive the fecundated ovum; to supply to it the materials necessary for its development; and to expel it Avhen mature. The uterus is situated in the cavity of the pelvis, in the median line betAveen the bladder and the rectum, beneath the mass of intestines, and above the vagina (see Fig. 10). It is held in its position, slung or sus- pended by different folds of the peritoneum and by muscular bundles, principally situated in these folds. Closely connected also Avith the blad- der, Fallopian tubes, rectum, and vagina, these structures all concur in maintaining the position of the uterus. The ligaments of the uterus are six in number, three on each side ; namely, the broad ligaments, the round ligaments, and the utero-sacral ligaments (see Fig. 2). The broad ligaments are two folds, formed by the peritoneum and stretched across the cavity of the pelvis, extending from the borders of the uterus to the sides of the pelvis, and thus, Avith the uterus suspended between them, forming a septum Avhich divides the pelvis into two parts. The broad ligaments are of quadrangular form, their inner border is attached to the border of the uterus, or, more correctly speaking, the two laminae Avhich form them separate to receiA-e the uterus in the space between them. It is to be remarked that the broad ligaments are attached on a level with the anterior aspect Of the uterus, so that the Avhole thickness of the uterus lies behind the ligaments. Their external border is con- tinuous with the peritoneum which lines the pelvic cavity. At the level of their inferior border the two laminae of the broad ligaments separate 3 34 UTERUS. to line the floor of the pelvis ; a loose cellular tissue, including very little fat, is interposed at this level between the laminsv, and unites them to the superior pelvic fascia. This cellular tissue is directly continuous Avith that Avhich is found on the sides of the vagina and rectum beloAV ; in Fig. 10. Longitudinal Section of the Pelvis, made after Freezing—(after Breisky). the iliac fossa laterally, and around the bladder in front, it also communi- cates through the sciatic notch with the deep cellular tissue of the nates. This disposition is of importance to bear in mind in the study of the col- lections of blood and pus Avhich may form in this region. The upper border of the broad ligaments is divided on either side into three second- ary folds, formed, the posterior one by the ovary and its ligament, the anterior one by the round ligament, and the third or middle one by the Fallopian tube. It is this arrangement which has caused the broad liga- ment to be likened to the Aving of the bat (ala vesj>ertilion.ig~). (See Figs. 2 and 4.) The middle fold or Avinglet is the largest and the hio-h- est, and constitutes the true upper border of the broad ligaments. These ligaments are formed of two peritoneal laminae and by an intermediate layer of cellular tissue, in which run the numerous vessels and nerves belonging to the uterus and ovary, as well as a multitude of muscular fibres springing from the uterus. They also inclose the remains of the Wolffian body or organ of Rosenmiiller. The muscular fibres of the broad ligament, according to M. Rouget, all rise from the sides of the uterus, and are directed tOAvards the Avail of the pelvis. Forming a thin sheet-like expansion it has been likened to the platysma myoides. ROUND LIGAMENTS. 35 The celluln-vascular layer betAveen the peritoneal folds is thin supe- riorly, but Avidens from above doAvmvards and outwards ; so that at the level of the floor of the pelvis and of the sides of the uterus it attains its greatest thickness. It is traversed by: l,the uterine artery and its first divisions, Avhich spread out like a fan on the sides of the uterus, Avhere they anastomose; 2, the uterine vein, the principal branches of Avhich form at the sides of the uterus a voluminous plexus; 3, by lymphatic vessels and nerves. The fibres do not form a continuous layer, but their bundles of various sizes form a kind of lace-Avork or open canvas, mixed with the vascular and nervous networks, the Avhole covered and masked by connective tissue. M. Rouget describes the uterus and its appendages as being inclosed in a broad muscular membrane, of Avhich the peritoneal ligaments are a dependency. The broad ligaments do not prevent the uterus from inclin- ing backAvards or fonvards. M. Richet says they oppose flexions of the body on the neck. Although never fully on the stretch, they resist lateral deviations of the uterus ; but their poAver in this Avay cannot be great. They alloAV the uterus to be sensibly lowered Avithout being dragged. The structure of the round ligament has been carefully examined by Mr. Rainey.1 He says it is a muscle rather than a ligament, and he has shoAvn that it consists principally of striped or voluntary muscle. It arises by three fasciculi of tendinous fibres ; the inner one from the ten- don of the internal oblique and transversalis muscle near to the symphysis pubis, the middle one from the superior column of the external abdominal ring, near to its upper part, and the external fasciculus from the inferior column of the ring just above Gimbernat's ligament. From these attach- ments the fibres pass backAvards and outAvards, soon becoming fleshy; they then unite into a rounded cord, Avhich crosses in front of the epigas- tric artery and behind the loAver border of the internal oblique and trans- versalis muscles; it then gets betAveen the layers of the peritoneum forming the broad ligament, along which it passes backAvards, doAvmvards, and imvards to the anterior and superior parts of the uterus, into Avhich its fibres, spreading out a little, may be said to be inserted. The striated muscular fibres are not confined to the surface of the round ligament, but form almost the Avhole of its substance, and are more particularly distinct near to its centre ; nor do they extend completely to the uterus, but after passing between the layers of the broad ligament to about an inch or an inch and a half from its superior part, they gradually lose their striated character, and degenerate into fasciculi of granular fibres mixed with long threads of fibro-cellular tissue. Mr. Rainey found a similar structure in the monkey, dog, sheep, and coav. The round ligaments contain also numerous vessels, also some nerves and absorbents. The arterial trunks are large, but the capillaries, into Avhich they ultimately divide, have the same size and arrangement as those of ordinary muscle. The lymphatics are situated on the outer side of the ligament: their glands are sometimes of considerable length, and even pass through the external abdominal ring; connecting all these 1 Philosophical Transactions, 1850. 36 UTERINE LIGAMENTS. parts together, there is a considerable quantity of areolar tissue, espe- cially where the striated muscular fibres are absent, or are about to terminate. Mr. Rainey, reasoning from the structure of the round ligaments, says the presence of voluntary muscular fibre proves that they are not fitted to seiwe as mechanical supports to the uterus ; but that, their real use is in some Avay or other to act in copulation. Considering the position of their points of attachment and the direction of their fibres, it is evident that their combined action will bring the uterus nearer to the symphysis pubis, and thus tend to draAv it someAvhat from the vagina, in this way tilting the os uteri upAvard and backAvard. Noav the only Avay in Avhich it can be imagined that these changes assist in sexual intercourse, is by their causing the semen to be attracted into the upper part of the vagina and vicinity of the os uteri. This opinion, as to the use of the round liga- ments, had been enunciated by Velpeau and Maygrier. The round ligaments also contain a great number of vessels, especially veins, which may become varicose, especially after many pregnancies, says Oruveilhier, particularly at the level of the external orifice of the inguinal canal, Avhere they have sometimes simulated a hernia. The artery comes sometimes (Sappey) direct from the epigastric, but most frequently from the cremasteric. It is continued to the uterus, to Avhich organ it is principally devoted. From it spring numerous arterioles, Avhich lose themselves in the muscular bundles. In the foetus, and occasionally even after birth, the round ligaments are accompanied in the inguinal canal by a prolongation of the peritoneum, quite analogous to that Avhich ac- companies the spermatic cord. This diverticulum, known under the name of the canal of Nuck, sooner or later becomes obliterated. But sometimes this obliteration does not take place, and this explains the fre- quency of inguinal hernia in Avomen. The round ligaments are never on the stretch, and cannot resist displacements of the uterus. The anterior or utero-vesical ligaments are two lateral folds of perito- neum, containing bundles of fibrous tissue. They are found Avhere the peritoneum is reflected fonvards on to the bladder, opposite the point of junction of the body and neck of the uterus, and from the lateral bound- aries of the utero-vesical peritoneal pouch. The posterior or utero-sacral ligaments extend from the loAver part of the body of the uterus to the outer sides of the sacrum, enveloped by peritoneum; they form two semilunar or falciform folds—the folds of Douglas; their inner borders are concave and sharp, and pass on to the sides of the rectum, forming an oval opening, Avhich leads to a cavity formed by the recto-vaginal depression of the peritoneum. These liga- ments, and the pouch betAveen them (Douglas's sac), are well seen when the uterus is draAvn forw*ards. The utero-sacral ligaments are composed of smooth muscular fibres, Avhich spring from the uterus, and of a peri- toneal investment. The experiments of Malgaigne seem to demonstrate that these ligaments constitute the principal obstacle to the falling of the Avomb tOAvards the vulva. When traction is made upon the cervix uteri these ligaments are immediately seen to be tightened ; Avhen divided the uterus sensibly drops, but is soon arrested by the broad ligaments and the resistance of the floor of the pelvis, chiefly by the floor of the peri- Douglas's pouch. 37 toneum, Avhich is reflected from the Avails of the pelvis over the bladder, uterus, and rectum. M. Richet believes that the utero-sacral ligaments further serve to preArent the uterus from being driven forwards upon the bladder, thus preserving this organ from the severe compression to Avhich it Avould othenvise be subjected. Notwithstanding the pathological interest attaching to the so-called Douglas's pouch, its anatomical features have been very imperfectly de- scribed, hod first by clinical observations, it appeared to me that the lowest part of the pouch Avas not directly behind the uterus and vagina, but distinctly on the left side. This has been completely confirmed by observations on the dead body, in Avhich I have been assisted by Dr. EAvart, curator of the museum at St. George's Hospital. We find that on the right side, that is, behind the right ovary and right broad ligament, the pouch is very shalloAV, scarcely more than an inch deep; that, dipping obliquely tOAvards the left, it descends behind the uterus and the upper part of the vagina ; and that, still dipping, it attains its greatest depth quite on the left of the uterine neck and vagina, so that it partly lies not only behind these organs, but partly on the left upper fourth of the vagina. Thus behind the left ovary and broad ligament the sac is mainly situated, being here often three inches or more deep. All these points are de- monstrated by measurements, casts and dissections. I have referred to this anatomical question in a memoir in St. George's Hospital Reports, 1877, entitled, " A Clinical Study of Retro-uterine Tumors."' It is chiefly in elderly Avomen, and under presumed pathological processes that the pouch is found of equal depth on both sides. In this memoir, and in subsequent parts of this Avork, illustrations of the pathological import of this pouch will be found. When the uterus is loAvered, attended by a corresponding degree of vaginal inversion, this pouch ahvays goes along Avith it, so that in com- plete procidentia and inversion of the vagina the pouch will be external to the vulva behind, whilst the base of the bladder Avill be outside in front. The extent and directions of movement of Avhich the uterus is capable form an important subject of study. The first question to determine is, What is the normal position of the uterus? A line draAvn from the upper margin of the symphysis pubis to the lumbo-sacral articulation Avill strike the upper margin of the fundus of the uterus. Another line draAvn from the lower border of the symphysis pubis to the loAver margin of the fourth sacral vertebra, will touch at its middle the point of the cervix (see Fig. 1). The movements of the uterus are limited by its connections, and are influenced by the changes of condition of the surrounding organs. The greatest amount of mobility is enjoyed by the fundus. The cervix, being bound to the bladder and vagina, enjoys a more limited amount of motion. The fundus may be throAvn backwards or fonvards, and thus acting as a lever it Avill throw the os in the opposite direction. The fundus does not move round the os exactly as upon a pivot, but the os is projected a little fonvards or backAvards Avhencver the fundus moves in the opposite direc- tion. Distension of the bladder will throAv the fundus backwards : load- ing of the rectum Avill press the fundus fonvards and doAvmvards. In retroversion of the fundus of the uterus, enlarged by gestation or other causes, the cervix may be driven so firmly against the symphysis pubis 38 MOVEMENTS OF UTERUS. as to close the urethra : and as the base of the bladder to Avhich the cer- vix uteri is attached has a certain amount of mobility, in anteversion of the body of the uterus, the cervix may be carried back close to the pro- montory of the sacrum, dragging the "attached Avail of the bladder with it. But the upward mobility of the part of the bladder to which the cer- vix is united is limited ; hence it happens that when the fundus is throAvn backAvards, the cervix, held.doAvn in some degree by its A'esical attach- ments, becomes bent, so that the os looks doAvnwards, instead of being projected fonvards exactly in a line Avith the axis of the fundus. The Avhole uterus may be driven fonvards closely behind the pubes. This takes place Avhen a solid body gets into Douglas's pouch behind the uterus. The chief bodies so acting are, small ovarian tumors, dermoid cysts, extra-uterine gestation cysts, and intra-peritoneal blood-tumors or haematoceles. A fibroid springing from the posterior Avail of the uterus may produce similar displacement. In addition to the bnckAvard and fonvard or see-saAv movement, the uterus may move to either side. Here again it is the fundus especially that is displaced. These lateral movements are restricted someAvhat by the broad ligaments. It must, hoAvever, be remembered that there exists commonly a certain lateral obliquity. Another movement is upAvards or doAvmvards. The pressure of the abdominal viscera may carry doAvn the entire mass of the pelvic viscera towards the perineum, or the uterus may be elevated slightly by upward pressure on the cervix. Some amount of alternate elevation and depression of the uterus takes place normally, under the influence of respiration and of voluntary mus- cular exertion. On inspiration the entire mass of abdominal viscera is forced doAvmvards, pressing the uterus before it. On expiration there is a general movement of collapse tOAvards the centre of the body, under the influence of atmospheric pressure. This of course bears most directly upon the external soft parts. The perineum and vulva are pressed in- Avarcls, and the uterus rises tOAvards the abdomen. Under the influence of defecation, again, or of any poAverful muscular exertion in Avhich the chest-walls are fixed, the uterus is driven doAvmvards ; sometimes, indeed, so violently that complete prolapsus has been thus induced. I have knoAvn complete prolapsus of the uterus occur in a A'irgin, under the violent efforts of epileptic convulsions. The descent of the uterus, anterior Avail of the vagina, and base of the bladder, is very obvious, if vomitin^ or coughing occur during an examination by speculum. The instrument is easily driven out, as the os uteri is often brought quite doAvn to the vulva. This observation proves that the so-called ligaments of the uterus exert but a small influence in preventing prolapsus. All these movements may be verified by manual examination. By placing the tip of a finger of one hand on the os uteri, as in examination per vaginam, and applying pressure upon the fundus, by the other hand, through the abdominal Avail above the pubes, the cervix mav be felt to move about according to the direction of the pressure applied by either hand. The True Axis of Movement of the Uterus.—The centre around which the chief movements take place is, of course, its most fixed point. This AXES AND MOVEMENTS OF UTERUS. 39 is the anterior part of the supra-vaginal portion of the cervix Avhich is closely connected Avith the base of the bladder (see Figs. 1 and 10). At this part the uterus is held, Avhilst its tAvo extremities, body and vagi- nal portion, are free. Hence the movements of Avhich the uterus is capable are relative and general. The first order of movements are those in Avhich the uterus inclines backAvards or fonvards, or to either side. The second order, or those in Avhich the uterus moves upwards and doAvnAvards, can only be accomplished simultaneously Avith corre- sponding movements of the base of the bladder. The organs move en masse, preserving more or less completely their relative positions, as Avhen the rectum is distended by fecal accumulations, or, Avhen empty, it re- treats. The Direction of the Uterus.-—-The longitudinal axis is directed ob- liquely from above doAvmvards and from before backAvards, that is, it is nearly coincident Avith the axis of the brim of the pelvis, and forms Avith the axis of the vagina an obtuse angle. It folloAvs that the fundus of the uterus looks upwards and forwards, its apex, or the os, backAvards and doAvmvards (see Fig. 10). This, the normal direction, is, hoAvever, subject to variations, Avhich cannot be always regarded as the pathologi- cal significance. As a general fact, it is to be obserA^ed that the connections of the uterus are loose and extensile, and permit the organ to float in the cavity of the pelvis, performing more or less extensive mo\rements. The ease Avith Avhich the uterus can be draAvn doAvn tOAvards the vulva in certain surgical operations, and the displacement Avhich it undergoes during pregnancy, Avhen it rises into the abdomen, are proofs of its great mo- bility. This property is turned to account to facilitate exploration, and the detachment of the ovum in cases of hemorrhage in abortion. For these purposes strong pressure is made upon the fundus by the hand applied to the loAver part of the abdomen. There is one deviation from the standard axis of the uterus Avhich appears to be nearly constant; it is that in Avhich it takes an oblique direction from right to left. It is thought to depend upon the presence of the rectum on the left side of the pelvis. Boulard, Verneuil, Follin, II. Bennet, Richet, Aaran, and others, have made very precise observa- tions, which establish the fact that the uterine axis is not a straight but a curved line, that it is bent about the middle, presenting an anterior concavity. In introducing the uterine sound it is therefore proper to give a small curvature to the instrument, and to make the point describe a gradual curve fonvards after passing the os uteri externum. In the human subject the uterus is single ; in most animals it is double. The so-called double uteri observed in the human species are, in reality, only bifid or divided uteri, depending upon an arrest of development. The bifid character may be limited to the body, or may extend to the cervix, and even to the vagina. The uterus may even be absent. In one case I failed, after the most minute exploration, to discover a trace of such an organ. But-most commonly, Avhere dissection has been insti- tuted, a rudimentary uterus has been discovered between the rectum and the bladder. 40 UTERUS. The abnormal forms of the uterus will be described with its pathologi- cal condition. The size of the uterus varies according to the age and certain physio- logical conditions. It is very small before puberty, the neck much pre- dominating over the body (see Fig. 11). When menstruation sets in it grows greatly, and it enlarges a little at every period, returning during the intervals to the ordinary size. Pregnancy exerts a more durable influence; after delivery the uterus commonly retains an increased bulk. In old age the uterus shrinks, so that it is sometimes reduced to the size presented in new-born children. Fig. 11. Uterus and Appendages of an Infant—(after A. Farre). a, cavity of hody laid open ; b, cavity of cervix ; e, anterior lip of the cervix ; d, left ovary opened ; e, Fallopian tube ; /, right ovary ; g, internal os uteri, marking the division between the body and cervix. The development of the uterus is sometimes imperfect. It may retain the dimensions and other characters of immaturity. This imperfection may bear upon the body or upon the cervix. In the latter case, the part Avhich projects into the vagina is often more conoid than natural, and the os externum is a very small round opening Avhich barely admits the uterine sound. In these cases there is also commonly present a greater curvature of the uterus, sometimes amounting to angulation at the union of the body and cervix. This condition is usually associated Avith sterility, dysmenor- rhoea, or monorrhagia, sometimes amenorrhoea, and it mav even lead to menorrhagic effusions into the peritoneum, by opposing the free natural exit of the menstrual fluid. The weight of the uterus in girls at the age of puberty is from 360 to 1000 grains; from 1200 to l (see Fig. IT ). (>n each of these walls is distinguished'a vertical column running along the entire length of the neck, swelling out above and continuous with the median column Fig. 17. Half Natural Size. Shrinkage of the AValls in Natural Size of Cervix laid open—(after Hassall Old Age, and Return to the Triangular Form of and Tyler Smith). th<" Infantine and Undeveloped Uterus—(after A. Farre). of the body of the uterus. The two columns of the neck do not descend quite so Ioav as the os externum, but stop a little above the circle of the orifice, Avhich is always smooth (see Fig. 17). M. Guyon has observed that these columns are never situated exactly on the median line ; the anterior one is a little on the right, the posterior one a little on the left; so there results a kind of dovetailing of the Avails of the neck ; especially marked at the upper part of the cavity. From the tAvo borders of each column a certain number of smaller folds proceed, at more or less acute angles, and are directed upwards and outAvards, resembling a fern leaf. These oblique folds have their free border directed doAvmvards, and inclose furrows or pits, in Avhich are seen the gaping orifices of the uterine glandules. Sometimes they bifurcate. The arbor vitse is com- monly much smoothed doAvn after the first labor. But this is not constant, since the arbor vitse is sometimes found intact after several labors. The isthmus is generally 0.20 in. to 0.25 in. long: 0.10 in. across, and 0.12 in. from before backAvards in imparous Avomen. In multiparas the length of the isthmus, Avhich is ahvays included in the measurement of the body, is reduced to 0.16 in. and even less. The uterine sound is commonly arrested by the constriction of the isthmus, and only pene- trates it under a certain pressure. After the cessation of menstruation the isthmus contracts considerably, and often is completely obliterated. The orifice of the os externum also I haAre frequently found obliterated in old Avomen. M. Guyon says this obliteration ahvavs coincides with the obliteration of the isthmus. This, however, I have" found to be far from constant. Fio. 16. UTERUS: DIMENSIONS. 45 The inner surface of the body of the uterus is much more vascular than that of the neck. This difference is especially marked in Avomen Avho have died during menstruation. The walls of the uterine cavity, apart from pregnancy, are 0.40 in. to 0.00 in. thick. The thickness is greater in Avomen Avho have had children than in the virgin. The thinnest part corresponds Avith the insertion of the tubes. The walls of the neck are thinner than those of the body. The dimi'nsions of the uterus have been determined by M. Richet in the folloAving manner: The uterus remaining intact he first measured the cavity by the sound, then haAring removed the uterus from the pelvis, he split it from before backAvards along the median line, and measured it again from the neck to the fundus of the 'uterine cavity first, and then from the neck of the upper border of the organ. He obtained the fol- lowing dimensions:— The vertical diameter of the uterus .... Vertical diameter of the cavity..... Transverse diameter of the uterus .... Transverse diameter of the cavity .... Good standards are so important that the folloAving tables are added. The subjoined measurements are given by Sappey:— Length of uterus Width..... Thickness . • . . the virgin. In women. In mothers 2.20 in. 2.52 in. 2.T2 in. 1.80 in. 2.20 in. 2.44 in. 1.24 in. 1.80 in. 1.90 in. 0.60 in. 1.08 in. 1.24 in. Virgin. Nulliparae. Multipara, . 2.35 in. 2. 50 in. 2.70 in. . 1.50 in. 1. 55 in. 1.70 in. . 0.85 in. 0.90 in. 1.00 in. add the measurements of other observers : — Huschke. P. Dubois. Richet. Aran. 2.70 in. 2.70 in. 2.50 in. 2.80 in, 3.60 in. 2.90 in. 2.70 in. 2.75 in, 1.55 in. 1.75 in. 1.70 in. 1.65 in, 2.35 in. 1.90 in. 1.85 in. 1.25 in. T ,, Nulli parte Length { ,r u-r ° ( Multipara VY" 1th i Nulliparae lc { Multipara Huschke's long diameter is manifestly erroneous; it must have been taken from a specimen in Avhich the involution-process after pregnancy had not been completed. Dubois's is also someAvhat exaggerated. Sappey confirms Richet, Avhose observations included forty Avomen from eighteen to fifty years old. Comparing the three diameters in virgins, nulliparae, and multiparae, it is seen that they increase but little in passing from the first column to the second, and that they lengthen sensibly in passing from the second to the third. The influence, therefore, of pregnancy is manifest; that of coitus is much less pronounced. Rouget shoAved that Avhen the Avhole vascular system of the organ is injected, its dimensions are often more than doubled. The turgescence attending ovulation is not so great; but 46 uterus: cavities. it is greater than is commonly thought. Under the influence of this con- gestion its two faces become more convex, its border is thicker, the whole organ becomes rounded, so that its increase bears more upon the trans- verse and antero-posterior diameters than upon the vertical. In estimating the above measurements horroAved from Sappey and others, it must be borne in mind that they Avere made on organs removed from the body, and consequently wanting the turgor of vascular activity. The extent of the shrinking thus endured is difficult to determine ; but it is certainly considerable. During life the sound commonly gives 2-J in. as the length from the lower border of the os externum to the internal aspect of, the summit of the body of the uterus. To this Ave may gener- ally add J in. at least as the thickness of this part, making quite 3 in. as the life size of the organ, to compare with barely 24; in. as the size after death, represented in Figs. 12-18. There are tAvo purposes for Avhich it is desirable to settle the standard normal uterus in the several states of virginity, nulliparity and uniparity, or multiparity. The one is for clinical use, the other for forensic appli- cation. For the first purpose the data quoted are sufficiently precise. M. Guyon,1 as Avell as Richet, has examined the uterus at the different physiological epochs, and both find that the uterus attains its maximum during the menstrual periods, and its minimum in the intervals. It is important in practice to bear in mind that during the five or six days Avhich precede and folloAV the catamenia, the uterine diameters Avill gener- ally exceed the means, whilst during the intermediate period they will fall a little beloAV. The vertical diameter of the uterus is divided unequally betAveen the body and the neck. In the virgin the longest portion belongs to the neck. In multiparous Avomen, the two diameters are nearly equal, the difference, if any, inclining in favor of the body. In multiparae the body continues to groAV, Avhilst the neck has undergone an absolute or comparative shortening, which reduces its vertical diameter in some cases beloAV that of the body (see Fig. 19). The shape of the cavities of the body of the uterus and of its cervix, and the relations of their Avails, are best demonstrated by longitudinal sections, and by transverse sections made at different points. If Ave first make a vertical section in the antero-posterior direction, as in Figs. 12 and 19 b, we see that the Avails of the body of the uterus lie in contact. The cavity is represented by a line running from the fundus to the cervix. This cavity is, under ordinary circumstances, potential rather than actual. But Avhen fluids are retained, or a solid body is in- troduced into or groAvs in the space betAveen the tAvo Avails, the cavity is capable of enlarging to an almost indefinite extent. This enlargement of the cavity is ahvays, at least Avhen considerable, effected chiefly by gradual growth of the uterine Avails. When the uterus is emptied this groAvth ceases, a process of absorption and involution takes place; and generally the triangular form of the cavity is resumed, the anterior wall being again flattened upon the posterior. Where any distinct holloAV remains, it may be assumed that there is more or less habitual retention of 1 "Etudes sur les cavites de l'uterus," theses iuaug. 1858. uterus: cavities. 47 fluids, and that there is some pathological condition of the mucous mem- brane or Avail of the uterus, or obstruction at a loAver point of the canal. This contact of the wall of the body of the uterus, together Avith the mucous plug usually filling the cervix, and the closing of the vagina by approximation of its Avails, prevent the intrusion of air into the cavity, and thus obviate the foulness that would otherAvise result from decompo- sition of the secretions. Fig. 18. Multiparous Uterus, tet. 26—(after Sappey). A. Anterior aspect. B. Uterine cavity. A. 1, body of uterus, much larger than that of the neck; 2, the neck ; 3, isthmus ; 4, os tinea ; 5, os externum, a transverse fissure, its margin notched ; 6, 6, vagina. b. 1, cavity of body ; 2, left lateral border ; 3, 3, upper border ; 4, 4, its upper or lateral infundibu- liform angles continuous with the Fallopian tubes; 5, its lower angle forming the os internum; 6, cavity of the neck ; 7. arbor vitas; S, posterior lip of os externum ; 9, vagina. The cemcal cavity is fusiform in some cases, conical in others, accord- ing to the extent of the opening of the os externum. Although the columns of the arbor vitae are so adapted as to dovetail Avith each other, there is usually a distinct cervical cavity, the Avails not being commonly in close apposition. If Ave next make a longitudinal section transArersely, so as to separate along the entire length the anterior half of the uterus from the poste- rior, Ave see the triangular shape of the cavity of the body of the uterus, with its two superior angles drawn out funnel-Avise, to be continuous Avith the Fallopian tubes, and its inferior angle contracting to be continuous at the isthmus Avith the canal of the cervix (see Figs. 18, 19). BeloAV the isthmus is the cervical cavity, fusiform or conical. In multiparae, in Avhom the os externum is a Avide fissure, the conical form is more mani- fest in this section than in the antero-posterior section, from its giving the Avhole Avidth of the tincae; but even in these the base of the cone at the os tincae is commonly more contracted than the middle part of the canal. 48 uteris : cavities. In nulliparae the os externum is still more contracted, so that the canal approaches the fusiform character. In many cases of sterility, the os externum is a mere round hole no bigger than the os internum, and the central part of the canal is then generally more dilated than usual, so that it is completely fusiform. (See figures of sections under " Dys- menorrhoea.") Fig. 19. A J» 3 C 7 U- Virgin Uterus, set. 22—(after Sappey). A. Anterior aspect. B. Median section. c. Transverse section. A. 1, body of uterus ; 2, 2, its superior angles ; 3, neck ; 4, isthmus ; 5, vaginal portion of neck ; 6, os externum, small and circular ; 7, vagina. B. 1, 1, profile of anterior surface of uterus ; 2, vesico-uterine cul-de-sac of peritoneum ; 3, 3, profile of posterior surface; 4, body of uterus; 5, neck; 6, isthmus; 7, cavity of body; 8, cavity of neck; 9, its upper extremity ; 10, anterior lip of os tincae ; 11, its posterior lip ; 12 vagina. c. 1, cavity of body; 2, its left border ; 3, upper border ; 4, 4, its lateral infundibulifonn aii-les; 5, its inferior angle ; 6, cavity of neck ; 7, arbor vitas of posterior wall; 8, lower end ; 9, vagiua. A series of horizontal sections, made through the Avails of the body, will exhibit a narrow line marking the contact of the anterior Avail flattened Fig. 20. Ad Nat.—(after Farre). Section made through cavity of the body of the uterus above the entrance of the Fallopian tubes. upon the posterior; made through the isthmus or os uteri internum, a round hole of about the calibre of a No. 8 or 9 catheter, the fibres of the Avail dis]03ed in a circular or sphincteric manner around it; and at the mar- uterus: cavities. 49 gins, right and left, the gaping orifices of the vessels Avhich enter the uterus in greatest size and number at this level; made loAver doAvn across the cervical canal, the cavity of this canal is S3en someAvhat flattened antero-posteriorly (see Figs. 20, 21, 22). Fig. 21. Fig. 22. (After A. Farre.) (After A. Farre.) Section through centre of cavity. Throu-jh centre of cervical canal. There is another Avay of representing the shape and size of the uterine cavities, namely, by taking casts or moulds with Avax or plaster of Paris. The information thus acquired has a certain value, but is apt to mislead. Liquid poured into the uterus distends the caAdty, and Avhen it has set Ave get a mould of a cavity such as does not normally exist. But in the case of morbidly dilated cavities, these casts give more accurate repre- sentations. Interior Conformation of the Uterus.—The cavities of the uterus vary in dimension and shape in the virgin and multiparous uterus. In the CASTS OF CAVITIES OF UTERUS. (After Guyon.) Fig. 23. Fig. 24. 1. Uterus of Arirgin, set. 17. 2. Multiparous Uterus, set. 25-30. a. Narrowing and lengthening of isthmus. b. Dilatation of cavity of neck. c. Narrowing of os externum. virgin and nulliparous uterus the entire length of the cavity is on an average 2.10 inches, divided in the following manner: Cavity of the body, 0.9 inch; cavity of the neck, 1 inch; the intermediate cavity or 4 50 uterus : cavities. the canal of the isthmus, 0.20 inch. In the multiparous uterus the total length rises to 2.:>0 inches, of which the cavity of the body takes 1.10 inch: the cervix, 0.90 inch: the isthmus, 0.20 inch. The length of the cavity, therefore, increases under the influence of pregnancy, and in pro- portion that it lengthens the vertical diameter of the cavity of the body, CASTS OF CAVITIES OF UTERUS. (After Guyon.) Fig. 25. Fig. 2(5. 3. Multiparous Uterus, set. 42. 4. Multiparous Uterus, set. 35. a. Dilated isthmus. a. Dilatation of cavity of body. b. Marked narrowing of os externum. b. Narrowing and torson of isthmus. at first a little shorter than that of the cavity of the neck, comes to exceed it. In the woman Avho has borne children, the cavity of the body pre- serves its triangular shape, but instead of representing a triangle Avith incurved sides, the sides are rectilinear. Sometimes, hoAvever, a degree of curvature persists. The shape and dimensions of the vaginal portion are modified under the influence of repeated gestations. The orifice often becomes large enough to admit the tip of the finger; it is a transverse fissure, measuring from half an inch to an inch, and split at each end. Nor does the vaginal portion commonly project so much into the vagina as in the virgin or multiparous case. It is said that in Avomen Avho have had many children the os tincae may disappear completely, so that in its place one finds at the fundus of the vagina nothing but a hemispherical depression, pierced in the centre by a small round hole. In two women who had had, the one seventeen, the other nineteen children, Caseaux found no projection Avhatever into the fundus of the vagina. My OA\n observations do not bear out this proposition in its absolute sense. In women Avho have borne as many children as those cited by Caseaux. I have found a fairly prominent vaginal portion if they Avere examined UTERUS: STRUCTURE. 51 before the age of fifty. After this age, some Avomen who have had only a few children may, under an exaggerated senile atrophy, exhibit the conditions described by Caseaux. The capacity of the uterine cavity has been examined by Sappey in the following manner: He closed the os externum, then tied one of the Fallopian tubes, and injected the cavity by means of a lymphatic-injection tube, fitted to the other Fallopian tube. When equilibrium Avas estab- lished betAveen the resistance of the Avails and the mercurial pressure, he tied this other tube at its junction Avith the uterus. Then incising the body, he collected the mercury, and estimated its volume by pouring it into the holloav of a Avax mould of one cubic centimetre capacity. The capacity in nulliparae ranged from tAvo to three centimetres, and in mul- tiparas from three to five centimetres. The structure of the uterus must be examined under the opposite con- ditions of vacuity and of fulness. A serous investment pertaining to the peritoneum, a proper tissue of muscular nature, an internal or mucous membrane, vessels and nerves, are the constituent parts of the uterus. A. The external or peritoneal membrane.—The peritoneum, which has invested the posterior face of the bladder, is reflected over the anterior surface of the uterus, covering, hoAvever, the upper three-fourths only, the loAver fourth being in immediate relation Avith the bladder. Thus is formed the utero-vesical, or anterior pouch of the peritoneum. The peritoneum passes over the fundus of the uterus, clothes the pos- terior surface throughout, and is prolonged for a short distance doAvn the vagina, below the utero-sacral ligaments, and then is reflected upAvards over the rectum. It is the transverse extension of the peritoneum Avhich constitutes the broad ligament. In the space Avhich separates the bladder from the uterus, this membrane forms tAvo very small falciform folds, Avhich bear the name of vesico-uterine ligaments. Two other folds, much larger, stretching from the posterior aspect of the neck of the uterus to the sides of the sacrum, constitute the utero-rectal, or utero-sacral liga- ments. For a description of the retro-uterine, or Douglas's pouch, see ante, p. 37. The adhesion of the peritoneum to the uterus, on a level Avith the neck and tOAvards the borders, is very loose, but becomes closer the more Ave approach the median line. It is also more intimate on the posterior than on the anterior aspect. The looseness of the connection of the peritoneum at the level of the neck and borders of the uterus, explains the reason Avhy the peritoneum so rarely shares in even considerable rents of the cervix uteri, and Avhy the effusion of blood in such cases takes place between the tissue of the uterus and the peritoneum. B. The proper tissue.—In the non-pregnant state, this tissue is gray- ish, very dense, very resisting, and creaks like fibrous tissue under the scalpel. If the consistency of the body of the uterus seems less than that of the neck, this is solely because the first is the more frequently the seat of sanguineous congestion. The proper tissue which constitutes the principal portion of the uterine Avail is composed of fibres, that is, of parts disposed in a linear direction. These fibres belong to the muscular tissue of organic life. The contrary opinion Avas long held. But com- 52 UTERUS: MUSCULAR COAT. parative anatomy, the microscope, examinations during gestation, and physiological observations, have dispelled all doubts upon this point. During pregnancy, and in consequence of the development of tumors, or of an accumulation of liquid in the uterine cavity, the proper tissue assumes all the external characters and properties of muscular tissue, as it is seen in the instruments of organic life. The direction of the muscular fibres of the uterus has been the subject of numerous researches. Malpighi and Monro thought there Avas nothing regular in the disposition of these fibres; and in the empty state this appears to be the case. They are so interlaced and compressed, that it is in vain Ave seek to disentangle them. But during gestation, the mus- cular elements having undergone very considerable development, the mingling of the bundles become easier to folloAV. It may be admitted that the muscular Avail of the uterus is formed of three layers or planes of bundles—an outer, a middle, and an inner. These three layers are not clearly defined, as is the case in the heart. They send communicating bundles to each other. The arrangement of these muscular bundles is by no means constant, but they nevertheless ahvays approach a determinate type. 1st. The external or superficial layer comprises a longitudinal bundle, or rather a broad median ribbon, and transverse fibres. The median band, the looped band of M. HeTie,1 arises on the posterior aspect of the uterus, on a level with the union of the body Avith the neck, by fibres continuous with the transverse fibres. At its origin it is often overlaid by a thin stratum of these transverse fibres. Ascending over the poste- rior surface of the uterus, it is reinforced successively by similar fibres, Avhich are added to its borders, and by neAV fibres Avhich spring up in the openings of its primitive fibres. It then curves over the fundus uteri, Avhere its fibres, hitherto parallel, proceed diverging, so that three por- tions may be distinguished—an inner, an external, and a middle. The inner portion often crosses partially Avith that of the opposite side of the median line; the external portion runs towards the angles of the uterus, and mixes Avith the transverse fibres. The fibres of the middle portion descend over the anterior aspect, then successively curve outAvardly, to be continued with the fibres forming the round ligaments. Sometimes the innermost fibres of this bundle reach the level of the isthmus of the uterus, and in their turn curve outwardly to mingle with the transverse fibres. The transverse fibres form the principal mass of the external laver. On the loAver half of the body they are directly transverse; at a higher level they converge towards the angles of the uterus. Towards the median line, the most superficial fibres sometimes turn up so as to become longi- tudinal, and to be continuous with the looped bundle. The deeper fibres proceed directly from one side of the uterus to the other. Externally the superficial fibres are prolonged into the broad ligaments, over the ovi- ducts, and into the round and ovarian ligaments ; the deeper fibres curve round the borders of the uterus, passing from one aspect to the other. In » Recherches sur la disposition des fibres musculaires de l'nterus de>eloppd par la grossesse. Paris, lbti4. FF F UTERUS: MUCOUS MEMBRANE. 53 this course they meet the arteries and veins, Avhich they surround Avith contractile rings. At the same time the fibres pass from one plane to another, so that those Avhich Avere at first superficial, become deeper as they get behind. The fibres of the neck are generally transverse, but are a little oblique doAvmvards and inwards, and often crossed on the median line. They send expansions outwardly into the broad ligament, backAvards into the utero-sacral ligaments, and sometimes fonvards into the utero-vesical ligaments. 2d. The middle layer of the muscular fibres of the uterus forms about one-third of the uterine Avail. When sections of this Avail are made, it is distinguished by the great size of the vessels, principally veins, Avhich traverse it. It is composed of muscular bundles, Avhich cross each other in all directions, and send off frequent branches, Avhich circumscribe more or less completely large holes or canals in Avhich the bloodvessels are contained. This texture is the same throughout the Avhole body of the uterus, but is especially manifest in the region Avhich corresponds to the insertion of the placenta. There is nothing like it in the neck. 3d. The internal layer is principally composed of annular fibres from the isthmus as far as the orifices of the Fallopian tubes. But these fibres are covered on each of the surfaces of the uterus by a broad and thick band of longitudinal fibres, forming a triangular bundle, Avhose base is superior, and stretches from one tubal orifice to the other; and Avhose apex, directed downwards, descends nearly to the os internum uteri. It is formed of transverse fibres, Avhich curve from beloAV upwards, run for a certain distance in the longitudinal direction, and then again become transverse. An annular bundle, very poAverful, and ahvays a little prominent, surrounds the os internum uteri, forming a true sphincter, which explains the habitual constriction of this orifice. Muscular rings surround the infundibula of the uterine cavity. On the median line of the anterior Avail, and on the median line of the posterior wall, the rings of the right and left sides meet, and even interlace. Their upper halves constitute antero-posterior arcs, which form the roof of the uterine caArity. By their inferior halves they begin the series of the transverse annular fibres. In the neck, on the middle of each Avail, a branched muscular bundle gives rise to the projections of the arbor vitae; it rises from the middle of each Avail, and forms arches right and left. Beneath this bundle, but rather deeply, the fibres are transverse or annular, and are confounded with those of the external layer. C. The internal or mucous membrane.—Some anatomists, and in par- ticular Morgagni and Chaussier, Avho observed the inner surface after delivery, have denied the existence of the uterine mucous membrane. But the microscope has set at rest all disputes upon this point. The mucous membrane, hoAvever, presents different characters in the cavity of the body and in that of the neck. The lining membrane of the body of the uterus undergoes a cycle of changes recurring at every menstrual period. It is therefore neces- sary to trace these changes in the order of succession. Tyler Smith stated clearly, that after the menstrual Aoav the inner surface of the body 54 UTERUS: MUCOUS MEMBRANE. of the uterus was left bare, a sharp line of demarcation being observed at the os uteri internum. This I have had opportunities of Aeritying. John Williams has carefully described the changes through a fairly com- plete series of specimens. Fig. 27 represents the bare condition just Menstruation just ended. Three days after menstru Just before menstruation. Mucous membrane quite ation. Mucous membrane Mucous membrane at shed. regenerated. maximum development. (After John AVilliams.) after the shedding of the membrane under menstruation. Fig. 28 repre- sents the uterus three days after menstruation, when the mucous mem- brane is in course of reformation. Fig. 29 represents the condition from a Aveek after menstruation, Avhen the membrane is still further developed. The mucous membrane of the uterus proper, says Kundrat,1 is distin- guished by its peculiar connective tissue basement-layer rich in cells, and by the absence of a sub-mucous tissue. The tubular glands are also cha- racteristic. These Kundrat and others describe as running more or less perpendicular to the free surface. Williams finds them more often vari- ously oblique. They form culs-de-sac at their commencement, Avhere they often divide, and dip in betAveen the muscular fibres of the uterine Avail. The narroAvest portion of their canals is at the outlet on the free surface, Avhere the openings are seen as little pits by the naked eye or magnifying glass. They are round or oval on cross-section. They are lined by columnar cells Avith cilia. The connective tissue of the mucous membrane spreads outAvards into the muscular tissue, thus uniting the tAvo. This description applies to the uterus from the time of its full development until the stage of climacteric atrophy. 1 Strieker's Jahrbucher, 1873. UTERUS: GLANDS. 55 The glands are imperfectly formed at four years old. They then form small depressions in groups. At ten these depressions have lengthened Fig. 31. Fig. 30. ) The others, not less considerable, spring from the ovarian arteries, called for this reason by Cruveilhier, utero-ovarian; they reach the upper angles of the uterus, then descend along the borders of this organ, to anastomose Avith the uterine arteries. The branches furnished by the two arteries which, on ether side, run along the border of the uterus, course at first under the peritoneum, sur- rounded by the muscular bundles which proceed from the uterus ; then, after a certain course, they plunge into the substance of the muscular tissue, Avhere they ramify and anastomose Avith each other, and with the branches of the opposite side. All these branches, Avhich are very numerous, are remarkable for their cork-screAV tAvistings. It Avas thought at one time that this helicine disposition Avas designed to favor the de- velopment of the pregnant uterus by uncurling, and becoming straight as the uterus greAV ; but the fact is, that the arteries, even in advanced pregnancy, are as flexous as in the non-pregnant state. These arteries are not distributed equally to all parts of the uterus ; the neck receives but a small number ; at the neigborhood of the upper angle of the uterus, on the other hand, the utero-ovarian artery supplies suddenly from tAvelve to eighteen tufts of arteries, spirally curled, Avhich cover with their rami- fication the Avhole of this region. At the level of the furroAV, Avhich separates the body from the neck, M. Huguier has described an arterial circle formed by the anastomoses of the arteries of the right side with those of the left. The ultimate ramifications of the arteries of the uterus are distributed in the mucous membrane. The ramuscules in this mem- brane are of importance as to size only in the deeper layers ; beneath the epithelium they form a capillary netAvork, very fine and close, the interspaces of Avhich receive the orifices of the glands. The coats of the arteries are, as Mr. Rainey pointed out, very thick, and are apt, unless care be observed, to be mistaken for the proper fibre of the uterus. 2d. The veins of the uterus are remarkable for their enormous deve- lopment ; they are large canals holloAved out of the thickness of the mus- cular substance, and frequently communicating Avith each other. They have been called the uterine sinuses, and M. Rouget has described them under the name of the corpus spongiosum of the uterus. The uterine sinuses occupy all the body of the uterus, and cease abruptly at the level of the os uteri internum. The neck itself has a much less marked venous development. BetAveen the uterine sinuses, Ave find in the Avail of the uterus venous ducts twisted spirally, like the arteries, and Avhich are analogous to the corpus spongiosum of the male urethra. On the lateral borders of the uterus these sinuses communicate with vast venous plexuses, situated in the thickness of the broad ligaments, and continuous beloAV with the vaginal plexus, and above Avith the sub- ovarian plexus. They have received the name of the pampiniform plexuses. From these plexuses proceed beloAV, the pudic veins ; in the middle, the uterine veins ; above, the ovarian A^eins. These last present but very feAv valves, and assume full development only after puberty. 3d. The lymphatic vessels, during pregnancy and after delivery, are, UTERUS: VESSELS, NERVES. 59 like the veins, of considerable size. They form sevreral planes in the thickness of the uterus ; the superficial are the largest. They are divided into tAvo groups ; those of the neck, Avhich run to the pelvic ganglia; those of the body, Avhich terminate in the lumbar ganglia. These last accompany the utero-ovarian veins. Dr. Lucas-Championniere1 describes a ganglion situated above the lateral vaginal cul-de-sac, closely applied at the union of the body and neck. When this ganglion is missing, its place is taken by close networks of lymphatics. Gallard thinks this ganglion or network plays an important part in pathology, as the starting- point of puerperal and other affections. 4th. The nerves proceed, some from the renal plexuses and inferior mesenteric, to reach the uterus, being closely bound to the utero-ovarian arteries ; others, proceeding from the hypogastric plexus, are formed by some anterior branches of the sacral nerves, and by branches proceeding from the lumbar ganglia of the great sympathetic. These tAvo plexuses anastomose in the thickness of the broad ligaments, and send off filaments over the two surfaces of the uterus which penetrate into the substance of the organ, keeping in intimate contact with the arteries, or coursing in the spaces betAveen the arteries. The folloAving account by M. Boulard is adopted by Cruveilhier:— 1. The nerves of the uterus are very feAV in number. 2. They do not increase in size during pregnancy. The principal differences, observed during pregnancy and in the non-pregnant con- dition, bear more upon the state of the plexuses than on the volume of the nerves. 3. In the child, the elements of these plexuses, croAvdecl together, seem to constitute a true nervous membrane ; from these there proceed very delicate nerves, Avhich run to the uterus and broad ligaments to give off their filaments, Avhich are entirely capillary. 4. In Avoman Avhose uterus is developed, the plexus is carried higher up, its elements are separated, and form more or less considerable spaces; and as to the nerves issuing from it, they only differ in being longer, coinciding Avith greater tenuity if compared with those met Avith in the normal uterus of an adult Avoman. 5. These nerves issue from the hypogastric ganglion and plexus, as Avell as from the nervous ring or ganglion Avhich surrounds the urethra at its entry into the bladder. They reach the sides of the uterus, and thence folloAV in part the distribution of the arteries. In every case they are accompanied by a very fine arteriole. Some, very fine, reach the anterior and posterior surfaces, as Avell as the fundus of the uterus. 0. As to the neck, imitating the prudent reserve of Longet, Boulard does not absolutely decide the question on account of the extreme diffi- culty of the dissection. He, however, believes that the uterine neck, that is the vaginal portion, is not completely deprived of nerves. He thinks he has traced a nervous filament ramifying in the anterior lip of the os tincae. Sappey finds nerves in the neck. 7. M. Boulard has never seen uterine plexuses or ganglia. It is 1 Lvmphatiqnes nterms et lyruphaugite uterine. Bull, de la Soc. Med. des hopi- taux de Paris, vol. vii. 60 VAGINA. enough, he says, to cast the eye upon the Avails of a developed uterus, after having removed the peritoneum, to recognize how easy it is to fall into error, and Iioav easy to represent as nerves and ganglia, muscular fibres, venulae, lymphatic A^essels. etc., especially after a prolonged sub- mersion. The supravaginal portion is freely supplied, but the infra- vaginal portion is very scantily supplied with nerves. Hence excision, division, cautery, may cause little pain unless inflammation be present. The pain sometimes evoked on touch is often due to communicated pres- sure in parts beyond. In cancer there is little pain, so long as the disease is limited to the vaginal portion. THE VAGINA. The vagina is a musculo-membranous canal extending from the vulva to the uterus. It is at the same time the organ of copulation m Avoman, and the canal serving for the passage of the menstrual blood on the one hand, and of the product of conception on the other. It is situated in the cavity of the pelvis, between the bladder and the rectum. Maintained in its position by intimate adhesions Avith the sur- rounding parts, the vagina is still not so fixed but that it may undergo an inversion upon itself like the finger of a glove or an invagination. This, in fact, is the true nature of most of the cases of so-called prolapsus Avith procidentia of the uterus. It is to be observed that the anterior Avail of the vagina is shorter than the posterior Avail; the difference being from 0.4 inch to 0.8 inch. Its direction is oblique from above doAvnwards, and from before doAvmvards. When the bladder is empty, its axis forms Avith that of the uterus a right angle. When the bladder is full, the angle of junction is obtuse, the open aspect of the angle looking upwards and fonvards. The vagina is not of equal Avidth in all parts of its length. Its loAver or vulvar orifice is the narroAvest part; its upper extremity has much larger dimensions. In Avomen who have had children, the fundus of the vagina forms a large bag, in Avhich the speculum may be made to sweep freely, and in Avhich also a large quantity of blood may accumulate in cases of uterine hemorrhage. Moreover, this canal is eminently dilata- ble, as is proved by parturition; it is, at the same time, elastic; and after labor it may return nearly to its original dimensions. The part Avhich is most dilatable and the least elastic is certainly the upper part, to Avhich the name of vaginal bag might Avell be given, whilst the lower orifice might be called the vaginal strait. When not dilated by a foreign body, the Avails of the vagina touch each other at every part, so that its cavity is completely closed. This may be clearly demonstrated by Avatching the behavior of the vagina during the Avithdrawal of the tubular or bivalve speculum. As the in- strument retreats from the fundus, the Avails of the vagina close up behind it, and even help to expel the speculum by its elasticity and contractile action. There are, hoAvever, cases in Avhich the fundus of the vagina presents a true cavity, the Avails not being in contact. This I have chiefly seen in women Avho Avere subject to prolapsus. It is also often remarkable during the process of abortion. If a horizontal section of the oro-an is VAGINA, RELATIONS OF. 61 made, it exhibits a transverse slit not ahvays of exactly similar shape. (icnerally this slit is slightly curvilinear, Avith anterior convexity, and each of the tAvo extremities falls upon an antero-posterior slit, Avhich gives to the Avhole the form of the letter H. This form is perfectly adapted to that of the neighboring parts; for the urethra is placed in the opening of the anterior branches, and the rectum is received into the posterior space. The transverse branch is generally about 0.25 inch long in the adult. In the child it is shorter, and the section takes rather the shape of a star. The calibre of the vagina is smaller in virgins. It is comparatively in- extensile. Its muscular poAver seems greater than in married Avomen, and especially than in those who have borne children. Hence the care that is necessary in the selection and use of instruments, as the speculum and pessaries, in single Avomen. Still the Avails of the vagina are gene- rally easily extensible ; but they Avould not be extensile enough to permit the child's head to pass in labor, if the vagina did not share during preg- nancy in the hypertrophy of the uterus ; and if in hypertrophying it did not dilate sufficiently to prepare it for this function of an excretory canal. Itelations.—1. The anterior aspect of the vagina, which presents a slight concavity in the transverse direction, ansAvers above to the base of the bladder. To this organ the vagina is united by a dense filamentous cellular tissue. LoAver down the vagina is united to the urethra, and the relation is so intimate that the urethra seems to be holloAved out of the anterior wall of the vagina. The urethra may thus be felt like a promi- nent cord running along the median line. It thus forms an excellent guide to the situation of the meatus, serving as a direct clue in passing the catheter. This intimate adhesion of the vagina Avith the bladder and urethra explains why these latter organs are constantly dragged down in displacements of the uterus. 2. The posterior aspect of the vagina ansAvers to the rectum, through the peritoneum in its upper third or quarter, and immediately in its tAvo loAver thirds or three quarters. But I have shoAvn that the peritoneum comes doAvn loAver on the left side of the vagina, than it does in the me- dian line behind. This disposition of the peritoneum explains Avhy, Avhen the posterior Avail of the vagina is torn in its upper third or fourth, the intestines may fall through the rent. The vagina adheres to the rectum by a cellular tissue much looser than that between the bladder and vagina, so that the rectum is not so liable to be dragged doAvn in the displacement of the vagina. The recto-vaginal septum is the septum formed by the apposition oi the posterior Avail of the vagina and of the anterior Avail of the rectum. Interiorly the rectum detaching itself from the vagina, there is formed a triangular space, whose base is below, and whose antero-posterior dia- meter defines the thickness of the perineum (see Fig. 1). 3. The lateral borders of the vagina give attachment above to the broad ligaments; beloAV to the pelvic aponeurosis. They are crossed by the levatores ani muscles, which, hoAvever, take no insertion here. The inner surface, or mucous membrane of the vagina, is smooth in its upper portion, and presents on its two Avails flattened rounded tubercles, measuring from 0.04 inch to 0.12 inch in diameter, and pressed against each other; or else there are crests or transverse imbricated prominences 62 VAGINA: VULVA. representing very nearly the irregular asperities of the roof of the palate. These different prominences all spring from a median crest, which stretches under the form of a raphe along the walls of the vagina. The two median raphes are called the columns of the vagina. They present Avide dissimi- larities in individuals in form and size, and appear to be a vestige of the vice of conformation Avhich consists in a median vaginal septum—a vice Avhich although coinciding most frequently Avith bifidity of the uterus, may exist independently. The (interior column sometimes begins imme- diately behind the meatus urinarius, sometimes at a little distance from this orifice under the form of a large tubercle which serves as a guide in introducing the catheter. Greatly developed and very prominent at this point, it gradually diminishes, and is insensibly lost in the upper third of the vagina. The anterior column is often divided by a median groove, more or less deep, into tAvo lateral portions. The posterior column is generally less prominent than the anterior. The columns of the vagina are formed of a kind of cavernous or spongy tissue. The venous plexuses situated around the vagina send numerous prolongations into the thickness of the muscular tunic, ami even into the mucous tunic ; around these the bundles of muscular fibres interlace in all directions, representing the trabeculae of erectile tissues. The rugae of the vagina, very numerous in the neAV-born child and in virgins, are partly obliterated after delivery in the upper part of the vagina ; but they always persist in the loAver part, and especially at the vulvar orifice and in front. These rugosities are not folds, and cannot serve in facilitating the distension of the vagina. The inferior or vulvar orifice presents in front an extremely rugous transverse prominence. This prominence, Avhich is seen as soon as we separate the labia majora and minora, narroAvs, and even seems to close the entrance of the vagina. It belongs to the anterior column. The vulvar orifice is not situated in the centre of the inferior strait of the pelvis; it approaches the pubic arch, and is separated from the coccyx by a much more considerable space. Fven after labor, and throughout life, the vulvar orifice remains narroAver than the rest of the vaginal canal. Hence a Avell-designed speculum should pass the vulva easily, and admit of expanding at the fundus of the vagina. It is only AYhen the perineum has been extensively torn, or after long dilatation in complete procidentia Avith eversion of the vagina, that the vulvo-vaginal orifice loses its proper character. In virgins the orifice is provided Avith a membrane, the existence of which is constant in the normal state, but Avhose form is subject to nume- rous variations. This is the hymen (from v^v, a pellicle) ; it is a kind of diaphragm interposed betAveen the internal genital parts on the one side, and the external parts and the orifice of the urethra on the other. The situation of the hymen does not seem to be constant. I have sometimes found it, or an equivalent fold or valve of mucous membrane higher up than usual, that is, (quite half way between the vulva and the roof of the vagina. This membrane is usually crescentic with the concavity anterior: it occupies the posterior half of the circumference of the vulvar orifice and its extremities come fonvard to lose themselves on the sides of the meatus V A G IN A . 63 urinarius. Sometimes it forms tAvo-thirds of a circle, or even a complete circle, perforated near the anterior part of its circumference. The ad- herent border of the hymen is its thickest portion. Its free border is thin, concave, often irregular, notched in shreds or fringes, Avhich lap over the meatus. Not seldom the hymen forms a membrane Avhich com- pletely closes the inferior orifice of the vagina, constituting the vice of conformation knoAvn as imperforate vagina. It usually is large enough to admit the forefinger Avith some little difficulty. If examination is made under anaesthesia, the membrane more easily stretches ; but other- Avise it is readily torn and bleeds. But it may be Arery resisting, fibrous, or even cartilaginous, and render copulation impossible. It may also happen that the hymen is very loose, or is provided Avith a large opening; it has been simply pushed back by the penis Avithout being torn, and has been preserved intact until the moment of labor. It has even been knoAvn to persist in prostitutes. When the hymen has been torn, the bleeding shreds are retracted and cicatrize: they shrink, and give rise to the tubercles called carunculce myrtiformes. The number, form, and situa- tion of these carunculae vary extremely. Most frequently they are three, thick and fleshy, and occupy—one, the posterior part, the other tAvo the sides of the entrance of the vagina. Sometimes, instead of tubercles, lengthened shreds are found, or slight eminences Avith hooked borders, like a cock's-comb, or small pediculated polypi. The laceration of the hymen may be partial; then it persists as a complete half circle, narroAV, with notched edges, or Avith fissures extending to the base. The hymen is constituted by a mucous fold, containing betAveen its lamellae a layer of cellular tissue, inclosing numerous elastic fibres, and some muscular bundles of organic life. Some bloodvessels ramify in its thickness. Pavement epithelium covers its tAvo surfaces. Structure of the Vagina.-—Thin above, the vagina thickens consider- ably at the level of the urethra, and terminates by a rugous, and very prominent enlargement, forming the protuberance at the entrance of the vagina, already described. The vagina invested behind, for a short space, by the peritoneum, has membranous Avails not at all resembling those of the uterus. They are composed essentially of an internal or mucous coat, and of an external or muscular coat, which it is impossible to isolate by the scalpel, but Avhich, on section, may be distinguished by their color. The first is Avhite, the second reddish. Their thickness increases as Ave approach the vulvo-vaginal orifice. Around these tAvo tunics is stretched a thin layer of cellulo-fibrous tissue, in Avhich are found numerous elastic fibres. The muscular tunic of the vagina is composed of bundles anastomosing and crossing so as to form nets in the large openings filled up Avith con- nective tissue. Sometimes the connective tissue, sometimes the muscular predominates. The disposition of the muscular bundles presents nothing regular. The longitudinal and the circular fibres do not form distinct layers. The first, hoAvever, predominate near the mucous membrane, the latter near the external surface of the vagina. According to M. Rouget, the longitu- dinal or oblique fibres cross from side to side of the vagina; one part are continuous above with the external longitudinal fibres of the uterus; the 64 VAGINA. other part more numerous, run doAvmvards and backAvards on the sides of the rectum, and pass betAveen the large vessels, united here into plexuses. The vaginal mucous membrane is' formed of a very dense connective tissue, abounding in elastic fibres. This it is which explains its great strength and the enormous distension it can undergo in the act of labor, Avithout bursting. Numerous vascular papillae, conical or filiform, cover the surface of the membrane ; but they are buried and hidden in the investing stratified pavement epithelium. They are met Avith also in the interval of the prominences of the vaginal mucous membrane. They are absent only in the neighborhood of the uterine neck. There are no glandules in the vaginal mucous membrane. According to Henle there are found exceptionally follicles analogous to the solitary follicles of the intestine, especially in the upper portion, and on the uterine neck. Huschke says, it is rich in muciparous glands. Sappey, on the other hand, affirms that after long and patient researches he has found nothing of the kind. Certainly if Ave may reason from the char- acter of the discharges given off from the surface, I should agree with Sappey. These discharges are not mucous, but epithelium scales. The Bulb of the Vagina.—Besides the rugous tubercle found in front of the orifice of the vagina there exists around this orifice a SAvelling or large cavernous body, filling the space which separates the entrance of the vagina from the roots of the clitoris. This is the bulb of the vagina. Not very thick in front Avhere it is placed between the meatus urinarius and the clitoris, it SAvells progressively from this middle portion, and ends beloAV on the sides of the vagina by a rounded extremity. The posterior part of the vaginal orifice only is deprived of bulb. It avouIc! be more exact, perhaps, to admit two bulbs, one on either side. These two bulbs have been compared by Kobelt to tAvo gorged leeches. The dimensions of the injected bulb according to Kobelt are: length, 1.50 in.; width, 0.50 in. to 0.80 in.; thickness, 0.36 in. to 0.50 in. But these vary extremely according to age, frequency of sexual relations, of labors, and, lastly, to individual peculiarities. The external surface of the bulb is convex, and covered by the constrictor muscle of the vagina; it ansAvers to the ischio-pubic ramus. Its internal surface is concave, and is applied around the vaginal orifice. The two halves of the bulb are united ante- riorly, from which part issue numerous veins, establishing a communi- cation betAveen the bulb and the gland and corpora cavernosa of the clitoris. These veins receive also those which proceed from the fraenum and labia minora in front, and from the labia majora behind. Some run directly to the dorsal vein. Behind, the bulb furnishes not less numerous veins Avhich communicate Avith those of the Arestibule, vulva, urethra, and the venous netAVorks situated around the bladder. From the terminal enlargement of the bulb also, large venous trunks, the true efferent Aressels of the bulb, run to the internal pudic vein and communicate with the external hemor- rhoidal veins. The bulb of the vagina represents the corpus spongiosum in the urethra of man. It is composed of an investing membrane, very thin, and of an areolar spongy tissue, the spaces of which, rather lar«-e are bounded by trabeculae formed of connective tissue and smooth muscular VULVA. 65 fibres. The bulb receives from the internal pudic artery a considerable branch, Avhich penetrates at the posterior enlargement. This branch supports some very delicate nervous filaments Avhich are distributed with it in the bulb. I ^essels and Nerves of the Vagina.—The principal arteries, the vaginal, proceed from the hypogastric. The uterine, vesical, and internal pudic all give branches to the vagina as Avell. All these branches ramify in the substance of the muscular tissue, to Avhich they supply numerous ramuscles, and terminate in the substance of the mucous membrane. The veins arise from the capillary netAvork of the mucous membrane, reach the borders of the vagina, and empty themselves into the rich plexuses Avhich surround it. These veins communicate beloAV with those of the bulb, above Avith those of the uterus. The lymphatic vessels, easily injected through the lymphatic network of the mucous membrane, proceed to the lymphatic ganglia of the pelvis. The nerves come from the hypogastric plexus. l)evelopmeut istruation. The suffering becomes urgent in the highest degree, and nothing short of an operation Avhich shall liberate the retained secretion will save the patient. Some cases again of suppressed menstruation, leading to effusion of blood behind the uterus, setting up circumscribed peritonitis, and displacing the uterus so as to press upon the bladder, may cause retention of urine. Here again local examination is imperative. This may be said of every case of retention of urine. Menorrhagia is a relative term ; that is, some Avomen lose much more than the average Avithout suffering in health ; but Avhenever the loss con- tinues profuse, obviously entails anaemia and general debility, and persists 72 CONDITIONS INDICATING EXAMINATION. in spite of internal remedies, local examination is clearly necessary. *\\ e shall often find a sufficient local cause in polypus, tumor, inflammation, congestion, hypertrophy, displacement, or malignant disease, all of which conditions require local treatment. When Ave come to study the history of dysmenorrha-a, we shall find abundant proof of the almost constant'association of this disorder with a mechanical condition of the uterus impeding the easy performance of the function. So long, however, as the distress does not clearly affect the general system, so long as it does not exceed endurable bounds, and if it appears to be moderated by general remedies, it is not necessary to ex- amine ; but, in the contrary condition, examination should not be long postponed. To postpone examination is to postpone discovery of the cause and effective treatment. This is more especially imperative in the case of a married Avoman in Avhom dysmenorrhoea is complicated Avith " dyspareunia" and sterility. Abortion, if not primarily depending upon some local disease or displacement of the uterus, is so very likely to be folloAved by some such condition that an examination should be instituted. If a sanguineous discharge, even periodical, resembling menstruation, goes on during lactation, especially if it be excessive in quantity, and attended by leucorrhceal discharge, it may be almost confi- dently predicated that there exists some uterine disorder requiring local treatment. I have used a neAv word, " Dyspareunia.'''' It is incumbent upon every one Avho coins a new Avord to explain its meaning and to justify the innovation. Just as the Avord " dysmenorrhoea" has been coined in order to express compendiously the condition of difficult or painful men- struation ; just as " dyspepsia" is used to signify difficult or painful digestion,—Ave Avant a word to express the condition of difficult or painful performance of the sexual function. Such a word would be convenient in many Avays. It would enable us to avoid the longer and coarser terms in use, by substituting a single Avord at once euphonious, expressive, and in harmony Avith medical language. After consulting Dr. W. H. Stone, I have adopted the Avord " dyspareunia." It is derived from bvondptwos, a Avord used in this sense by Sophocles. However disagreeable the topic may be, it is impossible to escape reference to a function so important. Dyspareunia in the female is perhaps the most absolute of all the indica- tions of local malformation or disease. It calls the most imperatively for local examination as to its cause. In its milder forms it may make the sufferer's life a course of physical and mental Avretchedness ; in its severe forms it virtually unsexes her; and in any form it may lead to the most disastrous social calamities. Taking this condition, dyspareunia, as a symptom of disordered func- tion, Ave shall be astonished, Avhen Ave proceed to direct examination of the organs concerned, at finding hoAV many those causes may be, and Avhat a Avide field of pathological inquiry is associated Avith it. For example, there may be original defect or malformation; there may be obstructing tumors or groAvths, inflammation, dislocation or altered form disordered innervation. In short, almost every disease to Avhich the sexual organs are liable may entail dyspareunia for one of its conse- DISCHARGES. 73 quences; and in not a feAv of these diseases disregard of this symptom may entail positive danger. The existence of certain discharges, such as blood, under conditions of quantity and times of occurrence which distinguish it from normal men- struation, mucous, purulent, albuminous, aqueous, fleshy, or membranous, if at all protracted, point clearly to some local disorder as their origin. Then there are some subjective signs, as pain, lumbo-dorsal, iliac, pelvic, or crural, and a sense of bearing down or pressure upon the rectum or bladder, associated with disorder in the function of these organs. These, especially if connected Avith abnormal discharges and other symptoms, call distinctly for local investigation. Then Ave must observe the constitutional or remote effects of the fore- going conditions. Disorder of the pelvic organs seldom goes on long Avithout entailing anaemia, disordered digestion, hypcraesthesia, neuralgia, or other manifestations of nervous derangement or prostration. When these conditions are observed in association Avith marked signs of derange- ment of function of the pelvic organs, the necessity for exploring the physical state of these is as clear as is that of examining the state of the heart or lungs Avhen these organs perform their function Avith distress, and the Avhole system suffers. Such, then, is a summary vieAv of the conditions, chiefly subjective, which point out to us the desirableness of instituting direct observation of the pelvic organs. This direct obserAration commonly enables us to ana- lyze the groups of subjective symptoms ; to determine the cause and sig- nificance of each, separately and collectively. It ahvays brings to our assistance the discovery of other symptoms, entirely objective ; and almost ahvays puts it in our poAver to apply the proper treatment. The special study of the significance of the several symptoms of pelvic disease, subjective and objective, will be traced in subsequent sections. We have ranked discharges amongst the most pressing indications for instituting local exploration. In health it may be said that, excepting the monthly discharge of menstruation, there is no escape of fluid from the vagina. It is true that in some women leucorrhcea to a moderate extent precedes and folloAvs the menstrual sanguineous flow; it is also true that in some, leucorrhcea continues throughout the intermenstrual period Avithout in any obvious Avay entailing local or constitutional dis- tress. Admitting this, the rational and safe rule in practice still is, to examine in all cases Avhere a. discharge at all copious escapes from the vagina attended by pain and signs of constitutional impairment. This may be stated as a general proposition Avithout distinction as to the nature of the discharge. But Ave will noAV examine Avhat the discharges are, and Avhat is the special significance of each. And, in limine, let us agree upon the meaning to attach to two Avords Avhich Ave shall frequently have occasion to use. " Secretion" and " excretion" must be accurately applied. FolloAving Continental custom, I shall use the Avord " secretion" to distinguish the act of separation of the discharge from the free surface of the organs ; and the Avord ,v excretion" to distinguish the act of voiding from the bodv altogether. To take an example : the menstrual fluid mav be poured out from the mucous surface of the Fallopian tubes and uterus—that is secretion. The escape of the fluid by the vulva is excre- 74 CONDITIONS INDICATING EXAMINATION. tion. Excretion is the natural complement of secretion. But the process mav stop short at secretion—that is, the secreted fluid may be retained. Thus, if there be occlusion of the genital canal at any point below the os uteri internum, the secreted menstrual fluid will be shut up in the cavity of the uterus and in the Fallopian tubes. There is no excretion, and therefore, apparently, no secretion. Taking the discharges'as they first come under the notice of the clinical observer, that is, after their excretion, they may be roughly classed under the folloAving heads: 1. Sanguineous. 2. Mucous. 3. Purulent. 4. Watery. 5. Membranous. 6. Solid or fleshy. 7. In the case of fistu- lous openings into the bladder or rectum, urine or feces may escape. 8. Then there are foreign matters, fluid or solid, Avhich find their Avay into the uterus and vagina from Avithout. Amongst these may be men- tioned semen distinguished by spermatozoa. 9. On rare occasions true hydatids have escaped by this route. If Ave limited our inquiry to the examination of these discharges Avhen excreted, Ave should hardly attain to any more precise knoAvledge than is expressed in the general terms by Avhich we have designated them. We cannot arrive at a certain knoAvledge of their source, or form a trustAvorthy estimate of their pathological significance, unless Ave examine minutely the organs from Avhich they are secreted. I may state another proposition: most of the diseases of the uterus and vagina are attended by discharges. But it must not be assumed that, Avhen no discharge exists, or is noticed by the patient, there is no disease. Serious disease of the ovaries and uterus may exist for a long time without being attended Avith any discharge. And still more fre- quently discharges are overlooked by the patient, but become obvious enough on examination. Of all the discharges the only one Avhich can be called strictly normal is blood ; and this is only normal Avithin certain conditions of circumstance, time, and quantity. PreAdous histological study will lend the most mate- rial aid to direct observation in determining the sources and significance of discharges. We may start from the proposition that, Avith one or two rare exceptions, all the discharges Ave have to deal Avith come from mucous membrane, or at least from organs normally clothed by mucous mem- brane. The discharges will generally bring Avith them some of the dis- tinctive elements of the part of the mucous tract from Avhich thev are secreted. Hence microscopical examination of a discharge will almost always reveal epithelium-cells Avhich tell their OAvn tale as to the region they come from. In this way Ave can distinguish uterine mucus from vaginal. Nearly the Avhole genital tract secretes mucus. It is only Avhen exces- sive in quantity, or altered in quality, that the secretion of mucus acquires a pathological significance. The natural mucous secretions are :— 1. A whitish mucus from the Fallopian tubes and cavity of the uterus proper. This probably comes principally from the uterine glands. It has an alkaline reaction. It is distinguished under the microscope by the presence in it of columnar ciliated epithelium-cells. In health this secre- tion is moderate in quantity, and attracts no attention. But in the con- DISCHARGES: MUCOUS. 75 dition knoAvn as uterine catarrh it is very abundant, sometimes, especially in aged women, accumulating in the uterine caAdty, and causing colic pains to expel it. The uterine mucous membrane may also be stimulated to excessive secretion by gonorrhoeal infection spreading from the vagina. Fig. 35. Fig. 36. Fig. 35.—Mucous discharge from the healthy cervix uteri, taken from the mucous crypts. The mucous corpuscles are arranged in strings by the viscidity of the plasma in which they are entangled —(after Tyler Smith and Hassall). Fig. 36.—Mucous corpuscles, epithelial particles, and oil granules from cervical leucorrhcea—(after Tyler Smith and Hassall). 2. A transparent viscid, mucus in the cervix uteri. This is also alka- line. It consists chiefly of mucous corpuscles, caudate corpuscles, minute oil-globules, and occasionally dentated epithelium, all entangled in a thick tenacious plasma (see Fig. 35). In health this secretion is rarely formed in such excess as to appear externally, but it is almost always found in the cervix filling up the canal. The mucous plug thus formed is Avashed aAvay at each menstrual Aoav ; it exists generally throughout pregnancy. Its uses are probably to shut off the uterine cavity, so as to protect it from external agencies, and to form a suitable medium for the passage of the spermatozoa. At the beginning of labor this secretion is formed in increased copiousness, and senses to lubricate the passages, and to facilitate their dilatation. In certain morbid conditions the cer- vical glandular structure also acquires extraordinary activity, and then the proper cervical mucus assumes the character of a discharge. It is poured in large quantity into the vagina, so freely, indeed, as to be a serious drain upon the system, and a source of Aveakness. It constitutes the most frequent form of so-called " whites" or leucorrhcea. If the speculum be used it may be seen issuing from the uterus as a glairy, albuminous fluid, resembling unboiled Avhite of egg. This exaggerated secretion is almost ahvays the consequence of inflammation, more or less acute, of the cervical canal, or of a condition analogous to catarrh of the bronchial or intestinal mucous membrane. 70 CONDITIONS INDICATING EXAMINATION. 3. A mucus consisting of plasma, not viscid, but containing multitudes of scaly epithelium-cells. This comes mainly from the external surface of the cervix uteri, labia uteri, and the fundus of the vagina. It is of acid reaction. The proportion of epithelial cells to that of the fluid plasma varies considerably. In some cases the fluid part is so scanty that the secretion adheres to the mucous membrane, covering the os uteri as with flakes, or a layer of opaque yellowish-white friable membranous- looking substance, simulating and suggesting diphtheria. It often ad- heres in the form of a thick layer upon india-rubber pessaries. Under the microscope this is found to consist almost entirely of scaly epithelium and oil-globules. In other cases, the plasma being a little more abun- dant, the secretion looks like cream or pus. But in these cases the microscope reveals the same constituents—namely scales of epithelium. These forms of secretion depend upon chronic or subacute inflammation of the mucous membrane—vaginitis, not necessarily accompanied with abrasion or ulceration. The puriform mucus, more or less opaque and viscid, varying in tinge from creamy-white to yelloAvish or light green, is often due to gonorrhocal infection, or to suppu- ration from surfaces denuded of epi- thelium and granulating. When due to gonorrhceal infection the mucous membrane from os uteri to vulva is swollen, angry-red, and painful, and the meatus urinarius exhibits the same characters. The creamy form of secretion is frequently found during pregnancy on the vaginal portion of the uterus. It is the result of the active throAving off of squamous epi- thelium due to hyperaemia. 4. The remaining or loAver tract of the vagina secretes an acid mucus. Under morbid states this sometimes contains pus-globules, an infusorium, the Trichomonas vaginalis of Donne, and a fungus, the Leptothryx buccalis of Robin. But the parasites are really mainly due to neglect of cleanliness. Whitehead suggests that the use of the acid of the vaginal mucus is to prevent the coagulation of the catamenial fluid in the vagina. It certainly seems to possess the property of coagulating the alkaline mucus coming from the cervix. I doubt the correctness of Whitehead's theory. It is important that the blood should not coagulate in the uterus, because clots there cause severe pain and congestion, and are apt to keep up hemorrhage ; but a clot in the vagina is of little consequence. Pus stops coagulation; so does mucus, provided the proportion of blood is small. I believe it is the normal mucus Avhich maintains fluidity. Whenever the proportion of blood is greatly in excess it is apt to coagulate. 5. There is a clear viscid secretion from Bartholhir s glands, Avhich is discharged in jets during copulation. It has been seen to escape on irri- Fio. 37. Epithelium from vaginal leucorrhcea—(after Tyler Smith and Hassall). LEUCORRHCEA. 77 tation, expelled by the action of the muscular fibres in the ducts. It is also poured out freely during labor, serving to lubricate the vulva. 0. The small sebaceous and mucous glands of the vulva and labia majora secrete an oily mucus, serving for lubrication. This is sometimes increased in quantity, becoming puriform. We may here refer very briefly to one or two other points connected with mucous discharges. Donne says when the acidity of the vaginal mucus, or the alkalinity of the uterine secretion, is morbidly exaggerated, the spermatozoa are killed. Hence one explanation of the frequency of sterility Avhen there is inflammatory disease of these parts ; and of the occurrence of pregnancy when the disease which gives rise to the morbid secretions is removed. One proof of the alkaline property of the cervical mucus is seen Avhen the cotton, impregnated with tincture of iodine, is passed into the cavity of the cervix: the color is discharged. THE SIGNIFICANCE OF THE DISCHARGES : LEUCORRHCEA ; WATERY DIS- CHARGES; PURULENT DISCHARGES; BLOOD DISCHARGES; GASEOUS OR AERIFORM DISCHARGES. The preceding summary of the various mucous discharges Avill enable us to estimate more accurately the history of leucorrha'a. Although leucorrhcea, or Avhite discharge, is generally a symptom only, and not an essential morbid condition, it is necessary to study its history and significance separately from the morbid conditions Avhich produce it. In a considerable number of cases leucorrhcea may be regarded as a catarrh of the uterine or vaginal mucous membrane analogous to catarrh in other mucous tracts. We accordingly see not infrequently that leu- corrhcea is cured or cures itself Avithout topical treatment. I have drawn attention to the fact that the uterine mucous membrane is subject, like other mucous membranes, to epidemic influence. For example, Avhilst in some this influence would affect the alimentary canal causing diarrhoea ; Avhilst in others, or at other seasons, itAvould cause bronchitis or pneumonia ; in some Avomen itAvould give rise to uterine catarrh. Not a feAv women have leucorrhoea whenever the weather is cold. This is explained in some cases by sudden changes of temperature, checking the secretions of the skin; in other cases the direct exposure of the patulous vagina to draughts of cold air, as from using an open privy, has appeared to be the cause. Certainly, I have known this cause to bring on pelvic cellulitis and peritonitis in patients Avho Avere predisposed by recent delivery, or the recent performance of operations on the pelvic structures. In the article " Leucorrhe'e," in the Dictionnaire des Sciences Medi- cales, facts illustrating the occasional epidemicity of leucorrhoea are referred to on the authority of the physicians of Breslau, in 1702 ; of Morgagni, in 1710 ; of Bassius, in 1730; by Raulin, at Paris, in 1765; and by Leake, in England. Certain forms of leucorrhcea may be regarded as physiological. Amongst these may be classed that excessive secretion of mucus which often attends the hyperaemia of pregnancy. This may not always be so profuse as to escape externally and attract the notice of the subject; but it is rarely absent, and by the speculum it is seen as a white opaque 78 LEUCORRHOEA. secretion of creamy consistency, occupying the bag of the fundus and furrows of the vagina. This secretion also consists chiefly of epithelium scales. If the vaginal mucous membrane exhibit with this secretion a deep violet-red or purple color, and prominent rugae or brain-like corru- gations, the presumption in favor of pregnancy is great. This form of leucorrhoea requires no treatment. Another form of leucorrhoea which may be called physiological, is that pale mucous discharge Avhich precedes and folloAvs, but chiefly follows, the proper menstrual flow. The first effect of the flux which takes place under the ovarian nisus, is to stimulate the glands of the uterus to in- creased activity. Hence the secretion of mucus in larger quantity, Avhich sometimes appears externally before the proper menstrual blood exudes and mixes with it. This increased secretion of mucus goes on all through the stages of menstruation, and persists for a while after the exudation of blood has ceased. This post-menstrual leucorrhoea may be likened to the so-called "green-Avaters" of childbed. It Aoavs from the uterine cavity, as does the proper menstrual discharge. An allied variety of' this form of leucorrhoea is that Avhich is often witnessed in girls Avho do not menstruate properly. In these cases, leu- corrhcea is the substitute for the healthy menstrual sanguineous Aoav. It is evidently the result of an imperfect menstrual molimen. It is provoked by ovulation more or less perfect. It may, therefore, Avith strict justice be called menstrual leucorrhoea. It is more especially prevalent in chlo- rotic girls, and then may degenerate into a morbid flux. What has been said about physiological leucorrhcea sufficiently proves that inflammation is not a necessary factor. Indeed, inflammation may exist Avithout leucorrhoea, and leucorrhoea Avithout inflammation. In the great majority of cases of leucorrhoea, uterine, vaginal, or vulvar, there has been no history of inflammation. Those forms Avhich are more directly traced to inflammatory conditions, as acute and chronic catarrhal metritis, will be more conveniently discussed Avhen describing the patho- logy of the uterus. Leucorrhoea may be the expression of a constitutional diathesis. Thus the strumous diathesis is known to be commonly attended by a tumid development of the mucous membranes generally, and a disposition to glandular engorgements. Girls and women possessing this diathesis are frequently the subjects of leucorrhoea Avithout shoAving any special altera- tion of the genital mucous membrane. But occasionally there is a dis- tinct tuberculous condition of the mucous membrane. When this is the case, the attendant leucorrhoea is peculiarly intractable, even incurable. Leucorrhoea is not uncommon in women suffering from tubercular dis- ease of the lungs. The syphilitic diathesis produces analogous effects; and that not only Avhen the diathesis has been acquired by primary infection, or through the gestation of an infected ovum, but also Avhen the diathesis has been transmitted hereditarily. The gouty and the rheumatismal diatheses are described by some Avriters as disposing to leucorrhcea, and that of a very obstinate form. In certain states of great debility, marked by anaemia and defective nutrition of the tissues, mucous fluxes are easily excited, and the ^enital leucorrhcea: diathetic 79 mucous tract is especially prone to be so affected. In such cases there need be no inflammation, no breach of surface, no abnormal growth. The coats of the vessels, the tissues of the mucous membrane, the mus- cular structure of the uterus are all so deficient in tone and contractility, and the blood is so Avanting in plasticity, that an exudation of the watery element, mingled Avith mucous secretion, readily takes place. This state of anaemia may be induced by various causes, as acute or chronic dis- ease, hemorrhages, or by over-suckling. It may also be induced by toAvn-life and unhealthy occupations pursued in bad hygienic conditions. Accordingly, leucorrhoea is belie A'ed to be more frequent in toAvns than in the country, although the statistics cited to prove this position are by no means free from fallacy. The feeble, relaxed state of health induced in Europeans living in tropical climates, is certainly often attended by leucorrhoea; and in this Ave see another example of the relationship be- tAveen leucorrhoea and hemorrhage. Thus, I have knoAvn instances of women who ahvays suffered from leucorrhoea whilst in India, remain free whilst staying in England. Diet has been supposed to have some influence in the production or promotion of leucorrhoea. No doubt a diet deficient in nutritive poAver may, by inducing general debility, favor the occurrence of leucorrhoea; and it is equally certain that a good nutritive diet, by imparting tone and general health, will tend to prevent or cure leucorrhoea; but I am not aAvare of any precise observations to prove that any particular articles of food have a distinct or specific action in promoting leucorrhoea. Leucorrhoea is common in association Avith disorder of the digestive organs. Dyspepsia, flatulence, distension of the stomach and abdomen, constipation or diarrhoea are frequently observed. To determine Avhich was the antecedent disorder is not ahvays easy; but this much is certain: almost all the dyspeptic women Avho have copious leucorrhoea, and in Avhom physicians are so ready to explain the leucorrhcea by the disor- ders of digestion, have uterine disease. Leucorrhoea rarely lasts any considerable time without entailing dyspepsia and mal-nutrition. Leu- corrhoea may, hoAvever, be an expression of vascular turgescence, the re- sult of difficulties associated Avith the liver, kidney, or heart. How local hyperemia, depending upon remote or general causes, may give rise to leucorrhcea, is well illustrated in the hypersecretion of pregnancy. Leucorrhcea is frequent among women avIio folloAV sedentary occupa- tions, and in Avhom the boAvels are habitually loaded. I have knoAvn Avomen who Avere leading a fairly active life ahvays subject to leucorrhoea Avhen their bowels Avere constipated. The same condition favors monor- rhagia. But after making every alloAvance for the influence of disordered diges- tion, and of other distant or indirect factors in producing leucorrhcea, the fact remains that in the great majority of instances, after childhood, leu- corrhoea is dependent upon some uterine abnormality. I may repeat Avhat 1 have already said that almost every morbid condition of the uterus is liable to be attended by discharge. When there is acute or chronic endometritis, abrasion, tumor, polypus, or displacement, leucorrhoea is rarely absent. Hence the significance of leucorrhoea as a symptom pointing to uterine disease. Generally it may be stated that when leucor- 80 LEUCORRHCEA. rhcea is constant it is significant of uterine disease, that is, of a persistent cause : and that when intermittent, that is, ceasing between the menstrual epochs, it is of purer physiological import. In Avomen Avho are in any way constitutionally predisposed to leucor- rhoea slight causes will provoke "it. Excessive exercise, as in walking, excess in sexual indulgence, the Avearing a pessary, in short, almost any local irritation is sufficient. When there is no special predisposition, the like causes long acting may provoke leucorrlnea. The presence of a tumor in the Avail of the uterus attracting an undue quantity of blood, the chafing of a polypus against the Avails of the cervix or vagina, or even the presence of a hypertrophied vaginal portion Avill seldom fail to pro- duce leucorrhoea. The division of leucorrhoea into uterine, vaginal, and vulvar, as pro- pounded by Donne and Tyler Smith, is based not less on clinical than on anatomical foundation. As Ave have seen, the microscopical and chemical analysis exhibits distinctive characters, and the pathological history too is often different. It may be stated as a general proposition, one admit- ting, indeed, of numerous exceptions, that vulvar leucorrhoea is more peculiar to childhood, vaginal to young Avomen, and cervical and uterine to middle and advanced age. All the forms may coexist in the same patient, but in many one may exist alone. This is especially the case with the vulvar leucorrhoea of children. It is also often true of the vulvar leucorrhoea attending pruritus in aged women. The characters of the discharge in vulvar leucorrhoea are different at different ages. Thus in children in whom the sebaceous glands are not yet developed the dis- charge is serous or sero-purulent, resembling that Avhich results from eczema of the skin. At puberty, and during the child-bearing epoch, the same kind of sero-purulent secretion may exist, but it is commonly mingled Avith the proper secretions of the vulvo-vaginal glands and of the sebaceous glands Avhich are at the acme of their development at this time. The secretion Avill be viscid, unctuous, giving a characteristic cheesy or fishy odor. The vulvar leucorrhcea of advanced age reverts to the characters of infancy, the sebaceous follicles haAring in great measure disappeared from atrophy. Vaginal leucorrhoea at all ages consists essentially of an exaggerated formation and shedding of pavement epithelium scales (see Fig. 37). In many instances a great part of the fluid element of the vaginal dis- charge arises from the cervical cavity. Cervical leucorrhoea is most frequent in the child-bearing period. It is chiefly mucous; it exhibits the characters seen in Figs. 35, 36. Uterine leucorrhoea or catarrh will vary in character according to age. During the child-bearing epoch the uterine glands contribute a quantity of mucus to mix Avith the epithelial de'tris. At a later period the epithe- lial debris assumes a creamy or milky consistence from fatty metamor- phosis and the admixture Avith a serous exudation. In all the cases pus may be found if there is breach of surface, as from ulceration and <>ranu- lation. Uterine and cervical leucorrhoea is a frequent attendant upon dysmenorrhoea, especially of that form Avhich is characterized by partial retention. If there be atresia or narroAving at the os externum, the con- gestion consequent on the futile attempts of the uterus to expel its contents LOCAL EFFECTS OF. 81 excites to increased activity of the uterine and cervical glands. And the product of this increased activity finding in its turn difficult escape, tends to accumulate, and to dilate the cavities of the cervix and body of the uterus. Thus spasm or colic is excited, and the mucous accumulation may be expelled en masse. It is in this Avay Ave account for the fre- quently intermittent character of leucorrhceal discharges. If called upon to describe summarily the distinguishing characters of uterine, vaginal, and vulvar leucorrhoea, Ave might say that the first is mucous, the second epithelial, and the last sebaceous. The someAvhat greasy character of vaginal leucorrhcea is mainly attributable to the fatty metamorphosis of the epithelial scales. The leucorrhoea of children deserves careful attention. The occur- rence of a discharge being often attended Avith local irritation, the child is likely to resort to friction or scratching for relief. The redness and tumefaction thus added to the discharge are very apt to excite suspicions of foul play, and thus to lead to false accusations. It is therefore in the last degree important to bear in mind the conditions under which leucor- rhoea in children may arise, lest Ave too hastily adopt the suspicions that may be suggested to us by others. Many years ago1 I made the observation that acute exanthemata, as smallpox and scarlatina, Avhich Ave know affect the Avhole mucous tract, as Avell as the skin, occasionally left, as sequelae, vaginitis and leucor- rhoea even in children. Graves, Scanzoni, and others have confirmed this observation. Strumous children are especially subject to vaginal and vulvar leucor- rhoea. Irritation of the rectum as from ascarides, commonly produces it. In children of this taint it alternates Avith, or accompanies crusta lactea or impetigo, herpes, eczema. It is said to be due to the irritation of teething, but this I have not noticed, except in cases where a strumous diathesis offered a sufficient explanation. In many cases the vulvar leucorrhoea in children is kept up by neglect of cleanliness. The principal features which would favor the conclusion that leucor- rhoea observed in a child is due to a criminal attempt, are: marks of contusion, swelling, ecchymosis, turgescence of the vessels of the vulva and vagina ; extreme rapidity, and intensity of the disease. If there Avas gonorrhceal infection, then there will be a purulent discharge, green- ish-yelloAV in color, copious enough to bathe the external parts and to stain the linen, thick enough when drying to glue together the lips of the vulva, and floAving equally from the vagina and urethra. This urethral complication is especially important, for according to Tardieu, violence done to the sexual organs of a child by a healthy man may produce an inflammation as acute, and a discharge as copious and thick, as that done by a man affected Avith gonorrhoea. It is obvious from the foregoing considerations that the greatest possible circumspection is necessary before committing one's self to the expression of a positive opinion as to the origin of an apparently virulent discharge in a child. 1 Medical Gazette, 1850. 6 82 LEUCORRHCEA. A question which has attracted some attention is this : Does the leu- corrhoeal discharge by contact Avith the mucous membrane, on avhose surface it is retained or over Avhich it Aoavs, exert any irritating or injurious action ? We frequently find associated with leucorrhoea patches of the surface of the vaginal portion denuded of epithelium, small ulcer- ations they may be called, a state of tumefaction, even redness. Are these caused by the leucorrhcea ? In the majority of cases they assuredly are not. They mostly take their origin in those processes Avhich produced the leucorrhoea as Avell. They are frequently the consequence of labor or abortion, during Avhich processes the cervix uteri undergoes severe injury. It is conceivable, hoAvever, that long-continued maceration of a mucous membrane in leucorrhoeal fluid may effect some alteration, as softening of its tissue, and this, leading to excessive exfoliation of its epithelial layer, may facilitate the denudation of the basement layer. This would be especially likely to happen under the influence of any unusual accidental irritation, as excessive walking or sexual indulgence. Dr. Tyler Smith, however, submitted that sometimes the discharge possessed decided acrid or irritating properties, capable of directly in- ducing ulcerations, granulations, follicular cysts, and other disorders. That is, he looked upon leucorrhoea as a primary disease. This opinion appears to me to Avant confirmation. It is intelligible that the permanent increased turgidity of vessels, and the consequent altered condition of the tissues attending habitual leucorrhoea, may in the end entail the altera- tions named. But this is a different thing from their direct production by the irritating property of the discharges. If fluid be retained inside the cavity of the uterus, then it will act mechanically according to hydrostatic laws. It then excites contractile efforts of the uterus, and as the fluid does not escape, or only partially, the equal eccentric pressure of the fluid against the walls of the containing cavity leads to the dilatation of this cavity. Its retention on the surface of the mucous membrane would also interfere materially with the per- formance of some at least of the functions of this membrane, as, for ex- ample, the healthy course of menstruation and the carrying of spermatozoa. There is, however, reason to believe that the sebaceous secretion of vulvar leucorrhcea, if retained, may become especially offensive and acrid, and keep up or produce an inflammatory state of the tissues bathed by it. Another question has been started: Can the secretions classed as leucorrhoea be absorbed, and give rise to constitutional toxaemia ? I con- tent myself with citing the question. I knoAv of no precise evidence to support an affirmative answer. There is, hoAvever, evidence to shoAv that such poisons as lead, carbolic acid, chromic acid, used to vaginal surfaces bared of epithelium, may be absorbed, and produce their specific toxical effects on the system. It is also certain that foul secretions retained in utero may be taken up into the uterine veins and lymphatics, and give rise to inflammation of the broad ligaments, peritonitis, and general septicaemia. This is especially the case in the puerperal state after childbirth at term and after abortion, and also from cancerous ulceration. But these facts, although proving that the way is open to invasion do TREATMENT. 83 not prove that the system is ever so invaded by the matter of ordinary leucorrhoea. The diagnosis of the kinds of leucorrhoea from each other is sometimes presumptive, sometimes almost absolute. It is generally presumptive in cases of constitutional disorder, as in strumous or chlorotic girls, in Avhom it may be reasonably inferred that there is no uterine lesion, and in whom physical exploration is not pursued. Diagnosis is still presumptive, even in married AvomenAvho haAre had children, until local examination is made. The sources of the discharge may be demonstrated by the speculum. We may actually see the viscid albuminous secretion coming out of the cervix. So again in the chronic uterine catarrh of old age, with atresia of the os externum, and in that form which is associated Avith dysmenor- rhoea from retention, we may by dilating the os uteri give vent to the retained secretion. Not rarely, leucorrhoea exists to a very considerable degree, and yet escapes the observation or attention of the subject. Women not seldom, Avhen questioned as to the existence of discharge, say they have none, Avhilst examination shoAvs copious collection of mucous fluids in the vagina, and issuing from the cervix uteri. This arises from the patient either not being conscious of the escape of discharge, or being careless about it. Sometimes the uterine viscid secretion is expelled in a mass during defecation, and thus is not noticed. This unobserved leucorrhoea might be called "occult leucorrhoea." As a general rule, Avherever leucorrhcea exists, other subjective symptoms are present, and indicate the expediency of examination. Treatment.—The principle in therapeutics should be, first, to determine Avhether the leucorrhoea depend upon or be complicated Avith any consti- tutional diathesis or disorder. If this be determined in the affirmative, our treatment should first be directed to the correction of this complica- tion. The treatment, even when the leucorrhoea depends upon a morbid dia- thesis, is general and local. We may, for example, accomplish a certain amount of good by internal remedies and hygienic means, in producing improved general nutrition, and thus in improving the condition of the tissues, including the affected mucous membrane. And in some cases, perhaps in many, these general measures may be successful. This is especially true of the strumous and chlorotic cases. But in others, topi- cal applications to bring about a healthier tone of the mucous membrane will be extremely useful, if not indispensable. We must not then too hastily assume that the treatment of strumous or of syphilitic leucorrhoea resolves itself into the constitutional treatment of the struma or the syphi- lis. When the conjunctiva is affected Avith catarrh or other form of in- flammation Avhich takes its rise in, or some of its characters from a stru- mous or syphlitic taint, Ave find the most precious adjuvant in topical applications to the eye. So of the skin. No less so is this the case with uterine and vaginal leucorrhoea. It Avould unnecessarily encumber this Avork to enter Avith any degree of detail into the general treatment of scrofula or syphilis. If I pass this by, it is not because I in any way undervalue its importance. General treatment is indispensable. Before topical treatment is adopted, avc ought to form a fairly precise 84 LEUCORRHOEA. diagnosis as to the source of the leucorrhoa, that is, Avhether it be ute- rine, vaginal, or vulvar. It is for want of attention to this point that vaginal injections are found to be so often useless. Araginal injections fail, because they do not touch the main seat of the disorder, which, in the majority of cases, is in the uterus itself. But although they fail to cure, they may be useful as far as they go. In constitutional leucor- rhoea, the vaginal mucous membrane as well as the uterine is commonly involved; and something is gained if Ave improve the condition of a part of the affected tract. There is, therefore, sufficient reason to prescribe them, and thus to enlist the patient in her OAvn service. She may her- self mangage the vaginal injection. For the topical treatment of the uterine mucous membrane she must have recourse to her physician. The most useful and convenient topical applications in strumous and most other forms of leucorrhcea are astringent liquids. Amongst these, acetate of lead, sulphate of zinc, sulphate of alumina, decoction of oak- bark, solutions of tannin are the best. The topical applications best suited for the interior of the uterus are sulphate of zinc, nitrate of silver, sulphate of alumina, iodine. The best mode of applying these will be described hereafter. Emmet1 extols hot vaginal injections. Their first effect is dilatation; secondly, contraction. The hips must be raised, and a properly-shaped bed-pan be placed under- neath. A gallon of Avater at (J.S° F. must then be sloAvly injected. This must be done by a nurse. It allays local irritation, and soothes in less time than any drug. In the case of syphilitic taint the same means are useful, hut in addi- tion I commonly use the iodide of mercury ointment, introduced by means of the ointment-carrier, I have contrived for the purpose. In the strumous leucorrhoea of children, cod-liver oil and iron are of signal service. The second indication is, if Ave discover any local disease, as a tumor, a polypus, displacement, abrasion, congestion, hypertrophy, to endeavor to remove this cause or complication. The third indication is, in the event of our detecting no constitutional diathesis or local disease, to treat the leucorrhoea as an independent dis- ease, if the discharge be excessive or entailing obvious local distress or general weakness. In this class of cases Ave should begin by correcting any disorder of the digestive organs. We should be especially careful to regulate the action of the boAvels, to remove and to prevent the accu- mulation of feces in the loAver boAvel. We should then endeavor to restore the general tone and strength by good diet, tonics, and exercise. Amongst the remedies most useful are strychnine, iron, quinine, and arsenic. The last is often remarkably efficacious in leucorrhoea depend- ing upon debility. Local remedies, as alum or zinc injections, are often useful adjuncts; but in young Avomen, in Avhom the presumption is against any morbid condition of the mucous membrane, they will be generally unnecessary, and for other reasons it is desirable to avoid them. Balsamic medicines, especially turpentine, are often very useful, and now that they can be given in capsules, or "pearls," the chief objection 1 New York Med. Journal, 1874. WATERY DISCHARGES. 85 to their use is overcome. Courty speaks highly of the advantage to be derived from tar-water mixed Avith the Avine drunk at meals. It is made palatable at first by mixing with seltzer-Avater. The same excellent author extols hydro-therapeutics. In the chronic forms of leucorrhcea cold Avater in every form, as full baths or hip baths, produces the best results. It is, at the same time, the best revulsive and the best tonic. In this chapter I have attempted to give merely a general account of leucorrhoea, regarding it, as for practical purposes it often is regarded, as a distinct pathological condition. Leucorrhoea, as a symptom depend- ent upon morbid conditions of the uterus and vagina, will be incidentally described as a part of the history of these several morbid conditions. The Avatery and purulent discharges might not inaccurately be included under the common head of "Leucorrhoea." It will be useful, at any rate, to study them in this connection. THE WATERY DISCHARGES. When these occur, we must first of all determine the presence or absence of pregnancy. It is no uncommon thing that discharges of water, more or less profuse, take place in pregnant women. This is the "hydrorrhcea gravidarum." Gushes of water, quite clear, may occur at almost any time during pregnancy; but they are more frequent in the latter months, and especially in the last month. Happening at this time, they are commonly taken as an indication of commencing labor, and many are the false alarms which patient and doctor have to suffer from this cause. "The waters have broke," says the nurse. You go, as in duty bound, and find probably the os uteri closed, nothing resembling active labor pains. What are you to do ? If you Avait for labor, you may wait for a week, or two or three weeks. If, on examination, by ballottement, you find the child still floats in the uterus, the os uteri not open, and no active pains, you may go home and Avait in peace for another summons. What is the source and nature of this hydrorrhcea gravidarum? Seve- ral theories have been expounded. The 'character of the fluid differs in some respects from that of liquor amnii. It is odorless and resembles blood-serum or the serous fluid effused in the peritoneal sac. Ruysch and Rcederer thought it came from rupture of lymphatic vessels, or of hydatids of the uterus; Bohmer thought it escaped from a second abor- tive ovum; Delamotte and Cruveilhier that it came from a cyst near the ovum; Deleurye, Puzos, Naegele, and Dubois that it came from the inner surface of the uterus, being secreted externally to the ovum. Dubois says it is the result of loosening of the membranes from the uterus when the vessels pour out serum. Hegar says the source is the uterine glands of the decidua. Thus he describes1 the glands of the mucous membrane as being found in decidua at the sixth month of gestation, and argues that their sudden disappearance in the subsequent months is improbable. In a case of hydrorrhcea he found in the decidua vera, at the beginning of the eighth month, an enormously developed glandular body._ At the bottom of this morbid growth was a general hypertrophic condition of the 1 Monatsschrift fur Geburtskunde, 1863. 86 AVATERY DISCHARGES. decidua and its glands. These gave out the excessive secretions. In a case related by Dr. Graef,1 repeated discharges took place, and the foetus was expelled at the end of six months. The membranes Avere very delicate, and openings Avere found in them. In this case, it is probable that the fluid Avas true liquor amnii. In another case the patient suffered, during the last three months, from repeated Avatery discharges; the uterus rising and falling Avith the gathering and escape of the fluid. The mem- branes Avere found Avithout rent. Graef regarded this as a case of catar- rhal hydrorrhcea. I believe there are various sources. In some cases the fluid is liquor amnii. This may come either .from rupture of the membranes; from rapid transudation under pressure; from rapid formation and accumula- tion of liquor amnii in the amnion; or from the bursting of a cyst formed betAveen the amnion and chorion, or between tvvo layers of chorion, the proper amniotic sac remaining intact. In the majority of cases, hoAvever, the fluid is not amniotic. It is then the result of a rapid secretion from the uterine glands or from the cervical cavity. In the early months, whilst there is still a free space betAveen the decidua vera and the decidua reflexa, there is a large area of developed glandular surface. In one case, which Avas under my close observation, hydrorrhcea to the extent of a pint or more daily, occurred during the three latter months of gestation. This certainly came from the cervix. Other cases satisfy me that the cervical glands may secrete large quantities of watery fluid; and that there is generally no necessity to seek higher up for the source. This copious secretion finds analogy in the occasional free secretion of Avater from the stomach, and in the profuse salivation of pregnancy. As I have shoAvn elseAvhere, the entire glandular system is rendered more active in pregnancy; and the increased vascular tension of this condition is relieved by discharges, sometimes at one point, sometimes at another. I do not think it is desirable to try active means to control these dis- charges, Avhich are really of physiological significance. The only true remedy is the termination of gestation, which must be aAvaited with patience, unless serious constitutional impairment threaten. I have observed a puerperal form of hydrorrhoea. Thus Avaterv dis- charges may continue for a month or longer beyond the proper lochial floAv. Generally in these cases the Avater is dirty, discolored, occasion- ally stained Avith blood, and offensive. The most common cause I have found to be the retention of a portion of placenta or of clots in the uterus; but a polypus may produce like results. The Avatery discharges alter- nate, but not always, with discharges of blood. The fluid may, under certain conditions, collect in considerable quantity in the uterus, so that the organ becomes greatly distended before the collection is expelled in a gush. Sometimes Avatery fluid is mingled Avith air, constituting ph/jso-hydro- metra. This is also a puerperal or post-puerperal condition, and is com- monly the result of retention of some portion of placenta or membranes and the admission of air into the uterine cavity. If an examination is made when the uterus is relaxed after labor, especially if the hand be 1 Jeuaische Zeitsclirift, 1805. VARIETIES OF. 87 introduced into the uterus, the vaginal walls are separated from their usual contact, and a channel is formed along Avhich air easily enters. Merely turning on the side, or a little more prone, Avill often, by favoring the fall of the uterus fonvards, produce a vacuum into Avhich air will rush. This is one reason amongst others why I am unable to approve of the abolition of the old-fashioned binder, Avhich some people would condemn, for no better reason that I can see than because it is old- fashioned. After labor, especially in pluriparae, the abdominal Avails are so relaxed that they can give no support to the uterus. The binder does temporary duty for the inert abdominal Avails. The history of physo-hyclrometra is, I belie\re, this: a portion of placenta, membranes or clots, remains in the cavity of the uterus after labor; some air gets in as I have described; decomposition ensues, and the gases of putrefac- tion are added to the air from Avithout, Avhilst the os uteri is occluded by the placenta or blood-mass falling over it. When this occurs, there is invariably hectic or irritative fever; peritonitis and septicaemia commonly attend; great abdominal pain. The enlarged, distended uterus can be mapped out rising as high as, or higher than, the umbilicus; and reso- nance is made out on percussion. One condition, the result of impregnation, often leads to copious and repeated discharges of Avatery fluid: the hydatid iform degeneration of the chorion. In this case the ordinary signs of pregnancy may not be present, and even the patient herself may not think she is pregnant. There is, hoAvever, ahvays evidence of enlargement of the uterus, and generally great pelvic distress. The water escapes in gushes at uncer- tain times ; it is often tinged Avith blood, resembling red currant water; it has not the offensive odor belonging to the Avatery discharges of cancer; sometimes, but not often until late in the progress of the case, cysts will be found SAvimming in the Avater; it is generally expelled Avith painful uterine contractions. In a case I saAv at St. Thomas's Hospital, the nature of the disease Avas not at first suspected. There was some abdo- minal enlargement, retention of urine requiring the catheter, and most distressing pelvic pain Avith irritative fever. The os uteri Avas found high up above the symphysis pubis, Avhilst behind it the pelvic cavity was filled Avith a large, rounded, firm mass, taken to be either the retroverted gravid Avomb or a fibroid tumor. One day a large quantity of water, blood, and a mass of chorion-cysts Avere expelled. We had, in fact, the condition of retroverted gravid Avomb complicated Avith hydatidiform or cystic degeneration of the chorion. I have since seen a similar case at St. George's. Apart from pregnancy, watery discharges are sometimes of grave sig- nificance. During and after the climacteric period, the most frequent cause is some form of malignant disease, especially the so-called caulifloAver excrescence of the uterus. In this case other symptoms will probably point to the seat and nature of the disease. The fluid discharged is seldom clear; it is generally turbid, dirty, often tinged with blood, re- sembling water in Avhich flesh has been macerated; it contains shreds or flocculi of solid matter, the proceeds of superficial erosion or necrosis of the surface of the diseased groAvth, and is almost ahvays of a peculiar offensive odor. It often alternates Avith hemorrhage. Local exploration 88 DISCHARGES OF AIR. will place the nature of the case beyond doubt. Another form of malig- nant disease giving rise to Avatery discharges is the "oozing excrescence of the labia." But Ave must remember that similar discharges may take place from polypus or inversion of the uterus. Hence avc have another example of the Avisdom of not pronouncing a diagnosis until avc have made an internal examination. Water may escape in large quantity from the rupture or perforation of an ovarian cyst in the vagina. In such a case, the rapid concurrent diminution of the abdominal tumor will lead to the right con- clusion. • I have seen profuse watery discharge from the uterus and its neck in cases of retroversion and retroflexion of the uterus. Here Ave may infer that their glandular system Avas unusually active, and that the vascular fulness was increased by the imperfect return of the blood by the veins, compressed or strangled by the malposition or distortion of the uterus. Certain it is that in one very marked case profuse Avatery discharge ceased Avith the restoration of the uterus to its normal position. Watery discharge may be urine escaping from a vesico-vaginal fistula. The character of the fluid and other circumstances seldom fail to establish the exact nature of the case. Under certain conditions of the mucous membrane of the uterus, more especially of the cervix, copious secretion of Avatery fluid may take place rapidly. I believe this chiefly occurs Avhen the mucous membrane is hypertrophied. In this case the numerous glands are probably also hy- pertrophied, and acquire a greatly-increased activity. It will be remem- bered that all the mucous membranes at times discharge large quantities of Avatery fluid. Thus the mouth is the seat of ptyalism, the stomach of pyrosis, the intestinal canal of diarrhoea. It is rational to infer that causes analogous to those Avhich induce Avatery secretion from the mucous membranes in these organs, may induce the like event in the mucous membrane of the genital tract. DISCHARGES OF AIR. Air may get into the vagina, if not into the uterus, in the non-preg- nant state. In the normal condition the Avails of the vagina are main- tained in perfect contact, and no air, or probably very little, is admitted. But Avhen the parts are greatly relaxed, the vulva open as when the perineum is torn, the loAver part of the vagina is no doubt exposed to the contact of air, but the very condition of patency prevents the retention of the air to such a degree as to lead to its escape in perceptible volume. Air also penetrates Avhere too large a pessary is Avorn, which keeps the vaginal Avails apart. But under peculiar circumstances air enters in large quantity, to be expelled Avith noise. Dr. George llarley details1 a curious case, in Avhich he carried out decisive experiments, to prove the correctness of the diagnosis. A pluripara frequently expelled air from the vagina with a loud noise. It Avas ascertained that no connection existed betAveen the rectum and vagina. Dr. Harley took a full-sized 1 Obstetrical Trausactions, 1863. DISCHARGES OF AIR. 89 male catheter, to Avhich Avas attached a long india-rubber tube with a stopcock at the other end. The catheter Avas introduced into the uterus, the end of the tube Avith the stopcock being placed in a tumblerful of Avater. ^ No air escaped when the instrument was in this position ; but, on placing the open end of the catheter in the vagina, an instantaneous discharge of gas took place. The Avater Avas found to be sucked up through the tube into the vagina. It Avas found that the vagina sucked in and expelled the air by spasmodic action. It Avas further observed that the abdominal muscles assisted in the suction process. The uterus Avas completely retroverted. This displacement being remedied, and the health improved by tonics, a cure ensued. Dr. M'Clintock says:1 "Tavo or three Avomen avIio had prolapse of the Avomb have told me that soon after getting up in the morning they have been conscious of the escape of air from the vagina. The vagina Avas enlarged, the loAver part of the uterus hypertrophied. There Avas no fistula; the air came from Avithout." If Ave observe the vagina wdien the duck-bill speculum is applied, the movements of rise and fall under the influence of the rise and fall of the diaphragm are seen. Dr. Adolph Rasch has investigated2 these pheno- mena Avith great care. He says, if a multipara, Avhose genitals are nor- mal, be placed on her back, Avith the thighs flexed and abducted, and the vaginal orifice closed, movements caused by respiration are seen, but no air enters. In the lateral position the same thing is observed even if the vagina is lax, and even Avhen the perineum is ruptured. When the patient is placed in the prone position, or on all-fours, if the vulva be open, air will enter, because the intestines falling doAvmvards by gravity causes a vacuum. Under this condition violent exertion may expel air, giving rise to vaginal flatus. If the abdomen be supported by the hands or a bandage, no air enters. There are several interesting applications of this knoAvledge. It teaches that the best position after labor, if not during labor also, is the dorsal decubitus ; that the same position is also best in the case of pelvic abscess or haematocele discharging into the vagina; and that Ave must carefully consider this respiratory rise and fall of the vagina Avhen selecting pes- saries. It is by turning to account this action that Ave derive the greatest advantage from the spoon or Sims's speculum. The blade draAving the perineum Avell back, Avhilst the semi-prone position of the patient favors the falling fonvards of the abdominal viscera, air fills the vagina, counter- acts the effect of inspiration, and thus enables us to get a good vieAV of the os uteri. The same position also greatly aids our efforts at reducing in- Arersion of the uterus, and in replacing a prolapsed umbilical cord. On the other hand, in most operations upon the uterus and vagina, where it is of importance to bring the uterus as Ioav doAvn near the vulva as pos- sible, the dorsal position, by bringing the force of gravity to counteract the respiratory rise of the uterus, and Avhich can further be greatly aided by direct pressure by an assistant's hand above the symphysis pubis, is the best. 1 Diseases of Women, p. 54. 2 Obstetrical Transactions, 1870. 90 PURULENT DISCHARGES. THE PURULENT DISCHARGES. Some purulent-looking discharges are in reality mucous, the appear- ance being due to epithelium-cells, not to pus-globules. When pus-glo- bules in large proportion are found, they indicate generally a breach of continuity of the mucous surface—that is, a granulating or ulcerated sur- face. When pus escapes in quantities, suddenly at intervals, and some- times by continuous draining, the source probably is an abscess Avhose seat is outside the uterus or vagina, as in Avhat is called pelvic cellulitis, opening into the vagina. In such a case examination by touch internally, and externally in the iliac regions, will reveal the extra-uterine disease. The uterus will be felt set fast by surrounding firm plastic effusion. The os uteri will generally be found in the centre of the pelvis, Ioav doAvn, or inclined to one side, if the pelvic peritonitis is chiefly unilateral. This position of the os uteri distinguishes pelvic peritonitis from retro-uterine hematocele, which pushes the os uteri fonvards close behind, and some- times above, the symphysis pubis, and Avhich may also be attended by suppuration. A suppurating ovarian cyst may contract adhesion with the roof of the Aragina, and form a fistulous perforation through Avhich pus may escape. I have had under my care a case in Avhich pus is voided by the vagina, the origin of Avhich is an abscess in the left hypochondriac region open- ing into the intestine, and which at a lower part has formed a fistulous communication Avith the vagina. The glands of the cervix or of the vulva, especially the vulvo-vaginal gland, when inflamed, as from gonorrhoea, discharge pus freely. Ab- scesses may form in the connective tissue between the uterine neck and bladder, or at any loAver point of the vagina, or in the loose tissue of the labia vulvae : and, bursting, will give a purulent discharge. To distinguish some apparently purulent discharges from mucous, ap- peal to the microscope is necessary. The distinction is important, be- cause' it is generally true that the unbroken mucous membrane of the genital tract does not yield pus. When true pus appears, it is therefore mostly an indication of erosion, ulceration, or abscess. As Virchow has pointed out, all mucous membranes with cylinder-epithelium are little disposed to form pus. The matter Avhich is produced is found, on accu- rate examination, to be only epithelium, though it may, to the naked eye, have a thoroughly purulent appearance. The intestinal mucous mem- brane rarely produces pus Avithout ulceration. The mucous membrane of the uterine tubes, which is often covered Avith a thick mass of entirely puriform appearance, shoAvs almost always only epithelial elements. On other mucous membranes—the urethra, for example—we observe copious discharges of pus Avithout the least ulceration. We thus see hoAV numerous and strange are the sources of pus in the vagina, and that a purulent discharge is no sure evidence of disease of the uterus or vagina. Exploration must extend beyond these organs. HEMORRHAGES. 91 THE SIGNIFICANCE OF HEMORRHAGIC DISCHARGES. Discharges of blood from mucous membranes are not necessarily sig- nificant of local disease. For example, epistaxis from the Schneiderian membrane is not infrequent in childhood and old age, unconnected Avith organic disease anywhere. Although Avhen it has once set in, the bleed- ing may go on to an excesshre, to an alarming, and sometimes even to a fatal extent, it seems in the first instance to be determined, by an effort of the vascular system, to unburthen itself of a superfluous accumula- tion. It appears to be critical, and in many cases to be beneficial. During the period of sexual life the uterine mucous membrane is the outlet tOAvards which any overflow is directed ; during this period Schnei- derian epistaxis or other forms of hemorrhage are rare ; the seat of election for critical and other hemorrhages is the uterus. And it is re- markable that, as a result probably of the disposition Avhich the uterus had acquired of acting as a periodical evacuant, long after the cessation of menstruation proper, it still continues to be the safety-valve by Avhich vascular repletion or tension is relieved. The aptitude of the uterus to serve in this way is occasionally mani- fested also at an early age ; that is, just before, or about the institution of the menstrual function. Young girls sometimes begin Avith a copious flooding, Avhich does not appear to be distinctly determined by ovulation. In the cases referred to, hemorrhage even copious does not necessarily imply disease, at least not disease of the ovaries or uterus. It is an expression of constitutional or general vascular tension. Still hemor- rhage from the uterus, especially if prolonged or repeated, is so com- monly a consequence of disease of that organ, that it ought, as a general rule, to be taken as a warning to make local examination. This is the more imperative, because in many cases this examination leads at once to the detection of a cause Avhich can be quickly removed ; and in almost all cases the surest way of stopping dangerous hemorrhage is by topical applications. This tendency of the vascular system to seek its outlet by the uterus is fortunate. If a vent were not found here, the risk of internal effu- sions Avould be enormously increased. And not even excepting the Schneiderian membrane, the uterine mucous membrane is the most under control. Climacteric uterine hemorrhage may avert an attack of apoplexy. The outlet of blood from the uterus may avert effusion from the ovary or its plexuses into the peritoneum. In this way Nature often proves herself a better physician than the modern practitioner Avho has abandoned the use of the lancet. It may be stated, as a general proposition, that whatever produces hyperaemia predisposes to hemorrhage. Thus inflammation takes high rank as a cause of hemorrhage. Inflammation involves a vis & froute, attracting blood to a part, and so filling the capillaries that they may burst. As in other parts of the body, hemorrhage from the uterus may be active or passive. In active hemorrhage rupture of vessels arises from the attraction of an inordinate quantity of blood into them. In passive 92 HEMORRHAGES. hemorrhage the escape arises not simply from distension from excess of blood, but generally also from the depraved quality of the blood, from the ill-nourished, Aveakened condition of the coats of the vessels, and the impeded return of the venous blood. In a Avoman who had suffered much from metrorrhagia, the blood contained only 2 parts in 1000 of globules, 1.8 of fibrin, 01 of solid materials of serum, and 015 of water. Hemorrhage from the uterus is sometimes called menorrhagia, some- times metrorrhagia, sometimes flooding. The term menorrhagia implies an excessive Aoav of the menstrual dis- charge. Although in fact the menstrual nisus or OA-ulation exerts a poAverful initiative and aggravating influence in the production of hemor- rhage, yet there often exists in association Avith apparent menorrhagia some local disease Avhich is more strictly the cause. That is, Avithout this local disease the ovarian stimulus Avould produce no more than the ordinary menstrual Aoav. But a mucous membrane once set bleeding easily goes on pouring off blood. It may be likened, and indeed often is so by patients, to the turning on of a tap. The vessels of the mucous membrane, Avhether they have burst or not, pour off blood Avith the greatest readiness ; and the stream being once directed to a given part Avhich affords ready outlet, a derivative action tOAvards this part is easily kept up. Metrorrhagia means very much the same thing as flooding. It is used to express a copious Aoav of blood not obviously associated Avith menstru- ation. Uterine hemorrhage is another synonym. As a general term it is free from the objection Avhich applies to " menorrhagia," as it expresses simply a fact independently of all theory of causation. In almost every case of uterine disease leading to hemorrhage, period- icity more or less regular is observed. There are commonly intervals of remission or cessation. Women observe that their courses last for tAvo or three weeks at a time, leaving only one or two Aveeks of freedom. The explanation is found in the periodical increase of vascular and nervous tension attending ovulation and the menstrual nisus. This periodicity is often preserved long after the natural menopause, when any disease, as cancer or tumor, continues to be the cause of hemorrhage. In the same Avay as patients of tuberculous diathesis are eager to persuade themselves that occasional hemoptysis is due to accidental insignificant causes, so Avomen in Avhom losses of blood, more or less periodical, continue or recur long after the menopause, are ready to believe that these losses are natu- ral or exaggerated menstrual discharges, and that they may be taken as evidence of protracted sexual life. To determine Avhat losses must be ascribed to natural menstruation and Avhat to pathological causes, we must seek to define the characters of natural menstruation. Any marked departure from these characters must then be made the subject of closer investigation, in order to sepa- rate or analyze the often combined physiological and pathological factors. The history of menstruation will be studied more methodically here- after. It will be enough to state here the leading features of healthy uncomplicated menstruation. Fluid blood, someAvhat glutinous, is dis- charged gradually, to the amount of two to four or six ounces, over a period of tAvo, three, or four days, at regular intervals of tAventy-eight HEMORRHAGES. 93 days, or nearly so, beginning at the age of tAvelve, thirteen, or fourteen, and lasting until forty five or forty-eight. There is a range of variation in all these characters, depending in some cases upon individual peculiarities. For this alloAvance must be made. But it is a safe and prudent clinical rule to suspect that any Avide departure from these characters depends upon some pathological compli- cation. Taking the characters of normal menstruation as our standard, Ave shall be justified in concluding that discharges of coagulated blood, discharges habitually exceeding four or six ounces, discharges continued for a week or more, leaving intervals of freedom shortened to three Aveeks or less, discharges occurring during the proper intervals between the periods, and discharges occurring long after the age of forty-five or forty- eight, especially if excessive or irregular as to periodicity, are of patho- logical significance. The same thing may be said of hemorrhagic dis- charges recurring in Avomen after the menopause ; that is, after a complete cessation of the ordinary menstrual Aoav for a year or more. It may be assumed, as a physiological fact, that the function of ovulation is not resumed after having been suspended at its natural term. The ovary has then undergone a process of involution or atrophy Avhich is incom- patible Avith the development of ova. Discharges of blood, then, after the menopause depend upon other causes than normal ovarian stimulus. The circumstances under Avhich hemorrhage appears Avill occasionally declare its character. For example, hemorrhage may immediately folloAV some accident, as sudden exertion, or coitus. In addition to the general or average standard deduced from the study of the natural history of mestruation, Ave shall often draAV the most trust- Avorthy conclusions from the particular study of the individual patient. She herself must often furnish her own standard of comparison. Any marked change from the habitual characters of the menstrual function will point to the necessity of inquiring into the cause. Hemorrhages may generally be considered abnormal which are irre- gular in their appearance, or excessive in duration or quantity, or Avhich obviously tell upon the system by inducing anaemia or debility. Another test of abnormality will often be found in the association of other symp- toms Avith the hemorrhage. Abnormal hemorrhage is not ahvays marked by excessive quantity. Blood may appear in streaks or small quantities mixed Avith the mucus of leucorrhoea. This will often be connected Avith breach of surface of the mucous membrane, as abrasion or ulceration ; often, however, Avith simple congestion or inflammation. Apart from pregnancy, a copious Aoav of blood will generally depend upon some organic alteration in the structure of the uterus, as hypertrophy of the body or cervix, the growth of tumors or polypi, or malignant disease. If copious hemorrhages occur in a Avoman past the child-bearing age, the probability is great that the cause is malignant disease; and tiiis probability rises if the cessation or diminution of the blood-flow is fol- lowed by a Avatery discharge stained Avith blood, offensive in odor, and showing debris of tissue in the form of shreds. It must be remembered, however, that the discharges attendant upon polypus and inversion of the uterus may present very similar characters. Many cases of polypus 94 HEMORRHAGES. have been seen in Avhich the history, subjective symptoms, and discharges so nearly resembled those of malignant disease that opinions Avere strong in favor of this vieAv until corrected by examination. And in this con- nection avc must not forget that copious hemorrhages occasionally occur in aged women in Avhom no disease Avhatever can be detected. These hemorrhages are similar in their significance to the Schneiderian epistaxis of the aged. If not excessive they may eA'en be beneficial. A clinical test of some value may be found in the folloAving facts: Immediately preceding and following ordinary menstruation some amount of leucorrlnea is not uncommon ; but during the intermenstrual times there is no discharge of any kind Avhen there is no local disease. When, therefore, the hemorrhage is not great—and the rule will apply Avith especial force in young and single Avomen—examination may be postponed. On the other hand, Avhenever there is continuous discharge, hemorrhagic or leucorrhoeal, the probability is great that there is local disease, and the indication for local examination is more distinct. A discharge of pure bright blood occurring suddenly after intercourse or exertion is presumptive of early malignant disease. In polypus the hemorrhage is usually folloAved by mucous or Avatery discharges. Abortion or labor at term is not seldom folloAved by hemorrhages more or less continuous or intermittent for many Aveeks or even months ; so long, indeed, that their dependence upon the puerperal changes may be lost sight of. Uterine hemorrhages may be classified as folloAvs :— A. Hemorrhages escaping externally, without alteration of the struc- ture of the uterus, as— 1. From primordial disease of the heart, liver, or lungs. 2. Exaggerations of the menstrual function, as in plethoric girls at the onset of menstrual life, and in Avomen at the menopause. 3. Throughout menstrual life, or beginning tOAvards its close, from ab- dominal or hepatic congestion or obstruction. In some, hemor- rhagic menstruation seems hereditary. 4. From emotion or physical shock. 5. Complementary of hemorrhages suppressed elsewhere. 0. From sudden suppression of the action of the skin. 7. From ovarian or mammary excitation. Excess of coitus, especially if at menstrual epoch. 8. The climacteric and senile hemorrhages. 9. From blood-disease ; as variola, scarlatina, typhoid, acute atrophy of the liver, leucocythemia, scurvy. In this class we see that the cause of hemorrhage may be distant from the uterus. Hypertrophy of the heart is a not uncommon cause of uterine hemorrhage, especially in pregnancy and childbed. The hypertrophy may be the result of antecedent disease, or of pregnancy. This is one cause Avhy the risk of hemorrhage increases with the number of preg- nancies. There is an increasing difficulty in the process of involution of the heart, and an increasing disposition to fall into fatty defeneration. A feeble, fatty heart also I haAre observed disposes to uterine hemorrhage. Imperfect involution of the uterus is common in the subjects of fatty heart. CLASSIFICATION OF. 95 Liver disease may act simply, or as complicating heart-disease. It acts especially in Avomen past forty, during the climacteric, and in those Avho indulge in drink. Lung-diseases, especially those marked by dyspnoea and hyperaemia or oedema, dispose to uterine congestion and hemorrhage. Uterine hemorrhage is sometimes observed in phthisis, although more commonly this disease induces amenorrhoea. It is not always safe or judicious to stop hemorrhage depending upon remote obstructions to the circulation hastily or completely. There can be no doubt that they act as useful evacuants and derivatives regulating tension. Menorrhagia has occasionally proved fatal at the onset of the menstrual function in girls. The late Mr. Obre" related the case of a virgin, aged fourteen years and three months, in Avhom the first menstruation set in violently, and could not be checked. Everything was found healthy, except the uterine mucous membrane, wdiich was softened and ecchymosed, and in some places detached from the muscular coat. This alteration Avas probably nothing more than the menstrual decidua infiltrated with blood. I saw, Avith Mr. Hodgson, of Brighton, a girl of fourteen to fifteen, who on several occasions lost blood so profusely under the sole influence of menstruation that her life Avas barely saved. Once the flooding was arrested after dilating the cervix and injecting perchloride of iron. All other remedies seemed ineffectual. B. The hemorrhages of pregnancy. 1. Abortion. 2. Detachment of placenta. 3. Extra-uterine gestation. 4. Retained placenta or clots—placental or fibrinous polypus. 5. Hydatidiform placenta. 0. Varix of the vulva or vagina. It must he borne in mind that in many cases of hemorrhage in preg- nant Avomen the blood does not come from the cavity of the uterus, but from the cervix uteri, which may be abraded and hypertrophied. The hyperaemia and the great tension of the vascular system of pregnancy easily issue in hemorrhage Avhere the mucous surface is unsound. Many of the conditions, Avith or Avithout alteration of structure, Avhich occur in non-pregnant Avomen may occur also in the pregnant; and preg- nancy may even increase the disposition to hemorrhage. C. Hemorrhages with alteration of structure. 1. Metritis proper. 2. Inflammation of the cervix uteri. 3. Engorgement of the body and cervix induced by stenosis or dis- placement or distortion of the uterus or other causes. 4. Hypertrophy of the cervix or of the body of the uterus, especially of the mucous membrane, as from syphilis. 5. Fungous granulations of the os, abrasions, ulcerations, especially if there is syphilitic complication. 6. Fibroid tumors. 7. Polypi of the uterine cavity, cervix, or os, or of the vagina. 96 HEMORRHAGES. 8. Cancer or sarcoma in the non-ulcerated state, and in the ulcerated state. 9. Wounds of the uterus, vagina, or vulva from accident, operations, leech-bites, abrasion or irritation as from ill-selected pessaries. 10. Voiding the blood of thrombi or of retro-uterine haematoccles. 11. Varicosity of the vessels of the labia, Avhich may burst. 12. Imperfect involution of the uterus and obstruction of circulation kept up by impeded mobility from peri-uterine effusions. 13. Hyperaemia induced by the uterus being Avithin the range of any abnormal vascular activity, as an extra-uterine gestation-cyst. Haematuria, or disease of the meatus urinarius, may possibly be mis- taken for hemorrhage of uterine origin. xVnd, on the other hand, it is necessary to bear in mind that apparent haematuria may be due to uterine disease. Thus I have knoAvn urine Avhich escaped by a fistula, the result of cancerous erosion, be retained for a time in the vagina, and being.dis- charged mixed with blood, taken for haematuria, the result of bladder or kidney disease. D. Hemorrhages poured out internally— 1. Retro-uterine haematocele, from blood from ovary, ovarian plexuses, or Fallopian tubes, under menstrual nisus. 2. Peri-uterine haematocele or thrombus, or effusion into the connections of the broad ligaments, or between the bladder and cervix uteri. Similar events may happen from abnormal ovarian congestions ; from rupture of ovarian tumors, or of vessels in their walls; from rupture of varices of the ovary or broad ligaments. Under ovarian menstrual stimulus blood may be poured out into the abdominal cavity, because there is some obstruction in the course of the genital canal. 3. The Fallopian tubes may be occluded; there may be stenosis or atresia of the uterus, vagina, or vulva ; there may be retroflexion of the uterus. In these cases blood may accumulate above the seat of the obstruction, and regurgitate into the abdomen. 4. There may also be retrograde hemorrhage from abortion. 5. Abdominal hemorrhage may arise from rupture of the sac of an extra-uterine gestation. External hemorrhage commonly precedes or attends the rupture and the internal effusion. 6. The gravid uterus may rupture, Avith or without violence, after the fourth month. This is more likely to happen Avhen the gestation is mural, or in one horn of a tAvo-horned uterus. In these cases there will probably be some external hemorrhage also. Lastly. Hemorrhage may take place in the abdominal cavity from various sources not connected Avith the genital organs or functions. A methodical analysis of the various causes of uterine hemorrhage for diagnostic purposes Avould carry us through almost the entire field of ovarian and uterine pathology. The morbid conditions Avhich are at- tended by hemorrhage will be described in their proper places. We can only now enumerate the conditions, physiological or pathological Avhich are associated Avith hemorrhage ; and seek to lay doAvn compendious principles of diagnosis and treatment. TREATMENT OF. 07 In practice avc are continually called upon to treat symptoms or con- sequences of disease. It is the merest folly or affectation of science in many cases, to pretend to remove a disease by at once attacking the pre- sumed cause. The folly is often as great to postpone treatment until Ave have discovered the cause. In no case is this pretension more absurd or more dangerous than in that of hemorrhage from a mucous membrane. Whilst Ave are Avaiting to discover the cause, the patient may bleed to death. If we apply ourselves at once to stop the hemorrhage, Ave may save her, and so gain the opportunity of attacking the cause. Treatment.—The first practical rule to observe Avhen in presence of a profuse flooding is to take off the pressure of gravitation, by placing the patient in a horizontal posture Avith the pelvis someAvhat elevated; to remove all articles of dress Avhich, by their pressure upon the chest or waist, impede the circulation ; to remove, as far as possible, all sources of excitement or emotion ; above all, to obtain absolute rest. Wounds or injuries Avhich Avould be of no consequence if the patient remained per- fectly quiet and recumbent, may, so rich is the vascularity and so free the intercommunication of the Aressels of the pelvis, lead to fatal hemor- rhage, if she assume the erect posture, or undertake any bodily exertion. The next practical rule is to endeavor to stop the bleeding as quickly as possible, Avithout Avaiting to inquire into its cause. This can rarely be done effectually or certainly Avithout the application of topical remedies. This necessarily implies a preliminary examination by the finger, hand, or speculum. We thus obtain incidentally useful, often adequate, diag- nostic information. For example, Ave find a polypoid tumor or a Avound. The hemorrhage may then be stopped by treatment ad hoc. We may find malignant disease ; and then all Ave can do is to stop the bleeding by the application of poAverful astringents or cauteries, as the perchlo- ride of iron, chromic acid, nitric acid, or the actual cautery. We may find a fibroid of the uterus; and the hemorrhage may be controlled by the same remedies, postponing treatment adapted to prevent the recur- rence of bleeding to a more favorable opportunity. We may find an ovum presenting at the os uteri, or some other form of hemorrhage connected with pregnancy. The treatment of these forms cannot be discussed in this work. I have described them carefully in my Lectures on Obstetric Operations. 'Where Ave find no cause that admits of immediate removal, we may still arrest the hemorrhage. The method Avhich is commonly the readiest, because it requires no special appliances, is plugging the vagina. Whilst waiting for these special appliances, it may be desirable to plug. This is done by pushing pieces of lint, linen, sponge, or silk handkerchiefs into the vagina. First of all, it is desirable to remove clots by the hand, and to wash out the vagina with cold Avater. Then holding the labia apart Avith the expanded fingers of one hand, the plugging materials lubricated in oil, or better with oil containing an eighth or tenth part of carbolic acid, or lard, are pushed in gradually by the fingers of the other hand, or by aid of the uterine sound, the handle of a tooth brush, or any other accessible instrument. The plugging must be firm,-packing the vagina pretty tightly. It is, however, generally preferable to plug by the5 aid of a speculum. The pieces are thus accurately packed, and the 7 98 HEMORRHAGES. speculum is gradually Avithdrawn. In this way uterine and vaginal hem- orrhage may frequently be checked for a Avhile, and time be gained for choice of more scientific remedies. But plugging is not free from objec- tions. In the first place, if the case be one of malignant disease, tight packing of the vagina is apt to break doAvn the fragile malignant tissue, to increase the bleeding, and favor ulceration. In the next place, after a Avhile the elastic and contractile vagina compresses the plug saturated with blood, which coagulating forms a compact ball Avhich no longer fills the canal; blood then easily Aoavs past; or being retained concealed, may give rise to a false security, and lead us to defer more effectual re- medies. In the third place, plugs, hy heating and distending the parts, are a source of irritation and distress ; they often in this Avay seem even to keep up hemorrhage. In the fourth place, if retained a feAV hours, the plugs, or the retained blood, decompose and become exceedingly foul. Fifthly, the compression of the urethra, or the metastatic irritation, often causes retention of urine. And e\Ten if the plug have arrested the hem- orrhage, this often breaks out again Avhen the plug is removed. In the majority of cases, therefore, it is Aviso to look upon plugging as a mere temporary expedient, to be adopted Avhilst preparing for more trustAvorthy means. I could give no rule of more general application or more valuable than this: In all cases of hemorrhage coming from the body of the uterus obtain and maintain free patency of the cervical caned. In cases of abortion, of the hemorrhages of gestation, of intra-uterine polypi, or fibroids, of hypertrophy of the mucous membrane, of malig- nant disease of the interior of the uterus, to obtain free external escape for the hemorrhage and free access to the source, in order to control the bleeding, is the first necessity. We might, it is true, in almost every case introduce a catheter or tube to carry a styptic injection into the uterus. But this proceeding, invaluable if properly carried out, may be useless or even dangerous if resorted to Avhilst the cervix uteri is con- tracted. Blood retained in the cavity of the uterus forms clots Avhich, under the spasmodic contractions they excite, become compressed into firm masses of fibrin by the squeezing out of the serum. These coagula cannot make their Avay through the constricted cervical canal; they may even become closely adherent to the Avails of the uterus, forming the "fibrinous polypi." Their presence in any form is a source of irritation and suffering: by causing alternate contraction and dilatation of the uterus they keep up hemorrhage ; and, occupying the uterus, injections throAvn into the cavity are lost upon the clots instead of constringino- the bleeding surface. Moreover, as I shall shoAv hereafter, Avherever there has long existed a narrowing of the cervical canal, there will be produced a dilatation of the genital tract above the stenosis. Hence, there will be serious danger of injected fluids being driven along the dilated Fallopian tubes into the abdominal cavity. As a consequence of the same condi- tion, there is also serious danger of the blood Avhich gathers in the uterine cavity and tubes being driven in a retrograde course into the peritoneum. This is one way in Avhich retro-uterine haematocele is produced. It is the Avay Avhich may most successfully be guarded by securino- a free out- let by the cervical canal and vagina. HAEMOSTATICS. 99 In the case of retained ova, membranes or placenta, or clots, the first indication is usually to remove these. To do this it is often necessary to pass in one or tAvo fingers to break them up and to bring them away. In the case of intra-uterine polypi, there must be room to introduce an instrument, as Avell as a guiding finger. In the case of an unhealthy condition of the uterine mucous membrane, free passage is avanted for the application of haemostatics. These are, I believe, most useful if applied in a tolerably concentrated form. To do this, it is preferable to introduce them soaked in cotton-Avool twisted on a roughened platinum probe. If a SAvab cannot be introduced, and it may be difficult to do it, unless the cervix be widely open, because the charged swab as it touches the cervix in its passage contracts the canal, it is then necessary to resort to injection, or the introduction of styptics in the solid form. The best Avay of applying styptics I have found to be by inserting small bits of sponge in a tube made on the model of my uterine ointment-positor, and saturating this with the styptic. The end of the tube is then carried into the cavity of the uterus, Avhen by pressing upon the piston, the fluid is squeezed out in drops upon the lining membrane of the uterus. If this plan be inefficient, we must then inject a larger quantity through the tube by help of a syringe. If any further reason were Avanted to recommend the preliminary dila- tation of the cervix uteri, it Avould be this: It is in many cases enough to arrest the bleeding. And, if not of itself successful, it at any rate opens the road by which Ave can pursue a treatment that Avill succeed. What are the means of dilating the cervix? These are various, and the choice will depend upon the nature of the case. If it be one of abor- tion, of intra-uterine polypus or tumor, or of morbid condition of the mucous membrane, it Avill generally be easy to place one or more lami- naria-tents or sponge-tents, Avhich in the course of a few hours will effect the desired dilatation, and, Avhilst acting, will probably check the bleeding. If the case be metrorrhagia from fibroid tumor, or menstruation ob- structed by stenosis of the os externum uteri, it may be necessary to dilate the part by incision. This operation Avill frequently not only pre- pare the Avay for relief from the immediate danger, but it is an essential condition of prevention in the future. When Ave have stopped or moderated the bleeding, our next inquiry will be, how are Ave to prevent its recurrence ? This Avill lead to the study of the causes immediate and remote of the hemorrhage, and of the means of alleviating or removing those causes. I cannot in this place further anticipate the history of the conditions associated with hemor- rhage. They will be systematically discussed under their appropriate heads. Active hemorrhage is characterized by increased vascular tension, by rapid determination of blood to the pelvic organs, by heat, throbbing, perhaps pruritus, pain, sense of fulness or Aveight, and bearing doAvn of the uterus. If examination be made by touch, the vagina is felt hot; perhaps the vaginal pulse is perceived ; there is increased softness of the vaginal portion; and tenderness of the uterus when pressure is made upon its Avails through the vaginal roof. The general system evinces the perturbation caused by the local molimen. There is a state of febrility, 100 HEMORRHAGES. of vertigo, of SAvimming of the eyes, the eyes are suffused, and nervous symptoms of an hysterical kind are frequent. Passive hemorrhage is not marked by the signs of fluxion or active determination. There is not the same local hyperemia as in the active form ; and it is not preceded by the same heat, vascular tension, or at- tended by the vaginal pulsation. Having once occurred, passive hemor- rhage tends to establish itself by degrading the quality of the blood, and by altering the tissues, impairing their tonicity, and rendering them more easily permeable. The blood discharged often becomes more serous in character. It is in this form that arsenic, strychnine, and iron are especially serviceable. The mode of dealing Avith hemorrhage is often too empirical. There are four principles that give a rational basis of treatment, and which may, in most cases, help to guide our proceedings. 1. Bearing in mind the great physiological factor that is almost ahvays in play in the hemorrhages of women, namely, the general vascular ten- sion, the increased action and irritability of the heart, associated Avith increased nervous tension, and the special determination of blood to the pelvic organs excited by ovulation, Ave must adjust measures to moderate this peculiar excitement. This is the principle that is most commonly neglected. The most useful agents in this connection are: digitalis, aconite, bromide of ammonium or potassium, sometimes opium, ipecacu- anha, chloral, salines, as acetate of ammonia, nitrate of potash. Cold or a reduced temperature will often be useful. In this association the avoidance of emotion is of great importance. The influence of emotion in turning the blood-tide to the uterus is most remarkable. And Avhen Avith this unusual afflux the nerve-force is di- verted, used-up in other Avays, the vessels having lost their restraining poAver easily give Avay ; the flood-gates are opened. The reflex or diastaltic function, Avhich is invoked Avith such pre-emi- nent effect in the floodings Avhich attend parturition, must not be lost sight of in the hemorrhage of the non-pregnant. The local application of cold by means of ice or cold-Avater is often useful. Ice in the vagina, or cold- Avater injections, should generally be tried before Ave resort to local styp- tics. Cold may be applied to the spine. But the too common Avay of applying ice and cold-Avater to the abdomen or vulva is open to serious objections. It is rarely efficacious. It is apt to depress the system. It often lays the foundation of peritonitis or other inflammations. Emmet extols hot-Avater injections. 2. The undue current or tide setting in tOAvards the pelvic organs may be further controlled by agents that effect a diversion or attraction to other parts. Of these perhaps the most effectual is one hardly likely to be often revived. It is the small bleeding from the arm. Cupping from the nucha or loins might ansAver the purpose. Ligatures round the limbs, the object of Avhich is to retain a portion of the circulating fluid in the extremities, have been used. I should not be disposed to trust to this method for more than a momentary purpose. Position is important. We may call gravity to our aid instead of letting it work against us, by keeping the pelvis at a higher level than the rest of the body. Amongst the most useful revulsive measures is purgation. Saline purgatives espe- AFTER-TREATMENT. 101 daily, by diminishing the volume of the circulating mass, and by loAver- ing the heart's action, operate Avith great advantage. 3. Certain agents taken internally appear to possess a special poAver, by modifying the constitution of the blood, or by constringing the coats of the vessels, or by promoting contraction of the uterine muscular fibre, in checking the escape of blood. Of these the most useful are turpen- tine, which may be SAvalloAved in capsules: ergot, Avhich may be given in the form of fluid extract or poAvder, or injected under the skin, or ergotine ; tincture of hamamelys, in five or ten drop doses every three or four hours ; cinchona or quinia, strychnia or nux vomica, sulphuric or phosphoric acid, tannic or gallic acid, acetate of lead, the Vinca major, Indian hemp, ipecacuanha. Various combinations of these often ansAver better than any one in the simple form. 4. To secure the equilibrium of the circulatory apparatus, care should be taken to put the stomach, liver, and kidneys in the best Avorking order. For this purpose alteratives, aperients, and salines are often essential; and Avhere there is any gouty tendency, indicated by lithiasis, " rheu- matic pains," or arthritic SAvellings, lithia and colchicum will be useful. And Avhere there is no imperative contra-indication, exercise in the open air will be an effective adjuvant to, or substitute for, the Materia Medica. But all these means may fail; or before they have time to act the patient's condition may be desperate. We must then rely upon local styptics. The bleeding area must be staunched by direct action. Of these the best are: perchloride or persulphate of iron, nitric acid, styptic colloid, iodine ; the actual cautery, the most convenient mode of supply- ing Avhich is by the galvanic battery, or by Paquelin's thermo-cautery. After-treatment.—Hemorrhage, especially the active form, is folloAved by a stage of reaction, of erethism, Avhich has been, not inaptly, called hemorrhagic fever. The pulse is quickened, the skin is Avarm and dry, there is intense beating headache, restlessness, hyperaesthesia manifested in general irritability, and morbid sensitiveness to light and sound. In this condition it is a serious clinical error to administer iron. It may be theoretically true that the vascular system Avants iron ; but the effect of giving it is to add fuel to the feArer and excitement, to parch the tongue and mucous membranes generally, to check secretions, to increase head- ache and restlessness, to disturb digestion and nutrition. The system may Avant iron, but it Avants saline solutions more ; and it Avants these first. Saline solutions serve better than anything else to replenish the exhausted circulating fluid. The vessels seem to crave in the first in- stance for a sufficient volume of fluid as a necessary condition for the efficient dynamic action of the circulating apparatus. It is a fact deter- mined by the observations of Dr. Little and Mr. L. S. Little on cholera patients^ that the injection of saline solutions of about the specific gravity of the blood will revive persons on the point of sinking. I can affirm, from large experience, that the exhibition of salines after hemorrhages is folloAved by the best effects. They exert a marked influence in subdu- ing vascular excitement; they allay the fever, calm nervous irritability, improve the secretions, and prepare the Avay for iron and other tonics, which at a later stage find useful application. The best form of saline 102 NERVOUS PHENOMENA. is the acetate of ammonia, freshly prepared. To this may usefully be added a sedative, as Battley's solution, and sometimes digitalis or aconite. At a later stage, hamamelys, ergot, quinine, mineral acids, and bark, in decoction, or the liquor cinchonae may be given ; and later still iron. The best preparations arc the citrate, acetate, or chloroxide of iron, given in an effervescent form, or dialyzed iron. The doses at first should be small, so as to feel the Avay. Strict rest must be maintained, so as to economize to the utmost the feeble poAvers of the system. To promote this, sedatives to procure sleep are often of signal sendee. If opium can be borne, as it often is, it may be given Avith the saline, or separately, in the solid form, as the compound opium pill, in 5-grain doses, or as Dover's poAvder-, in 10-grain doses. If it is not borne, Ave have a pre- cious resource in chloral, Avhich may be given in scruple doses. Since active hemorrhage may induce a severe degree of anaemia, Avith conse- quent tendency to thrombosis in the iliac, femoral, or subclavian veins, great care is necessary to avoid exposure to cold or other disturbing causes. Alcohol in the form of Avine, or spirits, will at times act as an efficient sedative, as Avell as a stimulant. But stimulation, or " keeping the patient up," is often overdone. Stimulants must be given Avatchfully, and Avith discretion. Taken largely, they disturb the balance of the stomach, provoke vomiting, excite the circulation unduly, and may even maintain or cause a return of the hemorrhage. Light, easily assimilable nourishment should be given in small quan- tities, at short intervals. THE SIGNIFICANCE OF NERVOUS PHENOMENA, INCLUDING THE VARIETIES OF PAIN. It may be stated, as a general laAv, that pain referred to a particular part or organ is presumptive evidence of disorder, structural or func- tional, of that part or organ. Of course, in some cases, the disorder is only secondary or consequential upon disorder in some other part. Thus, one form of headache is the consequence of disordered stomach, and is cured by correcting the condition of the digestive organs. Pain in one part may be the reflex response to distress in another part. Of this Ave see repeated examples in the history of ovarian and uterine disease. Pain in the dorsal, lumbar, and sacral parts of the spine is a frequent phe- nomenon in connection with uterine disease. It is often the predominant symptom. The spinal pain may be so severe and enduring that it attracts the chief attention; and, unless the rule of interrogating all the func- tions be carefully folloAved, it is easy to fall into the snare of regarding the case as one of spinal irritation, vertebral disease, or simply hysteria. If this error be committed the patient will probably be doomed to a long course of mechanical or medicinal treatment, under Avhich the general health may break doAvn, the original disease pursuing its course all the while. Attempts well deserving consideration have been made by observing the seat of the pains complained of, and interpreting by the knoAvledge of the sources and distribution of the nerves supplying the pelvic organs, SIGNIFICANCE OF PAIN. 103 to diagnose with something like precision the nature and seat of the pelvic disease. There are certain facts Avhich are so frequent in their recurrence and association as to lend Aveight to this method of analysis. But, like all other methods of clinical research conducted upon one line, it is exceed- ingly apt to lead astray. It is useful as a means, but not as the only means. We Avant help from every quarter. Pain, in association with ovarian and uterine disease, is referred, first, to the region of the ovary or uterus itself; secondly, chiefly to the sacral, or lumbar, or lumbo-sacral region ; thirdly, to the hips, thighs, and doAvn the legs. In many cases pains may be said to radiate from the pelvis as a centre in various directions, as to the back, abdomen, and thighs. Pain in an organ, arising during or aggravated by the performance of its functions, is especially presumptive evidence of structural disorder of that organ. This is true of pain during menstruation, and of pain in the performance of the sexual act. This part of the subject will be dis- cussed more particularly under the heads "Dysmenorrhoea" and " Dys- pareunia." Pain described as in one or other inguinal region or rather deeper, is often referred to the ovary, and is taken as evidence of ovaritis, or of OA'arian irritation. But in the great majority of instances this presumed ovarian pain is the signal of sub-acute or chronic inflammation of the neck of the uterus. This has been insisted upon by Dr. Henry Bennet. I find this pain so frequent in connection with disease of the neck of the uterus, there being no perceptible concurrent disease of the ovary, that I hesitate in every case to regard it as due to ovarian disease until I have examined by touch the ovaries themselves, as Avell as the uterus. If under touch Ave make out that the ovaries are SAvollen, and exhibit in- creased tenderness, Ave get the required confirmation as to the implication of these organs. I have several times obtained experimental proof of pain in the ovary being due to uterine disease. Touching the os uteri has caused pain referred to the region of the ovary. By those Avho do not examine at all either uterus or vagina, except by external palpation, this ovarian pain is often called " ovarian irritation," or " ovaritis ;" and to subdue it leeches, blisters, or irritating ointments are resorted to. This so-called " ovarian irritation," hoAvever, does not deserve to be ranked as a morbid entity demanding special treatment. There may indeed be irritation of the ovary; but then there must be something to irritate it. It is this something Ave should search for. xVnd this something, in the majority of cases, has its seat not in the ovary itself, but in the uterus. The pain is more frequent in the left ovary than in the right. Pain referred to the uterus itself, intensified under touch, is often attributed to "irritable uterus," and this vague expression is sometimes accepted as a satisfactory diagnosis. Noav, as in the case of kk ovarian irritation," logic and clinical observation compel to the con- clusion that since the uterus sIioavs signs of being irritated, there is an irritating cause, Avhich it is our business to find out. Another expression Avhich is often adopted as a conventional substitute for precise diagnosis is " neuralgia of the uterus," or " hysteralgia." These terms really mean nothing more than " pain in the uterus." 104 NEURALGIA ; HYSTERIA. The same remark applies to " mastodynia." " the irritable breast, or "neuralgia of the breast." Pain in the breast may. indeed, be the ex- pression of disease in that organ, and therefore justify direct examina- tion. But pain in the breast is a frequent attendant upon dysmenorrhoea. It may be simply reflex or sympathetic, pointing to functional or organic disease of the uterus or ovaries. And Avhere examination detects no hardness or SAvelling in the breast, pain in it, "neuralgia," may be taken as an indication for exploring the pelvic organs. If, then, Ave consent to retain the terms " irritable uterus" and "hys- teralgia," " mastodynia," it must be because they have, by long prescrip- tion, established for themselves a kind of footing in nosology ; and not because they embody pathological entities. Neuralgia of distant parts, as of the face or breast, is often, if not strictly symptomatic, certainly consequent upon uterine and ovarian dis- ease. This dependence is often quite overlooked by physicians Avho devote special attention to neuropathy. Neuralgia, studied apart from its antecedents, is apt to assume much of the importance attached to an idiopathic or essential disease ; and being treated accordingly, it persists rebellious against all the artillery of the Pharmacopoeia. The folloAving is the chronological history of a large proportion of the cases of neural- gia in Avomen. Uterine disease, attended by hemorrhagic and leucor- rhoeal discharges, saps the general strength, degrades the quality of the blood ; then all the organs, especially those concerned in digestion and assimilation, being badly nourished, perform their functions imperfectly. Concurrently Avith this general impairment of nutrition, the nervous cen- tres suffer ; these centres become extremely susceptible to the exhausting influence of pain—and pain is constantly proceeding from the uterine disease. Thus the tone of the nervous centres is constantly being Avorn doAvn, and preparation is made for every kind of irregular or aberrant nervous action. The nerves of the face, breast, and limbs become keenly sensitive to external impressions of cold, and to Avhat are called the sym- pathetic impressions brought from internal organs. Neuralgia is the culmination of all this. To cure it Ave cannot depend upon quinine, mor- phia, actea, alteratives, the hot iron, or division of the nerve ; avc must trace the disorder back to its source, and by curing the uterine disease, arrest the primary cause of the blood-degradation and nervous wear and tear. This done, constitutional correctives and tonics will act beneficially, and Ave may reasonably expect the neuralgia to disappear. The history of a vast number of cases of " hysteria" is exactly the same. In short, hysteria is commonly one phase of aberrant nervous action, the result of nervous exhaustion from disease and mal-nutrition. Pains referred to the uterus, and described as " expulsive," " bearing- doAvn," likened to colic, generally indicate retention of fluid, or solid matter, in the uterine cavity. This explains the chief part of the pain of dysmenorrhoea, though, no doubt, the ovaries, by their direct partici- pation in the trouble of menstruation, and by the reflected distress from the uterus, contribute to the suffering. " Bearing-doAvn pains" are also significant of uterine prolapsus, or retroversion. Pain referred to the uterine region, causing the patient to bend the body fonvard, is often found in connection Avith sub-acute metritis and PAIN, SIGNIFICANCE OF. 105 sub-involution of the uterus after labor. Pain in the lumbo-sacral region of a dull Avearing character, attended Avith more or less impairment of the use of the legs, is frequently associated Avith retroversion and retro- flexion of the uterus. The presumption that this displacement exists Avill be increased, if there is dyschezia and habitual constipation. The pain is probably not due so much to direct pressure of the body of the uterus, even Avhen enlarged, upon the sacral nerves, as upon the in- direct pressure occasioned by the accumulation of hardened faeces in the rectum. Pains extending doAvn the legs, especially if attended Avith sensation of numbness and a degree of motor paralysis, is presumptive evidence of pressure upon the sacral plexus and other nerves in the pelvis. This ](resumption acquires greater force if there be attendant oedema of the feet and legs, indicating pressure upon the pelvic and abdominal veins. Pain and irritability of the bladder frequently attend anteversion of the uterus, or pressure from the uterus enlarged by fibroid, or the ad- vance of cancer. It may also, of course, be the consequence of disease of the bladder or urethra. Pains in either side of the pelvis, described as of a dragging character, and attended often Avith lumbo-sacral aching, is a frequent consequence of prolapsus. It is, in all probability, due to stretching of the uterine ligaments. A pain, described as "throbbing," and attended Avith a sense of ful- ness, often precedes the onset of the menstrual Aoav, especially in Avomen Avho, from the presence of tumors or other disease in the uterus, are sub- ject to metrorrhagia. A valuable presumptive test of the dependence of pain upon local dis- eases, especially inAammation or displacement, is the production or aggra- vation of it, after exertion and fatigue. In some cases pain is relieved by Avalking or by the erect posture, and is aggravated by the sitting or recumbent postures. Where there is uterine disease, attended by inAammatory action or enlargement, the pain is usually aggravated in a remarkable degree by the kneeling posture. Various reflex pains in distant parts are often associated Avith uterine and ovarian disease. The dorsal, lumbar, and sacral pains have been already referred to. Other instances are the occipital headache, the left hypochondriac stitch or pain, and pains in the breasts. Pain, described as "pricking," "stabbing," "shooting," usually per- sistent, is commonly considered to be pathognomonic of cancer. In the advanced stages of malignant disease pain of this kind is not unusual. But it is by no means constant. Its presence cannot be accepted as proof of malignant disease, nor can its absence be accepted as proof of the ab- sence of malignant disease. Physical examination alone can solve this question. Pain must be taken as an indication for examining. Pains in one side of the body, attended Avith sensations of numbness and pricking, or tingling in the arm, and especially of the leg of the affected side, constituting Avhat might be called pseudo-paralysis, are not uncommon at the climacteric age. They do not indicate ovarian or uterine disease, although the tAvo conditions are frequently associated. 100 NERVOUS PHENOMENA. THE SIGNIFICANCE OF NEURALGIA : SPINAL IRRITATION ; PARAPLEGIA ; OTHER FORMS OF PARALYSIS ; MENTAL DISORDER ; VOMITING; CONVUL- SION ; EPILEPSY ; HYSTERIA. Apart from pain, the significance of other nervous phenomena in rela- tion to intra-pelvic disorder is often very great. These phenomena may be classed in this connection under the following heads. Signs of de- pression and exhaustion, mental or bodily, or commonly both, the result of continuing or recurrent pain, and changes of nutrition ; nervous dis- order, the evidence of toxaemia, resulting from the absorption or reten- tion of noxious matter in the blood: sympathetic phenomena; reflex phenomena, mostly of a convulsive character, as vomiting, epilepsy, hys- teria ; central, as cerebral or spinal; irregular or aberrant nervous mani- festations. The nervous phenomena, more especially associated with particular intra-pelvic conditions, will be described in their proper con- nections. In this place it Avill, hoAvever, be useful to point out concisely the chief indications furnished by the nervous accompaniments. The significance of Neuralgia and Sjjinal Irritation has already been discussed. Dr. Little, wdio has studied " spinal disease" in the broad clinical spirit, recognizes a class of cases in which the spinal affection is distinctly traced to disease of the uterus or of the rectum. Paraplegia.—In some peculiar cases spinal irritation or Aveakness of the spine is associated Avith such loss of power over both legs that Avalk- ing is all but impossible. Such a condition is chiefly observed after labor. We may conjecture that the first condition is one of shock or exhaustion of the nervous force attendant upon the labor; and undoubt- edly there are cases where we fail to detect such persistent intra-pelvic disorder as could account for the nervous depression. But in the majority of cases, imperfect involution, catarrh, hemorrhages, and, most frequent of all, retroversion or retroflexion of the uterus will be found. When these are relieved, it is sometimes astonishing to see hoAV quickly the paraplegia disappears. The reflex nervous phenomena, as vomiting, convulsion, are amongst the most striking attendants upon some cases of ovario-uterine disease. The vomiting of early pregnancy, the eclampsia associated Avith albumi- nuria of advanced pregnancy, link the physiology to the pathology of menstruation. The conditions of menstruation present close analogy to those of pregnancy. They throw a strong light upon each other. When vomiting recurs every morning, dating from suspension of menstruation, the first conjecture is of course in favor of pregnancy. The diagnosis of pregnancy will be discussed in a subsequent chapter. Here, it may be pointed out, that in many cases of dysmenorrhoea, vomiting is a reflex symptom; that in other cases it is a sign of uterine disease or displace- ment. Sometimes vomiting is relieved by simply giving the uterus the support afforded by a Hodge-pessary. In other cases vomiting is the outcome of nervous exhaustion and degraded blood. Epilepsy in numerous instances is associated with menstrual difficulty. When this dire disease occurs in young Avomen, and especially if it has resisted ordinary means, the physical state of the ovaries and uterus DYSPAREUNIA. 107 should be iiwestigated. The key to many nervous affections, more espe- cially those of a convulsive character, will be found in the exalted nervous and vascular tension attending the menstrual nisus as Avell as pregnancy. It is a factor that must never be left out of account. I have discussed this with some care in my Lumleian Lectures.1 A remarkable feature of the neurotic affections of Avomen is their mimetic aspect. This is most remarkable in the nervous phenomena of the climacteric stage of life. The term " pseudo" has been attached to some of the simulated conditions in order to express this, and also no doubt to evade the difficulty of giving a more accurate description. Paralysis in all its forms is often simulated, and sometimes so closely as to throw the physician off the true scent. Mental aberrations are com- mon ; and not seldom the patient dreads the issue in insanity. Some- times, indeed, the transition is realized ; the border-line is passed. But I am entitled to affirm from observation that a due and timely apprecia- tion of the underlying associated conditions of the ovario-uterine system will often enable us to control these nervous aberrations Avithin the limits of health ; and in not a few cases to bring the subjects back within the line of reason which had been overstepped. A similar argument will apply to that condition, or indefinite class of conditions, to Avhich the vague term of hysteria is applied. Much more might be said upon this theme. But these sections may be fitly closed with the tAvo folloAving clinical rules: 1. We must care- fully bear in mind that any of the described nervous phenomena may depend upon or exist in association with disorders of the cerebro-spinal, thoracic, or abdominal organs. 2. That Avhere they depend upon, or are influenced by, disorders of the ovaries and uterus, special symptoms of distress in these organs Avill rarely be wanting to furnish indications for local exploration, and to verify or to exclude this complication. THE SIGNIFICANCE OF "DYSPAREUNIA," INCLUDING " VAGINISMUS." I have ventured to introduce the term " dyspareunia" as a convenient and concise description of an affection which is often the immediate occa- sion of great physical and mental suffering, Avhich is apt to entail the most serious disruptions of conjugal relations, and Avhich is almost ahvays a symptom of some morbid condition that admits of more or less success- ful treatment. There is no disturbance of function, no subjective symptom Avhich more imparatively dictates resort to physical exploration than difficulty or pain in the performance of the sexual function. In the great majority of cases dyspareunia depends upon some local imperfection or disease. In many instances it is not safe to neglect the Avarning Avhich this symptom gives of something Avrong; in many this neglect condemns the subject to the keenest agony—agony not the less hard to bear because affection or other motives too often induce her to conceal it. 1 "On the Convulsive Diseases of Women," delivered before the Royal College of Physicians, 1S75. 108 DYSPAREUNIA. The causes of dyspareunia may be classed under the congenital and the acquired. Lender congenital conditions are ranged absence or imperfection of the vagina or vulva; a dense unyielding hymen ; too short a vagina, the uterus being set too Ioav in the pelvis, so that the os uteri is Avithin an inch or a little more of the vulva ; undue length of the vaginal portion, or its projection as a conical mass into the vagina. I amputated by the galvano-caustic Avire, a redundant vaginal portion, the cause of intolera- ble dyspareunia, Avith complete relief. In the case of the uterus being set too Ioav in the pelvis, the vagina being short and not easily distensi- ble, dyspareunia results from the uterus not being able to rise or retreat under the impact of the male organ. Hence congestion and inflammation not uncommonly arise. In many cases a compensatory condition is es- tablished in time, by the gradual dilatation of the retro-cervical vaginal roof. This is developed into a considerable pouch. Although the dys- pareunia may gradually subside, the subjects often remain sterile. I have met Avith a form of dyspareunia Avhich, in one case, gave rise to the question of seeking for a divorce. The pubic symphysis Avas un- usually deep and continued so far back that the vulvar fissure Avas carried far behind the normal seat. In this case, as in many others Avhere inef- fectual or unsatisfactory attempts at intercourse have been continued'for a long time, an extreme degree of mental irritability and local hyperaes- thesia had been induced. Acquired Causes of Dyspareunia.—-Amongst these are found: Con- traction or atresia of the vulva and vagina, the result of disease, injury, or cicatricial processes. Cases belonging to this order will be discussed under "Atresia." Almost all the inflammatory affections of the pelvic organs entail dys- pareunia. Congestion and inflammation are commonly attended Avith in- crease of nervous irritability. Structures Avhich, in the ordinary state, e\rince little sensibility become, Avhen congested or inflamed, intensely painful. This is markedly the case Avith the vaginal portion. Proof of this is obtained Avhen the finger presses upon it; by the speculum when the blades are being expanded, and the ends chafe against the inflamed vaginal portion; when in adapting a Hodge pessary the posterior limb is being pushed back across the os; in some cases, Avhen the patient is at stool the solid motion pressing upon the tender os. In all these cases pain is complained of; it is not surprising that coitus should also be painful. When the body of the uterus is enlarged from hyperaemia or conges- tion, especially Avhen complicated Avith retroflexion, dyspareunia is°an almost certain result. In this case on making an examination, touching the vaginal portion may not evoke pain; but pressure by the finger upon the body of the uterus, through the roof of the vagina or through the rectum, is almost sure to do it. Inflammation or congestion of one or other ovary is attended by the same result. A frequent cause of dyspareunia is colpitis or inflammation of the vagina, no matter to what the inflammation may be due. Thus inflam- VAGINISMUS. 109 mation from blenorrhagia, or from injuries during labor, will frequently render sexual relations intolerable. When colpitis exists there is often entailed a spasmodic contraction of the vagina, Avhich greatly intensifies the suffering. This condition, for Avhich Dr. Marion Sims proposed the name " Vaginismus," is exceedingly distressing. It may be likened to colitis or dysentery. The inflammation excites spasmodic contractions of the muscular coat, and especially of the vulvar sphincter. The friction of the inflamed mucous surfaces against each other under these morbid contractions is the immediate source of pain, and it increases the inflammation and spasm. The cure of dyspareunia here depends upon the cure of the colpitis. This is to be accomplished by "rest" in the most comprehensive sense of the Avord. It is mainly by its efficacy in securing rest from the spas- modic contractions of the muscular coat, that Dr. Marion Sims's and my instruments for keeping the Avails of the vagina apart, act so beneficially. Tavo or three weeks' use of one of these instruments during the daytime, and lead lotions on removing it at night, will often effect a cure. Pelvic cellulitis and peritonitis, Avhether in the acute or chronic stage, almost constantly entail dyspareunia. This is due not only to the in- creased sensibility attendant upon inflammation, but also upon the loss of mobility of the uterus. Whene\rer the uterus is fixed at a definite Ioav level in the pelvis, unable to retreat before the propulsion of the male organ, dyspareunia is an almost inevitable consequence. Hence this condition is frequently observed in cancer of the uterus, and in fibroid tumors affecting the loAver segment. Various conditions of the vulva are peculiarly apt to cause dyspareu- nia. This is not surprising Avhen it is remembered that the structures of this part are richly supplied Avith sensitive nerves, and that they have to encounter the chief force and irritation. All the varieties of inflamma- tion of this part necessarily expose the patient to this form of suffering. I have knoAvn it depend upon vascular excrescence of the meatus urinarius, and upon fissure at the fourchette, and removed Avhen these affections Avere cured. It attends pruritus and the follicular inflammation. But the most severe distress is often produced Avhen the entire circum- ference of the vulva is involved in a peculiar inflammatory process which may in many cases be traced to violent or unskilful attempts at inter- course. In some of these cases there may be observed a dark-red angry-looking ring of inflammation around the orifice, sometimes even abrasions or slight fissures Avhich easily bleed on touch, and generally the carunculae inyrti- formes present the appearance of SAYollen inflamed excrescences. This local inflammation entails extreme sensitiveness or hyperaesthesia; the slightest touch is intolerable; the patient shrinks at the very thought of examination, and actual touch excites uncontrollable spasmodic constric- tion of the part. This constitutes one of the conditions which may be included under the general term "Vaginismus," although the vagina it- self immediately beyond the vulva may be quite free from disease. In some cases of this kind it is almost certain that there has never been complete intercourse. Indeed, where this condition is developed at the 110 VAGINISMUS. outset of married life, the dyspareunia and spasmodic contraction are so acute that complete intercourse is all but impossible. The distress, so long as the patient continues exposed to attempts at intercourse, is gene- rally aggravated by time ; health breaks doAvn under the nervous exhaus- tion produced by repeated suffering, and Avhat may be called the disap- pointment of Nature under an unfulfilled function. In some cases the irritability of the nervous centres become so great, the sensitiveness of the peripheral nerves at the vulva so acute, and reflex action thereby so intensified, that the attempt at intercourse will induce convulsion, or be followed by syncope. Exaggerated emotions, the conflict between affec- tion and the dread of pain, may induce similar results. Sometimes vaginismus is due to the presence of small fissures or sores on the edge of the perineum or vulva. These cases are analogous to those of spasmodic contraction of the anus from similar causes. Vagi- nismus and dyspareunia may also be occasioned by disease of the rectum, as fistula, or fissure, or inflamed piles. Indeed these reflected conse- quences are sometimes so much more extensive than is the direct distress at the seat of mischief, that the true origin of the pain is apt to be over- looked. In some cases no lesion of surface, no inflammation can be discovered; and Ave are driven to the conclusion that the spasmodic irritability is due to hysteria or simple hyperaesthesia, or to emotional influences. The cure of this painful affection obviously depends mainly upon a period of rest, that is, suspension of all attempts to reneAV sexual inter- course. The exhausted nervous system must have time and opportunity to recruit, the general health must be restored, and the local source of irritation must be relieved. To accomplish the last indication various measures are useful. In a first order of cases of minor severity, such as are not unfrequent during the first feAv days of married life, a few days' rest, fomentations Avith Avarm Avater, or tepid hip-baths, and the use of lotions or injections of subacetate of lead may be sufficient. In a second order of cases of longer standing than the first, and in- cluding some cases Avhere the difficulty has arisen after complete inter- course, and even after labor, the remedies mentioned may be most usefully supplemented by Avearing for several hours during the day Dr. Marion * Sims's dilator, or my " vaginal rest." The action of these contrivances is to keep the irritable surfaces apart, and thus, by avoiding the irritation of friction, to alloAV the inflammation to subside. They also further act beneficially by distending the vulvar orifice, stretching the muscular sphincter, thus wearing out spasmodic contraction, and using the parts to bear the presence of a foreign body. Vaginal pessaries, containing acetate of lead, belladonna, bismuth, borax, or zinc, and made up with glycerine, are useful adjuncts. In the third and more serious order of cases surgical intervention will commonly be required. After subduing the acute inflammation by rest, fomentations, and lead lotions, it may be necessary, if the orifice of the vulva is found unusually small, to enlarge it by making tAvo or three in- cisions through the skin on either side of the fourchette. The subcutane- ous division of some of the fibres of the sphincter vaginae has been recommended. This, if adopted, could be done by passing a tenotomy VAGINISMUS. Ill knife under the mucous membrane, just Avhere it merges into skin at the posterior edge of the vulva, near the perineum, and Avhen the knife has penetrated flatwise about an inch by turning the edge on and cutting out- Avards tOAvards, but not through, the skin. A period of rest should fol- Ioav this operation. If there are remains of hymen, or carunculae myrtiformes, presenting an inflamed hypersensitive condition, there is no remedy so effectual as the removal of these parts by the scissors. The operation is performed by putting the patient in anaesthesia, placing her in the lithotomy or in the semiprone position, Avith the nates hanging Avell over the edge of the bed or operating table. Assistants aid in holding apart the labia vulvae by fingers or retractors, Avhilst the operator, seizing a portion of the affected structures Avith tenaculum forceps, snips them aAvay all round, removing, if need be, a complete ring. The incision should not be deep, the affected structure being generally quite superficial. Some bleeding usually attends. This may be controlled by ice and by pressure, or styptic colloid. Pressure should be applied by plugging the vagina wtith pled- gets of lint soaked in carbolized oil. The plug may be removed and reneAved next da v. During the healing of the surface it is Avell to Avear an elastic vaginal rest. At the end of three or four Aveeks a cure will generally be effected. Disappointment is apt to follow this operation if the smallest caruncle or other affected portion be left. Almost as much irritation and suffering may be maintained by the presence of a small remnant of diseased structure as if the Avhole Avere alloAved to remain. Hence the expedi- ency of carefully removing the entire circle. In some cases Avhere the hymen is very dense and the fourchette is thick and unyielding, so as to contract excessively the vulva, enlarge- ment of the opening by slight incisions is the least painful and the readiest proceeding. Scanzoni, summing up his OAvn very considerable experience of cases of Avhich vaginismus was the urgent symptom, opposes the use of the knife. He has ahvays succeeded in bringing relief by first subduing all inflammatory complications, and next by effecting gradual dilatation by means of graduated glass specula Avorn for short intervals at a time. Courty cured a case by forcible stretching by the fingers under chloro- form. This is carried out, the patient being in the state of anaesthesia, by introducing the tAvo thumbs, back to back, and then forcibly distending the vulva for five or six minutes. I have cured many cases by methods similar to those used by Scan- zoni and Courty; but I have met Avith cases Avhere the knife or scissors gave, in my opinion, not only the quickest and most efficient relief, but also at the least cost of pain and other distress. Certainly the judicious use of these instruments is far less painful than forcible stretching. It is needless to observe that inflammation of Bartholini's glands is a cause of dyspareunia and vaginismus. The SAvelling attending this con- dition often nearly closes the vulva, and the pain is so exquisite that the slightest touch is intolerable. Dvspareunia may be the result of imperfect or disproportionate devel- opment. This is a form not unfrequently observed in girls Avho marry 112 THE SIGNIFICANCE OF STERILITY. too young. It may also be experienced by Avomen avIio marry late in life. After the climacteric, especially in women who have not been ac- customed to sexual relations, the uterus, vagina, and vulva undergo a kind of atrophic involution, in the course of which the vagina and vulva lose much of their glandular structure, and the tissues lose elasticity and distensibility. Sexual relations under these circumstances may be not only painful but e\Ten dangerous. There is a preparation in St. George's Museum of a vagina ruptured through the roof by the sexual act. The condition called coccygodynia by Sir J. Simpson may also be a cause of dyspareunia. It must be remembered that dyspareunia in Avomen may in many cases be traced to the other sex. Imperfect, aAvkAvard intercourse induces a chronic, nervous irritability, Avhich in turn renders approach intolerable. This is a not infrequent source of distress in couples ill-matched as to age and physical strength and disposition. I think it important to insist that Avhenever a discharge of blood fol- Ioavs sexual intercourse, AAdiether it be accompanied by pain or not, a local examination should be instituted. Bleeding excited in this manner is often the first indication obtained of the existence of organic disease of the uterus and vagina; and it is superfluous to say that the prospect of curing organic disease will in many cases depend greatly upon seizing the earliest indications. THE SIGNIFICANCE OF STERILITY. The discussion of the significance of sterility naturally folloAvs upon that of the significance of dyspareunia. It may be stated, as an obvious general proposition, that dyspareunia entails sterility. Of course there are many exceptions; for although intercourse may be difficult and painful, still it may be accomplished ; and. numerous cases prove that complete intercourse is not necessary to impregnation. But these exceptions do not invalidate the general law that dyspareunia is an obstacle to fertility. This is further proved by the frequent occurrence of pregnancy Avhen dyspareunia is cured. It is not simply because dyspareunia so frequently involves the suspension or incomplete performance of the sexual act that it entails sterility. Various conditions, as inflammation, displacement, Avhich produce dyspareunia, are also often of themselves obstacles to im- pregnation. This is proved by the fact that in numerous instances these conditions entail sterility, although sterility is not complained of. It is no part of the object of an essentially clinical work to dAvell upon the moral or social aspects of this question. But it is strictly Avithin the scope of medical discussion to observe that sterility is not a purely nega- tive evil, that is, the history of sterility is not summed up by saying that it is simply the negation of fertility. Complete sexual life in Avoman implies the due succession of the functions of ovulation, of gestation, and of lactation. The ovaries, the uterus, and the breasts ought in the natural cycle or order to relieve each other. AVhere the ovaries alone act continuously under the excitation of married life, a sense of an unful- filled function arises Avhich in many organizations is likely to induce phy- sical as Avell as mental disturbance. The familiar saying that Avomen in THE SIGNIFICANCE OF STERILITY. 113 a certain condition of health Avould be Avell if they could have children is a popular mode of expressing this physiological fact. Referring to the evils attending sterile marriage, Dr. West observes that chronic ovarian irritation and chronic congestion of the Avomb lead- ing to hypertrophy and menorrhagia are apt to ensue. This is undoubt- edly true ; but I may remark that these cases would be less frequent, if the necessity of dilating the narroAV os externum uteri Avere more gener- ally recognized. When this is done, even although pregnancy do not follow, the injurious local affections are much less liable to arise. The significance of sterility, from a medical point of vieAV, then, may be taken generally to be painful or imperfect sexual relations, some disease of the vulva, vagina, uterus, or ovaries, or disability on the part of the husband. Sterility is itself a symptom or condition that may call for medical investi- gation and treatment, apart from the pain or other symptoms Avhich take their rise in concomitant diseases. In discussing the subject it is necessary to bear in mind the distinction betAveen sterility in a Avoman from conditions inherent in herself, and sterility Avith potential fertility. It would be convenient if we could differentiate these cases by the appropriation to each of definite terms. Thus Ave might say a Avoman Avas " sterile" whose inherent conditions precluded her from conceiving, and Ave might say a Avoman Avas " barren" Avho was in every respect apt to conceive, but Avho remained childless, be- cause, first, the fertilizing element Avas Avanting ; or, secondly, because if she conceived, the ovum did not come to maturity. We should fall into grievous error, hoAvever, if avc Avere to conclude that sterility ahvays implied an abnormal condition of the sexual organs in either the man or the Avoman. Numerous instances prove that sterility may be relative only. Certain degrees of affinity seem to be unfavorable to fertility. Upon this subject Francis Galton has adduced many most interesting and valuable historical and statistical illustrations. Thus, he shoAvs in his book on Hereditary Gfenius hoAV evil is the infiuence of consanguineous marriages. Mr. Galton also sIioavs the bad inAuence of marriage Avith " heiresses." Heiresses are presumptively single children, the feeble fruit of worn-out stock. Many peerages have become extinct through this. One-fifth of the heiresses have no male children at all, a full third have not more than one child, three-fifths have not more than tAvo. It has been the salvation of many families that the husband outlived the heiress Avhom he first married, and Avas able to have issue by a second Avife. " I look," says Galton, " upon the peerage as a disastrous institution, OAving to its de- structive effects upon our valuable races." The researches of Galton are confirmed by those of Sir J. Simpson on the fertility of the peerage. Thus Sir James found that out of 495 marriages in the British peerage 81 Avere Avithout issue, giving 1 in 6.11 as the proportion of sterile marriages ; whilst 075 ^marriages in the vil- lages of Grangemouth and Bathgate, one being agricultural the other seafaring, gave 05 sterile, or about 1 in 10. The available materials for estimating the proportion of sterile Avomen are very scanty, so much so that no precise deductions can safely be drawn from them. Indeed, here, as in so many other cases Avhere the phe- 8 114 STERILITY. nomena of life are concerned, the complicating conditions, and therefore the sources of fallacy, are so numerous that it is almost impossible to isolate the bare fact of sterility, the word being taken to imply inca- pacity, absolute or temporary, to bear children to any considerable num- ber of instances, so as to make up a statistical column, all the constituent elements of Avhich shall have equal value. Under the usual statistical process there remains nothing but a caput mortuum, from Avhich all the facts, all the truth, have been sublimed away. As a matter of general political interest, hoAvever, it may be^ stated that Dr. Farr calculates the mean fruitfulness of marriages in England in ordinary periods to be in eA'ery 100 marriages 420 children, giving an average of 4T% children to every marriage. The subject is pursued in many of its bearings in Dr. Matthews Duncan's Avork on Fecundity, Fer- tility, and Sterility. All speculations and calculations of this kind are obviously of little use in elucidating medical problems. The practical physician deals with the concrete, he has to study the individual case that comes before him; to search out the conditions associated with the particular disorder for which relief is sought; to endeavor to estimate the infiuence these con- ditions may exert upon the disorder ; and by removing as far as he can all presumed interfering conditions, to enable nature to resume her course. Applying this, the clinical method, we find that sterility in woman may be either congenital or acquired; it may be absolute and incurable, or relative and temporary. The cases may be ranged under the following heads:— 1. Those in Avhich ovulation does not take place ; or, if taking place, the escape of the ovule from the ovary is prevented. The ovary may be absent, in which case there will probably be absence or imperfect de- velopment of the uterus also. The ovary may be diseased, so that the Graafian follicles, quoad their proper structure, may be destroyed. The ovaries may be covered Avith false membranes, forming an investment through which the ova cannot penetrate. There may be a general or local failure of nutrition arresting the maturation of ova. In such cases menstruation is generally absent. This condition may be temporary; indeed, it is often cured by appropriate constitutional treatment. It is exceptional for Avomen who do not menstruate to conceive. But Bischoff relates a case Avhich appears to show that an ovum may ripen, the men- strual fiow occur, and sterility ensue, because the follicle does not burst. The ovum may decay in the Graafian sac. A not uncommon result of protracted difficulty of ovulation is gradual atrophy of the ovary, and hence entailed sterility. This fact is an illustration of the general laAV, that if an organ is long left idle it is apt to degenerate in structure, and to lose its functional capacity. Scanzoni further suggests that a diseased ovary may produce diseased ova. 2. Those in Avhich»the ovum may mature and escape from the ovary, but in Avhich its due progress along the Fallopian tube and into the uterus is prevented. This is the case when the Fallopian tubes are absent, twisted, or severed; occluded by strictures, or false membranes; Avhere the fimbriae are absent (Baillie); Avhere there is multiplication of the abdominal orifices, and pavilions (Richard); Avhere the fimbriae are STERILITY. 115 bound down to neighboring structures, so that they cannot be brought into apposition Avith the ovary. This Avas described by Ruysch. The uterus itself may be absent, or, as Courty calls to mind, may have no cavity. Fibrous tumors growing at the uterine orifices of the tubes, blocking them up, or in the walls of the uterus, especially of its lower segment and neck, by compressing and distorting the canal, may cause sterility. Indeed, Avhen fibroid tumors exist, impregnation is compara- tively rare. o. Those in which obstruction is interposed to the meeting of the sper- matozoa and ovum. This order necessarily includes the preceding cases; for the obstruction Avhich arrests the progress of the ovum will equally arrest that of the spermatozoa in the opposite direction. But to the causes which arrest the ovum must be added those which block out the spermatozoa, as atresia, congenital or cicatricial, of the os uteri, vagina, and vulva ; those Avhich produce closure or deviation of the uterine canal, as excessive involution or atrophy, tumors, polypus, versions, fiex- ions ; certain peculiar formations of the uterus, especially of its vaginal portion, as a narrow os externum, excessive hypertrophic elongation of the vaginal portion, Avhether original or acquired, offers a decided obsta- cle to impregnation. It is a not uncommon cause of dyspareunia. For this double reason I have amputated the part with success ; tolerance of the sexual function, impregnation, and natural labor ensuing. Dupuy- tren, Huguier, and others have related cases in point, and Scanzoni re- lates one in which impregnation folloAved six Aveeks after amputation of the hypertrophied posterior lip. Excessive development of the labia vulvae may prove an obstacle to intercourse. In such a case resection is indicated, and may be safely performed. Some cases of double uterus and vagina, as the following: Dr. Laaser describes1 the case of a lady who had been married several years Avithout pregnancy. On examination it Avas found that the finger entered easilv into a capacious vagina of normal length, Avhich ended above in a nearlv blind sac. There Avas only a rudiment of a vaginal portion Avithout os uteri; but there Avas a longitudinal septum forming a smaller vagina, Avhich latter Avas surmounted by a portio-vaginalis and os uteri. It Avas presumed that the uterus Avas also double. The sterility Avas accounted for by the blind vagina only being used, the vagina connected Avith the normal cervix being pushed aside. The septum Avas slit, so as to throw the two A'aginae into one. 4. Those in Avhich there is some imperfection in the performance of the sexual act. If Velpeau and Rainey be right in their view of the use of the round ligaments in draAving fonvard the fundus of the uterus, so as to throAv back the os uteri into direct relation with the penis during ejaculation, and if this relation is as a rule necessary for impregnation, the reason Avhy Avomen wdio are the subjects of fiexions, displacements, and disease of the uterus are so commonly sterile, is partly explained. This relation is absent in many cases Avhere the vagina is unduly short, Avhere the uterus seems set too low doAvn in the pelvis, and Avhere—under 1 Monatsschrift fur Geburtskunde, 1864. 116 STERILITY. the effect of intercourse—the vagina is gradually lengthened by stretch- ing into a pouch extending considerably above and behind the os uteri. In many cases it is not simply the flexion which prevents impregnation by distorting the uterine canal and throAving the os uteri out of relation, but the secondary accidents, as inflammation or congestion, attended by unhealthy secretions, which act adversely. It is, of course, necessary that the seminal fluid should be retained. " But there are cases, including many in Avhich the vagina being too short, shalloAV, and irritable, it is forciby expelled by spasmodic contraction. It has been said that spas- modic stricture of the os internum may cause sterility; but the reality of this condition is not easy to prove. 1 have also knoAvn cases of extreme gaping of the vulva, from laceration of the perineum, in Avhich impregna- tion did not take place until the normal condition Avas restored by opera- tion. 5. Those in Avhich unhealthy secretions are formed, unfitted for the maintenance of the vitality of the ovum and spermatozoa. Donne" -ob- served that some kinds of vaginal secretion instantly killed the sperma- tozoa. The qualities shoAvn to be uncongenial are excessive alkalinity of the cervical mucus, excessive acidity of the vaginal mucus, the mucus of uterine catarrh, and other abnormal secretions; indeed, any secretion excessive in quantity amounting to leucorrhoea is also likely to have an unfavorable effect. Menorrhagia is often attended by sterility. Sterility Avhere a vesico-vaginal fistula exists is not, of course, a neces- sary result, but it is nevertheless frequent. 6. Those cases in Avhich the mucous membrane of the uterus is unfitted to afford a nidus for the impregnated ovum. Thus there is a class of cases—and it is a large one—in Avhich pregnancy fails, not because there is an obstacle to impregnation, but because the structures upon which the ovum should be grafted and supported are not in a condition to per- form their part. In such an event the ovum, falling, as it Avere, upon bad soil, decays. The break-down occurs at variable periods. In many, probably, the ovum hardly gets any hold of the unhealthy mucous mem- brane or decidua. In many others, the mucous membrane undergoes the proper development for a stage, then breaks doAvn. In many cases also there is little doubt that the ovum itself, although impregnated and engrafted on the decidua, perishes from inherent defect. We thus see hoAV, by a large class of cases, sterility is brought into relation Avith abor- tion. It may seem paradoxical to say that many of the causes of sterility are also causes of abortion; but the proposition is, nevertheless, true. Some of the conditions above described, such as a minute os uteri ex- ternum and flexions of the uterus, do not oppose absolute obstruction to impregnation. But when this occurs, especially in the case of retro- flexion, abortion is very apt to ensue. The same is true of hypertrophv, engorgement, ulceration, attended or not with displacement. In these conditions impregnation is not very rare, but the unhealthy state of the organ will be apt to lead to abortion. There is a kind of hyperplasia of the mucous membrane, sometimes depending upon a. strumous, sometimes upon a syphilitic diathesis, Avhich is very unfavorable to the support of the impregnated ovum. It is liable to undergo fatty degeneration and to break down. Abortion is the result; and Avhen this happens, as it STERILITY. 117 often does, repeatedly, other chronic changes, as hypertrophy, engorge- ment, are more and more likely to ensue, and to add neAV obstacles to impregnation and gestation. Ovarian irritation is also likely to cause sterility and early abortion, especially Avhen it leads to menorrhagia. Excessive and prolonged flow will so alter the mucous membrane that it becomes unfitted to form healthy decidua. And if impregnation have occurred, the ensuing menstrual nisus, too poAverful to be controlled by the pregnancy, may be attended by a profuse hemorrhage which brings about extravasation into the deci- dua, or such other.disturbances in the uterus as are incompatible Avith the maintenance of the ovum. In many cases of this class it is difficult or impossible to determine whether impregnation have taken place or not, that is, Avhether or not the case be one of early abortion. The practical result, hoAvever, is the same, and the indication for treatment is the same. Correct the unhealthy state of the uterine structures, allay the morbid irritability of the ovaries, and not only will impregnation be likely to occur, but the ovum may be supported and matured. By far the most common associated conditions Avith sterility, in my experience, are congenital narroAving of the os externum and retroflexion of the uterus. These conditions are frequently combined. They are commonly attended by dysmenorrhoea ; and dysmenorrhoea is often pre- sumptive of sterility. The importance of this narroAving of the os ex- ternum uteri as an obstacle to impregnation is questioned by some physi- cians, and amongst others by Scanzoni. He urges that he has knoAvn impregnation take place Avhere the os externum Avas no bigger than a millet-seed. Of this I too have seen examples, but I am satisfied from very extensive observation that these cases are quite exceptional. So preponderating is the association of a minute os externum and retroflex- ion, separately or combined, Avith sterility, that in any given case of a Avoman who remains sterile five years after marriage and suffers from dvsmenorrhcea, it may be predicated Avith almost certainty that one or other, or both of these conditions exist. That these are efficient causes of sterility is further proved by the frequency Avith Avhich pregnancy follows upon their removal. Of this I have seen many striking examples. Two sisters, both young, Avere referred to me by their brother, a former pupil. Both had ahvays suffered from dysmenorrhoea, Avhich had been increased by marriage, and both remained sterile after tAvo to four years. In both I found exactly the same congenital formation, namely, retro- flexion of the uterus and a minute os externum. In both I divided the os externum and corrected the retroflexion by the use of a Hodge-pessary. Both Avere relieved of the dysmenorrhoea, became pregnant, and bore children. This subject will be"further discussed under the head of " Dys- menorrhoea." Treatment.—Examining the foregoing summary of causes from a therapeutical or practical point of vicAv, it will be seen that there is one order of cases in Avhich the sterility is absolute from defect of structure or other conditions which cannot be removed, and Avhich render impreg- nation impossible. The number of such cases is not great. We see another order of cases in which there exists some mechanical obstacle, congenital or acquired, Avhich may be removed by surgical 118 STERILITY. operation. The number of these cases met with in practice is consider- able. Fecundity in these exists potentially. It is only necessary to re- move the obstructions. We see another order of cases in which actual proof of fecundity has been given by the birth of a child. With this one effort the capacity seems to be exhausted, at least for a time. This is " acquired sterility." This condition is in some cases due to excessive involution of the ovaries and uterus, which shrinking, appear to undergo premature senility. In other cases it is due to the flexions, hypertrophies, subacute inflamma- tions attended by unhealthy secretions Avhich sometimes folloAV labor. In these the sterility commonly ceases Avith the cure of the abnormal con- dition. In some, hoAvever, in Avhich there has been pelvic peritonitis, the ovaries and tubes may have been involved in membranous adhesions Avdiich impede the escape of ova or their reception into the tubes. But it must not be supposed that pelvic peritonitis is a necessary cause of sterility. I have knoAvn many cases Avhere there Avas no interruption to subsequent pregnancies. Peritonitis may cause temporary sterility by binding doAvn the uterus in an unfavorable position, especially in retro- version. This Avill often admit of cure by Avearing a suitable lever-pes- sary, Avhich, constantly tending to lift up the fundus, puts the adhesions on the stretch, and gradually causes their removal by absorption. The waters of Schwalbach and Kreuznach have acquired a reputation for the cure of sterility. It is true that a number of women have become pregnant after visiting these places ; but I have good reason for saying that in some of them at least the happy result Avas not due to using the waters. Some had previously tried them in vain, and having subse- quently been submitted to surgical treatment for the removal of physical impediment, had returned to SchAvalbach or Kreuznach, and then con- ceived. In some cases, hoAvever, those for example Avhich depend upon chronic engorgement or hyperplasia, Avith unhealthy secretions, the in- fluence of change of air, repose, and the use of saline chalybeate and iodized Avaters in curing these conditions is decided; and these being cured, the attendant sterility will often disappear. With this qualifica- tion, I can speak Avell of SchAvalbach, Kreuznach, and other places, but they do not deserve the blind faith Avhich many patients and some phy- sicians aAvard to them. The rational course is to remove all the abnormal local conditions first, and then, but not till then, the patients may be sent to SchAvalbach or other convenient place for time to do the rest. The above-mentioned conditions account for a large proportion of the cases of sterility. All these conditions may, in the majority of instances, be remedied, and in all the prospect of impregnation is reasonable. That disappointment in this respect will occasionally follow, even Avhen a de- tected associated morbid condition is removed, is no valid argument against treatment. It is sound practice to remove every abnormal con- dition Ave can. It is possible that any given abnormal condition which Ave discover, and Avhich Ave knoAv is in itself sufficient to entail a certain result, may be the only cause. It is of course possible that another cause lying beyond the first may coexist, and continue after the first is re- moved ; but there is no harm done in removing the first. On the con- trary, the first detected condition is often the cause of other evils beside STERILITY. 11.9 the particular one Avhich it is our special object to cure : and it not in- frequently happens that the removal of one condition opens the Avay to the discovery and cure of other conditions. In short, the obvious principle of acting is to obtain as healthy a state as possible of the genital organs. The vulva, vagina, and uterus, and in some cases the Fallopian tubes, are within our range. When this portion has been brought into a satisfactory state, and Avhen all morbid action of the ovaries has been subdued, Ave shall have overcome a very large proportion of the causes of sterility. The residuum will comprise those cases of obstruction from adhesions of the tubes and ovaries, of ovarian disease or defective development, which are mostly beyond the reach of successful treatment. Sterility being, in so far as the fault lies in the Avoman, a consequence of some abnormal condition of the sexual organs, the treatment of it is involved in the treatment of these abnormal conditions. These cover a wide range of ovarian and uterine pathology, and form the subject-matter of this Avork. Sensual gratification is not necessary to conception ; neither does its absence preclude conception. The essential condition is that the fertiliz- ing element should have ready entrance to the cervix uteri at the right time. Failure in this condition may result from a variety of causes in persons in Avhom no fault of structure in the ovaries or uterus can be found. Ovulation may be perfect, the Fallopian tubes and uterus may be healthy, the elements on both sides may be normal, and yet there may be persistent sterility. It is difficult to follow out this subject minutely. Some of the conditions referred to hardly fall Avithin the scope of strictly medical discussion. It is not, however, out of place to remember that the cause of sterility may reside in the man. It is customary to say that sterility in man is extremely rare. I am inclined to think otherwise. It does not fall Avithin the design of this work to investigate the causes of sterility in the male sex. But I may refer to Mr. Curling's work on the Diseases of the Testis (-M edit.) for the best information on this subject. He confirms by precise observations the opinion expressed by John Hunter, " that Avhen one or both testicles remain through life in the belly, they are ex- ceedingly imperfect, and probably incapable of performing their natural functions." Thus, Mr. Curling shoAvs that in cryptorchids the seminal fluid is commonly destitute of spermatozoa. In nine men this Avas ascer- tained to be the case, and their wives Avere barren. Several of these did not seem to be deficient in copulative poAver, and emissions occurred. When, therefore, Ave find no marked abnormity in the Avife, we must consider the possibility of defect in the husband ; and it will be proper, before subjecting her to a distressing and perhaps painful course of treat- ment, to ascertain whether the fault is not on the other side. 120 BLADDER DISORDERS. CHAP TEE III. SIGNIFICANCE OF SYMPTOMS CONNECTED AVITH BLADDER AND URINARY DISOR- DERS IN RELATION TO UTERINE AND PERI-UTERINE AFFECTIONS: — RETEN- TION of urine; ischuria; partial retention; incontinence; cys- titis; ABNORMAL MATTERS IN URINE:--BLOOD, PUS, FECULENT MATTER, HAIR, FAT, BONKS, ALBUMEN—SIGNIFICANCE OF; MALIGNANT DISEASE OF BLADDER, PRIMARY AND SECONDARY ; DYSURIA. SIGNIFICANCE OF SYMP- TOMS CONNECTED WITH RECTUM ANI) BOAVEL-DISOKDERS IN RELATION TO UTERINE AND PERI-UTERINE AFFECTIONS, HEMORRHOIDS, FISSURE, DYS- CIIEZIA, CONSTIPATION, RETENTION OF FECES ; COPR.EMIA : BLOOD, PUS, MUCUS IN THE FECES; HAIR, TEETH, BONES, FCETAL ELEMENTS. When a patient complains of pain in a particular organ, or of diffi- culty in the performance of its function, it does not necessarily folloAV that that organ is the real seat of disease. This is eminently true of the bladder in Avomen ; so true, indeed, that in the majority of cases of bladder distress the cause will be found outside the bladder. To estimate rightly the significance of subjective complaints referred to the bladder, avc are therefore necessarily led to institute an objective examination not alone of the bladder but of the other pelvic organs as well. The blad- der is so intimately associated Avith the uterus and vagina, and so con- stantly participates in the affections of these organs, either directly or indirectly, that the clinical study of symptoms referred to it is daily forced upon the gynaecologist. In many instances these symptoms are induced by disease of the uterus, ovaries, or vagina ; the bladder being only affected by irritation propagated from its neighboring organs, or being hindered in its function by pressure of these organs displaced or enlarged. Proximus ardet. In another series of cases, disease commenc- ing in the uterus or vagina spreads to the bladder, Avhen symptoms of bladder disease will, of course, be added to those of the primary disease. In a third series, the primary seat of disease is in the kidneys or blad- der. I think it may be affirmed that cases of this last series are the least frequent. In these cases the chief symptoms will naturally be re- ferred to the bladder, but uterine or ovarian distress will often be en- tailed. As it does not fall Avithin our theme to discuss the strict diseases of the kidneys and bladder, it may be useful to point out at the onset the lead- ing indications by Avhich they may presumably be distinguished from cases of the first two series, and especially from those of the first. Strict kidney and bladder diseases are recognized by functional derano-ement of those organs, by correlated constitutional disorder, by alterations in the characters of the urine, and by physical examination. Severe pain in the region of the kidneys, occurring in paroxysms, attended bv vomit- ing, and the presence of pus, blood, gravel, or calculi in the urine, point RETENTION of urine. 121 to the kidney as the source of trouble. The presence of albumen, casts, uric acid, oxalic acid, sugar, pus, or blood, usually points to structural changes in the kidneys or bladder, or to functional disorder of the nutri- tive apparatus. This proposition is generally true ; but pus and blood may find their Avay into the bladder through a fistulous communication with an ovarian cyst, or be formed in the bladder as the consequence of obstruction to excretion. So that eA'en the most probable indications of strict kidney and bladder distress should not turn us away from the direct exploration of the neighboring pelvic organs. Of course this exploration will be the more imperative if Ave learn that there are subjective symp- toms referred to the ovaries, uterus, or vagina. If Ave folloAV the rule of systematically investigating the condition of all the pelvic organs Avhen one of them sIioavs signals of distress, Ave may noAv and then discover, after the event, that we have clone something superfluous, but Ave shall ahvays have the satisfaction of knowing that Ave have taken the best course to avoid error in diagnosis, and consequent risk of adopting use- less or injurious treatment. There are BLADDER COMPLICATIONS DUE TO MECHANICAL CONDITIONS OF THE PELVIC ORGANS. Of these the most important is retention of urine from obstruction of the urethra. This imperiously urgent symptom may come on suddenly, or it may be preceded by attacks of dysuria or partial retention. In almost every case retention of urine in Avomen is the consequence of pressure arising outside the bladder. It is therefore a symptom, not of bladder disease, but of disorder of other pelvic organs. Retention from atresia or stricture of the urethra, or from blocking by a calculus, is ex- tremely rare in Avomen. The canal is short, of large bore, and easily distensible ; in all these respects differing from the male urethra. Pres- sure may be developed in a feAv hours so as to completely compress the urethra against the symphysis pubis. The bladder filling above the ob- struction, the symptoms of retention quickly folloAV. Or the pressure may be developed very sIoavIv, as Avhen a fibroid tumor is enlarging in the pelvis. So long as the pressure does not completely obstruct the urethra, the retention will be only partial. Or the retention may be in- termittent. This may be due to changes in the position or size of the obstructing body. All pelvic tumors are apt to induce more pressure at the menstrual epochs than in the intervals. This is not necessarily be- cause the tumors themselves are increased in bulk at these times, but more often because of the general increase of turgidity of all the pelvic structures. The diagnosis of retention of urine is not always easy ; at least, in practice it is occasionally not made out. This is because retention is rarely absolute. Under the enormous hydrostatic and expulsive pressure brought to bear Avhen the bladder is greatly distended, a little urine will be driven along the urethra, and escaping externally, impose upon patient and attendants the belief that the bladder empties itself. Stillicidium, or dribbling attended by that form of dysuria which may 122 RETENTION' OF URINE. be called bladder tenesmus or straining, is presumptive evidence of re- tention more or less complete. It may look paradoxical, but it is never- theless true that the loss of control over the sphincter vesicsc, resulting in loss of poAver to hold the urine, is proof of retention. Since retention cannot be endured many hours without involving the risk of serious damage to the bladder and kidneys, and the absorption of urinous elements into the blood, early recognition of this state is of primary importance. It should therefore be established as a rule in practice, in all cases of stil- licidium, as Avell as of complete retention, to examine by catheter. We may knoAv that the bladder is distended Avhen the sense of relief is not complete; Avhen pain is still referred to the pelvis and hypogastrium, and accompanied by recurrent attacks of impressible bearing-down or straining efforts; and when a tense SAvelling has formed in the loAver abdomen. When the SAvelling due to accumulation is great, Ave may fail to find distinct fluctuation. The tension is too great. But there Avill be dulness on percussion extending as high as, or even above the umbilicus; increase of pain on pressure ; and the shape of the tumor, if the abdo- minal Avails arc thin and yielding, is peculiar. The bladder keeps close to the anterior abdominal Avail. It points more under the umbilicus than does the pregnant uterus or an ovarian tumor. Both these spread more laterally, and, of course, have other characteristics peculiar to themselves. Araginal examination Avill commonly give confirmatory evidence. If there is obstruction from a retro-uterine mass, the os uteri will be found jammed close behind the symphysis pubis. In other cases, the distended bladder throAvs the uterus backAvards, especially the fundus ; and thus the brim of the pelvis is felt through the vaginal roof to be occupied by a smooth tense body, the base of the distended bladder. On pressing this with the finger, Avhilst the other hand presses upon the abdominal SAvelling, some urine will be forced out of the urethra. When the catheter is passed, in proportion as the urine runs off, the tension being lessened, fluctuation becomes more distinct; the abdominal tumor subsides; and the vaginal roof-stretching is relaxed. The quantity of urine retained is sometimes very large. It may amount to three quarts or more. When the retention has lasted twenty-four hours or longer, the urine draAvn off will usually be turbid, sometimes smoky from sanguineous exudation, ammoniacal, and commonly extremely offen- shre. Considerable relief folioavs the evacuation, but not so complete as might be expected. A Ioav degree of cystitis may have been induced, and the extreme distension to which the bladder has been subjected Avill leave a degree of paralysis of the muscular coat. Hence the urine is liable to accumulate again, even although the obstructing cause mav have been removed. Therefore the practice of passing the catheter two or three times a day should never be omitted until Ave get certain knoAvledge that the bladder has fairly recovered its tone. This is shown by the freedom from local distress, by the consciousness that urine is passed in a stream, and by our finding on passing the catheter that only a moderate quantity of limpid urine is drawn off. The effects of retention of urine, if not timely relieved, are: The bladder, it is said, may burst. This may be looked upon as a possible rather than a probable event. I do not know of a case in Avhich this RETENTION OF URINE. 123 catastrophe has happened. Three compensating factors are at work to obviate it. These are: stretching of the bladder, overfloAv by dribbling, absorption of part of the urine. Long before bursting could take place the patient Avould die from exhaustion by pain, by the structural changes produced in the bladder and kidneys, and by blood-poisoning. The first effect upon the bladder is irritation, Avhich leads on to congestion, and then to inflammation of the mucous coat especially. This is the most common form of cystitis. The intense congestion leads to exudation of blood into the urine. If the interior of the bladder is seen at this stage it looks swollen, pulpy, dark-red or even black, and viscid mucus mixed Avith blood may be adhering to the mucous membrane. The swollen mucous membrane and viscid mucus entangle the deposits Avhich soon take place, so that the inner surface is often coated Avith triple phosphates. From a moderate degree of congestion and inflammation the bladder may recover. But if the retention be long continued the mucous mem- brane may be cast off. Several cases of complete exfoliation are knoAvn. This, in itself, is not a fatal accident. Several patients have recovered. One of them I saAv at the London Hospital. When the exfoliation occurs as the result of severe labor, the duration of the retention need not be very protracted. TAventy-four hours maybe enough. But in these cases there is commonly superadded considerable contusion of the bladder from the pressure of the child's head or by instruments. But if Avhere it results from simple obstruction of the urethra, usually a much longer time has elapsed. Protracted retention after severe labor has in several cases been folloAved by exfoliation of the mucous membrane. The mem- brane separates from the bladder in shreds, or as a Avhole, so that when extruded it represents a perfect cast of the bladder. In one specimen which came from a woman Avho had suffered a severe labor, and Avhich Avas given me by Mr. Nicholson, of Stratford, the substance did not present the elements of mucous membrane; it Avas a tough fibrillated tissue coated Avith phosphatic crystals. It had been pulled out in shreds through a vesico-vaginal fistula, Avhich bore evidence to the difficulty of the labor. But in other cases the true characters of mucous membrane have been distinctly recognized. Dr. Wardell relates a case.1 Spencer Wells re- lates two cases.2 Dr. J. J. Phillips gives another.3 Dr. Schatz has also described and figured one.4 Where obstruction to the voiding of urine is found from the presence of some substance blocking the urethra from Avithin, it would not be difficult to give relief by dilating the urethra and draAving out the substance by forceps or by a small blunt hook. Rest, demulcent drinks, and sedatives would diminish irritation whilst a neAV mucous membrane Avas forming. The next effect of retention, and one Avhich very quickly folloAvs, is absorption of some of the fluid collected in the bladder. Hence symp- toms of urinnemia are rarely Avanting. But this absorption will not avert retrograde pressure upon the ureters and kidneys. This leads to disten- sion of the ureters and pelvis of the kidneys, and then to arrest of secre- tion. Congestion of the kidneys easily merges into nephritis. Some 1 British Medical Journal, 1S71. 2 Obstetrical Transactions, vols, iii., iv. 3 British Medical Journal, 1S71. 4 Arcliiv fiir Gynakologie. 124 RETENTION OF URINE. degree of albuminuria is not uncommon: and the elements Avhich ought to be secreted from the kidney, throAvn back upon the blood, the circula- tion is further poisoned, and brain-symptoms arise. This, 1 think, is the most common cause of death. If the patient survive, chronic cystitis and chronic nephritis are very probable events. After the retention is relieved and the bladder has recovered some amount of poAver, the Avhole urinary tract is liable to chronic inflammation. Peritonitis sometimes folloAvs retention of urine. It will, of course, be sometimes difficult to assign this Avith certainty to the retention, Avhere great disorder of other pelvic organs Avhich led to the retention coexists. But in some cases there is reason to suspect that, under the enormous pressure exerted by the distension of the bladder, increased by the futile efforts to expel its contents, some degree of oozing or permeation of the urine may have taken place through the coats, and thus have produced irritation of the peritoneal investment. Starting, then, with the proposition that retention of urine may be caused by compression of the urethra against the symphysis pubis, Ave may usefully pursue the subject by inquiring Avhat are the various causes which may exert this injurious compression. We may bring these causes into the following groups:— I. Conditions inherent in the uterus itself. II. Conditions external to the uterus, but acting, for the most part, by driving the uterus against the bladder, and this against the pubic symphysis. The situation of these is, of course, behind the uterus. Other conditions have their seat in front of the uterus. Others have a lateral position. III. Vaginal conditions. IY. Conditions depending upon labor or the puerperal state. V. Conditions, mostly dependent upon nervous disturbances, Avhich do not fall under any of the preceding groups. I. If Ave analyze more precisely the conditions that fall under these several heads, Ave shall find in the uterine group:— 1. Retroversion or retroflexion of the uterus, gravid or not gravid. 2. Prolapsus of the uterus, gravid or not gravid. 3. AnteA'ersion or anteflexion of the uterus, gravid or not graAdd. 4. Recent inversion. 5. Enlargement and locking in the pelvis, more or less displacement attending. (i. Hgematometra, or retention of blood in the uterus, from atresia of the os uteri or vagina, or occlusion of the vulva. 7. Tumors in its Avails or cavity. 8. General hypertrophy from hyperplasia. 9. Thrombus in the uterine neck. II. Causes external to the uterus. Many of these act, partly at least, by producing displacement of the uterus. The chief of these are:__ A. Bodies getting in front of the uterus—that is, betAveen it and the bladder; as— 1. Ante-uterine haematocele or blood-effusion in the cellular tissue be- tAveen the ceiwix uteri and the bladder. RETENTION OF URINE. 125 2. Ante-uterine phlegmon, or abscess in the same tissue as the effu- sions of blood. 3. Rarely, an ovarian tumor, the dermoid variety being the more probable. 4. Malignant disease binding the bladder to intestine or other adjacent structures. B. Bodies getting behind the uterus. These are more common and more important than the preceding. The principal ones are— 1. Retro-uterine haematocele. 2. Collections of inflammatory effusions, serous, fibrinous, or purulent, the result of peritonitis, general or pelvic, or of cellulitis. 3. Ovarian tumors, dermoid or cystic, of such moderate size that they can, Avholly or in great part, be retained in the pelvis. 4. Extra-uterine gestation-cysts. 5. Collections of feces in the rectum. 0. Tumors in the rectum, or springing from the pelvic Avails. C. Bodies on one or other side of the uterus. These, generally, Avhen they cause retention of urine, get someAvhat behind the uterus also. The principal are— 1. Inflammatory effusions, the result of peritonitis, general or pelvic, or of pelvic cellulitis. 2. Ovarian tumors. 3. Other tumors in the broad ligaments. 4. Tumors or distension of the Eallopian tubes. III. Certain conditions of the vagina form a sufficiently characteristic group. These are— 1. Tumors formed in the Avails of the vagina, or contained in the canal, as dependent uterine polypi, or the inverted uterus. 2. Phlegmon or abscess in the Avails of the vagina. 3. Plugs introduced to arrest uterine hemorrhage. IV. The group of puerperal causes Avould include some of the causes stated in the foregoing groups, but it is of especial clinical convenience to consider these in their relation to labor and childbed, a study beyond the scope of this Avork. X. There remain yet other causes of retention of urine Avhich do not fall Avithin any of the preceding groups. Some of them may be traced to nervous disturbance or aberration, as— 1. Retention folloAving upon operations upon the neck of the uterus. This is strictly analogous to the retention Avhich sometimes ensues upon operations upon the rectum in the male subject. 2. Retention, partly voluntary, induced by the dread of pain during micturition when neighboring organs are diseased. 3. Hysterical retention. 4. There is a form of temporary recurrent paralysis, which cannot be called hysterical, in Avhich the proper moment for the evacuation being lost, it is found that the bladder refuses to act at a later time, and the catheter has to be resorted to. In some cases I have seen there Avas no neighboring disease and nothing abnormal in the urine. 5. Paraplegic, or from progressive general paralysis. 120 RETENTION OF URINE. Lastly, we must be careful not to mistake suppression of urine for retention. Suppression rarely occurs except in association with fever. The catheter, by showing tliat the bladder is empty, establishes the diagnosis. Fig. 38. Showing the Situation, Direction, and Relations of the Uterus when the Bladder is full—(after Sappey). 1, bladder distended with water; 2, fundus of bladder rising 1£ inches above the symphysis pubis, and remaining well behind the abdominal wall ; 3, cul-de-sac of peritoneum formed by passing from abdominal wall to bladder. It comes down close to the upper edge of the symphysis ; 4, end of right ureter; 5, uterus driven back as well as the vagina, 7 ; 6, utero-vesical cul-de-sac ; 8, lower end of vagina ; 9, meatus urinarius ; 10, 11, labia of vulva ; 12, rectum much depressed by uterus. Mere retention of urine can, of course, be relieved for the time by the simple use of the catheter. But as this does not touch the cause, reten- tion Avill recur. It becomes, therefore, indispensable to determine what is the particular cause. For this it is necessary to institute a thorough physical examination of the pelvic organs. The history of the case may help : and it may mislead ; for in medicine, as in politics, trustworthy history is not easily found. We may, indeed, at once eliminate some of the causes Ave have enumerated by noting the age and other conditions of the patient. Thus we shall exclude the probability of causes depend- ing upon pregnancy in women whose age is incompatible with that state. By similar reasoning we may in most cases quickly dispose of a consid- erable number of causes, and be enabled to reduce the problem Avithin narroAV limits. But in the end we must fall back upon local examination, not only to establish an accurate diagnosis, but also for the purpose of treatment. ISCHURIA. 127 Fig. 38 is introduced to illustrate the effect of artificial distension of the bladder. Like all illustrations draAvn from the dead body, it must be accepted with some qualifications. The conditions in the living are often very different. Charcot describes hysterical ischuria,1 and vindicates the claim of this affection to restoration to the place in pathology from Avhich scepticism had discarded it. In ischuria of hysterical patients the obstruction is not situated in the urethra or in the bladder. It lies higher up, either in the ureters or in the kidneys, or still more remotely. The principal fact is that the quantity of urine secreted in the twenty-four hours, and AvithdraAvn by the catheter—for hysterical ischuria is almost ahvays com- plicated by urethral retention—is remarkably under the normal amount. It is even frequently reduced to zero, and during several days there is absolute suppression of urine. As Lay cock wrote,2 oliguria, or even total suppression of urine may be only a transient phenomenon. This Ave occasionally observe in hys- terical patients, especially at the catamenial periods, a complete suppres- sion, Avhich does not last more than tAventy-four or thirty-six hours. There may, perhaps, be some feeling of uneasiness, and the pulse may be quickened; but after a short time a feAV spoonfuls of urine are expelled, and the normal state is restored. In other more serious cases the ischuria is protracted. For several days there is no secretion. In these another phenomenon is superadded. Repeated vomitings occur so long as the ischuria lasts. The vomited matter occasionally, it is said, presents the appearance and exhales the odor of urine. Charcot points out that in experiments on animals a vicarious elimination (of urea) is effected by the intestine; and that so long as this elimination takes place the animals seem to suffer little in- convenience ; that it is only Avhen they become enfeebled, and the sup- plementary excretion ceases that grave phenomena appear. But in hysterical Avomen the alternation between renal excretion and vicarious excretion may continue for weeks and months, Avithout any visible dis- turbance of the general health. The great point, of course, in a clinical point of vieAv, is to distinguish ischuria from retention. The catheter is the indispensable means of solving this difficulty. It is important to remember that ischuria may happen in women quite independently of hysteria. It is one of the immediate causes of death where cancer, spreading from the uterus, invades the bladder, and retro- grade obstruction induces compression and atrophy of the glandular struc- ture of the kidneys. Irritable bladder, by the uncontrollable reflex forcing pains induced, may cause subjective signs which the patient may readily ascribe to pro- lapsus of the uterus. The chief means of diagnosis are: the touch, vaginal, rectal, and ab- dominal; the sound; the catheter; the aspirator-trocar. The speculum is rarely useful in these cases, and in many it could only be introduced with difficulty and pain. ' Lectures on Diseases of the Nervous System, New Sydenham Society, 1877. 2 A Treatise on the Nervous Diseases of Women, 1840. 12S IRRITABLE BLADDER. The first step in diagnosis and in treatment is to pass the catheter. This, by emptying the bladder, reduces the case to a simpler condition, and facilitates"the application of other modes of exploration. The vesical tumor removed, Ave can immediately, by percussion of the abdomen down to the level of the symphysis pubis, and by pressing the fingers back tOAvards the spine, determine Avhether any tumor or solid body exists in the abdomen; or, this point being negatived, Ave have traced the diffi- culty to the pelvic cavdty, and may then concentrate our attention upon the study of the causes Avhich avc knoAv to be of pelvic origin. The observations almost inevitably made during the passage of the catheter may alone sometimes almost settle the question. If, for exam- ple, on passing the guiding finger along the urethra we ascertain that there is no pressure upon it, and if the vaginal canal and the uterus be in normal relations, we infer that the retention is due to paralysis or other nervous disorder. If, on the other hand, Ave find the vagina com- pressed, the os uteri difficult to reach high above the symphysis pubis, and the catheter difficult to pass because the urethra and its meatus are dragged up from their normal seat, Ave may presume with great confidence that the case is retroversion of the gravid uterus. But to determine this point Avith certainty further examination is necessary. And Ave may use- fully set before ourselves the possible conditions between Avhich we have to decide. To pursue this diagnostic analysis here Avould be to anticipate the sub- ject-matter of future chapters. A condition allied in nature to retention impartial retention. Although rarely so dangerous in its effects, death may result. The bladder is never completely emptied; and the desire to empty it is left unsatisfied, frequently inducing more or less futile straining efforts. A familiar cause of this is procidentia of the uterus. The bladder, intimately con- nected Avith the neck of the uterus, is dragged doAvn by the uterus in its descent. A pouch is thus formed beloAV the ordinary level of the urethra and its meatus. In this pouch urine accumulates, and the retention is apt to give rise to phosphatic and lithic concretions. This condition is easily verified by passing the sound or catheter into the uretha. The instrument passes directly doAvmvards in front of the procident cervix uteri, and its point may be felt near the os uteri, quite outside the vulva. The Avorst consequences of this condition are generally averted by the variable state and degree of the uterine prolapsus. In the recumbent posture, and often during rest, the uterus rises into the pelvis, carrying the urinary pouch up Avith.it, when the urethra comes into a position to drain it. In many cases the woman overcomes the difficulty by pushing up the procident uterus Avith her finger during micturition; and this is more effectual if practised in the knee-elboAV posture. Irritable Bladder.—Next to retention of urine, perhaps, the most troublesome complaint is a too frequent desire to empty the bladder. In some cases the Avant is irresistible and incessant. And yet there may be no disease of the bladder or kidneys. All may be due to abnormal con- ditions of proximate structures. It may be stated generally that all the causes which ultimately lead to retention, commonly in their earlier stages cause irritation of the bladder CYSTITIS. 129 expressed by frequent desire to empty it. Hence the paramount impor- tance of taking this symptom as a Avarning to institute a local physical examination. Thus I have knoAvn a Avoman die from the consequences of retention caused by retroflexion of the gravid uterus, who for tAvo months previously had been attending a surgeon for irritation of the bladder, the cause not being suspected. Ordinary irritability of the bladder is dis- tinguished from cystitis by the absence of mucus in the urine. ('ystitis, subacute or chronic, is almost sure to ensue sooner or later from partial retention of urine, just asAve have seen acute congestion and inflammation ensue from complete retention. And since most of the causes of retention, partial or complete, arise externally to the bladder, Ave might easily fall into error if we sought exclusively in the urinary apparatus for the cause of cystitis. Subacute cystitis arising from lesser degrees of retention or other causes—such as an irritating condition of the urine—may pass also into chronic cystitis. This is sometimes due to tubercular deposit in the uri- nary mucous tract. It is possible that this may exist independently of tubercular matter in the genital tract: but it is rare for the urinary tract to be affected alone. Evidence of other organs—as the lungs—being involved will seldom be Avanting. Dr. West, hoAvever, thinks that inflam- mation of the kidneys and bladder may occur as secondary to tubercular deposit Avhen yet no other symptom of tuberculosis is present; and, further, that such a disease may run its course to a fatal issue Avithout phthisis supervening, even without any deposit of tubercle in the lungs or elseAvhere than in the bladder and kidneys, and the absorbent glands in their imme- diate vicinity. I think I have seen subacute or chronic cystitis arise out of puerperal fever apart from any direct injury from seArere labor or re- tention. It may also take its origin from exposure to cold Avhilst the organ is in a susceptible condition. Chronic cystitis or irritation may arise from vesico-intestinal fistula, giving passage to portions of fecal matter into the bladder. The case is rare, but I detected this communication in one instance by microscopic examination of some semi-solid matters passed in the urine. The case was that of a young lady who had recovered from typhoid. No doubt ulceration of the intestine had occurred, attended by peritonitic adhesion to the bladder ; and thus perforation Avas effected into this organ, instead of the more usual escape into the cavity of the peritoneum. In another case feculent matter Avas frequently found in the urine. A tumor Avas detected in front of the uterus, and apparently between this organ and the bladder. On post-mortem examination, we found a dense mass of fibrinous substance glueing the small intestine to the fundus of the bladder. This mass had been perforated by a fistulous communication between the two organs. The cause of this appeared to be malignant disease beginning on the mucous surface of the small intestine. Blood and pus had preceded the appearance in the urine of feces. The use of the microscope here was very manifest. Dr. Orel, toAvhom I gave samples of the urine, without telling him anything of the case, gave me a correct account of the food upon Avhich the patient had been sustained. The characteristics of chronic cystitis are usually: great irritability of the bladder, marked by frequent and urgent calls to pass urine even 9 130 BLADDER DISORDERS. Avhen there is no accumulation: the presence of mucus or pus in the urine : and pain above the pubes. Mere irritability may be due to proxi- mate disease, as in the uterus: but Avhere the quantity of mucus in the urine is large, the mucous membrane of the bladder is affected. Local examination made by the catheter brings out pain when the point of the instrument touches the wall of the bladder, and the finger applied to the anterior roof and Avail of the vagina evokes the same symptom. The consequence of this distressing complaint is frequent spasmodic contraction and gradual thickening of the muscular coat. The bladder seems to contract upon itself; it is no longer able to hold urine enough to be distended to its normal dimensions. After a time ulceration of the mucous membrane is apt to folloAV; then the muco-purulent admixture is increased, blood may appear, and the irritability and pain become more se\rere. The treatment consists in the employment of all those means best cal- culated to diminish the irritating qualities of the urine. The digestive organs will therefore demand care. Everything knoAvn to promote dys- pepsia and lithiasis or oxaluria must be avoided. Demulcents and then tonics Avill be useful. Where lithiasis is present, alkalies, as soda, potash, or lithia, will be serviceable ; but more commonly the condition to be remedied is the phosphatic, Avith tendency to ammoniacal urine. Here moderate doses of mineral acids and tonics will be most useful. Ad- vantage has sometimes been gained from Avashing out the bladder by injecting Aveak acid solutions or demulcent and sedath'e fluids ; but in some cases the irritability of the bladder is so great that this treatment is resented, and must be given up. Warm baths offer great relief Avhen the pain or spasm is urgent. In retention, partial or complete, it is of the utmost importance to use a male elastic catheter. The ordinary silver female catheter is quite inadequate. It may draw off a considerable quantity of urine, and yet leave the patient unrelieved. In many of these cases the bladder seems to be compressed into tAvo loculi or pouches. You may empty one, and think your work is done. The short catheter may never have reached the more distant pouch. Noav a long flexible male catheter will Avorm its Avay along a tortuous channel, and run into the furthest part of the bladder. On the principle that the greater includes the less, doing all that the lesser can do, and more, I have come to the conclusion that the male catheter should ahvays be used. For many years I have not pos- sessed a so-called female catheter. The flexible male catheter has the further advantage of having a longer portion protruding beyond the A'ulva, thus conducting the urine more easily into the receiving vessel. Irritability of the bladder, apart from cystitis and catarrh, is a very common symptom or effect of uterine disease. Hypertrophy, conges- tion, and inflammation of the cervix uteri especially cause it. Malignant disease of the cervix is almost sure to produce it. It is a frequent con- sequence of ante version and anteflexion of the uterus, especiallv if the body be much enlarged, so as to press upon the bladder. This is a familiar symptom of early pregnancy, in Avhich condition the enlarged uterus is commonly anteverted. It may happen that the bladder-distress INCONTINENCE OF URINE. 131 becomes the most troublesome effect of the uterine disorder, so that at- tention is concentrated upon it to the neglect of the primary condition. Inflammation of the uterus not seldom entails, through the disturbance it causes in the digestive function, an altered condition of the urine. Thus we see an excess of phosphates and lithates and mucus, and the irritation attending the abnormal character of the urine aggravates the local suffering from the disease of the uterus. It may also cause irritation of the bladder, manifested in incontinence and dysuria by mere contiguity, just as inflamed hemorrhoids in the male may irritate the contiguous bladder. This is further illustrated by the increased dysuria, sometimes amounting to partial retention, which occurs at the menstrual periods. Incontinence of urine may be due to a fistulous communication be- tween the bladder and the vagina. This is usually discovered some days, perhaps a Aveek or a fortnight, after labor. The opening is rarely made immediately by direct force, but is established gradually as the result of necrosis and sloughing of the part which Avas subjected to greatest pres- sure. This process takes some days to be completed. It not seldom attends cancer, being due either to perforation of the bladder or to loss of sphincter-poAver from extension of the disease. But incontinence may be the result of disease of the nervous centres. Thus I have been consulted in a case of incontinence Avhere it Avas sus- pected that a fistula existed, but the infirmity Avas really due to progres- sive general paralysis. Of course, in advanced cases of paralysis, other nervous symptoms are so predominant that the bladder infirmity is readily referred to its true cause. But the interesting point in relation to our present theme is that the bladder infirmity may be the earliest symptom to attract attention, and then it is likely to mislead. Dysuria.-—Painful micturition is frequently a symptom of bladder or urethral disease. It is pretty sure to attend the vascular excrescence of the meatus urinarius ; and the presence of this condition is rendered more probable if a little blood attends micturition. Dysuria again may be due to urethritis, simple or gonorrhoea!, or syphilitic. If attended by copious muco-purulent discharge, specific infection may be suspected. In rare instances stricture of the urethra may be the cause. In in- stances also rare the cause may be calculus in the bladder or urethra. In any case persistent dysuria is an indication for local exploration of the pelvic organs. Abnormal excretions from the bladder are usually more characteristic of functional disorder or disease of the nutritive organs of the kidney or bladder than of retention, irritability, or incontinence. But we should often be led astray if Ave assumed that this Avas universally the case. Hematuria.—Thus, blood in the urine may be symptomatic of calcu- lus in the kidney, or of malignant disease of the bladder ; but it may be simply a form of vicarious menstruation. Blood in the urine, again, may accompany albuminuria induced by pregnancy, as I saAV in a case at the London Hospital. She applied on account of haematuria; when this intermitted Ave found albuminuria. There Avas dropsy throughout. Not seldom blood mixed Avith the urine may be traced to a vascular tumor of the meatus urinarius, or to a vascular state of the urethra. And 132 DISEASE OF BLADDER. I have seen cases of bloody urine that passed for lucmaturia until a can- cerous fistula Avas discovered. The urine escaped into the vagina, Avhere it became mixed Avith blood from the cancerous ulceration. Pus, again, may denote disease of the kidney or bladder; but it may find its Avay into the bladder from the most singular and unsuspected sources. Thus I have under care Avith Dr. Crisp a case, in Avhich, for many years, large quantities of pus are occasionally passed in the urine. The source of the pus is not the bladder. It finds its Avay into the blad- der from a dermoid cyst, Avhich has made for itself another opening near the umbilicus. Pus frequently comes from this external opening. A probe passed into it finds its Avay into a cavity doAvmvards for a distance of four or five inches, whilst another sound passed into the bladder runs up an equal distance, so far, indeed, that the points of the two instruments cross each other. Although they do not touch, there can be no doubt that both run into the same cavity. It is remarkable how in this case the bladder retains its healthy state, notAvithstanding the irritation it is subjected to. The day after passing a large quantity of pus, clear urine is voided, and irritation subsides. Hair, fat, teeth, may find their Avay into the bladder and urine. They afford conclusive evidence that a dermoid cyst has contracted adhesions with the bladder and established a fistulous communication. Bones of foetal character may arise from an extra-uterine gestation-cyst. In these cases, signs of dysuria, of incontinence, of irritability of the bladder, per- haps the appearance of blood or pus, will have preceded the discharge of the hair, fat, teeth, or bones. And in most cases the tumor Avhence these matters proceeded may be made out by a careful vaginal, rectal, and abdominal palpation, aided by the sound. The most unequivocal indications of disease of the kidneys or bladder are the alterations in the chemical qualities of the urine. Thus, excess of phosphates or lithates, or the presence of albumen, of sugar, of oxalic acid, point to disorder of the nutritive functions. It must not, hoAvever, be forgotten that these conditions are sometimes secondary upon condi- tions of the ovaries and uterus. For example, metritis, acute or chronic, frequently induces such a disturbance in nutrition that phosphates and lithates appear in superabundance in the urine. So mucus and pus may folloAV an acute or chronic cystitis ensuing upon retention of urine from any of the causes we have discussed. And albuminuria may sometimes be traced back to pregnancy, even in cases Avhere eclampsia was not manifested. The excretion of sugar also may have begun under the in- fluence of pregnancy. It is true that albumen and sugar usually dis- appear from the urine soon after pregnancy has been brought to a term, but occasionally the morbid process, once started, persists after the cessa- tion of the original cause. Bearing in mind this association of albumi- nuria, sugar, and pregnancy, we should not omit, when these abnormal ingredients are found in the urine, to institute a careful examination to determine the presence or absence of pregnancy. Primary malignant disease of the bladder is very rare in Avomen. Dr. West relates one observation so complete that I am induced to quote it in lieu of giving an abstract description of the affection. A Avoman, aged sixty-tAvo,had suffered for a year previously from pain in the reo-ion DISEASE OF BLADDER. 133 of the bladder, aggravated after passing Avater, the calls to Avhich became more frequent than natural, Avhile at the same time her urine grew tur- bid, and deposited a thick sediment. Blood now frequently appeared in her urine; sometimes in small quantities, sometimes in clots, and once in very large quantity. She had of late suffered from pain in the back. A surgeon introduced a catheter, Avhich Avas folloAved by considerable hemor- rhage, which lasted for several days, and Avas apparently stopped by gallic acid. On admission the pulse Avas 80, soft. No tumor Avas per- ceptible in the abdomen, but firm pressure immediately over the pubes caused some pain. The uterus Avas high up, small, healthy. In front of the uterus, pushing it into the posterior half of the pelvis, was a firm, someAvhat irregular groAvth, reaching from the anterior half of the pelvis in the situation of the bladder. This groAvth Avas perfectly immovable. It seemed to be connected with the pelvic Avails ; Avas someAvhat tender on pressure. It occupied the whole anterior half of the pelvic brim, though not dipping much into the cavity. The urine was pale, alkaline, depositing ropy mucus, and shoAving crystals of triple phosphate and cells of nucle- ated epithelium. Shortly aftenvarcls the Avoman met Avith an accident, and died of erysipelas. The uterus and vagina were found perfectly healthy; but the Avhole posterior half of the bladder Avas occupied by a medullary groAvth, Avith an irregular surface, Avhich projected into the cavity of the organ, its substance being in part firm, in part almost semi- fluid. The anterior half of the bladder Avas quite healthy, as Avas also 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 infundibulum of the right kidney Avas enormously enlarged. In this case the distinctive character of malignancy Avas the hemor- rhage. The tumor felt in front of the uterus might be due to a blood- mass in the cellular tissue connecting the uterus and bladder, or in the vesico-uterine peritoneal pouch. The profuse bleeding also distinguishes the disease from the other causes of hematuria. These are : 1. A cal- culus. In this case the blood is seldom more than a feAV drops, and the catheter Avill detect the stone. 2. Foreign bodies. The most incon- ceivable things have found their way into the bladder; hair-pins, for example. These give rise to cystitis ; phosphatic deposits collect around the foreign body. The sound will detect these as Avell. 3. The hemor- rhage may be vicarious of menstruation. Here the quantity is not so great as in malignant disease ; it occurs in comparatively early life, and the menstrual irregularity is marked by other symptoms. Secondary malignant disease of the bladder is unfortunately too com- mon. It arises mostly as an extension from cancerous disease of the cervix uteri. The invasion of the bladder is then marked by cystitis, but this symptom, although adding much to the patient's distress, is noAV but of subsidiary importance. Often the bladder is perforated from Avithout by the advancing necrotic or ulcerative process, so that the urine escapes involuntarily. But this symptom, Kiwisch rightly observes, when occurring in the course of cancer of the uterus, is not to be regarded as certain evidence of perforation of the bladder, for this symptom is fre- quentlv only the consequence of carcinomatous infiltration of the neck of the bladder, and especially of that part corresponding to the sphincter, 134 DISORDER OF RECTUM. by which it is hindered in the performance of its functions, and thus per- mits the urine to run off. Opium in some form or other is indispensable in the treatment. It may be given by the mouth, by vaginal pessary, by rectal suppository, or by subcutaneous injection. SIGNIFICANCE OF SYMPTOMS CONNECTED AVITH RECTUM AND OTHER BOWEL- DISORDERS IN RELATION TO UTERINE AND PERI-UTERINE AFFECTIONS. Although the uterus is not in such intimate relation to the rectum as it is to the bladder, it is still so close to it in position that disorder or dis- tress referred to the rectum is an extremely frequent complication of uterine disease or displacement. The unity of the pelvic vascular system is such that engorgement or inflammation of the uterus cannot fail to cause increased afflux of blood and haemostasis in the other pelvic organs. To this increased Aoav of blood, determined by inflammation or congestion of the uterus, there is necessarily added the mechanical effect of increased Aveight and bulk. Thus tAvo conditions already combine to cause accu- mulation of blood in the hemorrhoidal vessels. A third condition is rarely Avanting long. This is displacement of the uterus. The prolapsus consequent upon increased weight of the uterus, and the relaxation of its supporting structures bring a further aggravation of pressure to bear upon the rectum just above the anus, increasing the difficulty under Avhich the hemorrhoidal vessels labor in unloading themselves. To these mechanical influences in producing local vascular stagnation other remote and secondary causes bring a contingent of trouble. The gradual impairment of digestion and other nutritive functions, the enforced inactivity, consequent on uterine disease, entail constipation and loss of sphincteric tone. Hence the disposition of the hemorrhoidal vessels to dilate, to become varicose, and to favor the formation of piles and thrombi, is enforced in a variety of concurrent Avays. The foundation of rectal and anal distress is often laid in pregnane v. The active developmental nisus, bringing to the pelvic vessels a large quantity of blood, leads to distension, to venectasis, Avhich does not ahvays subside after labor. The dilatation of the vascular plexuses around the loAver part of the vagina and vulva arising during pregnancy is also found around the anus. During labor the extreme compression to Avhich this part is subjected may retard the circulation in the vessels for several hours, and then, during the final act of expulsion, the tissues in Avhich the vessels are embedded, being inordinately stretched, perhaps even lacerated, the vessels themselves undergo serious injury, from Avhich they may never recover. At this stage there is often absolute eversion of the lower part of the boAvel; the mucous membrane is exposed, SAvollen, and livid from intense congestion ; and sphincteric power is more or less impaired. I believe that in some cases fibres of the sphincter are rup- tured without rupture of the mucous or cutaneous investments ; there is in fact, subcutaneous or submucous division of the muscle. It is only in this Avay that we can explain the lax and half-open state of the anus so often observed in Avomen Avho have borne children. Pregnancy and labor form the frequent starting-point of hemorrhoids DIAGNOSIS OF DISORDER OF RECTUM. 135 in Avomen. But menstruation, a mimic parturition, if difficult or compli- cated by constipation and other troubles of nutrition and circulation, not seldom entails the like condition. The same act of distension, Avhilst the parts are turgid Avith blood, sometimes causes small lacerations of the edge of the anus, Avhich, not healing, become fissures or ulcers. In some cases, again, the sphincter is found to have lost something of its contrac- tile poAver. This loss is complete, or nearly so, Avhen the sphincter has been torn through, as in many cases of laceration of the perineum. In these cases, the Avant of power to retain the feces—incontinence—ob- served after labor, is usually enough to suggest the true nature of the case, and examination being made, the injury is revealed. In Avhatever Avay these lesions may have arisen, they are apt to be kept up by uterine disease, the two conditions exerting a mutual vicious influence. On the other hand, hemorrhoids, fissures, and ulcers of the rectum and anus may be primary, or at least exist independently of uterine disease or displacement. The symptoms they give rise to may be taken by the patient, and in the first instance by the medical attendant, as evidence of uterine disease. And disease of the rectum, if involving much conges- tion and pain and difficulty in the performance of its function by the con- sequent accumulations and straining, may induce congestion and prolapse of the uterus. Here, as in the converse case, the morbid condition of each organ exerts a vicious influence upon the other. The displacements of the uterus almost always induce some rectal complication. In prolapsus simple, or Avith the usual attendant retrover- sion, the uterus falls into the loAver part of the sacral hollow, and, there- fore, projects more or less into the anterior Avail of the rectum. It induces some degree of obstruction, to overcome Avhich increased bearing- doAvn efforts are excited. This increases the evil. The progressiva pro- lapsus causing inversion of the vagina, the recto-uterine peritoneal pouch is dragged doAvn, and then the anterior Avail of the rectum is draAvn into a pouch, constituting vaginal rectocele. It is a matter of observation that the reduction of the displacement is frequently folloAved by the return of healthy peristaltic action. In anteArersion, the vaginal portion of the uterus is tilted up and back, so as to form a conical projection into the rectal cavity, easily felt by rectal digital touch. If, as often happens, the vaginal portion is con- gested or inflamed, exquisite pain is experienced Avhen a stool has been passed. In some cases this pain on defecation is felt only, or at least is felt Avith especial severity, at the menstrual epochs. In retroversion and retroflexion the body of the uterus, most probably enlarged and painful, presses into the anterior Avail of the rectum, en- croaching upon its calibre, acting as a ball-valve, causing a degree of obstruction, paralysis, dyschezia, and retrograde or ascending disorder of the intestinal canal. Sometimes, in retroversion of the gravid Avomb, the strain upon the rectum is so great that actual tenesmus is induced. But often Avhere there is no uterine disease, the forcing due to disease of the rectum or anus will simulate uterine displacement or disease; and what is important to remember, may ultimately induce it. The diagnosis of rectal from uterine or vaginal disease can be made by direct examination. Symptoms such as pain on defecation, pain Avhen 136 RETENTION OF FECES. the sphincter acts, discharges of mucus or blood from the anus, Avill, of course, point to the seat of the disease. But direct inspection is neces- sary to determine not only what is the exact morbid condition, but also what is to be done. Rectal exploration as a means of making a correct diagnosis of uterine disease is often indispensable. Thus in the course of examining for uterine disease avc often discover rectal complications. But apart from this incidental exploration, Avhen symptoms referred to the anus are complained of, special examination of this part should be made. I have several times in this Avay detected a fistula Avhich had not been suspected by the patient. The rectum and anus may be exa- mined, first, by the touch. The finger, oiled, is passed into the rectum and made to explore the cavity as far as it Avill fairly reach. In this Avay a polypus may be felt, or any tumor or constriction in the cavity; and Ave may judge Iioav far the intrusion of the displaced uterus may be a cause of distress. Secondly, Ave may bring the loAver edge of the rectum inside the sphincter into vicAV fry the folloAving manoeuvre; pass the forefinger, having Avell pared doAvn its nail, into the vagina above the perineum, so as to get its tip as fairly over the seat of the anus as pos- sible ; then by depressing this strongly the loAver part of the rectum is everted, and made to protrude through the anus. In this Avay hemor- rhoids, fissures, or ulcers, and the state of the mucous membrane, can be seen. Or, thirdly, the anal speculum may be used. By this aid Ave obtain inspection of the mucous membrane higher up, and can see a polypus or other morbid condition that may exist. It is almost superfluous to say that constant irritation of the boAvels, and especially the loss of poAver to retain the motions, is motive enough for suspecting the existence of laceration of the sphincter and perineum. It may, indeed, indicate general paralysis. In this case, hoAvever, other signs of nervous disease Avill probably be detected. But incontinence of urine and feces may be the earliest manifestation. Thus I have had a patient brought to me principally on this account, the grave disease of the nervous centres being not yet suspected by the patient or her friends. Diarrhoea is frequent at the menstrual epochs, due, no doubt, to the increased irritation of the mucous membrane and the hypemsemia in- duced. If Ave folloAV in a similar order to that observed in the case of the blad- der, Ave shall first study the significance of retention of feces. This will lead to the investigation of the causes of obstruction. Noav, the need of defecation is far less imperious than that of micturition. If the bladder is not relieved Avithin twenty-four hours such urgent distress ensues as to compel attention. But accumulation may go on in the boAvel for many days. There is a further difference. If we except the case of strangu- lated hernia, it is comparatively rare for complete obstruction of the boAvel to come on suddenly, as does obstruction of the urethra. These tAvo conditions render the approach and existence of bowel-obstruction more insidious and more difficult to realize. In the majority of cases bowel-obstruction from pelvic disease comes on very gradually. As the obstruction increases, defecation is more and more difficult and scanty. Retrograde dilatation of the intestine above the obstruction takes place, which, by giving more room for the lodgment of feces, affords some com- OBSTRUCTION OF BOWEL. 137 pensation for the Avant of outlet; the absorption of the watery constituent of the feces, and the more scanty food taken, further tend' to postpone the climax and to prolong the delusion that Ave have to deal simply Avith obstinate constipation. The climax is at length determined by the dis- tension of the belly—partly by flatus, partly by feces ; by the abdominal pain; by the sense of distress that never fails to attend the non-fulfilment of a necessary function; perhaps vomiting; surely loss of appetite; earthy, dirty, yelloAv tinge of skin, due to empoisonment from absorption of fecal elements and bile—a condition analogous to uringemia, and for which I have proposed the name "coprasmia;" and by the failure of purgatives and encmata to bring aAvay fecal matter. When things have come to this pass, a strict examination is imperative. If exploration of the abdomen discover no sufficient cause, Ave must explore the pelvis. This is done by the vagina and rectum. The instrument needed are the finger, the sound or a whalebone probang, the aspirator-trocar, and the enema-syringe. I once saAv retention of urine in an old Avoman caused by a compacted mass of feces in the rectum; it filled the holloAV of the sacrum and pushed the uterus fonvards against the symphysis pubis, turning the vagina for- Avards in much the same manner as retro-uterine haematocele. The mass yielded like putty before the finger; the indentations made remained; there Avas no elasticity in it; and the finger in the rectum became em- bedded in the mass. Copious enemata Avashed aAvay the tumor and relieved the bladder. Retention may be incomplete or complete. The retention caused by retroversion of the gravid Avomb is rarely complete ; and the distress arising being of quite minor importance to the attendant retention of urine, the subject need not detain us. But there are cases of incomplete fecal retention caused by retroflexion of the enlarged uterus in Avhich there may be no serious retention of urine. In these cases the enlarged body of the uterus, rolled back into the sacral holloAV, compresses the anterior Avail of the rectum against the posterior Avail, acting like a ball- A-alve. To some degree this difficulty and its retrograde consequences attend most cases of retroversion or retroflexion of the uterus. It is sometimes more pronounced Avhen there is impaction of the uterus enlarged by fibroid tumors. Examination by vagina and rectum will reveal the true nature of the obstruction; the uterine sound will lift the mass out of its false position, and then a suitable pessary Avill keep it from falling back. Thus complete relief to the boAvel is often attained. Obstruction from pelvic cellulitis or peritonitis is diagnosed by the signs described under this head. But something more is required. The patient under chloroform, the finger is passed as high as possible into the rectum, and, folloAving its course, Ave come to the constriction caused by the fibrinous deposit nearly encircling the boAvel, and nearly closing it by concentric contraction. I saAv a case in which things had gone to such extremes that death seemed imminent. The stricture admitted barely a bougie. The pelvic brim Avas occupied by a dense mass matting all the organs together. It was difficult to decide Avhethcr this Avas due to malignant disease or to simple inflammatory effusion. I suggested as the only apparent prospect of relief the resort to colotomy. Whilst this Avas being debated, suddenly 138 OBSTRUCTION OF BOAVEL. an immense gush of pus took place, the bowel was liberated, and recovery ensued. Such a lesson could not be forgotten. In several cases which have since come under my care I have penetrated the mass by the aspi- rator-trocar, and have thus draAvn off pus with manifest relief._ The marks of irritative fever will aid in raising the suspicion of imprisoned pus. But this kind of evidence is not wanted to justify the puncture. The operation, as far as I may judge from a considerable number of ob- servations, is quite harmless, and its value in diagnosis and treatment is so great that I think it should be resorted to in every instance where local or systemic distress is manifest. I have even seen reason to believe that punctures thus made for diagnostic purposes have had a curative action by stimulating absorption of the effused material. It is necessary to be provided with special trocars. The ordinary ones supplied are not available for intra-pelvic use. Messrs. Weiss have made for me trocars eight or nine inches long, supported on a firm stem, Avhich ansAvei-Avell. They can be adapted, like the ordinary needles, to the same mount of the aspirator-tube. Another disease Avhich may proceed in a similar manner, and lead up to the same result, is cancer. Whenever this dire disease invades the mucous outlets or canals, it tends to close them by gradual concentric contraction. We see this in the oesophagus, in the anus, the vagina, and the urethra. So Avhen it extends from the uterus, invading the neighbor- ing structures, it not seldom seizes the rectum about the sigmoid flexure, surrounds it, and, gradually closing in, the tube is reduced to the smallest bore, so small as to be quite inadequate to the function of defecation. In this Avay cancer occasionally proA^es fatal. All the symptoms of co- praunia and starvation precede. In such a case the only hope of reprieve lies in colotomy. We may puncture by the aspirator-trocar, but nothing beyond diagnostic satisfaction will be gained. Ovarian tumors have caused death by obstructing the bowel. Dr. Parker1 relates a case. Rokitansky describes fatal constriction caused by the rotation of an ovarian tumor. When symptoms of dangerous boAvel-obstruction supervene in connection Avith ovarian tumor, the expe- diency of immediately proceeding to extirpation must be earnestly dis- cussed. The same rule will apply to closure from a locked fibroid tumor. A muscular tube depends for its healthy Avork on the freedom of its mus- cular action. This action is liable to be arrested or paralyzed if the tube be encroached upon by inflammatory or other deposit in such a manner as to interfere Avith its mobility, or to lessen its calibre. Nay, the mere proximity to an inflamed or enlarged organ seems often to be enough. Whenever a function can only be exercised at the cost of pain, the sys- tem instinctively tries to avoid pain by suppressing the function. And there may be other causes of nervous diversion leading to this induced local paralysis. Dyschezia (from hva- and ^1^).—Difficult or painful defecation may be due to hemorrhoids, fissure, or excessively vascular condition of the anus. If blood folioav the stool rather copiously, whether of arterial or venous character, Ave may suspect hemorrhoids. If the pain is more 1 Edinburgh Medical Journal, 1563. STRANGE MATTERS IN STOOLS. 139 acute, and the quantity of blood small, the probability is in favor of fissure. But these conditions can neither be Arerified nor successfully treated Avithout examination. As in the case of the bladder, so in that of the boAvel, Ave have to consider the significance of abnormal matters in the excretion. In both cases these may or may not be indications of disease of the organ from Avhich they Aoav. Thus, blood, mucus, pus, may be the manifestations of dysentery and ulceration of the intestine or of hemorrhoids. But they may spring from quite different causes. For instance, blood in con- siderable quantity is sometimes discharged under the exalted vascular tension of pregnancy, or of menstruation ; or it may be due to a polypus in the rectum. Whenever blood comes from the boAvel apart from the obvious conditions of fever, dysentery, or liver disease, the possibility of pregnancy should be considered, and the pelvic portion of the boAvel, Avith its relations, should be carefully examined* Blood may come from a pelvic haematocele. It may issue from a der- moid or cystoid tumor. So may pus, hair, or bones, or teeth. Indeed, the rectum is the often elected channel for the voidance of the contents of most of the pelvic tumors. Abscesses resulting from pelvic inflam- mations most frequently empty themselves by this road ; and this is also the favorite channel for the elimination of the foetcd elements of extra- uterine gestation cysts. Intra-pelvic examination is essential for the recognition or the exclusion of these conditions. And this examination must be thorough. In urgent cases it may even be necessary to pass the Avhole hand into the rectum—of course Avhilst the patient is in a state of anaesthesia. One lesson Avill be draAvn from the clinical deductions made in these studies of the relations of bladder and bowel distress to disease of the neighboring structures. It Avill be seen how impossible it is to pretermit close examination of the surrounding organs Avithout serious risk of over- looking conditions that may be fatal if neglected, and Avhich may be remedied if discovered. Whilst Ave are looking at the kidneys or the intestine, because they are disturbed in their functions, it may be the uterus or the ovaries that are in fault. We thus see Iioav dangerous it is to practise in the spirit of pure specialism ; hoAV absurd it is to map out the body, and assign particular territories to particular classes of practi- tioners. It will be seen hoAV intimately, hoAv indissolubly that part of medicine Avhich takes for its basis the particular study of the generative system in Avoman, is linked Avith the disorders of the alimentary, vasau- lar, and nervous systems ; that is, a pure specialty cannot exist. A more monstrous thing cannot be conceived. 110 INSTRUMENTS. CHAPTER IV. THE INSTRUMENTS SERVING EOR DIAGNOSIS AND TREATMENT. Having taken a cursory survey of the principal symptoms, chiefly sub- jective, attending ovarian, uterine, and vaginal disease, the methods of investigation by Avhich Ave bring out the objective signs and seek to esta- blish a full diagnosis might noAV be described. But as the means to be employed in this investigation involve the use of instruments, I haA'e thought this Avould be the most convenient place to introduce a description of the instruments employed and the mode of using them. Having be- come acquainted Avith our tools, and knoAving Avhat they can do, Ave shall then be in a better position to proceed to diagnostic analysis. THE GYNAECOLOGIST'S ARMAMENTARIUM. It will serve the purpose of order and conciseness if Ave gather into one vieAV the chief instruments and materials employed in the diagnosis and treatment of the diseases of women. Independently of reasons of economy and method for collecting all these things into one compact portable case, stands the great practical fact that, Avhen about to investigate a case of presumed ovarian, uterine, or vaginal disease, Ave cannot tell Avhat in- struments Ave may want to carry out the indications in diagnosis and treatment which may present themsehes. For example, all local exami- nation necessarily begins with the digital touch. This may be sufficient, but often it gives information which is imperfect, and which requires to be folloAved out by the speculum or sound; and when we have got the full diagnostic knoAvledge Avhich finger, speculum, and sound can give, it frequently happens that we are immediately in a position to apply an appropriate remedy. Thus diagnosis is made the true handmaid of treat- ment. The patient is often spared the double distress of tAvo separate examinations. It is in this quality that lies the highest recommendation of the diagnostic instruments Ave employ ; it is this quality Avhich invests them Avith a practical superiority over most of the instruments employed in the investigation of diseases of other parts of the body. The stetho- scope, for example, an instrument invaluable, but not absolutely indis- pensable, for diagnosis, and thus helping to form a scheme of treatment, is of no use in carrying out the treatment. Like the sphygmograph or the thermometer, it is purely an instrument of observation. It Avould appear to be a natural classification of our appliances to divide them into diagnostic and therapeutical. Rigorous adherence to this is defeated by the double quality Avhich some of the instruments possess. But still this division is rational and convenient. It is not, perhaps, superfluous to preface the enumeration and descrip- tion of instruments by recalling attention to the hand and eye of the INSTRUMENTS. 141 physician. The eye, of course, is simply an instrument of observation ; its application is often only possible Avhen aided by other instruments, as for instance, the speculum; and in a great many cases it is not Avanted either for diagnosis or treatment. But the hand is pre-eminently the obstetric instrument; it possesses a Avide diagnostic and therapeutical range of usefulness ; it is not only in itself competent to the detection of many morbid conditions, and to the treatment of some, but it is also an indispensable element in the use of other instruments. The Diagnostic Instruments are : — The speculum. The endoscope. The speculum-forceps. The uterine sound. A flexible Avhalebone sound. The sponge or laminaria-tent. Dieulafoy's aspirator Avith special trocars. A bit of Avax-candle, or small reflecting candle-lamp for speculum examinations and operations in dark weather or unfavorable positions of the patient. The Therapeutical Instruments are:— The uterine sound. The catheter. The speculum-forceps. Simpson's metro tome-knife. The metrotome-scissors. Sims's single tenaculum-hook to hold the Araginal-portion. A Avire ecraseur. The intra-uterine solid caustic-carrier. " " fluid and ointment-carrier. The tube for carrying sticks of sulphate of zinc, or other sub- stances, into the uterus. Barnes's laminaria-tent carrier. A scarificator. An intra-uterine injecting apparatus. A probang mounted Avith sponge. A syringe for washing out the vagina or uterus. A subcutaneous injecting syringe, to Avhich may be adapted a long holloAV needle to draAV off fluid from a tumor for microscopical and chemical analysis. An aspirator-apparatus Avith special long needles for penetrating tumors by rectum or vagina. To explore and tap retro-uterine tumors, 1 have designed a very efficient trocar consisting of a tube twelve inches long, carrying a fine blade which serves both to puncture, and if needs be to extend the opening ; the knife withdrawn a coil-drainage tube can then be carried through the tube into the cyst. 142 INSTRUMENTS. The most useful Jfateria Jledica are :— Perchloride of iron (solid). Chloroform or ether. Chromic acid, in crystals. Richardson's styptic colloid. Bromine of caustic poAver. Carbolic acid. Nitric acid is often Avanted, but it cannot be carried or packed Avith other things, unless in hermetically sealed tubes. Tincture of iodine. Acetic acid, concentrated. Nitrate of silver. Sticks of potassa cum culce. Sticks of sulphate of zinc. Iodide of mercury ointment. Medicinal pessaries: 1. Perchloride of iron pessaries. 2. Belladonna. 3. Morphia. 4. Gallic acid. 5. Iodide of lead. The following articles should also be at hand : — Cotton-Avool, plain and prepared with styptics and disinfectants. String, silk, lint. Needles, half-curved, carrying silver wire. Forceps for holding needles. A small collection of pessaries. (The most useful are three sizes of Hodge's lever-pessaries.) Thomas's or Galabin's pessaries for anteversion. One or tAvo of the author's intra-uterine galvanic pessaries. A vulcanite intra-uterine pessary. A Sims's or Barnes's vaginal rest. A Gariel's or other air pessary. The pessaries Avill be described in a succeeding chapter. The stethoscope and thermometer are, of course, the constant com- panions of every medical practitioner. In addition to the knives, scissors, forceps, etc., required for special operations, it will be useful to possess a galvano-cautery, and a Paquelin's thermo-cautery. The galvano-cautery, of which the most convenient form is Mathieu's of Paris, is cumbersome, and troublesome to work; but it does what Paquelin's ingenious instrument will not do, and there- fore cannot be dispensed with. Instruments for use by patients :— Higginson's vaginal syringe. Barnes's speculum for self-application of vaginal pessaries, and avooI carrying solutions of lead, bromine, etc. The special requirements of particular cases, or the views of the prac- titioner, Avill suggest further or different things to make up the equipment. THE SPECULUM. 143 ^7 object is to enumerate those Avhich are the most generally useful. A selection of the above, especially including the diagnostic instruments, should be kept in a suitable hand-bag or case. Some of the articles require a more particular description. To take first the speculum. Specula may be classed under three heads according to their mode of action :— 1. Tubular, Avhich act by distending the vagina longitudinally, thus lengthening the vagina and pushing the uterus away before it. 2. Valvular, Avhich distend the fundus of the vagina, thus widening and shortening the vagina, and bringing the uterus loAver and nearer to the vuha. 3. The single duck-bill, which acts by retracting the perineum and posterior Avail of the vagina. In private practice, the most generally useful speculum is that knoAvn as Fergussons glass tubular instrument, silvered and coated Avith vul- canite (Fig. 39). The light this gives is superior to that Avhich any other form of speculum can give ; and this is an advantage of primary importance, for Ave cannot ahvays in the houses of patients command a good, direct horizontal light. Two sizes should be kept; one of com- paratively large size for Avomen Avho have had children, and one of small calibre for others. Both should be six or seven inches long, othenvise the vagina may not be distended enough to bring the os uteri into vieAv. The tubular speculum has the disadvantage that, Avhen introduced its full length, it possesses no poAver of increasing the distension of the fundus of the vagina, so as to bring out the vaginal-portion from behind over- lapping folds of a lax vagina; therefore, unless an instrument of adequate size be used, it may fail to exhibit the os uteri. A serious objection to Fergusson's speculum is its liability to break. All its advantages are secured, Avithout this draAvback, in an instrument of the same shape made of metal plated Avith nickel. Plain glass specula are, hoAveA'er, useful; and if made of " verre trernpe." AArould resist ordinary risk of breakage. They possess the ad- vantage of being cleanly beyond suspicion. The German " milch-glass speculum" has equhralent merits. Good valvular specula overcome the difficulty inherent to the tubular. Being introduced their full length in a closed state, the blades can be opened at their extreme points so as to stretch out the folds at the roof of the vagina, and thus bring the os uteri well into the field, Avithout in- creasing the distension at the vulva. As the uterine ends of the blades expand, it is not only more easy to bring the vaginal portion into the field, but by continuing the expansion, the roof of the vagina is put on the stretch, and thus pulls open the os uteri, exposing often a considerable part of the cavity of the cervix, and thereby much facilitating the direct application of remedies. For many years I used a modification of Henry Bennett's bivalve speculum. It is an excellent instrument, but I have been led to prefer for general use Cusco's speculum (Fig. 40). The Avooden plug, an ob- jectionable complication of most other bivalves, is got rid of. The blades are Avide and nearly flat, so that, Avhen brought together, they touch along the whole extent of their margins, and represent a Avedge Avith 144 INSTRUMENTS. smooth edges. This makes the plug superfluous. It is not, hoAvever, quite so easy to introduce ; some care is requisite to keep off the rather narroAV edge from the os pubis. When introduced, the sci-cav at the handle expands the blades at the uterine end, and distends the vaginal Fig. 39. Fio. 40. Fergusson's Speculum. (Half natural size.) Cusco's Speculum. (Half size.) roof in a very efficient manner. This instrument is in many cases self- retaining. It is virtually a double duck-bill speculum. I have found it useful to increase by an inch or more the part in Avhich the screAV is Avorked at the handle. This takes the hand clear of the range of vision, and the screAV from entangling the pubic hair. Marion Sims''s Single Duck-bill or Spoon Speculum (Fig. 41).— This is a most serviceable instrument. It is almost indispensable in the performance of protracted operations, such as the closure of vaginal fis- tulas. It is not, hoAvever, so convenient for ordinary practice. In many cases an additional instrument to serve as a retractor to hold back the anterior vaginal Avail is required ; and this makes an assistant necessary. It is, moreover, only available in the semi-prone position, or in the litho- tomy position, neither of Avhich is it always easy to obtain in private practice. It is convenient to have it made the two blades united by a screAV, so that the blade serving as a handle may be made to turn either way. The Author's Bivalve Speculum. " Crescent Speculum.''''—There is no speculum Avith Avhich I am acquainted so useful for facilitating opera- tions upon the vaginal-portion as the modification of Neugebauer's, Avhich I have designed (Fig. 42). In many cases this instrument is sufficiently THE SPECULUM. 145 self-retaining to afford the manipulator the opportunity of applying reme- dies to, or even of performing operations upon, the cervix uteri Avithout assistance. It gives freer space for operative manipulation than any other speculum. It brings the os uteri so near that it is commonly easy to reach it by finger. Fig. 41. Sims's Speculum. The tubular and valvular specula afford a perfect inspection of the Avhole tract of the vagina and vulva. The time for making this inspec- Fig. 42. Barnes's Speculum (R. B.). (Half size.) tion is during the AvithdraAval of the instrument. As this is slowly done, the vaginal Avails close in upon the retreating speculum, and come suc- cessively Avithin its field. Except in very extreme cases of relaxation, 10 146 INSTRUMENTS. the contractility and resilience of the vagina are poAverful enough to aid in expelling the speculum. Weiss'g Self-retaining Duck-bill Speculum.—This instrument is the adaptation of an apparatus for fixing a duck-bill or Sims's spoon-blade in the vagina, so as to dispense with the use of hands to hold it in situ. In this Avay many operations may be conveniently carried out Avithout assistants. I have used it, and find that it ansAvers its purpose. All the above-described specula, excepting Fergusson's, should be plated with nickel. This gives a beautifully smooth surface, Avhich re- sists the action of many of the corroding agents employed, and is easily kept bright. The Endoscope.—In connection with the speculum, it is proper to refer to the endoscope, which may be defined as a prolongation or extension of the ordinary speculum. The design of the uterine endoscope is to ena- ble the surgeon to see beyond the os uteri externum into the cavity of the cervix, and even into the cavity of the body of the uterus. Several ingenious instruments have been contrived for this purpose. One, that of Jobert, consists virtually of a small two-bladed speculum, capable of being introduced closed into the cervix uteri. The tAvo blades being mounted on a long stem, are, after introduction, made to diverge by working a screw in the handle. It resembles in principle and action Weiss's urethra-dilator. Another contrivance that may be mentioned is that of Tyler Smith.1 This instrument is applied through a modified Cusco's speculum. It consists of a mirror and a cylindrical tube, both provided Avith long handles. By means of a screw, the mirror can be inclined at any angle, so as to receive and transmit a ray of light through the tube Avhich is passed into the uterine cavity. Another form of en- doscope is adapted for intra-rectal inspection. The uterine sound is an instrument designed on the principle of the sound made to explore the male bladder. It is a special form of the surgical probe. The probe indeed, or some form of it, has long been used to facilitate the exploration of the uterus. Its application to the diagnosis of polypus from inversion of the uterus is described in the early editions of Samuel Cooper's Surgical Dictionary. Huguier says the uterine sound Avas knoAvn to Hippocrates. Harvey relates a case in Avhich he used an equivalent instrument for the express purpose of ex- ploring the cavity of the uterus. But still the application of the sound to uterine examination, an application which would seem to Aoav so natu- rally from the familiar use of the instrument in investigating the condi- tion of the bladder, remained in abeyance until it Avas revived bv Lair, who described a uterine sound in 1828.2 The late Sir James Simpson, in 1843, made knoAvn his conclusions upon the mode of examining by help of a uterine sound or bougie, and described the form of instrument he recommended. His instrument is the one Avhich I have selected for illustration in this work. It is the one Avhich I most frequently employ. It is provided, like the common male sound, with a flat handle to facili- tate manipulation, and terminates at its other extremity in a rounded 1 Obstetrical Society's Catalogue of Instruments, 1867. 2 Nouvelle Methode de Traiteinent de* Ulcered de l'Uterus. Paris, 1828. THE SOUND. 147 knob or bulb, Avhich enables it to ride more easily over the rugae of the cervical canal, and lessens the risk of injuring the uterus. The stem tapers gradually from the handle to the knob, the thickest part being Fig. 43. Fig. 44. •impson's Uterine Sound. (Half size.) Barnes's Whalelione Sound. (One-third size.) equal in calibre to a No. 8 catheter, the portion near the knob being equal to a No. o catheter. The exploring half of the sound should be made 148 INSTRUMENTS. of silver only moderately alloyed Avith copper, so as to permit of its being readily bent by the fingers. Some are made with virgin silver. This is too flexible,"as it is apt to bend during use, especially in cases of flex- ion of the uterus. The stem is about ten inches long, and is graduated so as to indicate the depth to which it may penetrate. The graduation is marked in the figure. (Fig. 48.) There is one principal mark which is the most essential as a standard of comparison, made by an elbow or projection, just "2h inches from the knob. This marks the normal length of the uterine cavity. When the sound has been introduced as far as this, resistance is commonly felt, and Ave knoAV, by feeling the elboAV on a level with the os exturnum uteri, that the knob is 2} inches in the uterus. It is useful to have a mark betAveen the elboAV and the knob half an inch above the elboAV. This is useful in giving precise measure- ment Avhen the knob will not go the full distance. BeloAV the knob the stem is graduated by inches. These secondary marks are best made by slight notches. There are different Avays of making the index-marks; but as Simpson rightly insists, the marks should be so made as to be readily felt by the finger in the vagina, so as to admit of being read off Avhen the instrument is AvithdraAvn. The sound, as sold in the shops, is almost ahvays bent at an obtuse angle at the 2J-inch elboAV, the two parts above and beloAV being quite straight. It is more convenient in practice to give a slight curve to the part above the elboAV. There are cases, notably those Avhere the canal of the uterus is much deviated by tumors, Avhere the use of the rigid sound is objectionable. In cases of this nature it is occasionally more useful to employ a flexible bougie or sound. An ordinary male bougie is very suitable. Dr. Henry Bennet commonly uses bougies of soft material, Avhich retain the impres- sion of any constriction they may have passed through. Dr. Thomas uses1 a hard rubber sound, about twelve inches long, provided Avith a knob at the end similar to the figure (Fig. 44), taken from the instru- ment which I use. This is made of Avhalebone, Avhich is sufficiently flexible and durable, and is not likely, as the vulcanite one is, to break. My instrument is fifteen inches long, not at all too long to track the elon- gation of the uterine cavity produced by some cases of fibroid tumor. The speculum forceps should be about tAvelve inches long, and straight. It is sometimes made Avith an angle betAveen the joint and the finger-holes, under the mistaken idea that Avhen straight the handles and hand occlude the field of the speculum, and interfere with accurate manipulation. This objection is not real. There is a practical inconvenience in the handling of a bent forceps. It will not, for example, rotate handily, so as to Avipe off adhering secretion, as the straight forceps will. The instrument should be toothed at the ends, and grooved longitudinally, so as to hold a rounded stick of nitrate of silver, or potassa cum calce. Metrotomeg.—The instruments I employ to incise the cervix uteri are Simpson's metrotome, and either a scissors designed by myself or Kiichen- meister's. The reasons for this preference Avill be given when discussing the operation. Simpson's metrotome is really a bistouri cache, Avith a long handle. When closed the blade and its guard or sheath form a rod 1 Diseases of Women. Philadelphia, 1872. METROTOMES. 149 about the size of a sound, Avhich is easily passed into the cervix uteri. When there, by depressing the handle to an extent determined by a regu- lating screAV, the blade is made to start from its guard, and cuts its way out. The guard is sometimes made double, so that the blade sinks back betAveen the tAvo parts. This is inconvenient. When the blade, after having cut, is allowed to fall back into its guard, the point is apt to pinch a bit of tissue in the guard, and the AvithdraAval of the instrument is thus made aAvkward. A single guard answers quite as well, and is free from this little difficulty (see Fig. 46). Fig. 45. Kiichenmeister's Metrotome-scissors. a. Half size. b. Full size. Kiichenmeister's Metrotome Scissors.—Ordinary scissors are not Avell adapted to make an incision clear through a rounded Avedge-shaped body, 150 INSTRUMENTS. which shall be of equal depth at every part. The blades are liable to slide away a little towards the finish of the stroke, leaving a spur of tissue uncut. To remedy this I have often completed the incision made by my scissors with Simpson's metrotome. But for some years I have discarded Fig. 46. Fig. 47. 11 i '.V' P Simpson's Metrotome. Sims's Tenaculum Hook. ray own scissors for a modification of Kiichenmeister's scissors, one blade of which is provided Avith a small recurved hook. This buries itself in ECRASEUR--TENT-CARRIER. Fio. 4S. Fig. 49. 151 Improved Wire ficraseur. a. Full size. Barnes's Instrument for introducing Laminaria or Sponge-tents into the Uterus (R. B.). (Half size.) a. The hollow laminaria-tent. b. The sponge-tent. c c. The stilets upon which the tents are mounted. 152 INSTRUMENTS. the tissue as soon as the part is seized, and holds it secure whilst it is being cut through. The instrument answers well. (Fig. 4-).) Sims'8 Tenaculum Hook.—This is a very useful little instrument for seizing and holding steady the cervix uteri for examination, and during other operations through the speculum. (Fig. 47.) The Wire Ecraseur.—Advancing experience has gradually proved the superior convenience of the form of ecraseur here illustrated. (Fig. Is.) For ordinary purposes, such as the removal of polypi, the single Avire is far more convenient than the chain. The tAvo ends of the Avire are hooked on to the hook Avhich travels in the screAved stern of the instrument. The loop of Avire, Avhich has seized the body to be cut through, is draAvn through the flattened eye at the end of the stem Avithout any saAving movement. This involves a considerable loss of poAver; but in the ma- jority of cases this is of no importance. An advantage possessed by this arrangement is that a much longer loop can be Avorked, since the loop comes doAvn double ; Avhereas, when one end of the loop is fixed, and one only travels, the travelling end may be brought home too soon, that is, before the loop has cut through the tissues embraced in it. There is, hoAvever, the advantage of a half-saAving or cutting action, Avhich increases poAver. To obviate the inconvenience of the ends of the Avire travelling home before the loop has done its Avork, Messrs. Weiss have constructed a very poAverful ecraseur, furnished with a Avindlass upon Avhich the Avire is Avound as it is brought home. This gives practically an endless rope. It is a splendid instrument; and in some cases it will succeed Avhere or- dinary instruments will fail. To cut through large fibroid tumors a very poAverful instrument is necessary. The Laminaria and Sponge-tent Carrier.—This is a very useful in- strument, contrived by me some years ago, to carry laminaria-tents into the uterus. It consists of a piece of elastic catheter having the end cut off, so that the stilet may project about two inches. Upon this portion of stilet the tent, Avhich is holloAV, is mounted. It thus makes one with the catheter, and can be passed into the uterus nearly as easily as the uterine sound. When the tent is in situ, Avhich is ascertained by the guiding finger at the os uteri, the stilet is AvithdraAvn; the unsupported tent is then left in the uterine canal. This description shows that an efficient instrument can be improvised out of a catheter. But it is convenient to have a special instrument. (Fig. 41>.) Mine is provided with two sizes of stilets, Avhich screAV into the stem ; also with a pointed stilet to carry sponge-tents. These stilets are stowed in the handle, Avhich is hollow. At the handle-end of the catheter or tube is a disk or shield which gives a point of resistance for the thumb, Avhen the handle and stem are with- draA\m. The same instrument can be adapted to introduce the galvanic and other intra-uterine pessaries. The Intra-uterine Caustic Carrier.—My contrivance for the applica- tion of nitrate of silver to the os and interior of the uterus is an adapta- tion of a plan Avhich I learned, Avhen a student, from Sir Benjamin Brodie. This illustrious surgeon used to arm the end of a silver probe by dipping it into fused nitrate of silver. I have had made a long probe mounted on a handle. The last three or four inches should be made of silver, FOR TOPICAL MEDICATION. 153 platinum, or aluminium, so as to be flexible, as it is often convenient to give a curve. The extreme end should be roughened so as to hold the fused caustic better. To arm it, proceed as folloAvs: Fuse about half a drachm of nitrate of silver in a watch-glass or platinum-crucible, over a spirit-lamp or small gas-flame ; dip into the fused caustic the end of the probe several times, so as to get several layers upon it. The probe should be moderately Avarmed in the flame before dipping, or the nitrate of silver Avill be apt to break off Avhen cooled. (Fig. 50.) By means of this armed probe, caustic can be carried into the cervical canal, and even into the cavity of the uterus, Avishout any fear of leaving a piece behind. It may even be used Avithout the speculum, although in doing this, unless it be guarded by a sheath, the caustic is liable to touch the vulva in passing, and to cause some irritation in consequence, and to blacken the surgeon's fingers. Armed Avith a sheath it resembles Lalle- mand's porte-caustique. The Tube for carrying Solid Substances into the Uterus.—To apply sulphate of zinc, chlorate of potash, and some other substances, it is very convenient to fuse them into slender sticks of a given Aveight. To intro- duce these sticks into the uterus through a speculum by help of a forceps is a needlessly troublesome and sometimes difficult proceeding. A far more simple Avay is to cut off the end of an elastic male catheter, to place the stick in the end, and then to pass the catheter half an inch or more into the cervical canal, as you Avould a sound : then by pushing up the stilet, the stick is deposited in the uterus, and the instrument can be Avith- draAvn. This can be done more easily Avithout the speculum than with it; and Avhere an application of this kind has to be repeated once or tAvice a Aveek, this is a great advantage, saATing the patient annoyance and fuss, and the surgeon trouble. Instead of this improvised positor, it is better to have the special in- strument figured. (Fig. 51.) This is a silver or nickel tube furnished with a stilet. The Tube for carrying Ointments, etc., into the Uterine Cavity.— It is often convenient to make applications to the interior of the uterus in the form of ointment or fluid. For this purpose I have designed, with the assistance of Messrs. Wreiss, a very handy instrument. It is a long silver, nickel, or vulcanite catheter, having tAvo long eyelet-holes at the end, and a conical well-fitting piston or rod. It is easy to charge by plunging the end of the catheter beyond the eyelets into the ointment, and Aviping off the superfluity which hangs to the outside. The instru- ment is then passed like a sound into the uterus, and then the piston, being pushed forward, expels the ointment by the eyelets on either side, leaving it, of course, in immediate contact Avith the uterine mucous mem- brane. This is an especially useful Avay of treating the uterine membrane affected by syphilis. The iodide of mercury ointment is thus readily applied. (Fig. 52.) It ansAvers equally for the application of fluids. Thus by placing a bit of sponge in the end, and saturating it Avith the fluid, it can be passed into the cavity of the uterus. In this Avay I con- stantly apply tincture of iodine or nitric acid to the interior of the uterus. An Intra-uterine Injecting Apparatus.—By means of the above con- 154 INSTRUMENTS trivances for depositing solids, ointments, and liquids in the uterine cavity, the necessity for resorting to fluid injections is much restricted. Fig. 50. Fig. 51. h a n Barnes's Nitrate of Silver Cautery (R. B.). (Half size). Barnes's Tube for Depositing Fused Sticks a, Roughened end. 6, Armed. of Sulphate of Zinc in Uterus (R. B.). A. Piston pushing out. b, The zinc stick. But an intra-uterine syringe is sometimes indispensable. A good form is a small vulcanite tube, having minute perforations at the sides__not FOR TOPICAL MEDICATION 155 at the end—so that fluid projected may escape in fine streams or drops. The propelling force is best obtained by a movable caoutchouc ball. Fig. 52. !-> Fig. 53. m Barnes's Uterine Ointment Positor (R. B.). The left-hand figure is full size. A, the sliding- piston, which, being pushed on after the catheter is in situ, expels the ointment, or fluid soaked in sponge. Higginson's Vaginal Syringe. (Half-size.) Hii/t/inson's Syringe for Vaginal Injection and Irrigation.—There is no form of vaginal syringe more generally convenient for the patient's 156 INSTRUMENTS. 54. "\ Barnes's Speculum to Facilitate Application of Medicated Cotton- AA'ojI in the Viigina ,R. B.). (Haifsize.) own use than that knoAvn as Iligginson's. (Fig. ;>•■>.) It should be furnished with a vaginal tube four inches long. Barnes's Speculum for Introduction of Cotton-wool charged with remedies into the Vagina.—The best Avay of introducing pledgets of cotton-Avool charged with fluids or poAvders into the vagina is by help of the or- dinary speculum. But this requires skilled assistance. To enable the patient herself to carry out this treat- ment, I have devised the speculum figured (Fig. 54). It is made of vulcanite, a material not injuriously acted upon by the materials most frequently used. It con- sists of two blades, moving on a pivot about the middle, and a piston. The blades above the pivot are made to diverge by a spring inside ; this divergence causes the blades beloAV the pivot to come together, forming a IioIIoav cylinder in Avhich the pledget of wool is placed. The blades inclosing the pledget are further kept in contact by a strong elastic ring outside. When charged, the patient, by simply opening the vulva, can pass the instrument into the vagina, directing the point back- Avards as far as necessary; then by compressing the external diverging blades, the internal ones are opened, and by pushing on the piston or rod, the pledget is de- posited in the vagina. The speculum is then Avithdrawn by leaving off the compression upon the external blades. The action of this instrument will be better understood by an illustration. It was suggested to me by the ingenuity of a lady Avhom I had advised to introduce pledgets of avooI soaked in solution of bromine. She made use of a glove-stretcher to separate the labia vulvae, and then slipped in the pledget with her fingers. My speculum is like a glove-stretcher, with the blades holloAved to protect the pledget Avhile passing, and a piston to thrust it out into the vagina. The pledget of avooI is tied round with a bit of string. This string hangs outside the vulva, and by means of it the pledget is easily AvithdraAvn. No pledget should be Avorn longer than five or six hours. DIAGNOSIS. 157 CHAPTEE Y. THE DIAGNOSIS OF DISEASES OF THE PELVIC ORGANS. THE TOUCH—THE SOUND—THE SPECULUM. The general knowledge Ave have noAv acquired of the value of subjec- tive symptoms and of the instruments of diagnosis, will enable us to pur- sue with greater advantage those means Avhich bring out the objective signs, and thus to gain all the possible elements of a complete diagnostic conclusion. One guiding rule should be impressed upon the mind of the young practitioner, Avhen he has a case of presumed disease of the pelvic organs under investigation. Do not concentrate all attention upon this one region of the body. Remember that the fault may be in distant parts; that disease in other organs may complicate disease in the pelvic organs. Do not, in short, fall into the deplorable snare of becoming a specialist. Do not imitate the error of those physicians Avho, whilst repudiating the idea of being specialists, and Avho, when in the presence of a case marked by disorder of the nervous system, of the heart, lungs, or abdominal vis- cera, carefully explore the state of the organs contained in the skull, chest, and abdomen, yet scrupulously avoid exploring the not less im- portant organs contained in the pelvis; and that even although the symp- toms point to disorder in this region. The great clinical rule should be: Interrogate all the functions; exa- mine every organ. In this Avay only can Ave acquire a Avell-founded con- fidence that important disease is not overlooked; in this Avay only can Ave rightly estimate the relations of symptoms to disease, and the reactions of disease upon distant organs, and frame a rational plan of treatment. A Avork Avhose intention it is to illustrate the pathology of the pelvic organs, must necessarily obseiwe the limits of the design. The art of diagnosis, therefore, as applied to the pelvic organs, demands the most elaborate description. But in tracing this Avith almost exclusive care, as it must be done in a work ad hoc, it must not be supposed that general pathology or general diagnosis can ever be pretermitted in actual practice. If it be admitted to be necessary to investigate all the functions of the body in connection Avith any presumed localized disease, d fortiori it is necessary, in any case of presumed disease of one of the pelvic viscera, to examine the state of the rest, its immediate neighbors. We must then never neglect to inquire into the state of the bladder and rectum. These organs seldom escape disturbance when the uterus, vagina, or ovaries are affected; primary disease in them, in its turn, affects the uterus, vagina, and ovaries; and not seldom, symptoms seemingly indicative of disease in the uterus or vagina are really due to disease in the bladder or rectum. The order of clinical proceeding, then, may be laid doAvn as folloAvs:—■ If a patient complain of distress referred to the pelvic organs, or dis- 158 DIAGNOSIS. order of their functions, note first the subjective symptoms : 2, interrogate the functions of the nervous, circulating, respiratory, and nutritive organs : 8, elicit the history of the patient as to her general health, and the ante- cedents and course of her disorders; 4, if the indications point to disease in the chest or abdomen, subject the organs contained in these cavities to physical exploration by sight, palpation, percussion, measurement, auscultation, etc.; 5, subject to physical examination, by the methods here- after described, the state of the pelvic organs, observing at the time, or reserving for chemical and microscopical analysis, the nature of the local secretions, or of solid substances expelled; G, Avhen all necessary informa- tion has been obtained, compare the symptoms and facts in their individual, relative, and aggregate significance, so as to work out the diagnosis which shall determine treatment. Fig. 55. skeleton Diagram for Recording Alterations of Size, Position, and Relations of Pelvic and Abdominal Organs. In taking doAvn a case, it is well to follow the order indicated above • and since " Avord-painting" can hardly be so graphic as actual drawimr' DIAGNOSIS. 159 it Avill be found of great service to attach to the notes diagrammatic memoranda of the position, shape, size, and other conditions of the organs under observation. These become extremely valuable as standards of comparison during the future progress of the case, and by furnishing more intelligible records for other persons. To record these observations, Fig. 56. SkI'lcton Diagram for Recording Alterations of Size, Position, and Relations of Abdominal and Pelvic Organs. outline or skeleton diagrams like those represented in Figs. 55, 56, will be extremely convenient. The idea of these will be found in the grandest memoir on the diagnosis of abdominal tumors ever published, that of Dr. Bright, in Guy's Hospital Reports. 160 DIAGNOSIS. The physical exploration of the pelvic organs is conducted chiefly by the touch! The touch is applied either directly by the hand, or mediately through instruments. The touch is sometimes aided by sight, facilitated or not by the speculum or other contrivances for bringing concealed parts into vieAv. The touch is also sometimes aided by the sense of smell. The touch takes precedence in importance and in order of application of all other methods. We may therefore usefully recall Avhat Gooch said about the " tact us eruditus." " Some are of the opinion that this art is a blind tact, to be gained only by practice ; but this is not true ; the period of my life Avhen I improved most rapidly in the art of deciding by examination cases of doubtful pregnancy Avas that in Avhich I gained clear and orderly notions of the objects of examination. The faculty of obser- vation requires rather to be guided than to be sharpened; the finger soon gains the faculty of feeling, when the mind has acquired the knoAvledge of what to feel for." The "tactus eruditus" may be defined as the " educated touch." Hoav is the finger educated? Greatly by practice in feeling the various condi- tions of form, size, consistency, and relations of the parts upon Avhich this sense is to be exercised. But touch alone will never give perfection to the finger as an instrument of diagnosis. We must be content, if avc would attain precision in its use, to imitate the example of children A\dio, in their earliest introduction to the study of external objects, correct the evidence of one sense by appealing to another. When they see a strange object they try to feel it also, and eAren to taste it. It is by this tenta- tive method of cross-testing that children extend their knoAvledge of Na- ture. We must do the same. We must correct touch by sight, and even call the other senses to our aid. Manual examination, or examination by touch, embraces the folloAving modes of exploration: In some, one or both hands only are used; in some, the hand is aided by the sound or other instrument. 1. Simple vaginal touch, by one finger. 2. Abdomino-vaginal.—The vaginal touch is aided by abdominal pal- pation Avith the other hand. 3. Simple rectal touch. 4. Becto-ahdominal.—The finger in the rectum is aided by abdominal palpation. This mode is often useful in determining the size and relations of the uterus, the complication Avith uterine or extra-uterine tumors, or the existence of the uterus in vaginal atresia. 5. Becto-vaginal. 6. Urethrovaginal.—The finger in the vagina is aided by the sound in the urethra. 7. Uretho-rectal.—The finger in the rectum is aided by the sound in the urethra ; indispensable in investigating cases of vaginal atresia. 8. Simple abdominal palpation and percussion. 9. Uterine exploration by the sound. 10. Utero-abdominal.—The sound in utero is aided by abdominal pal- pation. 11. Utero-rectal.—The sound in the uterus is aided by rectal touch. 12. Examination by speculum.—Here the sight is the main source of information. MODES OF EXAMINING. 161 13. Examination of the secretions, discharges, or substances expelled. Before instituting intra-pelvic exploration it is desirable to ascertain the state of the abdomen. The patient in dorsal decubitus is examined by palpation and percussion to determine the presence or absence of ab- dominal tumors or of pelvic tumors rising into the abdomen. This sub- ject will be found carefully discussed under the diagnosis of ovarian tumors. THE MODE OF MAKING A DIGITAL EXAMINATION. Examination by the hand should always precede the use of instru- ments. Because,—1st. In many cases the information gained by the hands is sufficient; 2d. The information gained by the hand commonly tells us how best to use other diagnostic instruments ; 3d. In some cases, notably in cancer, in Avhich sufficient information can be gained by the hands, instruments may do positive harm. The patient is placed either in the lateral or dorsal decubitus. Each position has its advantages. In making a first exploration for diagnosis, it is most convenient to place her first on her left side, the knees draAvn up, the head and shoulders directed obliquely across the couch, on a level, or nearly so, Avith the nates, and the nates brought near the edge of the couch. This affords perfect facility for digital touch, also for the sound, and often for the speculum. If the patient lies on her left side, the surgeon will find it best to use his left hand, for then his right hand is conven- iently disposed for palpation above the pubes, and to examine in concert with the finger of the left hand in the vagina. If he can only touch Avith his right finger, he must cross his left hand aAvkAvardly over his right to get at the abdomen. It Avould be better in this case to place the patient on her right side, Avhen things will be disposed conveniently for the right- handed surgeon. But the obstetric surgeon, like his ophthalmic brother, ought to be ambidexter, and should sedulously cultivate the equal use of both hands. Supposing the patient to lie on her left side, the usual obstetric posi- tion, the surgeon having anointed his left index Avith cold cream, olive oil, glycerine, ATaseline, or soap, arranges the bed-clothes or dress Avith his right hand. To lessen risk of infection, it is Avell to use carbolized oil. The radial edge of the left hand is then directed between the nates, and determines the relation of the parts by feeling the loAver end of the sacrum and coccyx and anus : the finger then passing along the raphe of the perineum, comes necessarily to the edge of this structure at the pos- terior commissure of the labia, and therefore falls surely between the labia ; the pulp of the finger is made to enter at this spot, and its further progress is made by pressing the back of the finger against the distensi- ble perineum and omvards, folloAving the curve of the sacrum. The reasons for this mode of proceeding are to save the patient the annoyance of touching the sensitive structures at the pubes, and to get at once be- tween the labia, Avhich it is not ahvays easy to do, if the finger be directed more fonvards. It is also much more easy in this way to folloAV the curve of the vagina. To reach the os uteri, Avhich often lies high up under the promontory of the sacrum, it is commonly necessary to press 162 DIAGNOSIS. the perineum Avell back. The os uteri is found, then, by making the finger feel its Avay all along the posterior Avail of the vagina to its roof, until the cervix is reached. It first takes note of the size, shape, firm- ness, and character of surface as to its smoothness or roughness of the vaginal-portion of the cervix ; of the character of the os externum as to patency or closure, of its form, Avhether a fissure or round. Having made these observations, the finger next takes note of the condition of the supra-vaginal portion of the neck and of the body of the uterus. Feeling all round the \raginal portion, pressing the finger lightly into the fundus of the vagina, in some portion of the circumference, the re- sistance due to the solid cervix or body will be felt. FolloAving this, the cervix is traced by continuity into the body. If the uterus is in normal position, its body is felt in front of the cervix through the upper and an- terior Avail of the vagina. Three other points may noAV be studied: the bulk, the sensitiveness, and mobility of the uterus. The bulk is estimated by poising the cervix uteri on the tip of the finger, Avhilst the hand is pressed in above the symphysis pubis, until the solid body of the fundus uteri is felt. Thus, the uterus is caught in its extreme length between the two hands, and allowance being made for the thickness of the abdomi- nal Avail, a fair idea is obtained of its length and bulk. The necessary pressure will determine the sensitiveness of the uterus; and the poising of it on the finger, alternating with depression on the fundus, brings out the degree of mobility. If the uterus is in reclination, the solid resistance of cervix and body is felt through the vaginal roof behind the os. Again, by combined abdominal palpation, the body is caught between the two hands, not in its long axis, for the fundus lies under the sacral promontory, but across its body. The diagnosis is verified by bringing the examining finger in front of the cervix; and then when abdominal palpation is resorted to, the hands approaching each other, find no intervening body, i. e., no uterus betAveen them. The finger next explores, by aid of abdominal palpation, the lateral regions of the pelvis. In this Avay, if there is deposit in the broad liga- ment, distension of the Fallopian tubes, or enlarged or prolapsed ovary, the abnormal condition may be made out. THE DIGITAL EECTAL TOUCH. The lateral position of the patient is still the best for the examination by the rectum. The forefinger, lubricated, is passed into the rectum, and exploring as it goes the anterior wall, the uterus is felt through it. Com- monly, the vaginal-portion is easily made out. If the uterus is strongly anteverted, so that the os is thrown backwards, this part will project into the rectum. This position will account for the pain sometimes suffered at stool, when the cervix uteri is inflamed and enlarged. One of the greatest advantages, however, gained by rectal touch, is the greater reach it gives one over the body of the uterus ; and the greater area brought under exploration. The finger not only reaches much higher, but may be made to sweep right and left in the lax rectal pouch, getting Avell behind the broad ligaments, feeling the ovaries, and examining the state EARLY PREGNANCY. 163 of Douglas's pouch. If the uterus be retroverted or retroflected, the finger may usually reach the very fundus, and thus take a very accurate estimate of its bulk, form, position, and sensitiAreness. The OAraries, again, which lie a little behind the uterus, may, in some of their abnormal con- ditions, often be explored Avith precision by the rectum. In the case of some uterine tumors and retro-uterine effusions, as haematocele, or peri- uterine effusions, examination by rectum supplements vaginal touch, giving often even more valuable results. Combined with abdominal palpation, rectal touch determines with great accuracy the bulk of the uterus. It can often be commanded more completely in this Avay than by vaginal touch. In some cases it is justifiable, under anaesthesia, to pass the whole hand into the rectum. EXAMINATION BY THE BLADDER. It is possible and sometimes desirable to explore the bladder by the finger in the urethra. This canal in the female is short and very dis- tensible. It may be dilated very quickly by Weiss's urethral dilator. But in the majority of instances, mediate exploration by the catheter or uterine sound supplies the information that is sought. The exploration of the abdomen by palpation and percussion is, of course, best conducted with the patient in the dorsal decubitus; and this position is also often the best for the combined vaginal touch and abdomi- nal palpation. The uterus in this decubitus is more easily grasped and pressed doAvn into the pelvic cavity into contact with the finger in the Aragina. Further information is gained by the sound. This is virtually a lengthened finger. It extends the sense of touch beyond the point Avhich the finger can reach. If there be sufficient indication to use it, it should be introduced before the finger Avhich has been making the observations already described is AvithdraAvn, as it is desirable to avoid the necessity of haA'ing to repeat the vaginal touch. Before taking up the sound, one precaution is imperative. Be satisfied that the patient is not pregnant. We may acquire reasonable assurance of this negative if, by combined vaginal touch and abdominal palpation, Ave find the uterus not exceeding the normal bulk, and the "os uteri hard and small. If, on the other hand, Ave feel the os uteri soft, tilted far back under the promontory of the sacrum; if Ave feel " anterior vaginal roof- stretching," and the bulk of the uterus increased, the presumption of pregnancy is great. Then, do not take up the sound. Another rule is useful. 'Never use the sound unless you have trustworthy evidence that the patient has fairly menstruated within the preceding fortnight; or that the suspension is not due to pregnancy. As this rule in practice is exceedingly important, I introduce a special illustration in order to draw attention to the physical signs Avhich afford presumption of early pregnancy. (Fig. 57.) The suspicion of preg- nancy, hoAvever, does not necessarily exclude the speculum. And this instrument may be the means of clearing up the doubt. The deep violet color of the vaginal-portion and vagina, and the thick creamy discharge, added to the increased bulk and anterior vaginal-roof stretching, con- 164 DIAGNOSIS. stitute a strong body of eA'idence rendering the diagnosis of pregnancy almost certain. It is also generally improper to use the sound it there is evidence of metritis, or extreme tenderness on touching. Designed to illustrate Diagnosis of Early Pregnancy (R. B.). B, Bladder, r, Rectum, u, Gravid uterus in anteversion. o, Os uteri tilted up, and stretching the anterior vaginal wall from o to v, making this part tense and elastic. THE MODE OF USING THE UTERINE SOUND. The patient still lies on her left side. The examining finger on the os uteri serves as a guide. The sound, held Avith its concavity forward, is carried along close to the examining finger to the os, into Avhich it is introduced. When it has passed an inch or so, an obstruction is com- monly met; this is the isthmus, or os uteri internum. At this point the direction of the cervico-uterine canal changes ; and a corresponding change must be given to the direction of the point of the sound. When the axis of the uterus is normal, the canal curves gently forwards, so that by carrying the handle of the sound lightly backwards the point will folloAV this curve. In giving the direction to the sound we are guided by the information gained by the digital touch. The body of the uterus has been felt in front of the cervix. As the point of the sound passes on, the finger on the os uteri takes note of the extent to which it passes, and when it feels the elbow or projection Avhich marks off two and a half inches from the point, on a level with the os externum, a sense of resist- USE,OF THE SOUND. 165 ance is communicated to the touch. The point has reached the fundus of the uterus, usually the most sensitive part, and the patient will commonly complain of pain unless the utmost gentleness is used. The introduction of the uterine sound resembles the introduction of the vesical sound or catheter in the male urethra. It requires the like delicacy of touch ; the instrument is made to feel its Avay rather than to be propelled by force. When the sound has touched the fundus, by imparting light movement to the handle backAvards and forwards, we ascertain more clearly the mobility of the organ, its relation to neighboring parts, and especially if the form or bulk of the uterus is altered by fibroid or other tumor in its Avails or outside. Whilst the sound is in sitii supporting the uterus, the hand outside depressed above the pubes readily feels the fundus, and this pres- sure is communicated through the sound to the hand Avhich holds it. By this combined manipulation also a closer idea is formed of the size, form, mobility, and relations of the organ. The variations in the mode of using the sound required by different morbid conditions Avill be described in the appropriate places. It will be sufficient to add in this place a brief description of the mode of usin the cervix at the bottom. This direction is also the most convenient for therapeutical manipulation. The mode of passing the instrument is easy. The exploring finger determines the position of the cervix uteri, and the capacity of the vagina and vulva. The larger or smaller blade is selected accordingly, and then holding open the vulva with one or tAvo fingers, the end of the blade is slipped in as near the perineum as possible, first Avith the width of the spoon in a line Avith the vulvar fissure, and then, as soon as the end has fairly entered, the instrument is rotated so as to bring the back of the spoon against the perineum; the guiding finger in the vagina then, aided by gentle pressure on the handle by the other hand, carries the point of the blade along the posterior Avail of the vagina to its place behind the cervix. When in situ, in order to bring the cervix into vieAv it is neces- sary to hold back the instrument firmly against the perineum, Avhich being distensible and yielding permits the curved vagina to become straight, and thus the cervix to be seen. Sometimes wdien the vagina is large and lax, the anterior Avail will bulge up against the speculum, and hoAvever much the perineum may be retracted, the cervix cannot be seen, until either by the finger, the handle of the sound, or a retractor made like a tongue-depressor, the anterior Avail of the vagina is pressed up against the pubes. Sims further recommends the use of a fine hook (see Fig. 47) to seize the vaginal portion, to pull it up into sight, and to fix during the application of remedies to the surface or to the anterior of the uterine cavities. This hook causes little pain, and the Aoav of a feAv drops of blood. But although very convenient in some cases, it may be dispensed with as an habitual aid in examination and treatment. Introduction of the Author's " Crescent-Speculum."—The passage of the first blade is made exactly in the same Avay as Sims's speculum. The patient lying in the semi-prone position on her left side, the surgeon takes the larger blade (Fig. 42) in his left hand,Avhilst one finger of the right hand introduced through the vulva feels for the os uteri; this finger serving for a guide, the end of the blade is slipped in over the perineum in close approximation to the finger, and carried along it so as to get be- hind the os uteri. If this direction is folloAved, there will be no hitch against a fold of the vagina. AVhen the blade has passed in, the handle is held Avell back so as to depress the perineum. The right knee is then raised so as to enable the surgeon to introduce the second blade, Avhich being a degree smaller than the first, fits into it as in a groove. The uterine end is adapted inside the blade of No 1, held firmly Avith the left hand, and is then made to slide doAvn in No. 1 until the handles of the tAvo blades are on the same level. Then the tAvo handles being brought forward, the two blades Avork as bent levers, upon the angle of junction of handle and blade, Avhich serves as a hinge or fulcrum; the uterine 170 THE OVARIES. ends thus diverge like tAvo valves, stretching the roof of the vagina, and giving an excellent view of the vaginal portion. The withdrawal of the instrument is very simple. The two blades are removed separately, the anterior one first The gentlest traction in a curved sweep following the curve of the blade Avill bring the instrument out, the contraction of the vagina helping to expel it. CHAPTEK YI. THE PATHOLOGY OF THE OVARIES.—THE HISTORY OF MEXSTRUATIOX AND ITS DISORDERS. The relation of the ovary to the function of menstruation has been re- ferred to Avhen describing the anatomy of this organ. A feAV further observations upon this subject are necessary to serve as an introduction to the study of the disorders of menstruation, and of the organic diseases of the ovary. The most important laAvs in this application to pathology are illustrated in the folloAving facts :— The catamenia, the name given by Aristotle to the monthly discharge from the uterus, indicates the periodicity of menstruation. In all lan- guages, and throughout all ages, names indicating this periodicity have been adopted. The " menses," " menstruation," " les mois," " les regks," are examples. But this character of periodicity, so striking, Avas not traced to its true cause or connection until the present century. It was scarcely suspected, certainly not demonstrated, that the periodical monthly Aoav Avas depend- ent upon another periodical act, the ripening of ova. Dr. PoAver, a man of singular sagacity, seems to have been the first to seize upon this great fundamental fact. In 1821 he distinctly enunciated the theory. Gird- wood, in 1826, brought neAv observations in proof. It Avas, hoAvever, warmly disputed in this country, especially by Dr. Robert Lee, whose authority probably retarded its general acceptance, so that it Avas not until Xegjrier,1 in 1831, Avorking as it appears independently, proved by adequate researches and anatomical preparations, that the outAvard and visible periodical discharge of menstruation Avas the expression, the con- sequence of an internal and hidden, but superior function. Gendrin, Paterson, Raciborski, Bischoff, and others folloAved Avith fresh proofs which are generally held to have established the theory. The prepara- tions of Coste, preserved in the College of France, shoAv the following 1 Recueil de faits pour servir a l'Histoire des Ovaires. Angers, 1858. MENSTRUATION. 171 points : A Graafian vesicle, the ripening of Avhich always coincides Avith the turgescence of the genital organs, pursues the course of its develop- ment during the various phases of menstruation; and, according as the circumstances are more or less favorable, it may burst at the commence- ment, or tOAvards the end, or at any moment of this periodical discharge. In a Avoman Avho died on the first day of the appearance of the menses, the ovarian vesicle Avas manifestly ruptured. In another, Avho died four or five days after the cessation of the menses, the right ovary presented a vesicle still intact, but so distended that the slightest pressure made it burst. Lastly, in a young virgin, who died fifteen days after menstrua- tion, there Avas no recent trace of a yellow body, and it could not be doubted that the Graafian vesicle had been arrested in its development. The subjects of these observations had all died a violent death in the midst of health. Thus, we may conclude that at each menstruation a Graafian vesicle assumes a marked preponderance over the rest, arrives spontaneously at maturity, and, generally, bursts at an indeterminate moment of this period, in order to expel the ovum it contains. But, nevertheless, in certain cases this vesicle may also remain stationary, or be totally absorbed. The double phenomenon is analogous to Avhat is observed in other mam- mifera, during the rut. Riederer1 observed that the ovaries greAv towards the epoch of com- mencing menstrual life, and became atrophied at the menopause. He distinctly found that the atrophy of the ovaries Avas more marked and more closely associated with the cessation of menstruation than Avas the atrophy of the uterus. If the ovaries are absent or ill-developed, girls do not menstruate, the breasts are flaccid or defective in development; the characters of Avoman- hood do not become manifest. This may be said to be experimentally proved by the celebrated case of Pott. A girl, aged 23, of good con- stitution, Avent to BartholomeAv's Hospital, in consequence of tAvo tumors situated in the groins, Avhich had for several months caused her so much pain that she could not attend to her work. She Avas healthy, and men- struated regularly. The tumors Avere soft, une\ren, easily movable, and lay externally to the tendinous apertures of the inferior abdominal Avail. Pott determined to remove them. After dividing the skin, a thin mem- branous sac Avas found, in Avhich a body Avas inclosed that Avas taken to be the ovary. It Avas removed, and the same operation Avas repeated on the other side. From this time forth she never menstruated, her breasts fell aAvay, and the muscular system became developed as in man. Since ovariotomy has been so Avidely practised several cases have been observed in Avhich both ovaries have been removed. In some of these menstrua- tion has continued to recur. Still it may be affirmed as a general laAV that Avhen the ovaries are extirpated or become atrophied, menstruation does not reappear. Raciborski says the menses may be a little postponed, but that this does not ahvays prevent the follicles from pursuing their regular course, and from accomplishing dehiscence. He has seen on OA-aries of young girls one or tAvo cicatrices, although they had never 1 Icones Uteri Humani, 1779. 172 THE OVARIES. menstruated. Thus also women who had never menstruated have con- ceived. Whitehead relates cases. But these cases are rare. Concep- tion during lactation whilst menstruation is suspended is not uncommon. The first dehiscence corresponds with the first appearance of the menses. Dr. Ritchie1 also adduced evidence to show that ovulation may go on although there is no menstrual discharge. Negative observations, then, as to the menstrual Aoav do not prove that ovulation is also suspended; and ovulation is obviously the condition of impregnation. Objections, however, to this theory have been urged by W. B. Keste- vcn2 who may be said to have led a reaction against it. lie insists that: "1. Menstruation is a periodical function of the uterus ; 2. That ovula- tion is the constant function of the ovaries ; 3. That ova are discharged at all periods of female life, in the intervals of, as well as at the time of, menstruation ; 4. That ovulation and menstruation being often concurrent, indicates that they are both the result of the attainment of a certain point in the development of the female economy ; 5. That the laAv of periodicity in the one not obtaining in the other, leaves still wanting the link in the chain of causation, Avhereby menstruation can be sIioavii to be the effect of ovulation ; 6. That at the menstrual periods the ovaries experience an extension of the uterine congestion, and become, equally with the uterus, the seat of increased functional activity." These objections have been taken up by several German writers. The only fact of importance added to Mr. Kesteven's argument is, that several Avomen have continued to menstruate after the extirpation of both ovaries. We are probably not yet in a position to set forth absolutely the relations of these functions to each other, and to other processes in the economy. That the relation is intimate is certain ; the order of occurrence or prece- dence is uncertain. But the objections cited are less weighty than may be supposed. That ovulation should sometimes fail to evoke menstrual discharge does not prove that it is not the normal efficient factor ; and the recurrence of menstruation after removal of the ovaries, is explained by the habit of periodicity acquired during the ovarian activity. This habit is seen in climacteric Avomen Avho often have periodical hemorrhages long after the atrophy of the ovaries and uterus. There is one remarkable circumstance Avhich has not attracted the Aveight it merits in this discus- sion. It is this : Menstruation, the uterine function, is almost peculiar to Avoman; but ovulation is the universal laAv throughout the animal and vegetable world. The presumption is therefore ovenvhelming that it is the essential, the primary phenomenon. Another fact upon Avhich I would insist is that in numerous cases pregnancy occurs at an early age, before the uterus, the nidus, is sufficiently developed for the accommoda- tion of the ovum ; and that in such cases abortion is the common issue. Analogous cases occur at the other extreme of sexual life ; conception occurs Avhen the uterus is undergoing the atrophy of reproductive extinc- tion. Here again abortion is the frequent issue. Here Ave have evidence of attempted response of the infantile or the senile uterus to the ovarian 1 Ovulation during Amenorrhoea. Ed. M. & S. J., 1845. 2 London Medical Gazette, 1849. MENSTRUATION. 173 stimulus. Since then, the ovary begins to act before, and continues to act after, the uterus is fit for its share in the work of reproduction, the presumption is strong that the ovary is the initiative organ, the primum mobile in generation. This vieAV is further strengthened by the following observations of Professor Laycock: "When we remember the influence of the ovaria in exciting abnormal development of other structures con- nected with them, as the larynx, mammae, and thyroid body, the changes Avhich they undergo often resembling those consequent on pregnancy, Ave may hypothetic-ally infer that similar changes may occur in an appendage having so close a connection Avith the ovaria as the uterus, and that an hypertrophy of that viscus may be produced, giving rise to all the pheno- mena of pregnancy, and originating in ovarian irritation."1 Of so little importance indeed is the uterus that reproduction may be successfully carried through Avithout a uterus. There are many examples of this in the animal kingdom ; and the history of extra-uterine gestation proves the same proposition in Avoman. Nor must it be supposed that the phenomena of ovulation and menstrua- tion are strictly local. In my Lumleian Lectures, and in various other Avritings, I have pointed out that menstruation, and probably ovulation also, are, like pregnancy, preceded and accompanied by, 1. Increased central nerve-irritability ; 2. Increased vascular tension. There are three associated phenomena Avhich strike the observer. A general increase of nervous and vascular tension ; ovulation or the enlargement of the ovary; the development of the uterine mucous membrane and the menstrual Aoav. Do these phenomena, essentially concurring as they do in the accomplish- ment of one definite purpose, arise simultaneously ; do they arise succes- sively ; and if they arise successively, Avhat is the order of succession ? Upon this question I am in a position to throAV light. I have had the opportunity of observing in my Avard at St. George's Hospital a case in which there Avas hernia of the left ovary. Thus the organ, naturally removed from direct observation, offered itself to continuous inspection. Observations were made—1. Of the vascular tension as tested by the sphygmograph; 2. Of the temperature ; 3. Of the size, and other condi- tions of the ovary ; 4. Of the appearance of the menstrual flow. The vascular tension Avas noted first; then the Aoav and the SAvelling of the ovary nearly simultaneously. The following tracings (Figs. 59, 60, 61) are taken by Dr. Fancourt Barnes: Fig. 5i> sIioavs the high tension preceding the menstrual Aoav, Fig. 60 shows the extreme high tension at the end of gestation. It is comparable to the high tension of chronic Bright's disease. Fig. 61 shows the ordinary tension after menstruation. The fall quickly folloAvs the menstrual Aoav. Amongst the lastest investigations that have attracted attention are those of Kundrat and Engelmann.2 These authors consider that the men- strual hemorrhage is a retrogressive process, under Avhich the superficial layers of the mucous membrane, having undergone fatty degeneration, are being exfoliated. It would folio av from this vieAV that with the ap- 1 Nervous Diseases of Women. 2 Strieker's Med. Jahrb., 1873. 174 THE OVARIES. pearance of the menstrual hemorrhage the generative processes of the period are brought to a close, and that a conception occurring at any moment after this time, must be due to a newly-discharged ovum which imbeds itself in the mucous membrane as it is newly formed. They, Fig. 59. Fig. 60. High Tension preceding Menstruation. High Tension in Ninth Month of Gestation. Fig. 61. After Menstruation; Tension fallen (after Fancourt Barnes). however, appear to overlook the general nervous and vascular tension, an essential factor in the process. And the analogy they assume between fatty degeneration of the mucous membrane in connection with menstrua- tion and fatty degeneration of the placenta at the end of gestation fails, by the fact that the placenta does not, under normal conditions, undergo fatty degeneration. The theory that the placenta underwent fatty degenera- tion preparatory to labor was started by Druitt whilst studying my origi- nal researches. It is disproved by observation, and is at variance Avith physiology, since vessels in degeneration would become unfit for their function, and this at a time Avhen the function is at its highest pitch, and calling for perfect integrity of tissue. Menstruation, then, is the natural epoch for the escape of ova ; and, consequently, it is the most favorable to conception. But a question of great interest is attached to this conclusion. Do the epochs of ripening and of the natural fall of the ova ahvays and of necessity return in a regular manner? That is, are there not other influences besides the rut and menstruation, capable of hastening the epochs of maturation and fall of the ova ? This must be answered in the affirmative. Thus, the pigeon in its wild state lays eggs only once or tAvice a year, whilst in our pigeon-houses it lays seven or eight times. Hens, whose eggs are taken away from them to prevent their sitting, lay almost every day for eight months in the year. The rabbit, which in a state of liberty has only one or two litters a year, has perhaps seven when its young are taken away at a suitable time. The period of maturation, then, far from being MENSTRUATION. 175 immutable, appears to depend upon certain conditions Avhich may accel- erate or retard it. Similar conditions exert similar infiuences in Avoman ; and there is reason to believe that sexual intercourse may hasten the ma- turation of ova, and especially their escape from the ovary. Admitting, hoAvever, as we must, the occasional operation of disturbing circumstances, the general laAv is that these phenomena are reproduced periodically; and that during the periods Avhen they are mainifested cer- tain signs attend, Avhich in the aggregate bear the name of menstruation. Consequently the ripening of ova, and most frequently their dehiscence, are revealed outwardly by the appearance of the catamenia. We may now conveniently study this function from a clinical point of vieAV, fixing our attention mainly upon those phenomena Avhich are open to direct observation. Pouchet1 has distinguished the different phases of menstruation with great precision, by defining its different periods, and by comparing, by help of the microscope, the discharges attending it Avith those of the intermenstrual period. Characters of the Menstrual Discharge.—The first sign of the advent of the menses is the manifestation of a particular odor imparted to the mucus secreted by the sexual organs. The second sign is a change of color of the utero-vaginal mucus ; at first, dull Avhite, it becomes broAvn- ish ; some blood-disks, mingled with numerous mucous globules and fragments of epithelium, floating in the liquid account for this change of color. The first period lasts one or two days. Sometimes it immediately precedes the Aoav of blood; sometimes the mucus becomes normal again ; then, after an interval of a day, blood,#almost pure, suddenly escapes from the vulva. The Aoav of ruddy blood constitutes the second period. The fluid secreted is composed of blood, not differing from arterial, mixed Avith vaginal mucus. By the microscope Ave find mucous globules in various stages of development, thin fragments of transparent epithelial scales, mixed with innumerable blood-disks. This flow usually ceases in three or four days ; but in some Avomen it is continued for seven or eight days, Avithout obvious departure from the physiological condition. The menstrual blood differs from pure blood, in not coagulating ; that is under ordinary conditions. Dr. Whitehead explained this by shoAving that the vaginal mucus has an acid reaction, and that contact of the blood with this acid prevented its coagulation. Donne" also says that menstrual blood is acid, containing phosphoric and lactic acids. Mandl, hoAvever, sIioavcmI that the smallest quantity of pus or mucus stopped blood from coagulating. Noav, the menstrual discharge is blood mixed with mucus. That admixture with mucus accounts for the fluidity of the menstrual discharge may be admitted; and so long as the quantity of blood is Avithin normal bounds, the proportion of mucus supplied is sufficient; but if the blood be in excess, and if it be retained a little Avhile, it will coagulate. Thus it is that in menorrhagia clots are frequently passed. The quantity of the blood exhaled becoming less and less abundant, its color changes from red to broAvn, the proportion of blood-disks diminishes, whilst that of the mucous elements increases: at length the 1 Tbiorie Positive de l'Ovulation Spontanee. Paris, 1847. 176 THE OVARIES. mucus itself becomes thinner. It is especially at the end of this period. that the Graafian vesicles may burst spontaneously. When the menstrual discharge has ceased, the internal surface of the uterus, and also that of the vagina, cast off numerous epithelial scales, at first nearly entire, but soon reduced to fragments of more or less tenuity. These scales or debris constitute during the first intermenstrual days the greater part of the solid elements contained in the excretions by the vulva ; the rest is composed of a variable number of mucous globules. \ irchow insists that the detachment of the uterine mucous membrane is more com- plete than is generally supposed, and that in normal menstrual blood heaps of cells are often met Avith, Avhich by their structure reveal their origin in the uterine glands. As in Avomen avIio have already menstruated, the menses are preceded by a modification in the quantity and color of the normal secretions ; so in the girl, who, having not yet menstruated, has arrived at puberty, the menstrual hemorrhage is often preceded by a serous whitish or broAvnish discharge. This discharge may anticipate by several months the appear- ance of the blood, and may recur several times before this makes its appearance. Often also after the first sanguineous discharge in a young girl, several months may intervene before the menses set in. The similarity of the phenomena attending the first advent and the climacteric cessation of menstruation is especially deserving of note. There is, 1. Irregularity as to periodicity. 2. Occasional excess of blood-loss, amounting to hemorrhage. 3. Alternate enlargement and subsidence of the abdomen. 4. Pain and induration of the breasts. The quantity of blood discharged at each epoch varies in different Avomen, and in the same Avoman under different circumstances. It usu- ally ranges from three to four ounces. Generally it is more abundant in Avomen living in luxury. And, according to Burdach and Brierre de Boismont,1 it is more copious in hot than in cold countries. Our country- women in India are .more subject to menorrhagia that Avhen in England. A vulgar error still prevails that the menstrual blood has fetid or even poisonous properties. This is only true under the conditions of retention, of uncleanliness, or admixture with the products of disease. The Source of the Menstrual Blood.—Haller Avas aware that it came from the Avomb. Observations in point have been made under two different conditions ; that is, in the living and in the dead. First, the uterus exa- mined in cases of complete prolapsus, and where there is no prolapsus, by the speculum, blood is seen to issue from the os uteri; and in cases where the uterus is turned inside out the menstrual blood is seen directly oozing from the mucous membrane of the body of the uterus. Secondly, on examining the bodies of Avomen Avho have died during menstruation, Coste and others, myself among them, have seen the vascular apparatus of the uterus developed and injected in an extraordinary manner. The vascular structure of the mucous membrane, in particular, forms on the surface, under the fine layer of epithelium Avhich covers it, a beautiful network, each mesh of which incloses a glandular tube. This vascular 1 De la Menstruation dans ses Rapports Physiologique et Pathologique. Paris, 1842. MENSTRUATION. 177 reticulation is so marked and rich that it gives a more or less deep violet tint to the inner surface of the uterus. According to all probability it is through the Avails of these ramuscules that the menstrual blood oozes. "In one case," says Coste, "death took place exactly at the moment Avhen the blood began to ooze through the engorged vessels. There were seen in the course of these vessels an innumerable multitude of small red points, as if the mucous membrane had been pricked with a fine needle, each prick giA'ing issue to a minute droplet of blood. Here and there, under the epithelium, Avere small ecchymoses, indicating that the hemor- rhage, suspended by death, had not yet made a complete escape. In other women the phenomenon being more advanced, the cavity of the uterus Avas found filled with red fluid blood, about to escape by the neck." Some experiments made by MattheAvs Duncan to determine " the poAver of,the uterus to resist a bursting pressure" (1868), seem to me to find application here. Air Avas forcibly driven by a pump against a piece of uterus stretched over a tube. " It was curious," he says, " to observe the permeability of all the unruptured tissues to this fluid." The experi- ments being performed under Avater, the air bubbled up, or effervesced from the peritoneal surface by innumerable minute points. In all pro- bability the mucous membrane of the uterus and the delicate coats of the bloodvessels offer even less resistance under the hydraulic pressure to Avhich they are subjected by the increased local turgescence and general vascular tension attending menstruation. This oozing from a free surface is a protection against extravasation in closed cavities or tissues, Avhich could not fail to be injurious. This intense vascular engorgement involves the ovaries and Fallopian tubes as Avell as the uterus; and there is no doubt that blood is effused from the Avhole tract of the tubo-uterine mucous membrane. Dr. Letheby {Phil. Trans., 1852) describes the microscopical characters of the men- strual fluid found in the tubes in the bodies of tAvo young Avomen Avho died whilst menstruating. The preparations are in the London Hospital. Periodicity.—The typical periodicity is every twenty-eight days. In many Avomen the return is exact to the day. There is, hoAvever, a range of variation in different Avomen ; in some the interval from the commence- ment of one menstruation to the return of the next is less than twenty- eight days, in others more rarely exceeding thirty days ; that is, if strict periodicity be observed. In Avomen whose intervals vary, being some- times more, sometimes less than tAventy-eight days, some pathological clement probably exists. The Age at which Menstruation begins.—In temperate climates, be- tween the ages of thirteen and fifteen, concurrently Avith the appearance of other signs of puberty, as the groAvth of hair on the genital parts, and the SAvelling of the breasts, the menses begin to Aoav. Here, again, there are considerable variations. Cases are recorded of menstruation begin- ning at ten, and even as early as seven or six years of age. These must be regarded as instances of quite exceptional precocity. Retardation is more common; cases are not infrequent of the first appearance, or at least, of the fair establishment of menstruation, at sixteen or seventeen. In these there is mostly some pathological condition. Since the outbreak of this function of the uterus is a symptom or consequence of the entry 12 178 THE OVARIES. into active function of the ovary, it may be concluded that Avhatcver causes hasten or retard the evolution or ripening of the ova, will have a corresponding effect upon menstruation. Hence luxurious living and libidinous excitement tend to forestall the ordinary period, whilst the contrary conditions of hard living and freedom from sexual emotion tend to postpone it. Climate has been said to have a poAverful influence. The observations of Brierre de Boismont and others seem to have proved that the advent of menstruation is decidedly earlier in hot climates than in cold. And common observation proves that, tested by their physical and intellectual characters, girls pass into Avomanhood at a someAvhat later age in cold and temperate climates; whilst the women in hot climates fall at an earlier age into sexual decrepitude. In Siam, according to Dr. Campbell (Edin. Med. -/wtm.,1862), some girls arrive at puberty at tAvelve, but the more usual ages are fourteen, fifteen, and sixteen. Dr. Goodeve gives about tAvelve as the mean, and Dr. Leith, of Bombay, tAvelve and a half. But of a series of cases tabu- lated by him, the largest number menstruated after fourteen. In (irermany Schroeder says menstruation generally begins at fifteen, and ends at forty-five. According to Louis Mayer, brunettes begin earlier than blondes. The influence of cold is further seen in the character of the menstrua- tion. Thus, Dr. McDiarmid, surgeon to Sir John Ross's Arctic Expedi- tion, says that amongst the Esquimaux, menstruation is often delayed until the tAventy-third year, and then only appears scantily during the summer. I also know Avomen of feeble sexual development avIio menstruate in the summer only ; and others who menstruate in India and not in England. Probably, race may have as much to do with the period of advent of menstruation as climate. Observation of the Jews, Avho are to be found in almost every climate, might determine this question, and thus enable us to appreciate more accurately the influence of climate. Is the first appearance of menstruation amongst the Jews inhabiting different coun- tries uniform or not ? Many cases of precocious menstruation are recorded. In some, the common signs of puberty appear to have been almost congenital. These cases form a class distinct in some features from the premature menstrua- tion Avhich appears at from nine to twelve years of age. Dr. Harris, of Washington {American Journal of Obstetrics, 1871), discusses the sub- ject. Sir Astiey Cooper narrates the history of a child which commenced to menstruate at three years old, and was last noticed by him when seven years and five months old; at this early age she had all the appearance of a thick-set stunted woman ; she measured four feet one inch, and had so large a pelvis that she could no doubt have given birth to a child {Bond. Med. and Phys. Journ., 1810). Le Beau mentions a similar case (Annaleg d'Hygibie, vol. x.). In the case of infantile puberty, the ribs and pelvis are excessively developed, and shortness of stature results. Where menstruation begins at eight or afterwards, the growth of the body is not usually interfered with. Bouchut adds a more recent observation:1 1 Paris Medical, 1876. MENSTRUATION. 179 N. 0., born on 27th January, 1872, in London. Menses appeared at tAventy-two months, and since every four Avecks, equal in amount to that of adults. The appearance.is preceded by malaise; she says "the ab- scess is going to burst." On the 16th April, 1876, the breasts are large, completely formed; there is a marked increase in their size at every menstrual epoch. "There is doAvn on the pubes, and there are other marks of development. A similar case is related by 0. Wachs.1 Fie also gives a fairly complete summary of the cases recorded by others. That early menstruation depends upon early ovulation is further proved by the occasional occurrence of very early pregnancy. Several well- authenticated cases of girls being mothers at thirteen, or even tAvelve years old, are recorded. Dr. Roberton tells of a girl, Avorking in a cotton factory, avIio Avas delivered of a full-groAvn child Avhen only a feAV months advanced in her twelfth year. She had menstruated before falling preg- nant. Mr. Smith, of Coventry, relates {Record of Obstetric Medicine, vol. i.) the case of a girl Avho at tAvelve years and seven months gave birth to a full-groAvn healthy child. She began to menstruate at the age of ten. Dr. J. G. AVilson reports (Edin. Med. Journ., 1861) the case of a girl Avho began to menstruate Avhen tAvelve years and six months old in January and until April. She Avas delivered of a full-grown child at thirteen years and six months. In several cases of premature menstruation, exhaustion and death have occurred (Clifford Allbutt, Med.- Chir. Trans., 1866). But this is not the rule. Kussmaul says precocious menstruation is sometimes the result of disease, especially of neAV groAvths in the ovary. The period of disappearance of menstruation is more uncertain than that of its commencement. Usually about the age of forty to forty-frve some irregularity begins. But the function often continues Avith complete regularity until forty-five and sometimes fifty, and even beyond. The instances, not infrequent, in which periodical discharges of blood, not distinguished by the subject from ordinary menstruation, are continued much beyond fifty, may, Avith considerable confidence, be suspected to be due to some abnormal condition. This is especially true Avhen the issue of blood is greater in quantity and lasting longer than the subject had been accustomed to observe; and the presumption that some disease, local or remote, is present, is very great Avhen profuse losses of blood, periodical or not, break out after the menstruation has ceased for some months. It is a popular belief that, if a Avoman begins her menstrual life at an early age, she will cease to menstruate at an earlier age than those who begin later. Another mode of expressing this theory is to say that the epoch of menstrual life, that is, of active ovulation, and hence, of apti- tude for conception, lasts for thirty or thirty-five years. Negrier's ob- servations, however, seem to prove the reverse. He says: "It seems Avell proven that the ovarian function, creative of germs, is prolonged in life in direct ratio of the volume of the ovaries and of the precocity of ovulation: thus, the girl, nubile at tAvelve, will continue menstruating until fifty, or even fifty-five ; whilst the girl Avho did not menstruate until 1 Zeitschrift fur Geburtsh. u. Gynak. 1877. 180 THE OVARIES. eighteen or twenty, a fact which reveals feeble development and small energy of the organ, will cease to menstruate at forty, an early age. Considerable departures from this limit are probably due to some morbid disturbing element: and in many cases the departures are more apparent than real. For example, at the"commeneement, although no sanguineous discharge may mark the onset or establisment of menstruation for several months, or a year or two, there is no doubt that ovulation, the essential motive of menstruation, goes on. This is proved by cases in which preg- nancy has occurred Avithoitt menstruation. In other cases, a leucorrhceal discharge, " white menstruation" it might be called, returns periodically, attended by the usual indications of menstruation. In a third series of cases, even the Avhite discharge may be wanting, and still a sluggish kind of ovulation may occur. This is observed in some forms of amen- orrhoea. At the other end of the history Ave sometimes find menstruation ceas- ing at a comparatively early age ; that is, before forty, even at thirty- seven or thirty-six. These can hardly be instances Avhere the allotted thirty years have run out, from having begun prematurely. Most fre- quently the explanation is that ovulation, or its exponent, menstruation, has been prematurely arrested by some intercurrent condition^ of the ovaries or of the uterus. Sir James Simpson described a condition in Avhich the ordinary involution of the uterus Avhich folloAvs delivery, seems to pass the physiological bounds, and to proceed to positive atrophy, thus ushering in a premature senility. Whatever the explanation, I can attest the fact that Avomen Avho have borne a child at thirty-six or thirty-seven have henceforth never menstruated or conceived again. In most of these Avomen I have found the uterus reduced beloAV its normal bulk, and pre- senting the other features of the senile uterus, whilst the breasts also, Avhich obey so closely the impulse of the ovaries, have shrunk; these Avomen are overtaken by an early climacteric. In not a few instances, hoAvever, the explanation of Xegrier holds good, namely, that the early cessation of menstruation is due to original feeble ovarian development. In these Avomen the menstrual excretion is scanty and appears late ; their languid genital capacity is exhausted long before the normal epoch. In other instances the premature failure is due to the exhausting influ- ences of disease. The most distinct evidence that healthy menstruation may be protracted beyond the age of forty-five is drawn from the fact that pregnancy occa- sionally takes place after that age. But many of the cases of alleged child-bearing at advanced age are apocryphal. My own observation is in accord with the conclusions of Fordyce Barker.1 Fie met in his oavti practice a lady born May 5th, 1801, Avho was delivered May 6th, 1852, and again in June, 1853. He knoAvs two other women over fifty avIio became mothers. Dr. Barker says: " After the most careful and laborious research, I can find but one authentic case, based on the evi- dence of a reputable medical man, avIio carefully investigated the docu- mentary proof, Avhere a woman who had reached the age of fifty-five has 1 Philadelphia Medical Times, 1874. VICARIOUS MENSTRUATION. 181 given birth to a child. This case is recorded by Dr. Davies, Hertford, England {Loud. Md. Gazette, vol. xxxix.). I feel Avarranted instating the proposition that the laAvs of physiology, the experience of mankind, and the ilecisions of courts of laAv justify a medical man in declaring that a Avoman over fifty-five years of age is past the period of child-bearing." Vicarious or ectojtic menstruation occurs Avhen hemorrhagic discharges take place periodically from other organs than the uterus. The occur- rence of this remarkable phenomenon is evidence of the force of the periodical habit. It seems as if every month a state analogous to ple- thora, or an accumulation of blood, arose, Avhich must be relieved by evacuation. It is evidence of the high arterial tension attending men- struation. The active physiological process going on in the ovaries naturally determines the blood-current in especial force to the pelvic organs; hence the uterus is the natural evacuant organ. It is a remark made by Trousseau, that all the physiological discharges of blood take place from mucous membranes. A happy proAdsion, for mucous mem- branes all lead to external outlets. It Avill generally happen, then, Avhen the mucous membrane of the uterus is not disposed to execute its func- tions, that some other mucous membrane Avill supplant it. The most frequent seat of vicarious menstruation is the Schneiderian membrane. In young people especially, epistaxis is easily excited. Certainly men- strual ejiistaxis is a quasi-physiological phenomenon, Avhich should be checked only Avith great circumspection. In some cases I have knoAvn epistaxis to accompany the ordinary menstrual discharge from the uterus; thus supplementing, not supplanting it. Various parts of the alimentary canal may assume the work of the uterus. The stomach is perhaps the most frequently called upon. Thus we have menstrual hannatemesis. Hemoptysis is occasionally a manifestation of vicarious menstruation. The right appreciation of this condition is obviously of great importance, lest it be misinterpreted as a symptom of tubercular mischief. Other parts may, hoAvever, do similar duty. Thus Ave occasionally see hemorrhage from the rectum. And tOAvards middle age, Avhen hemor- rhoids are not uncommon, these bleed more freely at the menstrual periods. I have notes of cases in Avhich menstrual hsematemesis seemed to be hereditary. In some there is a distinctly hemorrhagic diathesis, as in the folloAving instance : A young lady, aged tAventy-four, had several attacks of Imematemesis more or less profuse, and at last one Avhich Avas so severe and protracted that she made a very narroAV escape Avith her life. It appeared to be connected with menstrual deviation. She re- covered fairly; but six months later, just Avhen menstruation Avas due, Inoving felt sick, and oppression at the stomach, she vomited a small quantity of dark blood, the menses appearing at the same time scantily. She never suffers dysmenorrhoea. A sister, Avhen sixteen, Avho had hitherto menstruated scantily, had hsematemesis at her periods. A brother, aged five, died of epistaxis after purpura. The father died of epistaxis at fifty-six, caused, his wife says, by intemperance, Avhich pro- duced epilepsy. Whenever he had a fit he had hemorrhage. The conjunctiva is another mucous membrane which evinces a particular 182 THE OVARIES. proclivity to pour out blood vicariously. I have seen a woman avIio every month suffered profuse ecchymoscs of both eyes, some blood escaping from the surface, and some being effused under the conjunctiva', to be gradually absorbed, and passing through all the stages of ecchymo- sis of the eye from direct violence. Liebreich has figured in his Ophthalmoscopic Atlas (Plate YIII., English edition, 1870) an example of retinal hemorrhage after suppression of menstruation. The skin is not infrequently the seat of vicarious menstrual hemorrhage. Sometimes the blood appears in the form of petechia or small ecchyraoses on various parts of the body ; sometimes it has been seen to ooze from the surface, forming a true bloody SAveat. There seems some analogy betAveen these cases and the bumps of erythema nodosum, which are not uncommon on the legs of girls suffering from amenorrhoea. In some instances the blood is poured out from a varicose ulcer or other tore. Dr. Mason relates {Edin. Med. dourn., 1866) a case in Avhich menstruation began at eight, and continued to recur until eleven, then stopped until thirteen. A large abrasion then formed in the right cheek, suppurating in the centre, and inclining to bleed tOAvards the circumference. The menstruation Avas noAv irregular. After a time this place healed ; blood then oozed from the skin of the face. Dr. Bassett relates {Presse Medicale) a case of periodical discharges of blood by the nipples. Menstruation, hoAvever, Avas also present, although scanty. The patient had borne three children. In 1876, I saw a girl, aged thirteen, at St. George's Hospital, who had vicarious menstruation by.vomiting, and also oozing of blood from the nipples. Mr. d'Andrade relates a case.1 The subject was a stout, healthy Parsee lady, aged eighteen. She had menstruated regularly from thirteen to fifteen and a half, Avhen the catamenia became first irregular, then ceased, being re- placed by. bleeding at the gums and nose, and vomiting of blood. Men- struation returned. No pregnancy. Mr. d'Andrade observed blood to ooze from the healthy skin of the left breast, and of the right forearm. The blood exuded shoAved red and Avhite globules under the microscope. The skin-hemorrhage recurred every month or two. Subsequently blood oozed from the forehead. The following case,2 which occurred in St. George's Hospital, under Dr. John Clarke, is especially instructive in its physiological and patho- logical bearings : " J. C-----, single, aged eighteen, admitted May 30, 1872. Had never seen any catamenial discharge ; for three months be- fore admission she had from time to time suffered pain at the lower part of the back and between the shoulders. During these attacks of pain she had bleeding from the nose and gums, which lasted about a week, and then ceased, returning again after the lapse of one month. For two or three weeks before she came into the hospital she had had great irrita- bility of her skin, to relieve Avhich she had recourse to scratchino-; but this gave rise to immediate bruising of the parts. For four months past she had complained of pain in the left side, accompanied Avith difficulty 1 Trans, of Med. and Phys. Soc. of Bombay. Bombay, 1862. 2 Lancet, 1S72. VICARIOUS MENSTRUATION. 183 of breathing, cough, and spitting of blood. She had never had rheu- matic fever; but about five years ago she suffered from chorea. On admission she Avas very anaemic, the lips and conjunctivae being almost bloodless. She suffered from shortness of breath, and had frequent bleed- ings from the nose, mouth, and skin. There Ave re hemorrhagic spots on the tongue, inside the lips, and on the gums. Some of the spots on the tongue were as large as half a split pea, and the tip Avas so covered Avith ecchymoses that it had the resemblance of a straAvberry. The surface of the chest was more or less marked with these hemorrhages, but here some of the spots could be picked off. On the legs and thighs the spots had more the character of purpura. In many places the blood seemed to have actually exuded from the skin. For four or five days she had suffered from epistaxis. On examining the chest, a loud mitral murmur, most marked at the apex, Avas heard, the heart's action being very irregular and rapid. The lungs Avere resonant, and air freely entered; but the breathing Avas rapid and labored even after slight exertion. There Avas a troublesome cough, and occasionally the patient spat blood. There Avas no vaginal orifice ; the small cavity representing the canal of the vagina ended in a cul-de-sac, and Avas not deep enough to hold a teaspoonful of fluid. The urethra Avas in the middle of this cavity. The labia majora were Avell formed, but small, and there Avas an ordinary amount of pubic hair. The space betAveen the rectum and the urethra measured about half an inch. On passing the finger into the rectum, no uterus could be discovered; and, Avhen a catheter Avas introduced into the bladder, it could be distinctly felt through the anterior Avail of the rectum. Numerous ecchymoses were present on the inner side of the labia majora. • " The patient continued to improve till June 11th, Avhen the breathing became much embarrassed, and accompanied Avith severe palpitation, cough, and spitting of blood, death taking place at 3 P.M., conscious- ness remaining till the last. "Autopsy.—Body well nourished; limbs and trunk covered Avith ecchymoses. Mammae fairly Avell developed, but nipples small. Color of the hair light brown. On opening the thorax the pleurae Ave re found to be spotted with ecchymoses. The lungs Avere cedematous, and gorged with blood. The pericardial cavity contained a little light-red fluid, but the Avails were dotted Avith hemorrhagic spots, especially the visceral Avail. The endocardium at the upper part of the left ventricle was thick- ened and opaque. The aortic valves Avere thick, puckered, and inefficient; the mitral valve thickened, and so contracted that the orifice Avould only admit the tip of the little finger. The right ventricle and left auricle much hypertrophied. The liver, spleen, and kidneys presented no abnor- mal appearance. The ovaries were very Avell deAreloped and congested, and contained a recent false corpus luteum. The uterus Avas absent (evidently congenitally), only a small nodule of fibrous tissue being found in the folds of peritoneum between the rectum and the bladder." Here Ave see exhibited in a striking manner the influence of ovulation upon the system. There being no uterus, the menstrual blood sought outlet in almost every direction, and the function failing, the patient died. The case is valuable, as shoAving that absence or imperfect de- 184 THE OVARIES. velopment of the uterus does not imply defective development of the ovraries. I have seen other examples of the influence of the general law of vas- cular tension seeking relief by extraordinary means when normal men- struation fails. Subjects of amenorrhoea, it is knoAvn, often have oedema of the legs and face. I have seen (edema recur periodically, that is, vicariously. This is, of course, more likely to be the mode of relief selected when the quality of the blood is deteriorated. But in one case specially noted, there Avas no anemic sound. These cases of vicarious menstruation prove hoAV intense is the effort of Nature to seek an outlet for blood. They seem to shoAv that the gene- ral tension of the vascular system becomes greater Avhen the outlet by the uterine mucous membrane is not free. This general tension is illus- trated by the frequent sensation complained of by sufferers from amenor- rhoea and dysmenorrhoea, of " those things flying to the head," evidenced by headache, vertigo, and epistaxis. These phenomena of vascular ten- sion suggest that the rational treatment consists in diminishing tension by purgatives and leeches, or by cupping. It seems in high degree pro- bable that in the struggle of the circulation to find relief from the men- strual tension, the ordinary vicarious safety-valves may sometimes fail; that then the internal organs, as the brain, lung, liver, kidney, spleen, have to bear the strain, and that thus the foundation of structural organic disease may be laid. Tavo conditions in the healthy subject suspend menstruation—Preg- nancy and Lactation. The arrest of menstruation is the most familiar presumptive evidence of pregnancy. The law is, that from the moment of conception menstruation is stopped, and does not return until the child is weaned. Many exceptions, hoAvever, occur. When pregnancy occurs, the lining membrane of the uterus, being wanted for the neAV function of connecting the impregnated ovum Avith the uterus, undergoes a remark- able change of structure. If it Avere noAV to pour out blood, the relation of the ovum to the uterus Avould be disturbed, and abortion Avould ensue. In fact, this not seldom does occur. Notwithstanding the general truth of the theory of the Genesial Cycle, so Avell described by Tyler Smith, which expresses the laAv of the successive domination of the ovaries, uterus, and breasts in the woman, it is certain that, although during pregnancy and lactation the ovaries are comparatively subdued or quiescent, ovula- tion occasionally, if not ahvays, goes on. Negjrier and Scanzoni have especially insisted that pregnancy does not arrest ovulation. If in the majority of cases we miss the common proof or exponent, menstrual dis- charge, yet the other signs of ovarian activity are frequently present. There is a monthly molimen or nisus, marked by greater turgidity and accumulation of blood in the pelvic organs. Hence the epochs Avhen the return of the menses is due are those when abortion is most likely to happen. The influence of o\rulation is also seen in the later months of gestation, markedly when the placenta grows to the lower or cervical zone of the uterus. In this case hemorrhages are apt to break out at the menstrual epochs; and generally premature labor is more likely to occur at these than at intermediate periods. But menstrual hemorrhage may occur, especially during the first three MENSTRUATION DURING LACTATION. 185 months of gestation, Avithout interfering Avith the relations of the ovum to the uterus. This may be explained in two Avays: First, the blood may be poured out from the free surface of the decidua vera lining the inferior zone of the uterus, and even from the free surface of the decidua reflexa. Secondly, it may exude from the congested cervical cavity. This is especially likely to occur Avhen there is ulceration or abrasion of the os or cervix, or inflammatory congestion. During pregnancy, Avhen the uterine mucous membrane is barred against hemorrhagic response to the ovarian excitation, I have seen many instances of hemorrhage from the mucous membrane of the stomach, intestines, nose, lungs, and even the bladder. In these cases the ectopic eruption of blood is not neces- sarily due to the suspension of the ovarian function or to an altered con- dition of the uterine mucous membrane. It is rather to be ascribed to the high vascular tension of pregnancy. Menstruation during lactation is much more frequent than during gestation. Although, normally, the breasts are noAV in the ascendant, the ovaries are not ahvays dormant. Many Avomen really menstruate throughout lactation, and not infrequently, in spite «f suckling, pregnancy occurs. In the majority, perhaps, menstruation is in abeyance for nine, ten, eleven, or twelve months, if suckling is kept up. Some Avomen, hoping to postpone pregnancy, go on suckling for fifteen, eighteen, or even twenty-four months. Only a certain proportion succeed in their object. After nine months the OArarian excitement usually becomes too strong to be subdued by the more languid activity of the breasts ; menstruation reap- pears, the milk dries up, and pregnancy often quickly follows. Where from the child being still-born or other causes, suckling is not undertaken, the first menstruation commonly appears a month after the labor, thus giving evidence of the labor being determined by an ovarian stimulus. In other suckling Avomen, hoAvever, the menstruation is chiefly appa- rent. Discharges of blood, simulating menstruation, may have the sig- nificance of hemorrhage, a subject discussed in a preceding chapter. In very impressionable or nervous Avomen, the mere act of applying the child to the breast will cause a discharge of blood from the uterus, offer- ing one example of the many of the intimate correlation betAveen the ovaries, the uterus, and breasts. It is convenient here to notice the influence menstruation exerts upon the milk. It is generally believed that the milk is injuriously affected ; and common observation sIioavs that the suckling is often griped, or has diarrhoea, at the nurse's monthly periods. Raciborski, indeed, says the milk is not sensibly-altered in its properties ; it simply appears to be less rich in cream. I have, hoAvever, observed that colostrum-globules Avere reproduced at every menstrual epoch. And it must be borne in mind that the activity of the ovaries renders the nurses more susceptible to moral impressions and to emotions. The influence of emotion in disturb- ing the milk cannot be doubted. In the contention for supremacy the ovary is pretty sure to win. If the Avoman is exposed to sexual relations, active ovulation and menstruation are very likely to be quickly resumed. Thus, in spite of suckling, impregnation often occurs Avithin two or three months of delivery : and not a feAv Avomen fall pregnant within six months " Avithout seeing anything between." On the other hand, women who 186 THE OVARIES. have become widoAvs before or soon after delivery, and lived a single life afterwards, out of a feeling of concentrated affection, keep up lactation for eighteen months or two years Avithout a return of menstruation. But this, perhaps, they could not have done had the ovaries been subject to the excitement of married life. As a rule, nursing Avomen continue unfruitful until the activity of the mammary secretion has remitted, this remission being sliOAvn by the necessity of adding foreign substances to the infant's food. We may now attempt to trace the local and constitutional reactions, that is, the symptoms or concomitants of menstruation. First, the local conditions. "There is congestion or hyperaemia of all the genital system; ovaries, uterus, and breasts swell and become turgid. Scanzoni had an opportunity of directly observing this. In a remarkable case of in- guinal hernia, the contents of the sac included the uterus and ovaries. He found these organs to SAvell and become painful to the touch at every menstrual period. Conception took place twice whilst the uterus Avas in the sac (Beitiage, 1S71). I have noted ovarian swelling. Many women are conscious of a sense of fulness, Aveight, and pain in the region of the ovaries. Then there is the evidence of post-mortem inspection of the ovaries of Avomen dying during menstruation, Avhich sIioavs them to be full to the point of bursting with blood. Indeed, Avhen an ovum escapes there is an actual rent in the capsule of the ovary; in some cases, phe- nomena in a certain sense traumatic, as severe pain, a kind of shock, are present. The state of the uterus has been partly described. The mucous mem- brane overgorgecl, actually alloAVS blood to ooze from its surface. The bulk of the uterus is increased. This may be determined by its greater Aveight as ascertained by touch, and by examination betAveen the tAvo hands. The vagina also is more vascular and turgid. The breasts sympathize Avith the pelvic molimen. They swell visibly, become firmer, sometimes painfully hard. This is especially the case at the age when menstruation is being established. Under the ovarian stimulus the breasts, like the uterus, actually groAV ; they assume their full development or evolution. So great is the activity thus provoked, that, occasionally, this rapid, almost sudden, action passes the physio- logical boundary; the glands present nodular masses, extremely tender to pressure ; they may even infiame, and I have seen these phlegmons form abscesses in the breasts of virgins, produced apparently under this sole ovarian excitation. This is in strict analogy Avith the history of the pro- duction of phlegmons in the breast after labor. I have, however, sus- pected, in some cases, that libidinous manipulation of the breasts Avas concerned. The formation of abscesses is, indeed, rare ; but it is not rare to find at puberty nodular painful points in the breasts, Avhich give rise to great anxiety as to their real nature. HoAvsoever rare and im- probable cancer of the breast may be in young girls, it is not always easy to allay the apprehension that it exists. Mere surgical examination is not ahvays enough to establish a decisive diagnosis, affirmative or neg- ative. At any rate, I have knoAvn surgeons of great experience at fault in these cases; and it Avas only on further consultation that, in two in- stances, I rescued the patients from undergoing needless amputation of PR0DR0MATA OF MENSTRUATION. 187 the breast. In considering these cases, then, Ave must make great alloAV- ance for the physiological stimulus, and deliberate Avell, calling Time, which solves so many problems, into consultation. These local conditions are usually Avell marked throughout menstrual life. But the remote or induced phenomena are generally more strongly characterized at the first appearance of the function. The folloAving de- scription, hoAvever, Avhilst it applies more strongly to the first menstrual periods, will serve, with modifications in degree, for the subsequent men- strual history. The vascular excitement of the genital organs cannot fail to affect other parts of the body and the general system. The nervous centres, espe- cially, feel and respond to the altered condition of the genital system. Here Ave must recall to our attention the tAvo conditions to Avhich I have already adverted : 1st. The augmented central nervous tension. 2dly. The augmented central and general vascular tension. These conditions explain many of the physiological and pathological phenomena. In most instances, there are prodromata, forerunning signs, the signi- ficance of Avhich is well knoAvn to the subject. These, like the signs Avhich occur at later stages, will vary in different individuals. In Avomen whose health is good, Avhose organs are perfectly adapted to the easy performance of their function, the prodromata are scarcely noticed, and all the phases of menstruation are gone through Avith little or no local or general disturbance. In such persons a slight sense of fulness in the pelvis, some little perturbation of the circulation, signs suggesting ple- thora, are speedily followed by the Aoav Avhich brings complete relief. All sense of trouble passes away Avith a momentary lassitude, that does not compel to the interruption of ordinary duties. Such persons are often more cheerful and animated at the menstrual periods ; their ideas Aoav more brightly ; their emotions are more kindly. But in many women things do not run so smoothly. The function is performed Avith more or less difficulty, and is attended by more or less general disturbance. This may arise from one or two, or a combi- nation of the tAvo, circumstances. The subject may be of an excessively impressible temperament, stirred too readily and immoderately by ordi- nary excitation. Or, secondly, there may be local mechanical, or other hindrances to the fulfilment of the menstrual acts. Or the tAvo con- ditions may be combined. In either of these cases, not only may the prodromata be severe, but the stage of menstruation itself will be attended with suffering, and, even Avhen the function is fairly completed, distress w ill not be altogether allayed. Amongst the prodromata are pain in the pelvis, a sense of fulness, backache, pain especially in one iliac region, and radiating doAvn the thighs. The alimentary canal reveals the impression made upon the ganglionic centre by vomiting and diarrhoea. Lassitude, to the extent of prostration, seizes the patient. The mind is always more or less disturbed. Perception, or at least the faculty of rightly interpreting perceptions, is disordered. Excitement to the point of passing de- lirium is not uncommon. Irritability of temper, disposition to distort the most ordinary and best meaning acts or Avords of surrounding per- sons, afflict the patient, Avho is conscious of her unreason, and perplex her 188 THE OVARIES. friends, until they have learned to understand these recurring outbursts. Despondency to the verge of melancholy, violence to the verge of mania, impulse ungovernable to the verge of monomania, false ideas, distorted judgment to the verge of delusion, and sometimes overstepping the bound- ary, render the sufferer for a time really irresponsible. Lunatic asylums offer numerous examples of comparative abeyance of the usual manifesta- tions of insanity during the intermenstrual periods, and of their exacerba- tion when the catamenia return. Not even the best educated women are all free from these mental disorders. Indeed, the more preponderant the nervous element, the greater is the liability to the invasion. Women of coarser mould, who labor with their hands, especially in outdoor occu- pations, are far less subject to these nervous complications. If they are less frequently observed ; if they less frequently drive refined women to acts of flagrant extravagance, it is because education lends strength to the innate sense of decorum, and enables them to control their dangerous thoughts, or to conceal them until they have passed aAvay. In other cases the ovarian excitation evokes a fit of Avhat is called hys- teria. This, too, is sometimes to a great extent kept in subjection by a determined will; but Avhen once this habit has groAvn, the attack is usually irrepressible. I, as Avell as other physicians, have observed cases in Avhich a fit of eclampsia has ushered in menstruation. In some of these there existed an hereditary or other predisposition to this form of convul- sion ; but still the exciting action of ovulation was clear. Sometimes stupor or lethargy is the prominent symptom, but this is more frequent as a result of hysteria or eclampsia. Associated occasionally with hys- teria, or independent of it, erotic passion is the prominent symptom. When this occurs, the lapse into insanity is often near. After committing the grossest excesses, Avhich may for a time be attributed to moral de- pravity, the disorder passes, perhaps suddenly, into unmistakable mania, and seclusion becomes necessary. In association Avith this subject, Ave cannot avoid allusion to masturba- tion. I must express my opinion that this subject has been invested Avith an atmosphere of gloom and terror very much darker than cool observa- tion Avarrants. The history of the countless celibates of both sexes Avill carry a just conviction to the reflective mind. But, making all due allow- ance, the fact remains that the practice is, in some instances, the result or the cause of the most deplorable nervous disorders. Experience has shown that the attendant disorder is not necessarily dependent upon the condition of the external genital organs. The vice has been practised Avhen the clitoris Avas small; it has been continued even after the clitoris has been amputated. It is kept up in some cases, as is the scratching of pruritus, by local inflammation. I have seen the vulva intensely red, the epithelium abraded, even ulcerated. In extreme cases of erotic mania, and e\'en in cases less severe, I belie\Te—the enthusiastic advocates of non-restraint notwithstanding—that resort to the camisole is dictated by the soundest medical and ethical laAvs. A remarkable fact amongst the phenomena of menstruation is the effect on pigmentation. The complexion is commonly changed; it loses it3 clearness, becomes dull or salloAV, and a dark, even black ring, espe- cially marked in brunettes, is traced around the eyes. This is often so AMENORRHEA. 189 conspicuous as to reveal to the initiated Avhat is going on. It is similar to the state of pigmentation wrought by pregnancy, and thus affords evi- dence of the analogy or relation betAveen the two states. Dr. Lavcock says excessive pigmentation is brought about by imperfect oxidation of the carbon; that by imperfect elimination of the carbon, in deficient menstruation, diseases of the liver and kidneys are induced; and that these conditions are promoted by the excessive production of carbon from the use of highly carbonized food. But it is certain that the nervous action is intimately concerned. Thus, in a case figured in the Obstetrical Transactions, Vol. XYIL, there is in each nipple-areola a part Avhere pigmentation is absent, the rest of the areola being intensely pigmented. We cannot conceive that the blood distributed to the pale portion of the areola Avas different in quality from that Avhich fed the dark portion. We are driven to conclude that the difference Avas due to nerve-distribution. CHAPTER YII. DISORDKHEI) MENSTRUATION (PARAMENIA, AV. FARR).—AMENORRHOEA, CHLORO- AN.EMIA, PRIMITIVE, SECONDARY; ARRESTED OR SUPPRESSED MENSTRUA- TION ; RETENTION OF MENSES OR OCCULT MENSTRUATION ; ATRESIA VULVAE, VAOIX.-E, UTERI. The departures from the ordinary character of healthy menstruation are conveniently classified under amenorrhoea, including the deficiency of the Aoav ; menorrhagia, indicating excess; and dysmenorrhoea, indi- cating that the function is performed Avith difficulty and pain. These terms, like so many others Ave are obliged to use in medicine, do not represent any definite disease. Under each of them the most Avidely differing pathological conditions, mechanical and systemic, are grouped. Many different pathological conditions may alike lead to one symptom that shall be more prominent than the rest. That symptom is the first thing that fixes attention, and for Avhich the patient seeks advice. It is the business of the physician to analyze the patient's condition, and to discover, if he can, what are the associated phenomena, and Avhat is the cause of the leading symptom. This is the method Ave are daily forced to adopt at the bedside. We will, then, take the symptom, amenorrhoea, search out the conditions upon Avhich it depends, and study the various forms it presents. Some authors associate Avith primitive absence of menstruation those cases in which the menses are retained by closure of the genital canal. Logically and pathologically, it is obviously more rational to consider these cases apart. They will be discussed under "Retention" and 190 DISORDERED MENSTRUATION'. "Atresia." The amenorrhoea here is not real. There is secretion, but excretion is mechanically hindered; menstruation is occult. The most rational division of amenorrhoea is into—1. Primitive, that is, the Aoav has never taken place. 2. Accidental, or secondary, that is, the func- tion has at some time been established, but has been suppressed. Primitive Amenorrhaa.—The appearance of menstruation may be retarded for one or tAvo years beyond the usual age Avithout any obvious derangement of health. But in a large number of cases, concurrently with non-menstruation, a remarkable condition of the general system is observed, to which the name chloro-ancemia, or chlorosis, vulgo, green- sickness, is given. A marked feature of this condition is a great dimi- nution of the red corpuscles of the blood, and a consequent excessive proportion of water. A thin, pale blood, incapable of carrying on efficiently the functions of nutrition, respiration, or circulation, flows languidly in the vessels. Every organ, every tissue feels the want of adequate nourishment and stimulus. The skin and mucous membranes present a peculiar pallor tinged Avith green. The lips, gums, and tongue look white. The patient is unwilling to make any exertion, and even the most moderate effort is folloAved by mental and physical prostration, or an outburst of hysteria. She is listless, indolent, droAvsy. The taste and appetite are often depraved. The ordinary diet, as meat or fish, is rejected Avith loathing. The craving is usually for fruit, cucum- bers, pickles, vinegar, or things in Avhich sourness predominates. It is more than probable that the craving for these things is the cry of Nature for a supply of elements which the degraded blood is in need of; it should not, therefore, be too absolutely tliAvarted. In some cases earthy and alkaline substances chiefly excite the morbid appetite. The heart, ill-nourished, acts feebly ; it endeavors by increased frequency of beat to make up for the deficiency in quality of the blood it sends into the general system. It is easily excited to hurried action, Avhich assumes the Avell-knoAvn character of palpitation, and Avhich may on pushing ex- ertion, such as ascending stairs or hills, too far, readily lead to fainting. Excessive irritability of the heart under emotion or physical exertion is the characteristic condition. Severe pain, more or less fixed under the heart, is commonly complained of. Headache is very common, and is easily induced by exertion or emotion. The Avatery state of the blood, the general laxity of all the tissues, including the Avails of the capillaries, and the feeble poAver of the heart, lead to local stagnations and to effusions of serum into the cellular tissue of depending parts. The feet especially sAvell, are cold, readily affected by chilblains. The hands also swell; and this Avould be frequently observed, Avere it not that they are subject to constant changes from the hanging position. The face gets puffy, bloated, especially so the loose tissue of the eyelids. The muscular system is flabby and feeble, incapable of bearing any strain; and pains in the muscles are easily induced by even moderate exertion. Depending upon a similar systemic condition Ave occasionally see those nodules of limited hyperaemia, ecchvmosis, and hyperplasia, which are known as erythema nodosum. These chiefly appear in the leo-s, but sometimes also in the arms. They indicate the extreme debility of the AMENORRHOEA. 191 walls of the vessels, and of the surrounding tissues, Avhich in their healthy state contribute so much to the support of the vessels ; and may possibly be a form of vicarious menstruation. The normal Aoav of blood is not uncommonly replaced by a periodical Avatery discharge. This must be regarded as a menstruation. The vas- cular system yields under the ovarian stimulus the best substitute for healthy blood Avhich it can afford. This may be called " imperfect men- struation." In these and other cases it is not uncommon to note a per- sistent leucorrhoea. This form of leucorrhoea is one of those Avhich are not the result of physical lesion justifying local examination. The dis- charge seems due to relaxation or Avant of tone in the vessels and mucous membrane. It commonly ceases Avhen healthy menstruation is restored. In every case in which the deficiency of red globules is marked, a bloAving sound, recognized as the anaemic bruit, is heard at the base of the heart, and extending along the arterial trunks of the neck. Where this deficiency is extreme there is commonly heard in the vessels of the neck that peculiar and characteristic noise knoAvn as the " bruit-de-diable," or the German "Nonnengerdusch." This sound gives not only precise diagnostic indication of the malady, but its intensity affords accurate estimate of its progress. In proportion as the quality of the blood improves under treatment the noise diminishes. It ap]tears to be directly associated Avith the relative absence of the red globules. When these are present in due proportion the sound is no longer heard. I have observed this sound in a marked degree in anaemia associated Avith menorrhagia ; and notably in some cases Avhere there Avas suspicion of commencing tuberculosis. In some of these cases of associated chloro-anaemia and amenorrhoea it is not easy to determine which is the primary factor. Is the Avant of menstruation the cause of the degraded condition of the blood? Or, on the other hand, is the degraded condition of the blood the cause of the amenorrhoea ? If Ave could tell which condition came into existence first, and Avhich followed, the sequence, if constant, would settle the question. But the ovary is beyond direct observation ; Ave are almost limited in our conclusions as to its activity by noting the subordinate phenomena of menstruation. One fact comes out prominently; the state of chloro-anaemia stands in constant relation to the menstrual function. It seems probable that at the age of puberty, ovulation which ushers in such a striking revolution in the economy, stimulating, almost visibly, development of the whole system, and remarkably of certain organs, takes at least an indirect part in the function of blood-making. Or to put it in another way : that evolution of the system at puberty, that almost sudden bursting into womanhood, cannot be perfectly accomplished, unless the ovaries give the impetus. This is illustrated by the occurrence of relapses. For ex- ample, a girl avIio has quite recovered from one attack of chloro-anaemia, may again fall into exactly the same condition, amenorrhoea attending. Chlorosis, says VirchoAV, is distinguished from leukaemia in this: the entire number of the corpuscles is smaller. In leukaemia, colorless cor- puscles in some sort take the place of the red ones, and a real diminution in the number of the cellular elements in the blood is not produced. In 192 DISORDERED MENSTRUATION. chlorosis the elements of both kinds become less numerous, Avithout the occurrence of any disturbance in the numerical relation between the colored and colorless corpuscles. Anatomical observations, he goes on to say, indicate that the foundations of the chlorotic ailment are very early laid ; for the aorta and the larger arteries are usually, and the heart and sexual organs frequently, found imperfectly developed. To originate a neAV function, to bring to perfection a hitherto unexer- cised poAver, makes larger demands on the strength than are required for its continued activity. The feeble phthisical child fails, as the time of Avomanhood approaches, to menstruate, and the signs of chlorosis gradu- ally manifest themselves. Numerous instances, hoAveArer, are observed in which after menstrua- tion has been fairly established for months or even years, chloro-anaemia almost suddenly makes its appearance, and entails suppression of men- struation, partial or complete. In many of these cases emotion plays an important part. Jealousy, disappointment in love, the "spretse injuria format" are often the immediate antecedents. No one Avho has had a large experience can fail to remember numerous examples of the poAverful infiuence of emotion in altering the quality of the blood. At the advent of puberty, organs hitherto existing only in a latent or potential condition, almost suddenly come into the foreground, and a neAV function that dominates the Avhole system appears, or ought to appear. The perfection of the ovaries entails the evolution of the breasts and uterus, and provokes a rapid development of the whole frame. To a certain extent this general physical development will take place, Avhether ovulation be perfectly performed or not. But, to carry out the full change in the ovaries, a fair supply of healthy blood is requisite. If the sudden excessive demand for healthy blood requisite for this pur- pose, and for the attendant general physical growth, be not adequately met, menstruation will be hindered. And the continuing, although im- peded, general groAvth, exhausting the blood supply, quickly induces the marked blood-degeneration which is so characteristic. Things once at this stage, a various circle of morbid action and reaction is established. On the other hand, it is observed that Avhen the quality of the blood has been improved under suitable treatment, menstruation usually returns; and that when a degraded condition of blood is induced by defective nu- trition, or subjection to bad sanitary conditions, menstruation is suppressed. The inAuence of the ovaries is at times strikingly manifested, as Avhen, under the inAuence of marriage, ovulation being stimulated, the chloro- anaemia often disappears. We may, perhaps, best sum up the argument by stating these propo- sitions : 1. That the due action of the ovaries gives an important stimulus to innervation, sanguification, and the general well-being. 2. That the due action of the ovaries, as of other organs, depends upon their being properly nourished by a supply of healthy blood. 3. We cannot always tell Avhich factor is first in default. It has been happily said that amenorrhoea is a cry of distress indica- ting something wrong in the organism. The opposite condition of plethora will sometimes delay menstruation. AMENORRHEA. 193 Girls suddenly exchanging a poor vegetable diet for one rich in nitrogen, whilst neglecting exercise, are apt to fall into this state. A very frequent complaint attending amenorrhoea is acute pain under the left breast, in the intercostal spaces, in the sacral region, or in the temples. These pains have often been described as " hysterical;" and the " hysterical knee" of Sir Benjamin Brodie might perhaps be classed under the same head. It is rather a form of neuralgia, induced by the Avaste of nervous force in Avrong directions. There are local causes of primitive amenorrhoea. The most free from doubt are absence, defective development, or disease of the ovaries and uterus. It is not easy to discover defective development of the ovaries ; it can at best be inferred from the existence of defective development of the uterus, and the defect of the menstrual functions. But this is far from being constant. A small infantine uterus may be recognized by the touch and measured by the sound. The uterus is sometimes only an inch and a half or two inches long, the cervix or vaginal-portion is very small, the ' os uteri a small round aperture, and the body may be defiected to one or other side. In these cases there is commonly sexual indifference. Cystic and malignant diseases of the ovaries are rare at the age of puberty. And in a considerable proportion of those cases which occur at a later period, a portion of the gland, adequate to form ova which run through the normal phases, and escape, evoking the attendant phenom- ena of menstruation, may for a long time resist the invasion of the disease. This residuum of efficient ovary may easily be overlooked ; its possible existence must be borne in mind when we meet Avith cases in which men- struation has continued concurrently Avith even extensive ovarian disease. But it must not be concluded that absence, or imperfect development of the uterus, is a certain exponent of absence, or imperfect development of the ovaries. For proof that the ovaries may be well developed and perform their function, although the uterus may be wanting, I refer to a case observed at St. George's Hospital, and cited at page 182. When the chloro-anaemia has lasted some little time, a slow chronic feArerish state sets in. The treatment of this form of amenorrhoea should be governed partly, at least, by the knoAvledge of the inAuence of ovulation. But here, as in almost every case which the physician is called upon to treat, we must treat the symptoms, alleviate the consequences of the disease, as well as attack the cause. The two indications can generally be followed out at the same time. Our first effort, then, should be to improve the condition of the blood, since Ave can hardly expect the ovaries to assume their function energetically until they are properly nourished. It is accepted as an axiom in medicine that, the blood being deficient in red globules, iron is the remedy par excellence. This is true; but it requires more judgment in administering it than is often shown. t Long clinical experience has taught me the general laAv, that in all states of blood-degradation, whether resulting from mal-nutrition, from wasting diseases, or from hemorrhages, iron is ill tolerated at the beginning. In all extreme anemic states the febrile irritability I have adverted to is liable to be aggravated by iron, if rudely and precipitately "throAvn in," as the phrase is. The tongue gets parched and broAvn, indicating a like 13 194 DISORDERS OF MENSTRUATION. state throughout the alimentary canal, inducing constipation, and gene- rally impeding nutrition; violent headache ensues; the pulse rises in frequency. The true indication is, first, to allay vascular irritability, so as to prepare the system to assimilate iron. This is best done by salines, of Avhich I believe the best is the fresh prepared acetate of ammonia, the old spiritus JMindereri. If freshly made it is not only more grateful from containing a quantity of carbonic acid, but it is more efficacious. A little nitrate of potash may sometimes be usefully added; and in almost every case the combination of some light tonic, as hop, cinchona, or calumba, will be of service. Ten drops of the tincture of veratrum, and four or five grains of free carbonate of ammonia, often add to the efficacy of the saline. Digitalis is often useful in allaying irritability of the heart. So marked is the benefit often arising from this exhibition of salines, that one cannot resist the conclusion that the blood is in want of salines as well as of iron, and that the saline material is the first Avant. This vieAV is confirmed by Avhat is observed in transfusion. In extreme anaemia revival has folloAved the injection of saline fiuids into the veins. When vascular irritability is subdued, Avhen the secreting organs have been brought to a cleaner and healthier state by salines and aperients, iron may be cautiously tried. Nothing surpasses, probably, Griffith's mixture. This also should be freshly made. There is a special virtue in nascent combinations. But it is very nauseous; and modern chemistry has supplied us Avith other excellent preparations of iron. The citrate of iron and ammonia, Avhich may be given in an effervescent state, if desired, is an excellent medicine; it is generally easily borne. I have long given Avith great advantage the solution of acetate of iron, or the liquor ferri dialysatus of Squire. These seem easily assimilable, and are, perhaps, the most agreeable of all ferruginous preparations. It is not desirable to give large doses. Iron should rather be regarded as an element of food than as a medicine. The blood Avants it; but it must be taken in such a Avay that the system have time to deal with it like other food- elements, to assimilate it, and convert it into blood. Iron must, therefore, be given for a considerable time; that is, until the return of color to the cheeks and mucous membranes, the vanishing of the bruit-de-diable and the anemic souffle, and the establishment of menstruation announce that the system has regained the independent power of carrying on the func- tion of blood-making. Coindet and Boinet extol the virtue of iodine in amenorrhoea. Trous- seau also advises it, saying, hoAvever, that it comes in most usefully after iron. Ever since I folloAved the clinique of this admirable physician I have prescribed iodide of potassium in these cases. But my observation, Avhilst confirming most distinctly Trousseau's opinion of its efficacy, has led me to prefer giving it before proceeding to the administration of iron. It seems to me to occupy an intermediate place betAveen ordinary salines, Avhich should be given first, and chalybeates. Iodide of potassium may be given in five-grain doses, with or without ammonia and bark, two or three times a day. Bromine is especially valuable as a sedative of the nervous and vascular excitement. An old popular remedy is saffron. Trousseau extols it. I have tried it extensively, but generally in combination Avith iodide of potassium, so that I am unable to speak positively of its independent virtues. AMENORRHEA. 195 The restorative poAver of iron is often much increased by the addition of small doses of strychnine or ergot. Under these agents the nervous system especially acquires more tone. Sometimes arsenic is of great service. Apiol has been much extolled1 in doses of fifty centigrammes daily, choosing the natural nisus as the time. " It is," says Ih\ Joret, "the stimulant and the moderator of the menstrual function?' The digestive organs display the same sluggishness Avhich oppresses every function. Constipation is frequent, and the peristaltic action of the boAvels requires stimulation. Purgatives are generally necessary, and the favorite ones are aloes or rhubarb combined Avith myrrh or other stimulating adjuvant. Hoffman said he had seen better results from Rufus's pill—the " pilula de tribus"—consisting of myrrh, aloes, and saffron, given in repeated small doses, than from any other medicine. The concurrence of experience as to the efficacy of this" pill should rescue it from neglect. Concurrently Avith the use of these medicaments, diet and exercise must be carefully studied. The diet should be generous. Milk is espe- cially useful; but a fair proportion of roast meat, fish, vegetables, and fruit should be taken. Wine, of Avhich claret, Carlowitz, and Rhine wines are the best suited, or beer, should be prescribed in moderate amount. Exercise, mental and physical, must be graduated to the strength and poAver of endurance of the patient. In the profound impairment of nu- trition which affects every organ, the nervous centres cannot supply the requisite nerve-force, nor are the Aveak, pale, fiabby muscles capable of strong or sustained exertion. Every tissue has to be regenerated. This is a Avork of time, and during this period care must be taken to make exercise keep pace Avith, but not exceed, the groAving strength. The aim being to create or to restore the " habit" of periodical menstru- ation, special care is indicated to favor any molimen that may reveal itself by pain, sense of heat or Aveight in the pelvic organs, or by ner- vous or vascular phenomena elsewhere. Perhaps the most precise indi- cation might be obtained from sphygmographic observations. Warm hip-baths—adding enough mustard to act as a slight rubefacient—warm vaginal douche of plain Avater, or even with the addition of sufficient free ammonia to communicate a soapy feel to the water, may be tried. One or tAvo leeches applied to the anus or inside the thighs have often started the natural uterine secretion. These means act by derivation to the pelvic organs. As further means of following up this indication Schoenbein and Scan- zoni recommend aloetic enemata. Golding Bird and Duchenne advised electricity. This agent has been extensively tried ; but I am not awrare that it has fulfilled the expectations that were at one time built upon it. Direct excitation of the uterus has been resorted to. Light applica- tion of nitrate of silver to the cervix uteri has undoubtedly been success- ful. More successful still is the injection of a feAv drops of liquid ammonia into the uterus. The catheterization of the uterus has been said to be serviceable. The wearing of an ivory or metal stem in the uterus has 1 Dr. Joret, Bulletin General de Therapeutique, 1S60. 196 DISORDERS OF MENSTRUATION. also been advised. The most effectual local remedy is probably the gal- vanic pessary. But there are obvious objections to having recourse to these topical "proceedings in single girls, and the cases are not many in which less objectionable means are not effectual. Probably these direct local excitants or derivants are the only true " emmenagogues." According to the old idea, an emmenagogue is a medicine possessing the property of causing the menses to flow, that is, of inducing a discharge of blood from the uterus. It is not clear that any known medicine possesses this property in a direct or immediate manner. But if Ave adopt the modern theory that menstruation is a function consisting essentially and primarily in the ripening and discharge of an ovum from the ovary, and secondarily of a discharge of blood from the tubo-uterine mucous membrane, we shall see still further reason to doubt the reality of emmenagogues. It is difficult to imagine how any agent Ave know of can in any direct or immediate way determine ovulation. Iron, Avhich enjoys the greatest popular reputation as an emmena- gogue, undoubtedly acts by first gradually restoring the quality of the blood, and improving general nutrition. If it occasionally acts promptly, it may be supposed that large doses of iron may produce temporary con- gestion in the pelvic organs. But I have knoAvn the experiment to be repeatedly tried and fail. So in the amenorrhoea of phthisis, menstruation may sometimes return when, under cod-liver oil, iron, quinine, and suitable hygienic means, the disease is arrested, and a comparatively healthy haematosis has been gained. But no one Avould call cod-liver oil an emmenagoguge. It is interesting to observe that those agents Avhich appear to exert a special influence upon the uterus are precisely those which have the pro- perty of checking hemorrhage from that organ ; indeed, the bleeding is checked through that very property of causing contraction of the muscu- lar wall. Thus ergot, which possesses the most undoubted power to originate uterine contraction, possesses also the poAver of checking hem- orrhage. It has no obvious action as an emmenagogue. The same ob- servation applies, although in a less degree, to quinine, strychnine, and digitalis. Mr. Cockburn, an eminent surgeon practising in India, tells me that in that country quinine is very apt to cause abortion in women of delicate fibre. Fordyce Barker has given satisfactory evidence of its poAver as an oxytocic. Patients have told me that a single dose of qui- nine has stopped the menstrual flow almost immediately. Quinine no doubt acts Avith greater intensity on subjects Avhose nerve and muscle irritability is exalted by tropical heat. Indian hemp again is credited, I believe justly, Avith oxytocic proper- ties ; but its action in checking uterine hemorrhage is even more certain. To this rule galvanism may appear to be an exception. The powers of galvanism as an oxytocic, and even in originating uterine contraction, Dr. Radford and I proved some years ago. And it is regarded by some as the only direct emmenagogue. Leroux1 relates a case in which compression of the femoral arteries 1 Observations snr les pertes de sang des femmes en couches, 1610. AMENORRHCEA. 197 was tried in order to restore menstruation. Hamilton of Edinburgh, in a case of suspended menstruation, applied compresses on the femorals by tourniquet. In tAventy minutes the pulse became more frequent; in thirty minutes the patient felt a sense of weight and fulness in the region of the uterus, and in an hour and a half the menses set in. Many of the factors wdiich account for primitive amenorrhoea will also induce secondary or accidented amenorrhoea. Thus, defective nutrition, unhealthy occupations in crowded, ill-ventilated rooms, blood-tainting from exposure to sewage-emanations, Avant of exercise in the open air, Avhich implies privation of the Avholesome influences of the sun, will all impede the advent of menstruation. Girls verging on puberty, sent to boarding-school or into business in large town establishments, commonly fail to menstruate, Avhilst the function often is accomplished on their re- turn to free life in the country. In these cases the blame cannot ahvays be assigned to insufficient food, for girls Avorking in trades in cities often get a more substantial diet than they were previously used to. What is Avanting is out-door exercise, and less rigorous strain upon the mind and body. Cretinism exerts a remarkable influence. Lunier {Nouveau Diet, de Med. et de Chir. Pratiques, 1869) says "that puberty is almost always held back, or is only developed at the age of nineteen or twenty in girls, and later even in men. The cretin remains until puberty what he Avas in the first childhood, and very often there is nothing to distinguish the boy from the girl." Dr. Langdon DoAvn tells me " that he is able to say with much certainty that idiocy retards by quite t\vo years the first appearance of the menses. In a large number of cases it is much longer postponed, and sometimes never appears. Necroscopic inspection of idiots reveals, as a rule, Avant of development in the ovaries as to size. Associated Avith the non-appear- ance I have observed considerable increase of adipose tissue." The causes of arrest of menstruation are numerous. We exclude, of course, the physiological suspension during pregnancy and lactation. When an organ happens to be in a state of physiological activity, it is specially liable to suffer if the system be exposed to any physical or mental shock. Physiological activity implies hyperaemia ; under sudden excitation hyperaemia readily passes the physiological boundary, and the function Avhich Avas in progress is arrested. Hence, exposure to cold and Avet during the menstrual Aoav Avill frequently check it. It is said that some Avomen Avilfully avail themselves of this deleterious inAuence, in order to escape from the temporary abandonment of their pleasures Avhich menstruation compels. They encounter a very serious danger. It is not to be expected that the effect will stop short just at the point desired. Ovaritis and pelvic peritonitis are very likely to attend this violent sup- pression, and permanent, even fatal, mischief has resulted. Dr. White- head relates a case in Avhich menstruation Avas suppressed by cold, Avhich ended in fatal peritonitis. There Avas no effusion of blood. In another case the same physician found all the large sinuses of the brain distended to their utmost limit, gorged Avith black, firmly-coagulated blood; no ex- travasation. Menstruation had been suddenly suppressed by intense mental emotion. On the other hand, it must not be concluded that de- 198 DISORDERS OF MENSTRUATION. cided organic change in the ovaries necessarily attends the sudden sup- pression of menstruation. Aran made minute examinations upon this point, His results were mostly negative. The absence of any serious organic lesion is further proved, in many cases, by the return of the menstrual function at no distant date. The arrest of the Aoav must there- fore be regarded, in some cases, as a reflex phenomenon, the peripheral or centric irritation Avhich caused the suppression causing a diversion of nerve-force and of blood in other directions. It is analogous to the sup- pression of epistaxis under the application of a cold body to the skin. I haA-e lately seen a remarkably Avell-developed young Avoman Avho never menstruated regularly after receiving a Woav on the side. Abrupt suppression is, however, often marked by signs of local dis- tress. Pain and a sense of fulness in the pelvis and groins are felt. If examination be made by touch, the uterus is found to be tender, and some tumefaction of the ovaries may be detected. The vaginal-portion is injected. Constitutional disturbance also reveals the local trouble. The pulse rises. Uterine and ovarian disease not seldom entails amenorrhoea. Inflam- mation may suspend it, but advancing degeneration of the ovaries is more likely to lead to complete suppression. That menstruation so often goes on notwithstanding the development of enormous ovarian tumors, is explained by the fact that commonly one ovary is healthy, or that Avhere both are affected, yet some portion of one or both retains so much of its normal structure that the process of ovulation goes on, whilst the " habit" is so strong that even slight ovarian nisus provokes the customary Aoav from the mucous tract. Emotion, sudden, or that attending a great change in the mode of life, will often suspend menstruation. Thus it is not uncommon to observe in young women absence of the menses for two or three months after mar- riage, giving rise to the idea that pregnancy has begun. This is often nothing more than an emotional suspension. So, under the greater emo- tion of illicit connection, the same thing occurs. Passion, depressing news, domestic calamities, have often caused so great a shock that the menses haAre been arrested even permanently. Amenorrhoea frequently folloAvs acute diseases, especially fevers. Thus I have seen girls Avho had exhibited all the characters of" healthy devel- opment cease to menstruate for months after recovery from scarlatina or typhoid fever. I have known examples of amenorrhoea dating from simply nursing a scarlatinal patient. Exposure to the poison was suffi- cient, Avithout the development of the fever. In some, the functions are for a long time irregular, imperfectly performed, and the constitution is manifestly impaired. In particular, the complexion seldom regains its original clearness, growth is checked, and the temper is more uncertain and irregular. Ague may have a similar effect. In some cases of arrested menstruation I have suspected the existence of disease of the supra-renal capsules. In these the arrest came on at ages betAveen thirty and forty ; the complexion underwent the most marked dirty sallo\v change, freckles and spots becoming almost black; there Avas great mental depression occurring in fits, and great emaciation. Associated Avith amenorrhoea, probably as cause, there may sometimes AMENORRHOEA. 199 be found a general torpor or deficient innervation of the sexual system. This probably implies defective evolution of the ovaries. There is an original or acquired insensibility. There is no sexual feeling. This has sometimes been observed to folloAV a labor: but in many cases it is orig- inal, and is attended by sterility. Attendant upon this ovarian defect, there is commonly imperfect development of the uterus. In amenorrhoea folloAving labor, the suppressed ovarian function is accompanied by super- involution of the uterus. Diagnosis.—In studying this question Ave must bear in mind all the conditions associated with amenorrhoea ; Ave must revieAV the history of the patient, and of her present illness. To trace the circumstances under Avhich the absence of menstruation commenced, Ave must interrogate all the functions, in order to detect disease in organs unconnected Avith the genital system. The exploration of the chest is especially important, on account of the frequent relation betAveen amenorrhoea and phthisis. And in many cases it is necessary to examine the vagina and uterus to ascer- tain if there be any physical defect or obstruction to the excretion. This applies to married as Avell as to single women. The possibility of preg- nancy must not be lost sight of. The signs of "Retention" will be dis- cussed hereafter. Prophylaxy.—Many of the causes of amenorrhoea are avoidable. Nevertheless great carelessness, even recklessness, is shoAvn in encoun- tering them. It ought to be needless to insist upon the observance of repose, physiological and physical, at the menstrual periods, the avoid- ance of exposure to cold or mental disturbance. Adults may be expected to take care of themselves ; but young girls verging upon puberty require the watchful care of a mother. Serious mischief often arises from their being taken by surprise at the first appearances. Not being forewarned, in their alarm they may seek to check the bleeding by bathing in cold Avater, and they are apt to commit other imprudent acts Avhich may sup- press the natural fiow, and lay the foundation for serious protracted or permanent disease. Many girls, for example, have never menstruated again. They should be Avarned then to dress Avarmly, to avoid excitement, and to keep quiet Avhen the period is approaching and during the Aoav. The course, duration, and consequences of amenorrhoea vrary. Where there is no organic disease, as tuberculosis, and the subject is submitted to proper hygienic and medical treatment, the function is generally restored in a feAv months. But in those cases Avhere amenorrhoea is complicated with, or dependent upon, disease in the heart, lungs, \\\ev, kidneys, or ovaries, Ave can look Avith no confidence to the end of the symptomatic or consecutive disorder. On the other hand, Avhere the defective action of the ovary appears to be inherent or primary, its long continuance often entails such impairment of nutrition and innervation as to give rise to distant organic disease. Where there exists hereditary morbid diathesis, especially tubercular, the evil Avhich might othenvise have remained latent is very likely to be developed. The influence of protracted amenorrhoea upon the nervous system is almost ahvays prejudicial, and is sometimes deplorable. The leading characteristic is Avant of poAver or tone. The general physical condition 200 DISORDERS OF MENSTRUATION. is loAvered ; the patient is unequal to more than moderate muscular exer- tion ; the fits of irritable temper alternate Avith torpor; headache is fre- quent : it is difficult or impossible to sustain any mental effort; memory is feeble ; and in some instances mania or dementia has ensued. Treatment.—The hygienic care is of great importance. Careful watch must be kept for the invasion of phthisis. Hence it is often useful in amenorrhea, Avhether there exist any special cause for apprehending the invasion of tubercular mischief or not, to winter in a mild, pure air, as in Tourquay, Bournemouth, Ventnor, or the south of France or Italy. The treatment of acute amenorrhoea from accidental suppression must be governed greatly by the nature of the cause of suppression. If it be the result of cold, a warm bath, rest in bed, sudorifics, as acetate of am- monia, ipecacuanha, a moderate opiate, or terebinthinate enemata will be useful. But if there be evidence of pelvic congestion or inflammation, it Avill be unwise to seek to provoke the menstrual flow by local excitants. If there be much pain, increased on pressure, a quickened pulse with hot skin, some leeches applied to the groins or anus, hot fomentations to the stomach, salines, constitute the best treatment. When the pain has come on very suddenly, and with great severity, there is reason to fear that an effusion of blood has taken place from the turgid Fallopian tubes or ovaries into the peritoneum. This case will be discussed under " Haema- tocele." Chronic amenorrhoea usually falls practically under the same rules as the primitive amenorrhoea. Iodide of potassium, iron, strychnine, suit- able hygiene, are our chief resources. AMENORRHOEA FROM RETENTION : RETAINED MENSES FROM OCCLUSION OR ATRESIA OF THE UTERUS, VAGINA, OR VULVA, OR FROM IMPERFORATE HYMEN—OCCULT MENSTRUATION--HiEMATOMETRA. The study of those cases in which amenorrhoea is only apparent, in which the secretion is effected, but is retained in the cavities of the uterus or vagina, will, for clinical reasons, be most conveniently undertaken here. In its practical bearings it will be found naturally to take its place between amenorrhoea and dysmenorrhoea. The history and symptoms of retained menses very much resemble those of dysmenorrhoea. For a considerable time, the negative sign of absence of the ordinary menstrual flow chiefly attracts attention;° and the case may be looked upon simply as one of amenorrhoea. The leading clinical feature is the combination of signs of dysmenor- rhoea with amenorrhoea. And since retention commonly induces enlarge- ment of the uterus, and hence of the abdomen, the combination of amenor- rhoea and this enlargement leads to the suspicion of pregnancy. When things have arrived at this point, the character of the patient, no less than the physical distress and danger, imperatively point to the necessity of an examination. The usual history is as folloAvs: A girl, having arrived at puberty, does not menstruate. Month after month, perhaps for two or three years or more, pass by, and nothing is seen. But every month, perhaps"\vith RETENTION OF MENSES. 201 occasional intermission, pains in one or other iliac fossa, such as com- monly indicate difficult ovulation, are felt; pain in the centre of the pelvis referred to the uterus folloAvs or precedes, often of a forcing or bearing-down character, that is, uterine colic, such as occurs when the organ is struggling to expel something from its cavity; frequently the pain spreads to the abdomen, so that the patient cannot bear to be touched, and suggesting the presence of peritonitis. Flushed face, accelerated pulse, headache, vomiting, pains doAvn the legs, irritation of the boAvels and of the bladder commonly attend. After a feAv days these symptoms subside, seldom entirely; and the patient is left to an interval of com- parative ease. But her general health suffers. A degree of irritability of nervous system remains. Not seldom, occasional rigors appear, and these are folloAved by quickened pulse, increased temperature, nausea, muddy complexion; in short, the usual signs of blood infection. When irritative, hectic, septicaemic, or pyaemic fever sets in, the case is com- monly hastening to a climax; and the physician is soon compelled to search for the source of the disorder. In other cases, the irritative fever, although existing in a minor degree, is not the immediate cause of chief distress. This is due to the disten- sion of the uterus, or vagina, or both, progressing so as to distend the abdomen. The pain, causing vomiting and prostration, may be so great that the local source cannot be overlooked. The enlarged uterus may press the bladder fonvards, and jam it against the symphysis pubis, causing retention of urine. The distress arising from this, and the en- largement of the abdomen, admits of no delay. In other cases the enlargement of the abdomen is sIoav, and the pain is tolerated. It is only Avhen amenorrhoea and enlargement of the abdo- men excite suspicion of pregnancy that advice is sought. In some of these cases the history of the enlargement, extending over a longer period than the normal time of gestation, and other circumstances, are enough to remove all doubt of her chastity from the minds of all but the censorious. The governing fact, then, is retention of the menstrual fluid in the uterus or vagina. Menstruation is non-apparent, but it exists. The proper term, then, is not amenorrhoea, or amenorrhoea from retention, Avhich is a contradiction in terms, but " occult, or concealed menstrua- tion." The ovaries act, the uterus responds, the menstrual blood is secreted, but OAving to some physical obstruction it cannot be excreted, that is, it is retained. These cases may be divided into two kinds: 1. There is retention ab initio; there is some congenital defect, or some condition acquired in childhood. 2. The retention has arisen after puberty, and most frequently after child-bearing, and is the consequence of an obstruction acquired after maturity. We have, then, to examine the cases of Atresia of the Vulva, Vagina, and Uterus, and the other defects of formation which lead to retention of menstrual secretion. Atresia (<* priv. tp»}, cavity of vagina distended ; o u, os uteri, and cavity of uterus above it also distended. Complete occlusion of vulva (R. B.). There is a feature in the history of stenosis and atresia of the genital canal, which it is interesting to describe, on account of its bearing on 206 DISORDERS OF MENSTRUATION. treatment. Under the condition of stenosis or atresia long persisting, this canal obeys the same laAv Avhich rules OA-er other canals or hollow organs. It undergoes retrograde dilatation above the scat of stricture. This is the almost inevitable consequence of the futile attempts of the muscular coat to expel the retained contents. This successive ascending dilatation of vagina, cervix, body of uterus and tubes, is illustrated in Figs. 62 and 63, taken from preparations in St. George's and the Rad- cliffe Museums. This effect is seen in the most marked form in cases of imperforate hymen. The vagina being the most distensible part of the canal dilates first, forming a large pouch ; then the cervix uteri is dis- tended ; then the cavity of the body of the uterus ; and lastly, the Fal- lopian tubes. This dilatation, conservative in its effect by accommodating the contents Avhich cannot be evacuated, has its limits. When these are reached, the danger of rupture or perforation at the Aveakest part is great. But before this comes to pass, there are two events Avhich may happen. The first is transudation of the more fluid part of the contents under the concentric compression to Avhich it is subjected. The experi- ments of Dr. Duncan, to which I have referred (p. 177), shoAv that under a certain degree of hydraulic pressure, air or liquids traverse the entire Avail of the uterus. This is the old experiment of the Florentine metal globe applied to organic tissues. His experiments, of course, Avere performed on dead tissue. But there is good reason to believe that the force Avhich the living uterus exerts in its efforts to expel Avhat may be in it, Avhether it be a foetus or imprisoned fluids, is enough to drive fluid through its walls, in the form of a fine oozing or deAv, which hangs on the peritoneum. It seems to me probable that it is in this Avay that some cases of puerperal pelvic peritonitis are produced; and I have seen cases of septicaemia and peritonitis occurring from retention of menstrual fluid, greatly resembling puerperal fever, in Avhich there was no rupture, and no escape of fluid by the open ends of the Fallopian tubes. Supposing that the structures retain their integrity, it is natural that the concentric compressive force should drive the contents along any pas- sage that may be pervious; hence the escape by preference along the tubes. This is rendered more likely by the dilatation Avhich commonly takes place at their uterine ends. This compressive force is exerted with most effect immediately after the puncture of the closed hymen. The sudden collapse of the Avails of the uterus ensuing upon the partial escape by the opening excites the uterus to contract. This contraction drives the contents in all the three directions, and some will probably escape through one or other of the tubes into the peritoneal cavity. The more common event is the laceration of the tubes at the Aveakest place, caused by the sudden dragging upon them by the retreating uterus, the tubes being, perhaps, held back by adhesions. Other consequences of retention, if not relieved by operation, are: the distension of the uterus leads to perimetritis, with adhesion to the sur- rounding parts, especially of the Fallopian tubes to the ovaries and broad ligaments. The thinning of the uterus may proceed to bursting. The dis- tended Fallopian tubes may burst, or Avithout bursting, an overflow of blood may escape into the peritoneum, causing peritonitis. (Brodie, KiAvisch.) MENSTRUAL RETENTION. 207 Beclard relates a case in Avhich the uterus burst, discharging into the blad- der. Scanzoni and A rthur Farre relate cases in which the distended hymen burst: in Farre's case death resulted. In other cases (see Puech) the ob- structing membrane has given Avay by ulceration, and a cure has resulted. The constitution suffers from hectic, the result of pain, and the absorp- tion of the altered blood from the uterus. In some cases—Lize" relates one {Union Medicale, 1863)—the impossibility of evacuating the collecting menstrual blood induces amenorrhoea; the ovaries and uterus give up their functions. Lize believed that in his case atrophy of the uterus Avas in- duced. Dr. Murray, of Newcastle, relates a case {Brit. Med. Journ., 18<>8), of a single lady, aged twenty-seven, Avhose vagina was closed by smallpox in infancy. Menstruation had been suspended for fourteen years. The vagina being opened up, no collection Avas found in the uterus, but exactly a month afterwards menstruation appeared, and re- curred Avith tolerable regularity aftenvards. In this case it Avas clear that the ovaries Avere not atrophied, but that the uterus ceased to pour out menstrual blood. This is in accordance with what sometimes occurs in appareut amenorrhoea, without uterine obstruction. Ovulation may go on Avithout exciting menstrual Aoav. This returns Avhen a healthy state of the blood is restored. Simon relates {Mon.f. Geburtskunde, 1851) a case of complete closure of the vagina, Avith a distended uterus. A vain attempt Avas made to establish a vagina. The patient maintained good health notAvithstanding. The character of the retained blood is remarkable. It is dark-colored, deficient in fibrin, of treacly consistence, rarely containing coagula ; it contains mucus, and often cholesterine scales. It is glutinous, inodorous. The quantity varies Avith the duration of retention. Occasionally the tolerance and accommodation are surprising; the uterus may be expanded to the size of the end of pregnancy. Ten pounds of blood haATe been collected; I have collected forty ounces, and this perhaps is an average amount. Puech deduces from comparison of quantity and time of reten- tion that, as a rule, the quantity is less than the number of menstrual periods Avould have produced normally. Letheby {Lancet, 1845) ana- lyzed forty ounces, which gave Avater, 875.4 ; albumen, 69.4 ; globulin, 49.1 ; hsematosin, 2.9 ; salts, 8.0 ; fat, 5.3 ; extractive, 6.7. There is another analysis of retained menstrual fluid by H. Mtiller in Henle and Pfeuffer's Zeitseh rift, 1846. Sometimes the fluid undergoes decomposition, and then gas mixed with the blood constitutes physo-hcematometra. The symptoms and diagnosis of retention are those Avhich might be expected from obstructed functions. " Impediuntur coitus, conceptio, et purgatio." Until the advent of puberty, nothing may cause suspicion of abnormality. But Avith the onset of menstruation distress begins, due to retention of the • menstrual fluid; at first, perhaps, this is limited to passing attacks of uterine colic, marked by pelvic pain and bearing doAvn or expulsive efforts. Vomiting often attends, as in all cases Avhere the uterine fibre is suddenly stretched. These attacks, more or less periodical, are not attended by the expected appearance of the menses. Occasionally there is a vicarious discharge of blood in form of epistaxis. In Pallen's"case, one of absence of the vagina, there Avere marked men- 208 DISORDERS OF MENSTRUATION. strual molimina, but no accumulation of menstrual blood in the uterus or neighborhood. When an artificial vagina Avas made, menstruation took place periodically by this channel, and the epistaxis ceased. Gradually the distress increases. A sense of fulness in the pelvis arises ; the hypo- gastrium enlarges; the abdomen is visibly larger ; perhaps pregnancy is suspected ; there is sometimes retention of urine from the pressure of the uterus and vagina distended with the accumulating menstrual secretions ; defecation is difficult, and the digestive function is disturbed; irritative feAer, Avith a salloAV skin, and vomiting—the result of absorption of the watery part of the confined fluid—sets in. 7V firm, even tumor is felt rising from the pelvis behind the symphysis pubis, sometimes as high as, or even higher than the umbilicus. The uterus gradually yields under eccentric pressure ; as in pregnancy, or Avhen it contains a groAving polypus, it then grows, its muscular walls as Avell as its cavity enlarging. This process meets to a certain extent the pressure of the accumulating fluid ; but the contained matter receiv- ing fresh increments at every menstrual epoch, after a time requires more space : then other compensating processes bring alleviation, and stave off for a while the critical moment when the strain can no longer be borne. The more Avatery element of the contained fluid is absorbed. To supple- ment the imperfect distension of the uterus, another cavity is formed by the distension of the vagina. The tubes stretching, form further supple- mentary receptacles. The uterine and vaginal cavities are usually divided by a strait formed by the cervix uteri (see Figs. 62, 63). This vaginal pouch may be very large, especially if the occlusion exists at the vulva, Avhen it may so compress the rectum as to obstruct defeca- tion (Tuckwell), or cause retention of urine. The obstruction to normal menstruation is sometimes compensated by menstrual deviation, that is by fluxes from the intestines, bladder, nose, skin, etc. If the occlusion exists higher up the vagina, a pouch is still formed. And it is remarka- ble that the vaginal wall undergoes hypertrophy in the same way as the uterine wall. In a fatal case, Dr. Sutton {London Hosp. Reportg, 1867) found the vagina so much hypertrophied that the walls at the upper part were quite as thick as the uterine parietes. Klob contends that in cases of obstruction at the vulva, it is the vagina that chiefly, or almost exclu- sively, forms the sac, the uterus scarcely contributing. This is certainly not always true ; and it may be doubted whether it is even generally so. Dr. Tuckwell's case (see Fig. 63) exhibits manifest dilatation of both uterus and vagina ; and that this Avas also the case in two women whom I relieved by operation, I had distinct evidence. The uterus certainly enlarges considerably, and the easily distensible Fallopian tubes become generally distended, forming distinct tumors, readily felt on either side; sometimes, as Bernuth remarks, mistaken for pelvic phlegmons. The Fallopian tubes have been found distended, even Avhen shut off from the uterine cavity; but generally the uterine orifices of the tubes are ex- panded. A further stage leads to the escape of blood from the Fallopian tubes at their fimbriated extremities, or through rents into the peritoneum. This event, long ago pointed out by Brodie, has been amply confirmed by subsequent observers. The blood collecting in Douglas's pouch con- stitutes retro-uterine haematocele. The common effect of this is pelvic MENSTRUAL RETENTION. 209 peritonitis, sometimes fatal, at others resulting in segregation of the effused blood by plastic matter; a later stage of Avhich is a process of suppuration or necrosis of the posterior vaginal Avail and possibly dis- charge of the haematocele and cure. As Bernutz says, and I venture to add my OAvn testimony in support, the foregoing phenomena of obstructed menstrual Aoav may result from uterine deviations, especially flexions, from spasmodic contraction of the cendx uteri; and, according to my OAvn observation, from congenital narrowing of the os externum uteri associated Avith a conical vaginal-portion. The symptoms of abdominal shock and peritonitis folloAving upon those of retention of menses, indi- cate the occurrence of effusion of blood from the Fallopian tubes into the peritoneum. These symptoms depending on the same accident are very liable to folloAV operations for the discharge of the retained fluid. The history of haematocele will be fully discussed hereafter. A tumor is formed, sometimes of considerable size, in Douglas's sac ; at first, this is soft, fluctuating ; it then gets harder under coagulation, and the effusion of plastic matter around it; a firm tumor may be felt rising above the pubes, even to the umbilicus. The abdominal Avails can be made to glide over it; the limit of the tumor may be defined by percussion ; inferiorly the tumor sinks into the pelvis. By the vagina, Ave find the tumor push- ing forward the roof and posterior Avail of this canal, shortening it, and compressing it from behind fonvards, so that the finger is guided to the os uteri driven fonvards behind the symphysis. The os felt in this posi- tion, and a firm rounded mass extending behind it, has been mistaken for retroversion of the enlarged Avomb, and this the more readily, because retention of urine has often been an urgent symptom. Sometimes the atresia, especially in the acquired cases, as when cica- tricial occlusion takes place after fevers, sloughing from severe labor, or from injury by instruments, is not quite complete. There may remain a narroAV fistulous track, communicating Avith the expanded sac which receives the menstrual collection, and Avhich affords an occasional, but rarely complete relief by oozing. Such a fistulous tract may act for a long time as a sort of safety-valve, by which extreme tension is relieved. It is liable to complete occlusion at times. The folloAving case is an in- structive illustration. The subject had been delh'ered by instruments of tAvins after a severe labor. From that time she had suffered more or less difficulty in men- struation. This difficulty had increased gradually; and at the end of twelve years her condition had become anxious. At each menstrual epoch severe colic with expulsive pains set in. An enlargement Avasfelt rising considerably above the pubes. Partial relief had been obtained by escape of blood and offensive ichorous matter. At times retention of urine had occurred. The passage of the catheter was difficult, OAving to the urethra being compressed by the tumor. Distress increased at the menstrual periods. The vagina was quite occluded by contracted cica- tricial tissues, extending from the meatus urinarius to the anus, nothing but a scarred furroAV marking the site of the vulva. There was a minute fistulous tract, Avhich had probably given partial relief at times. I dis- sected up carefully between the urethra and anus, and struck the sac 14 210 DISORDERS OF MENSTRUATION. about an inch above the external surface. Offensive ichor, mingled with dirty-Avhite clots, escaped. She made a good recovery. In the first edition of this Avork (p. 2()4) is also related the case of Mrs. W-----. Since that publication the case has issued in a catastrophe especially interesting as illustrative of atresia. After recovering from yelloAv fever in South America she suffered from aggravated dysmenor- rhoea, inducing despondency and other nervous symptoms. The vagina Avas represented by a Avide shalloAv cul-de-sac, not an inch deep. About the middle of this sac was a small round hole, Avhich just admitted the point of the sound. Pursuing this track for two inches, a small solid body was felt by the finger in the rectum, Avhich I concluded to be an imperfectly developed uterus. Whether the atresia Avas congenital or acquired is uncertain. It might have dated from the yelloAv fever. The parts Avere dissected up at two sittings, and a free communication made Fig. 64. Atresia of Vagina. R, rectum ; B, bladder ; u, uterus ; v, cul-de-sac at vulva ; A, dense tissue in place of vagina traversed by a narrow fistulous tract between v and uterus (R. B.). Avith the uterus. The new vagina was kept open by a Hodge's pessary. A month after the last operation, the vagina was Avell preserved, and examining by a Fergusson's speculum during a period, 1 could see the menstrual fluid being poured into the summit of the vagina. For the RETENTION OF MENSES. 211 first time she Avas menstruating Avithout pain, and her health and spirits were already improved. She menstruated healthily several times; her health was fairly restored. Then her husband joined her. A feAv months after this she was seized suddenly with signs of "abdominal shock'' and collapse, and died. The cause, as I was informed, was rup- ture of an ectopic gestation cyst. The uterus was probably two-horned, and the gestation an instance of gestation in the imperfectly-developed horn. The issue, lamentable and beyond prevision, proves, nevertheless, the success of the operation. I have endeavored to represent the state of the parts before operation in Fig. 64. Dr. Gardner cites1 from Meigs " a case of unusual form of stricture of the vagina, which was the cause of an almost fatal error in diagnosis." The stricture Avas traversed by an extremely narroAV fistula just permit- ting of Avhat has been called " stillicidium mensium." Professor Thomas2 describes a similar case. Simpson described "a kind of adhesive or obliterative vaginitis" in adults, differing in some respects from the adhesive vaginitis of infants. In infants the inflammatory closure is usually limited to the orifice of the vagina, and produces complete occlusion. In adults it generally com- mences at the upper part of the vagina, spreads gradually doAvmvards, and seldom produces complete occlusion. It is almost ahvays attended Avith a circumferential contraction of the canal at the site of the disease, so that Avhen it is limited, as it often is to the top of the vagina, the os uteri is felt draAvn up to the apex of a narroAV conical or funnel-shaped cavity. But it occurs without this circular contraction, says Simpson; and I feel justified by observation in affirming that this funnel-shaped contraction of the upper part of the vagina may occur independently of inflammation. The adhesion is more agglutinative, like that Avhich unites serous surfaces in the early stages of inflammation, than true fusion. The finger can separate the adhering surfaces. It is a remarkable circumstance in connection with the history of atresia, or absence of the vagina, where no uterus can be found, or at least only such a rudimentary one as to be incapable of performing the functions of a uterus, that the artificial formation of a vagina brings con- siderable relief. Of this I have seen examples; one especially Avas that of a well-developed young lady, avIio had suffered from what may be called difficult ovulation; there Avas evidence of menstrual molimina, but there was no discharge. I dissected up a canal between the rectum and bladder; a good vagina was maintained by Avearing a Hodge's pessary; and she recovered health, remaining free from pain, and married. This, and other cases (see Dr. Clarke's case, p. 182), and one which I may specify of a young Avoman at St. Thomas's Hospital, prove that ovarian development may be good, and the uterus remain undeveloped. They prove that the general frame may be well developed, notAvithstand- ing the want of a uterus, and that the evolution of the general frame is due to the ovaries. Treatment.—In the case of apparent absence of the vagina there are 1 Gardner on Sterility, New York. 2 Diseases of Women, Philadelphia, 1869. 212 DISORDERS OF MENSTRUATION. three methods of proceeding. The first is to cut a channel through the tissues betAveen the urethra and the rectum up to the uterus. The second, adopted by Fletcher {Lancet, 1830-1831) and Amussat {Gazette Medi- cate, 1885), is to tear or stretch out a canal by the fingers or other dilat- ing instruments. The third may be called the mixed method, making use both of cutting and dilating. The last combines the advantages of the tAvo preceding, and at the same time reduces their disadvantages. Whatever mode is adopted, the patient is placed in lithotomy position, the place between the urethra and rectum is carefully examined, the index of the left hand is passed into the rectum, the sound is passed into the bladder, and feeling for it by the finger in the rectum, the amount of tissues available for burroAving, and the position of the uterine tumor are deter- mined. Then, the sound is held up under the pubic arch, whilst the finger carries the rectum aAvay in the opposite direction. A transverse incision is made in front of the anus through the skin, then cautiously nicking Avith the knife or scissors and stretching out with the fingers, working, from side to side, betAveen the finger in rectum and the sound in urethra as guide, a canal is opened to the uterus. Care should be taken not only to make all incisions laterally, but to Avork backAvards towards the rectum, as the chief danger is that of penetrating the Avail of the bladder. If the os is felt, a sound should be tried first; if the os be impervious, it may be perforated by a trocar or by the knife. It may be desirable to carry out the proceeding at different sittings. It will generally be necessary to place a tent or bougie in the uterine opening to prevent closure; and the artificial vagina must be preserved by plugging with lint steeped in carbolic oil, glycerine, or Avhat I have found to ansAver better a narrow Hodge pessary. The tendency of the parts to contract and close again after operations for the restoration or formation of a vagina is very great. The operation may have to be repeated, unless great care is taken to preserve patency by artificial means. Where the closure of the vagina is the result of cicatrices from sloughs, the same cautious mode of dissecting and dilating may be adopted. Where the vaginal canal exists, and there is closure of the vulva by agglutination of the nymphae, or from imperforate hymen, the prepon- derance of testimony is in favor of making an opening into the vagina. The distended fluctuating membrane indicates the spot. This is pierced by a trocar, or better by a knife. Imperforate Hymen.—It has frequently been discussed how the catas- trophe of sudden escape of the retained fluid into the peritoneal cavity can best be averted. Is it better to make a very small opening in the hymen and let the fluid drain aAvay gradually, hoping that in this Avay the suddenness of the collapse of the uterus might be diminished ? This is the plan I have hitherto followed. But others have preferred making a free incision at once, and even proceeding to wash out the cavity. I am not sure that this is not the best plan. A free external outlet Avould make it easier for the contracting uterus to expel its contents by this route, and thus take off the pressure tOAvards the tubes. On the other hand, the rapid retreat of the uterus would favor laceration of the tubes, if held back by adhesion. The balance of advantages and of drawbacks of either plan is difficult to strike ; and it is to be apprehended that cases IMPERFORATE HYMEN. 213 will continue to occur in Avhich a fatal result will follow any method of treatment. A plan Avhich I should be disposed to try is to draw off a little at a time by the aspirator-trocar, so as to effect a very gradual diminution of the cavity before finally freely dividing the obstruction. In any case absolute rest should be rigidly enforced. On no consideration should even simple puncture of an imperforate hymen be done in the consulting room. I believe the opening should be sufficiently large to admit of easy evacuation, and that to prevent the entry of air a compress should be applied over the uterus and sustained by moderate pressure with a ban- dage. In some cases injections of Avarm water have been used to Avash out the uterus. It is doubtful Avhether this is good practice at the time of the operation, but if there should arise decomposition, the gentle injec- tion of a Aveak solution of permanganate of potash or carbolic acid will be desirable. After a few days it is proper to enlarge the opening by removing a circular piece of the membrane. Absolute rest in bed for some days is a wise precaution, notwithstand- ing the histories of cases Avhere impunity has folloAved its neglect. Symp- toms of peritonitis, indicating that retained fluid has suddenly escaped into the peritoneal cavity, have set in on the third or fourth day. The contraction of the uterus leading to this catastrophe does not take place immediately after the operation. The greatest care therefore is necessary for some days aftenvards. Drs. Ramsbotham and Lefort collected several cases in Avhich simple puncture of imperforate hymen terminated fatally. Simpson relates a case of occlusion of the vagina from adhesion causing a septum of no great thickness. Retention of menstrual fluid Avas going on, so a very small incision was made ; the patient remained Avell for tAvo or three days, great quantities of the usual dark grumous fluid constantly escaping by the Aragina. On the third day surgical fever set in, and in a feAv days she died. The autopsy showed that the interior of the distended uterus had become the seat of a very intense inflammation, which had spread thence, and led to a severe and fatal peritonitis. This Avas probably set up by air getting into the uterus and causing decomposition and septicae- mia. It strengthens the argument for free incision and washing out the uterus. In cases of occlusion of the uterus Avith retention of menses, the indi- cation is to make a passage into the cavity. The opening into the uterus is best made by a fine-pointed knife. After piercing in the central point, the natural seat of the os uteri, incisions may be made on either side, and by carefully dissecting upAvards, a passage is made into the cavity of the uterus. The fluid evacuated, it is necessary to introduce a tent—a me- tallic one is best—to preserve the opening, Avhich would otherwise close, and lead to a repetition of the mischief. This liability is especially great in cases of contraction after amputation of the neck. Some have advised puncturing by the rectum in preference, and even puncture of the uterus above the symphysis pubis has been recommended. The experience of puncture of the rectum is not so favorable as to show any superiority over opening by the vagina. It is an imperfect operation, for the establishment of a vaginal canal avouIcI still be indicated Avhen 214 DISORDERS OF MENSTRUATION. relief from haematometra has been obtained. In cases where opening up the natural route is impracticable or too hazardous, opening by rectum may be resorted to as a temporary expedient. Fatal peritonitis folloAved in cases treated in this way by Antoine Dubois and Dupuytren.^ Dr. Oldham {Guy's Reports, 1857) reports tAvo cases in which punc- ture per rectum was practised. In one there Avas congenital absence of vagina; the os uteri Avas felt through the rectum, the trocar Avas made to pierce at this point. The operation was repeated on four occasions; at last the opening continued patent, and menstruation took place by the rectum. In the other case the vagina Avas closed by dense cicatrix ; the os uteri Avas felt by rectum, and was punctured ; relief followed. A third case at Guy's is reported by Dr. Hicks {Medical Times and Gazette, 1*61) : here there was an absence of vagina : puncture by rectum Avas folloAved by relief, and, as far as the report goes, there was subsequent amenorrhoea. When these cases of retention have been relieved, and have apparently recovered, it must be remembered that the Fallopian tubes do not at once, perhaps not for a long time, recover their normal calibre. Some degree of abnormal dilatation remains. This is certainly the case in the partial retention due to stenosis of the cervix and to retroflexion. The knoAvledge of this fact is of the highest importance in practice. The long- continued obstruction having entailed dilatation of the uterine cavity, and catarrh of its mucous membrane, with very often a disposition to metrorrhagia, the physician is tempted to inject astringent fluids into the uterus. Fatal accidents have followed this practice, and much discus- sion has taken place as to the immediate cause of these accidents. The prevailing idea is that the injected fluid is driven along the tubes by the force of the syringe, its return by the cervix being stopped by the inject- ing tube which fills it. I am disposed to believe that Avhere there is unusual patency of the Fallopian tubes this may occasionally be the case. But the more common mechanism, I am convinced, is that Avhich I have just explained as occurring in retention from imperforate hymen. The astringent fluid throAvn into the uterine cavity acts primarily as an irritant and constringent. This action is forcible and rapid. The uterus instantly contracts and pumps on the fluid along the patent Fallopian tubes. That this Avas Avhat occurred in a case in Avhich a solution of perchloride of iron Avas injected into the uterus, on account of hemorrhage from retro- flected uterus, in the London Hospital, seems to me beyond doubt. The tubes Avere found patulous, and fluid had run along them into the peri- toneal cavity. DYSMENORRHOEA. 215 CHAPTER VIII. dysmenorrhea--neuralgic; congestive; from obstructed excretion; inflammatory; ovarian dysmenorrhea; dysmenorrhea membra- nacka, or exfoliativa. Dysmenorrhea is the term used to express that menstruation is per- formed Avith difficulty and pain. It is a very frequent affection, being symptomatic of, or consequent upon, a variety of morbid conditions. These morbid conditions of course are mostly'unknown to the patient; she ap- plies for relief of the functional distress. To give the sought-for relief Ave must form a clear idea of the causes of the distress. The method by Avhich this knoAvledge is arrived at is partly by clinical observation and study of the phenomena Avhich present themselves, and of the condition of the organs involved ; and partly by observation of the effects of treat- ment. It may be admitted that the means of treatment employed are sometimes empirical; that is, they are not directed by a clear com- prehension of the cause of the distress ; but if Ave find that this is fre- quently followed by success, empirical though it be at first, it will lead us to a clearer knoAvledge of the evil Avhich it overcame, and thus it be- comes rational. By this double process Ave arrive at the conclusion that cases of dys- menorrhoea may be classified under the following heads:—namely, 1. Neuralgic, or sympathetic. 2. Congestive, or inflammatory. 3. Me- chanical anomalies of the uterus. 4. Fallopian obstruction. 5. Ovarian disorder, constituting a distinct form of dysmenorrhoea. The simple study of the subjective phenomena will not enable us to distinguish cases of one kind from those of another kind. Indeed, so long as this very imperfect method was exclusively pursued, all cases of dysmenorrhoea Avere confounded together, or the distinctions made Avere necessarily arbitrary and fanciful, and treatment, being aimed at random, Avas generally unsuccessful. This is a logical necessity. For the prac- titioner Avho limits his observation to the subjective symptoms must per- force exclude from his resources those means which are suggested by the objectiAre method of investigation. Not many years ago, dysmenorrhoea Avas almost universally looked upon and treated as a nervous affection of the uterus itself, or sympathetic Avith disorders of distant organs, or the expression of constitutional debility. But in proportion as precise ob- jecth-e methods of investigation have been applied to the study, it has been discovered that in most cases the nervous phenomena are dependent upon distinct abnormal conditions of the uterus or of the ovary. If, therefore, Ave still retain the term neuralgic dysmenorrhoea, Ave must do so on the understanding that, although expressing a really exist- ing disorder, it is a convenient asylum iynoranticv, under Avhich Ave may class a number of cases, the true pathology of Avhich eludes our research. 216 dysmenorrhea. We have already averted to the " irritable uterus." The late Dr. Robert Ferguson, commenting on Gooch's description,1 said : " This malady, I believe, is deeply rooted in the very essence of that complex organic function termed the generative : Avhich, in its most comprehensive sense, includes no inconsiderable portion of the moral as well as of the physical development of the female organization.....The local changes have been the fluctuating, the nervous affection, the constant element; in it, therefore, and in no doctrine of a phlogistic origin, can I place the essence of this strange disease." This vague description really carries us very little way behind the ideas of Gooch. Henry Bennet assigned inflammation as the real pathological condi- tion ; Rigby thought many cases Avere due to a rheumatic diathesis ; and other authors have from to time, impelled by the accidental nature of their experience, or the bent which preconceived theories had imparted to their observations, given prominent or exclusive importance to some other complication. If Ave carefully analyze a large number of cases, noting the complications, and the effects of treatment, Ave shall find that the cases of " irritable uterus" resolve themselves into the folloAving groups,—viz., 1. In Avhich there is manifest enlargement from congestion of the uterus ; 2. Suit-involution Avith chronic inflammation of the uterus, folloAving labor or abortion ; 3. Reclination or flexion of the uterus, most frequently retroflexion ; 4. A projecting conical vaginal-portion, Avith very small os externum uteri; 5. Lateral reclination, mostly asso- ciated with imperfect development of the uterus ; 6. Disorder of distant organs, especially of the digestive organs, attended or not by one or more of the preceding structural faults, and almost ahvays Avith impaired san- guification and nutrition; 7. A morbid condition of the ovaries ; lastly, a residuum of cases in Avhich, Avhether from not pushing investigation to the proper point to discover the associated fault, or because there really is no physical fault, Ave are obliged to conclude that the dysmenorrhoea is simply the expression of nervous disorder. The truth is, that difficult menstruation so exhausts the tone of the nervous centres, that the general or local hyperaesthesia is almost certain to folio av. I think observation Avarrants this general conclusion: The healthy, well-formed uterus is rarely an " irritable uterus," or associated Avith dysmenorrhoea. Or the case may be stated as folloAvs: For menstrua- tion to occur healthily, the genital canal, from its commencement at the fimbriated extremity of the Fallopian tubes to the vulva, must be easily pervious. This presumed purely neuralgic dysmenorrhoea Ave will noAV endeavor to describe. If Ave folloAV a chronological order, and consider first the dysmenorrhoea Avhich is observed at the very outset of the function, Ave find a number of cases from Avhich Ave may fairly exclude the idea of inflammatory ulceration or other tissue disease, since these conditions very rarely occur in early girlhood. The reverence due to youth, and pre-eminently to female youth, imperatively forbids physical examination, unless under urgent circumstances and the failure of ordinary treatment. We are therefore precluded in most of these cases from determining in 1 New Sydenham Society's Edition of Gooch's Works, 1859. NEURALGIC DYSMENORRHEA. 217 the first instance the presence or absence of uterine flexions and narrow- ness of the os uteri, Avhich are perhaps the most frequent causes of prim- itive or initial dysmenorrhoea. Whether the pain be due to recognizable mechanical conditions or not, the phenomena observed are nearly the same. The disorder may be associated Avith an hysterical disposition; it is generally associated Avith a highly susceptible nervous temperament, which may be defined as the hyperaesthetic temperament. Extreme susceptibility to pain is one of the penalties of high civilization, and of too luxurious rearing. Hence the neuralgic dysmenorrhoea chiefly affects the easier classes. It is not common, I believe, amongst the laboring agricultural population ; but it is by no means infrequent in tOAvns, Avhere, although girls and Avomen may have to Avork for a living, they are never- theless exposed to many enervating influences, hygienic and moral. The first onset of menstruation is generally late ; it is marked by pain coming on a day or tAvo before the Aoav, sometimes so intense that the sufferer Avrithes upon the floor, and is compelled to take to bed. The pain begins in the pelvic region, radiates to one or both groins, and shoots doAvn the legs. It is commonly paroxysmal, resembling colic—it is, in fact, uterine colic. It is often likened to labor. Often the Avhole abdominal surface is tender to the touch. At times it simulates perito- nitis. This pelvic eccentric irritation, commonly involving, as it does, ovarian irritation, propagated to the nervous centres, may evoke other nervous phenomena, as hysteria, vomiting, hiccough, headache, even de- lirium, and in some cases, mania. Tetanoid rigidity is not uncommon. The urgent symptoms subside in tAvo or three days ; the patient recovers so much strength as to enable her to resume her ordinary mode of life. But as the period comes round the same series of painful phenomena is reneAved. The pain is often diminished Avhen the Aoav sets in, Avhich is often attended by the expulsion of a clot. But it sometimes attends the Avhole period Avith more or less severity. It does not appear to bear any con- stant relation to the amount of the discharge. If there is no recognized organic change in the uterus, or displacement in the first instance, Ave may be certain that some complication of the kind will appear sooner or later. I coincide in the statement of Scanzoni, that long-standing dys- menorrhoea rarely fails to induce some change of tissue in the uterus, the most common being hyperplasia. The nervous phenomena described may attend all the forms of dys- menorrhoea. We are thus led to ask: is there any physical condition of the organs concerned that can account for the pain ? The colic, the spas- modic character of the pain, seem to indicate a contracting uterus seeking to expel contents that irritate it; and this is often true. But not ahvays. It is a well-recognized character of the nervous function that its pheno- mena or actions have a tendency to periodicity, as if, like electricity, it required a certain degree of accumulation of the vis nervosa before it can act. So in the case of pain we often see alternations of acme and of ease, of discharge and accumulation. The fact that the period of most intense pain is usually twenty-four hours before the appearance of blood, is held to prove that these uterine colics or paroxysms cannot be due to anything contained in the uterus, and irritating it to contract. This 218 DYSMENORRHEA. objection rests upon the assumption that there is nothing but blood, fluid or coagulated, that can be there. But this is overlooked—the rapid preliminary development of the mucous membrane into menstrual decidua, the congestion of this structure, and of the uterus generally. This is enough to cause tension of the uterine muscular fibre, and to excite it to contract, and this SAvelling of the mucous and muscular Avails may close the os internum, and lead to partial retention Avhen the flow begins. The fre.) '•The ovary forms a cyst with thick walls, and contains what appears to be a coagulum of blood as large as a chestnut."—(Catalogue.) 5. The degeneration to Carcinoma may ensue upon the preceding fibrous degeneration, or occur independently. "Congestion of the ovary" and "oophoralgia," " neuralgia of the ovarii,"'" ovarian irritation," have been discussed in the preceding chapter. m That cases marked by excessive pain are especially apt to pass into inflammation is highly probable. There is congestion of the ovaries, tubes, and uterus beyond the physiological measures, so that escape of blood'into the peritoneum is not unlikely to occur. But intensity of pain is not evidence of inflammation. I have known an ovarian cyst to burst, discharge its contents into the peritoneal cavity, and death ensue under the most excruciating agony ; vet examination has not shown a trace of in- flammation. Again, in these cases we find the uterus remaining movable, with entire absence of anv thickening or perimetric swellings, even after years of suffering. It may be true that the ovary proper may be inflamed alone, it is hardly conceivable that repeated attacks of oophoritis should fail to involve the peritoneal investment. It is, moreover, scarcely m accordance with the history of inflammation to return in an organ every month, to run its course in a few days, and to leave the organ essentially sound,1 that is, in a condition ultimately to perform its functions, let 1 270 OVARY : DISEASES OF. have seen cases Avhere this oophoralgia lasted for years, was cured, and healthy menstruation ultimately established. ff Fibrous Tumor of Ovary from a woman aet. 50 (R. B.). The uterus also contained a fibrous tumor. (St. George's, XIV. 140. Nat. size.) The ascertained conditions are extreme local hyperaemia or congestion, and exquisite sensibility of the ovaries, combined Avith great irritability of the nervous centres. These conditions furnish the indications in treatment. It is very im- portant to eliminate the idea of inflammation where the thing does not exist, because antiphlogistic treatment will in the long run aggravate the disease, and reduce the general poAvers. Thus I have several times seen great prostration, increase of local hypersesthesia and of general local irritability produced by the repeated application of leeches to the groins or to the os uteri. It is true that in some of these cases the patients expressed relief at the time ; but the relief could hardly be said to be real; it was not attended by cure, and seemed to me to do more harm than good. Counter-irritation in the form of blisters or chloroform-embro- cations to the iliac regions has appeared to be beneficial. Another proceeding very apt to be carried to mischievous excess is lying down. Nutrition must suffer, and as a consequence the nervous centres become more irritable. The true course to adopt is to follow the three indications given by— 1. The general depression of the system ; 2. The exaggerated irritability of the nervous centres; 3. The congestion and hyperaesthesia of the ovaries and surrounding parts. It is superfluous to enumerate the medicinal, dietetic, and hygienic remedies Avhich help to fulfil the first indication. The task of allaying the extreme irritability of the nervous centres Avill be made easier in pro- portion as the general tone is improved. The nervous centres will also OOPHORITIS. 271 recover poAver as the third indication, that of tranquillizing the ovaries, one source of irritation, is effected. Rest in the physiological sense, that is, abstinence from " married life," is imperative. To subdue the hyperesthesia, the Avearing for a feAv hours every day one of the forms of " vaginal-rest" will be found of great service. If there is any displacement of the Avomb this must be corrected by suitable means. Abrasion, congestion of the cervix uteri, must be cured. I have found it useful to effect a derivative action in the cervix, by making a small eschar on the vaginal-portion with potassa cum calce. This is far less painful and more efficacious than blistering the groins. Bromide of potassium acts in some degree as a sedative of ovarian excite- ment ; but it is not to be depended upon alone. Sedative pessaries con- taining opium or belladonna applied to the fundus of the vagina a day or tAvo before the advent of the menstrual epoch are useful. The boAvels must be ay ell regulated to prevent accumulation in the rectum. Salt-Avater or Vichy baths, tepid or cold, according to the season, are often eminently useful. INFLAMMATION OF THE OVARY. It is not Avithin the scope of this Avork to describe the disease^ of the puerperal state. I pass over therefore those forms of oophoritis Avith which pathological anatomists are most familiar. The oophoritis of child- bed is seldom met with, perhaps never, apart from complication with in- flammation, extending from the uterus, tubes, and broad ligaments. The ovary is not affected primarily, but is caught secondarily in the spread of an active inflammation which invades most or all of the pelvic structures. It is difficult so to isolate the oophoritis in these cases as to extract any trustworthy facts to illustrate the history of pure oophoritis. Nor do Ave derive a much larger amount of precise information, ad hdc, from the examination of subjects Avho have had oophoritis apart from childbed. Here, too, the oophoritis is not often simple, but a part of an inflammatory process involving other structures. ^. Simple oophoritis is rarely fatal; so that the opportunities of seeing the condition of the ovary under the influence of acute or recent inflam- mation are necessarily rare. Rokitansky declares that apart from childbed oophoritis is verv rare. But this statement must be taken as expressing the experience of the dead-house. I believe that simple, or conjoined with metritis, it is not uncommon. But as the cases recover more or less perfectly, distinct evidence of the inflammatory action to which the ova- ries have been subject is rarely seen. All such evidence had disappeared during life, or had become confounded with the results of complicating diseases. . One of the most frequent conditions found is fibrinous adhesions ot various age uniting the ovaries to the sides and posterior surface of the uterus, to the broad ligament, or other neighboring structures. These are often found in women who have never borne children. We are thus driven to the conclusion that women are liable to frequent pelvic inflam- mations apart from pregnancy. These adhesions of course are the re- sidua of peritoneal inflammation, and commonly extend beyond the ovaries to other parts of the pelvic peritoneum. 272 DISEASES OF OVARY. Assuming that the ovarian implication is often secondary, it cannot be doubted that there are cases of primary oophoritis proper. All active function involves determination of blood to the organ performing it; but there is hardly any organ Avhose functional activity attracts blood in such profusion as the ovary. It goes beyond simple transient hyperemia; the rush and work are so violent that actual extravasation of blood and laceration of structure take place. It cannot then be surprising that under certain conditions interfering with the normal accomplishment of this function, activity so great should pass the narroAV physiological boun- dary, and terminate in inflammation. Scanzoni describes the post-mortem appearances in what seems to have been a typical case of acute oophoritis. The subject died of pneumonia, the result of cold, and with symptoms of peritonitis in the right ovarian region. In this situation Avas found a mass of coagulated fibrin, the size of a fist. On removing this the right ovary was seen two inches long, nearly as much across, and one and a half inches thick. It Avas ovoid, considerably enlarged, as the measurements show ; its surface was violet- blue, covered with numerous dilated veins, and near the inner angle of the posterior surface Avas a black spot, the seat of recent rupture of a vesicle. The organ Avas pasty, almost fluctuating in parts. On incision there escaped a considerable quantity of blood, and the section showed the same violet color, and some veins strongly congested. The ruptured vesicle still held some liquid black blood. ToAvards the other extremity of the ovary, where the congestion Avas less intense, there Avas an abscess in the parenchyma ; and at the side were other smaller abscesses, all deep in the parenchyma. This case shoAvs a combination of all the forms of oophoritis. Causes.—Oophoritis may be said to be almost strictly limited to the reproductive period of life. It is accordingly found to arise under con- ditions Avhich offer obstruction to the ordinary course of the ovarian func- tion. Impressions, physical or emotional, occurring during menstruation may goad the physiological congestion into inflammation. It has fol- lowed operations on the os uteri, and intra-uterine injections, and the spread of blennorrhagic inflammation along the Fallopian tubes. Ricord described this last form as analogous to the orchitis arising from blennor- rhagia in the male. Its origin in obstructed menstruation will account for the fact of oophoritis being more frequent in virgins than inflammation of the uterus, Avhich as yet has only entered upon the subsidiary function of menstruation. It is often secondary upon disease of the uterus, tubes, and broad liga- ments. The intimate vascular communications betAveen these organs offer a ready channel of extension for inflammation from the uterus. The dysmenorrhoea resulting from a contracted or nearly impervious os uteri is very likely to induce chronic inflammation of the'ovary. Retroversion is a frequent cause of swelling and great tenderness of the ovary, not unfrequently amounting to oophoritis, from the fundus of the uterus pulling the ovary backwards, and thus by the tension of the broad ligaments producing obstruction to its returning circulation. Sexual intercourse for the first time, or in excess, particularly if dur- ing the menstrual nisus, especially if there have been previously an irrita- OOPHORITIS. 273 ble state of the ovary, Avith dysmenorrhoea, is not unfrequently followed by oophoritis. Early abortions also may lead to the same condition. Oophoritis, arising othenvise than in childbed, is often single. But the ovaries appear to be subject, like the eyes and other double organs, to consensual suffering. Thus, inflammation of one ovary is likely to be folloAved by inflammation of the other. In some cases it is easy to ob- serve that common predisposing and exciting causes act upon both ovaries alike, although one may be affected earlier and more severely than the other. Inflammation of the Follicles of the Ovary.—Apart from the ordinary peritoneal inflammatory action proceeding from the ripened and burst follices, one or more ripe follicles may be seen Avith injected walls, red, softened, easily torn, Avith turbid, flocculent, puriform contents, and the surrounding parenchyma infiltrated. This leads to atrophy of the follicle, or causes its degeneration to a cyst. Ndgrier describes " Vesiculite" simple. In most cases the trouble re- mains local. A point of the ovary becomes tumefied and torn, an inflam- matory areola has surrounded the little Avound, sometimes, has invaded the peritoneal hrvestment, and even the pelvic peritoneum. " Vesiculite" is " simple" Avhen easily stopped, and ending in resolution. " Vesiculite" is "grave," Avhen ending in suppuration, or Avhen the inflammation has spread Avidely to the pelvic peritoneum. Khvisch says the inflammation of the follicles is commonly confined to one Graafian vesicle. An indication of the inflammatory process is seen in the menstrual metamorphosis of the follicles. The products of this in- flammatory condition are more or less plastic, and in general much infil- trated Avith blood ; the follicle is distended to the size of a pea or a cherry. When several follicles are implicated, the surrounding stroma participates in the inflammatory condition, and is found in a state of hyperemia, serous infiltration, or inflammatory softening. Parenchymatous Oophoritis.—This very rarely runs to suppuration. It often, however, leads in young persons to peritoneal false membranes and adhesions, to increase of bulk and thickening (sclerosis) of the stroma, thickening of the tunica albuginea, Avith atrophy of the follicles, especially of the peripheral ones, and enlargement of the ovary, with tuberose sur- face. Inflammation of the stroma is rare in the non-puerperal state. KiAvisch relates tAvo cases in which the entire organs were affected, both ending fatally in a short time ; in the one by acute abscess, in the other by a sanious disintegration. In both consecutive peritonitis was the cause of death. Simple peritonecd oophoritis can hardly be said to exist. It is peri- tonitis, not oophoritis; and the inflammation will rarely be limited to the surface of the ovrary. Ovarian peritonitis is commonly a part of the Avide-spread pelvic peritonitis of childbed, or other forms of general pelvic peritonitis. Primary ovarian peritonitis is more frequently limited to one side, and is the result of, or attended by traumatic or other lesion proceeding from the bursting or disease of a Graafian follicle. But even 18 274 DISEASES OF OVARY. in such a case the inflammation is very apt to spread to peritoneum beyond the ovary. Symptoms and Diagnosis.—When oophoritis is complicated Avith metritis and pelvic peritonitis, its special symptoms are lost or con- founded in those of the attendant inflammation. The peritonitic symp- toms especially preponderate, and govern both diagnosis and treatment. Where ovaritis is simple, or the chief morbid condition, the symptoms. being more concentrated, ought to be more characteristic. But they are not free from ambiguity. The local symptoms attending many severe cases of dysmenorrhoea. are referred by the patient and traced by the physician to the ovary. Intense pain in the ovarian region, swelling and tenderness of the ovary under touch, burning, shooting pain in the pelvis, pain in defecation, febrile moArement, including hot skin and quickened pulse, suggest inflammation, and seem to fix that inflammation in the ovary. But these symptoms subside in a few days, as menstruation passes off; and if Ave noAV examine the ovary Ave may find little or no tenderness or SAvelling. If, then, inflammation attended the painful men- struation, it Avas an inflammation of a very transient character. Pain in the region of one or other ovary, even if increased by pressure, is not, as Ave havre seen, sufficient evidence of oophoritis. Pain of this character is a frequent, almost constant, attendant upon inflammation of the neck of the uterus. On the other hand, ovarian disease is very liable to be overlooked, because attention is likely to be concentrated on attend- ant uterine disease. Before concluding that the ovary is inflamed, we must continue our observations during the inter-menstrual period. The history of the onset and progress of the affection will offer different points. If intense pain referred to one or other ovarian region supervene quickly on exposure to cold, excessive venereal excitement, emotion, in the course of blennor- rhagia, or after operations on the uterus, or intra-uterine injections, the state of the pelvic organs should be explored by internal and external palpation. It is probable that the uterus will be found to share in the tenderness and swelling which affect the ovaries; perhaps, too, the broad ligaments and pelvic peritoneum will be involved. Where this is the case, it will be difficult to get at the ovaries, which will be surrounded by swollen and tender structures. But where the ovary is principally affected, or when the concomitant affection of the uterus and other struc- tures has subsided, the state of the ovary comes into prominence. Pal- pation supplies the only trustworthy evidence. In every examination per vaginam, the finger is first directed as a point of departure to the os and cervix uteri. On touching this part, pain will in all likelihood be caused, and we may conclude that the uterus is the organ at fault. The pain may, however, be due to the pressure of the uterus upon the inflamed ovary. We, therefore, seek to eliminate the uterus by pressing the finger gently against the vaginal roof in front, at the sides of, and behind the uterine neck. When pressing at one or both sides upwards, the pain will be greater, and we may possibly, by conjoint external pres- sure on the abdomen, embrace the painful structures betAveen the two hands. The deep pressure in the sides of the pelvis on the abdomen alone causes pain, and there is a feeling of resistance, caused partly by OOPHORITIS. 275 the SAvelling of the parts, and partly by the muscular tension exerted instinctively to Avard oft" the dreaded pressure. But the clearest evidence of the state of the ovary is to be attained by the recto-abdominal touch. The ovaries, especially if inflamed, can commonly be reached by finger in the rectum; and this the more surely if they be pushed on to the examining finger by the hand pressed firmly doAvn upon the uterus through the aclbominal Avail. We may then recognize the ovary by its form, position, mobility, and tenderness, and judge by its increased size, and pain on touch, Avhether it is inflamed or not. But the ovaries, even much enlarged by inflammation, may be insensible to considerable pres- sure—a proof, says Schultze, that oophoritis need not necessarily impli- cate the peritoneum. There are many examples in medicine of treatment becoming an ele- ment in diagnosis. But the conclusions drawn in this manner are some- times fallacious. Thus it is frequently observed that ovarian pain and other symptoms taken to indicate oophoritis are cured by cauterizing the os and cervix uteri, Avhich may at the same time exhibit marks of disease. It seems rational to infer that the ovarian symptoms Avere only sympto- matic, or dependent upon the affection of the uterus ; and in the majority of cases this, I believe, is true. But it is also true that the treatment applied to the uterus may really have cured ovarian disease, first, by acting on the principle of derivation or counter-irritation, and secondly, by removing uterine disease, which Avas the source of disease in the OA-ary. The pain is chiefly due to peritonitis, which is almost certain to ensue. Tumefaction is so inconsiderable in recent inflammations that it can hardly be the cause of marked subjective symptoms, and it is not easy to mea- sure it even by physical examination. An inflamed ovary seldom exceeds tAvicc its ordinary size. Menstruation may be suppressed, or there may be an increased flow. In very rare cases the affection proves fatal in a feAv days. This ter- mination is due to sanious decomposition of the ovary, or to acute per- foration by an abscess. Where it commences with unusually severe symptoms, and particularly Avhen it leads to extensive degenerations of the ovary, or causes much peritoneal exudation, it may continue for Aveeks or months Avith more or less marked remissions. In other cases perfect intermissions occur, and the paroxysms are synchronous Avith the catamenial periods. In the most favorable cases, which are also the most common, after a short time the exudative process is arrested, and the exudation is either removed by absorption, or undergoes the usual metamorphosis into cellular or stringy strata, Avhich bind the ovaries to the surrounding structures. Sometimes a fibrous condensation of the exudations takes place, and dense capsules are formed round the ovary, leading to atrophy of its tissue. The exu- dations into the follicles also lead to various metamorphoses, with shriv- elling and atrophy of the affected vesicle. When the course is less favorable, a neAV morbid process starts from the inflammation, and abscesses and various chronic tumors of the ovaries are developed. 276 DISEASES OF OVARY. Professor Fave1 relates a case of abscess in the ovary in a pregnant woman. She had been delivered by forceps. During pregnancy (her first) she suffered much from vomiting: and tOAvards the end she had a fixed pain in the right side of the abdomen, and several convulsive fits. On the night after delivery she had severe pains, mistaken for after-pains. Next day, the pains were more bearing-down in character; the abdomen Avas tender and tympanitic. She died fifty-three hours after delivery. Douglas's sac was found filled with a thin purulent sanguineous exuda- tion. An abscess in the right ovary had burst; the remains of the organ had changed into a mere pulpy detritus. There was considerable degeneration of the cortical substance of the kidneys, and there were many extravasations of blood under the serous membrane covering the kidneys, liver, and lung. Associated with abscesses, although probably different in origin, is the case narrated by Dr. Farre, " in Avliich the ovary Avas entirely reduced to a diffluent pulp of a yellow or broAvnish-green color, of the consistence, and having someAvhat the appearance of very soft putty, immiscible with water. Of this morbid condition, Avhich may, hoAvever, be cancerous, I met Avith a striking example in a case of sudden death occurring in the seventh month of pregnancy. Both ovaries Avere of the size and form of a bullock's kidney, their natural structure Avas entirely destroyed, and Avas replaced by the soft substance just described. The circumstance that both ovaries Avere thus affected renders it evident that the disease could not have existed in any great degree at the time of impregnation." Most of the recorded cases of large abscess, holding from one to twenty pints of pus, are probably instances of suppuration taking place in the cavities of ovarian cysts. The terminations of suppuration or abscess of the ovary are: 1. The ovary may burst into the peritoneum, causing abdominal shock, collapse, or peritonitis ; 2. Small perforations may take place, exciting more cir- cumscribed peritonitis, and leading to plastic effusions surrounding the diseased ovary ; 3. Adhesions may be formed with the bladder or intes- tine, and a fistulous communication be established, by Avhich the pus may be more or less completely discharged; 4. The suppurating ovary, being the focus of a pelvic cellulitis or peritonitis, may terminate, after the manner of this form of pelvic inflammation, by discharging into the rectum, vagina, or externally above Poupart's ligament. The treatment must be conducted on the same plan as that which is laid doAvn for pelvic peritonitis which has proceeded to suppuration. The exit of pus should be favored when there is distinct evidence of eliminatory process. If there is tension and SAvelling in Douglas's pouch pushing the uterus forwards, puncture should be made by the aspirator-trocar. Chronic oophoritis is characterized by a sensible deformity of the affec- ted ovary; the surface is knobbed, its consistence harder than normal. This induration results from the hypertrophy of the parenchyma, which in its turn proceeds from the transformation of the effused matter into cellular tissue. Possibly also there is thickening of the tunica pro- pria. Henkel and VirchoAv compare this to the interstitial hyperplasia 1 Schmidt's Jahrbuch, 1860. CHRONIC OOPHORITIS. 277 of other glands, for example, the cirrhosis of the liver. The thickened capsule prevents the external dehiscence of the Aresicles. The ovum per- ishes in the effused blood in the vesicle. On seAreral occasions Scanzoni found the sanguineous effusion had taken place not only in the interior of the vesicles, but also in their immediate neighborhood; it thus became evident that the friability of tissue Avhich sometimes accompanies chronic oophoritis is an important cause of what is called apoplexy of the ovary. Chronic oophoritis may succeed to the acute form; it may be a continu- ation of oophoritis of childbed, or it may arise in a subacute manner. The causes Avill be similar to those Avhich induce the acute inflammation. It is extremely probable that cystic disease in some cases, if not in many, takes its origin in a sIoav inflammation of the follicles. The early stages of cystic disease are often attended by intense pain, and the other signs of dysootocia. The menstrual Aoav in the early stages of the disease will generally be increased in quantity and protracted in duration, and irregular hemor- rhagic discharges may occur. At a later period, when probably the follic- ular structure has become impaired, diminution or suppression of menstru- ation may be observed. The disease very often affects one ovary only, so that menstruation, or rather ovulation, is not necessarily ahvays attended by dysmenorrheal phenomena. Not seldom, one or two periods may pass without pain. This may be explained by Negrier's theory of the alter- nate action of the OAraries. When there is no pain, the healthy ovary is at Avork. In other cases, every period is attended by severe dysmenor- rhea, and then Ave may infer either that both ovaries are affected, or that the general pelvic hyperemia of ovulation may involve the healthy as Avell as the inAamed ovary. Leucorrhoea frequently attends, but can hardly be regarded as symp- tomatic, although the discharge may in some measure be a means of relieving the gorged ovario-uterine vessels. Impregnation may take place, since one ovary only may be involved; and even where both are involved, there may still remain some follicles in a condition to bring forth healthy ova. Sterility, hoAvever, is common, partly because the ovaries are disabled by obliteration of the follicles, or by external adhesions, and partly because pain forbids effective inter- course. It may terminate in cure by resolution. But it may undoubtedly go on to destroy the proper structure of the organ. The vesicles may become compressed and atrophied, the result being incurable amenorrhea and sterility. It may proceed to suppuration, and then the symptoms described under Abseess'of the Ovary will be observed. It has been said "that chronic oophoritis may run on for years, or for any length of time, without the ovary becoming fixed by adhesions, and Avithout causing suppuration in the neighborhood. That this happy negation may occur may be admitted; but I think the escape is excep- tional, and agree Avith Aran, Avho says the great danger of chronic oopho- ritis is the constant liability to peritonitis. It is not unreasonable to suspect that many of the cases relied upon as evidence that chronic 278 DISEASES OF OVARY. oophoritis may persist for years Avithout inducing mischief beyond the ovary are examples of oophoralgia without infiammation. Chronic oophoritis is marked by dull, heavy pain in the seat of one or both ovaries, more or less constant, but aggravated by menstruation, by coitus, by standing or exertion in the upright position, sometimes by loaded rectum or bladder. The pain radiates from the ovary as a centre to the bladder and surrounding organs. Constitutional symptoms, marked in some cases, attend. There is some danger of fever, accompanied by hectic, if suppuration have taken place. Nervous symptoms, indicating exhaustion, irritability from constant pain, will generally sIioav themselves. But, except in the very early stages, Avhen the disease is likely to be confounded with ordinary dysootocia, the nervous symptoms do not often put on the hysterical form. To establish a diagnosis, pain, as described above, must exist. And besides ascertaining this, Ave must exclude other pelvic diseases. Where the ovary only is affected, Ave may by touch determine its increased bulk, sensitiveness, and perhaps prolapsus. Touch single and bi-manual, vaginal, rectal and recto-abdominal must be performed in the same manner as for the detection of the acute form. Since the inAamed ovary is commonly enlarged, and is disposed to drop behind the uterus, it may be felt in the situation assumed by the body of the retroAected uterus. The sound will lift up the body of the uterus, and the ovary, if adherent to it, as is not unlikely, Avill be carried up along with it. But by a little care the uterus may generally be isolated from the ovary. Treatment.—We must rely mainly upon rest, physiological and physi- cal, and derivation. Bromide of potassium, sedatives, occasionally leeches to the iliac region, chloroform-blisters on the same spot, iodine-painting, or, Avhen pain is acute, fomentations or poultices. A valuable means of derivation may be pursued by setting up a small issue or eschar on the vaginal-portion of the uterus by potass cum calce. This makes a healthy granulating surface Avhich heals with some cicatricial contraction. If the uterus Avere perfectly healthy one would hesitate before restoring to this remedy ; but in many cases there is so much complication of uterine dis- ease as will by itself justify the application. I have in several cases seen great relief obtained by wearing a Hodge- pessary. It gives relief probably by maintaining the ovary at its proper level, thus favoring rest of the organ and disgorgement of its vessels. There is a, fibroid degeneration of the ovary which is attended by com- plete disappearance of the follicles. There 'is a remarkable specimen of this kind in St. Thomas's Hospital. Both ovaries are enlarged to twice or thrice the normal size ; they are deeply furrowed or convoluted, and sections through their substance present smooth surfaces. This is proba- bly the consequence of chronic inAammation, the contracting parenchyma gradually obliterating the follicles. TUBERCLE IN THE OVARY Is considered to be extremely rare. KiAvisch says it is not met with. Rokitansky knoAVS but one case. There Avere round yellow knots in the CANCER. 279 ovaries, and also tuberculosis of the tubes and peritoneum. Possibly an unequivocal instance of tubercle limited to the ovaries has yet to be demon- strated, but tuberculization of the ovaries in association Avith tubercle else- Avhere, especially in the uterus, Fallopian tubes, and neighboring glands is not rare. Thus in St. George's Museum (No. xiv. 78) is a preparation exhibiting scrofulous disease of the uterus, tubes, and ovaries. Both ovaries Avere converted into cavities, and contained remnants of a thick semi-fluid, tubercle matter. They Avere greatly enlarged, and their walls much thickened. There was extensive tuberculization of the lungs, and pleurisy, also scrofulous ulceration of the right sterno-clavicular joint. No. xiv. 79 in the same museum is another example. Some may question the tubercular nature of the matter contained in the ovaries of these and similar specimens ; but the probability that the o\Taries thus involved should be affected by disease different in character from that which invaded so many other structures in the body is infinitely small. In the case of cancer being diffused through various structures and organs, the cancerous nature of similar disease found in the ovary is not questioned. Dr. BristOAve demonstrated {Path. Trans, vol. vi.) the tuberculous nature of an ovary, diseased in common Avith the tubes and uterus. The Fallopian tubes Avere filled Avith soft tubercular matter. The cavity of the uterus Avas distended by a mass about as large as a pigeon's egg, of softish, opaque, yelloAvish-white cheese-like tubercle. The mucous mem- brane of the fundus Avas wholly deficient, and the subjacent muscular tissue Avas irregularly destroyed, the tubercular deposit at many parts extending into the substance of the muscle. The os and cervix uteri Avere someAvhat congested, otherwise healthy. The right ovary Avas healthy. The left ovary contained tAvo masses of tubercular deposit, one about as large as a horse-bean, the other as large as a Spanish nut. The deposit exactly resembled that in the uterus and tubes. Bristowe says the same thing has been satisfactorily demonstrated by Dr. Ogle. Bernutz and Goupil also describe an autopsy, in Avhich, Avith much other disease, in- cluding tubercular lungs, they found both ovaries containing crude tuber- cles, just like those met Avith in the testicle. The course run by tubercle in the ovary, the disease in this organ being generally secondary, and of minor import than its concomitant presence in the lungs or other organs, scarcely calls for independent con- sideration. Advancing disease elseAvhere, and attendant exhaustion of the Avhole system, preclude the idea of directing any special treatment to the ovary. Where, however, the ovary is converted into a sac contain- ing tuberculous pus, it is conceivable that this may burst, and thus pre- cipitate death, by causing peritonitis. And it may be possible to evacuate by aspirator-trocar an ovary so affected through the vaginal roof. CANCER OF THE OVARY. Cancer resembles tubercle in being a diffusive disease. More fre- quently than tubercle it is primary in the OArary. But, still, in the majority of cases, by the time at least that it attracts attention in the living, and almost always as it is seen in the dead, cancer has invaded 280 DISEASES OF OVARY. other organs as well. It is frequently consecuthe upon disease of the uterus and the pelvic and abdominal glands. The secondary invasion of the ovary by cancer was accurately made out in a specimen exhibited by Dr. Bristowe to the Pathological Society. In this case innumerable cancerous nodules Avere attached to the perito- neum. There was also an ovarian tumor shoAving cancerous disease. The ovarian tumor was essentially unilocular. It was originally an ovarian cystic tumor, the parietes of which had become secondarily in- volved in cancerous disease from its peritoneal connection. Next to cystic disease, cancer is the most frequent disease of the ovary. It is often combined Avith the cystoid formation. Every form of cancer may be reproduced in the ovary. It frequently appears as medullary carcinoma, in the form of a distinct mass, or of a roundish tuberous tumor completely supplanting the ovary, and groAving to the size of a fist, or of a child's head, or bigger. In some places it resembles in its firmness and the preponderance of its framework, the fibrous cancer, in others it is soft, very juicy, fluctuating, encephaloid. The degenerated ovary is sometimes free, but mostly united to surrounding structures by adhesion. In some rare cases, says Rokitansky, carcinoma of the ovary arises from the degeneration of a corpus luteum. Often, the medullary cancerous degeneration is, in size and form, sym- metrical. It occurs especially in young persons as a primitive disease. It is also associated with cancer of the uterus, breast, liver, peritoneum, stomach, intestine, and lumbar glands; and appears as a part of a general wide-spread cancer formation. How cancer may invade an ovary in the midst of active function is illustrated in a specimen (No. 2640) in the College of Surgeons. It con- sists of a uterus, Avith ovaries and appendages. " There is a well-formed fetus, of about five months, Avith its membranes and placenta within the uterus. The ovaries are both extensively diseased—enlarged. The tissue of the left is soft, flocculent, and vascular; that of the right is replaced by a collection of cysts, most of which are filled with soft, laminated, and apparently medullary substance." In St. Thomas's Museum is a similar specimen (No. FF. 51). Both ovaries are of ovoid shape, much nodulated on the surface, and not pre- senting in any part the appearance or structure of ovary. They appear to consist entirely of medullary (encephaloid) matter. The same dis- ease Avas found in the mammae and liver. The Avoman was five months pregnant Avith a well-formed fetus. Medullary cancer occurs upon the cyst-walls and the cyst-cavities, especially in the form of villous cancer. The gelatinous cancer thus appears in the cystoid growths. On the inside of the cysts, here and there, are seen flat, rounded, medullary knots; or villous, cauliflower- like excrescences. Both grow from all points of the cyst-wall, until they fill the cavity; and at length the growth may penetrate the Avail, so that the medullary carcinoma grows free in the peritoneal cavity, seizing neighboring structures, and the whole cystoid-formation becomes fixed in all directions. This cysto-carcinoma also often occurs symmetrically in both ovaries—more commonly so in the more mature periods of life. Cancer of the ovary is most frequently seen in the encephaloid form. CANCER. 281 It may attain considerable size, forming a globular mass, with spheroidal knobby projections. Courty relates a case in Avhich a tumor of this kind, weighing about eleven pounds, left the corresponding tube quite unaffected, whilst there Avas congestive hypertrophy of the uterus, and return of hemorrhages simulating the menses in a Avoman Avho had passed the menopause. The encephaloid masses, diffluent in several places, ap- peared to have arisen in the Graafian vesicles, so encysted Avere they; they even seemed, as Rokitansky pointed out in other cases, to have sprung up on the internal membrane of the vesicle, preserving there an areolar or alveolar aspect, Avhilst the centre Avas filled Avith liquid, chiefly blood. Several of the cysts Avere distended Avith blood, the result of internal hemorrhage. In some of the cysts some black pigment Avas accumulated in the Avails. Cancerous tumors of the ovary sometimes come under the category of solid tumors. Thus, the specimen (No. 224645) in Guy's Museum shows "• both ovaries affected by carcinoma, Avhich has converted them into solid tumors, about the size of the human kidney. The subject, aged forty, Avas under Dr. Gull for carcinoma of the brain, breast, and various other parts. She Avas delivered prematurely of a child in hospital, a few weeks before her death." " The most remarkable examples of hard cancers with fibrous tumors that I have yet seen," says Paget, " have been in the ovaries of certain patients Avith common hard cancers of the stomach or breast. In these cases the place of the ovary on either, or on both sides, is occupied by a nodulated mass of uniformly hard, heavy, Avhite, and fibrous tissue. The mass appears to be generally of oval form, and may be three or more inches in diameter. Its toughness exceeds that of even the firmest fibrous tumor, and its component fibres, though too slender to be measured, are peculiarly hard, compact, closely and irregularly Avoven. With these I have found only feAv and imperfect cancer-cells, with more numerous nuclei, elongated and slender. They are not mingled with elastic or other ' yelloAv-element' fibres." Melanosis resembles other forms of malignant disease in its diffusive property. I have not met with example or record of melanosis limited to the ovary. Like other forms of malignant disease, it probably almost ahvays attacks the ovary secondarily. There is a good example (No. 31.16) in St. BartholomeAv's Museum: "The ovaries are altered in form; their natural structure is removed, and its place occupied by a very soft melanotic matter. There are also some small circumscribed deposits of melanotic matter in the peritoneum covering the uterus. Taken from a young Avoman in Avhom melanosis existed in many other organs." In St. George's Museum (XIV. 112) is a specimen of " simple cysts in each ovary." The following note is probably Avritten by Sir B. Brodie: " The cysts contained a thick, black, unctuous and nauseous substance of the consistence of tar. A small polypus is attached to the cervix: a small ulcer is seen in the interior of the fundus. The Avoman had her knee amputated for fungus hematodes by Sir Benjamin Brodie, and the disease of the organs of generation Avas not knoAvn during life. Is the color of the ovarian fluid OAving to the same substance as mela- 282 DISEASES OF OVARY. nosis?" Other illustrations of melanosis in the ovary, attended by simi- lar diseases in other organs, are found in the College of Surgeons (Nos. 2642 and 2642a). The frequent transition from the cystic tumor to colloid cancer sug- gests the suspicion that some forms at least, especially the proliferous, partake of the cancerous character. If this be assumed, then the primary origin of cancer in the ovary must be admitted to be frequent. The history of pathological processes does not, I believe, lend much con- firmation to the hypothesis of the ready convertibility of one form of morbid product into another. For example, if I may appeal to my own observation, I should say that fibroid tumors of the uterus are not greatly more liable to the invasion of cancer that is the normal tissue of the uterus. Cancer of the uterus begins as cancer, and not as any other disease. So far, then, as analogical reasoning may be trusted, that Avhich in its advanced stages is obviously cancer, in the ovaries, is, as elseAvhere, cancer ab initio. That cancer of the ovary preserves for a comparatively lengthened time, its exclusive habitat in the ovary bcfoj-e spreading to other parts, may be explained by the comparatively isolated terminal position of the ovary. This vieAV is strengthened by the observation that colloid ovarian tumors are often attended by colloid groAvths in the contiguous struc- tures. Thus in a case I saAv at St. Thomas's, in 1S74, small colloid pyriform tumors attached by very slender but strong stalks greAV from the omentum, Avhere it Avas in contact with an ovarian tumor filled with colloid. Is it not possible that proliferous cells exude from the colloid tumor, or escape by small perforations, and becoming attached to the adjoining structures there develop? A familiar example of proliferation by contact is seen in the spread of gummata on opposing surfaces of skin and mucous membrane. This lingering isolation in the ovary must weigh greatly in favor of regarding the compound proliferous cysts of the ovary practically as non- malignant, and, therefore, as being suitable for extirpation. The strong innate disposition of the ovary to develop cystic formations may determine the frequent assumption, by the original cancerous element, of the cystic or alveolar form. Cancerous disease of the ovary, as elsewhere, occurs more frequently in middle life and later life ; but it may arise in childhood. When cancer has existed some time in its pronounced forms, and espe- cially Avhen the broad ligaments and glands of the pelvis and abdomen are involved, ascites is a frequent complication. The course of ovarian cancer is frequently involved in that of malig- nant disease elseAvhere ; but it not uncommonly takes the lead in pro- ducing the cachexia and peritonitis Avhich cause the fatal issue. The colloid cancer grows rapidly, and to a large size ; but does not quickly tend to destroy life by contaminating the system. The opportuni- ties of examining the primary stages of its formation are, therefore, rare except in cases where the affected ovaries have been removed by opera- tion. Mr. Heath exhibited to the Pathological Society {Path. Trans., vol. xvi.) a specimen of cancer of both ovaries, in which death Avas pro- duced by obstruction of the bowels. I have seen an autopsy at St. FIBROMA. 283 George's Hospital, in Avhich death ensued from uremia, the result of invasion of the ureter and atresia at the point of contact Avith a cancer- ous ovary. The ureter above this spot Avas much dilated, and the kidney was partially atrophied. Diagnosis.—The circumstances Avhich, according to Dr. T. Gaillard Thomas, most prominently point to the development of the disease, are: "1st. The rapid development of a solid tumor in an ovary, with 2. Marked depreciation of the strength, spirits, and general condition. 3. The occurrence of edema pedum and spanemia at an early period, and consequently dependent upon a general blood-state, and not the conse- quence of pressure. 4. Lancinating and burning pains through the tumor. 5. Cachectic aspect. 6. The occurrence of ascites without evi- dence of cirrhosis or other hepatic disease; organic disease of the kid- neys, or heart, or chronic peritonitis ; the fluid accumulating in such large amounts as to force aside the supernatant intestines, and produce dulncss in place of resonance on percussion in dorsal decubitus." , These signs must, hoAvever, be taken Avith some qualifications. G^dema of the legs and ascites are not constant, even at stages when the disease has produced marked ravages upon the general system. I have, more- over, found it in practice difficult to distinguish solid malignant ovarian tumors from malignant disease around the caput coli. Solid Tumors of the Ovary.—For want of more precise pathological materials for discrimination, it is convenient to group certain tumors of the ovary under this general term. On clinical grounds this distinct recognition of solid tumors of the ovary is of great value. The solid tumors include not only fibrous or fibro-cystic tumors, but tubercular and malignant tumors of the ovary. Solid tumors in the ovary then, frequently, are a local expression of diffusive disease Avhich involves other organs as Avell. This consideration of the characters of solid tumors will strengthen the rule to hesitate before attempting the extirpation of solid ovarian tumors. Of Avhat use, for example, Avould it be to remove a cancerous ovary, Avhen it is in the highest degree probable that the dis- ease has extended to other organs ? A. Fibroma. Fibrous or fibro-muscular tumors of the ovary are so rare that their existence has been doubted. In some instances Avhere it has been concluded that one or both ovaries had been the seat of fibrous tumors, it is reasonable to conjecture that the tumors really arose in the uterus, and, becoming pedunculated, pressed upon the ovaries, Avhose proper structures became obscured ; or tumors arising in the broad liga- ments may simulate ovarian fibroids. At the same time, since fibrous and non-striated muscular elements form a natural constituent of the ovary, there is sound histological reason for admitting the possibility of tumors being developed from exaggerated extension of these elements. There is a specimen in the London Hospital Museum described by Dr. Ramsbotham (No. Ea. 27) as " a large fibro-muscular tumor projecting from the fundus uteri. The ovaries are as large as a hen's egg, nodular surface, and converted into dense fibrous masses." Cruveilhier had draAvn attention to the fact that fibrous tumors Avere found implanted upon or in the substance of the ovary, Avhich by their structure could not be distinguished from fibroid tumors of the uterus. 284 DISEASES OF OVARY. He observed that they Avere often found at the same time in both organs, as in the specimen referred to of Dr. Ramsbotham. Dr. Baillie also Avas struck Avith the identity of structure, and observed that these tumors of the ovary ran the same course, and Avere liable to the same cartilaginous and bony transformations as the fibroids of the uterus. In Guy's Museum is a specimen (No. 2246) consisting of uterus and ovaries. " The latter are converted into large tumors, each the size of a cocoa-nut, by the production of a fibro-plastic material. The stomach Avas affected in the same way by a groAvth Avhich resembled that seen in the recurrent fibroid tumors." No. 2225 in the same museum sIioavs both ovaries converted into solid tumors. The tumors are quite smooth externally, and the section exhibits a perfectly homogeneous appearance. A specimen in St. George's Museum (No. XIV. 140) seems to offer the clearest features of a fibrous tumor of the ovary. It is represented in Fig. 73. It is described in the catalogue as " A fibrous tumor of the o\Tary from a Avoman aged 50, Avho died of disease of the heart. The uterus also contained a fibrous tumour in its Avails." The position of the tumor in this case in the centre of the ovary excludes the objection urged against other cases, that its origin might be uterine. Dr. Goodhart and Mr. Walsham each exhibited {Pathological Trans- actions, 1875 and 1876) a fibroma traced "unmistakably" to the true fibrous capsule of the ovary. A specimen at St. George's (XIV. 139) shoAvs calcareous degeneration of an ovarian tumor presumed on this account to be fibro-muscular. A specimen exhibited at the Obstetrical Society was examined by Dr. Wilson Fox, Avho described it as a " loculated fibroid ; as having in the more central and transparent parts of the loculi a great number of non- striated muscular fibres." In most of the presumed fibrous tumors the cystic cavities have been the most noticeable features. The cysts may be more or less obliterated by the hyperplastic condition of their Avails. These overgroAvn partitions are made up of a fibrous vascular mass, not in any Avay distinguishable from that usually seen in cyst-Avails. This kind of fibro-cystic tumor groAvs very rapidly, and has a strong hemorrhagic disposition, causing in some cases effusion of blood into the cyst-cavity. It appears then to be highly probable that most of the apparent fibrous tumors of the ovary differ from undoubted cystic tumors, chiefly in the greater relative proportion of the fibrous walls, and the lesser development of the cyst. Scanzoni's larger specimen referred to above seems to confirm this vieAV. Dr. Wilks reporting on three tumors of the ovary exhibited to the Pathological Society1 says " the specimens referred to afford examples of the various grades of disease Avhich the ovaries may undergo. We may see in them the connection between a hard fibrous tumor and the simple cystic disease. We may have in the first place a multilocular cystic dis- ease ; then a similar disease with the addition of solid fibro-cellular groAvths between the sacs ; thirdly, a disease made up of the same parts, but Avhere the solid predominates ; fourthly, a uniform fibrous tumor; Pathological Transactions, vol. ix. CYSTIC OVARIES. 285 and lastly, a hard dense fibrous groAvth resembling the analogous tumor in the uterus." Dr. BristOAve and Mr. Hutchinson suggest that the absence of muscu- lar fibres in ovarian tumors distinguishes them from the uterine tumors. But this test is fallacious. They admit that large fibrous tumors may groAV from the ovary. B. Encliondromatous Tumors.—Khvisch says he has observed two examples of this tumor. In one, cartilaginous concretions surrounded the ovary in the form of numerous scales or rounded protuberances. In the other case the right ovary was transformed into a tumor the size of the fist, surrounded with false membranes of which the external layers inclosed cartilaginous nodules, coarse and hard, Avhilst the interior re- sembled a cartilaginous mass, hyaline and of less density. Diagnosis.—During life it will be difficult to arrive at more than a conjectural diagnosis of the nature of solid ovarian tumors, or even to distinguish them from some fibroids of the uterus. Mobility or fixity is the important clinical point. Treatment.—We may be called upon to interfere, in the event of tumors getting locked in the pelvis and obstructing the bowel or bladder. The first indication Avould be to dislodge them from the pelvis, by push- ing from beloAV either by rectum or vagina. Extirpation might have to be discussed if disloclgment failed. In this case operating by gastrot- omy will be generally preferable to attempt at removal by vagina or rectum. CHAPTEE XII. OVARIAN CYSTIC TUMORS: THEIR NATURE—SIMPLE; MULTI- PLE, PROLIFEROUS; CYSTO-SARCOMATOUS; TUBO-OYARIAX ; DERMOID CYSTS. We have already observed that tumors of the ovary may, for clinical purposes, be divided roughly into solid and cystic. The solid tumors have been described in the preceding chapter. The cystic are the most common, and practically the most important. Ovarian cysts are distinguished by Paget as A. Simple or barren, containing fluid or unorganized matter: and B. Compound or prolifer- ous, containing variously organized matters. They may further be use- fully distinguished as Malianant or benian. All these tumors, on account * 7 • 7 T * of their glandular origin, are grouped together as adenoid. In associa- tion with ovarian cysts proper it is convenient, and even necessary, to 286 OVARIAN DISEASES. study certain extra-ovarian or pseudo-ovarian cysts. For example, there are cysts which are developed in the broad ligaments, or which are formed in structures so close to the ovaries that they closely simulate ovarian cysts in the living, and are not ahvays easily distinguished by dissection in the dead. A. Simple ovarian cysts. The most simple idea of an ovarian cystic formation is derived from the observation of certain specimens of disten- sion or enlargement of Graafian sacs in the early stage. By examining, for example, such a specimen as that represented in Fig. 74, which re- Fig. 74. Section of Ovary. Early Stage of Cystic Disease (R. B.). (Nat. size.) St. Bartholomew's Museum. presents a section of an ovary in St. Bartholomew's Museum, one cannot help being struck Avith the appearance of the cysts arranged in a row close to the free border of the ovary, just as the Graafian sacs are dis- posed in the normal ovary. Fig. 75, from a specimen in Middlesex Mu- seum, illustrates the same points. These are, in fact, morbidly dilated Graafian sacs. In different specimens we may see similar appearances, the cysts being larger and larger, until their distinct existence is lost by the septa between them being absorbed by pressure and atrophy. That such is the real history and nature of the ordinary simple ovarian cyst is proved by the following observations. 1. The structure of its Avails is identical Avith that of the Graafian sac. 2. Rokitansky1 has found ova in cysts of this kind ; and this very in- teresting, if not crucial fact, Avas verified by the late Dr. Ritchie in 1864. Dr. Woodham Webb confirmed Ritchie's report. Dr. Ritchie2 further says: " Since August, 1864, I have succeeded in finding ova in a large number of ovarian cysts. Some of the ova were perfect, with a sharply-defined zona pellucida, a germinal vesicle, and a germinal spot; others Avere more or less imperfect, many having the ap- pearances mentioned by Rokitansky. I have never found an ovum in a loculus larger than a cherry, and never in a loculus Avhich contained jelly-like contents." There is an excellent " Hunterian" preparation in the College of Sur- 1 Wochenblatt d. Zeitschrift d. kk. Gesellschaft d. Aerzte zu Wieu, 1855. 2 Ovarian Physiology and Pathology, 18ti5. CYSTIC DISEASE. 287 geons (Xo. 2616'), shoAving incipient ovarian cystic disease. It is "an enlarged ovary, in the anterior of Avhich are numerous small oval, smooth- walled cysts, with distinct thin Avails, all probably enlarged Graafian vesicles." Fig. 75. Showing Incipient Cystic Enlargement of the Graafian Follicles in both Ovaries. Middlesex Museum (R. B.). 3. Cystic disease of the ovary rarely begins except during the period of normal ovarian activity. Cysts have indeed been found in young girls, even under ten; but menstruation sometimes is premature ; and some cysts springing from the broad ligaments may have been erroneonsly re- garded as ovarian. 4. Cysts are more frequent in the ovaries than in any other organ; and in many respects they differ from the cysts seen elseAvhere. The small cysts sometimes seen on the peritoneal investment of the ovary and of the uterus are different in nature from the true ovarian cyst. Although it is frequently the case that several, if not many Graafian sacs are affected together, this is not ahvays so. Even in cases where one or more sacs have become so large as to have called for removal by abdominal section, menstruation has continued, and portions of healthy ovary have been found. Frequently the degeneration of the follicles is symmetrical, both ova- ries being affected in a similar manner as in Fig. 75. Up to a certain point several follicles may enlarge with tolerable uni- formity, as in Figs. 74 and 75. But after a while, one generally takes precedence of the rest, and groAving more rapidly compresses them, so that they either remain small, or their walls becoming atrophied and thinned, the cysts hitherto distinct are fused into one. By a kind of 288 DISEASES OP THE OVARIES. natural selection one obtains predominance, absorbing the others, or de- stroying them. Sometimes portions of the minor cysts remain in the form of projecting processes, constituting chambers or loculi, communicating with the large cyst. In this Avay what are called multijde cysts are formed. They are really simple in their nature. Although multiple in number, they are nothing but agglomerations of simple cysts, and do not, collectively any more than singly, possess the distinctive property of the compound" or proliferous cyst, that of self-multiplication by endogenous gemmation. In some cases there appears to be one, or chiefly one, follicle affected, and when this happens this follicle may be found not at the periphery of the ovary, but deeply imbedded in the stroma. In these cases it is reasonable to surmise that the ovum Avas prevented by the thickness of the surrounding structure from making its way to the surface at the pro- per time; that the effort would result in distension of the sac, the out- pouring of an excessive quantity of blood into it; and hence, if the epi- thelial lining retained, as it is likely to do, its proliferous virtue, the gradual formation of a cystic tumor. In University College Museum (T \ ) is a good specimen of hemorrhage into the ovary. In Guy's Museum is a specimen (No. 228120), shoAving "an ovary much distended, having been filled with blood." (See Fig. 72.) There is also an excellent specimen in St. George's Museum. Dysmenorrhoea is a frequent antecedent of ovarian dropsy. This observation corroborates the opinion that some obstruction to the due maturation and escape of ova is one cause. It has often been conjectured that a single life by suppressing one ovario-uterine function led to abnor- mal action of the formative-force. Out of Spencer Wells's 500 cases 221 Avere unmarried, and 18 were widoAvs. On the other hand, the com- plication of ovarian dropsy Avith pregnancy is not very uncommon. What is the beginning of this transformation of the Graafian follicles? The formative-force is peculiarly active in the ovary. If interrupted or hindered in its ordinary progress, it may be supposed that, still persist- ing, it will reveal itself in abnormal results. In University College Museum (No. 866) is an interesting specimen, which may serve to illus- trate the effect of obstruction to the healthy course of menstruation. It exhibits cysts in the ovaries and tubes, and a fibroid tumor of the uterus inside which probably obstructed the uterine openings of the tubes. Rigby says he traced in one case an ovarian dropsy from its beginning in oophoritis. Scanzoni says there is no doubt that dropsy of the Graafian follicles is sometimes caused in this way; the menstrual con- gestions in the ovaries do not attain sufficient intensity to effect the burst- ing of the follicular wall, and the result is that an increase of secretion and its accumulation in the cavity thus takes place. The follicular Avail is thus gradually hypertrophied, and by the formation of new vessels causes a permanently increased secretion. The comparatively great fre- quency of these follicular dropsies in women Avho have lono- suffered from chlorosis or other diseases, combined with amenorrhoea, speak in favor of this view. B. The principal varieties of the complex or proliferous ovarian cysts have been described, as Paget truly says, "to the very life," by Dr. PROLIFEROUS CYSTS. 289 Hodgkin, to Avhom we are indebted for the first knoAvledge of their true pathology. Hodgkin divides them into two principal or extreme forms of endogenous cysts ; namely, those which are broad-based and spheroidal, imitating more or less the characters of the parent cyst, and those that are pedunculated, clustered, and thin-walled. Between these forms many transitional and mixed forms may be found. A typical example of the first is in the Museum of the College of Surgeons (figured p. 417 of raget's work). It is a large cyst, with tough, compact, and laminated Avails, polished on both their surfaces. On its inner surface there project, Avith broad bases, many smaller cysts, of various sizes and variously grouped and accumulated. These nearly fill the cavity of the parent cyst; many of them are globular ; many deviate from the globular form through mutual compression ; and within many of them are similar but more thickly-Availed cysts of a third order. Respecting the mode of generation of the endogenous cysts, they appear to be derived from cell-germs, developed in the parent cyst-Avails, and thence, as they groAV into secondary cysts, projecting into the parent cavity; or disparting the midlayers of the Avails, and remaining quite inclosed betAveen them ; or more rarely groAving outwards, and project- ing into the cavity of the peritoneum. Dr. Wilson Fox1 says, "All the forms of cysts met Avith in the ovary originate from the Graafian follicles, and that the multilocular forms are not the result of any special degenerations of the stroma of the ovary, but are due to secondary formations from the interior of parent cysts thus formed." Fie divides them into three classes. The first and most frequent manner in Avhich secondary cysts are formed is the result of the production of a series of glandular structures, presenting a tubular type, on the inner Avail of the parent cyst. Dr. Fox describes the mode of formation of these glands as differing from those of other glands, which for the most part originate in the embryo as diverticula from surfaces. The process in this case commences Avith a stratification of the epithelium, into which project papillae formed of the stroma of the wall of the parent- cyst, each papilla carrying a delicate vascular loop. The characters of the proliferous form are Avell described by Wilks and Moxon: " The capsule is thick, Avhitish, fibrous, the interior of the greater cysts pale, their contents glairy or more tenacious, often turbid, and more or less deeply-discolored. The inner surface of the large cysts is softish-looking, and bears more or feAver knobs or excrescences of some form standing up in relief. The Avails of the smaller cysts are more vas- cular ; sometimes they have a honeycomb-like or cribriform appearance from fringes of membrane coursing about on them Avith variable divisions and reunions, Avhile the more solid-looking parts and the section of the solid-looking excrescences are, at first glance, not unlike cancer, being pink, creamy, and vascular. " The appearances under the microscope differ according to the part chosen. The Avail of a large cyst is fibrous, generally laminated, the inner part more delicate and areolar, with vessels visible in it; the lining 10 1 Medico-Chirurgical Transactions, 1864. 290 DISEASES OF THE OVARIES. covered Avith epithelial cells, generally cylindrical ; these are easily removed. The same cylindrical epithelial cells, perhaps generally cilia- ted, usually much defaced, float in the mucous fluid : but pus or blood may be present. If you take the Avail of a smaller cyst it shoAvs signs of greater activity, and is more full of vessels and the epithelium more regular. But the most striking characters of this kind of cysts are seen in the formation of bud-like processes Avithin the cysts ; they are best brought to vieAV in the most solid-looking parts, and especially within the larger or smaller excrescences on the Avails of the principal cysts. These microscopical bud-like knobs grow out and branch, uniting with each other, forming arches, or they extend across the cavity they are in, and thus spaces are inclosed which, in section at least, look very like mucous follicles ; and they are lined with the cylinder epithelium, Avhich usually everywhere clothes the buds. The buds have vessels in them; they branch and branch until they no longer are clothed with a distinct epithelium, but the twigs confuse each other, and the cells are massed together like those of cancer. This Ave have seen in parts of a tumor where other parts showed the usual bud, and in this case there were metastatic forma- tions in the liver, thus shoAving that this form of tumor, Avhen \erj vivid and rank in its growth, will prove malignant like any other." Fig. 76. X220. Fibrous Stroma of Compound Cystic Tumor of Ovary (by H. Arnott). The histology of these tumors is well illustrated in Figs. 76, and 77, for which I am indebted to Mr. Henry Arnott. Fig. 76 represents three thin sections from the solid stromal portions of a multilocular cystic tumor, removed by Mr. Croft, in Xovember, 1872. The specimens Avere fresh COMPOUND CYSTIC. 291 and stained Avith carmine. All sIioav varieties of developing fibrous tissue. Fig. 76 a. Dense connective tissue, studded with irregular rod-shaped nuclei; the outlines of the cells not discernible. b. Delicate connective-tissue, Avith slender cells at rare intervals. c. Rapidly-groAving connective tissue, rich in nuclei, plump and oval, which can lie seen, here and there, to be contained in large spindle-cells. Fig. 77 shoAvs epithelium from the inside of the same compound cystic tumor. Fig. 77. Epithelial Liuing of a Compound Ovarian Cyst (H. Arnott). a. Detached flakes of columnar epithelium, vieAved sideways. b. Part of a large surface of epithelium, lining a small cyst; shoAving the polygonal aspect of the columnar cells as seen from above, and sIioav- ing, besides, dilatation of the wall, in Avhich the cells appear swollen and partly out of focus, rendering their nuclei less distinct. < 1ysto-sarcoma of the ovary.—Miiller applied this name to those tumors in which the fibrous intercystic substance equals or exceeds in quantity the contained fluid. Brodie called them sero-cystic sarcomata. Flow- ever, all degrees may be observed in different tumors, and we cannot therefore venture to separate abruptly ovrarian cystic tumors into different classes. Good typical examples of all of them—a, the simple; b, the simple but multiple cyst; c, the proliferous or compound cyst; d, the proliferous or compound cyst, Avith colloid contents ; e, the proliferous, with large sarcomatous formation—may frequently be met Avith ; but in a large majority of instances, ovarian tumors share the characters of two or more of these varieties. The more active the proliferous tendency, the further the departure from simplicity of organization, the more nearly 292 OVARIAN DISEASES. does that tumor approach in its relations to malignancy. Whether, how- ever, any form of ovarian tumor, excepting the fungoid (medullary) is truly cancerous in its tendencies, is a matter of much doubt; and prac- tically all must be treated as if it were proved that they are not so, unless thev are solid. Alveolar or colloid tumor of the ovary is a not infrequent form of the compound cyst. It contains very numerous loculi, which arc filled with a semi-solid tenacious substance resembling gum. It, however, often complicates tumors in Avhich many cysts contain fluid, and which resemble those of the common compound form. Fig. 78, taken from a specimen in University College Museum, pre- pared by Dr. Fox, exhibits a section of the colloid or alveolar tumor. Fig. 78. Section of an Ovarian Tumor showing the Alveolar Structure (E. B.). Univ. Coll. Mus., Xo. 505-1 (from nat. half-size). Fig. 79, also from a preparation in University College Museum, ex- hibits a form of proliferous cyst. Both ovaries are affected. In one the cyst is perforated by a dendritic proliferation. By eccentric pressure, the result of endogenous growth, the capsule of the ovary has given Avay, so that the dendritic processes project on the surface. Tubo-ovarian Cysts.—Adolph Richard1 first described a form of cyst, into the composition of which both the Fallopian tube and the ovary en- tered. He detailed five observations, and cited analogous cases from Morgagni, Frank, Chambon, BoiAdn and Duges, KiAvisch, and others. He demonstrated that ovarian cysts may open into the uterus by the tubes; that after having received the fluid of the cyst, the tube continues to 1 Memoires de la Societe de Chirurgie, 1856. TUBO-OVARIAN CYSTS. 293 undergo a pathological action, by Avhich its calibre increases, its length being doubled, its walls thickened, the folds of its mucous membrane Fig. 79. Both Ovaries affected with Proliferating (Malignant?) or Papillary Disease. Dendritic Processes perforating the Investing Structures (R. B.). Univ. Coll. Mus. (from nat. two-thirds size). smoothed out; that lastly, the dilatation extending gradually to the in- ternal part of the oviduct, the communication betAveen the canal of the dilated tube and the cyst remains, and there is thus made up a cavity or cyst compounded of dilated tube and the ovarian cyst. My former colleague at the Western General Dispensary, Mr. Ander- son, described a clear case of tubo-ovarian cyst. A Avoman Avho was Avait- ing to be tapped began to pass an excessive quantity of urine, and her distress subsided. The fluid passed Avas albumenized serum, Avith choles- terine plates. After six months the woman died from a sudden outburst of haemoptysis. A large empty cyst was found lying, collapsed and loose, in the belly; it had thick Avails, and included some lesser cysts. A good-sized staff passed with the greatest facility from the cyst along one of the Fallopian tubes into the uterus and vagina. The supposed urine did not come from the bladder, but was cystic fluid Avhich escaped by the tube, uterus, and vagina. We may conclude, then, that tubo-ovarian cysts may be formed: 1. By the establishment of a communication betAveen an ovarian cyst and the Fallopian tube, the outer end of Avhich dilates to form one cavity with the opened ovarian cyst; 2. By the bursting of a Graafian follicle, dis- eased or healthy, under circumstances which provoke peritonitis and the formation of adhesions uniting the fimbriated extremity of the tube to the ovary, the communication with the Graafian sac being maintained or 291 OVARIAN DISEASES. not; 3. It is possible that a tubo-ovarian cyst may be formed in a differ- ent way from the two preceding. The tube may be distended with pus or other irritating matter, which set up inflammation, and give rise to plastic effusions binding the fimbriated extremity to the surface of the ovary. Most frequently the matter escapes into the peritoneal cavity, and the peritonitis is Avidely diffused; but it may be Avholly or in great part surrounded by the rapid throAving out of plastic matter Avhich forms a cyst of the kind described. The characteristic of these cases is their rapid formation under symp- toms of ovaritis or peritonitis folloAving upon sudden escape of ovarian fluid by the vagina, Avhere there had previously existed a tumor, or symp- toms of acute ovaritis or peritonitis Avith rapidly-forming SAvelling. Cysts from development of wandering ova.—That ova impregnated, and especially non-impregnated, occasionally fall into the abdominal cavity, not being caught by the Fallopian tube, there is every reason to believe. WThen discussing the pathology of retro-uterine haematocele, and of extra-uterine gestation, this accident will be again referred to. In this place it is only necessary to refer to an hypothesis of Boinet, that ova Avhich have gone astray in this manner may give rise to cystic groAvths:—" May not," he asks, " that happen for the formation of cysts of the ovary, Avhich happens for fecundated vesicles? These are sometimes developed in the ovary itself, or in the Fallopian tube, or in the peritoneum, constituting abnormal gestations. May it not, then, happen that the non-fecundated ovum, diseased through causes referred to, may be pathologically developed either in the ovary Avhere it remains fixed, or in the tube Avhich it has reached, as at the moment of fecunda- tion, or lastly in the peritoneum, into Avhich it has fallen?" Lloyd Roberts has published a case Avhich illustrates Boinet's view. He removed a cyst by gastrotomy, which, after drawing off 17J lb. of clear fluid of 1004 sp. gr., weighed 6 ounces. It Avas thin, homogeneous, highly vascular. It had no connection Avith the ovaries or their appen- dages. These were quite normal. He concluded that this Avas a stray ovum. CUTANEOUS PILIFEROUS CYSTS ; OR, DERMOID CYSTS OF THE OVARY. Lebert gives the name of " dermoid cysts" to those structures, either in newly-formed or in pre-existing spaces, Avhich shoAv on the inner sur- face of a sac new formations, whose identity with the structures of the skin is unmistakable, as bone, cartilage, teeth, and hair. Tumors of this kind are not very uncommon in connection with the uterine appendages. They call for careful clinical study in relation to ovarian tumors, to ectopic gestation, to recto-uterine haematocele, and other pelvic tumors. The walls vary in thickness. The inner surface is either smooth, or in places there are prominences. The superficial layer of the inner sur- face consists of thick layers of pavement-epithelium. Indeed, elements representing all those of skin are found. Hair, fat-glands, sweat-glands, are recognizable; so that along with hair we find the contents of the cyst to be a yellowish, fatty unguent, made up of free fat, cast-off pavement- epithelial cells, and cholesterine crystals, which sometimes distinctly DERMOID CYSTS. 295 glisten. The general likeness of the interior of the cysts to skin had been often noticed. Kohlrausch demonstrated it. It Avas at one time thought that these dermoid cysts were the result of an incomplete fructification of an ovum. But Baillie found them in children Avho had never menstruated; they have even been found in males. Anatomists noAV generally agree that they are quite independent of conception. Brain-matter has been discovered in cysts of this kind by Gray, Chalice, Friedreichs, and Rokitansky. Friedreichs even found recently-formed strong cords of broad nervous branches, and unipolar and bipolar pig- mented ganglionic cells. VirchoAv has seen a similar case; and he has also described muscular fibres. Bone is sometimes developed. It is found in small scales or lamella: in the areolar tissues beneath the skin-forma- tion. These, as they groAV larger, acquire the most extraordinary shapes, with branches and spicula. The osseous structure itself is that of genuine bone, the Haversian canals and bone-cells being arranged in lamellae. This formation of bones may easily impose upon the observer the con- clusion that he has to deal with an ectopic gestation. But a case recorded by Velpeau1 suggests caution in this respect, and also that there is still obscurity hanging over the origin of these tumors. " A young man, aged 20, was admitted into the Charity Avith a tumor the size of a fist connected Avith the testicle. It had existed from birth. It contained several bones and parts of a foetus. It was imbedded in the testicle." A case recorded by Hulke {Path. Trans., 1873) suggested to Wilks that these cysts may be infectious, like cartilage Avhen associated with malignant groAvths. In Hulke's case there Avas cancer of the uterus, a large dermoid cyst full of hair surrounded by several smaller cysts of the same kind, connected with the uterine appendages, and several simi- lar cysts, Avithered, attached to the under surface of the liver. Hulke tells me he thinks all the cysts Avere old and congenital. This formative poAver is well illustrated in a case, presented {Path. Trans., vol. viii.) by the late Mr. Moore. The abdomen was larger than at full period of gestation. An opening formed near the navel, and dis- charged pus. The opening was enlarged, and about seven pounds of stuff like putty was removed. Vomiting came on, and the patient died. There was one vast cyst adherent at every part of its surface, except near the bladder. The Avail was tough, in part cretaceous. It contained hair and perfectly-formed teeth. Left ovary not discovered. Among the peritoneal adhesions were many small cysts, some of which were attached by slender pedicles to the main cyst, Avhilst others were entirely unconnected Avith it, but like it contained soft, cheesy, yelloAv epithelium, mixed with hairs. But although the formative poAver is usually obstinate and persistent, the course of these tumors is, for the most part, sIoav, extending over many years. In the living body the fat exists in the fluid state. Thus there is a specimen in Guy's Museum (No. 223720) which, when opened, poured forth fluid fat, Avhich immediately solidified. In another specimen (No. 2235) the fat was wholly soluble in ether. The hairs Avere imbedded in 1 Archives gen. de Medeciue, 1840. 296 OVARIAN DISEASES. the usual way in the sheaths ; and abundant, large, well-formed sebaceous follicles opened into the hair tubes. Mr. Wood exhibited a tumor containing hair and fat, Avhich melted readily on being exposed to heat equal to that of the body. {Path. Trans., vol. x.) Dr. Hare mentioned another case where solid fat was found in an ovarian cyst after death, but which melted at 85°. ( Path. Trans., vol. iv.) In 1871 I drew off by aspirator-trocar, from a cyst Fig. 80. A Dermoid Cyst of the Ovary (R. B.). (Half-size.) From Specimen in St. Thomas's Hospital Museum. behind the uterus, 16 oz. of liquid fat, which set as solid fat when cool. Hair Avas aftenvards extracted. Ramsbotham {Path. Trans., vol. iv.) describes a case of labor ob- structed by a tumor in Douglas's space. The tumor Avas punctured by a long trocar through the vagina ; a large teacupful of thick, yellowish matter, like thick custard, Avas collected ; it became solid when cool, and consisted of fat globules. The tumor before puncture felt quite solid, no doubt from tension. Tavo cases, quoted from Ingleby, gave the same characters. In St. George's Hospital Reports (1877) I have described a case similar to Ramsbotham's, as Avell as other cases illustrating the diagnosis and history of these tumors. I have little doubt that hair and teeth con- tinue to be produced for years. Thus I have extracted tufts of hair at intervals during several years. From the methods employed I have been satisfied that no bones were left in the cysts after the explorations. And Avith regard to teeth Schna- bel1 found more than 100 teeth of all sorts, and Paget found 300. Some of these were probably loose, and therefore had been shed, the follicles producing neAV ones. Indeed, Meckel says these teeth are subject to the 1 Wurtembnrger Correspondenz-blatt, 1844. DERMOID CYSTS. 297 same laAvs as to duration and development as normal teeth, successive sets being produced. The hair is usually, not invariably, pale or blonde. Andral found it so in a cyst from a negress. It may be that exposure to light is necessary - to full pigmental deA^elopment. In one case, that of an old woman, some of the hair Avas gray. {Axel.) In the lower animals, dermoid products after their kind are found. Thus, in sheep, wool; in birds, feathers ; in cows, cowhair, have been found. {Lebert.) Dr. Gibbes1 relates a remarkable case, in which labor being terminated by the forceps on account of syncope, the patient was harassed by the most intractable after-pains. A tumor was discovered above and behind the pubes, distinct from the uterus, and movable. On a subsequent day: this tumor was felt per vaginam in the anterior cul-de-sac. It then in- creased rapidly to the size of the largest shaddock ; and it Avas considered: necessary to remove it. This was done, as by the operation for ovario- tomy. ^ It greAv from the left broad ligament. About three inches of the Fallopian tube were included in the ligature. The cyst contained pus and a mass of fine black hair. Menstruation occurred at several successive monthly periods through the Avound. The patient ultimately recovered. Cysts of dermoid character have been found in combination Avith serous or colloid cysts in the same ovary. {Lebert). These tumors do not groAV exclusively in the ovaries. Both kinds, says Paget, may be regarded as diseases of the same general group Avith the cutaneous proliferous cysts. The great formative power Avhich they mani- fest is consistent with their occurring only in embryonic life, and in the ovaries, in which, even independently of impregnation, one discovers so many signs of great capacity of development. A case interesting in its clinical as Avell as in scientific relations is recorded by Mr. KnoAvsley Thornton.2 He tapped a very large abdomi- nal tumor. Eighty-six pints of fluid looking like pus floAved ; then fatty matter came mixed Avith little broAvn balls ; next the canula got blocked from the fat solidifying in it and in the tumor under the influence of cold and the injection of carbolic acid. Hot-water bags and injection of hot. water melted the mass, and the Aoav Avas resumed. The woman died in three Avecks. The tumor came from the right ovary. The balls Avere glomeruli formed of short red hairs matted Avith cholesterine-scales, epithe- lium, and fatty matter. The tumor had been diagnosed after her first labor thirty-four years before her death, and she had been tapped nine years. The case shoAvs three points: the long duration of these cysts ; the great size occasionally attained ; the solidification of the fatty con- tents under cold, and the practical lesson to keep the tumor and instru- ments Avarm during tapping. In one of my cases the trocar got blocked from the fat solidfying ; it ran again when the instrument Avas Avell warmed. Occasionally the fluid as it runs out of a tapped cyst resembles gruel. When these cysts are of ovarian origin the symptoms they produce are generally similar to those Avhich attend other ovarian groAvths. They 1 Amer. Journ. of Med. Sc, 1869. 2 Pathological Transactions, 1876. 298 OVARIAN DISEASES. spring from the same seat; they extend in a similar manner. But they differ in several respects. Their rate of groAvth is usually much slower. They often date from an earlier age. They are mostly more solid and irregular in shape. Fluctuation is rarely so distinct; this symptom is not often developed, except as the result of suppuration or accumulation of fat. Dermoid cysts rarely attain so large a size as the dropsical tumors do. They more commonly terminate by setting up inflammation betAveen some part of their Avails and neighboring structures, and in this way effect communications with the holloAV organs, as the intestinal canal, or the bladder, or else they form fistulous openings externally through the abdominal wall. In all these respects they more resemble the abdomi- nal cases of extra-uterine gestation. For these indeed they are often mistaken. Like them they are apt to contract adhesions Avith the viscera amongst Avhich they are imbedded. It is rare, hoAvever, that this formation of fistulous outlets is attended by a cure. It is undoubtedly an attempt at elimination, but one Avhich is only partially successful. If the attempt is tOAvards the surface, the wall of the tumor forms adhesions with the abdominal Avail; inflammation attacks the skin, and erysipelatous blush appears ; the skin is thickened, tender; fluctuation appears ; an abscess points and bursts, if it be not opened by the surgeon. The elected seat is often near the umbilicus on one side. Nothing but pus may be discharged ; the swelling undergoes little diminution; suppuration goes on; the signs of hectic or irritative fever set in. Sometimes masses of hair, matted together, and quantities of fatty matter, may be present and be dragged out from the opening. This may go on for a long time, emaciation proceeding, and exhaustion ending in death. Teeth more commonly remain adhering to the walls of the cyst. When these tumors form a communication with the bowel, the course of events is similar. Pus, mingled with hair, and occasionally a tooth, escape from time to time, producing attacks of severe pain. When a communication is made with the bladder, the most puzzling symptoms are apt to arise. Dysuria may harass the patient for years; generally cystitis supervenes, and sometimes attacks of retention of urine occur. When fatty matter or hairs make their escape, the diagnosis is clear, especially if a tumor be observed in one or other groin or at the pelvic brim. The cyst occasionally relieves itself partially at intervals, and then may be felt to diminish in size. The symptoms set up may be so severe, either by threatening life by acute inflammation or by obstruction to the bladder, or by exhaustion from irritative fever, that an operation for removal of the tumor may be indicated. The operation for extirpation must be conducted on the same principle as that for extirpating ordinary cystic tumors of the ovary. But to relieve the bladder it may sometimes be enough to dilate the urethra, and bring away the offending matters. I have nowT under care with Dr. Crisp, of Chelsea, a case in which two fistulous openings have been formed near the umbilicus, and another into the bladder. At times urine or pus escapes by one of the abdominal fistulse, and gelatinous pus by the bladder. The case was first seen by the late Dr. Ramsbotham more than tAventy years ago. She has never been pregnant. The free external vents give her security. DERMOID CYSTS. 299 In a considerable proportion of cases the termination is accelerated by pregnancy and labor. The pressure of the gravid uterus and of the child during labor injures the cyst, and disposes it to inflammation. But for the accident of pregnancy it may remain quiescent and unsuspected dur- ing life, to be discovered only on autopsy. Denman cites a fatal case. In St. George's Hospital Reports (1877) I have related several illustra- tive cases. Treatment.—When there is evidence by pointing of working towards the surface, it is Avise to open the abscess by a bistoury. This should be done cautiously, to a limited extent, in the first instance. This incision may be subsequently extended, perhaps crucially, and the cavity of the cyst explored by sound and finger. Tapping will detect fat. The sound will detect teeth ; and the small hook (Fig. 81) will detect hair. In this way we may facilitate the evacuation of the contents. The cavity may be Avashed out with Condy's fluid, Aveak solution of iodine, or weak car- bolic acid. Generally a fistulous opening remains for an indefinite time, leading to hectic fever. It is therefore desirable to make tentative in- cisions with a view to extirpation. The adhesions they are so apt to contract will, however, often frustrate the attempt. It might be justifiable to lightly cauterize the inner surface of the cyst with the galvanic cau- tery, to modify its character. It is scarcely probable that much inflam- mation Avould be excited in surrounding healthy structures, and when the sloughs had been discharged, the cyst deprived of its formative elements would contract and the fistulous opening close. Since the generally elected seat of these tumors is the recto-uterine pouch, they can in most instances be attacked with the greatest advantage by the roof of the vagina, or through the rectum. The vagina is to be preferred. An exploratory opening may first be made with the aspirator- trocar, or with the modification of this instrument I have de- vised for the purpose. The cyst having been examined by Fig. 81. the sound and its nature determined, it is better to enlarge r\ the opening so as to give free vent to the fluid, hair, or teeth. t\ The best Avay to do this is, the patient being in lithotomy- ^ position, in anaesthesia, to open the cyst to the length of an inch or more by the thermo-cautery knife. Then a drainage- tube can be inserted, and the av ashing out is facilitated. From time to time we may estimate the size of the cyst by the sound, \ and by means of a small hook, make by bending the stilet of (r. b.) a catheter (Fig. 81), SAvept round inside the cyst, we are pretty sure to entangle any hair that may be in it. In this way I have frequently fished out tufts of hair. 300 ECTOPIC GESTATION. CHAPTER XIII. ECTOPIC OR EXTRA-UTERINE GESTATION": TUBAL; OVARIAN; TUBO-OVARIAN; ABDOMINAL; INTERSTITIAL; CERVICAL; ONE-HORNED UTERINE GESTATION. For clinical purposes it is convenient to study ectopic gestation in con- nection with ovarian tumors. The diagnosis betAveen them is often a pressing practical problem, upon the solution of Avhich hangs the choice of the method of treatment. Under the general term " Ectopic Gestation" I propose to include all gestations outside the cavity of the body of the uterus, the normal nidus of the impregnated ovum. The term "extra-uterine gestation" is defec- tive and inaccurate. Gestation in the cervical canal is not strictly extra- uterine, but it is abnormal and ectopic. The same objection applies to the intra-mural gestations. Ectopic gestations embrace 1. Tubal; 2. Ovarian; 3. Tubo-ovarian; 4. Abdominal; 5. Intra-mural; 6. Cervical. 1. Tubal Gestation.—Under various conditions the Fallopian tube may rupture or become perforated, Avhen its contents suddenly throAvn into the peritoneal cavity may cause shock, or peritonitis, and death. The best knoAvn of these conditions is the tubal form of extra-uterine gestation. The ovum may be arrested in any part of the tube. If caught in the fimbriae, a sac is formed partly out of the dilated mouth of the tube, and partly by attachments to neighboring structures, especially the ovary, thus forming the tubo-ovarian gestation. The sac in this case usually assumes a rounded shape. If the ovum be caught in the middle of the tube, the shape of the sac is more ovoid. It may be caught in the uterine portion of the tube, and the gestation is then called "inter- stitial" or " intra-mural." It may be said, generally, that the sac bursts the earlier the nearer its seat is to the uterus. Thus the tubo-ovarian sac may not burst until near the ordinary term of uterine gestation: whilst the tubal sac or the interstitial sac usually bursts at dates varying from six weeks to three months. Kiwisch saw a case which burst in four weeks. Gestation may, however, go on for four, five, or even six months. Spiegelberg relates one case in which it went to term. The tube, although consisting of a mucous and a muscular coat like the uterus, is ill adapted to keep pace in groAvth with the rapid develop- ment of the ovum. The adaptation is not simply, as in the case of ute- rine gestation, obtained by growth of the tube pari passu with its con- tents ; the tube is stretched as well; and there comes a time Avhen, the stretching exceeding the distensibility of the tube, the sac bursts, and the contents escape into the peritoneal cavity. Along Avith the ovum, or at least the embryo—for frequently the chorion remains attached to the sac—there almost invariably is poured out a large quantity of blood, TUBAL GESTATION. 301 which proceeds from the torn vessels of the tube. It is a form of abor- tion. There is partial detachment of the ovum and hemorrhage from similar causes. Under the high tension of pregnancy exaggerated at the menstrual epochs, the vessels connecting the ovum to its sac give way, and blood-extravasation results. The greater danger is mainly due to there being no external outlet. The injury sustained is compound. There is the traumatic violence attending the rent, producing shock ; and hemorrhage, producing anaemia. The symptoms are also tAvofold. Shock induces collapse. There is sudden intense pain following on a sense of something having given way in the loAver part of the abdomen. The immediate effects of the shock are coldness, prostration, near extinction of the pulse, vomiting; deadly pallor supervenes, and in a short time, often not exceeding a feAv hours, the patient dies. To this assemblage of symptoms I have given the name "Abdominal Collapse." It is dis- tinguished from the collapse Avhich attends sudden injury or ruptures in the head by the preservation of the mental faculties, and from the like injury in the chest by the absence of that terrible anxiety of respiration Avhich marks the chest collapse. The symptoms, coming as they do suddenly and destroying a Avoman, who up to the moment of the attack Avas in the enjoyment of good health, have often given rise to the suspicion of foul play by poison or mechanical violence. If the patient survive the shock, and reaction set in, the signs of hemorrhage become manifest; the anaemia is marked by the pallor of the body, the whiteness of the tongue, lips, and conjunctiva?, the hemorrhagic pulse, the distension of the loAver. abdomen, and sometimes by semi-fluctuation in a mass behind the uterus in Douglas's pouch, constituting Avhat I have ventured to call a " cata- clysmic" form of retro-uterine haematocele. Again, at this stage the patient is likely to sink under the exhaustion of the shock and loss of blood combined. But if she survive this stage, she has still a third and formidable danger to encounter. This is peritonitis. It usually super- venes rapidly. A few hours' time is often enough to light up almost universal peritonitis. Intense pain continues, the patient can hardly bear the slightest touch or the weight of the bed-clothes on the abdomen ; the abdomen swells, becomes tense, the pulse is rapid and small, the tempe- rature rises tAvo or three degrees above the normal standard, the counte- nance puts on the anxious draAvn expression characteristic of abdominal injury. Still the case may issue in recovery. The shock and hemor- rhage may be not greater than the patient can bear, and the inflammation may be limited to the pelvic peritoneum ; plastic lymph may be so throAvn out as to surround and encapsulate the blood-mass. When called to a Avoman suffering from an injury of this kind, refer- ence to her previous history for the purpose of diagnosis is but trifling in the presence of a great emergency. Nice diagnosis of the cause of the injury and source of the bleeding would afford little help in treat- ment. The present state of the sufferer demands all our care. Histori- cal investigation may be postponed. This is far from saying it should be neglected. What we Avant is such a perfect knoAvledge of the nature and course of a disease—and this remark applies Avith special force to the case under discussion—as will enable us to detect it in its incipient stages, to understand the changes that are in progress, and thus to acquire 302 ECTOPIC GESTATION. indications for treatment in anticipation of the disasters Avhich attend the climax. The hints we get that a tubal pregnancy is going on are com- monly so obscure that they are easily overlooked. The subject herself may feel no disturbance of health, or observe no sign so unusual as to lead her to seek medical advice. She may be satisfied that she is preg- nant in the ordinary way. The physician rarely indeed has the oppor- tunity of studying these cases during their progress. lie sees only the catastrophe. But phenomena sometimes present themselves, Avhicli, al- though not conclusive as to the existence of tubal gestation, are yet suffi- ciently important to dictate a careful local examination. I will not insist upon the suspension of menstruation, and the presence of the common subjective signs of pregnancy, further than to call to mind that if exami- nation of the uterus lead to the conclusion, and this is not easy to arrive at, that the uterus is not the seat of the presumed pregnancy, Ave should consider the possibility of an extra-uterine pregnancy. One difficulty in gaining the first step in diagnosis—that, namely, of excluding uterine pregnancy—lies in the fact that the developmental force working in the tube extends to the uterus, causing considerable enlargement of this organ. Another obstacle is imposed by the hypothesis of pregnancy, which forbids the use of the uterine sound. Tavo signs, singly or concurrently, justify exploration. These are pain and hemorrhage. These signs, of course, are far more likely to be con- nected with ordinary abortion, some disease of the uterus, or with dys- menorrhoea. But this probability does not detract from the expediency of examining. On doing this we may be able to exclude uterine causes. This is one step. The next is to obtain evidence of abnormity outside the uterus. If Ave find fulness of the vaginal roof on one side of the uterine neck, the uterus pushed over to the opposite side, if Ave can, by finger in rectum, and hand depressing the abdominal Avail above the pubes, define a swelling between them, the presumption rises that there is extra-uterine pregnancy. Tubal gestation is distinguished from en- cysted abscess of the broad ligament or pelvic peritoneum by its smooth- ness, uniformly round or oval form, and by its mobility. The long axis of the oval tumor is parallel with Poupart's ligament. The presumption of tubal gestation is strengthened in proportion as we increase the evi- dence of pregnancy. Thus Huguier says, the violaceous coloration of the vagina has always been to him an indication of pregnancy, uterine or extra-uterine. Vaginal pulsation may be felt. Evory Kennedy in one case detected the placental souffle.1 Analysis of numerous cases proves one thing, namely, that in many, perhaps in most, distinct symp- toms which may be regarded as premonitory, do occur before the final catastrophe. The pain, Goupil says, is constant. It is due, no doubt, to the stretching of the tube chiefly, and in part to the pressure of the enlarging sac upon neighboring structures. Kennedy's cases, my own,2 and many others, show that pain occurs early and continues. The hemorrhage is not less constant. I have several times pointed this out in the discussions at the Obstetrical Society. It strengthens the 1 British Medical Journal, 1869. z See St. Thomas's Hospital Reports, vol. i., 1871, Pelvic Haematocele. TUBAL GESTATION. 303 analogy with abortion. Goupil says, metrorrhagia is an almost constant phenomenon. Lesouef, in the most valuable monograph on extra-uterine gestation Avith Avhich I am acquainted, declares that hemorrhage is the initial fact of the fatal accidents, and that Avhen the foetal sac bursts, blood had already for a long time been poured into it distending its walls. Lesouef does not insist clearly upon the escape of blood externally in the form of metrorrhagia. But I belieA'e this phenomenon is so frequent that it may be regarded as indicative of Avhat is going on in the sac. The blood Avhich Aoavs by the vulva is to a certain extent the overfloAV. It no doubt postpones the climax in rupture. It should serve as a Avarn- ing of the impending danger. A point deserving of the most earnest attention is that in many cases the fatal catastrophe does not come in one single stroke. One or more minor attacks, evidently marked by rupture and effusion of blood, occur several days before the final Woav is dealt. The symptoms of these pre- liminary strokes are those of haematocele. The first rupture is probably small, the ovum perhaps remains entire. If Ave could seize this moment to puncture the sac, Ave might avert the fatal rupture. Diagnosis.—The physical signs taken alone might not enable us to distinguish an early tubal gestation from a small ovarian cyst or a tubal dropsy. But add to these physical signs, so similar in both cases, the history and signs of pregnancy, the pain and the hemorrhage, and we get an accumulation of evidence Avhich in some cases at least amounts to a very high degree of probability in favor of tubal gestation. Three conditions there are which are most likely to be a source of difficulty. Retroversion of the gravid womb ; a small ovarian cyst; retro- uterine haematocele. The first and third of these conditions Avill com- monly cause retention of urine, an accident Avhich seems comparatively rare in tubal gestation. In the first, almost constantly there is a history of pregnancy, and the characteristic signs of it; in the third also there may be a history of pregnancy. Retroversion may be distinguished by tracing the firm rounded body of the uterus by vaginal and rectal touch and by its other characteristic signs. Retro-uterine haematocele may be the result of abortion. It Avill, like tubal gestation, be attended by external hemorrhages. But the mass of blood behind the uterus will have folloAved on severe symptoms suddenly produced, and the uterus will present a degree of development much less than that commonly observed in tubal pregnancy. Although a small ovarian cyst may also cause retention of urine, it does not cause suppression of menstruation. Wre may always negative pregnancy. Lesouef cites a case in his Memoir (No. vi.) of an extra-uterine ges- tation mistaken for a retroversion of the womb at the fourth month. Puncture Avas made, and attempts at reduction. Two days later the foetus passed by the rectum. There had been almost complete suppres- sion of urine, and stoppage of feces. The case Avas seen by Dupuytren, Antoine Dubois, Lisfranc, and Maygrier. I have also seen cases of gestation in Douglas's pouch Avhich gave rise to the same symptoms and erroneous diagnosis. One is recorded in St. George's Reports, 1877. Fig. 82 is a good illustration of a tubal gestation, the cyst bursting at about the third month. The uterine decidua is dissected up, and is 304 ECTOPIC GESTATION remarkably developed. The tube is brought forward for the purpose of demonstration. In life it Avould get behind the uterus. Causes of Tubal Gestation.—These are interesting, as illustrative of the morbid conditions to which the Fallopian tube is liable. It is remarkable that, in a considerable majority of cases, it is the left tube which is the seat of gestation {Campbell, Hecker). This may pos- sibly be explained by the fact that the left tube is more liable to displace- ment and compression by the sigmoid flexure, which lies in close relation to it, and is often disturbed by feculent accumulations. Fig. 82. Gestation in the Left Fallopian Tube. The Sac Ruptured; the Embryo Suspended by its Cord: the Uterine Mucous Membrane Developed to a Thick Decidua (R. B.). (St. Thomas's Museum. H. 1L 19, uat. size.) ' The essential condition of tubal gestation is obviously arrest of the impregnated ovum in the tube. We have, therefore, to consider Avhat are the conditions Avhich may lead to this arrest? Naturally we look to some mechanical obstruction, and in some cases this is found. Amongst these are— a. Inflammatory adhesions.—Hecker1 believes this to be a common 1 Monatsschrift fur Geburtskunde, 1859. TUBAL GESTATION. 305 cause. He supports this opinion by eight dissections, shoAving adhesions impeding the free course and connection of the tubes Avith the ovaries ; by the fact of the frequent sterility antecedent to tubal gestation; by the Avell-knoAvn sterility of prostitutes which folloAvs upon colic—the colica scortorum. It has been remarked, that in many instances the subjects of tubal gestation had, up to the time of such gestation, been sterile. There is sufficient reason to admit this as a frequent cause, but many cases are knoAvn in which the course of the tubes appeared to be free ; and in some cases, in Avhich adhesions have been found, these were pro- bably not antecedent to, but the consequence of, the tubal gestation. b. Obstruction of the ostium uterinum by polypi.—Breslau1 relates two cases in Avhich polypi were found at the uterine end of the tube. In one, that of a Avoman, aged thirty, who died of abdominal hemorrhage six months after marriage, a cyst, containing chorion and blood, occupied the left tube. The cyst was close to the uterine mouth of the tube. Inside the uterus, close to the mouth of the tube, Avas a mucous polypus, not quite obstructing the passage of a small sound. This position of polypus is not very uncommon. I dissected a uterus in Avhich a polypus the size of a filbert was attached to the mouth of each tube and occluded it. Fibrous tumors in the uterus have been found in several cases. A very interesting one is related2 by Dr. Magrath, of Jamaica. In Univer- sity College Museum is a specimen (No. 4275) of tubal gestation, the sac having burst at the fifth month. The uterus contained several large fibroids. These tumors so distort the form and relations of the uterus, that obstruction to- the passage of the ovum may readily occur. Extra- uterine gestation, then, may be looked upon as one of the penalties a Avoman having fibroid tumors in the uterus may incur if she marries. It has struck me as remarkable, how often, in tubal gestation, tAvins have been found. May it not be that the tAvo ova may obstruct each other in their passage along the tube ? c. Another fact deserves notice. In the great majority of cases of extra-uterine gestation, the subjects have been Avomen exposed to hard work. In many cases the Avomen themselves have assigned this as the cause of their misfortune. It is quite possible that great bodily exertion during the first days after conception may so alter the relative position of the ovaries, tubes, and uterus, as to impede the due transit of the OArum; or great congestion of the organs may be induced, causing tume- faction of the mucous membrane. Coste conjectured that shock, moral or physical, might cause extra-uterine gestation. d. Oldham Avas, I believe, the first to observe that occasionally the corpus luteum Avas found in the ovary of one side Avhilst the ovum Avas developed in the tube of the opposite side. Hoav could this contradiction be explained ? The ovum must have travelled by an unusual route. The problem has given rise to the theory of the transmigration of the ovum. This theory offers two routes Avhich the ovum may take. 1 Monatsschrift fiir Geburtskunde, 1863. 2 Obstetrical Transactions. 20 306 ECTOPIC GESTATION. The extra-uterine transmigration.—Oldham and Wharton Jones found, in a left interstitial gestation, the corpus luteum in the right ovary ; the right pavilion Avas obliterated, and both observers believed that this ob- literation was of old date, so that the ovum could not have passed by it. The uterine portion of the left tube was draAvn tOAvards the posterior Avail of the uterus by false ligaments, which Avere also found at the far ex- tremity of this pavilion, Avhich Avas thus brought into contact with the right ovary, and had directly received the ovum from it. Fig. 83. Gestation in a Rudimentary Horn of the Uterus—Front View—(after Luschka). A, the developed horn of the uterus (right); B, the rudimentary horn with a rent, through which the foetus has escaped (left). 1, the Fallopian tube (right); 2, the Fallopian tube (left) ; 4, 5, right ovary and corpus luteum ; 6, round ligament. Rokitansky found in a woman, who had died after a uterine pregnancy, the yellow body on the left: the abdominal portion of the left tube, for a space of two inches, was thinned, impervious, its pavilion adherent to the sigmoid flexure above the brim of the pelvis; the right tube was mobile. He believes that the conception took place after these adhesions had been formed, and that the ovum had passed into the uterus from the left ovary by the right tube. In these two cases, then, it seems difficult to avoid the conclusion that the fertile ovum travelled from its ovary to the opposite tube. Klob and Kussmaul showed, what any one may see on the dead body, how easily the fimbriated extremity of the right tube may be applied to the surface of the left ovary, and vice versa. But Kussmaul does not regard this contact as necessary. He invokes observations made on amphibia, in Avhich it is certain that actual contact betAveen tube and ovary does not take place. And Miiller and Becker have described a vibratile current running from the ovary to the tube, which may SAveep the ovum over the intermediate space into the tubes. Maurer's case is another illustration of the extra-uterine transmigration. TUBAL GESTATION. 307 A case that seems decisive as to the possibility of the extra-uterine transmigration, is related by Luschka.1 A Avoman died under the usual signs of rupture of a fruit-sac Avhen about ten weeks pregnant. It Avas found that the fruit-sac Avas in the rudimentary horn of a one-horned uterus, whilst the corpus luteum was in the opposite ovary. No commu- nication could be found .between the sac of the rudimentary horn and the cavity of the developed half of the uterus, so that intra-uterine migra- tion is necessarily excluded in this case. It is convenient to give Luschka's figure here ; the reader can refer to it Avhen studying the subject of preg- nancy in a rudimentary horn further on (Fig. 83). In several other cases in Avhich the corpus luteum was found in the ovary of the same side as the fruit-sac, the rudimentary horn containing it had no communication Avith the cavity of the developed horn. Here Ave may conjecture that the spermatozoa found their Avay through the developed horn and its tube, being thus conveyed across outside the uterus to the ovary of the opposite side; unless, indeed, Ave conclude that, at the time of the conception, a communication betAveen the ca\ri- tics of the two horns did exist, Avhich became closed during gestation. Schultze2 relates a case of a tubo-uterine gestation, carried to term. The gestation Avas on the right side, the corpus luteum on the left. The right tube Avas impervious at both ends. This would appear a case of extra-uterine transmigration. In the London Hospital Museum (E. h. 28) is a specimen in point. It exhibits the uterus and ovaries of a Avoman who died very suddenly, and Avas suspected to be poisoned. There is a tubular conception and ruptured sac on the left side ; the corpus luteum is on the opposite side. Indeed, cases of this kind appear to be not very uncommon. Mr. Stirling, of the Edinburgh University, informed me (1875) that in eight out of tAventy sheep the ovum Avas found in the opposite horn to the corpus luteum; and that in five out of twenty sheep a double corpus luteum Avith only one lamb Avas found. The intra-uterine transmigration.—Tyler Smith, I believe it was, Avho started the hypothesis that the ovum might be received into its appro- priate tube, enter the uterus, cross the cavity, and penetrate the opposite tube, where it might become developed. There are facts Avhich support this idea. That the ovum does Avander in the uterine cavity is proved by the cases of placenta prsevia, Avhere the ovum gets to the cervical zone, and also in some rare cases even into the cervical cavity, constituting cervical gestation. Klob,3 however, disputes the possibility of intra-ute- rine migration. But it must be remembered that in a considerable proportion of cases of tubal gestation, the corpus luteum is on the same side as the embryonic sac, and that no obstruction by adhesions or tumors can be found. Here Ave may suppose that a temporary flexion of the tube may present a spur or valve at some point on the uterine side of the ovum and block its onward course. 1 Schwangerschaft i. d. rechten rudimentaren Home, etc., M. f. G., 1863. 2 AViirzburger Med. Zeitschrift, Band iv. s Wochenbfatt d. Ztschr. d. k. k., Ges. d. A. in Wien, 1861. 308 ECTOPIC GESTATION. I Avill noAV describe what I believe is the exact order and course of events in the greater number of cases of tubal gestation. The ovum is impregnated either in the ovary, as Coste thought probable, or after its reception in the tube. Arrested there, it groAvs, developing its chorion into placenta, and distending the Avails of the tube into a sac, until the time arrives—seldom postponed beyond three months—Avhen the growth of the ovum outstrips the groAvth and stretching of the tube Avhich contains it. The great majority of cases terminate in rupture within eight weeks {Hecker). Dr. Roper observed that the rupture occurred at a menstrual period. This increases the analogy I have pointed out between tubal gestation and placenta praevia and abortion. The tube does not burst at once; if it did there would be no premonitory hemorrhage. This hemor- rhage I account for on the same hypothesis as that by Avhich it seems to me certain that the hemorrhage in placenta prsevia is explained. In both cases the gestation is ectopic, that is, proceeding in an abnormal locality which is unfit for the office imposed upon it. The Fallopian tube, like the loAver segment of the uterine cavity, has only a limited capacity of growth. This is soon overtaken by the growing ovum, Avhich, not finding the room it requires, excites spasmodic contractions of the sac. Hence partial detachment of the ovum is caused, and some hemorrhage ensues. In the case of tubal gestation, partial detachment is very easy, owing to the scanty development of decidua. This hemorrhage, in cases both of placenta praevia and of tubal gestation, may escape externally. In the first case, the os uteri offers a ready exit; in the second case, the exit is not so easy, and the sac is comparatively feeble. Hence a large propor- tion of the blood poured out by the severance of relation between placenta and sac is retained in the sac. The distension becomes extreme. Re- neAved spasmodic action of the muscular wall is excited, and the sac bursts. The ovum itself does not always burst, and, probably, rarely does until the sac has done so. The accumulated blood in the tube, together with fresh blood proceeding from the torn vessels of the tube, is now poured into the abdominal cavity, causing the shock and other phenomena that mark the climax. The influence of extra-uterine gestation upon the uterus is an important point to consider. The remark of Yelpeau that the sexual organs show little departure from their ordinary state when the foetal sac is not in the tube, and do not contract adhesions Avith the uterus, is generally true. But in every museum which can shoAv specimens of tubal gestation will be found ample evidence of enlargement of the uterus, and of the develop- ment of the mucous membrane into decidua; and this is entirely in accordance with physiological knowledge. The uterine mucous mem- brane swells and undergoes development into decidua under the mere stimulus of ovulation. This development is a necessary preparation for the reception of the ovum. It is not a necessary condition for its forma- tion that the ovum should reach the uterus. But why, it may be asked, is the decidua so constantly found in tubal gestation preserved so long as three months when it is not wanted ? And why is it not observed in many cases of abdominal gestation ? The explanation is found in the remark, before cited, of Velpeau. In tubal gestation, the engorgement of the uterus and the physiological stimulus are maintained by the proximity of TUBAL GESTATION. 300 the foetal sac ; whilst in abdominal gestation the developmental stimulus and the vascular system supplying the sac are remote from the uterus. Still, in many cases Avhere the sac adheres to the uterus and presses upon it. this organ is greatly enlarged, and its mucous membrane is highly developed. As to the formation of decidua in the tube itself, it might be, d priori, supposed that the tube having a mucous membrane, and the physiological necessity for a decidua being present, a decidua would be formed. But Oldham,1 Khvisch, and Virchow have shoAvn that it is not so. The mucous membrane in the tube is deficient in the utricular glands which the uterine membrane possesses. A careful examination of specimens confirms VirchoAv's observation. The chorion-villi seem to be implanted directly upon the mucous membrane. The condition of the mucous membrane of the tube has been investigated by Poppel,2 Avho says that even if a decidua vera be formed, there is certainly no serotina. Hennig has also studied the question.3 He shoAvs greater similarity be- tween the behavior of the uterine and tubal mucous membranes under gestation than Avas before suspected. If, he adds, there be no serotina in tubal gestation, the placenta is developed on a different plan to that of the normal uterine placenta ; it is deAreloped according to the plan Avhich governs the normal gestation in rabbits, cats, and dogs. This slender attachment may serve to explain the facility Avith Avhich separation and hemorrhage take place. Also, in abdominal gestation, there is no true decidua in the sac. The placenta is attached directly to the surface of the uterus or of some abdominal organ. The Treatment.—-A careful study of the history, course, and premoni- tory symptoms of tubal gestation, will encourage the hope that Ave may in some cases at least avert the ultimate catastrophe. In the early stages, before hemorrhage has occurred, if pain and local distress have led to an examination, and the detection of fulness in the vraginal roof a little on one side of the uterus, which Ave conclude to be, on grounds described under " Diagnosis," due to a tubal cyst, Ave have, I think, a sufficient indication to act decishrely. Lesouef said that every Avoman who has become the subject of an extra-uterine gestation, is doomed to more or less speedy death. This is eminently true of tubal gestation. Error of diagnosis is the only justifiable ground for hesitation. And for what is a tubal gestation likely to be mistaken ? Most likely for a small ovarian cyst. Noav here is a case of Avhich Ave have many analogous examples in medicine. Whichever view be right, the same treatment applies; and hence the error entails no harm. The indication in both cases is to arrest the groAvth of the cyst. This can be done by tapping it; and tapping through the vagina or rectum by means of the fine aspirator-trocar is infinitely less dangerous than letting the disease go on to its ordinary and almost inevitable termi- nation. In the case of tubal gestation, there being no available outlet, we are precluded from the induction of labor. But the embryo may be killed, and thus the development of the sac cut short. 1 Guy's Hospital Reports, 1843. 2 Monatsschrift fiir Geburtskunde, vol. xxxi. 3 Ibid. 1869. 310 ECTOPIC GESTATION. Electricity.'—Dr. Bacchetti1 described a case in AAdiich two needles Avere passed into the tubal sac, and then a current of electricity Avas passed through by means of a Bunsen's pile. Tavo shocks Avere adminis- tered. The growth of the tumor Avas arrested, and the patient did well. Of course it may be doubted whether there Avas really a tubal gestation; but in any case it is proved that the puncture may be safely made. Duchenne, consulted by Lesouef, suggested resort to electricity in the state of tension by a Leyden jar. He ascertained that the discharge of a Leyden jar produced a profound local stupor, and that for a certain time the capillary circulation and calorification Avere diminished in the tissues operated on. The method he recommends is, to cover the stem of the excitors with a thick coating of wax, leaving only the terminal ball bare. One excitor is then passed into the rectum, endeavoring to place it in contact with the postero-superior side of the tumor. The lumbo- sacral plexus must be avoided, else the mother will receive the shock. The second excitor is passed into the vagina, and the ball is applied to the antero-inferior wall of the cyst. Thus arranged, the rectal excitor is put in communication with the external armature by a chain suitably isolated. It then only remains to bring the internal armature in contact with the vaginal stem by a glass stem excitor. The electricity will recompose it- self across the foetal cyst, and it seems inevitable that the stream must traverse the embryo. This mode of applying electricity seems preferable to that of Bacchetti, inasmuch as no wound is inflicted. Indeed, Bacchetti's plan may be ex- cluded on the ground that, having made the puncture, electricity is super- fluous. Drawing off the liquor amnii.—The sac deprived of this element will naturally collapse, the ovum will in all probability perish, and atrophy by absorption ensuing, cure will be attained. If the aspirator-trocar be used, the liquor amnii can be easily drained off. It had already been proposed by BasedoAV to puncture the cyst through the vagina, to drain off the liquor amnii, and thus to kill the embryo. This method Avas advocated by Khvisch,2 Avho recommended to pass a small trocar into the cyst by the vagina. Professor Friedreich3 of Heidelberg relates a most interesting case in Avhich, having detected a tubal cyst Avhich gave rise to great pain, and Avas increasing so rapidly that bursting Avas apprehended, he made three injections of a solution of morphia into the cyst. He based this pro- ceeding on the known susceptibility of the infant organism to opium. Complete success followed. The tumor shrank to a small hard knot, and all the distressing symptoms vanished. It is not, however, clear Avhether the same result might not have been obtained by the punctures alone, the morphia injections being superfluous. Some degree of inflammation is pretty sure to folloAV puncture. This Avould entail the death of the foetus. But the necessary drainage of the cyst Avould alone be efficient. Dr. Greenhalgh4 describes a case in Avhich he arrested the development 1 Gazzetta medica toscana, 1853. 2 Klinische Vortrage, Piag. 1849. 11 Abtheilung. S. 275. 3 Virchow's Archiv. 29, 1863. 4 Lancet, 1867. TUBAL GESTATION. 311 of a tubal gestation by puncture through the vagina. Professor E. Martin1 relates a case in Avhich he pursued the same method. The late Professor Simpson2 related a case in which a patient AATho had suffered rupture of an extra-uterine cyst Avas punctured by the vagina "to evacuate the liquor amnii, to effect death of foetus and subsequent decomposition and expulsion." Death occurred through peritonitis. The sac Avas formed by the enlarged uterus, broad ligaments, pelvic Avails, and sigmoid flexure. The foetus Avas of six months' development. Thomas relates a most instructive case.3 A Avoman had suffered several acute paroxysms of pain in the left iliac fossa. The uterus measured three and a half inches from os externum to fundus; it Avas in right ob- hque anteA'ersion, and not so movable as normal; to the left of the uterus Avas a tense elastic cyst Avhich filled the Avhole iliac fossa, pressing the uterus to the right, and extending doAvn to a little beloAV the level of the os internum. He detected ballottement in this cyst, and diagnosed tubal gestation. He opened the cyst through the vaginal roof by the galvano- cautery knife. A straAv-colored, slightly-colored pinkish fluid Avas ejected with such force as to fly into the operator's face. A finger passed into the cyst felt a foetus. This Avas extracted. Severe hemorrhage attended extraction of the placenta. He thereupon injected a solution of persul- phate of iron into the cyst. The bleeding Avas instantly checked ; but a bit of placenta Avas left behind. Septicaemia ensued ; but under repeated injections of carbolized Avater subsided. The bit of placenta came aAvay on the fifteenth day. The patient recovered. The foetus measured six and a half inches. The proceeding is Avorthy of adoption. It may, hoAvever, be doubted Avhether it would not be better to leave the placenta for gradual elimina- tion, keeping open the communication of the cyst Avith the vragina. Dr. Rupin4 relates a case of tAvin-pregnancy outside the uterus. A cyst Avas felt projecting in the roof of the vagina, Avhich was punctured, and liquor amnii drained off; a foetus of four months escaped. The patient died of violent hemorrhage three days aftenvards. On autopsy, a second foetus was found in a sac deep in the pelvis. Probably this Avas not a tubal gestation. Can we arrest embryonic growth by means of agents introduced into the blood? M. Delfraysse5 relates instances of retardation of the growth of the foetus by continued doses of iodine. Many attempts in ancient and modern times have been made by starvation and drugs to accomplish this object. I do not insist upon them, because I have no faith in their effi- cacy. It is possible, hoAvever, that strychnine carried so far as to produce minor toxical symptoms in the mother, might destroy the embryo. Syphilis has more poAver than almost any poison Ave are acquainted Avith over the foetus, almost ahvays either killing it, or impeding its development. Might it not be justifiable in such a case as Ave are discussing to practise syphi- 1 Monatsschrift fur Geburtskunde, 1868. 2 Edinburgh Medical Journal, 1864. 3 New York Medical Journal, 1875. J Gazette des Hopitaux, 1860. 5 Comptes rendus de 1 Acadeinie des Sciences, 1850. 312 ECTOPIC GESTATION. lization? I do not dAvell upon this repulsive method, because I believe simple puncture of the sac is the right course to adopt. If the opportunity of treatment during development has been passed by, and rupture has taken place, what is the course to be adopted '( "The question is often discussed, whether it is not advisable to perform laparotomy {^andpa, the soft part between ribs and hips, abdominal sec- tion) with a vieAV to removing the embryo and effused blood, to check bleeding by tying the Fallopian tube on the proximal side of the sac, and cutting away the sac? I do not imagine that this will be successfully carried out in cases of early tubal rupture. In the first place, the greater number of subjects die within a few hours from the primary shock of the injury and hemorrhage. Laparotomy must add to this shock, and cannot restore the lost blood. Secondly, to discover the source of the bleeding, and to remove the blood is by no means easy. I have found considerable difficulty in tracing the parts with all the advantages incident to a post-mortem examination. Thirdly, if Ave could tie the tube, and amputate the sac, the pain caused by the ligature might by itself exhaust the vital power. I fear the actual state of science has no resource beyond the old one of rallying the patient from collapse by cautious ad- ministration of stimulants, of procuring rest by opium, and by controlling inflammation, if the patient survives until this conservative process sets in. If this fortunate event should be reached, the case may resolve itself into one of encysted pelvic haematocele, and must be treated on the prin- ciples laid down for that condition. But this issue by cataclysmic rupture is not invariable. I agree with Lesouef s observation that extra-uterine gestation is a far more frequent accident than is supposed, and that if it be so rarely observed, it is be- cause the embryo in the greatest number of cases is destroyed in the first days of its development. No appreciable symptom then is manifested, or if the physician is called in, it is impossible for him to refer what he sees to its true cause. When a tubal, ovarian, or abdominal gestation is brought to an end in the first days, the hemorrhage may not be fatal, and the rational signs of gestation not having yet appeared, the source of the resulting haematocele escapes detection. In these cases the hemor- rhage may escape from the surface of the tube, or from its open end. There is not necessarily rupture of the tube; and the embryo perishes, and a haematocele is formed. I have related cases, upon my interpreta- tion of Avhich of course it is easy for criticism to cast a doubt, but which I nevertheless believe to be of this nature. In yet another order of cases, rupture of the tubal sac takes place early, the hemorrhage is not fatal, and the impregnated ovum escaping into the abdominal cavity may graft itself upon the peritoneum, when a sac will be formed by false mem- branes. Lesouef, quoting Bemutz, says : " If the rupture of the tubal sac takes place on a level Avith the attached border of the tube, the blood will find its way into the cellular tissue of the broad ligament, and thus find diffi- culty in effusion, whilst the ovum will insinuate itself in the route made between the folds of the broad ligament, and become de\reloped there. For it must be remembered that the ovum itself rarely ruptures, its envelopes remain intact, and its vitality is not necessarily destroyed." OVARIAN GESTATION. 313 The tubal gestation may go on to term. This issue is exceedingly rare ; so rare, that a case Avhich Spiegelberg1 relates he believes to be singular. Convulsions came on in a Avoman at term, with signs of labor; copious albumen was found in the urine. She died after three days, the convulsions and albuminuria having ceased on the death of the'child. The cause of death was perforation of the sac. Examination showed that the sac Avas tubal; a sound passed from the uterus into it; muscular fibres Avere found over the surface ; the sac Avas inclosed betAveen the tAvo layers of the broad ligament; the ovary was found entire. I am unAvilling to hint a doubt of the accuracy of so excellent an observer as Spiegelberg; but it appears possible, even in this case, that there had been at an early stage rupture of the tube at its loAver margin, Avhich had given opportunity for the ovum to extend its sac by opening up a space betAveen the folds of the broad ligament. The question of performing laparotomy to extract a foetus developed outside the uterus will be more conveniently discussed after the descrip- tion of the other forms of extra-uterine gestation. 2. Ovarian Gestation.—The reality of this form has been doubted. Velpeau and Arthur Farre especially contend for the negative. The reasons adduced are tAvofold: 1st, the physiological one, Avhich is based upon the assumption that the ovum must have escaped from the ovary before it can be impregnated ; 2d, the anatomical one. It is urged that there is no clear evidence of a foetus or foetal membranes having been discovered in the ovary. Professor A. Willigk2 advocates this view, and criticizes the alleged cases. He has carefully dissected several, and failed to find foetus or membranes in the ovary. It is needless to say that the microscope is necessary to identify presumed chorion-villi. On the other hand, there are cases which it is hypercritical to set aside as being imperfectly observed. And the physiological objection falls to the ground if Ave accept the conclusion of Bischoff and Coste that impreg- nation does take place in the ovary. Thus Duverney3 relates a case given by De Saint-Morissey, of a lady who, pregnant for the ninth time, at three months fell ill Avith collapse from severe colic in the right groin. She died in nine or ten hours. The abdomen Avas full of clots, and a small foetus Avas found in the midst. The right ovary Avas torn longitudi- nally, and in the half of the side not attached to the tube its whole capacity Avas filled Avith clots. Every one present Avas satisfied that this Avas the spot Avhere the foetus had been formed. Goupil cites a case from ITcelli. The uterus Avas enlarged. Drs. P. U. Walter4 and Hecker5 relate cases in confirmation. A case is related by Uhde6 of a young woman Avho died under the usual signs of tk abdominal collapse." Blood Avas found in the perito- neum. The right ovary Avas enlarged and emphysematous; at its lower and hinder part Avas a sac formed of chorion, Avhich had burst. It Avas the size of a large plum, and contained an embryo V" to 8'" long. The right tube Avas hanging quite free, its fimbria? loose. The preparation is 1 Archiv f. Gynakologie, 1S70. 3 (Euvres Anatomiques, 171. 5 Ibid., 1S59. 2 Prag. Vjlirtschr., Ixviii. 4 Monatsschrift fur Geburtskunde, 1861. e Ibid., 1857. 314 ECTOPIC GESTATION. preserved, and affords a good means of testing the reality of ovarian gestation. It is, prima,facie, unphilosophical to affirm an absolute negative. It is, then, wise to admit that ovarian gestation may happen, but safe to affirm that it is very rare. During life it Avould be difficult, if not im- possible, to diagnose it from tubal gestation. If detected before rupture, it Avould be right to treat it by puncture in the same way, for the histories of the feAv cases narrated show that the ovarian sac, like the tubal one, is a]it to burst early. Probably a more frequent issue is the merging into the tubo-ovarian or abdominal forms. 3. The tubo-ovarian form is not very infrequent. Probably its history commences Avith arrest and development of the ovum just within the fringes of the pavilion of the tube, so that this structure supplies part of the sac, the rest being made up by adhesions contracted with the ovary. It may also arise from original tubal gestation, early rupture of the tubal sac, and fusion of this with the surface of the ovary by adhesions. The occurrence of signs of pelvic inflammation at some period in the history of these cases supports the probability of this event. The tubo-ovarian gestation, like the abdominal form, differs from the tubal by the greater probability of the gestation going on to the full development of the foetus. What then happens will be considered under "Abdominal Gestation." 4. Abdominal Gestation.—It appears to me doubtful Avhether abdomi- nal gestation is ever primary, that is, whether the impregnated ovum attaches itself ab initio to some part of the peritoneum. It can scarcely be doubted that ova, impregnated or not, frequently are missed by the morsus diaboli, and fall into the abdominal cavity, there to perish. Ki- Avisch insists that the spermatozoa also find their Avay into the peritoneum, and may there meet the stray ovum, and give rise to primary abdominal gestation. Such a fortuitous concourse of atoms resulting in gestation, rests at present on conjecture. Probably, then, abdominal gestation is ahvays secondary upon tubal or ovarian gestation. After these latter forms have proceeded a little Avay, the sac, as we have seen, gives Avay, but the ovum is not cast out of its original habitat; it maintains its vital- ity by retaining part of its original attachments. Inflammation of the peritoneum is excited by the rupture and effusion of blood ; neighboring organs get connected by adhesions Avith the sac ; the embryo and its en- velopes grow into the new space ; fresh effusions of lymph are throAvn out surrounding all; and thus a new sac is formed, in Avhich it is difficult to trace the original tubal structure. It is only Avhen the opportunity occurs of dissecting the parts at an early stage of gestation, that we can expect to unravel the structures involved in the sac. No long time elapses Avithout the complication of inflammation and false membranes implicating neighboring organs, whilst possibly a process of atrophy of the original structures forming the cyst has altogether confounded analysis. That the original gestation may be ovarian and not tubal seems proved by a case related by the late Dr. Dyce, of Aberdeen. A woman died after having carried an abdominal gestation eight years, and having had two uterine pregnancies in the meanwhile. Both Fallopian tubeg were found entire, but no trace of one ovary could be detected. ABDOMINAL GESTATION. 315 The course of abdominal gestation observed may be like that of ordi- nary gestation up to a certain point. But intercurrent attacks of pain, the expression probably of attacks of peritonitis, are apt to occur. 1. The cyst may burst, as in a case related by Dr. Thormann {Wien. Med. Wochnschr., lKf>3). The cyst projected into the retro-uterine pouch, and under expulsive efforts it burst through a rent in the posterior Avail of the vagina, an arm of the foetus protruding. 2. In most cases, hoAvever, the cyst is too tough to burst. After labor- pains have persisted for some time, the fat us dies. ?>. Death may happen through exhaustion under the efforts at labor, and from compression of the foetus upon the abdominal organs. 4. The peritonitis may prove fatal, and the cause may escape detection unless a post-mortem examination be made. Peritonitis may be the result of rupture or perforation of the sac, and it may precede or folloAV the death of the foetus. In one case of this kind which I have related1 a fluctuating SAvelling was formed behind the uterus. The uterus Avas driven fonvards and above the symphysis pubis, and considerably elongated, I belie\re, by the pressure to Avhich it had thus long been subjected. The absence of uterine pregnancy was first established by the uterine sound, and by dilating the cervix to facilitate exploration of the interior. Then the SAvelling behind the uterus was punctured. Fluid in part resembling liquor amnii escaped. Death Avas caused by the peritonitis. In most cases, probably, the sac Avill encroach upon the pelvic cavity, getting be- hind the uterus. The soundwill isolate the uterus ; the finger exploring by vagina and rectum will detect the fluctuating mass, perhaps make out parts of the foetus, or foetal bones. There may, hoAvever, be no fluctua- tion, the mass being solid from absorption of the liquor amnii, or from presence of coagulated blood. Sometimes when perforation, spontaneous or surgical, has been made, the discharge is characteristic. It is a sort of blood-stained putrilage, and may reveal shreds of disintegrated foetal tissue. 5. In many cases the sac-Avails being formed in part by some portion of the alimentary canal or the abdominal Avail, or at least only sepa- rated from these by adhesions, a process of ulcerative absorption takes place, by which a fistulous perforation is made into the intestines, or through the abdominal wall. This process is attended by hectic or irritative fever and emaciation. It is rarely that the opening thus made is large enough to permit the easy or complete evacuation of the foetus. The attempt at elimination is a long, tedious, and exhausting process, under Avhich the patient commonly sinks. When such an opening is formed through the abdominal Avail, it is ad- visable to enlarge it by incision Avith a bistoury, or the cautery-knife, so as to give free exit to the remains of the foetus, Avhich should even be extracted by the fingers or forceps. The opening may be safely dilated to the necessary extent for this purpose, because the sac will almost cer- tainly have contracted large adhesions for some distance around. In the case of pointing and perforation into the rectum taking place, a similar course should be pursued; but the extension of the opening 1 St. Thomas's Hospital Reports, 1871. 316 ECTOPIC GESTATION. must be more limited. In either case, during the voiding of the fictal bones, and after they have been all collected, if any offensive discharge continue, the cavity of the sac may be washed out from time to time by injecting a solution of iodine, permanganate of potash or carbolic acid. Occasionally, but less frequently, elimination takes place by the blad- der. In this case it may become necessary to dilate the urethra, Avhich is easily done, so as to admit the finger or a lithotomy forceps, to facili- tate removal of bones. Another issue of abdominal and tubo-ovarian gestation is the carrying to term, when signs of labor supervene. The phenomenon offers points of remarkable physiological and clinical interest. It ought to throw considerable light upon the vexed problem—What is the cause of labor ? If unmistakable labor-effort occur Avhen the foetus is inclosed in a sac quite independent of the womb, Ave are entitled to exclude the Avomb as the primary seat of the cause of labor. And, as Ave cannot ascribe to the artificial Avomb in Avhich the foetus happens to be contained, greater virtue than the natural Avomb possesses, we are driven to conclude that the primary cause of labor lies in the foetus, unless we imagine some power resident in the mother. But this last hypothesis seems difficult to admit. I rather incline to the opinion that when the foetus has attained its full development, when its organs are prepared for external life, some change takes place in its circulation which involves a correlative distur- bance in the maternal circulation which excites the attempt at labor. Sometimes, even, a sanguineous show takes place from the vagina. The seat of the labor-pains is not even clear in these cases. Vel- peau believed the seat of the contractions to be the foetal cyst. If the cyst be formed by the Fallopian tube, its muscular Avail may be so de- veloped as to possess true contractile poAver. The same remark applies if the sac be developed betAveen the layers of the broad ligament. D6- zeimeris thought the contraction Avas in the uterus, which in tubal cases at least is sufficiently developed. In a tubo-ovarian case Avhich had passed into the abdominal form, the constitution of Avhich I investigated with Dr. Hall Davis and Dr. Cayley, abundant smooth muscular fibres were found in the Avails of the sac. Whenever the sac takes its origin in or involves the tube, broad liga- ment, or ovary, we may expect to find muscular fibres in its Avails. Whatever the initial cause of labor, the attempt is necessarily abor- tive. The pains subside, notwithstanding all the help derived from a duly irritable nervous centre, excited by impressions emanating from the foetus or its sac, and often vigorously seconded by emotional and volun- tary actions. Under these the sac may burst. Perhaps the attempt is reneAved at several intervals. Treatment.—What is the best course to pursue ? It is not necessary to say, that in the first place, accurate knowledge should be obtained as to the state of the uterus. Is it certain the uterus has no concern in the pregnancy ? It is proper, I think, in all cases, to dilate the cervix, so as to permit full exploration of the cavity. And this exploration should be especially circumspect and deliberate, for although we may be sure that the cavity so examined is empty and has nothing to do Avith the preg- nancy, the uterus may be double; the unexplored cavity may contain ABDOMINAL GESTATION. 317 the foetus ; or the gestation may be interstitial; that is, in one horn of the uterus. The foetus dies in many cases probably of asphyxia; in others from hemorrhage into the placenta. Large clots Avere found in the placenta by Koeberle.1 Supposing that we are able to exclude all forms of uterine gestation, ought we to undertake to deliver, and how shall we do it ? It will help us to answer this question if Ave examine the results that may occur if nothing be done. The foetus dies, the vascular system Avhich was brought into activity for its support becomes atrophied ; the sac assumes the cha- racter of an inert mass ; the system accommodates itself more or less to the burden, and things may go on for an indefinite time. There are in- stances of Avomen having carried an extra-uterine gestation for forty, even fifty years, ultimately dying of independent disease or old age. The sac may become calcareous, or retain its soft structure ; but it is almost always found intimately adherent to abdominal viscera. The foetus may undergo one of several changes ; for several years the fleshy part may be preserved, the skin retaining much of its original character, and the muscles also. The surface, however, is generally converted into adipocere. After a further time, the soft tissues, having first undergone this fatty metamorphosis, break doAvn, leaving the bones bare. These next become separated. The cyst-walls inflame and suppurate, and a fistulous communication is opened Avith the exterior of the body, or Avith the boAvels. If the attempt at elimination be tOAvards the surface by the abdominal Avail, the skin becomes red, a tumor forms Avhich becomes fluctuating; there is, in fact, an abscess Avhich will burst if it be not opened. Con- siderable irritative fever attends the process ; pus escapes from the open- ing at first, and it may be long before any part of a foetus is recognized. A probe should be introduced to feel for solid substances ; and the open- ing should be enlarged by the bistoury to permit the freer exit of the bones. Every bone should be carefully preserved to reconstruct the skeleton if possible, and thus to satisfy ourselves as to the progress of the case. If the attempt be made by the boAvel, commonly some distress in defe- cation arises, perhaps obstruction of the bowels, then sanguineous discharge or dysenteric symptoms. Pelvic inflammatory symptoms attend. If ex- amination be made by the rectum, a projecting tumor may be felt, and through its Avails Ave may make out solid bones. If this be clearly es- tablished, it is advisable to puncture the sac at once by a bistoury or cautery knife, and to aid the exit of the bones by fingers or forceps. There is a great advantage in the vaginal elimination, if a sufficiently free opening be made. The drainage is more easy and perfect. There is a greater tendency to contraction and obliteration. Access for obser- vation, injection, and extraction of bones is more easy. Or, in other cases, the foetus undergoes a calcareous metamorphosis. This seems the change most compatible with long life of the mother. 1 Des Grossesses extra-uterines et plus spScialemeut de leur traitement par la gas- trotomie, by Keller. 1S72. 318 ECTOPIC GESTATION. There is a specimen in St. Thomas's Museum, for Avhich I am indebted to Mr. R. W. Watkins, of Towcester. The foetus had been retained for forty-three years. It is an admirable specimen of " Lith<>p;edion," or conversion of the foetus into stone. {Obstet. Trans., vol. viii.) But this conversion of the foetus into a harmless mass must be regarded as a rare and fortunate accident. Various circumstances may arise to disturb the tranquillity of the sac, light up inflammation, and bring about dangerous, even fatal changes. A not uncommon circumstance thus acting, is a subsequent uterine pregnancy. The enlarged uterus may press upon the foetal sac, and thus mischief may arise even during preg- nancy. But the period of labor is especially perilous. During the ex- pulsion of the uterine child, the extra-uterine sac is exposed to damage. The sac may be fixed low down near the pelvic brim, and be a direct obstacle to labor. Accordingly, the histories of many cases show, that a supervening uterine labor has kindled the dormant mischief, and caused death. Cases are, hoAvever, knoAvn, in which women, carrying an extra- uterine foetus, have gone through a second and even several labors. They rarely escape in the long run. The danger is so great that it ought to influence our course of action. I have stated my opinion that rupture of a tubal gestation-sac is not necessarily fatal. The blood effused may fall into the retro-uterine pouch, become segregated there, Avhilst the remains of the sac, Avith or Avithout the embryo, may be shut off from the general peritoneal cavity by plastic effusions, and shrivel up. This view is confirmed by a remark- able case published in the Obstetrical Transactions, 1864, by Dr. Hay- don, the specimen being reported upon by Drs. Tyler Smith and Braxton Hicks. A young Avoman became pregnant, and was supposed to have aborted, but no foetus was seen. She Avas at the time dangerously ill, and not expected to live. Four or five years later she again incurred the risk of pregnancy, and six months afterwards died under symptoms of internal abdominal rupture. A gestation-sac in the right tube had burst, and a foetus of three months' development had escaped ; and appended to the edge of the rent was a small irregular solid mass, which proved to be a small foetus packed very tightly within a membrane. The conclu- sion draAvn was that the patient had had two distinct tubal gestations; that the first ended in rupture and isolation Avith shrinking of the embryo ; that the second, occurring some years afterwards, ended by fatal rupture of the sac six months after conception, the embryo having died three months before the rupture. Diagnosis of Abdominal Gestation from Ovarian Tumor and Normal Gestation.—The recognition of freely fluctuating ovarian tumors is gen- erally easy; but difficult Avhen the tumor is for the most part solid. Ovarian tumors are occasionally irregular in shape, and present hard projections which, if the mind is occupied Avith the idea of pregnancy, are readily mistaken for foetal limbs. After the utmost pains have been ex- pended in order to arrive at a conclusion, an exploratory incision may offer the only satisfactory information. As to the diagnosis of one form of extra-uterine gestation from another, Scanzoni declares that this is impossible during life. This must be taken Avith some qualification. The abdominal form at least may commonly be ABDOMINAL GESTATION. 319 distinguished from the tubal by its greater development, by its longer history, and by its terminations. The abdomen is generally less tense than in normal gestation; it is expanded transversely ; the umbilicus is often strongly draAvn in. If the foetus is living its movements may be felt more distinctly, and are often more violent than in ordinary gestation. The placental "souffle is said to be rarely heard. But Parry relates a case in Avhich this sound Avas heard Avith unusual intensity by himself and Drs. Duer, Ellerslie Wallace, and Goodell, of Philadelphia.1 The os uteri may feel like that of the pregnant uterus, the cervix being open. The body of the uterus is likely to be deflected to one side, and possibly fixed by adhesions. This fixing of the uterus, infinitely rare in uterine gestation, would raise a strong presumption in favor of extra-uterine gestation. In almost all these cases the uterus is elongated. This elongation and the direction imparted to the organ will be defined by the sound, if the circumstances seem to justify the use of this instrument. Or the sound in the bladder may aid in defining the position and size of the uterus. When the foetus is dead, the abdomen sinks ; the breasts fall; the uterus resumes its ordinary state, remaining, hoAvever, someAvhat above its normal length. The history will help. The subject will have been conscious of being pregnant. There will, probably, have been indications of peritonitis. Usually the liquor amnii is absorbed. But occasionally, as in a case related by Hutchinson,2 and in one Avhich I saw Avith Dr. Roper, fluid accumulates. If there is fluid enough in the cyst to permit of mobility of the foetus, the foetus may be felt to gravitate on putting the patient into the knee-elboAv posture. The question o f treatment has to be discussed under four different aspects. 1st. Lender the condition of early rupture, laparotomy might, as in the case of tubal gestation, be resorted to with a view to stopping the hemor- rhage. Yelpeau, Duparcque, Kiwisch advised it. Koeberle says he would not hesitate to do it. 2d. When the stage of danger of rupture has passed ; that is, after the fourth month. 3d. When labor supervenes at term. 4th. When labor has passed over and the child is dead. 2. What is to be done during the life of the child ? Shall Ave Avait, pursuing simply an expectant course, or shall Ave take means to kill the child, so as to stop the developmental stimulus, trusting to the reduction of the sac, to isolation from the general system, and atrophy ? or shall Ave resort to abdominal section, or other sure Avay of opening the foetal cyst so as to extract the child ? The decision is extremely difficult. During the developmental stimulus, the sac and surrounding structures are full of blood. To make incisions into them at this time, or even to puncture them is attended with serious danger from hemorrhage. If the opportunity of tapping the sac at an early date has gone by, I think it 1 Extra-uterine Pregnancy, its Causes, &c. By John S. Parry, M.D. Philadelphia, ]S7*>. This work should be consulted for much valuable information and judicious discussion. 8 Lancet, lb73. 320 ECTOPIC GESTATION. will be better not to disturb the sac until the full term of pregnancy has arrived, Avhen labor-effort is present, or when Ave know the child is dead. In one case1 Dr. B. Hicks, having felt a foetus of about three and a-half months in a cyst betAveen the rectum and the vagina, tried to destroy it by passing a strong galvanic current through it. Although the fcetal movements ceased during the administration, the embryo survived. A month later Dr. Hicks passed a small trocar into it. On the fourth day the patient died under symptoms of internal hemorrhage. Two pints of fluid blood were found in the peritoneum. Duchenne's plan of giving a shock from a Leyden jar might have ansAvered better. 3. What is to be done when the natural term of gestation arrives, the child being alive ? New dangers iioav arise. The cyst may burst. There is reneAved danger of hemorrhage, and of peritonitis. And, not seldom, accidents follow quickly on the death of the child. The cyst has on several occasions burst during the early days folloAving false labor, and acute peritonitis has proved fatal. To obviate these dangers, Levret advised laparotomy. So did Gardien, saying the placenta might be left. Velpeau and Kiwisch also advised it. Keller, who represents the opinions of Koeberle", is in favor of the proceeding. He cites nine cases in Avhich this, the primary operation, Avas performed, seven children and four mothers being saved. He narrates eight other cases, in which the operation might have been performed Avith advantage, the opportunity being lost. It must, hoAvever, be remembered that in a large proportion of cases the labor subsides, the dead child is tolerated, and for a time at least the mother goes on without serious distress. It is true another phase of danger succeeds, but the period for this may be remote. Looking first to the mother's safety, I think we must decide that this is best attained by not resorting to any operation to remove the child. The rule of action may be expressed as follows: If the labor-symptoms subside without sign of grave injury or hemorrhage, do not interfere. If, on the other hand, there arise evidence of severe injury, causing shock, peritonitis, or exhaustion, open the abdomen and remove the foetus. A Aveighty objection against opening the sac to remove the child whilst alive or recently dead, rests on the uncertainty as to the nature of the sac. In some abdominal cases it can hardly be said that a true sac with de- fined walls exists ; the placenta may adhere directly to the back of the uterus, to the surface of the intestines, even partly to the kidney, or as in a case of Koeberle, to the anterior abdominal wall, so that it Avas di- vided in the incision necessarily made to open the cyst. It may be almost impossible to cut down upon the foetus without disturbing attach- ments to such an extent as to produce hemorrhage that Avould probably be fatal. The case differs essentially from that of the Caesarian section. In laparotomy for extra-uterine gestation none of the favorable conditions proper to the Caesarian section are present. The placenta is almost ahvays much spread out, and sometimes very adherent. Moreover, if the extrac- tion of the placenta were possible, would it be prudent to effect it ? The placental insertion is not endowed Avith contractility as in uterine gestation; ' Obstetrical Transactions, 1866. ABDOMINAL GESTATION. 321 the maternal sinuses will remain gaping, and hemorrhage will be great. This objection to laparotomy whilst the child is living, loses some of its force if the attachments of the placenta are religiously respected, as the greater number of operators have understood the necessity for doing. The elimination of the placenta is then effected slowdy, and the maternal vessels have time to contract and to become obliterated. The most serious dangers of laparotomy performed at term are those which the elimination of the after-birth may provoke, that is to say, sec- ondary hemorrhage, peritonitis, and septicemia. But are these as great and real as they appear at first sight? In the first place the peritoneum is not always opened; the cyst has contracted adhesions Avith the abdo- minal walls. If an expectant plan be followed, if opium and perfect rest be employed, the vascularity of the sac and the organs connected with it gradually diminishes, menstruation returns, a degree of contraction takes place, and after a time probably further adhesions tend to complete the isolation. Still the patient's life may be said to be at the mercy of accidents, of which Ave may have no sufficient Avarning. The cyst may still rupture, or fatal peritonitis may ensue. If uterine pregnancy super- vene, the situation may quickly become critical. 4. If it be decided not to operate during labor, what is the alternative '( Shall Ave operate soon after the child's death? If the mother is suffer- ing, exhausted, in great pain, and adhesions be diagnosed, it may be Avise to operate within a few days. The placenta soon ceases to be a source of much danger. Its circulation has ceased. The blood coagulates in its villosities as Avas observed by Koeberle. If Ave decide to Avait, the patient should be kept under vigilant obser- vation. We should be ready to act the moment any sign of rupture or shock occurs. When an eliminative process begins, the propriety of in- terfering is clear, especially if irritative fever set in. The seat for ope- rative measures will commonly be indicated by the seat of the eliminative molimen. If there be pelvic distress, such as obstruction or irritation of the rectum, crowding the uterus forwards upon the bladder, causing reten- tion of urine, Avith or without local inflammation, and if Ave can detect parts of the foetus or a prominent fluctuating tumor between the rectum and the vagina, this is the place to select. An opening may be made first Avith a large trocar, and any fluid contents of the sac be allowed to drain off. A sound, or the finger introduced through the opening, may detect the foetus or bones. Opportunity may first be afforded for the spontaneous evacuation of the foetus piecemeal. If this does not proceed satisfactorily, no great time should be lost before enlarging the opening with a bistoury or by cautery-knife; and, if feasible, of extracting the foetal parts by finger or forceps. If the effort be directed to the abdominal Avail, the usual signs of abscess mark the point selected. The most common places are the neighborhood of the umbilicus, one or other flank about midway between the umbilicus and the anterior superior spinous process of the ilium, or a groin. In some cases a perforation may have taken place into the bowel or vagina, and there may also be eliminative effort towards the abdomen. The commu- nication with the bowel may be at a point quite out of reach of examina- tion by the rectum. In such cases the indication is to operate through 21 322 ECTOPIC GESTATION*. the abdominal wall. It is not constant that an inflammatory process takes place betAveen the sac and the abdominal Avail. But there is almost uni- versally increase of prominence at some part of the abdomen. If air get into the sac from the abdomen, and I suspect sometimes Avithout, decom- position proceeds rapidly, putrefactive gases distend the tumor, suppura- tion proceeds ; and Ave then get resonance over the projecting part of the tumor, and fluctuation at other parts. Probably pus may be discharged by the boAvel. With these local symptoms there will be hectic marked by rigors, SAveats, diarrhoea, perhaps vomiting, a quick Aveak pulse. When this concourse of symptoms is found, there can be no doubt as to the expe- diency of trying to relieve the patient. Extraction of the foetus and giv- ing issue to the offensive contents of the sac may save her life. There are many instances Avhere this course has been successfully pursued. Mr. Hutchinson1 is of opinion that Avhat may be called the primary operation by abdominal section should not be performed, but that the secondary abdominal section, i. e., at a time remote from the death of the foetus, Avhen inflammation of the sac has occurred, is strongly indicated. Campbell, who collected eighty-five cases of extra-uterine gestation, shoAved that sixty-tAvo recovered, Avhilst tAventy-three died as a direct consequence of the abnormal pregnancy. Of the sixty-two in Avhich re- covery took place, in tAventy-one the foetus remained quiescent through life for periods varying from four to fifty-six years, and in the rest its removal had been effected by ulceration. In a not inconsiderable num- ber of the latter, the natural processes had been materially assisted by the surgeon, as by extracting bones, enlarging the opening, and so forth. At the same time it does not seem desirable absolutely to condemn the primary operation; still less the operation at a time remote from the death of the foetus, even Avhen no inflammatory or eliminative effort has presented itself. I do not think the risk of danger from subsequent uterine pregnancy is sufficiently weighed. At all events the subject of an extra-uterine gestation should be emphatically cautioned not to incur the risk of another pregnancy. In the event of this complication occur- ring, the case should be treated on the same principles as those laid down when discussing the treatment of ovarian tumors complicated Avith preg- nancy. Very eminent men have advised the primary operation. Thus Levret. Gardien, Velpeau, and KiAvisch urged it, and that at a time Avhen abdom- inal surgery Avas imperfectly understood, when its dangers Avere really greater than iioav, and when they Avere thought to be even greater still. In recent times, Koeberle, whose authority is especially to be valued on account of his great experience and success in ovariotomy and in lapa- ratomy for extra-uterine gestation, pronounces himself decidedly in favor of the proceeding. Keller, after carefully Aveighing the arguments, for and against, decides in favor. He calls to mind that dangerous accidents may ensue quickly upon the child's death ; that the cyst has on several occasions burst during the early days of false labor; and that hemor- rhage and peritonitis may quickly prove fatal. On the other hand, it must, I think, be admitted that the risks attend- 1 Medical Times and Gazette, 1860. LAPAROTOMY. o o o O-O ing the primary operation are greater than those attending the secondary operation. Whilst the child is alive, the cyst and placenta are in the full vigor of vascular communication; the cyst has probably no contrac- tile property ; the placenta is likely to be Avidely diffused, its attachments projecting amongst intestines, perhaps deep in the pelvis ; or it may, as occurred in a case operated upon by Koeberle, grow to the anterior Avail of the abdomen, so that it must necessarily be cut through by the in- cision made to open the cyst. The cyst itself has probably not formed extensive adhesions to the abdominal wall, so that incision will be likely to open the peritoneum. There will thus be greater danger of secondary hemorrhage, of suppuration, of septicaemia, and of peritonitis. The question would be fairly stated as folloAvs: Are the dangers of the pri- mary operation greater than those of the secondary operation, plus the dangers immediately and soon folloAving the neglect to perform the pri- mary operation ? It is clear that the catastrophes, as rupture of the cyst, hemorrhage, and peritonitis attending false labor, must be taken into account, and added to the dangers of the secondary operation. It is also right to throAV into the same scale at least a certain proportion of the more remote dangers, as peritonitis, exhaustion from suppression, subsequent uterine pregnancy, and so on, to Avhich the Avoman is exposed. The latest Avriter on this subject, Dr. J. S. Parry, after a careful analysis of the fact, condemns the primary operation. He shoAvs that of 62 cases of abdominal section tabulated, 20 were performed at or before the end of the ninth month. Of these 14 died. Of 188 cases left to nature W died, or 17.35 per cent, less than if they had been sub- jected to laparotomy Avith the hope of saving the child. " In other Avords, nearly one out of every four mothers operated upon Avith the hope of saving her extra-uterine infant, dies, not from the terrible accident of which she is the Arictim, but from the knife of the surgeon, avIio is deluded into the idea that art is safer than nature." Add to this that the saving of the child, Avhich must according to the imperative law be held a secondary duty to that of saving the mother, is at best problematical. Twelve children out of the 20 only survived, and some of these only for a brief period. Thus a main argument for the primary operation breaks doAvn. The question may be summed up as folioavs : Absolute, universal truth does not rest with either side. Statistical eAidence must not be accepted with unlimited confidence. Cases may arise in which the pri- mary operation may be justified : others in Avhich it may be Aviser to tem- porize, to perform the secondary operation, or no operation at all. The second course will certainly apply to the majority of cases. The operation of laparotomy to remove an extra-uterine foetus.—The general preparations are the same as for the Caesarian section; but there are important modifications in the execution. The seat of the incision will generally be in the linea alba. It is, however, determined someAvhat by the point of greatest prominence of the tumor, or by the position of the foetus. A smaller incision is com- monly necessary than for the Caesarian section. The central point of pain and prominence is the most likely to be the centre of the adhesions formed betAveen the sac and the abdominal Avail. A longitudinal incision not exceeding tAvo inches in length in the first instance, is then carried 324 ECTOPIC GESTATION. carefully through the abdominal Avail, and a small opening is made in the sac. The finger is passed through this to feel for the limit of the adhe- sion, and guide the further extent and direction of the incision. This should be just large enough to permit the extraction of the foetus ; and it is better, if there be any difficulty in extracting the foetus Avhole, to bring it aAvay piecemeal, than to extend the opening much, lest Ave open the peritoneal cavity. If the cyst have not contracted adhesions with the abdominal Avail, care will be necessary to prevent the protrusion of intes- tines and the escape of blood and other offending matters into the peri- toneal ca\dty. To obviate this, the cyst, at the point Avhere it opens into the peritoneum, should be stitched to the edges of the abdominal wound. Sometimes there is no proper cyst. The foetus and placenta occupy a cavity made by displacement of the intestines. The extraction of the foetus requires some obstetric skill to do it without unnecessarily increas- ing the opening or disturbing the sac. I have seen a surgeon pull at an arm as soon as the foetus came in sight, and thus, not reflecting that he Avas really making a transverse presentation, fail to extract the foetus through a liberal opening. It was deli\rered with perfect ease by Dr. Ramsbotham, who seized the feet, performing the equivalent of version. The same consummate obstetrist, who had had considerable experience in cases of extra-uterine gestation, insisted upon the rule noAV generally adopted, of not removing the placenta, if it in any degree adhere. It is advisable to tie the funis, and let its end hang out of the Avound. If omen- tum interfere, the obtruding bit may be cut off and the vessels tied, or the bit may be removed by cautery-clamp. Refrain from all curiosity as to the attachment of the placenta and other matters, if it cannot be indulged without disturbing the parts or extending the opening. If the placenta do not come aAvay on gentle traction, leave it. In some cases it will already have melted doAvn, and its remains will come away Avith the pus and other discharges. In other cases it softens and breaks down Avithin a feAv clays after the operation, and will come aAvay in lumps or small debris. In other cases its attachments have yielded in a few days as the sac shrank, and it has come aAvay entire. Marked improvement commonly folloAvs the discharge of the placenta. Where attempts have been made to remove the placenta or the cyst, the result has generally been disastrous, and that, whether the case Avere primary or secondary, whether the child Avere alive or dead. Mr. Clay, however, tells me that in a case in which he left the placenta, fatal hemorrhage ensued. The wound may be closed with two or three sutures, leaving a suffi- cient opening for the funis and ligatures, if any vessels had been tied. If discharge continues, the sac may be lightly washed out now and then with a solution of permanganate of potash or carbolic acid. In such a case, Avhen the sac adheres throughout the extent of the opening, the operation is, as Mr. Hutchinson remarks, scarcely more serious than opening an abscess. In the case of a uterine gestation complicating an extra-uterine qesta- tion, at the time of labor, attempt first should be made to push aside the extra-uterine sac so as to permit the uterine child to pass through the pelvis. Should this manoeuvre not be possible, we should not hesitate to INTERSTITIAL GESTATION. 325 remove the extra-uterine fetus by laparotomy, and thus to allow delivery of the uterine fetus per vias naturales. Primary opening of the sac by caustics.-—A case is related1 of a Avo- man Avho had carried an extra-uterine foetus ten months. Blachet opened into the sac by five applications of caustic. No blood was lost; and the fetus Avas extracted. The patient nearly lost her life from the bleeding which ensued on removing the placenta. INTERSTITIAL OR INTRAMURAL GESTATION, GESTATION IN ONE HORN OF A TAVO-HORNED UTERUS, AND GESTATION IN THE HORN OF A SINGLE- HORNED UTERUS. It is convenient to discuss these conditions together. They approach each other so nearly in locality and other characters, that they hardly admit of distinct clinical demonstration. The seat of these varieties, lying betAveen those of tubal gestation and uterine gestation, must also occasionally give rise to difficulty in discriminating them from the latter. I entertain little doubt that some cases of presumed " missed uterine laboY," a part of whose history is the subsequent discharge of foetal bones by the os uteri and vagina, Avere cases of interstitial gestation, or of gestation in one horn of a tAvo-horned uterus. Ulrich2 relates a case, which ma v admit of a double interpretation. The foetus died at five months; discharge of placenta in pieces took place by vagina four months later, and then bones came by the same passage. A year after this, all escape of bones by vagina having ceased, bones passed per anum. The patient died exhausted. The uterus Avas found adherent to intestine ; some bones were encapsuled in the wall of the intestine ; a direct communication ex- isted between uterus and intestine. The cavity of the uterus was empty. It was concluded that the pregnancy was uterine, and that the discharge of bones into the intestine was the result of a fistulous opening established from the uterus. The most unequivocal case of a dead foetus long re- tained in utero is one that came under my care. A lady was sent to me from India with a presumed uterine tumor. At the term of a reputed ordinary pregnancy, labor set in and passed off without result. A year after this, assisted" by Dr. Fancourt Barnes, I removed a foetus piece- meal and'placenta from the cavity of the uterus, by hand working in the cavity. The uterus sloAvly underwent involution, and the patient re- covered. . ..-,,, T • Ramsbotham prefers the term "parietal" to "interstitial. It is remarkable, that when gestation takes place in the uterine portion of the tube, the dilatation, as a rule, affects solely the space between the inner and outer openings. The reason, Kiwisch suggests, may lie in the circu- lar disposition of the muscular fibres around these openings. The sac enlarges most freely in an outward direction, and forms a prominence with a broad basis on the side of the body of the uterus. It is surrounded by the uterine substance, which at first undergoes an eccentric hyper- trophy, and later, as the sac grows rapidly, is stretched, thinned at its ' Gazette des H6pitaux, 1856. 2 Monatsschrift fur Geburtskunde, 1857. 326 ECTOPIC GESTATION. apex, and then bursts. Interstitial gestation may. says Rokitansky, in rare instances like tubal gestation, merge into abdominal gestation. As id gestation in a rudimentary horn, it is often impossible to trace an opening from the tube into the sac. This becomes obliterated on either side as the sac is developed. But a peculiar modification at times occurs. The uterine mouth of the pregnant portion of tube may be dilated, so that the sac expands into the uterine cavity,constituting tubo-uterine gi'stat ion ; or the tubal mouth dilating, the sac enlarges in the direction of the tube, con- stituting interstitial tubed gestation. The first variety may end in a normal labor, whilst the latter is likely to burst into the abdominal cavity. The illustration of tubo-uterine or interstitial gestation, Fig. 84, is taken from Dr. Poppel.1 A pluripara died suddenly under symptoms of ab- dominal collapse and internal bleeding. She had been unaware of her pregnancy. The uterus measured from fundus to os 18 centim., at its greatest width 13 centim. The right side of the fundus was more pro- tuberant than the left, and showed at its hinder part two rents, through Tubo uterine Gestation—(After Poppel). a, Cavity of uterus clothed with decidua. b, Broad liga- ment, c, Tubo-uterine sac which contained fcctus. d, d, Thicker part of walls of cyst, e, Placenta. (One-third size.) which were seen portions of placenta and a foetus. The uterus opened longitudinally along its fore aspect, showing tAvo cavities. The loAver one {a in the Fig.) was clothed Avith a thick decidua. This Avas the proper uterine cavity. The upper cavity ((>, Fniver- sity College, and 2643, Royal College of Surgeons. No. 226130 in Guy's Museum shoAvs "a fibrous tumor of the uterus. Dr. Oldham dilated the os (uteri) to get at the tumor. Whilst under treatment, the patient was seized with acute peritonitis, and died. An abscess in the left tube, in which the ovary Avas involved, had burst." The symptoms produced by dropsy of the tube resemble those arising from other enlargements of the tube or ovary up to a certain point. There is, says Simpson, an uneasy sense of Aveight in the side affected, and a feeling of pressure in the limb ; usually the limb is rendered more or less numb from the pressure of the tumor on the nerves passing through the pelvis, and this may even extend to lameness, as in pelvic cellulitis. In some cases the swelling acts chiefly on the boAvels, keeping them loaded. More rarely there is a certain degree of dysuria. Intercurrent at some period of the history, signs of local peritonitis will probably appear. Jtiagnosis.—Dilatation of the Fallopian tube may be diagnosed from small cystic enlargement of the ovary by the shape of the tumor, its posi- tion, and by its relation to the uterus. It is of essential importance to clear the way by emptying the bladder, and by determining the exact position of the uterus by the sound. A small cyst of the ovary gets behind, and a little to one side of the uterus, pushing the uterus forwards against the symphysis, producing probably irritation of the bladder or retention of urine ; there is only slight obliquity imparted to the uterus. The shape of the tumor is more or less spherical. It is felt better by the rectum than in the roof of the vagina. Fluid distension of the tube produces an elongated, contorted, cylindri- cal SAvelling. Its position is more forward than that of the ovary ; it does not, therefore, push the uterus forward, but pushes the fundus tOAvards the opposite side ; there is greater obliquity of the uterus. The swelling also may commonly be felt behind Poupart's ligament, and can be defined betAveen the hand outside and the finger in the vagina. Vaginal touch will enable the observer to detect the swelling on one side of the cervix uteri. Except in the case of tubal gestation, affections of the tube are com- monly symmetrical, that is, both tubes are alike distended. This condi- tion itself would be greatly diagnostic from ovarian disease, which is not nearly so often double, and very rarely, indeed, symmetrical; one ovary, where both are affected, being more advanced in disease than the other. When both tubes are involved, they will keep the uterus straight between them, and a cylindrical contorted roll will be felt on either side. Fig. 86 gives an ordinary form of the dropsical tube. It comes from a girl, aged nineteen. Both tubes are tortuous, and each forms an elon- gated and somewhat conical cyst. The dilatation begins about an inch and a half from the uterus, and gradually increases until it attains a diameter of an inch. The parietes are thinned in proportion to the dilata- tion. The fimbriated extremities have become adherent to the ovaries DROPSY OF TUBE. 337 and other parts, and thus have become closed. In the living subject these distended tubes Avould occupy the iliac fossae, lying nearly in a right line with the fundus uteri. Fig. 86. Dropsy of Fallopian Tube (R. B.). (St. Thomas's Museum, nat. size.) Another specimen in the same museum, No. FF. 55, shows each tube dilated into a globular cyst. The cyst on the right side was filled with bloody fluid, and some laminated coagula still remain adherent to its upper part. The other cyst is distended with white, fatty matter, con- tained in numerous cells. The tubes at a short distance from the uterus are completely closed. The uterus is healthy. The specimen was taken from a woman, aged twenty-one, of dissipated habits, who died of phthisis. . An incidental consequence of most morbid conditions of the * allopian tubes is sterility. There mav be mechanical obstruction to the passage of the ovum anil spermatozoa"; or, if the canal be pervious, the condition of the lining membrane or of the secretions in it may be destructive to the vitality°of the male and female elements. Another incidental con- sequence is the proneness to extra-uterine gestation. 22 33S DISEASES OF FALLOPIAN TUBES. The treatment of dropsical distension of the Fallopian tubes consists simply in puncturing the cysts through the vaginal roof. If a tense fluctuating swelling be found in this region attended by local distress, there ought I think to be no hesitation in tapping it by the aspirator- trocar. This instrument combines in a high degree the merits of the sound and speculum, namely, in being diagnostic and curative. The range of liability to error in' diagnosis lies between dropsy of the tube, cysts of the broad ligament, cysts of the ovary, cyst containing an extra- uterine gestation. Now, in all these cases, the same indication exists to puncture of the cyst, so that absolute precision of differential diagnosis is not imperative. The diagnosis may become clearer after the tapping. Thus if the cyst be tubal, or in the broad ligament, it is not likely to fill; there is reasonable prospect of complete cure. But if the cyst be ovarian, it is not unlikely to fill again. There are many points of special interest in relation to tubal disten- sion. We knoAv the danger of rupture, perforation, or overflow. We knoAv that this danger is averted or greatly lessened, if the contents of the tube can be evacuated by the natural route into the uterus. (Jan nothing be done to turn the discharges into this, their natural drain ? To accomplish this object, Dr. Tyler Smith proposed uFallopian catheteriza- tion." He demonstrated the practicability of passing a fine Avhalebone probe into the tube. The proposition Avhen originally made, and since, encountered considerable criticism ; it Avas said to be rash, dangerous, and impossible.of execution. The real objection is that it is new and difficult. I think the operation will be established in spite of the ridicule and the arguments aimed against it, and that the difficulties of diagnosing the cases proper for its application, as Avell as of carrying it into execution, Avill be greatly lessened. Many of the reasons Avhich are recognized as justifying catheterization of the uterus, apply to catheterization of the tubes. The obstacle to the omvard discharge of mucus or pus from the tube commonly exists in the uterine portion, which is naturally contracted, and may be occluded by a plug of clotted blood or condensed mucus or pus. A very slight force Avould remove this impediment, and the passage of a flexible probe through this part Avould not be difficult. Whether it Avould be easy or feasible to pass a probe to any considerable distance along the canal, folloAving its sinuosities, is a matter for experience to determine. It will, I think, rarely be necessary. I can, indeed, imagine that a tubal gestation-sac might be ruptured in this Avay, and the gesta- tion so brought to an end. But the tapping of the sac may be better accomplished through the roof of the vagina. It deserves to be borne in mind that the secret of preventing many of the tubal diseases, of curing some and of averting the chief danger of others, consists in securing patency of the uterine ends. Fibroid tumors, or myomas, similar in character to the tumors so named of the uterus, may occur in the Fallopian tubes. Baillie describes k- a hard tumor growing from a Fallopian tube, Avhich exhibited precisely the same appearances as the hard tubercle (fibroid) of the uterus." They are developed out of the muscular coat. They attain a considerable size. Professor Simpson describes one as large as a child's head; but TUMORS OF TUBES. 339 probably this was of exceptional size. They are rare, or, at least, have been rarely identified as distinct from uterine fibroids or solid ovarian tumors. Arising on one side of the uterus, that is, in a situation very close to that of ovarian tumors, and being at first movable, the difficulty of discrimination must be almost insurmountable during life. And even after death there is room for doubt, for a fibroid tumor, taking its origin in the external strata of the uterine Avail, may be gradually cast off so completely that the pedicle even becomes atrophied and no longer traceable : the detached tumor then may lie between the folds of the broad ligament in such close proximity Avith the tube that appearances may support the idea that this Avas its true origin. They Avould differ from ovarian tumors in their progression. Comparatively inert, they annoy chiefly by mechanical pressure ; they may get jammed in the pelvis, and displace the uterus, and press upon bladder or rectum. If of large size, and situated above the pelvic brim, their bulk and Aveight Avould cause inconvenience, perhaps peritonitis. In the event of symp- toms severe enough to indicate the expediency of removing the tumors, the operation as for ovariotomy might be performed, Avith a fair prospect of success. It is also possible that small ones dipping low in the pelvis by the side of the uterus might be removed by the vagina. Tubercle most frequently occurs in association Avith tuberculous deposit in the uterine cavity ; but it may occur in the tubes alone. Such a case is preserved in St. Thomas's Hospital Museum. The tube is there filled with a cheesy, soft mass ; the tube is SAvollen, distended, resembling in outAvard form the distension from fluids. Generally both tubes are symmetrically affected. Rokitansky says tubal tuberculosis generally occurs as a primitive affection, and is aftenvards complicated Avith tubercle of the abdominal glands. It is also associated with tubercle of the lungs and mucous mem- brane of the intestinal canal. It appears sometimes in childhood, sometimes in the age of decrepitude, but usually in the period of puberty. Often it becomes developed in consequence of childbed. Rarely, the tuberculous mass goes into calcifi- cation. In St. George's Museum are two specimens of " scrofulous disease" affecting the mucous lining of the uterus and tubes. In one, both ovaries were also affected, "containing the remnants of a semi-fluid tubercular matter :" in the other, one ovary Avas converted into an abscess containing scrofulous pus. Both subjects had tuberculosis of other organs as well. Tavo specimens in Guy's Museum (Nos. 2251 and 225110) shoAv tuberculous matter in the tubes of children. One of these died of stru- mous inflammation of the brain. There Avere also tubercles in the lung. But it may happen that, although tubercle in the Fallopian tubes is generally of secondary importance as a cause of death, the function of the tube" being of little comparative moment, the disease in this part may be the immediate cause of death. Perforation of the tube may outstrip the fatal march of tubercle in the lung. Specimen No. 225140 in Guy's Museum exhibits the "tubes and ovaries inverted in adventitious tissue, forming part of a general tubercular peritonitis. The tubes were greatly 340 DISEASES OF BROAD LIGAMENTS. distended Avith thick white grumous matter. The subject, aged twenty- tAvo, died of phthisis and peritonitis. Carcinoma occurs as an extension of the same disease from the uterus or OA'aries. Khvisch saAv a case in Avhich the tube burst from distension of the Avails with cancerous tissue. THE BROAD LIGAMENTS. Apart from the puerperal imflammations Avhich are beyond the scope of this work, and the inflammations which arise in connection with uterine and ovarian disease Avhich are more particularly described as a part of the history of these diseases, and under the heads—Pelvic Peritonitis, Cellulitis, Perimetritis, Hematocele, the principal affections to arrest attention in this place are dropsy, cysts, fibrous tumors, and phlebolithes. Cancer, phlegmasia dolens, and diseases of lymphatics fall better within the history of uterine and ovarian diseases. Extra-ovarian cysts, or cysts of the broad ligament and of the Fallo- pian tube, are chiefly of tAvo kinds. One kind is a dilatation of the ter- minal bulb or vesicle of the tube (see Figs. 3, 0). In the form and size figured, they cannot be called pathological. They rarely exceed in size that of a pea or nut, but occasionally are found as large as an egg. They usually have thin Avails, are covered by peritoneum, and hang by a long slender pedicle. They may burst; but the small quantity and innocent nature of their contents cause no great irritation in the peritoneal cavity. The other variety of cyst is found betAveen the folds of the broad liga- ment, at least in its original stages. It is a development of one of the tubules of the parovarium (see Fig. 3). These cysts may attain sizes varying from that of a pea to that of a man's head; but the latter size is probably rare. The walls may become thickened by development of fibrous tissue; but still they remain comparatively thin. They differ from the greater number of ovarian tumors in their sphericity, and in fluc- tuation being equal in all directions. As these cysts are strictly simple and innocent, and not likely to fill again if emptied, there is no sufficient reason, supposing diagnosis be clear or even presumptive, for subjecting the sufferer to the grave risk of an operation for extirpation, or even to that of injecting tincture of iodine. Simple tapping is often enough for their cure. There can hardly be a doubt that some cases of presumed cure of ovarian cysts by injections of iodine or by vaginal tapping Avere really cysts of the broad ligament. At least I have no doubt that such was the true nature of some cases Avhich have occurred in my OAvn prac- tice. The possibility of a cystic dropsy being of this kind dictates the expediency of executing a preliminary tapping in cases where the fluctua- tion is very free and universal. The fluid draAvn off may determine the diagnosis. Dr. Bantock examined the contents of a cyst of this kind. The specific gravity was 1003.6. It Avas a Avatery, slightly albuminous fluid {Obstet. Trans., 1874). When smaller than an orange they may be retained in Douglas's pouch. Puncture by an aspirator-needle through the vaginal roof may be enough to cure them. CYSTS OF BROAD LIGAMENTS. 341 The features of a cyst of this kind, Avhen greatly enlarged, are illus- trated in a case operated upon by Mr. Wells. "A lady, aged twenty, had observed an increase of size for a year. The abdomen was occupied with a fluctuating tumor Avhich extended upwards tAvo or three inches above the umbilicus. The uterus Avas far backAvards, a little to the left, and freely movable ; the right side of the vagina Avas depressed, giving rise to the impression that the connection Avas Avith the right side of the uterus and rather close. The disease gave so little uneasiness that all in- terference Avas postponed for some months. In the mean time the increase had been rapid. The cyst Avas then removed, and the adjacent ovary along with it, as it felt hard and appeared larger and more corrugated than is usual in unmarried Avomen ; though from its being quite apart from the tumor, it would have been easy to remove the cyst and leave the ovary. The pedicle was not thicker than a finger. Another cyst, the size of a Avalnut, in the left broad ligament near the ovrary, Avas laid open and emptied. Dr. Wilson Fox reported the removed cyst as when dis- tended about tAvice the size of an adult head. The Fallopian tube flat- tened out is seen to course along its external surface. The fimbriie are, hoAvever, non-adherent and distinct. The ovary is found in a fold of the broad ligament distinct from the tumor, and presenting the natural appear- ance. It contains no cysts. The cyst itself has a smooth external wall. It is lined internally by a flattened polygonal epithelium. No villous or papillary growths can be discovered on its inner surface. This Avas of a delicate rose color. The vascularity of the cysts Avas not very great. No other cysts could be found in the broad ligament." The vessels in the broad ligaments are a favorite seat of phlebolithes, or stony transformation of blood-clots. The vessels, slenderly supported by the flaccid tissues through Avhich they run, liable to great variations of fulness and tension, and embraced betAveen layers of peritoneum ex- tremely liable to inflammation, are subject to dilatations and formation of thrombi. These vary in size from that of a pea to nearly that of a cherry. Undergoing hardening they may become calcareous. As in the case fig- ured in Carswell, the ensuing obliteration of the vessels may lead to atrophy of the uterus. Hematoceles, or blood-effusions, may form in the broad ligaments. These will be more conveniently discussed under the general head of Haematocele. 342 TERMINATIONS OF OVARIAN CYSTS. CHAP TEE X'V. NATURAL COURSE AXD TERMINATIONS OF OVARIAN TUMORS. The terminations of ovarian cystic tumors are various ; but the pro- gress is generally towards a fatal issue. This chapter on the history of ovarian tumors, by shoAving the dangers ahead, will give more accurate indications for treatment. 1. Ovarian cystic tumors tend to go on growing until the distension is too great to be borne. The cyst pressing in all directions, and not able to extend backwards or much into the pelvis, stretches the abdominal Avails in front, and the diaphragm above, driving the intestines backAvards and even encroaching upon the cavity of the chest. The circulation is impeded by the pressure upon the aorta and vena cava. The functions of the viscera, abdominal and thoracic, are impeded by pressure. The viscera undergo a degree of shrinking or atrophy. Nutrition, respira- tion, and circulation being imperfect, in the end exhaustion ensues. In cases of long standing, some amount of compensation is effected by dilatation of the superficial veins of the abdomen. Sometimes, but by no means commonly, relief is sought by serous effusion in the legs. More or less oedematous thickening of the integuments of the lower abdo- men, Avhere the overhanging of the tumor is greatest, is not infrequent. Probably the effusion into the cyst itself acts as an accommodating process. 2. Sometimes death occurs rapidly or suddenly from asphyxia, owing to the pressure upon the heart and lungs. Mr. R. F. Battye relates a case of this kind in a girl aged 13. {Obstet. Trans., vol. ii.) 3. As Bright says, some state of unexpected collapse, for which no reason can be assigned, takes place, and the patient sinks. I have seen several such instances. One occurred at St. Thomas's. A young wo- man was admitted with a large ovarian cyst which had formed rapidly. Tapping was contemplated, but before it was performed, death took place almost suddenly under symptoms of lung distress. It was conjectured that rupture of the cyst might have taken place ; but the cyst was found so universally adherent that there was no spot whence effusion could take place. The diaphragm Avas driven up so as to confine the heart and lungs within the narrowest space. The lower lobes of the lungs Avere so compressed that they presented a foliaceous appearance, resembling the atelectasis of neAv-born infants. I concluded that under the impetus of some excitement or exertion, the heart and lungs were suddenly taxed beyond their feeble powers of adaptation, and that thus asphyxia'was in- duced. In these cases of very large tumors there is not only encroach- ment upon the space naturally pertaining to the thoracic organs, but the chest Avails are nearly fixed. The proper respiratory movements are re- OBSTRUCTION OF RECTUM. 343 stricted, so that on any sudden impetus to the circulation or respiration, the balance is destroyed and asphyxia results. 4. The cyst being free from adhesion, and tolerably firm, may roll over on its axis. This may happen from the enlargement of the uterus tilting it over, or from over-exertion, Avhen one part of the tumor being more pressed upon than the opposite part, it rolls over. The effect of this axial twisting is to strangulate the pedicle ; the bloodvessels cannot return the blood from the tumor, so congestion and bursting of the ves- sels follow. Hemorrhage into the cyst, leading to sudden distension, produces shock and anaemia sufficient to cause death, without rupture of the cyst and hemorrhage into the peritoneum, Avhich may, hoAvever, also happen. Should the patient escape the more immediate danger of death from shock, hemorrhage, and peritonitis, the strangulation of the tumor is al- most sure to lead to gangrene. But when the strangulation takes place very gradually, or when the tumor is not very vascular, atrophy taking place slowly, and the pedicle being constantly stretched, complete separation has taken place, the tumor becoming loose ; or the tumor may shrink without being detached. The remains of tumors have thus been found in Douglas's pouch as hard, partly cartilaginous substances. I have related tAvo cases of this axial twisting in St. Thomas's Hospital Reports, 1870. In one case the rotation was caused by the growth of a gravid uterus ; gangrene had set in ; in the other there was no preg- nancy, and the rotation was in all probability caused by severe bodily exertion. Dr. St, John Edwards, of Malta, relates a case {Lancet, 1861). The subject had gone through one labor without mishap, not- withstanding the complication with a movable ovarian tumor; in a second pregnancy labor supervened at the seventh month, collapse and death ensued; the tumor was found twisted and strangulated. Knowsley Thornton1 relates a case similar to one of mine. The cyst rolled over three times on its axis under the rising of the gravid uterus. Gangrene set in. Ovariotomy was performed, but death ensued. Atlee refers to two cases of Dr. Van Buren, of New York, and to one of Dr. Crane. In the latter the twisting occurred during labor, leading to fatal peritonitis five days after labor. Dr. Malins relates {Lancet, 1877) a case in which rotation followed on tapping. Dr. Kidd {Dub. Quart. Journal, 1870) relates one in a non-pregnant girl. Rokitansky {Ally. Wiener. Med. Wochenschr.,1810) describes many dissections which show: a. Atrophy and twisting of a Fallopian tube, through the dragging of its ovary, as by an ovarian fatty cvst or serous cyst, which in its growth may pull, stretch, and rend the attached tube. b. Tearing asunder of a tube through the dragging of pseudo-membranous adhesions, as through adhe- sion of the right tube to the small intestines, c. Tearing asunder of a tube or corresponding ovary, as when the tube and ovary adhere in the recto-va<-inal space ; the tearing being caused by the uterus enlarging m repeated pregnancies, d. Axial twisting. Professor Turner also has contributed a valuable memoir " On Separation and Transplantation of ' Pathological Transactions, 1876. 344 TERMINATIONS OF OVARIAN CYSTS. the Ovary due to Atrophy of the Broad Ligament and Fallopian Tube." {Edin. Med. and Surg. Journal, 1861.) Klob also illustrates these events. 5. It is probable that some cystoids of the ovary undergo a kind of atrophic involution, Avhich may be regarded as a spontaneous cure. In old Avomen the ovaries are sometimes found as agglomerates of smaller or larger degenerated cysts, seated in an extremely hard thick stroma. On their inner surface are seen papillary outgroAvths, likeAvisc converted into hard knots. Such formation, says Rokitansky, must be regarded as involved shrunken cystoids. 6. Small tumors getting into Douglas's space may push the uterus fonvard upon the bladder so as even to cause ret coition of urine. In the case of large tumors, the neck of the bladder is sometimes pulled up along with the uterus, so that the control of the sphincter is impaired. Hence enuresis. This trouble is also created at times by the pressure of a large tumor downwards upon the bladder. Bladder distress is even more likely to arise Avhen the tumor is the centre of a mass of adhesions impeding the mobility of the pelvic organs. Cystitis and urinaemia may even be induced, and thus cause death. Or the tumor may so press upon the kidneys and ureters, as in a case told by Wells, that the kidneys may be almost obliterated, and thus produce urineemia. 7. In like manner ovarian tumors may encroach upon the rectum, causing at times obstruction to the passage of fveces. A fatal case of obstruction of the rectum by an enlarged ovary is related by Dr. Parker {Ed. Med. Journ., 1863). 8. Another mode in Avhich ovarian tumor may cause rapid death is by ileus. Vomiting, perhaps of stercoraceous matter, and the other symp- toms of intestinal obstruction, come on and carry off the patient. On examination after death no adhesions or other obvious cause of constric- tion of the intestinal canal are found. It can only be conjectured that, OAving to the extremely small space into which the intestines have been squeezed, they get thrown into angular contortions which, Avhen any un- usual pressure from without, or distension of a part by flatus or other- wise supervenes, the peristaltic action is disordered, and there occurs a virtual obstruction. In one case Rokitansky found a fatal constriction of the intestines caused by the rotations of the tumor, a dermoid one. 9. In other cases adhesions to the intestines have been found, Avhich Avere sufficient to account for the obstruction. 10. The disappearance of the disease by spontaneous resorption of the fluid and shrivelling of the cyst, is not proved. The lining membrane of the cyst has the property of throAving fluid into the cyst Avith extreme facility, but not in the converse direction. So long as the fluid is con- fined in the ovarian cyst it is beyond the influence of absorption. So much at least is true as far as sure clinical experience proves. Cases do, how- ever, occur in which considerable accumulations, believed to be in ovarian cysts, disappear more or less completely, either spontaneously or under the use of diuretic and other medicines. There was a Avoman in St. Thomas's Hospital under the care of Dr. Gervis and myself whose his- tory gave support to this hypothesis. She then carried a very laro-e ovarian cyst seemingly single ; two years before, she said, she had one BURSTING OF CYST. 345 nearly as large, and the SAvelling disappeared under medicines, water passing freely by the boAvels and bladder. I cannot help suspecting that in this and similar cases, the fluid escaped first into the peritoneal cavity by rupture or a small perforation, or else by a fistulous channel directly into the boAvel. 11. Bursting of the tumor and resorption of fluid from peritoneum.— When the tumor bursts with escape of contents into the peritoneum, the fluid, if limpid, may be taken up into the circulation and discharged rapidly by the excreting organs. Numerous cases are on record of the spontaneous or accidental bursting of ovarian cysts, folloAved by cure in this way. If the walls are thin, and the tumor tense, under gradual or sudden pressure or Adolence rupture may take place. The tumor in such cases is probably simple. In this Avay cysts have burst under the rapidly accelerated pressure caused by the simultaneous growth of the pregnant uterus, under sudden exertion, under direct violence as of a blow, or under concussion as from a fall. A remarkable case occurred in the temporary St. Thomas's Hos- pital. A Avoman under my care Avas descending in the lift to take the air in the grounds, Avhen the machinery gave Avay and the lift came doAvn the last few feet Avith a run. The concussion burst the tumor; large quantities of Avatery fluid Avere discharged during the next feAv days by the bladder, and she completely recovered, the tumor not returning. The recovery, however, is not ahvays complete. After bursting and absorption of the fluid, the tumor may form again, just as Ave see after the operation of tapping. Thus W. F. Soltau relates a case {Medical Times and Gazette, 1862) in Avhich the cyst burst three times into the peritoneum; the fluid was voided by diuresis. She was also tapped thirty-seven times. She died after the bursting. Disse relates a case {Monatsschr.fiir Geburtsk., 1860) in Avhich the patient recovered from one bursting, the fluid being discharged by the kidneys. After a feAv years the tumor burst again. The second rupture of the cyst Avas veri- fied by autopsy. Obstinate constipation folloAved the accident, then copi- ous watery discharge by rectum; in tAvo days eighteen quarts Avere measured. When this ceased, profuse discharge of urine occurred; during five days eight quarts Avere passed daily. She sank exhausted. Huguier expressed a doubt Avhether cases of this kind were really bursting of an ovarian tumor, and suggested that they Ave re more likely examples of simple cysts of inflammatory origin attached to the uterus. I think Ave must accept this explanation for some of the cases of pre- sumed cure of ovarian cysts folloAving rupture or simple puncture. But certainly the possibility of some ovarian cysts being so cured seems free from doubt. In the case at St. Thomas's, above referred to as having been caused by the shock of a fall, the ovarian nature of the cyst had been verified by repeated examinations. And the possibility of an ova- rian cyst healing after rupture is proved by two specimens in Guy's Hos- pital Museum, of ovarian cysts, Avhich had burst spontaneously, the rent cicatrizing. The first specimen, No. 224604, is "a large ovarian cyst, which had burst spontaneously, and had become repaired." Within it an inverted portion of the old Avail is seen, and a reduplication of the cyst is indistinctly seen in the section. The case Avas that of Ann B., 346 TERMINATIONS OF OVARIAN CYSTS. aged 46, under Dr. Addison, in 1836. When first seen, in March, 1S:,,4, she stated that she had had childen at an early age, and had menstruated regularly since; that five years before she observed a swelling in the right iliac fossa, that the tumor increased, although her health remained good until ten days ago, Avhen she fell, and struck her abdomen. She Avas seized with violent pain, sickness, and fainting, and then perceived that the SAvelling, Avhich Avas before local, had diffused itself over the abdomen. On admission she Avas suffering from acute peritonitis. She soon perfectly recovered, and again entered into domestic service in 1 <5, only a small tumor in the left iliac region being distinguishable. She died in August, 1836, and the sac Avas removed. There Avere adhesions in various parts of the abdomen; the ovarian cyst occupied the pelvis, and Avas closely connected to surrounding parts. It contained about two quarts of a reddish thick fluid, and the lining membrane Avas covered with thick layers of albuminous matter. Upon the front of the tumor was a band, formed by the folding of the Avails upon themselves as the cavity shrank. The walls Avere so firmly united that the reduplication Avas only clearly seen Avhen a section Avas made. The rupture had been about eight inches in length. The edges of the rent had not united, but the inferior lip Avas found floating free Avithin the cavity, whilst the supe- rior lip of the rent was glued over the opening to the cyst below. The other specimen, No. 223H84, is equally decisive. It is " a uterus and a portion of a large cyst from the left ovary. It is of a compound serous kind, and had burst spontaneously during the life of the patient, from which accident she recovered, and survived several months. The cicatrix appears in the portion of cyst preserved. The patient died from malignant disease of the stomach." A third specimen in the same mu- seum, No. 223156, affords evidence to the same point. In St. BartholomeAv's Museum is an illustrative specimen (No. 31.31). It " is a portion of a cyst that arose from the left ovary. It communi- cates with the ilium by a small aperture, between four and five inches above the ileo-ccecal valve. Some weeks before death, after the discharge of a large quantity of fluid per anum, the abdominal tumor had diminished in size, and the dulness to percussion over its region had been replaced by tympanitic resonance." These cases place the possibility of cure of ovarian cystic disease, by rupture or perforation, beyond dispute. In another class of cases, perhaps more frequent, the patient dies quickly, killed by the shock ; or if she rallies from shock, peritonitis sets in, which is most likely to prove fatal. This danger appears to depend in great measure upon the qualities of the fluid effused. If clear and watery the fluid itself may cause little irritation ; the peritoneum tolerates it Avell. If it act injuriously, it is probably chiefly because it is voided suddenly in large quantity, so as to disturb the balance of circulation greatly. It is the shock that is dangerous ; the fluid itself is harmless. But where the fluid is gelatinous or puriform it is clearly not favorable for absorption, and it may even possess acrid or irritating properties. Hence there is added to the simple shock, retention in the peritoneum of an irritating fluid. Peritonitis is inevitable ; and since the cysts which yield fluid of this nature are commonly multilocular and incurable bv OPENING OF CYSTS INTO BOAVEL. 347 simple tapping, the progress of the tumor is not stopped. If the patient survive the shock and peritonitis, the ovarian disease will pursue its natu- ral course notwithstanding. Mr. Spencer Wells relates a case {Medical Times and Gazette, 1S61) in which, after ovariotomy, the serum found in the peritoneum must have contained a very active animal poison. He himself suffered from absorption. Sometimes Avhen a cyst bursts, vessels in its Avails arc torn, and blood to a considerable extent may be effused into the peritoneum along Avith the ovarian fluid. This complication in- creases the danger of peritonitis, and adds that of anamiia. 12. Bleeding from the surf ace of the cyst or into its interior may take place Avithout rupture or twisting. In such an event death may be rapid under symptoms resembling those of rupture of an extra-uterine gestation cyst. The patient may bleed to death. In one case Mr. Wells says the blood escaped through the Fallopian tube and uterus from a large cyst in the ovary ; or the blood may collect in the recto-uterine pouch, Avhere it may be sequestrated as a haematocele ; or it may remain diffused, and cause fatal peritonitis. 13. The cyst may contract adhesions with the bladder or bowel, and by bursting or ulcerative perforation into one of these viscera, its con- tents may be discharged. Communication thus established Avith the ex- terior is more favorable than rupture into the peritoneum. The bladder and the boAvel—the latter especially—are less liable to injury, and can, moreover, readily get rid of the offending matter. In this way even fluid of tenacious or gelatinous nature may be discharged. Thus Ulrich {Monatsch.f. Geburtsk.,1859) relates a case in which a large quantity of thick fatty matter Avas emptied by the bladder; it Avas ascertained to be pure elaine ; several quarts Avere passed. For a long time the urine contained pus and fatty matter. The patient recovered, some remains of tumor being still felt. The tumor Avas probably dermoid. The London museums contain several interesting examples of ovarian tumors opening into the holloAV viscera. At Guy's is a specimen (No. 222835) from a woman, aged 36, under Dr. Gull, in 1861, for Bright's disease. At the same time there existed in the abdomen a remarkable tumor, being a cyst containing fluid and air. On striking it, a loud splash was heard, and at the same time it was resonant on percussion. After death, on opening the tumor, a foetid gas escaped, and at its lower part was a turbid purulent fluid. The intestines were adherent to it, and at the bottom was an opening communicating with the upper part of the rectum. Dr. Murchison {Path. Trans, vol. xviii.) relates the following: E. C, aged 37,for eight years had been liable to general dropsy and attacks of erysipelas of the face. About eighteen months before admission to Mid- dlesex Hospital she first noticed a swelling in the lower part of the ab- domen. On admission the abdomen was distended by a tumor rising above the pubes. The urine contained albumen. The patient began to suffer from diarrhoea ; the stools contained blood. This continued for six- teen days, during which time there was no diminution in the size of the abdomen. Then the stools contained a quantity of pus, which Avent on for three davs, and in a week all signs of the tumor had disappeared. The patient sank two or three days later. The liver, spleen, and kidneys 348 TERMINATIONS OF OVARIAN CYSTS. were very large. A collapsed cyst, the size of a cocoanut, Avas seen in the situation of the uterus. This'was a cyst of the left ovary, Avhich had emptied itself by an opening the size of a fourpenny piece into the rectum four inches abo\re the anus. In St. Thomas's Museum is a specimen (FF. 45) of a faecal abscess communicating with an ovarian cyst. Perforation must be distinguished from bursting. Perforation is a gradual process, and is more likely to occur in the glandular cystomas than in the simple cysts. An opening may be effected direct into the peritoneum, or into a holloAV organ. The causes of perforation are: 1. A wearing-through of the cyst wall by partial pressure of the groAvths from within a capillary cystoma. They may then groAV on unhindered in the peritoneal space, and, sooner or later, cause fatal peritonitis (see Fig. 79). 2. Supjmration, a frequent cause of perforation. In this case the opening is seldom inside the peritoneum ; it mostly opens exter- nally or into a neighboring hollow organ. Dr. O. Spiegelberg relates some good illustrative cases {Arch. f. Gyudkologie, 1870). Dr. Bristowe described these perforations {Path. Trans., 1853, vol. v.), having several times seen perforations of ovarian tumors into the peritoneum, precisely resembling those betAveen the cysts themselves, and (vol. xii.) says it is extremely common. Adjoining cysts are constantly opening into one another; and cysts are almost as constantly rupturing into the abdominal cavity. In both cases the steps of the process are identi- cal : first, the outer surface of the Avail yields at isolated points, in con- sequence of the distension due to the accumulating fluid Avithin, and circular or oval depressions of various sizes are produced ; secondly, these enlarge in area, and deepen, and finally perforate ; thirdly, the contents of the cyst escape, the cysts collapse more or less, atrophy, and ultimately, in consequence of the groAvth of neAV cysts in their Avails, of the enlargement of neighboring cysts, and of their oavii shrinking, form irregular crescentic or sinuous folds. Most commonly these perforations are attended by adhesions which, uniting the cyst with a holloAV organ, form a substance through Avhich a fistulous tract is gradually made. In this Avay the abdominal cavity is protected. I believe that it is through the small perforations occurring that the frequent attacks of peritonitis are produced ; and that Ave may thus look upon the adhesions so commonly found, as the effect and evidence of a conservative process enacted to limit the mischief. No sooner does a minute perforation take place than the opening is glued up by plastic effusion. But sometimes adhesions do not form in time. Then the perforation alloAvs the contents of the cyst to escape into the peritoneal cavity, and the result may be quickly fatal. In St. Thomas's Museum (No. FF 32) is an example of spontaneous perforations in an ovarian cyst. The perforations allowed free commu- nications with the abdominal cavity; their edges were Avell-defined, and bevelled off at the expense of the outer edge. No. FF 33 is an example of the same kind. Occasionally adhesions form to the diaphragm, and the ulcerative pro- cess, continuing in an upAvard direction, the pleurae and lung may be attacked. ULCERATION OF CYSTS. 349 In the College of Surgeons is a specimen (No. 2623) consisting of a portion of diaphragm, with part of a large ovarian cyst firmly adherent to its peritoneal surface. On the inner surface of the cyst there are nu- merous smaller cysts and tumors connected with it, and with one another by pedicles and bands of false membrane. A portion of lung adheres to the corresponding pleural surface of the diaphragm. The cyst had been tapped several times, but could not be completely emptied, for it was sac- culated. It adhered firmly to most of the abdominal viscera. {From MSS. of Geo. Lang staff.) Sometimes the ulcerative process works from the intestines tOAvards the cyst. BristoAve {Patli. Trans, vol. xiv.) presented an example. There was extensive ulceration of the mucous membrane of the large intestine. The patient suffered from phthisis. The ovarian cyst had not opened into the bowel, but the intestine ulcerated and opened into the cyst. Fecal abscesses had first formed, one of Avhich had perforated the ovarian cyst. Ovarian cysts may also discharge through the Fallopian tubes. Rich- ard cites cases of cysts Avhich had involved a considerable portion of a tube, through which their contents could be forced into the uterus. The portion of tube implicated had become increased in length and thickness, and the folds of its mucous membrane Avere partly effaced. A distinct aperture betAveen cyst and tube Avas found. In these cases the aperture Avas no doubt effected by a gradual perforative process. Apart from bursting, if not from perforation, intercurrent attacks of peritonitis are common in the progress of ovarian tumors. Such an attack may prove fatal, but more commonly recovery takes place, leaving adhe- sions of tumors to the abdomen and viscera. 14. Inflammation in the interior of the cysts also not seldom occurs. It is of a Ioav kind, and suppuration is often the result. This process may be limited to one or more of the cysts, others retaining their pris- tine condition. There is reasonable presumption that suppuration has taken place inside a cyst, if symptoms of hectic or irritative fever set in after acute pain in the seat of the tumor. This may occur Avithout de- tected cause, or follow on tapping or other form of injury. The disease may run on rapidly with intense symptoms and general peritonitis to a fatal termination; or it may be localized, and lead to suppuration in the caA-ities of the tumor. This may go on for some time, Avith the produc- tion of pus; or the contents of the cyst may be converted into any of the foul disgusting fluids, the result of decomposition. The fatal termination, if the cysts be not removed, may be due to diffuse peritonitis, but more commonly to septic or pyaemic fever, the result of absorption, or of ad- mixture more or less direct through the vessels of the cyst, of the putrid fluids or gases Avith the blood. Dr. Chadwick, of Boston, relates an in- structive illustration (1877). 15. The roof of the vagina may burst, and alloAV the ovarian tumor to protrude through it. Berry relates a case referred to in succeeding page. Luschka {Monatsschr. jilr Geburtsk., 1867) relates a case of rupture of the vagina, and protrusion of an ovarian tumor. Jobert de Lamballe com- municated a case in which under labor an ovarian cyst burst out through the vagina {Academic de Medecine, 1850). W. L. Dunn relates a case 350 TERMINATIONS OF OVARIAN CYSTS. in which an ovarian tumor coming doAvn before the head in labor accele- rated by ergot, tore its way through the vagina. Recovery took placc\ 16. The tumor may escape by bursting or perforation of Douglass sac throyqh the rectum, and present at the anus. A. W. Stocks {Brit. Med. dourn., 1S75) relates a case. The tumor was removed, and the Avoman recovered. The rate of growth or natural duration of ovarian cysts varies with the kind of tumor, and other circumstances, one of which is the age of the patient, The simple non-malignant cysts generally go on steadily in- creasing, attaining a size that entails distress of breathing and danger to life, in about two or three years from their first attracting attention. But it is almost certain that the earlier stages of groAvth may extend over a considerable time before, either by bulk or pressure on the abdominal viscera, the tumor is noticed by the^patient. We have, then, an unknown quantity to add to the known ; and this circumstance frustrates all attempt to arrive at a precise estimate of the rate of growth or duration. Not seldom there are alternations of increase and of standing still. After remaining passive for a considerable time, a stage of rapid accumulation may set in. Scanzoni believes menstruation stimulates the groAvth. The partly solid non-malignant tumors may last many years, groAving very sloAvly, thus admitting of gradual adaptation of the compressed organs, and of the system generally, to the inconvenience, before distress becomes intolerable, or a fatal result ensues. I have known distinct evidence of ovarian tumors to extend over twenty and even thirty years. The der- moid cysts especially are of unlimited duration. The malignant and proliferous forms proceed more rapidly. The his- tory of many of these cases is brief. It is measured by months rather than by years. In cases of long standing, oedema of the legs is a frequent consequence. It is caused either by pressure on the renal vessels, inducing hyperaemia of the kidneys, by independent or induced Bright's disease, by pressure on the pelvic A-eins, or by thrombosis in the pelvic and femoral veins. In the latter case the prognosis is bad, as it generally indicates malignant disease spreading into the broad ligaments, and matting the pelvic struc- tures together. If ascites be added, the probability of malignant disease extending to the abdominal glands and other structures is much increased. The effects of ovarian cystic disease upon the proper ovarian functions are various. We have seen that in many cases ovulation may go on. Even in a diseased ovary a portion may remain unaffected, and suffice to stimulate menstruation. And, although in many cases it is found that both ovaries are invaded, yet it is rare that the proper structure of both is entirely destroyed. In some cases, perhaps exceptional, and only for a time, there is menorrhagia. More frequently menstruation becomes scanty, and at last ceases. This undoubtedly is often the consequence of general dyscrasia. That menstruation may go on is prima facie evidence of the possibility of conception. Morgagni said {Epistola xlvi., art. 28) that a Avoman may conceive if there remain as much of one ovary sound as pertains to one mature vesicle. It is a fact that in many cases pregnancy does take place. It may even go on to the natural term, and delivery take place Avithout accident. I have knoAvn examples of several succes- DIAGNOSIS OF OVARIAN TUMORS. 351 sivc pregnancies thus being accomplished. But the risk is serious. In another class of cases the uterus is unable to pursue its full development, and abortion or premature labor sets in. During pregnancy the tumor may be tAvisted on its axis : it may burst; it may become inflamed and sup- purate. During labor, again, it may burst. I have seen a fatal result in this Avay. Or if bursting be avoided, the crushing of the tumor may give rise to hemorrhage, suppuration, or gangrene. There is an extraordinary specimen in St. BartholomeAv's Museum (No. 31.34) contributed by Mr. Berry, of Birmingham. It is an ovarian cyst Avhich had protruded through the external parts by rupture of the vagina, during labor, and which Avas afterwards removed bv ligatures Avith success—a singular in- stance of ablation of an ovarian tumor by this route. On the other hand, the uterus may rupture from the obstruction to labor caused by an ovarian cyst. (Ogier Ward, Path. Trans, vol. v.) The breasts are often affected. In some cases they become tumid, even yield a little milky fluid, and the areola is darkened. This chiefly happens during the earlier stages of the active tumors. Generally Avhen the disease is of long standing, the breasts become flaccid, and shrivel. This may be an indication that the follicular structure of the ovary has been destroyed. DIAGNOSIS OF OVARIAN TUMORS. The Diagnosis of Ovarian Tumors involves the analysis of all pelvic and abdominal tumors. The recognition of an ovarian tumor really in- volves very often the decision between life and death. Whether an ope- ration of a most severe, possibly fatal, nature shall be performed or not, depends upon the diagnosis. And if avc do not operate for Avant of an accurate diagnosis, the patient may equally incur the penalty of death. The pregnant uterus has been tapped or opened in mistake for an ovarian tumor. An ovarian tumor has been often mistaken for pregnancy; and this latter error may subject the patient to an imputation of dishonor, than Avhich death itself will, to some minds, appear more tolerable. The first point to determine is the presence or absence of pregnancy. Peaslee observes that the diagnosis of pregnancy in the early months does not come into practical consideration, since it is only when ovarian tumors have attained the size of the gravid womb at five months or more, that the question of extirpation arises. But there are other reasons for forming a diagnosis at even the earliest stage. A proper Aveight must be given to the evidence of history. This may or may not be useful; but it not safe to rely upon anything but physical exploration. We must, then, make a systematic search for the objective signs of pregnancy. We must examine the breasts ; observe the degree of tension, the veins run- ning to the areolae, the pigmentation and area of the areolae, the develop- ment of the follicles, the presence or absence of milky secretion. Then, examining the abdomen by careful palpation, Ave search for uterine and foetal movements ; by stethoscope in the groins and over the abdominal tumor Ave listen for uterine and foetal sounds ; by vaginal touch Ave deter- mine the softness or hardness of the cervix uteri, the patency of the os, its relative position in the pelvis ; the presence or absence of Avhat I have 352 DIAGNOSIS OF OVARIAN TUMORS. described as vaginal roof-stretching, that is, the tense inclined plane formed by the enlarged body of the uterus pressing upon the roof and anterior wall of the vagina—(see Fig. 57, p. 164)—and through Avhich, if the uterus be pregnant, Ave may feel its rounded solid bulk. The speculum may furnish almost conclusive evidence. If the dark-blue tur- gescence of the vaginal-portion and vagina, Avith softness of the vaginal- portion, the enlargement Avith anteversion of the uterus coexist, pregnancy may Avith confidence be affirmed. If to this combination be added venous and capillary distension of the superficial vessels of the legs, and increased vascular tension, we have a concord of symptoms Avhich 1 believe is only to be found in pregnancy. And this concord is found in early pregnancy. Later on, as the foetus groAvs, neAV signs are developed. Place the patient on her back, Avith the shoulders a little raised, then strike upon the rounded mass of the uterus in front of the cervix Avith the tip of the finger, to elicit the phenomenon of ballottement; or if the os be patulous perform this experiment cautiously through the os. If Ave thus get positive evidence of pregnancy, we have gained an important step in the diagnosis of the case. But it must not be hastily concluded that because there is preg- nancy there is not ovarian tumor. Both may coexist. And if Ave fail to bring out any of the absolute signs of pregnancy it must not hastily be concluded that the Avoman is not pregnant. It is not a very uncom- mon thing, even in an uncomplicated case of pregnancy of three, four, or even five months, to miss the unequivocal signs. And there are cases, rare it is true, in Avhich the pregnant Avomb is sunk out of reach in a large accumulation of ascitic fluid. This mostly happens in connection with albuminuria, Avhen there is anasarca as Avell. Ballottement of an enlarged uterus, or of a tumor partly suspended in ascitic fluid, may so nearly simulate the ballottement of the foetus sus- pended in the liquor amnii, that error is easy. The indication is never to rely upon one sign alone. Before discussing the special or particular cases for diagnosis, it will be convenient to describe summarily the general principles of proceeding by Avhich Ave determine the presence of an ovarian tumor. These flow partly from the knowledge acquired of the nature and progress of these tumors, and partly from the application of means of physical exploration. The means at our command are :— 1. Inspection of the Abdomen. The patient should be on her back, with the abdomen, and at least the loAver part of the chest, bare. We then note the shape, size, and position of the tumor. An ovarian tumor generally gives the abdomen an arched form, sometimes uniform, espe- cially if the tumor be mainly monocystic ; sometimes there is oblique or sloping form, one side being prominent, another depressed ; this indicates polycystic tumor. Arery large tumors may rise under the ribs, push up the liver, and make place for themselves by everting the false ribs and cartilages. It is not uncommon to find the xyphoid cartilage protruded fonvards. The recti muscles are sometimes parted ; and the tumor, projecting fonvards. may even find a resting place on the thighs and knees. Generally the abdomen is in full tension, the skin is shining sometimes marked by scar-like cracks, as in pregnancy. In the dependino- parts, PREGNANCY. 353 especially that which hangs over the pubes, the skin becomes thick and doughy from infiltration of serum into the cellular tissue. This is some- times so great as to give a braAvny or hypertrophied character to the skin. Fuitoavs and ridges are thus formed. This feature is rare in pregnancy. The form of the abdomen depends upon the form of the tumor. If the cyst be single and its Avails thin, so that it has yielded easily and uni- formly to distension, it will tend to arch out in the direction of least re- sistance ; that is, forwards, protruding the abdominal wall. The umbilicus. as in pregnancy, is pushed out, but the arching of the abdomen from beloAV the xyphoid cartilages to the pubes, is even more prominent, gene- rally, than is the boAv produced by the pregnant Avomb. It even seems sometimes to point above the umbilicus. The Avails of the gravid uterus are not merely stretched ; they grow, and the uterus ahvays preserves, more or less, its original shape, that is, it is pyriform, and compressed or flattened a little in its anterior wall. If the cyst is multilocular and the cysts arc distended unequally, the form of the abdomen will be unequal; but still, as one cyst, and that one which enlarges in the direction of least resistance, is sure to be most anterior, the general form is like that of the monocystic tumor. In the early stages there is commonly more prominence on one side of the abdomen, one iliac region being visibly more tumid than the other. By inspection, also, we observe the peculiar expression of countenance which attends so many cases of ovarian disease. This is often so striking as to be alone diagnostic to the trained eye. Wells1 gives a draAving, taken from a photograph by the late Dr. Wright, which represents this very graphically. He calls it the " fades ovariana." The emaciation, the prominent or almost uncovered muscles and bones, the expression of anxiety and suffering, the furroAved forehead, the sunken eyes, the open sharply-defined nostrils, the long compressed lips, the depressed angles of the mouth, and the deep wrinkles curving these angles, form together a face Avhich is strikingly characteristic. 2. Mensuration gives more precision to Avhat the eye has observed. Carry a tape from the spinal column round on either side to the umbilicus or linea alba. If the tAvo semi-circumferences are unequal, this raises a presumption in favor of ovarian tumor. Another measurement is perhaps more useful. Measure from each anterior superior spinous process of the ilium to the umbilicus, and also to the xyphoid cartilage. These comparative measurements Avill sIioav clearly the greater protrusion of one side, if it exist. Mensuration is more valuable as a means of keep- ing a precise record of the increase or diminution of the size of the ab- domen. The most precise results in measurement are obtained by aid of the cyrtometer. This instrument, consisting of bands of thin lead, enables us to take not only the distances betAveen two points, but also to take a mould of all the intervening projections and depressions, Avhich can be taken oft* in tracings for future comparison. Nothing brings out so clearly the differences on the tAvo sides. 3. Palpation. By feeling Avith the outstretched hands, we get in- formation as to the size, form and solidity or Avaviness or penetrability of 1 Diseases of the Ovaries. 23 354 DIAGNOSIS OF OVARIAN TUMORS. the abdomen. If the hands can be made to sink in a marked manner towards the spinal column beloAV the umbilicus, the presumption against ovarian tumor, unless a A'ery small one, is strong. If an ovarian tumor lie behind the abdominal Avail, this is impenetrable. Fat, phantom-tumors, tympanites may thus be excluded, especially if Ave aid relaxation of the abdominal Avails by anaesthetics, carrying the open hands all round the swollen abdomen. By gentle pressure Ave can often determine the out- line of the underlying tumor; Ave make out the rounded cyst or bag Avhich contains and confines, Avithin definite limits, the fluid Avhich is felt waving in it. This sense of a Avaving fluid is called fluctuation. It is most clearly brought out by placing one hand spread out, or one or tAvo fingers, lightly, at one point of the tumor, Avhilst Avith a finger of the other hand Ave gently flip in another part. By shifting the positions of the ob- serving and the striking hands, Ave explore the area of fluctuation and its degree in different parts. If the fluctuation be felt freely in all direc- tions, of equal force, transversely, obliquely, longitudinally, along the extreme breadth and length of the tumor, the inference is justifiable, not that the tumor is strictly monocystic, but that the main volume of the fluid is contained in one cyst. In polycystic tumors the long axis is often oblique. If Ave find there is fluctuation in one part of the tumor and not in an- other ; if Ave find the fluctuation is different in force in parts ; if Ave find the Avave propagated from one point is Avholly or partially arrested in its spread across to another part of the tumor, we may infer the presence of septa or solid parts, and hence that the tumor is polycystic. Plain as fluctuation often is, this sign is not free from ambiguity. I ha\re knoAvn a solid fibroid of the uterus communicate a sense of fluctua- tion that imposed upon skilful observers. And we may have Avhat may be called double fluctuation. There may be ascites as well as ovarian tumor. Or the fluctuation may be due to ascites. The latter case Avill be diagnosed by-and-bye. When, as not unfrequently happens, there is fluid in the peritoneal cavity as well as in an ovarian tumor, if the tumor be large, the peritoneal fluid will be diffused as a thin layer all over the tumor. Thus, when Ave first flip the abdomen, we may see and feel a light wave run along the surface. By pressing the fingers rather firmly and suddenly into the abdomen, Ave may displace the thin peritoneal stratum, and come doAvn upon the resisting bag of the tumor; then, by giving a rather smart impact to another part, we may elicit the feel of another deeper fluctuation, that proper to the tumor. But even this is open to fallacy. Striking in this manner, Ave may, displacing the fluid in a cyst, come down upon a solid mass projecting into the cyst. In pregnancy, also, when the uterine and abdominal walls are very thin, and the quantity of liquor amnii excessive, fluctuation may be as distinct as in some cases of ovarian dropsy. We may also make the phenomena of fluctuation available in determin- ing the limits of the sac. Thus, by applying two observing fingers spread out, so as to leave a space of two or three inches betAveen their tips, to one flank, whilst impact is given by the other hand, we may feel fluctua- tion by the upper finger, and not by the loAver one, shoAving that the boundary of the cyst is betAveen the two fingers. It is very difficult, BY TOUCH: PERCUSSION. 355 sometimes impossible, to differentiate the fluctuation of colloid matter from that of limpid fluid. The colloid tremor is propagated through a multilocular tumor Avithout being sensibly affected by the intervening septa. A form of palpation, sometimes decisive, consists in grasping the tumor between the hands, rolling it about from side to side, and lifting it up beneath the abdominal Avail. This gives conclusive evidence of tumor. If this lifting be practised by an assistant whilst the operator keeps an observing finger on the cervix uteri, the uterus may be felt dragged up by the tension put on the pedicle. Intra-vaginal touch is a form of palpation. By it chiefly, aided by the sound, Ave determine the state of the uterus and its relations to any complicating tumor. So long as the tumor is Avithin the pelvis, the uterus is almost invariably in front, pushed forward. When the tumor has risen out of the pelvis, it generally gets in front of or above the uterus. By touch Ave determine some of the physical signs of pregnancy, if exist- ing. In advanced cases, Avhere the tumor has assumed the balloon shape, and even the loAver pole of it is too large to enter the pelvic brim, the uterus is often dragged up a little, and tilted on one side, generally to the opposite side of the tumor; the os is generally directed backwards, the fundus forwards. The A'aginal roof is mostly covered in by the spherical pole of the tumor; it feels elastic if the tumor is monocystic, and sometimes fluctuation may be transmitted to it by flipping the abdomi- nal Avail. The upward dragging of the uterus tends to obliterate or conceal the vaginal-portion of the uterus ; it is draAvn out of the vagina, so that the os uteri is often felt almost flush Avith the vaginal roof. The vaginal roof itself is sometimes draAvn up into a cone. The body and neck of the uterus are sometimes greatly flattened and elongated. This is usually due to adhesion Avith tbe tumor, so that the tumor in its groAvth compels the uterus to spread Avith it. This is strictly analogous to the enormous hypertrophy to which, under like ciruumstances, the Fallopian tubes are subject. In the opposite class of cases in which the tumor, or a part of it, descends in Douglas's space, this space is much enlarged, the posterior vaginal roof is distended and made to protrude, sometimes so as to be prolapsed beyond the vulva. The touch is extended by the uterine sound. But before using it Ave must first clearly exclude pregnancy. This instrument, passed into the uterine canal, determines—1, the length of the uterus ; 2, its inclination or position ; 3, its mobility or freedom from the tumor. If the uterus is easily moved, and of its ordinary size, it may be inferred, not only that the tumor is extra-uterine, but also that the pedicle is long. Vaginal and rectal touch is further of great service in determining other questions, especially that of complication Avith malignant disease. The information obtained from inspection and palpation is corrected and supplemented by that obtained from 4. Percussion. This is perhaps the greatest test. It may be said to be but a form of palpation, but it brings out information that mere palpa- tion could not supply. By percussion Ave determine the areas of dulness and of resonance. In ovarian cystic tumor the relation of these areas is 356 DIAGNOSIS OF OVARIAN TUMORS. characteristic. The tumor, arising from one iliac fossa, pushes the hollow- intestines over towards the opposite side. Whilst the tumor is small, that is, not so large as to reach the level of the umbilicus, the contrast betAveen the dulness of the side where the tumor lies, and that Avhere the intestines are driven to, is marked. When the tumor is so large as to reach the scorbiculus cordis, this contrast is not so obvious ; but it may almost ahvays be traced. The intestines lie in the space between the last false rib and the crest of the ilium and back to the spinal column, because the cyst, occupying the opposite side of the abdomen, has left only this space for the intestines to retreat to: and has not driven them directly and all upwards, because it greAV, always occupying a more or less lateral position. The contrary of this happens in pregnancy and ascites, in Avhich conditions the intestines are driven straight and gradu- ally upAvards, the gravid Avomb rising from the centre, and ascitic fluid filling the loAver parts, to rise Avith its level uniformly upAvards. Hence we have in cystic tumors resonance on one side, between the last false rib and the crest of the ilium, whilst on the opposite side the dulness is more extensive, because the cyst is there. So much may be taken as generally true, but Ave must guard against fallacies. In pregnancy, as in ovarian tumor, the intestines are so croAvded back that, Avhatever the position of the patient, the dulness is heard all over the front of the abdomen, whilst there is an area of resonance in both flanks. In advanced pregnancy there is often marked obliquity of the uterus ; it inclines so much to one side that the area of resonance in one flank may be notably smaller than in the other. And in ovarian tumor we almost invariably find some resonance in both flanks, although the resonant area will be greater on one side. 5. Auscultation is chiefly of use in determining the presence of preg- nancy. It is true that by it we may detect a friction-sound, produced by the ascent and descent of the tumor under the respiratory movements; and sometimes a blowing-sound in one groin, which might impose for the souffle of pregnancy. But these signs are of minor clinical value. Some variety of vascular murmur is much more common in uterine tumors than in ovarian. It is synchronous Avith the pulse. Nor does the difficulty end here. Tavo or more of the above cases may co-exist. After discovering the existence of some one of the condi- tions enumerated, Ave may overlook a complication Avhich is masked by the prominence of that which we have discovered. For example, just as ovarian tumor may be complicated with pregnancy, so it may be compli- cated with uterine fibroid, or Avith ascites. Nor is it enough to deter- mine the presence or absence of complicating tumors or fluid collections. When we have settled that there is an ovarian tumor and nothing else, it is still important, with a vieAV to forming a prognosis and the selection of the mode of treatment, to determine—1, Whether the tumor be mono- cystic or polocystic ; 2, whether it be benign or malignant; 3, whether or not adhesions have been contracted with the abdominal Avails and vis- cera; 4, Avhether the uterus be enlarged, or in any way involved; 5, the condition of the general health, and especially the presence or absence of diseases of other organs, as of the heart, lungs, liver, kidney. ECTOPIC PREGNANCY. 357 A sound judgment as to these points will greatly influence the choice betAveen tapping, extirpation, or expectation. Diagnostic research must be applied to the solution of the followino- problems:— a. Is there a uterine pregnancy ? b. Is there an extra-uterine (ectopic) pregnancy ? c. Is there an extra-ovarian cyst ? d. Is there an enlargement of the uterus from fibroid tumor or fibro- cystic tumor ? e. Is there enlargement of the omentum and intestines ? f. Is there enlargement of the spleen, liver, pancreas, or kidneys ? //. Is there pelvic cellulitis or peritonitis or haematocele ? h. Is there ascites or encysted peritoneal dropsy or abscess ? /. Arc there adhesions ? j. Is the tumor benign or malignant ? k. Is there distension of the bladder or fecal accumulation ? It folloAvs from the foregoing discussion that to enter properly pre- pared upon the task of diagnosing ovarian tumor, the inquirer must have a good clinical acquaintance Avith thoracic and abdominal pathology. a. Is there a uterine pregnancy? This initial question has been al- ready discussed. b. Is there an ectopic pregnancy? This question trenches to some extent upon the first, a ; but it involves many points quite distinct from uterine pregnancy. Ectopic pregnancy is rare ; but for this very reason, and also because the seat of the tumor Avhich it forms is more nearly identical Avith that of ovarian tumor, the diagnosis is more difficult. The diagnosis betAveen extra-uterine gestation and ovarian tumors is discussed in Chapter XIII. on " Ectopic Gestation." But it is useful to add here that in some cases of abdominal gestation, there may be so much fluid in the sac that the foetus cannot be felt in the dorsal or erect positions. But in the knee-elboAV position the foetus may fall doAvn to the front, and give ballottement. Another point is that in extra-uterine gestation the sac usually projects loAver in the recto-uterine pouch than in ovarian tumor. It must not be lost sight of that ovarian tumor may be complicated with pregnancy, uterine or extra-uterine. In the case of uterine preg- nancy Ave may expect to make out the positive signs of pregnancy ; but these Avill be likely to mask those of the ovarian tumor. One character- istic of the double condition is that the abdomen is more Avidened out than in either of the single conditions; and Ave may usually define by palpa- tion, percussion, and auscultation the limits of each tumor. There is commonly a marked sulcus or depression at the upper part, where the tAvo spheres diverge, as shown in the diagram, Fig. 87. By auscultation we commonly mark the seat of the foetus. In ovarian solid tumors it almost ahvays happens that the tumor is of irregular form. There are projections, angles, sometimes simulating limbs of a foetus; but they do not move ; nor do Ave feel that peculiar vermicular movement characteristic of the gravid uterus. If the uterus be at all fixed, and any hardness be felt around it, ex- )]')$ DIAGNOSIS OF OVARIAN TUMORS. amine by rectum as well. If malignant, projections hard and irregular, will probably be felt more plainly here. c Is there an extra-ovarian cyst? When by internal and external examination, no nodular hardening of the cyst wall can anywhere be de- Fig. 87. Ovarian Tumor and Pregnancy. o T, the tumor lifted out of the pelvis by the uterus, u, which is pushed over to the side and over the brim of the pelvis ; f h, spot where foetal heart may be heard (R. B.). tected, Avhere the cyst is uniformly smooth and elastic over its Avhole surface, where the Avave of fluctuation is equally perceptible in all direc- tions, the inference is strong that the cyst is practically unilocular ; and if in a voting person it is either flaccid and of long duration, or exces- sively tense and of recent formation, the inference is almost equally clear, that the cyst is extra-ovarian and the contents limpid. It is a good rule in any case presenting the above characters to tap in the first instance, as this operation may be sufficieht to cure. d. Is there enlargement of the uterus from fibroid tumor or hydro- metra? This is one of the great practical questions. Under the belief that an ovarian tumor existed, the abdomen has many times been laid open, only to discover Avhat should have been known before, namely, that the tumor was uterine. The diagnosis is not seldom extremely difficult, and especially so Avhen the tumor is fibro-cystic, that is, containing fluid so superficially placed as to yield the phenomenon of fluctuation. The uniformly solid tumors ought rarely to deceive, so far as to carry one UTERINE TUMORS. 359 into the practical error of opening the abdomen. Uniformly solid ovarian tumors are so rare, whilst uniformly solid uterine tumors are so much the rule, that if I Avere disposed to be aphoristic, I would submit no aphorism with less hesitation than this: If you find a smooth, solid tumor, be- ware : it is uterine. If a solid tumor of the ovary be rare, a large solid tumor, so large as to give rise to questions of operating, may be said to be amongst the curiosities of pathology. In seeking to determine whether a tumor be uterine, Ave must be governed greatly by Avhat vaginal and rectal exploration teaches as to the condition of the uterus. The great point is to determine Avhether the tumor felt above the pubes is continuous or identical with the uterus. This is done by the immediate touch by finger in vagind, by mediate touch by sound in utero, separately and combined with palpation by hand outside on the abdomen. If, by these means Ave ascertain—1, that the uterine cavity much exceeds tAvo and a half inches in length ; 2, that the course of the uterine canal is tortuous (a flexible bougie, Avhich will worm its Avay along a tortuous canal, is sometimes better than the metal sound) ; 3, that the body of the uterus is directed backwards; 4, that the bulk of the tumor moved by the hand outside communicates a continuous move- ment to the cervix, as felt by finger or sound—Ave may fairly infer that the tumor is uterine. This inference will be strengthened if the tumor be of very long standing; and -if the patient have suffered from frequent metrorrhagia. But it is right to declare frankly that we cannot ahvays elicit these phenomena, although the tumor is fibroid ; and that some of them, Avhen elicited, are not absolute proof that the tumor is ovarian. I have pro- nounced a tumor to be ovarian, influenced by the apparent separate mobility of the uterus, in a case Avhere the tumor proved to be uterine. This sign is very deceptive. The great bulk of the uterine tumor may be connected with the uterus by a comparatively narroAV portion beloAV. At this narroAved jioint the portion of uterus below it may easily move upon the great mass above, Avhich is comparatively fixed by its volume and solidity. I think it may be affirmed Avith some confidence that a large abdominal tumor is uterine if we get a combination of the folloAving con- ditions: 1, absence of the fades ovariana; metrorrhagia; solidity of the tumor; descent of any considerable mass into the pelvis; deviation of the os uteri; distortion of the lower part of the uterus ; and especially if Avith the above, the sound travels to an abnormal distance. Or, in other cases, Avhen the vaginal-portion is effaced, the os uteri forms the centre of a rounded hard mass resting on the pelvic brim. It is not very uncommon to find a complication of fibroid of the uterus with ovarian tumor. In such a case we must carefully weigh the evi- dence shoAving that both organs are implicated. An OArarian tumor of moderate size, especially if in great part solid or semisolid, may closely simulate a uterine fibroid, if there be great thick- ness of the abdominal Avail. A thick mass of fat intervening betAveen the examining hands and such a tumor Avill often effectually mask the two •Treat distinctive features of an ovarian tumor, namely, fluctuation and irregularity of surface. We must depend upon careful examination of the uterus by the vagina, isolating, if possible, this organ from the tumor, 360 DIAGNOSIS OF OVARIAN TUMORS. aided by abdominal palpation under chloroform, to establish a diagnosis. The fades uterina differs from the fades orariana. The general health is often less affected in uterine tumor unless hemorrhage attend. Very deep sulci between masses of tumor, especially if these masses be hard, are more characteristic of fibroid tumors. Small marble like tumors ses- sile or pedunculated on the main mass are strongly suggestive of fibroids. Dr. C. C. Lee has collected nineteen cases of fibro-cystic tumor of the uterus ; and has analyzed them, with the vieAV of establishing grounds of diagnosis betAveen it*and ovarian tumor.1 As proof of the difficulty of diagnosis, it is stated that in one only was the true nature of the tumor ascertained before operation. Koeberle", however, thinks the diagnosis may be established by the following signs: 1. The discolored hue and dejected expression of the face, the so-called fwies uteriua of the patient. 2. The variable consistency of the tumor, as made out by abdominal pal- pation. 3. The results of tapping. If the trocar touch a fibrous spot in the tumor-Avail, blood will Aoav ; even when the cyst is reached the fluid ne\er presents the clear viscid character of ovarian cystic fluid, but is either yelloAvish, thin, serous, and rich in lymph or cholesterin, or it is broAvn, muddy, sero-purulent, or bloody, and the tapping leaves only par- tial collapse. 4. The indurated or nodular feel of the tumor after tapping. 5. The uterine connections of the groAvth, as made out by vaginal uterine examination, by aid of the sound. The uterus is more displaced than in ovarian tumor. The history, although liable to deceive, must be taken into account. The rate of development of ovarian tumors usually gives less than two years, Avhilst that of fibro-cystic tumors is generally much sloAver. Ovarian tumors begin early, uterine late. But the variations are numerous. The fluctuation in fibro-cystic tumors is confined to certain regions, gen- erally to the upper part, and the solid portions preponderate; whilst in ovarian tumors having solid elements, the fluctuating parts predominate, and the solid element is almost always at the loAver part. The charac- ters of the fluid draAvn by aspiration may offer valuable aid. We must, hoAvever, be prepared to find all the above signs giving, at best, ambiguous indications. The signs most common in fibro-cystic tumor may be present, or appear to be so, in ovarian tumors, and vice versa. Where doubt is unavoidable, error is excusable. Hence Ave are occasionally driven to the exploratory incision, and to the direct exami- nation of the tumor. This gives another order of signs. If the tumor be uterine, the exposed mass is dark, vascular, thick, and frequently fascic- ulated Avith fibrous bands. If it be ovarian, the sac is usually pearly white, or blue and glistening. But these appearances again I ha\re seen interchanged. More than this, even after removal from the body, tumors believed by the operator to be ovarian have turned out to be fibroid out- groAvths from the body of the uterus, more or less pedunculated. Some of the largest tumors Avhich have been the motive for laparotomy have been fibroid or fibro-cystic tumors of the uterus; and more than a hundred cases are on record Avhere the abdomen has been opened with the object of removing an ovarian tumor, Avhen the operator discovered that it was » New York Journal, 1871. TUMORS OF OMENTUM. 361 uterine. The uterus may be enlarged from a collection of watery or mucous fluid, constituting hydrometra. There is a specimen in Guy's Museum described by Wilks, of a uterus as large as the graA'id organ at seven months from this cause. Being of very sIoav development, not ansAvering to the progress of pregnancy, of which state also the ordinary signs are Avanting, such a case might simulate ovarian dropsy. This proba- bility adds force to the rule to explore the uterus by sound in every pos- sible case. Hematometrapresents analogous conditions. When due to vaginal atresia, there is small likelihood of error. Physometra usually folloAvs childbed: and the resonance ought to prevent error. e. Is there enlargement of the omentum and intestines? At the cli- macteric age, a woman, falling off perhaps in health, notices Avith alarm that she is increasing in size. She fears that it is due to a growing tumor. The phantom-tumor or pseudocyesis of the climacteric period has been already discussed. We have noAV to eliminate fibroid and ovarian tumors. Where there is nothing but fat and inflated intestines, we may always exclude large fibroids and ovarian tumors by palpation and per- cussion. Besonance in front may be dulled, but still the sound is differ- ent from the dead sound returned on percussing over a solid or fluid tumor. The hands will sink in towards the spine, on firm pressure, espe- cially if the abdominal muscles are made to relax under chloroform or under expiration. The sensation to the hands is doughy, not resisting. The condition of the uterus can commonly be determined by vaginal ex- amination and by sound, so as to leave only the possibility of ovarian tumor to investigate. And here Ave come to the practical difficulty of excluding a small ovarian tumor. This may be buried in one iliac region, so much masked by surrounding fat, that neither by external nor by in- ternal touch can Ave get at it so as to bring out distinctive characters. It may help us to remember that women Avho are storing up fat do not com- monly have ovarian dropsy or pregnancy. These states usually cause emaciation. Some of the most difficult cases to diagnose are those of malignant growths from the omentum. They may attain enormous bulk. Sometimes they may be turned out after separating adhesions. I re- moved such a mass, Aveighing 28 lbs. The woman recovered ; but another mass developed. This I removed in the folloAving year. It Aveighed 22 lbs. She recovered from this operation also ; but sank some months later from the development of fresh gixwths. These groAvths are gene- rally of irregular shape; fluctuation is indistinct or wanting ; and the aspi- rator-trocar draAvs nothing, excepting perhaps a feAv drops of blood. They are more likely to be extensively adherent than ovarian tumors. When the uterus is fixed, by the matting together of the structures at the brim of the pelvis, whether with or Avithout extensive ascites, the case is likely to be malignant. /'. Is there enlargement of the liver, spleen, pancreas or kidney ? Tumors of the stomach, liver, spleen, or pancreas may in most cases be eliminated by evidence shoAving that they groAV from above dowmvards. This mav generally be obtained by percussion. If dulness prevail from the ribs 'dowmvards, leaving an area of resonance beloAV the tumor, that is, between its loAver margin and the pelvis, the inference that the tumor is not of pelvic origin is nearly certain ; and this probability is greatly 3C2 DIAGNOSIS OF OVARIAN TUMORS. increased if the tumor be solid ; and generally the loAver edge of the liver can be made out Avell-defined, the fingers even able to penetrate beneath it. The hydatid of the liver is the condition most likely to deceive. Here Ave may have fluctuation and dulness over an area sometimes very similar to that occupied by an ovarian tumor. The history and the pecu- liar features of the disease will supply diagnostic indications. We shall generally have a resonant space beloAV the tumor. The hydatid tremor or thrill may be felt. Fluid drawn by aspirator-needle Avould show hook- lets of echinococci, and its specific gravity Avould be beloAV 1010. I have knoAvn a considerable area of resonance betAveen the pelvis and a tumor seated under the liver, Avhich proved to be ovarian. This had been carried up and rolled OA^er on its axis, the pedicle stretching and tAvisting under the pressure of a groAving gravid uterus. Spiegelberg relates1 a case of echinococcus of the right kidney, mis- taken for ovarian tumor, and operated upon Avith a fatal issue. The tumor extended from the ribs to the pelvis, and Avas felt by vagina. In reading this case it appears to me—so easy is it to criticize after the event—that the tumor Avas more strictly confined to one side than is usual in ovarian tumor. It extended all along the right side from ribs to pelvis, but did not much overlap the median line. Cystic disease of the kidney has given rise to mistakes. So long as the tumor formed by this disease is comparatively small, danger of mis- taking it for an ovarian tumor is not great. The dulness and fluctuation are more limited to one lumbar and hypochondriac region ; and an area of resonance will be made out between the tumor and the pelvis. But when the cystic enlargement is very great, extending across the abdomen and beloAV to the pelvis, the diagnosis is not easy. Renal tumors groAV- ing from behind press the intestines fonvard, so there is resonance in front. Babington and Bright pointed out that in renal disease Ave may expect changes in the urine, especially an abundance of phosphates and lithates. A very small ovarian tumor, with a long pedicle, might be mistaken for a floating kidney. In 1877 I saw a case Avith Mr. Christopher Heath, Avhich he operated on under our joint diagnosis that it Avas ovarian. It proved to be a renal cyst caused by impaction of a calculus in the ureter. This calculus had been felt through the abdominal Avail. The patient survived the opera- tion ten days. g. Is there pelvic cellulitis or peritonitis or haematocele? Here a history of sudden or rapid development under symptoms of local and general distress will, when given, generally be sufficient. But often cases come before us with no history, or only a misleading one. In these it requires great care to distinguish a consolidated mass of omentum or in- testines found near the pelvis from an ovarian tumor. This condition has frequently deceived, even to the extent of inducing the surgeon to open the abdomen. The distinction will rest mainly upon the more solid character of the inflammatory consolidation, the absence of fluctuation, and perhaps the presence of deadened resonance from intestine entamded Archiv fiir Gynakologie, 1870. PELVIC PERITONITIS OR HEMATOCELE. 363 in the mass. Here again the aphorism Avhich Avarns to be suspicious of a solid tumor finds useful application. It is also necessary to remember that peritonitis or haematocele may supervene upon ovarian cystic disease. In the first case, that of perito- nitis, it is singular to observe Iioav an area previously yielding distinct fluctuation, becomes hard, almost solid, from the effusion of plastic matter on the surface of the tumor. Where there has been no opportunity of examining before the inflammation set in, it is not easy to avoid the error of concluding that there is a solid tumor under the hand. In the absence of antecedent knoAvledge of the real nature of the tumor it is only by Avaiting until the inflammatory complication has to a great extent dis- appeared, that Ave can be sure of our diagnosis. in the second case, that of haematocele, the sudden access of grave symptoms at once arrests attention. Where there is an ovarian tumor the source of the effused blood is likely to be the tumor itself. Its Avails, or large vessels on its surface, may have burst. Abdominal shock is the first result. If the patient survive this, peritonitis, diffuse or limited to the pelvic region, follows. This will give rise to a firm tumor felt pro- jecting into the rectum and vagina, probably rising out of the true pelvis in one or both iliac fossae, and pushing the uterus forward against the symphysis pubis. For the distinctive characters of retro-uterine haematocele and other retro-uterine tumors I must refer to the chapter on this subject. Pelvic cellulitis may be confounded Avith ovarian tumor under two con- ditions : first, Avhere there is tumor only ; and secondly, Avhere there is a tumor which has burst, and is discharging purulent matter. In the first case, the history is important. Pelvic cellulitis is usually of recent formation. It has come on Avith acute symptoms after labor, abortion, suppressed menstruation, surgical treatment, or other accident; it sets the uterus fast in collar or framework of hard effusion in the brim of the pelvis, so that the body of the uterus cannot be distinguished. The uterus is not so affected in ovarian tumor. If there be fluctuation, there is commonly redness of the skin and the peculiar cedematous feel of the tissues Avhere the fluctuation is due to abscess. The pelvic distress, in- cluding dysuria, is marked in cellulitis, rarely so in o\rarian dropsy. Where there is escape of pus, this may be due to the perforation of a suppurating ovarian cyst. But this is a rare event; whilst it is a fre- quent issue of pelvic cellulitis. And it usually occurs within a few Aveeks of the commencement of pelvic cellulitis ; whereas it is extremely rare for an ovarian tumor to suppurate and discharge until it has attained a large size, that is, until it is of considerable duration. But these features, clear enough Avhen the Avhole course of the disease has passed under our observation, are not so clear if Ave are called to a case of long standing. For example, although pelvic cellulitis usually runs a tolerably definite course within a short time, cases occur where abscesses burst after some months, or at least in which suppuration goes on, and matter is discharged for months together by the vagina or rectum. It is not always easy, under such circumstances, to decide that the source of the pus is not an ovarian cyst; especially as a cyst, during the process of suppuration and perforation of the vagina, is likely to have set up pelvic peritonitis. This 364 DIAGNOSIS OF OVARIAN TUMORS. complication may be very puzzling; and Ave shall often be driven to the history for data upon Avhich to found a presumption one way or the other. The necessity, hoA\eArer, of forming a precise diagnosis in such case is of minor urgency, since even if Ave attained to the certainty of its being ovarian, the high probability of extensive pelvic adhesions would forbid the attempt at extirpation. h. Is there ascites, or peritoneal encysted drops//, or abscess? The distinction between pure ascites and pure ovarian dropsy is rarely so dif- ficult as to induce error. But the two conditions are so frequently asso- ciated that the subject demands discussion. The grand characteristics of ascites are : that if the patient be on her back, the intestines floating anchored to the mesentery, there will be clear resonance in front, Avhere in ovarian dropsy, pregnancy, and fibroid of the uterus there is dulness; that the dulness will be in the lumbar regions betAveen the false ribs and the crests of the ilia, Avhere the fluid gravitates, and where there is reso- nance in ovarian dropsy and pregnancy ; that the areas of resonance and dulness will shift on changing the position of the patient, because the IioIIoav intestines float to the surface, Avhereas in cystic dropsy and preg- nancy these areas do not shift. If percussion be performed, the patient lying on her back, the fluid in ascites gravitating to the flanks, and the intestines floating up to the front, the areas of resonance and dulness will be as in Fig. 88. In ovarian dropsy, the areas of resonance and dulness Fig. 88. Dorsal Decubitus. A. Ascitic dulness. I. Intestinal resonance. L. Liver. (R. B.) will be exactly the reverse, as in Fig. 89, and will not vary under change of posture. A striking contrast betAveen ascites and ovarian tumor may also be demonstrated by percussing in the erect posture. In ascites the line of demarcation betAveen dulness and resonance is concave, whilst in ovarian tumor it is convex. This contrast is seen in diagram, Fig. 90. In ascites, when lying on the back, the flanks widen,'bag out, whilst the belly becomes flatter. In ovarian dropsy the prominence is preserved. In ascites again the abdominal Avails are more even in outline, softer, and more yielding. Again, ascites is the consequence and therefore a symptom of disease ENCYSTED PERITONEAL DROPSY. 365 of the heart, liver, or kidneys. The history and other symptoms of these diseases Avill guide to a right appreciation of the dropsy. There is a form of encysted dropsy, the result of peritonitis, in which the peritoneum of the pelvic organs may or may not be involved. Peri- tonitis may be greatly limited to a portion of the omentum, and of the Fig. 89. Dorsal Decubitus. o t. Dull area of ovarian tumor, i. Intestinal resonance, l. Liver. (R. B.) Fig. 90. Differential Characters of Ovarian and Ascitic Dropsies in Upright Posture (R. B.). small intestines covered by it. Plastic matter may be so throAvn out as to form a cavity or cyst betAveen these parts in which serum is imprisoned. I saw a case which 1 concluded to be of this kind some years ago in con- sultation Avith Dr. Clapton and Mr. Litchfield of TVickenham. There Avas a large tumor in the right flank, passing across the median line, and giving fluctuation, which could be traced doAvnwards to the iliac fossa. It had been looked upon as certainly ovarian. The circumstances that made me doubt Avere the rapidity Avith which the tumor had formed; the severe attendant pain and history of fever; a certain singular thickness 366 DIAGNOSIS OF OVARIAN TUMORS. and doughiness of part of the Avails; and the more marked lateral site of the tumor than is usually found in ovarian cysts. I punctured the cyst; and in doing so it required some confidence in one's diagnosis, for the trocar had to be made to penetrate considerably deeper than is usually necessary in the case of ovarian cysts which lie close behind the abdominal Avail. A quart or more of horribly stinking putrid serum escaped, so that Ave suspected there had been a perforation of the intestine into the peritoneum as the cause of the inflammation. The entire disappearance of the tumor and recovery of the patient lent confirmation to the diagnosis arrived at. The general features of encysted dropsy of peritoneum are thus summed up: The fluid lies (in front of) above the intestines, these being bound doAvn by adhesions; it sometimes extends over the whole anterior aspect of the abdomen, being divided into several chambers, while in other cases it is bounded by narnw limits. Depressions are sometimes felt on the surface corresponding to the dissepiments, if there be any. The abdomen is not prominent, but flat. Fluctuation is Aveak and limited, and does not change its relations on changing the position of the patient. It does not interfere Avith respiration or digestion like an ovarian cyst, and is never attended by oedema of the legs or enlargement of the abdominal veins. The fluid draAvn by aspirator will contain flakes of fibrin and will coagu- late by heat. Fncysted peritoneal abscess may simulate ovarian dropsy. Thus a case Avas admitted under my care at St. Thomas's, in which a tense, ob- scurely-fluctuating tumor Avas traced from the right side of the pelvis, rising as high as the umbilicus, and passing the median line to the left. The uterus was three and a half inches long; its fundus deflected to the left by the swelling in the right of the pelvis ; the cervix Avas pushed forward near the pubes. In the fundus of the vagina, on the right of the cervix uteri, was a tense, stretched, elastic, smooth depression. The tumor had, the patient said, all formed within a month. Its onset Avas not marked by any acute symptoms. But when admitted there Avere signs of irritative fever; the pulse Avas about 100, the temperature ranged from 100° Fahr. to 104D Fahr. The physical signs could hardly be distinguished from those of ovarian tumor; but the rapidity of forma- tion, and the signs of irritative fever, pointed to the diagnosis of a perimetric abscess. I accordingly punctured by the vagina with the aspirator-trocar. Fifty-eight ounces of offensive pus were drawn off'; the tumor subsided, and the uterus returned to its normal position. More pus formed, which was again drawn off. The Avoman died of peri- tonitis and septicaemia. The diagnosis was verified, in so far that an encysted abscess was found. But a small ovarian cyst, which appeared to have ruptured, was imbedded in the abscess. In connection with ovarian cysts it is desirable to refer to certain cysts occasionally found on the external surface of the uterus, and described by Huguier. Two cases he described were the result of metro-peritoni- tis. I have seen several similar examples, mostly in connection with malignant disease, and where obvious indications of recent or old perito- nitis existed. I have, hoAvever, seen other examples of cysts containing serum seated on the peritoneal surface of the uterus, on the broad lio-a^ ENCYSTED DROPSY OF PERITONEUM. 367 ments and ovaries in Avhich association with inflammation or cancer could not be proved. Dr. McClintock also has referred to cysts attached be- hind the uterus. Another form of ascites is that ivhich attends upon malignant disease inducing peritonitis. Here the eAddence of malignant disease will com- monly be marked ; and Ave shall miss the characteristic signs of encysted dropsy. It is the complication of ascites tvith ovarian cystic disease Avhich is often puzzling. If the ovarian tumor be small, and the ascitic collection large, the tumor is easily overlooked. On the other hand, if the tumor be large and the ascitic collection small, the tumor alone may attract at- tention. In the latter case the practical consequences of mistake may not be serious, because the ovarian tumor is the disease that rules the choice of treatment, the ascites being secondary. In the first case, if there be urgent distress from accumulation of fluid, tapping by the aspi- rator-trocar Avould be indicated ; and then, the fluid removed, the tumor Avould come under manipulation. /. Are there adhesions? This is often an exceedingly difficult point to determine. I have seen extensive adhesions where it Avas confidently foretold that there Avere none. Accurate diagnosis is not so important as it Avas at one time thought to be. Abundant experience has now proved that moderate adhesions offer no serious diffculty in carrying out extir- pation, and do not jeopardize the recovery. Extensive and intimate ad- hesions, especially to the loAver surface of the liver, to the intestines, and to the pelvic cavity, will sometimes altogether frustrate the operation, or the injury inflicted in overcoming them may be so great as to prove fatal. But adhesions at these points cannot be diagnosed, so that in practice Ave are often compelled to disregard the possibility of their presence. The tumor may be presumed to be free from adhesions if— 1. There be no history of antecedent severe pain pointing to attacks of peritonitis. But this cannot be trusted. After recent adhesions a fre: mitus may be felt under the hand, a friction-movement, as the tumor rises and falls under respiration. 2. If Ave pinch up folds of the abdominal Avail, or make the abdominal Avail slide over the tumor. 3. I>y inspection in the semi-prone position, Avatching the effect of respiration: if, on inspiration, the tumor is seen to glide doAvmvards beneath the abdominal Avail, and to glide up again on expiration. 4. If on moving the patient, first to one side then to the other, the tumor be seen or felt to fall to the dependent side. 5. If the uterus be small and move freely under examination by finger and sound, the presumption is against pelvic adhesions. 6. If Ave can make out a thin layer of ascitic fluid, giving a wave su- perficial to the tumor, we have, perhaps, the best evidence of absence of adhesions. 7. Adhesions are less likely to be present if the tumor is benign; more likely if the tumor is malignant. Owing to the free peristaltic and other movements of the small intes- tines, adhesion of them to the ovary is comparatively rare. All the signs of free movement of the tumor may be found, and yet 368 DIAGNOSIS OF OVARIAN DROPSY. there may exist extensive adhesions. These may have become gradually draAvn out by the advancing growth of the tumor, have become elongated, partly atrophied, so as to admit of free movement, but yet to give some trouble to separate Avhen an attempt at extirpation is made. j. Is the tumor benign or malignant? In seeking to determine this question, we shall derive assistance from the history, aspect, and consti- tutional condition. If the aspect be clear, and the general health not impaired beyond what can be attributed to the mere bulk and pressure of the tumor ; if there be free fluctuation; if the uterus be capable of being isolated from the tumor; if Ave find the tumor free from adhesions, it may be presumed that the tumor is benign. k. Tavo other conditions, Avhich may possibly give rise to error, are distension of the bladder Avith urine, and fcecal accumulation. For the distinctive features of these conditions consult Chapter III. and Fig. 38. If the rule to pass the catheter before exploring further be observed, this error will be avoided. It is not easy, hoAvever free and universal the fluctuation may be, to predicate that the tumor is monocystic. Indeed, monocystic tumors are so rare that it is scarcely Avorth Avhile to contemplate the probability of any given tumor being of this kind. It is almost always a safe prophecy to say that it is polycystic. A single cyst will, ex necessitate rei, be perfectly uniform on its surface, and of spherical or ellipsoid form. Deviations from these characters, or variations in degree of fluctuation, or in the rate of growth in different parts, are conclusive against a single cyst. The tumor is probably malignant, if it have grown rapidly; if the aspect be earthy, salloAV, and of characteristic malignant cachexia; if emaciation be very great; if very irregular, knobby in form; if the uterus be found fixed to it; if irregular protrusions be found behind the uterus ; if on rectal examination—which should never be omitted Avhere malignancy is suspected—these projections into the rectum be more plainly felt; if the vaginal or other glands Avithin observation be enlarged and hardened; if there be any considerable amount of ascitic fluid, and especially if there be oedema of the legs, Avith or without phlegmasia dolens. The recognition of ovarian tumor in the earliest, stage is especially difficult. Very little distress may attend the early growth. Practically, it rarely happens that the case comes before us until a tumor of consider- able size has formed. The first inconvenience that attracts attention is the increased size of the abdomen; and this is often more annoying for moral than for physical reasons. An unmarried Avoman is visibly in- creasing in size, and censorious people whisper away her character ; and if dependent upon her oavii exertions, she is unable to find employment. But sooner or later physical distress from pressure is pretty sure to follow. When a small cyst containing fluid has formed, we may feel a smooth, rounded, tense body stretching the roof of the vagina on one side of the cervix, or a little behind. Small cysts get into Douglas's pouch, causing some amount of prolapse of the vagina. By bi-manual palpation Ave may possibly define the tumor, and even make out fluctuation. In this stage, a cystic ovary may be mistaken for a Fallopian gestation, or a dropsy of ENCYSTED DROPSY OF PERITONEUM. 369 the tube. In either event the uterus may be so pushed fonvards by the tumor as to obstruct the bladder and cause retention of urine, as in the folloAving case:—A young Avoman applied as an out-patient, complaining of retention of urine. In accordance Avith our practice in such cases, she Avas at once sent to bed. I found the os uteri pressed close behind the symphysis pubis ; after draAving off the urine I passed the sound into the uterus; it went in the normal direction forwards, and the fundus was felt just above the symphysis. This made it clear that the uterus of normal size Avas pushed bodily fonvards by something behind it. Exploring with the finger to the sides of, and behind, the uterus, the vaginal roof Avas felt stretched out, and a tense, elastic, defined SAvelling with fluctuation was made out by vagino-abdominal touch. The SAvelling did not rise above the pelvic brim, and except by the two-handed mode of examina- tion it could hardly have been distinguished. I concluded that it was an incipient ovarian cystic tumor; and since it Avas causing serious, even dangerous, pressure upon the bladder, I punctured it through the roof of the vagina by the aspirator-trocar, and dreAV off about six ounces of limpid lemon-colored serum. The uterus then retreated to near the centre of the pelvis, leaving the bladder. No bad symptom folhwed; but after some days there Avas again retention ; the uterus Avas again pushed for- Avards against the pubes. I repeated the operation, this time draAving off about tAvo ounces of fluid, and injected an ounce of tincture of iodine, hoping that a cyst so small might contract and be cured. For a time the patient seemed to be doing well; but irritative fever set in, and ended fatally. Unfortunately a post-mortem examination could not be made. We have since had another case in the hospital of retention of urine caused by a small ovarian tumor. Difficulty of diagnosis betAveen early cystic tumor of an ovary, tubal gestation and dropsy of the Fallopian tube, is the less to be regretted, because puncture by the aspirator-trocar is probably the best treatment in all these cases. It should be performed in all cases Avhere the pre- vailing character of the tumor is solidity, and Avhere the fluctuation is obscure and limited. The fluid draAvn off should be carefully examined. It sometimes gives diagnostic evidence. Spencer Wells says, in the case of uterine tumor, it is not the viscid mucoid fluid of multilocular ovarian disease, but a thin serum containing 5, 10, or 15 per cent, of blood intimately mixed with it. If Ave get fluid of this character or none, the idea of laparotomy should be abandoned, unless, indeed, Ave are prepared to undertake the extirpation of the uterus. A rare instance of difficult diagnosis arose in a case related by Disse [Monntsschrift fur Geburtskunde, 1857), in which an ovarian cyst formed part of a femoral hernia. Assuming the tumor to be ovarian, ivhich side did it start from,? Whilst the tumor is of moderate size this can sometimes be told by the canting of the uterus. The ovary rising out of the pelvis drags up the uterus, so as to throw the fundus over to the opposite side. This canting is determined by finger and sound. Sometimes this canting can be in- creased and made sensible to the finger placed on the cervix, by lifting up the tumor by pressure from beloAV it through the abdominal walls. 370 DIAGNOSIS OF OVARIAN DROPSY. Especially whilst the tumor is of moderate size, measurements taken from the umbilicus to either superior iliac process will probably differ by the tumor side being the longest. Tapping and Exploratory Incisions.—After exhausting all ordinary diagnostic methods, the indication to relieve from distressing symptoms and danger to life may still be so urgent that Ave are justified in resort- ing to certain operations in order to attain the precise knoAvledge neces- sary to direct ulterior proceedings. These operations are tapping and exploratory incisions. Tapping, indeed, is an operation of old standing. For a long time it Avas the only proceeding employed to relieve the distension and other urgent symptoms. The operation was looked upon simply as a palliative, and occasionally it turned out to be curative. ]Soav there is added a diagnostic value. When a tumor, apparently monocystic, is emptied of the greater proportion of its fluid, the cyst which contained this fluid collapses, and the operator can press his hand doAvn upon the base of the tumor and feel Avhat remains. Sometimes, but rarely, we may feel nothing; the tumor has to all evidence gone. In these cases the doubt is reasonable that the cyst Avas not ovarian, but a simple cyst of the broad ligament. In such a case the tapping may prove curative as Avell as diagnostic. The cyst-Avails may shrivel up, cease to secrete, and finally become atrophied. It is in such cases that the injection of iodine is likely to be followed by cure ; and it must often remain doubtful whether the iodic injection was not superfluous. Or Ave come to the conclusion that there is no cyst at all; that the case is one of ascites. The peri- toneum emptied, we can noAV examine the state of the liver and other abdominal viscera more easily ; Ave may find tubercular or other disease of the lumbar and pelvic glands. It is not always easy to determine that there is no cyst. Its walls may be so thin, and so adherent to the abdominal wall, that incision may go through the cyst-wall Avithout this being identified. In other cases, and these by far the most numerous, when fluid ceases to run by the canula, we come doAvn to a residual tumor more or less solid, more or less bulky. If there remain a considerable mass bulging up behind the abdominal wall on one side, or near the pelvis, and pre- senting fluctuation, we may diagnose another cyst, and the trocar may be used to puncture this, and even another in succession, or we may ex- plore through the canula by a sound to ascertain the condition of the tumor. Here the polycystic character is beyond doubt. And the the- rapeutical conclusion may confidently be drawn that neither by iodine injection nor by any means, short of extirpation, will a cure be obtained. In these cases the fluid is often gummy or colloid, sometimes puriform. Once opened, these tumors are liable to run a rapid downward course. Suppuration in the cysts is very likely to occur. In another class of cases, also numerous, when the fluid ceases to run, the great bulk of the swelling has disappeared. But by deep pressure through the now flaccid abdomen, we come upon a solid residuum in the pelvis, which may sometimes be grasped in the hand, and Avhich may always be defined betAveen the hand outside and a finger in the vagina. In these cases also it is of no use to inject iodine. 'The solid residuum FLUID AND SOLID TUMORS. 371 almost certainly contains smaller cysts, whose development, repressed by the preponderant activity of the one Avhich has been emptied, will quickly take its place, if indeed the first cyst do not fill again. When the tumor has thus groAvn again, it is generally advisable not to repeat the tapping, but to proceed to extirpation, Avhich holds out the only trustworthy hope. Exploratory Incision.—Before proceeding to this measure, the call for relief should be so serious as to justify extirpation, should this ultimatum be found practicable. Exploratory incisions are not, it is true, so danger- ous as the complete operation; but a fatal issue has with considerable frequency occurred. It properly claims consideration Avhen other means of diagnosis, including puncture or tapping, yield no results, or are con- traindicated. It is advisable on beginning the operation to have all things prepared for proceeding to extirpation. The patient should be in anaes- thesia. A small incision, an inch or two long, is made with a bistoury, midAvay betAveen the umbilicus and pubes. This is very cautiously made so as to aAroid all risk of incising the tumor, Avhich may not be ovarian. The incision should be just large enough to admit the finger to feel the tumor, and to SAveep round in a short radius, so as to ascertain if there are adhesions. This will generally be large enough also to enable one to inspect the surface of the tumor. The uterus, or uterine fibroid, pre- sents a dark-reddish fleshy appearance, which, if not absolutely differen- tial from the usual pearly-blue aspect of an ovarian cyst, should serve as a warning not to proceed to ulterior measures Avithout further investiga- tion. Or again Ave come upon irregular nodular masses not freely mova- ble upon each other, or en bloc, and especially if fixed by broad attach- ments at the base, there is prima facie evidence of malignancy. For clinical purposes we divide tumors of the ovary into tAvo classes namely, tumors which contain cavities, and those which form solid and compact masses. To the first belong the simple or multiple cysts, the cysto-sarcoma, the colloid tumor, and the cysto-carcinoma; Avhilst the second comprises the fibroid bodies, the enchondromata, and the cancer- ous tumors Avithout cavities. This division is certainly useful. But there is another division, Avhich, not displacing this one, I think is even more useful in practice. Ovarian tumors may be divided into benign and ma- lignant. It is not indeed easy in all cases to tell, in the living subject, to Avhich class a particular tumor belongs. But in many cases we can form a reasonably good opinion. For example, Ave may often negative malignancy. When we can do this the course of treatment to adopt is more easily decided, and the prognosis is more hopeful. On the other hand, Ave can often affirm malignancy; and in this case Ave knoAv the treat- ment must be more circumspect, and the prognosis be more grave. The evidence deducible from the examination of the fluids drawn by tapping.—Great hopes have been based upon this line of evidence. Chem- ical and microscopical analysis might be expected to reveal the source Avhence these fluids come. And undoubtedly the chemical and micro- scopical features of fluids from ascitic collections, ovarian cysts, cysto- fibromas, renal and hepatic cysts offer characteristic differences. Some- times, perhaps most frequently, trustworthy evidence maybe thus obtained. But in others, and these may be the most critical, where ordinary meth- ods give only doubtful evidence, and Avhere, consequently, Ave should most 372 DIAGNOSIS OF OVARIAN TUMORS. anxiously seek for assistance, this method has led to disappointment or error. This happened on one occasion to myself. I submitted some fluid to a gentleman justly considered an authority on this special point. Act- ing on his report I opened the abdomen expecting to find an ovarian cyst; the actual thing was an encysted peritoneal dropsy. Dr. Fordyce Barker informs me that the "characteristic ovarian cell" was found in the sac of an extra-uterine gestation recently operated upon in New York ! Strong testimony is borne by Thomas, Byford, and Atlee to the general accuracy of Drysdale's test when applied by himself. ¥ig. 91, from Drysdale, shoAvs the microscopical characters of ovarian fluids. Beginning with the normal Graafian vesicle, Ave find it to contain a minute quantity of a slightly viscid, Avhitish-yelloAV albuminous fluid, re- sembling the serum of blood. It is alkaline and transparent, limpid, readily separating into minute drops. It contains a small quantity of a substance which will coagulate with alcohol, or when heated. It holds in suspension spheroidal, nucleated epithelial cells, and shreds of epithelium from the membrana granulosa of the ovisac. Under pathological conditions the fluids of the Graafian follicles are changed. They may be arranged in three groups; 1, fluids resembling the normal fluid of the ovisac ; 2, ropy or viscid ; 3, resembling mucus. The fluids of the tAvo last groups are frequently met with in multilocular cysts, and in the alveolar and colloid tumors. The simple cysts commonly contain a clear, limpid, pale-citron or straw- colored fluid, Avhich Aoavs in a stream as rapidly as blood-serum, or even more so. Scherer demonstrated the presence of parcdbumeu and metal- bumen as albuminates peculiar to ovarian fluids. This character is shoAvn by the formation of a coagulum on heating, which is either entirely dis- solved or turned into a transparent jelly by adding an equal volume of strong acetic acid and continuing the boiling. When this is found the fluid is probably of ovarian origin. Fibrinogen is also a constituent of simple cysts. It may be demon- strated by Dr. A. Schmidt's test, which is the addition of a few drops of blood to the fluid, Avhen a distinct clot will form in from twenty-five to ninety minutes, involving the blood-corpuscles Avhich had been added. The clot is generally so firm that it can be raised unbroken, and if squeezed in the hand a quantity of fluid issues, leaving a loose bundle of fibrillated substance. Cholesterine crystals are sometimes seen in the fluid of simple cysts, glistening in the stream as it Aoavs through the canula on tapping. After standing awhile these crystals form a pellicle on the surface of the fluid. Scales of epithelium are almost always found floating in it. It must not. hoAvever, be assumed that even in simple cysts the fluid is always clear. Pus or blood is occasionally found ; and pus is occasion- ally apt to be found on a second or subsequent tapping, although the fluid draAvn by the first tapping Avas perfectly clear. Admixture of pus and blood will affect the color variously, according to the period and quantity of the effusion. Thus it may be yellow, green, broAvnish, or red. The turbidity of the fluid generally depends upon the admixture of these secondary matters. In compound cysts every variety of contents may be found. EVIDENCE FROM CONTENTS OF TUMORS. 373 The chemical and microscopical characters of ovarian fluids have been elaborately described by Eichwald.1 The first group of abnormal fluids, very liquid, are generally found in molecular cysts with a smooth internal surface invested Avith a layer of pavementoepithelium. Their specific gravity ranges from 1003 to 1006. They have no odor, and are either neutral or slightly alkaline. The folloAving analysis represents the aver- age composition: Water, 982.5; mineral salt's (sulphates, chlorates, phosphates), 12.0; organic salts (lactates), 4.0 ; cholesterine, occasion- ally traces ; albuminose, 1.5 = 1000.0. These fluids are devoid of fat and albumen. In the clear slightly ropy fluid of some of the small cysts in the broad ligament, minute flakes are occasionally found. They are granular, Avith a minute round or irregular cumulus of fatty granules in the centre. The second group of liquid but, ropy ovarian fluids.—They are of the consistence of oil or syrup, and frothing Avhen shaken. They are clear amber or lemon-colored, or pinkish like the peritoneal fluid. The reddish fluids, after standing, deposit the red blood-corpuscles to Avhich they OAve their color. These fluids may become turbid, and of grayish, yellowish-green or whitish color from the presence of cells and oil glob- ules, which they hold in suspension. Their reaction is alkaline; specific gra\dty, 1009 to 1018. Heat, alcohol, and nitric acid will coagulate them like blood or ascitic fluid. Baedeker, Thudichum, and others have found leucine. In the fluid Avill generally be found epithelial cells, prin- cipally the pavement-epithelium, which lines the cavity of the cysts. Besides these, there will be ahvays Avhite blood-corpuscles, sometimes red blood-corpuscles, due to capillary hemorrhage from the inner surface of the cyst. The fluid in very old cysts becomes thicker, and assumes the consistence and color of coffee-grounds. It will also contain granules of haematosine from disintegrated blood-corpuscles. Third group. Visdd and ropy fluids.—These are generally clear, colorless, or of a grayish tint, and semi-transparent. They are Adscid, adhesive, resembling the vitreous humor of the eye, or jelly-like, break- ing up into lumps. They Avill not pass, or only Avith difficulty, through a canula. They are alkaline or neutral; specific gravity 1010 to 1015 ; in colloid cysts 1040 or more. They coagulate Avhen exposed to high temperature, like the Avhite of egg, to Avhich they sometimes bear a great resemblance. The variations depend upon the conditions of the principal components, the colloid bodies and the mucus, and the intermediate stages of metamorphosis from one to the other. Epithelial cells and blood- globules are also found. They contain mineral salts, crystals, or crys- tallizable principles of organic origin, as fats, and principles allied to alkaloids, viz., urea, creatine, leucine, creatinine. The microscopical analysis shoAvs fat-granules and globules, large color- less colloid globules, Avith delicate margins and a large transparent centre, either perfectly homogeneous, or dotted Avith fine black spots. Some colloid globules inclose one or more granulated aggregations. There may also be found a large quantity of small circular corpuscles, clear, with a dark margin, containing a varying number of fine dark molecules, and some- 1 Wiirzburg, Medizinische Zeitschrift, 1864. 374 DIAGNOSIS OF OVARIAN TUMORS. times, also, several larger granules of high refracting power. They ap- pear to be identical Avith the pyoid bodies of Lebert, or the exudatire cells of Henle. Cholesterine crystals are found in great quantities. Pigment, dark-broAvn, reddish-black, or black, in granules of different sizes, is found. The folloAving propositions present a fair general guide to diagnosis in so far as indications can be draAvn from an examination of the fluid con- tents of abdominal tumors: — 1. Hair, teeth, oil or fat or a gruel-like fluid, give evidence of a der- moid cyst. Pus may come from an ordinary cystic ovary, but it is more likely to come from a dermoid cyst. 2. Bile-matter, or a more or less deep yelloAv or green fluid, indicates hepatic origin. In one case an operation that terminated fatally would have been avoided had the fluid been first examined. Echinococci also point to origin in the liver or kidney. 3. Fluids containing urea probably come from a renal cyst. 4. Fluids nearly free from albumen and of Ioav specific gravity point to cysts in the broad ligament. Fig. 91. Microscopic characters of ovarian fluids—(after Thomas M. Drysdale, Philadelphia, 1S73). a. epi- thelial cells, 6. oil globules, e. granular matter, d. cholesterine, e. granular cells, /. blood corpu- scles, i. Gluge's inflammatory globules, g, h. pus cells and blood. 5. If a clear bright or pale-yellow fluid, which is not viscid, forms a dense Avhite or Avhitish-yelloAv coagulum on heating, Avhich is often some- what yelloAved, but not dissolved by boiling in strong acetic acid it is probably ascitic. TREATMENT OF OVARIAN CYSTIC DISEASE. 375 6. If a fluid clear like Avater, or slightly opalescent, of Ioav specific gravity, forms little or no coagulum on heating, but often becomes markedly turbid if a feAv drops of acetic acid are first added, and then quite clear again Avith more acetic acid and more boiling, it is probably from a broad ligament cyst. 7. The specific gravity of ovarian fluids varies from 1015 upAvards. In extra-ovarian fluids Ave rarely find any microscopic elements, and the fluid is of low specific gravity—1003 to 1010 at the most. Hydatid cysts, hepatic or renal, also yield fluid of Ioav specific gravity, rarely so high as lolo. Hence a specific gravity below 1010 tells against an ovarian tumor. S. Fluids of colloid or syrupy consistence, fluids of specific gravity exceeding 1<)12, containing epithelial cells possessing the character re- presented (Fig. 77, p. 291, and Fig. 91), point to ovarian tumors. CHAPTER XYI. TREATMENT OF OVARIAN CYSTIC DISEASE: HISTORICAL NOTE; MEDICINAL, LOCAL MEDICATION, SCROICAL. TAPPING BY ArAGINA; BY ABDOMEN; TAPPING COMBINED AVITH IODIC INJECTIONS; INCISIONS IN CYST; ELEC- TROLYSIS ; OVARIOTOMY. The scope of this Avork precludes all attempt at history. The steps by which the present skill in abdominal surgery has been acquired are, how- ever, deeply interesting and instructive. I refer to Peaslee for the most able and impartial historical review. I will do no more in this place than to recall attention to the Avork and arguments of Dr. Blundell in dispelling the dread of abdominal surgery Avhich so long barred the way to surgical relief of abdominal tumors. Radford, imbued with the teachings of this master, encouraged Clay at the commencement of that career Avhich may be said to haAre placed ovariotomy upon a secure foundation. Southam, also, of Manchester, in 1843-5, recorded cases {Medico-Chiruryical Transactions), and spoke with unreserved confidence of the future of ovariotomy. Walne and Samuel Lane had before this date been operating with fair success, and never Avavered in their confidence of the merits of the operation. The operation was suggested by William Hunter ; its practicability and the mode of performing it Avere taught by John Bell; it Avas first practised, and that successfully, by an American, Mc DoAvell, a pupil of John Bell. The more recent successes of Atlee, Peaslee, Spencer Wells, Keith, Koeberle, and others, ought not to be allowed to obliterate the 370 TREATMENT OF OVARIAN TUMORS. claims of Walne, Samuel Lane, Bird, and Baker Brown, which although not unchallenged in some respects, yet deserve the honor that is due to enterprise and priority. The experience of a century has confirmed the conclusions arrived at by William Hunter, that ovarian dropsy Avas an incurable disease ; and that the only palliative Avas tapping. The methods by Avhich nature or accident effects a cure are uncertain, so unforeseen, that the expectation of relief by them cannot influence the conduct of the surgeon. Rupture, perforation, or tAvisting of the tumor may indeed effect a cure, but they are far more likely to cause death. It may Avith confidence be affirmed that if a Avoman is to be rescued from the danger of an ovarian tumor, the only reasonable prospect lies in extirpation. The folloAving proceedings may be recorded, chiefly as examples of failure:— 1. Medicinal.—The Pharmacopoeia has been ransacked in Arain. There is no trustworthy evidence that any internal remedy has the slightest influence in arresting the growth of an ovarian cyst. If in a feAv instances a cyst has seemed to disappear or to diminish under the use of bromides, iodides, chlorates, or other medicines, further trials have resulted in signal failure, suggesting that the cases of presumed cure Avere but examples of error in diagnosis. 2. Local Medication.—Peaslee says, " In several instances the groAvth of ovarian cysts in the early stage had been apparently arrested by the application, per vaginam, of iodide of lead. But," he adds, " further trials must demonstrate hoAV permanent is to be the benefit thus obtained." Firm pressure upon the tumor, at one time much vaunted, has passed into the domain of history. 3. Surgical Proceedings.—Although all surgical proceedings, short of extirpation, which have been tried for the relief or cure of ovarian cystic tumors, have yielded for the most part unsatisfactory results, a brief review even of those which have most unequivocally failed is useful. This revieAV may save us from repeating operations which experience has condemned. These proceedings may be regarded as experiments illus- trating the constitution and behavior of cystic tumors. And some of them, although they have lost claim to be regarded as generally applica- ble, may still prove valuable in exceptional cases. Tapping and iodic injections have to some extent been discussed under "Diagnosis." Many simple cysts may be .cured by simple tapping, or by tapping and injection of iodine. This especially applies to cysts of the broad ligament. Should examination of the fluid drawn by aspira- tion indicate a cyst of this kind, iodic injection may be resorted to Avith some confidence. But the case of true ovarian cysts is very different. Sometimes tapping itself proves fatal. It is not ahvays less hazardous than ovariotomy. In the great majority of cases the cyst will quickly fill again; and the operation must be repeated. Sometimes tapping is folloAved by inflammation and suppuration of the tumor. And although tapping will commonly give immediate comparative relief, it has been thought that the disease is often accelerated by it. Tapping finds an TAPPING BY VAGINA. 377 especially valuable application in some cases Avhere the diagnosis of ovarian cystic tumor is not sufficiently clear to justify laparotomy. Tapping by the vagina.—The argument for this proceeding rests upon the anatomical fact that the ovary ahvays occupies the loAvest position in the pelvis. It is in direct relation with the roof of the vagina, and beloAV the intestines. A fair amount of success has attended the operation ; but there is not sufficient reason to conclude that it is more favorable than tapping by the abdomen. There are tAvo forms of tapping: the one is simple tapping; in the other the tapping is supplemented by other proceedings, as keeping the cyst open, and throwing irritant or other fluids into the cyst. Simple tapping consists in puncturing the cyst, draining off the fluid contents, and then letting the opening close. This proceeding may be adopted as a palliative, with a vieAV to cure ; or as tentative Avith a vieAV to obtaining information to guide further treatment. It is useful only in a limited order of cases. Our first care then is selection. The favora- ble conditions are : a small cyst Avhich descends fairly behind the uterus, bulging out the posterior Avail and roof of the vagina; distinct fluctua- tion ; absence of solid masses at the most prominent point Avhere punc- ture must be made. The cases in Avhich vaginal tapping is most likely to be useful are the monocystic. But this condition can hardly be determined before tapping; and thus tapping comes to be experimental as regards treatment, and exploratory as aiding diagnosis. I Avould therefore strongly advise that the first or diagnostic tapping be made by the aspirator-trocar. Compara- tively little risk attends this method, but it is not absolutely free from danger. The Operation.—-The first point is to select the place for puncture. This should be determined with precision. The cyst, it is assumed, occupies by its most dependent part the peritoneal sac betAveen the uterus and rectum. Occupying this space, it causes the uterus and rectum to diverge, the uterus is pushed forwards and a little to one side, the rectum is compressed or flattened backAvards. The perforating instrument must therefore strike betAveen these two organs. First, pass a catheter into the bladder, to empty this organ, to insure its safety, to remove it from all interference. Secondly, feel for the position of the uterus by touch and by the sound. In front of the os uteri through the anterior vaginal Avail, Ave may feel the body of the uterus; by passing the sound, the position and relations of the uterus are made still more clear. This is one great landmark. We must keep behind this. Thirdly, pass the fore- finger into the rectum, the sound being still in the uterus. Aou Avill then ascertain the position and relations of the rectum at the level of the tumor and os uteri. There Avill probably be a space of one or tAvo inches or more between the os uteri and the anterior Avail of the rectum. It is within this space that the puncture must be made. The anterior wall of the rectum is the other great landmark. Fourthly, your finger quits the rectum and returns to the roof of the vagina behind the cervix uteri; then, feeling the cyst here, press firmly doAvn tovvards it the cyst from above by your other hand on the abdominal Avail abovre the pubes. lou thus get evidence of a fluctuating point. Tapping being resolved upon, 378 TREATMENT OF OVARIAN TUMORS. you place the patient in position. It is scarcely desirable to give chloro- form. The lithotomy-position is convenient ; but it is often quite as easy to operate, the patient lying in bed on her left side, the nates drawn well to the edge. An assistant presses the tumor firmly doAvn into the pelvis; the forefinger resting on the tumor an inch or so behind the cervix uteri guides the trocar, Avhich is thrust in perpendicularly to the surface, and carried in the direction of the axis of the pelvis for about an inch, parallel to the course of the uterus indicated by the sound, or until the sense of resistance is suddenly lost. Then, the fluid ought to Aoav either sponta- neously, or under the vacuum produced by the pump. The exhausting pressure should be kept up as long as fluid flows. Then explore to as- certain Avhat remains of the tumor. Withdraw the trocar. Enough has been done for the occasion. Time must be allowed to observe the sub- sequent course of events, before the diagnosis can be absolute, and before determining on further operations. As yet we cannot be certain that the cyst is not formed by a tubal gestation, or by dropsy of the Fallopian tube. In either of these cases it Avould not be desirable to enlarge the opening or to inject fluid into the cyst. Simple exhaustion of the fluid contents may be sufficient for cure of either of these affections, and also of a simple cyst of the ovary or of the broad ligament. It is obviously, then, sound practice to take the benefit of this possibility of cure. If the cyst be ovarian it will probably fill again. By repeated tapping by vacuum, a small ovarian cyst may gradually become smaller, shrivel up, and be obliterated. This process may be accelerated by iodine injec- tion, or by drainage. The most convenient drain is a silver coil tube. Firm pressure by compress and binder should be applied immediately after operation, and sustained for some days. The double use of this is to obviate the vacuum that might othenvise form favoring suction of air into the cyst; and to promote the reduction of the cyst by maintaining its Avails in contact. Rest in bed for a Aveek, salines and sedatives are to be recommended as after-treatment. If, aided by this preliminary tapping, the tumor be found to be ovarian, and be of the size of a fcetal head, or somewhat larger, we may then con- sider the expediency of tapping by the vagina, and keeping the cyst open, so as to alloAv continuous drainage to go on. The preparatory steps are the same as those already described. It is best to use the long tube, carrying a knife designed by me for similar operations, which can be con- nected Avith the aspirator, and will serve to introduce a coil drainage-tube. By this the Avound is enlarged, to alloAv the forefinger to pass into the collapsing sac, to ascertain the condition of the internal surface. On the second or third day, symptoms of inflammation of the cyst, Avith severe reaction, commonly set in. A discharge of ichorous fluid takes place, and there is great pain in the pelvic region. In favorable cases, says Khvisch, these symptoms gradually gave Avay to a purulent discharge, which ceased in from five to seven weeks, and then shrivelling and perfect obliteration of the cyst took place. As long as any secretion o-0es on it is desirable to inject carbolized water through the tube daily. TAPPING BY THE ABDOMEN. 379 Scanzoni1 is an advncate for the vaginal tapping, in preference to abdo- minal tapping, generally, when the cyst can be reached by the vagina, amongst other reasons, because it secures more perfect draining of the cyst. If this could be always performed, he says, abdominal tapping would disappear from the rank of recognized operations. Our experience of this method is, perhaps, insufficient. But it is certain that the advan- tages of it are not Avithout a draAvback of danger and of failure. There is always an element of uncertainty, owing to the varying character of these tumors, complications, and the idiosyncrasy of the patient. The operation is, therefore, of an experimental'kind. * The inflammation, the suppuration, may extend beyond the Avished-for limits. Then there is an objection Avhich especially applies to tapping through the vagina. The wound is necessarily made at the base of the tumor, where solid elements are most commonly found, and Avhere the bloodvessels Avhich feed the tumor are largest and most abundant. Kiwisch himself, the chief advo- cate for the measure, says it is only of use in moderately-large simple cysts, because in very large cysts the extensive decomposition must be very exhausting to the system, and compound cysts do not alloAv of a full shrivelling-up of the sac. Xoav here is the difficulty; we can rarely be certain that the cyst is not compound. Some cases are related by Mr. Wells. His conclusion is, that " simple tapping is more hazardous than tapping folloAved by drainage, and that drainage should be so complete, that no reaccumulation of fluid can take place, the cavity being kept open until the Avails collapse and unite, so that it is completely obliterated." I am disposed to qualify this vieAV. Assuming that only those cases are suitable for vaginal tapping, in Avhich there is .strong presumption that the cyst is single, I Avould first practise a simple tapping ; and if the cyst refilled I would combine the second tapping Avith drainage. Tavignot proposed tapping by the rectum. Where the tumor protrudes more Avithin reach by this canal, it may be preferable to tapping by the vagina. But whilst open to all the objections urged against tapping by the vagina, it is far less convenient for drainage. And dysenteric tenes- mus has been caused by the irritation produced. THE OPERATION OF TAPPING BY THE ABDOMEN. Tapping by the abdomen is an operation often of necessity to relieve urgent distress of breathing. It scarcely merits the rank of an operation of election; since, except in rare and unforeseen cases, it is at best a pal- liative only. But as a palliative it is exceedingly Araluable. It is appli- cable to a large class of cases, and especially to those large tumors Avhich are admittedly unfit for vaginal tapping. It is a legitimate resource in most cases Avhere, for any reason, extirpation of the tumor is excluded. It jiosscsscs the great advantages over the vaginal operation, that it is easier of performance, that it is done at a distance from the base of the tumor, so that Ave are more likely to avoid wounding solid and vascular 1 Maladies des Organs Sexuels de la Femrae. French ed., 1858. 380 TREATMENT OF OVARIAN TUMORS. parts; that there is, further, a considerable area of space within Avhich Ave can select the point for puncture. The folloAving dangers attend tapping by the abdomen:— 1. It is possible to Avound a vessel in the abdominal Avail large enough to cause serious bleeding. This is no real bar, because all serious bleed- ing may be avoided by selecting the linea alba for puncture, and by dividing the skin by a scalpel, by which precaution Ave can secure any injured vessel before plunging in the trocar. 2. The risk of wounding some large vessel in the Avail of the sac is more serious, and can hardly be secured against. This risk is, hoAvever, small in cysts presumed to be single, and in Avhich free fluctuation indi- cates that the Avails are thin. In the case of tumors partly solid, and Avhose Avails, even at the fluctuating parts are thick, the risk is very great, so great in fact, that if things generally are not adverse, the major ope- ration of extirpation should be at once preferred. The hemorrhage is dangerous in tAvo Avays: blood may be slowly poured out into the perito- neum, setting up peritonitis: or it may pour into the cyst to such an extent as to cause anaemia, as Avell as inflammation of the cyst. If, after tapping a thick-Availed cyst, symptoms of internal hemorrhage arise, the operation for extirpation should be immediately undertaken. By this means, and only by this means, can the bleeding be arrested by tying the pedicle, and the effused blood be removed. 3. The rapid emptying of the cyst may be followed by collapse, just as prostration sometimes folloAvs too rapid delivery. This is our reason for compressing the abdomen by bandages as the fluid escapes. 4. Some of the contents of the cyst may run into the peritoneal cavity and set up inflammation, Avhich may prove fatal. This accident may be avoided by using a sharp well-made trocar, by dividing the skin of the abdomen first by a scalpel, oiling the trocar, and piercing the remains of the abdominal Avail and the cyst-wall with a decided stab, so as to carry the canula a good inch or more through into the cavity of the cyst, before AvithdraAving the trocar. 5. Air may be sucked into the sac. When this accident happens, de- composition and suppuration are very likely to ensue. Irritative fever Avill set in, and the result may be fatal. This risk should be guarded against by using a trocar so constructed as only to permit Aoav from the cyst outwards, by keeping the delivery end of the drainage tube under water, and by steadily folloAving doAvn the emptying sac by pressure. 6. In the case of compound cysts, especially if malignant, mere tap- ping, where precaution against letting-in air has been successful, may be still folloAved by suppuration and fatal septicaemia. Indeed, in most cases, it is observed that after several tappings the nature of the fluid changes, becoming turbid, more viscid, or puriform. Where evidence of suppuration in the cyst is obtained, the feasibility of extirpating the tumor should be considered. 7. By repeated tapping the system is exhausted by the drain caused by the diversion of material to the cyst. This is probably often increased by tapping, which takes off the pressure that restrained"exhalation. Even Avhere no untoward accidents folloAV tapping, the relief obtained is often very transient. Fluid rapidly collects again, and the operation TAPPING BY THE ABDOMEN. 381 must be very soon repeated. It has been supposed that tapping accele- rates the progress of the disease—that it is, in fact, the beginning of the end ; that, once performed, the necessity for having recourse to it again and again recurs at a constantly accelerated ratio. There appears to me to be a fallacy lurking under this belief. Tapping is rarely performed until the symptoms are so urgent that relief is imperative. This implies that the disease is in high activity, and that things have reached a climax. From this time it is not surprising that the course should be doAvn-hill, Avhether tapping be performed or not. And it can scarcely be doubted that in most cases, tapping does afford a respite more or less prolonged. It certainly, in some cases, averts apparently imminent death. In some cases, unforeseen, it must be admitted, it is folloAved by complete cure. I think the question may be summed up as folioavs :— Tapping has its OAvn immediate dangers, but these are limited to a small proportion of cases ; tapping postpones death from the secondary effects, such as pressure of the tumor upon the viscera and bloodvessels, and alloAvs the sufferer to sink under the proper effects of the progressive disease. Dr. Fock published a memoir in 1856, in which it is stated that out of 132 cases of ovarian disease tapped for the first time, tAventy-five died Avithin some hours or a feAv days. KiAvisch lost nine patients out of sixty- four Avithin twenty-four hours after the first tapping. Air. Southam, of Manchester, collected tAventy cases of tapping from various sources; of these four died Avithin a feAv hours. I think, hoAvever, these figures give an exaggerated idea of the danger of tapping, if the operation be performed Avith proper circumspection. The Operation.—A trocar modified from that of Mr. Charles Thomp- son, designed for paracentesis thoracis, secures against most of the acci- dents liable to attend the use of ordinary trocars. The edges of the canula should not be thin, but perfectly smooth and Avell rounded off. This best obviates the risk of injury to large veins on the inner surface of the cyst; and the maker should be careful, when sharpening the cutting part of the holloAV trocar, to leave one-half of the lips quite blunt. If sharpened all round it Avould act as a punch, and cut out a circular hole in the skin. If the instrument is properly finished, only a semilunar cut is made in the skin and cyst, Avhich closes much more readily than the triangular puncture made by the old trocar. The best position is the semirecumbent in bed. Empty the bladder by catheter, as it is important to puncture beloAV the umbilicus. A firm linen binder having a long slit in the middle is applied round the belly, so that the slit corresponds with the linea alba ; the tAvo ends are then crossed behind the back and brought out in front, one on each side. A small incision is then made through the skin only in the selected spot betAveen umbilicus and symphysis pubis. The trocar is then plunged in. WithdraAving the trocar from the canula exerts a suction-poAver, and this sets going the syphon-action of the canula and elastic tube. The delivery end of the tube is kept under the surface of the fluid in the receiving-bucket. This is especially desirable towards the end, Avhen the cyst is nearly empty. As the fluid runs and the cyst col- lapses, the* ends of the binder are draAvn tighter in to keep up steady com- pression. If the canula gets choked, it may be cleared by hooking out 382 TREATMENT OF OVARIAN TUMORS. the obstructing matter with a stilet. If the Aoav stops while the tumor is partly collapsed, this may be due to the presence of other cysts Avhich do not communicate with the one tapped. It may then be useful to pass a sound through the canula to feel for these other cysts, Avhich may in turn be punctured, without withdrawing the canula, or there may be a solid residuum Avhich precludes all further benefit from tapping. In with- drawing the instrument it is always avcII to press the abdominal wall well doAvn upon the cyst, and Avith the finger and thumb of the other hand so to press the abdominal wall together behind the escaping canula, as to prevent the entrance of air. Should any bleeding follow, and not be stopped by a little pressure, a harelip pin should be passed completely across the opening, deeply enough beneath the skin to compress any injured vessel. Tavo or three turns of silk twisted round the pin make sufficient pressure to stop any bleeding. In ordinary cases a small pad of lint and a slip of adhesive plaster suf- fice to close the opening. It is often useful to apply pads or compresses of lint or napkins in the flanks to fill up the spaces left flaccid and hollow by the withdraAval of the fluid. The abdomen may then be supported by a binder over all. One effect following upon tapping is a temporary revival of the secret- ing poAver of the kidneys. The quantity of urine throAvn off is often con- siderably increased for a time. Tapping combined with Injection into the Cyst of Iodic or other Irritating Fluids. The success attending the injection of Avine or iodic solutions into the sac of hydrocele of the testicle naturally led to the imitation of this prac- tice in the treatment of ovarian cysts. But the analogy between the cases is only apparent. A simple serous sac which can be perfectly sur- veyed and commanded is in reality Avidely different from the imperfectly accessible and probably proliferous ovarian cyst. The difference in size alone alters the conditions materially. Still the method of injecting has been taken up with enthusiasm, especially by Boinet, a\1io in a valuable Avork1 details several cases in which it was successfully employed. He urged that, Avhen the cyst Avas unilocular, filled with a limpid, lemon liquid floAving easily, and the patient otherwise of good constitution, it should be tapped and an iodic injection made immediately afterwards. When the contents Avere draAvn off he passed an elastic catheter, of size just fitting the canula, through the canula, which was then withdrawn, leaving the catheter in its place. Through this the injection was made. He used equal parts of tincture of iodine and water, adding a little iodide of potassium. Of this solution he threw in about three ounces. The cyst Avas then kneaded, and the position of the patient changed so as to insure free contact everyAvhere of the solution; it Avas then, after five or six minutes, Avithdrawn, if necessary, by aid of the syringe. The catheter Avas then removed, and the abdomen well compressed and supported by a 1 lodotherapie. Paris, 1855. TAPPING AND IODIC INJECTIONS. 383 bandage. If fluid collected again in the cyst he Avould repeat the injec- tion several times, anticipating refilling and distension. In multilocular cysts containing a thick liquid, floAving with difficulty, further care is necessary. A large trocar was employed, and after let- ting all the fluid that could run, a catheter Avas passed, and a syringe ap- plied to draAv out all the thick viscid matter remaining. The rest of the proceeding was the same as in the simple cysts. But in complicated cysts it was sometimes necessary to keep the catheter in. This was to be done when the cyst sliOAved no tendency to obliteration. In these cases the catheter Avas plugged, fixed by a bandage, and unstopped two or three times a day to let off the gathering fluid. Washing out the cyst with tepid Avater or weak solution of iodine Avas practised occasionally to prevent decomposition, and to clean out the cyst. When the fistulous opening formed by the catheter was well established, so that all escape into the peritoneal cavity Avas prevented by adhesions, the catheter Avas replaced by an ivory canula furnished with a stopcock. Then iodic in- jections and Avashings Avere performed from time to time. The result Avas sIoav, the cysts taking months to contract and shrivel up. I practised iodic injections a good many times. In three, perhaps four, cases, the cure Avas complete and permanent. These Avere appa- rently monocystic tumors. Possibly they might have been simple cysts of the broad ligament; and possibly, also, simple puncture Avithout iodic injection might have cured them. In other cases, undoubtedly polycystic, I could not satisfy myself that good Avas effected. Suppurative inflam- mation of the cysts set in, and a fatal result, not visibly accelerated by the treatment, followed. In other cases the sac refilled, the patients left the hospital, or Avere submitted to ovariotomy. Acute pain and a degree of collapse not seldom set in during or soon after the injection. In all the cases it Avas easy to detect iodine in the urine ; in one case a strong iodic odor was given off from the patient. I detected iodine in the perspiration and in the breath. In another case, as Avell as in the foregoing, the signs of iodism ay ere marked. But I have not seen a case in Avhich it could be said that the patient was fatally poisoned by the iodine. Scanzoni and others think iodic injection ought to be rejected alto- gether. 1 think it should be rejected if the fluid drawn by tapping be colloid or puriform, if the tumor be of irregular form, or give other evi- dence of being polycystic. Since simple tapping may prove fatal, it can hardly be expected that tapping, plus iodic injection, should be free from danger. Dr. R. Low- enhardt1 relates a case in Avhich Siv. of a mixture of equal parts of tinc- ture of iodine and Avater, Avith gr. x. of iodide of potassium, was injected. Death folloAved in fourteen hours. The cyst Avas found collapsed ; there Avas no trace of inflammation; in the cyst Avas a small quantity of clear- broAvn Aveakly iodized fluid. Death was ascribed to shock. Legrand2 relates the case of a Avoman aged fifty-six, in whom a punc- ture, folioAved by iodine injection, Avas made. Little reaction ensued ; in eight days the patient was up ; the dropsy quickly returned. The ope- 1 Monatsschr. f. Geburtsk, 1860. 8 Gazette des Hopitaux, 1861. 384 TREATMENT OF OVARIAN TUMORS. ration Avas repeated, and tAvelve to fourteen pints of fluid Avere let out. At the instant of injection the patient sank into syncope ; a strong shiv- ering, vomiting, peritonitis set in, and death folloAved in sixteen hours. In this case, probably, some of the injection escaped into the peritoneum. It is better, I think, to use the concentrated tincture of iodine. There must ahvays remain fluid enough in the cyst to dilute it, and if used already much diluted, its caustic action on the cyst-Avail is lost, whilst absorption into the system is promoted. In performing the operation, the patient should be on her side in bed. Tapping must be performed in the usual Avay ; and Avhen the cyst is nearly emptied, a flexible catheter, closely fitting the canula, should be passed quite through it, so that the end shall project two or three inches beyond the canula into the cyst. Then the remaining fluid should be alloAved to drain from the cyst. When no more can be obtained, four ounces of tincture of iodine should be injected through the canula, and alloAved to remain about ten minutes. It may then be drained off as far as possible. I would then advise that an ounce or two of Avater be in- jected through the catheter to clear it of iodine before removal. The catheter and canula may then be withdraAvn together, taking care to keep the thumb over the end of the catheter, to prevent the escape of iodic fluid into the peritoneum during the passage of the instrument through the Avound. It would be unwise to reject Boinet's method altogether. It may fairly claim to be adopted in certain cases of presumably simple cysts where circumstances exclude ovariotomy, such as refusal of patients to submit to this operation, or the complication of severe disease, as phthisis. Tapping and keeping open the Cyst.—By this plan it Avas hoped that the fluid being alloAved to escape as quickly as it formed, the cyst Avould go on contracting gradually to complete obliteration. It Avas also ex- pected that the irritation set up in the cyst-walls Avould promote the attainment of this result. A favorable case is reported by Ollenroth (1843). Mr. Alexander Anderson treated two cases in this Avay, leav- ing a canula in the cyst. One woman recovered completely after long suffering, suppuration having gone on through the canula, attended Avith hectic and great emaciation. I saw this case several times, and could not help forming the opinion that her poAver of resistance against exhaust- ing influences Avas exceptional. The other woman died a few weeks after the tapping, from constant vomiting. Mr. Anderson abandoned the practice. It is not likely to be revived, unless in very exceptional cases. Cases have, however, occurred in which, after simple tapping, the punctured wound has kept open spontaneously, giving vent, from time to time, to cystic fluid. In this way a slow cure has been effected. Incision of the Cyst.—Ledran adA'ised and practised the following operation.1 When the liquid is thick, and contained in several cysts, he made an incision in the most dependent part of the tumor, and, according to its position, either in the median line, or outside the recti muscles; he then divided the cyst in the same direction, and broke down the in- 1 See Malgaigne, Medecine Operatoire, 4L-me ed., 1843. INCISION OF THE CYST. 385 ternal septa, which could be reached. He placed in the wound a strip of soft rag, for which, at a later period, he substituted a tent, and at last a canula, to preserve free vent for discharges and for detersive injections. By this proceeding the cysts empty themselves, their Avails suppurate, cleanse, and contract. Sometimes a fistula, difficult to close, remained. It Avas found that OAving to the retraction of the cyst, the opening in it getting beloAV the level of that in the abdominal wall, fluid Avould escape into the peritoneum. To obviate this accident, Re3amier and others sought to effect adhesion betAveen cyst and abdominal Avail by caustics before incision ; Trousseau by repeated insertion of long needles ; Bdgin by cutting through the abdominal Avail, so as to bare the cyst, and Avait- ing until adhesion had formed all around the wound before tapping and incision of the cyst. The results of the operation have not established for it a claim to a recognized place in the rank of elective proceedings. It is noAV chiefly knoAvn as a pis aller, as the best thing to do in certain cases where the attempt to perform ovariotomy breaks doAvn, either from insurmountable adhesion or other complications. In this Avay some most unexpected recoveries have taken place. It scarcely differs in principle from the preceding operation, of keeping open a fistulous canal after tapping. The dangers attending it are greater, and therefore it falls, d fortiori, under the like condemnation. A modification of this proceeding was proposed by Deneux and Sacchi. It consists in cutting aAvay portions of the Avail of the cyst. Malgaigne adA'ises it as a resource when extirpation cannot be carried out. In a case operated upon by Dr. Chambers, at the Chelsea Hospital for Women, Dr. Aveling and myself assisting, adhesions rendered it unwise to proceed Avith the intended extirpation. The cyst Avas compound ; all the contents that could be easily removed Avere taken aAvay; and the cyst-Avail being included in the sutures through the abdominal Avail, the Avound Avas closed, all but a small part at the loAver end. Several Aveeks later the Avound only gave vent to a slight oozing of pus ; and the patient Avas in a fair Avay to recovery. The excision of a part of the exposed cyst, and then closing the ab- dominal wound. Encouraged by the fact that cures have folloAved the accidental burst- ing of an ovarian cyst, and discharge of its contents into the peritoneal cavity, Avhence they have been removed by absorption, Dr. Blundell and others have been led to hope that ovarian dropsy might be successfully treated by deliberate imitation of this accidental process. Guerin, Bain- bridge, and others attempted to carry out this idea by making a subcu- taneous incision in the Avail of the sac by means of a small tenotomy-knife. But this mode of proceeding is open to the grave objection that it is working in the dark. Many tumors have large vessels ramifying on the surface, Avhich, if divided/might give rise to fatal hemorrhage. Mr. Bainbridge operated by cutting doAvn on the tumor, and excising a piece of the cyst-Avail. But"this plan, like Gudrin's, is open to the objection that the fluid Avhich is to be throAvn into the peritoneal cavity may be of a viscid and irritating character. It is true that by his plan Bainbridge avoids the risk of Avounding vessels; and as it gives the opportunity of 25 380 TREATMENT OF OVARIAN TUMORS. seeing the nature of the tumor and its contents, the operation need not be proceeded Avith. It might be treated thus far as an exploratory opera- tion, the information gained from Avhich Avould govern ulterior measures. Baker BroAvn operated after Bainbridge's method. The late Professor Simpson thought the proceeding might be usefully modified by making a preliminary tapping, with the view of ascertaining the nature of the fluid ; and if this were found to be benign, to alloAv it to escape into the peritoneum. In this Avay, he said, having made sure that the fluid was innocuous, he stopped the tapping by shutting up the cutaneous orifice, and allowed the last part of the fluid to run into the cavity of the abdomen. To provide for the escape of subsequent secretion into the abdomen, it is necessary to keep the lips of the puncture in the cyst from closing by first intention. This is the great difficulty. To gain this object, he sometimes made use of a large " quadrangular" tro- car. He then forcibly compressed the tumor daily, so as to break doAvn the adhesions Avhich tended to close the cyst. In this way, at least one cure Avas effected. These proceedings have not been justified by experience. Repeated simple tapping Avould seem preferable. It is better to get rid of the fluid directly, than to let it Aow into the peritoneal cavity. Electrolysis.—Does any resource still present itself before the ultima ratio, ovariotomy ? Some hope has been raised by the method of elec- trolysis. Like iodic injections, electrolysis Avas first tried upon hydrocele of the tunica vaginalis. When a student in Paris I saAv some cases treated not Avithout success by Leroy d'Etiolles by electrolysis ; and I have an indistinct recollection of his applying the same method to other tumors, including ovarian. Fieber reports {Wien. Med. duresse, 1871) an apparent cure. The case is further attested by Braun. Other promis- ing illustrations are cited if. America and Canada. A memoir on the subject, Avhich I have not had the opportunity of seeing, Avas read at the session of 1877 of the American Gynaecological Society. In 1876,Avheu on a visit to Montreal, Dr. Macdonald showed me a patient Avho, in his opinion, confirmed by another surgeon who had aided in the treatment, had been cured by electrolysis. I was not able to detect any remains of disease. Of uncertain efficacy in hydrocele, electrolysis does not promise much for the more difficult cases of ovarian cystic disease. Treatment must in any case be tedious. In the colloid or proliferous cysts, which make up the greater number of ovarian tumors, it is hard to understand that any benefit can be obtained. And the simple cysts can be dealt with by quicker and surer methods. Still reports of instances in Avhich electro- lysis has been tried on cysts precisely diagnosed are interesting. OVARIOTOMY OR EXTIRPATION OF THE DISEASED OVARY. Ovariotomy has been contrasted with tapping. The fallacy that de- prives this comparison of all practical application is of the same kind as that which invalidates all absolute doctrines in medicine. There are cases for Avhich ovariotomy is best; there are cases for which tapping is best. The great distinction between the two operations is, that the first PRECAUTIONS BEFORE OPERATING. 387 kills or cures ; whilst the second hardly ever cures, and can, at best, pro- long life. Looking to cure, we should prefer ovariotomy, if the case ad- mitted of this operation ; looking to mere palliation, Ave must in many cases resort to tapping. The first is more an operation of choice, the second rather one of necessity. It has been urged against tapping that it lessens the chance of ovari- otomy being successful by promoting the formation of adhesions. This objection has been disposed of by experience. The moderate parietal adhesions folloAving tapping rarely present any serious obstacle to the execution of ovariotomy. On the other hand, tapping is often useful in clearing up the diagnosis ; as a means of gaining time for the patient's general health to recover; or of lessening the shock by removing the fiuid a feAv hours or clays before removing the solid portion of an o\rarian cyst. Thus, it may be affirmed that tapping promotes the success of ovariotomy, instead of being antagonistic to it. PRECAUTIONS BEFORE OPERATING. 1. It is needless to say that a good diagnosis is the first point. 2. If there is much anasarca or oedema of the legs, it is Avell to tap some days previously. Great prostration, Avith quickly supervening dyspnoea, carry the same indication. The effused fiuid becomes absorbed and excreted, thus removing Avhat might be an injurious complication. If this be not done, the absorption-process must go on simultaneously with the A\ished-for process of healing from the operation. In this case the quality of the blood is impaired by having throAvn into it, just at the wrong time, a large quantity of watery and effete material. 3. Examine the urine for albumen. The presence of albumen is not indeed an absolute contra-indication, for it may depend upon temporary congestion of the kidneys, the immediate consequence of pressure by the tumor. The tumor removed, the kidneys may recover. But if the albu- men be accompanied by casts, by persistent oedema of the legs, hands, and face, heart-disease complicating, and be thus traced to permanent Bright's disease, the operation Avill be likely to fail. Brodie used to in- sist upon this condition as being highly adverse to the success of capital operations. Mr. Wells insists further that a small quantity of highly concentrated urine, depositing mixed urates in abundance, indicates a state of hepatic and renal disorder which should be corrected before operating. For this purpose saline purgatives, as sulphate of soda, carbonate of magnesia, and lithia-Avater may be given with advantage. 4. Avoid, unless the urgency is extreme, a menstrued epoch. When avc can select, the best time is within a week after a period. 5. The state of the heart and lungs should also be examined as to their soundness and fitness for Avork. If there is advanced phthisis it may be of doubtful advantage to operate. 0. The season.—When there is a choice it is wise to follow Brodie's advice as to avoiding operation during an east Avind. The wind is of more importance than the mere season of the year, the only point usually 388 TREATMENT OF OVARIAN TUMORS. noted in statistical tables. An east Avind in June may bring more hazard to a severe operation than a Avest Avind in March. 7. If there be evidence of malignant disease in the abdomen or else- Avhere it will rarely be advisable to operate. 8. Ovariotomy should not be practised whilst the tumor is small, nor until the constitution has undergone some degree of impairment from pressure, and the other effects of the disease. It was at one time very naturally thought that a patient would have a better chance if the opera- tion Avere performed whilst she Avas in robust health, and the tumor Avas small. But experience has not borne out this a priori reasoning. Wells prefers Avaiting. Keith says, " I prefer operating when the tumor is large, and when the patient has suffered a good deal." A better reason perhaps is that in long-standing cases the peritoneum has under constant friction by the tumor undergone such changes that it has lost much of its susceptibility to injurious reactions under exposure, and the other inter- ferences incidental to the operation. Where adhesions are extensive, it may even be said that we are no longer dealing with a peritoneum in the strict sense. 9. If by tapping or other means Ave get distinct evidence that the tumor is colloid, the danger of Avaiting outweighs the advantages. Such cysts may grow rapidly, and are very apt to undergo perforation, bursting, in- flammation, and suppuration. Unfavorable changes are very apt to follow tapping in these cases. Hence, whenever tapping shows colloid matter, or very little fluid of any kind, especially if the tumor presents irregular projections, it is well to be prepared to operate Avithin a feAv days. 10. The place chosen for the operation is a matter of importance. It should be fairly spacious, light, well-ventilated, and the furniture should be limited to what is necessary. Carpets covering the entire floor are objectionable. A strip on either side of the bed, and a piece or two in places much used, to prevent noise, and which can be taken out of the house to clean, are all that is desirable. 11. The nurse should be especially qualified by training; be able to pass the catheter; keep utensils perfectly clean by disinfectants; and able to exercise efficient yet gentle control over the room. She should have nothing else to do. This is a matter of course in a private house; but it is still more imperative in a hospital. A nurse attending an ova- riotomy patient should not come into contact Avith any other°patient; above all, she should not be exposed to the risk of contact with infectious or surgical patients. 12. This touches closely upon the great question Avhether ovariotomy should be performed by surgeons in ordinary hospitals. It may be urged, as a general fact, that all serious surgical operations are exposed to an increased element of danger in large hospitals ; but that this is not held to be an adequate reason for not performing them there. The circum- stances of the patient may leave her little choice; whilst the practised skill of the hospital surgeons, and the excellence of the general arrange- ments of the hospital, may be thought to outAveigh the attendant disad- vantages. This much being admitted, it will be asked, Is there any special condition attached to ovariotomy, which makes this operation an exception to the general rule, which turns the scale the other Avay ? I OVARIOTOMY. 389 think there is. Ovariotomy in some respects has analogies with parturi- tion. The sudden removal of an enormous growth feeding upon the system leads to a constitutional revulsion, and suddenly altered dynamic and constituent conditions of the circulation, Avhich, as in a woman after labor, render her peculiarly susceptible to external impressions, and espe- cially, to the deleterious action or morbific poisons. To this risk is added the exposure of the peritoneum, a structure remarkably obnoxious to toxi- cal influences, and easily absorbing any contaminating matter Avhich the operating surgeon or his assistants, Avho are constantly working, as Sidney Smith would say, in the midst of " pus and miasm," are so likely to con- tract. This danger may be materially lessened by careful adaptation of the antiseptic methods Avhich have been so successfully applied by Lister in other departments of surgery. With all possible precautions, hoAvever, I do not believe that ovariotomy in large general hospitals will ever give results that shall compare favor- ably with ovariotomy done in private houses or small special hospitals. In this country, at least, where the rights of the humbler classes are respected to a degree unknown elseAvhere, it is practically admitted that to deliver Avomen in lying-in hospitals or in general hospitals, is a pro- ceeding justifiable only under peculiarly exceptional conditions. Recog- nizing this unreservedly, I have felt it my duty steadily to resist the extension of lying-in hospitals, notAvithstanding the great temptations these institutions offer for scientific observation and teaching. The pas- sion for study must be kept in subordination to the claims of humanity. Instruments required.—The necessary instruments for a simple case are feAv. A scalpel and strong scissors, to divide the abdominal Avail; a director, to protect the cyst as this division is completed ; a trocar, to empty the cyst; a clamp, to secure the pedicle ; needles and silk, to close the Avound ; Avith forceps and ligatures, to secure any bleeding ves- sels, complete the list. But there is no operation where the surgeon may be so met by difficulties where he least expected them. It is Avise to take to every case a full armamentarium to meet every possible emer- gency. Clamps of different sizes, cautery clamps, and cauteries for cases Avhere the clamp is not applicable ; A\hip-cord and silk ligatures ; needles of different shapes and sizes, for cases where neither clamp nor cautery effectually deals with the pedicle; large harelip pins, or acupressure needles, for cases Avhere simple ligature cannot be trusted; clamps with ecreAV fastenings, for temporarily securing separated omentum or torn vascular adhesions ; artery forceps of different lengths, torsion forceps, bulldog forceps, vulsella specially adapted for holding large cysts; a chain and wire eeraseur; glass drainage-tubes; and perchloride of iron should ahvays accompany the operator. The thermo-cautery is conve- nient. A lamp and a small hand-mirror should also be provided. Preliminary Preparations.—A saline purgative should be given the day before ; and the bowel washed out by an enema on the morning of the operation. If the operation be fixed for the morning, and this is to be preferred, the patient will take only a light breakfast, at least an hour before. A strong narroAV table is placed conveniently for light and access. It is covered with a firm squab, over Avhich is laid a blanket, and then over 390 TREATMENT OF OVARIAN TUMORS. all a Avaterproof sheet. Tavo or three pails arc ready to receive the fluid and the tumor. A small table is placctl within reach of the operator's right hand, so that he can help himself to the instruments laid out on it. Iron or copper cauterizing implements are kept in the fire. An assistant is charged with the thermo-cautery, and a strong solution of perchloride of iron. On the fire also is a kettle of Avater boiling. A nurse has charge of basins, cold Avater, several sponges, and pieces of thin flannel steeping in hot Avater, ready to Avring out Avhen Avanted. All the Avater used should contain about one per cent, of carbolic acid. A special assistant is ready Avith the carbolic spray. The room is kept Avell ventilated by a fire ; but it is not found neces- sary to keep up a heat of 90° Fahrenheit, as it was at one time thought to be. The patient is clothed in flannel draAvers, stockings, and night-gOAvn, it being important to prevent long exposure of a large surface of the body to cold. She is rendered insensible by chloroform, bichloride of methy- lene, or ether in her bed, and then removed to the operating-table. The legs are strapped to the table by a belt like a horse-girth. The hands should also be secured by straps. This avoids the necessity of super- numerary assistants. It may be laid doAvn as an axiom, that every additional assistant brought into contact Avith the patient is an additional element of danger. A Avaterproof sheet, having a slit in the middle large enough to permit of the operation being done Avithin it, is laid over the patient. This obviates all overfloAV and mess on the patient and the floor by conducting the fluid contents of the cyst into large pans or buckets placed under the table. An assistant stands at the operator's left hand; another opposite on the other side of the patient. The assistant in charge of the anaesthetic apparatus stands at the patient's head. The catheter is first passed, to insure an empty bladder. The assistant in charge of the antiseptic apparatus plays the spray so as to envelop the hands of the operator and assistants and the abdomen of the patient in an antiseptic mist. In making the incision, the folloAving structures are successively divid- ed : 1. The skin ; 2, the subcutaneous areolar tissue, with fat of vary- ing thickness ; 3, the interlaced fibres of the aponeuroses of the abdominal muscles constituting the linea alba ; 4, layers of the fascia transversalis, Avith more or less fat (the uppermost layer adheres closely to the linea alba: the deepest layer is only very loosely connected with the perito- neum) ; 5, the peritoneum. The peritoneum may be raised Avith a hook or forceps. The membrane is then divided by horizontal touches Avith the knife, and an opening made large enough to admit the insertion of a broad director. Upon this the peritoneum should be slit up. It is desirable to keep the incision as short as possible. If the tumor will not come through the short incision first made, it can afterwards be lengthened. Any bleeding vessels in the abdominal wound may be se- cured pro tempore by haemostatic forceps; and aftenvards tAvisted, or tied with carbolized silk, if necessary. The incision is made with a scalpel in the linea alba from below the umbilicus towards the pubes, three or four inches long at first, proceeding OVARIOTOMY. 391 very carefully as the peritoneum is approached, lest the cyst be pene- trated, and its contents escape into the peritoneum before the Avound is completed. The peritoneum may be protruded through the wound by some ascitic fluid behind it, and impose upon the operator for the cyst. The touch will commonly correct this by feeling the more solid cyst behind it. The peritoneum is then opened. The cyst comes into aucav. If ovarian, especially if simple, it is recognized by a glistening, pearly, smooth aspect. If it be a compound cyst its surface may be uneven, it may be redder, vascular, and even hard. If it be a fibroid or fibro-cystic tumor of the uterus the appearance is dark-red, fleshy, and firm. The incision is made just large enough at first to admit the hand, Avhich should be passed in clean, and very gently, lest it rupture the cyst, and carried round be- tween the abdominal Avail and the cyst, to feel for adhesions, and if there be any to separate them. This is best done all over the front of the tumor, whilst the cyst is full and tense. The cyst is then punctured by a smart stab with a large trocar, to Avhich a flexible tube is attached, to carry the fluid into a receptacle on the floor. The trocars of Mr. Clay and Dr. Lloyd Roberts are the best I am acquainted with. They hold the cyst-Avail after puncture Avell, and Avithout much risk of tearing aAvay. As the cyst is collapsing its Avails are seized in one or two places by for- ceps, so made as to hold a good fold of the cyst-wall Avithout tearing it. Mr. Sydney Jones has contrived a good forceps for this purpose, and Avhich is also useful as a temporary clamp for adhesions. Whilst an assistant supports the sides of the wound Avith flannels Avrung out of warm water, Avith the double object of preventing the protrusion of intestines and the escape of fluid into the peritoneal cavity, the cyst is drained as far as it w ill fioAV freely. At the same time gentle traction is made on the cyst, to see if it will turn out of the abdomen. If this does not occur readily, the evacuation goes on, and the hand is passed in to explore all round the tumor, breaking doAvn adhesions, if necessary, and ascertaining the existence and extent of solid portions, Avhich may by their bulk oppose the removal of the tumor. If, during this proceeding, the cyst-Avail be kept Avell drawn out, and over one side of the patient, the opening made by the trocar will be clear of the abdominal Avound, and no fluid will escape into it. If there are no adhesions, or only such as are readily broken down, and if there is little or no solid element in the tumor, it will easily turn out. As this is done, the assistants, Avith warm moist flannels, carefully press up the abdominal Avail behind the tumor, so as to keep the cavity closed. Care is taken, especially at the last stage, to prevent the tumor falling suddenly, lest it drag injuriously upon the pedicle. When it is fairly out, and Avell supported, the operator examines the pedicle. The pedicle.—If the pedicle is of sufficient length to permit of the stump being secured outside the abdominal Avound Avithout dragging upon the uterus, this method should be preferred. This, the so-called extra- peritoneal method of dealing Avith.the pedicle, stands in contrast Avith the intra-peritoneal method of tying or cauterizing the pedicle, and leaving it in the abdominal cavity, closing the Avound over all. Mr. Hutchinson's introduction of the clamp to facilitate the extra-peritoneal plan has been very generally admitted to be one of the most substantial improvements 392 TREATMENT OF OVARIAN TUMORS. acquired for ovariotomy. The choice of a clamp is important. A good clamp unites the folloAving points: it is sufficiently long and slightly curved on the flat, so as to embrace the pedicle well and alloAv the ends to rise up aAvay from the Avound and the abdominal Avail : the ends are smooth and rounded, so as not to dig into the skin ; the two blades are roughened on the inner sides, and made by a screAV at each end to carry the blades together in perfect parallelism, thus safely strangling the ves- sels and crimping the stump ; the screAvs are accessible and Avork easily, so as to permit of easy removal of the clamp Avhen it has done its duty. The clamps Avhich, to my knoAvledge, most completely ansAvers to this de- scription, are those of Drs. Chambers and Lloyd Roberts. Securing the stump outside the Avound possesses the folioAving advantage : The surface, Avhich may bleed or yield noxious discharges, is ahvays kept in sight, and all discharge escapes externally. It has been urged that the seclusion of the stump within the abdominal cavity places it in a like position to a subcutaneous Avound, and that it is consequently less likely to undergo decomposition than if exposed to the air. The stump, it is affirmed, avi 11 be surrounded with benignant plastic effusions, and thus occasion no trouble. These propositions are to a great extent true. But experience proves that the method does not guard against danger so surely as that of keeping the stump outside. The ligature which is necessary to secure the pedicle must be very strong ; it must be draAvn very tightly to close the vessels in it; sometimes two or three stout ligatures are necessary. These themselves may be a source of irritation. Then, after a Avhile, the tissues embraced in the ligatures shrink a little, the ligatures become looser, and under returning reaction bleeding takes place into the abdo- men. Mr. Spencer Wells has also observed that on the return of men- struation, blood is poured out from the surface of the stump. Dr. Lloyd Roberts, Avho has carefully studied the relative merits of the two methods, is of opinion that menstruation is less likely to take place under the intra- peritoneal method; that under the clamp method the Fallopian tube is apt to maintain its patency, thus giving issue to menstrual secretion, and keeping up a troublesome sore. He, however, as a general rule pre- fers the clamp, and suggests that it is better suited to non-menstruating Avomen. My own observation Avould lead me to conclude that tying or cautery is more especially applicable to Avomen past the climacteric. Other disadvantages of the clamp are : the length of time required for its separation and for the healing of the Avound, owing to the ulceration produced by the pressure of the clamp. This last trouble may be les- sened by the choice of a good clamp. Another danger attending the clamp is that the stump strangulated in it, may slough and fall back into the abdomen. But the successful use of the extra-peritoneal method depends upon the pedicle being long enough to afford a good hold for the clamp, and for this to rest upon the abdominal wall without serious strain or draippng upon the broad ligament and uterus. This dragging is the source of great pain, and may lead to exhaustion or inflammation. If it is found to occur after the clamp has been applied, it may be Aviso to tie the stump below the clamp and let it drop into the cavity, either cutting the ligature close, or keeping the ends hanging out of the Avound. OVARIOTOMY. 393 Ligature.—If the pedicle is too short for a clamp, it is seized by a long screAv-forceps fenestrated ; and beloAV the fenestra a strong Avhip- cord is carried double on a needle through the pedicle, and then tied in two parts. One end may be brought out of the wound, or both ends cut short and dropped in. Cautery.—Where the pedicle is too short even for the ligature to give a secure hold, it should be grasped by a cautery-clamp, and the tumor severed from it by the actual cautery. Care should be taken to use a dull heat only, so as to char down very sloAvly. This method will pro- bably come into more extensive use, as one of election and not alone of necessity. Keith tells me (November, 1877) that out of fifty-nine cases so treated by him only four died. The cases best fitted for cautery are those in Avhich the pedicle is thick and fleshy. Another method of securing the pedicle is the "pocketing," so-called by Dr. H. Storer. The pedicle held in a clamp, is dhdded by scissors, bleeding vessels are secured by wire ligatures, and then having united the primary incision by means of iron-Avire sutures, he brings the extremity of the pedicle betAveen the inner lips of the Avound at its lower angle, and there " pockets it." One cause of mortality after ovariotomy is hemorrhage. It is the most preventable. No pains, no time can be misspent in securing against this accident. The bleeding mav come from three sources: 1, the large vessels of the pedicle. This of course is obviated by care in setting the clamp, or by ligatures or cautery ; 2, from vessels severed when separat- ing the cyst from adhesions. These may be secured by carbolizecl silk ligatures cut short and left in sitti, by torsion, or by cautery ; 3, from an inflamed or vascular surface oozing " en nappe" Avhere no bleeding-vessel can be seen. This is a peculiarly dangerous form, for unless effectually arrested before closing the Avound, it may go on aftenvards and cause death. I have tried actual cautery, colloid styptic, and SAvabbing Avith perchloride of iron, and have no hesitation in saying that the iron is the only thing to be relied upon. The bleeding surface should be SAvabbed with a strong solution, lightly Aviping off any superfluity. The application is, I believe, harmless ; I have had uninterrupted recoveries after it; and it is surely less to be apprehended than hemorrhage. To insure full visual inspection of the cavity of the pelvis or other hol- Ioavs, it is Avell to be provided with a hand looking-glass or a lamp to throw light into dark nooks. When the pedicle is secured, search for the other ovary, to ascertain if it be not so affected as to require removal. Also trace the omentum to see if all is clear from entanglement Avith the intestines. If a fibroid tumor project from the uterus, it is better to leave it alone. Clean out the Abdominal Cavity.—Remove by sponges all ovarian fluid or blood which may have found its Avay in. This is an object of paramount importance, and especially so if the contents of the cyst be viscid or puriform. But too great pains cannot be taken to prevent fluid getting into the peritoneum. If it be found, from the cyst being rotten or other cause, that the fluid will run over, turn the patient on her side, so as to give a dependent drainage away from the abdominal cavity. 394 TREATMENT OF OVARIAN TUMORS. Drainage.—When closing the wound the question of drainage must be considered. A large proportion of deaths occurs from septicaemia, connected Avith the collection in the peritoneum of jmrulent matter or blood, or serum undergoing change. If this could be drawn off, it is reasonable to infer that the prospect of recovery Avould be improved. Experience confirms this inference. Keith especially commends the prac- tice. It has been proposed to place in every case a drainage-tube through an opening expressly made in the bottom of Douglas's pouch into the vagina. Experience has not proved that this plan is judicious. In the first place, the simple cases, uncomplicated Avith hemorrhage, adhesions or foul matter in the peritoneum, commonly do so well Avithout drainage that it is prima facie umvise to introduce a possible element of danger. In such cases, then, drainage should be dispensed with. In cases where the adverse conditions are present drainage is of eminent service. In many cases a sort of natural drainage has been established by the side of the stump ; and sometimes Avhen this has not been considered sufficient, the surgeon has removed one or more sutures, so as to alloAv freer evacuation and syringing of the foul cavity. And this with good effect. But there is an advantage in making special provision for drainage. The following is the method of drainage adopted by Keith. I am indebted to him for the description. He uses a glass tube open at both ends, one end, and that which goes into the pelvis, being, moreover, perforated for an inch or so by several holes. The tube is selected of a length that may appear suitable. This is usually about six or seven inches. The calibre is chosen large or small just as oozing of blood or only serum is expected. On the neck of the tube is a raised shoulder or rim to hold a piece of thin sheet India-rubber 18 inches square, so as to wrap'over a sponge Avrung out of carbolic acid solution—1 in 30. This sucks up any fluid that may drain, preserves cleanliness, and enables us to know to a drop ho\v much escapes. The tube is placed tightly betAveen the two loAver stitches, the end passing clown into Douglas's pouch. Any fluid collecting in the pouch, can be draAvn off by passing a fine India-rubber tube doAvn the drainage tube and aspirating by a syringe. This should be repeated twice a day, if necessary, and the sponge replaced. The glass tube, it is clear, acts like the shaft of a well, and the syringe converts it into a pump. The tube may also serve as a means of washing out the cavity, by injecting weak carbolic Avater. The drainage tube may generally be removed at the end of five or six days. But, adds Keith, " Since I have regularly done my ovariotomies under the carbolic acid spray, I drain almost neA'er. If you leave SAveet serum behind and a SAveet abdomen, the peritoneum will take care of itself after oozing. Antiseptics will do away with the blood-poison." J.F.Miner {Buffalo Med. Surg. Joum., 1850) suggested a very well-designed plan of drainage. Having tied the pedicle as a whole, he carried the ends down through an opening made in Douglas's pouch, thus inverting the part like a funnel and securing a drain for any purulent matter that might form. Closing the Abdominal Wound.—Every variety of suture has been employed. The choice has not much effect upon the result of the opera- tion. Most operators use the sih cr-Avire. OVARIOTOMY. 395 It has happened to me to have to use both silk and Avire in the same operation. I found the Avire sutures Avere more free from purulent tracts than the silk. They are also more convenient for removal. Wire, there- fore, should be preferred. The sutures may be carried either by glovers' needles about tAvo and a half inches long, each end of the suture being armed Avith a needle, or by a strong, slightly-curved needle mounted on a handle. The advantage of the first plan is that each needle mayr be introduced from Avithin outwards, so as to attain more exact uniformity in adaptation. Each suture should take in about a quarter of an inch of peritoneum, and then perforating the Avhole thickness of the abdominal Avail obliquely, come out about three-quarters of an inch from the Avound. When the tAvo heads of the suture are brought together, the two sides of the Avound are thus accurately apposed. Sutures should be applied at intervals of an inch. The}* should not be secured until all have been introduced. An assistant holds all the heads in order as they are passed from above doAvnwards, so as to aAroid entangling. If the clamp has been used, a suture should be applied close to it, so as to bring the lips of the wound close together around the pedicle. The clamp is then warded off from the skin and wound by a pledget of lint soaked incarbolized oil laid beneath it. The surface of the stump should be sprinkled Avith dry perchloride of iron, or with tincture of iodine. The Dressing.—-Pledgets of carbolized lint are laid on the Avound. Over this is a layer of carbolized gauze. Pads of antiseptic cotton-Avool are disposed on each side ; broad strips of plaster are passed over all, so as to give firm support; and lastly, a flannel belt secures all. It is a great advantage to use a many-headed flannel bandage ; the heads cross- ing each other in front can be adjusted Avith great accuracy, securing uniform pressure ; and Avhen it is necessary to examine the Avound this can be done Avith the least possible disturbance, by simply thro av ing back the ends of the bandage. Certain complications may render it expedient to modify the opera- tion. 1. The cyst may be so friable or rotten that it breaks doAvn under the most careful handling. Great pains must be taken to bring aAvay the cyst Avithout leaving pieces of it, or the contents in the abdomen. 2. If the cyst is multilocular, so that after tapping the main cyst the tumor is still too large to come through Avithout enlarging the abdominal incision, the septa should be broken down by the hand, and any semi- solid contents brought away. It is only Avhen accommodation cannot be got in this Avay that the incision should be extended. 3. Extensive firm adhesions may be found in front. These can gene- rally be broken down by the flat hand Avorking under the abdominal Avail. But it mav be necessary to enlarge the Avound and evert its lips, so as to be able to divide the adhesions by the handle of the scalpel, by its edge, or by the adze-edged cauterizing iron. The latter is perhaps the best plan, as it stops bleeding. The bands of adhesion are first embraced by a clamp, such as of those proposed by John Clay and Chambers ; the iron of a dull heat is then applied to the cyst-side of the clamp, Avhich protects the visceral side from injury. If divided by knife it may be 390 TREATMENT OF OVARIAN TUMORS. necessary to tie small bleeding vessels with silk or Avire. When this is done the ends of the sutures should be cut off short. If obstinate adhe- sions to the intestines are found the same means must be employed to divide them. It has been found occasionally necessary to leave portions of the cyst adhering. If there be adhesions to the omentum these must be carefully detached as far as possible. The omentum itself must then be spread out on a clean napkin, and examined for bleeding points. Wherever these are found a silk ligature is put round them, the piece of omentum is cut off, and the ligature cut short. Mr. Hutchinson calls attention to a special difficulty caused by adhe- sions in front. Great difficulty may occur in distinguishing the cyst. The operator may mistake the cellular interspace betAveen the transver- salis fascia and the parietal peritoneum for that between the cyst and the latter. If not quickly discovered this error may be the cause of great damage. In endeavoring to avoid it the surgeon may commit another; he may incise the visceral peritoneum of the cyst, and proceed to sepa- rate it. In many cases the exterior of the cyst deprived of its perito- neum is smooth, white, and glistening, the adhesions are cellular and easily broken through, so that there is nothing to apprise the operator of his mistake. One plan there is in case of perplexity to avoid all risk of these two errors: it is to enlarge the Avound upAvards until the peritoneal cavity is opened at a part Avhere no adhesions exist. When once the operator's finger has touched the intestine he knows Avhere he is, and may proceed to detach adhesions Avithout any fear of mistake. In cases where the detachment of the cyst Avould be dangerous or im- possible, Dr. Atlee has solved the problem by a very ingenious plan. He leaves the peritoneum Avith its adhesions, by separating it from the fibrous Avail of the cyst, so that the adherent portion peeled off is left in contact with the viscus to which it Avas attached. " Dr. W. L. Atlee has prac- tised this," says Peaslee, " for many years past. In his 215th case ad- hesions seven or eight inches long Avere thus left attached to the transverse colon." This is a form of enucleation of the tumor, a proceeding by which the whole or the greater part of the tumor is peeled out of its peri- toneal investment. Dr. Miner claims the credit of designing this inge- nious plan. Dr. Walter Burnham, of Lowell, Mass., reports a successful case. Logan {Amer. Jouru. of Med. Sci., 1873) reports a successful case. I believe it Avas first practised in this country, at my suggestion, by Mr. MacCormac, in 1873, at St. Thomas's Hospital. It is a "resource that should be borne in mind as a means of avoiding the great violence and extensive injury which detachment from intimate adhesions to the liver and other organs Avould entail. Pelvic adhesions may require special management. T. Holmes says: "Any persistent attempt to dissect or tear away the mass from the pelvis may end in laceration of the ureters or great veins, and may after all be futile. The alternatives are to pull the cyst as far as possible out of the abdomen, and apply a clamp to its neck ; or to apply a clamp temporarily, cut aAyay the cyst, tear the cut edges with the cautery, and return the mass into the abdomen; or finally to stitch the edges of the cyst to the wound in the abdomen, and leave "the cavity of the cyst exposed." The first is preferable Avhen practicable. ACCIDENTS AFTER OVARIOTOMY. 397 Walter F. Atlee, M.D. {Amer. Journ. Med. Sei., 1877), relates a case, successful, in Avhich he brought out as large a portion of the cyst as possible, clamped, cut it off, and carefully closed the Avound behind it, trusting that the ovary would be sealed to the peritoneum of the ovary, and so close the peritoneal cavity. Wminds of Intestine.—In detaching intimate adhesions the coats of the intestine may give way, or a wound may be made into it by knife or scissors, or the fingers. Wherever intestine is the seat of inflammation or adhesion it becomes extremely lacerable. The opening should be neatly stitched up with a fine needle and silk, catting the ends of the suture short. This accident does not appear to compromise the success of the operation. I have seen several recoveries after it. Bleeding from a surface is to be controlled as already directed. AFTER-TREATMENT. Best is the great principle to be observed. To help this an opiate suppository, or an opium pill, should be given two or three times a day, to tranquillize nervous excitement and restrain action of the boAvels. If vomiting occur, or indeed to anticipate it, give the patient ice to suck; bismuth or oxalate of cerium may be combined Avith the opium. The diet should be highly nutritious, not stimulating: beef-tea, milk, eggs, con- stitute nearly all that can be given Avith safety. Wine or spirits must be given Arery sparingly, and rather as means of restoring the system, if it show signs of flagging, than as a recognized part of the diet. The blad- der should be emptied by catheter every eight hours. To relieve vomiting and tympanites I have found O'Byrne's tube passed a foot or more up the rectum very useful. And the injection into the rectum of half a drachm of chloral, with a drachm of bismuth, a little tragacanth, and four ounces of milk, is of marked service in allay- ing irritability. Unless local distress arise, the wound need not be disturbed for three days. On the fourth day the stump may be examined. It will commonly be found shrivelling up, sometimes even dry. The clamp may noAV be removed. If there be any discharge, Avash lightly Avith weak carbolic acid, and dress Avith lint steeped in carbolic oil. The abdominal Avound is often firmly united in four or five days : but the sutures, if of wire, may usefully remain until the seventh or eighth before being removed. It is desirable to keep a flannel belt or binder on for some days after this. To obviate hernia and to promote the return of the flaccid abdominal walls to due relation with the lessened bulk of contents, a Avell-adjusted belt should be Avorn for a year. Accidents that may interrupt recovery after ovariotomy. When bad symptoms follows ovariotomy, as pain, vomiting, fever with abdominal distension, it is probable that some fluid, blood, serum, or pus is collecting in the peritoneal cavity. It may collect in such quantity as to give rise to sensible fluctuation from one side of the abdomen to the other, or it may gravitate to the bottom of Douglas's space, and form a tense swelling behind the uterus. 398 TREATMENT OF OVARIAN TUMOKS. Whenever fluid can be detected by vaginal examination in the neigh- borhood of the uterus, it is usually in such quantity that it may be re- moved. This may be done bv a long rather fine trocar and aspirator. The seat of puncture should be Avhere there is free fluctuation behind the uterus, so as to strike a dependent part of Douglas's pouch. A drainage tube may be inserted. But a better plan is to remove a stitch in the lower part of the Avound, and insert a glass tube, Avhich will serve to remove offending matter by aspiration, and to cleanse by injecting. Untoward symptoms must be encountered according to their indica- tions. A survey of the causes of death under ovariotomy will supply the best guidance. The first and most immediate cause is commonly shock and collapse. A considerable proportion of all the deaths, I am con- vinced, occurs from shock. Recovery from this is greatly a question of individual poAver of endurance. We can hardly foretell what this poAver is in any particular case. Women recover from the severest operations attended by all the complications considered the most formidable ; others sink after the easiest and simplest operations. Women comparatively robust succumb, whilst the apparently fragile recover. In many cases the unexpected result is not due, at least appreciably, to difference in skill. It can only be referred to difference in innate power of resistance. This is an unknoAvn quantity, and is the chief cause of the uncertainty which surrounds the operation. No doubt the shock can be lessened by care and skill during operation, and the patient can be to some extent supported through it. Shock bears some relation to the length of the operation. Koeberle found the mortality increased with the time spent in the operation. The patient should be carefully watched and supported during the stage of depression which folloAvs the operation. A free sup- ply of Avholesome, fresh, Avarm air, Avithout draughts, should be secured. If the surface is cold, Avarm-water bottles must be applied to the feet and legs ; light stimulants, as a little brandy and Avater, or champagne, or ether, or sal volatile, may be administered. Hemorrhage.—Internal hemorrhage may proceed from tAvo sources— the vessels torn across in separating adhesions, and the stump. The modes of avoiding or diminishing this risk have been described. If hemorrhage to an extent to produce serious symptoms occur, it is bettor, desperate as the expedient may seem, to open the Avound, search for the source, and stop it by styptics, cautery, or ligatures. Peritonitis is a frequent cause of death. It may be purely traumatic, the result of the violence necessarily done during the operation. It may be due to the injury inflicted in separating adhesions. But it has often been remarked that those subjects in Avhom a large extent of peritoneum has been altered in character by previous attacks of inflammation, leaving adhesions to the cyst, are not so prone to peritonitis as are many subjects in Avhom there Avere no adhesions, the peritoneum retaining all its natural liability to injurious impressions. A more serious form of peritonitis is one that seems analogous to the puerperal form. Here there is commonly septicaemia, or inflammation is propagated from the seat of the pedicle, in Avhich some unhealthy action is going on. It will, of course, be espe- cially likely to occur in the incomplete operations, where a portion of cyst has been left behind. It is also seriously promoted by the escape ACCIDENTS AFTER OVARIOTOMY. 399 of the fluid of the cyst into the abdomen, and its imperfect removal. The fluid has been shown in certain cases to possess a peculiarly noxious, even poisonous property. The earliest signs of peritonitis are pricking and shooting pain in the abdomen ; or according to Hutchinson, a peculiar pallor of the cheeks and an anxious expression of countenance, with frontal headache. The pulse becomes quicker and smaller, the skin hot, the temperature rises to 1<>1°, 102-, 103-, or even 104°, the tongue becomes a little dry, and there is almost ahvays more or less sickness. At a later stage the face may become flushed, the skin painfully hot, whilst at the same time the pulse is rapid and very small. Distension of the abdomen Avith flatus is a common and distressing symptom ; and at a later stage the intestines become involved, and the abdomen is full and tympanitic. The peritonitis may be local or general. If limited to the parts adjacent to the pedicle and to the pelvis, it is protective rather than otheiwise, since it tends to exclude irritating matters from the general cavity. In cases, however, in which the peritonitis is encysted, very profuse discharge may take place, and the patient may sink ultimately from exhaustion. If from the first the Avhole peritoneum be invaded, recover}*- is rare. The treatment. Locally, leeches in the earliest stage are useful. The abdomen should be covered Avith a hot linseed-meal poultice. The relief thus given is not less marked than it often is in puerperal peritonitis. But ice has been used with apparent advantage. My OAvn opinion agrees Avith Hutchinson's as to the Aralue of mercury and opium, at least in the initiative stages. But salines are also serviceable, the best being the acetate of ammonia. Where the peritonitis is of a Ioav or erysipelatous type, twenty-drop doses of solution of perchloride of iron should be tried. Where internal hemor- rhage is feared, or Avhen the temperature rises with abdominal pain, the ice-cap is often of signal sendee. Septicemia may occur, although not commonly, Avithout much perito- nitis. The symptoms then are very similar to those of septicgemic puer- peral fever, and should be treated in a similar manner. It is in these cases especially that drainage and Avashing out the pelvic cavity are indicated. The septicemic fever requires careful watching. Having fulfilled the first indication, namely, to provide for the removal of the presumed source of the blood poisoning, the foul matter in the peritoneal cavity, we have to carry out the second indication, that of reducing the fever. The principle of loAvering the temperature of the blood by the external application of cold has been successfully applied. The plan advocated by Mr. Knowsley Thornton {Med. Chir. Trans., 1877), of adapting an'iec-cap to the "head made of coiled India-rubber, through which a stream of ice-cold water is carried, deserves further trial. Air. Thornton applies it whenever the temperature rises to 10z° F. Embolism and Thrombosis.—Some deaths have occurred from these conditions. Phlegmasia dolens occurs occasionally. When it occurs it will be on the side of the stump. Hence it may be assumed to be determined by the clotting of the blood in the vessels strangulated by the clamp or liga- tures. But I believe that the invasion of the blood in loco by septic matter is a nearly constant factor in thrombosis. This invasion Avould 400 TREATMENT OF OVARIAN TUMORS. also naturally be most likely to occur in the neighborhood of the stump, so that the tAvo factors, stagnation and empoisonment, Avould be acting together. It is not a necessarily fatal complication. In one case that seemed desperate at the time of operation, in which it Avas necessary to secure the pedicle by whipcord, and to drop it into the abdomen, recovery took place after phlegmasia dolens. Obstinate vomiting or hiccough may attend peritonitis. But sometimes they can only be referred to irritation of the ganglionic system, the irri- tating cause being pain starting from the structures included in the clamp or ligature, or other injury. The vomiting started by the inhalation of chloroform may persist, or it may be due to strangulation of intestine by entanglement by omentum. In tAvo cases tetanus proved fatal. In some cases obstructed intestine Avas the immediate cause of death. In one case Keith {Brit. Md. Journ., 1873) succeeded in saving the patient by puncturing the dis- tended colon with a fine needle. Inhalation of nitrite of amyl should be tried in such cases. Tavo or three further questions in connection with ovariotomy call for discussion:— 1. How to deal with a case in which the cyst has ruptured, or has given rise to effusion of blood, to peritonitis, or to septiccemia. This literally vital question has already been partly ansAvered by an- ticipation. The argument may be stated as folloAvs: The case is, that the patient is in the most immediate danger from the shock, irritation, and loss of blood attending the injury. The shock may be regarded as a bloAv struck at the vital poAvers. We cannot lessen the shock given by this Woav ; but Ave may, in some cases where there is some rally, do good by removing that Avhich is the cause of protracted shock. This cause consists in the irritation arising from the contents of the cyst, or the blood effused in the peritoneum, which irritation is quickly folloAved by inflam- mation. Of course the patient may sink rapidly under the primary shock, and thus defeat all idea of giving relief by operation. But, in not a few cases, the primary shock does not kill. The patient, hoAvever, will hardly pull through the secondary dangers of hemorrhage, peritonitis, and blood-poisoning, unless these be arrested in their course. There is the opportunity of trying to give relief to obviate these dangers. Here then is a case for the decided application of the great law in medi- cine : Remove the offending cause. If extirpation of a diseased ovary, Avhich is sloAvly sapping the vital powers, be recognized as a justifiable operation, & fortiori must the operation be conceded as necessary when the diseased ovary is the source of instant danger to life. It Avould be difficult to answer d priori reasoning like this, except by urging that, hoAvsoever plausible in theory, it Avould be useless in practice. But even this ansAver, which until recently was still urged, is noAV deprived of force by the results of experience. When the irritating cause has been re- moved, the patient has recovered. The signs of perforation are local and general. The local signs are: pain setting in more or less suddenly in the abdomen ; if a considerable quantity of the contents of the cyst have escaped, sensible diminution in the size of the tumor, marked by diminished tension of it; alteration in OVARIOTOMY DURING PREGNANCY. 401 the shape of the tumor, it loses sphericity, and any solid portions come into more distinct prominence : the signs of ascites may be added to those of the cystic tumor; fluids of OArarian origin may escape by boAvel or bladder. If this last event concur Avith diminished bulk and altered shape of the tumor the conclusion is clear. There may, however, be increased activity of the kidneys discharging the fluid throAvn into the peritoneum by absorption and secretion. The general signs are not constant. There may or may not be rise in pulse and temperature, and rigors ; and occa- sionally there is no appreciable shock. All that may be noticed is a sense of distress, local and general, a minor degree of depression. Mr. Wells says,1 " In several of my cases the operation has been per- formed after the cyst has burst, and its contents had escaped into the peritoneum. The peritoneum has been found intensely red, thick, soft, or villous, and occasionally covered by loosely adherent flakes of lymph. Yet the result has been surprisingly satisfactory. Twenty-four times has this complication presented itself out of the last 300 of my operations. Five of the patients have died, so that the ordinary rate of mortality does not seem to have been much augmented. At any rate the bursting of the cyst, or the filling of the peritoneum by oozing from the puncture made by tapping the cyst, is no bar to the operation, but rather a reason for doing it Avithout delay." Nor is this experience singular. My own and that of many others is to the same effect. In addition to the cases in which ovariotomy is resorted to deliberately as the best means of rescuing the patient from a more or less lingering death, it is justified under certain accidental circumstances of extreme urgency. Some of these are rupture or strangulation of a cyst, attended with internal hemorrhage and shock. 2. The occurrence of strangulation of the tumor as from twisting of the pedicle; of hemorrhage into; or suppuration in the cyst. In all these cases there will arise signs of local injury and constitutional distress, not easily distinguishable from those attending perforation or bursting of the cyst. But the indication to remove the offending body is the same. It is not necessary to determine precisely the mode in Avhich it offends. Dr. Malins relates {Lancet, 1877) a case in AArhich rotation of the tumor on its pedicle occurred as a consequence of tapping. He removed the tumor successfully. 3. How to deal with ovarian cystic tumors complicated with pregnancy. Ovariotomy during pregnancy has been performed several times, the operator not suspecting the pregnancy before the operation. What should be done Avhen a pregnant uterus is discovered during some stage of ovari- otomy ? Wells says, " Let it alone," that is the uterus. Dr. Atlee per- formed ovariotomy in the second month of pregnancy. It Avas followed by such great irritability of stomach, in consequence of the state of preg- nancy, that the Avoman could not be nourished, and she died, thirty days after, of starvation. In a case related by Mr. Burd, of Shrewsbury, in 1S47, of ovariotomy performed by him in the third or fourth month of pregnancy, abortion took place tAvo days after operation, and Avas folloAved by alarming symptoms, lasting several days. Dr. Marion Sims performed 1 Diseases of the Ovaries, 1872. 26 402 TREATMENT OF OVARIAN TUMORS. ovariotomy in the third month, not detecting the pregnancy until the ovarian tumor had been removed. The patient recovered Avell, and Avas delivered of a fine child at term. Mr. Wells says, " If inadvertently the uterus be penetrated, it any conclusion can be draAvn from the case in Avhich I made this mistake and emptied the uterus, and two other cases in which the same mistake Avas made by other surgeons, Avho did not empty the uterus, but closed the puncture in its Avail by wire sutures, both patients having died after abort- ing, while mine recovered, it would appear to be the safer practice to empty the uterus." Wells relates four cases, in one of Avhich ovariotomy Avas performed at the fourth month of pregnancy, after rupture of the cyst and peri- tonitis; in the second, third, and fourth operation Avas a matter of election to avoid other dangers. The result was successful. All three subjects gave birth to living children at term. When pregnancy supervenes on ovarian dropsy, there are three, per- haps four, courses out of Avhich to select. a. We may leave things alone, simply Avatching, prepared to act, if urgency from rupture of the cyst, axial twisting, or hemorrhage or ex- cessive pressure arise. In a considerable proportion of cases pregnancy goes on to term, and the labor is completed happily. Is it wise then to stand by and trust to the chance of this issue ? If Ave determine to antici- pate danger, Ave may b. Tap the cyst. This will, of course, at once lessen the inconvenience of pressure, and the danger of bursting. c. Or Ave act upon the uterus. We may lessen the distension and risk of rupture by draAving off the liquor amnii; that is, by inducing labor, postponing the question of dealing Avith the tumor, until the case is re- duced to its simplest expression, by eliminating the pregnancy. I have discussed this question in my work on Obstetric Operations, and have there given the reasons which appear to me to weigh in favor of this course. d. The opposite vieAV, that of acting on the ovarian tumor by tapping or extirpation, is Avell argued by Mr. Goddard {Obstr. Trans., 1871). No doubt in certain cases, either proceeding may be preferable to the other. But, as a general rule, I believe experience will show that it is better to act first upon the pregnant uterus. Mr. Wells refers to five patients whom he has tapped during pregnancy, one of them three times, one twice, and three once. In all these Avomen great relief was afforded by the tapping, no ill effect of any kind Avas ob- served to folloAV it, and in all the children Avere born alive, after labors of moderate duration. There is a peculiar state of nervous and vascular tension produced by pregnancy which should be taken into account. Pregnancy induces great irritability of the nervous centres, spinal and cerebral. This irri- tability accounts for the greater risk of abortion, of vomiting, if interfer- ence be resorted to. It also is a source of danger if accident or com- plication arise, as rupture of the cyst, or inflammation. And as this complication may be more serious than the operation, the operation may become justifiable as the lesser danger. DEVELOPMENTAL FAULTS OF UTERUS. 403 BelieA'ing, as I do, that a woman in Avhom pregnancy is complicated with an ovarian cvst, is in a position of imminent peril; that her life is threatened at any moment by some catastrophe which may strike so sud- denW and so violently as to leaAre no time for action, my opinion is decidedly in favor of eliminating the pregnancy. I have acted on this principle on several occasions with a successful result, not counterbal- anced by a single unsuccessful one. If the cyst actually burst, or give rise to hemorrhage or peritonitis, there should be no hesitation in attempting removal of the tumor, which is the cause of immediate danger. Ovaritomy by the Vagina.—In suitable cases where the tumor is small, and presumably free from adhesions, Thomas recommends removal through the roof of the vagina. The occasional extrusion of tumors by bursting through this route under the straining of labor lends support to his expe- dient. Thomas proposes to open Douglas's pouch by the vagina, to puncture the cyst, then to draAV it out, to tie the pedicle and cut off the tumor, returning the stump into the abdomen. Some dermoid cysts might admit of removal in this way ; but the frequent complication with adhesions Avould prove a formidable obstacle. Normal Ovariotomy.—The subject of ovariotomy cannot well be dis- missed without reference to the operation of removing the healthy work- ing ovaries, proposed by Dr. R. Battey, of Georgia, U. S. A. The ques- tion, of course, does not apply here. This form of " spaying" will be referred to more particularly Avhen discussing the treatment of fibroid tumors of the uterus. CHAPTEE XYII. SPECIAL PATHOLOGY OF THE UTERUS ; DEVELOPMENTAL FAULTS; UNILATERAL dk.velopment; uterus bicornis ; uterus bipartitus, bilocularis ; hypertrophy; atrophy. Before entering upon uterine pathology proper, it will be useful to take a rapid review of the congenital or developmental abnormities of the uterus. This review is necessary, because these abnormal conditions are often attended by disorder of function, and give rise to symptoms, the interpretation of which would be extremely puzzling, if not sometimes impossible, unless this association Avere present to the mind. Some of these conditions have been referred to in the history of Retained Menstrua- tion, and of Ectopic Gestation. The following summary is chiefly drawn from Rokitansky and Kussmaul, and from study of specimens in the London museums. The principal varieties of atresia, congenital and ac- 404 PATHOLOGY OF UTERUS. quired, have been considered in Chapter VII. on " Occult Menstruation:" and in Chapter XIII. on "Ectopic (Testation." that curious form of uterus resulting from arrested development of one horn, has been suffi- ciently illustrated. Complete absence of the uterus is extremely rare. When there is apparent absence of the uterus proper, there will be found in one or both sides, behind the bladder, in the peritoneal fold destined to receive the internal genital organs, one or two small flattened roundish bodies, solid, made out of uterine substance, and with a cavity lined with mucous mem- brane. These arc rudimentary uterine horns, to Avhich the Fallopian tubes have a distinct relation, although sometimes these are absent, and sometimes form a blind worm-like tube closed at the juncture with rudi- mentary uterus, or opening into it. This* uterine development in the form of two oval holloAV rudiments, from Avhich a Fallopian tube runs outAvards to its ovary, is Mayer's uterus bipartitus. Inwards, and betAveen the same peritoneal folds, these uterine rudiments are united by a closed cord of uterine substance. At the seat of the uterus is found a mass of connective tissue Avhich, mingled sparingly Avith the just mentioned cord of uterine fibres, assumes the outline of a uterine body, and is inserted beloAV into the roof of the vagina. In this roof a stellate scar is sometimes seen. When one of these rudimentary uteri has developed into a uterine body, then there appears the one-horned uterus, uterus unicornis. When both are developed, then Ave have the two-horned uterus, uterus duplex. The one-horned uterus ahvays appears as one-half of a uterus, that is, as the unpaired half of a two-horned uterus, and is either a right or a left uterus. There is a cylindrical or spindle-shaped prominence on the cor- responding side of the uterine body, from the upper end of which runs the tube. Compared Avith the normal uterus, the one-horned is smaller; the vaginal portion especially is smaller ; in the cervix the plicce palmata? are nearer to the convex border of the uterus ; the broad ligament on the side of the missing uterine half is larger, often of extraordinary size. The uterine rudiment of the other side presents all the above condi- tions : it is a solid or a hollow little body; it sometimes lies at a consid- erable distance from the one-horned uterus in a Avide-spreading peritoneal fold ; and sometimes it is altogether wanting. The corresponding ovary and tube folloAV the same rule. The junction betAveen the rudimental and the one-horned uterus presents the greatest diversities. At times there is none. At times there runs from the rudiment a round or flat- round cord, composed of uterine parenchyma in an oblique direction to- wards the one-horned uterus, and inserts itself into, or above the internal orifice, sometimes higher, sometimes lower. This cord is solid, or con- tains a canal Avhich connects the cavity of the one-horned uterus Avith that of the rudimental uterus, and makes this last susceptible of impregnation. But we have seen, especially from Professor Turner's researches, that impregnation possibly takes place even Avhere the structure uniting the rudimentary horn Avith the developed horn is solid. Here it may be useful to place the folloAving figure taken from Tiede- mann (Fig. 92). It is described as a " uterus strongly developed to the DOUBLE UTERUS. 405 right, the neighborhood of the isthmus atrophied." It is probably an instance of imperfect development of the left horn of the uterus. In such Fir. 92. Uterus strougly Developed to Right. Probably Imperfect Development of Left Side. (From Tiedemann.) cases it is probable that the general development of the uterus is also de- fective. I introduce it because I believe it represents a formation which Fig. 93. Double or Bicornute Utorus, with a Single Cervix and Os Uteri (R. B.). (From Nature, from a specimen in Guy's Museum, 2261".) is not very infrequent. I have many times met with cases in which the uterus resembled this one in size and position, there being a small os 406 PATHOLOGY OF UTERUS. uteri scarcely projecting into the vagina. They have been brought under observation on account of dysmenorrhea, amenorrluea, or sterility. When, as already said, the tAvo rudiments constituting the uterus bipar- titus are developed equally after the type of the one-horned uterus, there appears an excess of development in the shape of two uterine ha/res, which are fused together from one point of their convex borders in the form of a uterus bicornis. The degree of two-hornedness varies, and is determined by the spot from Avhich the tAvo uterine halves run together. The loAver this is, the more obtuse is the angle of union, and so much the greater is the divergence of the tAvo halves. It falls very rarely beloAV the orificium internum, and here the two horns run into one common cervix in such a manner that they lie horizontally. The higher the place of union, the more acute is the angle, so that at last the tAvo-hornedness is nothing more than an unusual divergence of the tAvo horns of the uterus, Fig. 94. Bicornute Uterus (R. B.). (Royal College of Surgeons, ad nat.) Avhich exhibits outwardly a somewhat broader fundus, but is otherwise normal. Under these conditions there appears betAveen the tAvo uterine- halves a uterine mass Avhich has the significance of a fundus uteri. The higher this connecting bond between the uterine-halves is, the more prominent is this significance ; and when it is on a level with the ends of the uterine horns, and overtops these Avith its arch, then the two-horned- ness has vanished. This is illustrated in Fig. 95, taken from a girl Avho died of phthisis at the age of seventeen. She was Avell developed. The Graafian vesicles Avere numerous and large. The vagina was well-formed. The horns DOUBLE UTERUS. 407 open into a common uterine cavity. The walls are unusually thick; the fundus, although depressed in the centre, indicating the original two- hornedness, is straighter than in Fig. 94. The bicornute uterus is illustrated in a remarkable specimen in the Royal College of Surgeons, taken from a mulatto {Physiological Series, 2&2H). In this specimen the body of the uterus is draAvn out into two long horns so that the line representing the fundus betAveen the tAvo horns is a long concave arch. More commonly the two horns continue parted for an indeterminate space by a septum descending from the fundus to a variable length. It may reach as Ioav as the os uteri internum, or even the os externum. If the septum is incomplete, it ends beloAV in a sharp edge, but it commonly stretches loAver doAvn, along the posterior wall, in the form of a ridge, like a raphe. In Fig. 95, also taken from a specimen in Guy's Museum, No. 226180, is seen a double uterus, with a single cervix, so that only one os uteri Fig. 95. Bicornute Uterus, the Septum dividing the Uterine Cavity into two, descends as far as the Isthmus. (R. B.). (From Xature, from a specimen in Guy's Museum.) opens into the single vagina. Such a case must be recognized in the living, bv feeling the indented fundus, as well as by the sound, Avhich might perchance enter the tAvo cavities one after the other. In other cases the division extends along the cervical portion, so that tAvo ora uteri open into one common vagina. Such a case may be very puzzling in labor, as I once experienced. I Avas called in consultation to a case of puerperal convulsions, in order to deliver the Avoman. The surgeon in attendance, using his right hand, always touched the child's head presenting at the os uteri. I, as is my custom, examining with the 408 DEVELOPMENTAL FAULTS OF UTERUS. left hand, could only feel the head through a thick solid Avail of flesh. It Avas not until I followed exactly the clue indicated by my friend that I touched the head, and could apply instruments. There Avas a double uterus. My finger had first entered the empty side. In Cruveilhier's magnificent Avork is a beautiful drawing of a double uterus, taken from a woman who died of puerperal fever. The uterus which contained the foetus presents much the same appearance as is usual after delivery, in the single uterus. The other uterus is enlarged in sympathy with its impregnated felloAv, but is considerably smaller. In a feAv very important cases there is atresia of one half of the uterus bicornis. To the twodiornedness, Avith formation of a septum, belongs the uterus bilocularis, Avhich consists in the septum-formation in a uterus, normal as regards the degree of divergence of its horns. The septum in the uterus bilocularis presents all the variations seen in the uterus unicornis. Its presence is often signified by a greater breadth of the uterine body, and sometimes by a shalloAv furroAv along its posterior Avail. The vagina presents corresponding diversities in the uterus bicornis and the bilocularis. It is normal, or there is a septum, dividing the canal more or less completely into two. Fig. 96. Double Uterus and Vagina (R. B.). (From Xature, from a specimen in Guy's Museum.) u, u. The right and left uterine cavities, communicating by separate cervical canal and os into v v right and left vagina. a. The septum of dense fibrous tissue, which runs along the median line. The septum may extend all along the uterus and vagina. The patho- logical relations of this form of uterus have been referred to in the Sec- tion on "Occult Menstruation." The condition is not, I believe, very uncommon. Most museums can show a specimen; and every now and DOUBLE UTERUS. 409 then a living specimen comes under notice, either accidentally or on account of some difficulty in the functions of menstruation or labor. But these difficulties are by no means necessary. Things may go on very well, one vagina and one uterus acting. The Figs. 96, 97, are taken from a preparation (22C185) in Guy's Museum. There is one equally typical in St. Thomas's. The Guy's specimen Avas taken from a Avoman Fig. 97. Transverse Section of the Vagina; of the same Specimen as the preceding Figure showing, v, v, the Separate Vaginal Canals (R. B.). (Nat. size.) aged fifty, Avho died of influenza; she had been married twenty years, remaining sterile. The tubes and ovaries Avere matted together by adhe- sions. The body of the uterus seen externally Avas single, only a slight depression marking the internal division. As regards menstruation, conception, and labor, the described forms of uterus behave as folloAvs: The constituent rudiments of the uterus bipartitus are capable of conception ; an accumulation of menstrual blood in the cavity of such a rudiment Avith dilatation of it may happen. Where such a rudiment is connected Avith a one-homed uterus by a perforated bond of union, it is capable of conception, and so evren Avhen it is solid. The gestation terminates, as in tubal gestation, by rupture, Avithin three or four months. The uterus unicornis and the uterus bicornis, as Avell as the bilocularis, are capable of conception. In the tAvo last, repeated ges- tations occur interchangeably, sometimes in one, sometimes in the other uterine half. When conception takes place in one half, a decidua is formed in the other half, and groAVS during the early part of the pregnancy equally with the pregnant half. Moreover, twin-pregnancy may occur, not only in one uterine half, but pregnancy has been observed in the tAvo halves simultaneously. In this case one foetus is usually arrested in develop- ment. In these uterine forms the ruptures, abortions, tedious labors observed are accounted for by the smaller mass of the uterus, and by the diminu- tion of the uterine fundus. When there is atresia of one-half of the uterus bicornis, retention of menstruation, with its perilous consequences, will occur. Bokitansky 410 DEVELOPMENTAL FAULTS OF UTERUS. relates a case Avhere the fluid retained in the closed half caused perfora- tion of the septum, and discharge into the half Avhich communicated with the vagina. Abnormal size of the uterus may originate in foetal life or may arise later, from premature sexual maturity. It consists in hypertrophy and dilatation. Hypertrophy affects the Avhole uterus or only a part of it. As partial hypertrophy, that of the vaginal-portion is especially deserving of atten- tion. General hypertrophy is commonly so formed that the uterine cavity is uniformly enlarged {eccentric hypertrophy). In lesser degrees the cavity is often normal, and less frequently it is narroAved {simple and concentric hypertrophy). The enlargement attains in the first form con- siderable degrees, becoming as large as a goose's egg, or a fist, and larger; its Avails becoming half an inch or an inch thick. The most im- portant enlargement occurs Avith connective-tissue tumors which prolapse into the cavity or grow in it. A simultaneous elongation occurs in hy- pertrophy of the prolapsed uterus. The hypertrophied uterine mass is often like that of the normal uterus, and often the connective tissue in it is increased, and thus its consistency is greater. Dilatation of the uterine cavity is commonly attended by thickening of its Avails {active dilatation) ; and often Avith thinning {passive dilatation). It is generally produced by accumulations Avithin, the result of stenosis or atresia at a loAver point. In Guy's Museum (220172) is a specimen shoAving dilatation of the body of the uterus Avith thinning of its Avails. A quantity of albuminous matter had collected Avithin it, and the os in- ternum was closed. Abnormal smallness of the uterus may be the consequence of defective development. The uterus is small from retaining its infantile form, or its groAvth Avas arrested. In the latter case it is small throughout, thin- Avalled, its mucus membrane is thin, its plicae palmatie very slightly raised. Commonly the other organs, the Avhole body, are retarded in development, and especially the heart is small. Atrophy.—The smallness may be due to atrophy. This may affect the Avhole uterus, or simply the cervix, or the vaginal-portion. Atrophy of the Avhole uterus folloAvs chiefly upon chronic catarrh in advancing age ; often prematurely upon cessation of menstruation ; and sometimes even in younger persons, in consequence of the rapid succes- sion of labors. Mostly, the uterine cavity is narroAved {concentric atro- phy), and here and there, in the cavity, or at the orifices, there are adhesions of mucous membrane. Often, the uterine cavity is enlarged by the accumulation of secretions. When these adhesions exist {eccentric atrophy) the uterine substance is dense, tenacious ; or especially in ad- vanced age, softened, pale, penetrated by rigid, Avidened, calcified arte- ries, a condition which disposes to bleedings. (See Fig. 98.) Fibrous tumors also lead to atrophy of the uterus. Atrophy of the cervix is commonly caused by the dragging which it undergoes from the rising of uterine and ovarian tumors into the abdo- men. It is draAvn out length Avise, made thinner ; the duplicature of the vagina which surrounds the vaginal-portion is unfolded, and the vaginal ATRESIA OF CERVIX. 411 roof is transformed into a cone. Then closures of the cervical canal ensue, and even at times a gradual separation of connection. Atrophy of the vaginal-portion occurs sometimes after repeated labor. Mr. Walter Whitehead relates1 a remarkable case, in which it seems probable that the uterus and OAraries completely disappeared after labor. A Avoman, aged thirty-nine, first menstruated at eleven, married at tAventv-five. had four children Avithin three years and a half, the first tAvo being born prematurely. Severe flooding took place after the last labor. She had a long convalescence, but there Avas no history of acute disease. During eleven years menstruation never returned, nor Avas there the slightest leucorrhcea ; she had become quite indifferent to sexual inter- course. For four months previous to birth of last child she had passed large quantities of blood per anion. She Avas a tall, pale, thin Avoman, Avith markedly flabby cheeks, and a commencing arcus senilis; the mam- mae shrunken and flat, Avith apparent atrophy of gland-structure. Xo cervix or uterus could be detected ; but a small triangular opening Avas felt and seen in the position of the os. A Xo. 12 elastic catheter passed, Avithout any pressure, eight inches through the opening. Every mode Fig. 98. Atrophy of the Uterus and Ovaries from Ossification of the Arteries. a, a, Uterus laid open ; b, Tube ; c, ovary ; d, d, d, the principal arteries, and several of their smaller branches completely ossified and nearly impervious ; the substance of the uterus e, containing a mul- titude of small arteries in the same state; a tumor/, composed of dilated veins and cellulo-fibrous tissue, occupying the fundus of the uterus. (After Carswell.) of examination failed to detect a uterus. The sound passed through the opening could be felt under the abdominal wall, two inches above the umbilicus. It might be conjectured that the sound Avent through the fundus of the uterus ; but repeated examinations, varied in manner, by ' Brit. Med. Journal, Oct. 1872. 412 ABNORMAL SHAPES OF UTERUS. Dr. Thorburn, Dr. Lloyd Boberts, and Mr. Windsor corroborated the conclusion draAvn by Mr. Whitehead. The preceding draAving (Fig. 98) taken from CarsAvell's Ma-hid Anat- omy represents a form of atrophy of the uterus connected Avith calcifica- tion of the ovario-uterine arteries. Obliteration of the uterine cavity is sometimes the result of concentric atrophy; it often results from adhesions folloAving accumulations of mucus, mucous polypi, or connective-tissue tumors. Obliteration of the cervix uteri and of the orifices is commonly caused by closure from pullulating ovula Xabothi. More often the os internum is closed by flexions. Occasionally it is the result of longitudinal drag- ging of the cervix. The os internum may be closed by cicatrices from lacerations and bruisings, from ulcerative loss of substance, from amputa- tion of the vaginal-portion, from the action of cauteries. In aged Avomen, it not unfrequently closes by a process of concentric atrophy, the margin of the ring of the os uteri getting glued up by dense epithelial scales resembling a membrane. Fig. 99. Stenosis ; Atresia ; Dilatation of Uterus (R. B.). London Hospital, Ea. 56, from nat. size (" Dr. Barnes"). Fig. 99, from a specimen in the London Hospital, put up by me presents closure at three different points of the uterine canal. This uterus came from a woman aged forty-three, married, barr It is divided imperfectly into three cavities. The upper two, a, b, STRUCTURAL CHANGES OF UTERUS. 413 hour-glass shaped; the loAvest, c, about three-quarters of an inch long, is separated from the middle one by a nearly complete fold of mucous mem- brane. In the middle cavity, the uterus is deeply furrowed, and studded Avith large gaping follicles. The atresia was no doubt due to endometritis Avith follicular inflammation. Abnormities of Shape of the Uterus.—As a congenital anomaly, there occurs the congenital obliquity in connection Avith the uterus bipartitus, unicornis, bicornis, and bilocularis. The most marked form of this is seen Avhen one horn with its tube stands higher than the other, and the vaginal-portion is correspondingly oblique. This uterus lies obliquely in the pelvis, inclining to one or other side of the vaginal roof. (See Fig. 92 from Tiedemann.) The broad ligament of this side is narrower, and the ovary lies nearer to the uterus. Sometimes this uterus is bent in an angular form on that side Avhich is highest. Often the higher side is more dense and bigger. There are asymmetrical forms of the uterus caused by excessive de- velopment of one half of the body of the uterus. When there is bending on this side, the retort form is produced. Among acquired malformations, there is obliquity from one-sided dragging of a fibrous tumor, or an ovarian tumor, from dragging in hyper- trophy of the vaginal-portion, from scars, from various accumulations in its cavity, and from inflammatory adhesions in one broad ligament. CHAPTER XYIII. GENERAL OBSERVATIONS ON UTERINE PATHOLOGY; EFFECTS OF LABOR AND LACTATION ; INVOLUTION IN DEFECT AND EXCESS. In studying the pathology of the uterus, it is especially necessary to keep in constant vieAV the peculiarities of structure and the physiology of the organ. No organ in the body undergoes such remarkable physiological changes. At each menstrual period there is increased vascularity, in- creased volume, increased muscular energy, the development of new tissue, folloAved by a retrograde process of involution, Avhich effects the return to the ordinary state. At every pregnancy the changes Avrought are more Avonderful still. Under its physiological influences, the uterus is thus continually subject to alternate hypertrophy and atrophy, or more strictly speaking, involution. The mucous membrane is endoAved Avith extraordinary regenerative poAver. And these active reproductive and solvent forces inherent in the uterus are constantly ready to be called 414 EFFECTS OF LABOR ON UTERUS. into action on any abnormal stimulus. Thus, if a fibroid tumor form in the uterine Avail, or project into its cavity, the vessels and tissues respond just as they do to the stimulus of impregnation. Interruptions, then, to the fulfilment of the organic changes evoked by function will account for a large proportion of the cases of uterine disease, especially congestion, engorgement, hyperplasia, hypertrophy, atrophy. Continuallv recurring functional acts will also exert an influence, gene- rally injurious, sometimes beneficial, upon morbid existing conditions. Perhaps there is no organ in the body more prone to hypertrophy than the uterus. Its functional hypertrophy has often been likened to inflammation, notably that hypertrophy of the mucous membrane which results in the formation of the decidua. The diatheses also must not be overlooked. When one of these exists, it may be the primary cause of the development of disease in the uterus ; or if one of them happen to complicate uterine disease which has arisen from other causes, it will impress its stamp, it Avill greatly increase the difficulty of cure, and will, therefore, dictate largely the course of treat- ment. The strumous, dartrous, or herpetic, rheumatic or gouty diathe- ses, or the syphilitic, tuberculous, or cancerous cachexia often play a most important part in the production, continuance, and curability of uterine diseases. The uterus is liable to alteration of structure and disturbance of func- tion from causes external to itself. Some of these may take their rise in distant organs, some in neighboring organs ; and the uterus, as an in- tegral part of the whole organism, is subject to the constitutional disorders Avhich affect the body, and to the disorders ensuing upon the multitu- dinous varieties of toxicohsemia. Thus the uterus is liable to tubercle. The blood dyscrasioe Avhich dispose to hemorrhages from the mucous membranes are perhaps more likely to induce hemorrhage from the uterus than from other organs. This is especially true during the period of sexual activity. Thus scurvy, smallpox, measles often cause uterine and tubal hemorrhages. Certain medicinal substances or poisons circulating in the blood act with special intensity upon the uterus. The uterus is remarkably susceptible to nervous impressions, emotional, reflex, and so-called sympathetic ; and through these nervous impressions it is certain that functional and even structural disturbances are produced. The uterus stands in the most intimate correlation with the ovaries and breasts. With the ovaries it is directly associated by its vascular supply, Avhich may be said to be common to both organs. The vessels supplying both so freely anastomose that it is impossible for hyperaemia to exist in the one Avithout involving the other in a similar condition. This is most strikingly manifested in the uterine hyperaemia evoked by the ovarian menstrual nisus ; but it is almost equally clear that Avhat is called ovarian dysmenorrhoea reacts upon the uterus also. The application of the suckling infant to the breast often causes con- traction of the uterus. I have often knoAvn it cause uterine hemorrhage. Many Avomen are conscious of pain in the uterus Avhen suckling. The application of leeches, blisters, or cupping glasses to the breast has brought on menstruation. This Avas knoAvn to Hippocrates. EFFECTS OF LABOR AND LACTATION. 415 Obstinate pruritus pudendorum, by keeping up a constant excess of blood and local nervous disorder, not seldom brings about a congestion, enlargement, or infarctus of the uterus. The uterus in its turn is the starting-point for manifold affections of the distant organs, and of the general system. I do not in this Avork more than glance at the influences Avhich the pregnant Avomb exerts. Those ay Inch spring from the non-pregnant Avomb are scarcely less striking. The uterus is especially liable to change of structure and disturbance of function under the influence of changes affecting its neighboring organs. Floating, as it does freely, between the bladder and the rectum, it is sub- ject to constant change of position, according to the varying conditions of fulness or emptiness of these organs, Of course, so long as these conditions are Avithin physiological limits, the uterus adapts itself readily to them ; but if the natural mobility of the uterus be impeded, as by plastic deposits about the broad ligaments, by blood-masses and plastic deposits in the retro-uterine pouch, by tubal gestation, or by any body becoming attached to it, uterine hyperaemia proceeding to infarctus or hypertrophy is sure to folloAV. In every case of pelvic peritonitis, or so- called pelvic cellulitis, the uterine Avails are found thickened. This is a frequent cause of secondary puerperal hemorrhage, and of hemorrhage continuing for months after labor as menorrhagia. This, it may be said, is due to arrested involution from the state of pregnancy, this form of inflammation commonly arising after labor or abortion. But I believe this is only one particular instance of a general law. The same state of engorgement and hyperplasia is obser\red, no matter Avhat the cause Avhich fixes the uterus. This fixing and the attendant changes in the circulation of the organ account in great part for the enlargement of the body of the uterus, which takes place Avhen cancer invades the neck. If inflamma- tion begin in the broad ligament or in Douglas's pouch, not spreading to the uterus, but fixing it by external deposits, enlargement equally follows. The uterus, also, I have observed is liable to hyperplastic enlargement, as the result of oft-repeated or long-continuous hyperaemia produced by disorder of the liver, kidneys, or heart. We shall find the history of the natural changes ensuing upon men- struation, pregnancy, and labor to be a necessary introduction to the right appreciation of engorgement, inflammation, hypertrophy, prolapsus, ver- sions and flexions of the uterus, and of other uterine and peri-uterine affections. This history, then, Avhich really includes the study of the etiological relations of so many disorders, will here be briefly traced. EFFECTS, LOCAL AND CONSTITUTIONAL, OF LABOR AND LACTATION. A very large proportion of the cases of uterine disease Avhich come under treatment are the result, more or less immediate, of parturition. To understand this aright it is necessary to study Avhat are the effects of parturition upon the uterus. Parturition is a violent process. Even in ordinary labor the dilatation of the cervix uteri is effected in great part by the direct pressure of the head or other part of the child. In many cases the pressure thus exerted amounts to severe bruising, contusion of 41»1 EFFECTS OF LABOR ON UTERUS. tissue, attended by a partial sliding, a glacicrdikc movement of the mucous membrane, aAvay from the subjacent tissues. This traumatic process necessarily involves the rupture of many small vessels, produc- ing ecchymosis and serous effusion in the connective tissue, and even in the Avail of the cervix. That the edge of the os externum uteri is almost constantly torn in first labors is notorious. The peculiar distress aris- ing from this rent has been Avell studied by Emmet. Impeded Involution.—The first in time, if not in importance of the results of labor, is the persisting enlargement of the uterus, which marks the failure of the process of involution. Within a month the uterus ought to complete its return to the ordinary state ; that is, it ought to recover from a bulk represented by one and a half pounds weight or more to tAvo or three ounces. This Avonderful change is brought about chiefly by tAvo processes. The first is one of active and tonic contraction of the muscular fibre, Avhich by diminishing the bulk of the organ, squeezes out of its vessels all superfluous blood. The second process is a compound one of absorption and excretion. The noAV useless solid tissue is first converted into granular fat, then absorbed into the circulation, and lastly ejected from the organism by the glandular apparatus. Both these pro- cesses are liable to be impeded. The first and most essential act, that of vigorous and persistent muscular contraction, is often badly performed. A degree of haemostasis remains, which keeps up congestion, disposing to hemorrhage and inflammation. The excessive bulk and Aveight of the organ occasion local distress. This condition, moreover, retards the second essential process of absorption. And if to this be added, as is too commonly the case, feeble glandular action and weak nutrition, invo- lution is seriously retarded. Besides mere want of poAver, other causes may concur in frustrating the due involution of the uterus and vagina ; and these it is desirable to enumerate. Associated under the general term, want of power, we of course include the influence of accidentally complicating diseases, as fevers, phthisis, and of the cachexiae, as struma and syphilis. Under the influence of these diseases involution rarely goes on well. A marked excess of bulk, Avith chronic endometritis, may be observed for Aveeks and months. Flooding during and after labor, by Aveakening general poAver, and especially by impairing tonicity of muscular fibre, retards involution. The occurrence of perimetric inflammation during childbed, especially if attended by effusions Avhich impede the mobility of the uterus, surely retards involution. Indeed, I think it may be laid doAvn as an aphorism that whenever the mobility of the uterus is arrested, whether the cause be external or internal, a degree of hyperplasia is the result. Thus, as in the case just mentioned of perimetritic adhesions, imperfect involution and a process of slow infarction folloAV. In the case of ectopic gestation Avhere the fcetal sac comes into adhesion Avith the uterus, the primary development of the uterus under the stimulus of conception is maintained, and even exaggerated. When peritonitis and adhesions form from malig- nant disease, the uterus is always increased in bulk, and this increase is greatly due to this cause, not alone to the direct influence of the malig- nant disease. The inevitable injury inflicted upon the cervix, and especially upon the PROPHYLACTIC TREATMENT. 417 vaginal portion, may evoke such an active process for repair that general involution may be impeded. Displacements of the uterus also impede involution ; and displacements arc very apt to occur after labor. The most common displacements are retroversion, retroflexion, and prolapsus. When one of these occurs the free circulation through the uterine vessels is necessarily interrrupted. The arteries may pump in blood, but the return by the veins is obstructed by the tortuous course and angulations produced by the displacement. Iheniostasis, frequent metrorrhagia, arrest of involution, and continuous infarction are the result. Fibroid tumors, or polypi in the uterus, retard involution, by keeping up a developmental attraction of blood. There is a kind of spurious gestation. I am disposed to fix the normal period required for complete involu- tion at one month. But this applies to persons in health, and placed in favorable circumstances. Hospital air is an unfavorable condition; and I am told that in the lying-in hospitals abroad six weeks is the time usu- ally required. The reduction in size Avhich the uterus has to undergo, and the brief space within which this change has to be effected, constitute one of the most striking facts in physiology. At the full term of pregnancy the cavity of the uterus, says Simpson, contains above 400 cubic inches ; and in the non-pregnant it can hardly be said to be equal to one cubic inch, let to this latter capacity the uterus must be reduced in a month. The extent of involution of the uterus after labor may be accurately traced, by observation, by touch, and by measurement Avith the sound. The folloAving diagram (Fig. 100), from Simpson, gives an idea of the ordinary difference in bulk of the uterus in Avhich involution has been ar- rested, and that of the uterus in its ordinary state. The uterus is especially enlarged in the antero-posterior diameter. Its Avails are thickened. The cavity is larger, and in many cases the Avails not coming into contact as in the normal state, there is an actual cavity in the body of the uterus, in which the sound Avill revolve. A considerable part of the bulk of the uterus in sub-involution is due to infiltration of fluid, as serum, in the tissue, and to blood partly stagnant in the capillaries and veins. Treatment, Prophylactic.—By proper care immediately after labor and during childbed, involution may be effectively promoted. The first care is to sec that the uterus is emptied of placental-remains and clots. The second point is to secure firm contraction, by compression, and by the administration of ergot, quinine, digitalis, or strychnine. For many years it has been my practice to give these remedies tAvo or three times a day from the very first. They help not only to lessen the remote dangers of imperfect hiAolution, but also the immediate danger of septicaemic puer- peral fever. The third point is to support the strength of the patient by liberal diet. The fourth is to insist upon rest for two or three Aveeks. And lastly, to be satisfied that the uterus is not prolapsed or retroverted. If retroversion or retroflexion, a very common condition in childbed, is allowed to continue, involution Avill surely be arrested. The evidence of the traumatic injury sustained in labor remains in 27 418 EFFECTS OF LABOR ON UTERI'S. the indented cicatrices round the margin of the os, Avhich are character- istic of the vaginal-portion in women avIio have borne children. But if the parts be examined soon after labor, much more striking marks of the injury they have sustained will be witnessed. Immediately after labor Fig. 100. The outer outline represents the bulk of the uterus avrested in its involution after pregnancy. The inner one represents the bulk it ought to retain. (After Simpson.) the vaginal-portion is large, flabby, pulpy, so as to be almost indistin- guishable to the touch. It is often some days before it retracts to any considerable extent, or regains much firmness of texture. The tissue of the cervix and of the connective tissue surrounding; the vessels at their entry from the broad ligaments is infiltrated with serum, which has to be absorbed. The entire thickness of the vaginal portion, as I have repeat- edly seen in post-mortem examinations, at the end of a Aveek or even ten days after labor, is still soft, large, and black from ecchvmosis. It must also be remembered that the vagina during pregnancy and labor undergoes changes analogous to those Avhich affect the uterus. Dur- ing pregnancy the extreme vascularity of the vagina gives a characteristic test of this condition. Its walls groAV in length and breadth : its tissues become softer, and more distensible. To the touch this is very percep- tible. During labor it is subjected to enormous distension, and even vio- lence. Involution Avill be arrested under the same conditions as those IMPEDED INVOLUTION. 419 which arrest involution of the uterus. The vagina then remains larger and looser: folds may even project through the vulva. Thus Ave get a heavier uterus, which has to be supported by a vagina of less than usual poAver. Under favorable circumstances, the process of repair is rapid and com- plete. But in a great number of instances, the conditions are not favor- able. Repair is retarded by a weakly state of the constitution, by the intercurrence of various morbid actions, by imprudence in getting about too soon, and the too early resumption of ordinary duties. I am per- suaded that rest, physical and physiological, for at least a month after labor, is essential to complete the repair of the injuries sustained, and the involution of the pelvic organs. This proposition will perhaps appear overstrained in the opinion of those who advocate a generous diet from the day of labor, and removal to the draAving-room in less than a Aveek. I have so frequently seen pernicious effects, immediate and remote, from this practice, that I cannot hesitate to condemn it. It is easy to induce any number of cases of Avomen avIio have been thus treated, and have made good recoveries. But the practice is not thus justified, if the ex- ceptions also are numerous. It is true, that many Avomen return to their ordinary mode of life Avithin a fortnight, and continue Avith more or less success to perform their duties. But the frequent penalty is uterine and constitutional disease. The speed and completeness of recovery from labor depend also greatly upon the health and physical power of the in- dividual. Women accustomed to hard Avork, hard living, and exposure to the Aveather, complete the process of repair much more quickly than those avIio are nursed in luxury, and Avhose first experience of hard work is acquired in the task of bringing forth a child. In the first class of Avomen, the muscular, vascular, and glandular systems are in vigorous working order. Effete matter is quickly got rid of. Every organ soon returns to its Avon ted state. In delicate and pampered Avomen, on the con- trary, the muscular fibre is lax, the glandular organs, especially those of the skin, including the breasts, are imperfectly developed; they do their duty feebly, and are easily overpoAvered Avhen an unusual strain is thrown upon them. The nervous system is stimulated beyond measure, and ac- quires predominance over the rest. Under these conditions, it is not sur- prising that the extraordinary revolution in the system, and the important local changes Avhich have to be effected after labor, are accomplished with difficulty, imperfectly, and are the point of departure for various constitutional and local morbid processes. Neglect of the due period of " rest" for repair is especially apt to retard the restoration of that part of the uterus to Avhich the placenta adhered. The changes that have to be effected here are more extensive than in the rest of the internal surface. It is no uncommon thing to see in women dying a month and more after labor, a rough area, marking the site of the placenta. This is often covered Avith muco-purulent secre- tions, showing that the return to the ordinary condition is not completed. It is easy to understand that to tax the uterus in this condition with the premature resumption of functional Avork, Avill start endometritis, Avhich Avill readily assume a chronic, and even a permanent character. Analogous conditions follow abortion, although the actual violence in- 420 EFFECTS OF LABOR ON UTERUS. flicted upon the cervix is not so important an element. Abortion also differs from labor at term in this respect: the development of the uterus is brought to a sudden termination prematurely—that is, before the tissues and the system have attained the conditions favorable to rapid and com- plete involution. Within the first three or four months, for example, the muscular contractibility of the uterus—a prime agent in starting healthy involution—is not nearly so effective as at term ; and, in addition to this, the transformation of the mucous membrane into decidua, is arrested at a stage when the adhesion to the uterus is much more intimate, more vascular, and embraces a relatively much larger area. Its separation is a far more violent process ; and it', as is not unlikely, the mucous mem- brane Avas unhealthy before conception, its separation will be apt to leave a subacute endometritis, Avith unhealthy neAV mucous membrane. Rest is as essential after abortion as after labor. The indifference with Avhich many Avomen in every rank regard " a slight miscarriage," is a source of much future trouble. A miscarriage is looked upon as slight in proportion to the earliness in pregnancy at Avhich it occurs. But it is a grave error to measure in this Avay the importance of an abortion. The earliest abortion may entail consequences far from slight, if due hygienic precautions are not observed. Noav, one of the surest means of inducing some one or more of the foregoing involution-retarding conditions, is premature exchange of " rest" for exertion. The upright posture Avithin the first Aveek or fort- night will surely increase the local vascular tension, and promote dis- placement of the uterus. To add the influence of gravity, and of in- creased hydraulic pressure in the vessels Avhilst the uterus is still of inordinate Aveight and softness, Avith its supports disabled, cannot fail to be injurious. The most healthy stimulus to uterine involution is the natural function of lactation. If this duty—this physiological complement to parturition—be neglected, involution will not go on smoothly. The application of the infant to the breast causes contraction of the organ. It is injurious to lose this. Lactation, moreover, causing a derivation of physiological activity to a distant organ, tends to promote rest in the pelvis. Indeed, one of the beneficent purposes of this alternative or cyclical action of the generative organs, is to give each in its turn the rest that is necessary for restoration. This natural order cannot be broken Avith impunity. The penalty, or rather, one of the penalties, of suppressing the function of the breasts, by depriving the uterus and ovaries of their allotted respite, is the resumption of Avork before they have had time or opportunity to recover their fitness for the task. It is to this evil that women of the easier classes are more especially exposed. The increasing neglect of the function of lactation, is, I believe, a prolific cause of uterine disease. This neglect does not, hoAvever, en- tirely arise from indifference to maternal duties, or the fancied more im- perative duties of social life. The inability to suckle is, in numerous cases, real. The system, the breasts, Avant the poAver, the capacity, to secrete milk. After honest endeavors, it is too often found that after a feAv Aveeks of scanty secretion and painful suckling, the child and mother alike sIioav evidence of the futility of the effort. Nothing can lend stronger confirmation to the theory I have expressed, as to. the rela- EFFECTS OF LACTATION. 421 tivc unfitness of a woman nursed in luxury to carry out in its complete- ness the function of reproduction, than this failure of the breasts. The breast are glandular organs deArelopecl out of the skin. They are closely analogous in structure to the sebaceous glands of the skin. Their activity and degree of development may be taken as a measure of the activity of the skin and other glandular organs. All shoAv the same kind and degree of incapacity. Unless the general system have been duly exer- cised and called into activity by the Avhole course of life, the glandular system, like the rest, will remain imperfectly developed. It is unreason- aide to expect the breasts to become all at once competent to do their work. On the other hand, there frequently occur amongst the working classes and others, cases Avhere involution of the uterus is arrested by lactation. This is because lactation is a task that exceeds the strength. Deficient food, bad health, and hard Avork combine to exhaust the struggling mother. The process of repair is arrested, and a chronic endometritis, with engorgement, abrasion of epithelium from the os uteri, and leucor- rhcea, sometimes tinged with blood, or even alternating Avith metrorrhagia, always more or less prolapsus or retroversion result. The worn, thin, pallid aspect of the subject attests exhaustion. The pulse is small, ac- celerated ; nutrition is feeble ; the muscles are flabby; at one point muscular debility is invariably marked, the dorsal muscles, especially betAveen the scapulae, are always painfully aching ; they are in fact over- strained by the heavy burden of carrying the child. The nervous system in many ways suffers from imperfect nutrition ; vertigo, syncope, are the sure signs of anaemia, and sIioav Iioav the brain is starved ; dimness of sight, muscae volitantes, every degree of amaurosis commonly attend. Mr. Jonathan Hutchinson has investigated this subject. He says that dimness of vision during suckling may be merely an indication of the ex- istence of hypermetropia, and does not necessarily indicate retinal disease. Until Aveakened by lactation, many hypermetropic women experience no inconvenience, being able to bear the accommodative strain necessary to overcome the error of refraction; but during lactation they find it diffi- cult to keep the ciliary muscle up to its unusual exertion. He says it is well to examine if spectacles are not requisite. Any nervous affection to Avhich the subject retains a predisposition, from antecedent attacks, or from hereditary transmission, is now extremly apt to break out. Thus, over-lactation induces a recurrence of epilepsy, chorea, hysteria, ague—affections fromAvhich the subject might otherwise have been freed. Another point of suffering is the lower lumbar and sacral region. This is partly the indication of reflex distress, proceeding from the diseased uterus, partly of pressure of the enlarged organ on the pelvic nerves, and partly of spinal exhaustion from the constant Avear and tear occasioned by the irritation of a diseased organ acting upon an imperfectly nourished nervous centre. These subjects will also frequently complain of pain referred to the seat of one or other ovary, most frequently the left. Dr. Henry Bennet has long insisted upon this as characteristic of irritation propagated from the inflamed cervix. It may, according to him, and I am disposed to 422 EFFECTS OF LACTATION ON" UTERUS. agree with him, be regarded as a consensual pain. Others, hoAvever, regard it as an indication of actual ovarian inflammation. The period Avhen over-lactation may be said to have begun cannot be fixed. It is determined by the relative strength of the individual. Whilst it may be said that Icav Avomen are able greatly to transgress the normal period of nine or ten months Avith impunity, it is certain that many show all the signs of over-lactation much earlier than this. We must, then, look to the symptoms, and not to the time the patient has been suckling. In a considerable proportion of cases, the functions of the ovary cannot be suppressed beyond a feAv months, if at all. It is in vain that the attempt is made to keep ovulation, with its consequences—menstruation and pregnancy—in abeyance by taxing the breast. The ovary is the dominant organ, and sooner or later will assert its supremacy. Accord- ingly, avc often find one of tAvo things taking place in the course of lac- tation. First, menstruation returns, sometimes in a feAv months after labor, and generally within a year, except, indeed, phthisis or other ex- hausting disease intervene, or premature atrophy of the ovaries and uterus be induced ; or, secondly, unless a neAV pregnancy occur. This may, or may not, be preceded by a menstrual appearance. Some Avomen " never see anything from one pregnancy to another." Whilst suckling, they fall pregnant, Avithout exactly knowing when. The position of a Avoman in this predicament is indeed trying. She is laboring to support three beings at the same time. She is goading into simultaneous Avork the breasts and the uterus, Avhich ought to relieve each other. No Avonder if, under this double outrage to Nature, her own strength break doAvn, and if the Avelfare of the child at the breast, and the existence of the embryo in the Avomb, be equally imperilled. Accordingly, we often ob- serve that abortion occurs under these circumstances. This accident is the combined result of the degradation of the mother's blood, which be- comes unfitted to carry on the nutrition of the embryo and of the structures Avhich bring it into relation with the mother ; of the reflex irritation con- stantly starting from the breast, and promoting congestions and contrac- tions in the Avomb ; and of displacement, such as prolapsus or retroversion and chronic metritis. The condition of the uterus after the exhaustion of over-lactation is usually characteristic. Its bulk is someAvhat excessive ; the body is thicker and softer ; its canal is patulous, easily admitting the sound ; the cavity of the body is a little dilated, so that its Avails are not in apposi- tion, as in the healthy uterus ; the appearance of the vaginal-portion is peculiar: its aspect is pallid, partaking of the general anaemia, its lips are SAVollen out in lobes separated by the scars resulting from the slight rents Avhich were produced during labor ; to the feel and sight the tumid os is flabby, soft, as if oedematous ; all round the os, and some Avay inside the cervical cavity, the epithelium is often abraded ; tenacious viscous mucus fills the canal; the sound ahvays causes a little oozing of blood ; and metrorrhagia is usual. Such is a common condition. Some- times there is great congestion and appearance of vascularity. The abraded portions present little granulating elevations, secreting a semi- opaque mucus. The margin of the abrasion is Avell defined ; where the EFFECTS OF LACTATION. 423 structure retains its epithelium-inArestment the color is bluish or purple. This color becomes much deeper if pregnancy has supervened. Although ready to sink from physical exhaustion, the mother still clings to the burden Avhich is dragging her to the ground. It often requires the most decisive authority the physician can exert to induce these poor women to give up the unequal struggle. The most effective argument often is to point to the child, Avhich is generally pale, thin, and deficient in the firmness of healthy nutrition. We may thus more easily persua.de the mother to give up a course which, whilst surely sapping her OAvn health, is doing her child no good. Treatment.—To wean, then, is generally the first injunction. The other indications are to restore the general health, to improve nutrition, to bring back the proper proportion of red-globules to the blood, and at the same time to cure the local disease. [n these cases quinine and iron are of inestimable value ; strychnine is of scarcely less. They almost take rank as food. The doses should not be large, especially at first. One, or at most two, grains of quinine two or three times a day, and one-thirtieth of a grain of strychnine is enough. More Avill not be tolerated if the exhaustion is great. Quinine has a special beneficial action beyond that as a general tonic. It has a distinct property in causing contraction of the uterine fibre. In thisAvay it promotes involution, the diminution of congestion, and the tendency to metrorrhagia. To produce this action larger doses are useful, and com- bination Avith ergot is of advantage. Strychnine possesses a similar pro- perty in a marked degree. That the diet should be as generous as can be digested, it is needless to say. Alcohol should form a moderate, strictly limited ingredient. The light Avines of France, the Rhine, and Hungary are the best stimulants and aids to digestion. But Avhere it can be digested, good stout or ale to the extent of a pint or tAvo pints daily is to be preferred. Cod-liver oil and iron are often of use. Under this regimen, the blood is speedily enriched in quality, and the effect is seen in returning strength, in improved nutrition, and more vigorous per- formance of all the functions. We shall thus have gained one necessary condition for the repair of local mischief. Without this improved con- stitutional poAver, mere local treatment Avould probably fail. The local treatment required is generally simple. One condition is rest. This is partly attained by keeping the prolapsed uterus at its pro- per level by means of a Hodge's pessary. This brings singular aid also by relieving the local hyperaemia, by facilitating the return of blood from the uterus. Once every four or five days the abraded surface of the vaginal-portion and the interior surface of the cervix uteri should be lightly touched Avith tincture of iodine. Or a stick of three grains of sulphate of zinc may be introduced every third or fourth day into the cervix. A vaginal injection of oak bark, tannin, or sulphate of zinc, or alum should be used daily or even twice a day. The cold douche, if it can be borne without pain, is often useful. In summer the cold hip-bath may be em- ployed. Under this treatment the abraded surface will commonly heal over; the congestion disappearing, the bulk of the cervix becomes reduced; the tendency to prolapsus is lessened by this diminished weight of the organ, 424 IMPERFECT INVOLUTION OF UTERUS. and by the recovered tonicity of the vagina and other uterine supports. If at this time, Avhen all active inflammation has ceased, any marked degree of enlargement of the vaginal portion and bearing (Ioavu remain, Ave find a useful remedy in the potussu- cum calce or Vienna paste. This should be rubbed gently across the most enlarged lip of the os uteri, so as to produce a small eschar. This sets up a moderate degree of local irritation Avhich stimulates to healthy granulation, and excites absorption. The raAV surface will cicatrize Avithin a Aveek or ten days, and the bulk of the vaginal portion Avill commonly be reduced. This treatment, although limited to the vaginal-portion and the canal of the cervix, exerts a beneficial action upon the enlarged body of the uterus. It is certain that the congested, inflamed state of the vaginal- portion keeps up a similar condition of the Avhole organ ; and it is also a matter of experience that remedies applied to the vaginal-portion act not only by removing the irritation of contiguous disease, but also by deriva- tion. The eschar, for example, set up by potassa cum calce upon the os uteri, acts by derivation upon the body as a blister does upon internal organs. To set involution going, Avhen the case is acute, Simpson recommends local antiphlogistics. This treatment is especially indicated Avhere any trace of inflammation remains. But in cases Avhere all inflammatory action seems to have died out, he says, a local antiphlogistic course has the effect of setting up absorption in the enlarged organ. If the patient is not very weak, he advises the application of a dozen leeches to the vaginal-portion of the uterus or to the perineum. In these more acute cases, and in all the more chronic cases, he in- sisted on the use of counter-irritants. Antimonial or croton ointments, or the cantharides blister applied to the hypogastric region, or painting this region with tincture of iodine until it produced vesication, Avere amongst his remedies. At the same time he kept the vaginal-portion of the cervix uteri immersed in ointments of mercury or iodide of lead, or bromide of potassium introduced as vaginal pessaries. As internal reme- dies he relied upon iodide and bromide of potassium. Scanzoni recommends the introduction into the vagina every night of a sponge saturated Avith a solution of iodide of potassium in glycerine, in the proportion of one in eight, or of an ointment consisting of five grains of iodo-chloride of mercury in an ounce of lard. I have found the iodine of glycerine decidedly useful. The patient may apply it her- self by the aid of my speculum. (Fig. 54, p. 150.) But as I have found solvents act better if applied more directly, my practice noAV is to introduce into the cavity of the uterus twice a Aveek during intermen- strual periods a little iodide of mercury ointment, or tincture of iodine, by help of the tube. (Fig. 52, p. 155.) I have also seen reason to think favorably of the use of the bromo- iodic Avaters of the Woodhall Spa. One is frequently asked " How long will it take to get well ? To this the physician can give no definite ansAver, unless all the conditions of cure be placed fairly Avithin his control. Whilst the patient is pursuing more or less actively her usual course of life, and the treatment is often interrupted, the disease may linger for any length of time. But take ABSCESS OF BREAST. 425 her into hospital, Avhere all the necessary measures, negative and posi- tive, hygienic and medical, are systematically carried out, and a cure within two or three months may Avith confidence be predicted. Closely associated with this subject is that of inflammatory engorgement and abscess of the breast. This condition is commonly the result of, and bears evidence to, constitutional debility, and unfitness of the breast for its function. It occurs at tAvo distinct periods. The most common is at the onset of the attempt to suckle. The other period is after lactation has been kept up for some months. Strumous women, Avho are especially liable to glandular and connective-tissue engorgements, are particularly liable to early abscess of the breast. The constitution and the organ at once rebel. If the attempt to force them be persisted in, phlegmons and abscesses are sure to form. It is not Avithin the scope of this Avork to discuss the physiology and pathology of pregnancy and childbed. I refer to lactation only in reference to our present subject. Much as, both in the interest of mother and child, it is desirable to suckle, it is better, Avhere the function is not likely to be successfully carried on, not to make the attempt. It is rare for abscess to form Avhere no attempt to suckle has been made. The constitutional conditions which contra-indi- cate lactation are general debility, anaemia, a strumous diathesis ; the local conditions are, depressed undeveloped excoriated nipples, or eA'i- dence of phlegmons in the breasts. These conditions, and others, lead to retention of milk. The secreted milk clogs the milk-ducts, and this condition leads to stasis, and inflammation in the capillary network sur- rounding the acini. When it has been determined to abandon lactation, it is a common practioe to apply belladonna to the breasts, under the be- lief that this drug possesses the property of drying up the milk. I very much doubt its efficacy. I have more faith in the internal use of iodide of potassium. To check secretion, Dr. Alstalter extols conium, given in one or tAvo-grain closes four or five times a day. The distinct indica- tion is to avoid, stimulating or exciting the breasts. If it be desired not to promote the secretion of milk, the breasts should kept in perfect rest. It is in carrying out this indication that the physician will experience the greatest difficulty. It is a conviction rooted in the minds of nurses Avith all the tenacity of prejudice, that friction, and that not ahvays gentle, and " draAving the breasts," are necessary. This infallibly keeps up irritation. Engorgement and inflammation are too apt to folloAV. One condition of rest is repose in bed, another is gently supporting the breasts, so as to obviate any tendency to hanging doAvn ; they should be kept Avell lifted up from beloAV and from the sides. The easy return of the blood from them thus diminishes the risk of stagnation. Another Avay to promote rest is to use the arms as little as possible. If there be any engorgement, it is Avell to keep the arm of the affected side in a sling. Coolino- lotions, as of acetate of ammonia and alcohol, are useful. It is only Avhen there is great tension that the overflow should be gently ab- stracted by a breast-pump, or, better still, by the soda-water bottle heated by hot Avater, and then applied empty, so as to draAv by vacuum. This is far safer in the hands of an ordinary nurse than the breast-pump. Saline purgatives, with digitalis, and moderate unstimulating diet, espe- cially postponing the conventional stout, are essential adjuncts. 420 EFFECTS OF LABOR ON UTERUS. When mammary abscess occurs after lactation has been carried on for several months, this is almost certainly because the system has been so reduced that it is no longer fit to keep up the function. Simpson described {Med. Times and Oaz., 1.S01) super-involution of the uterus as a morbid state the opposite of sub-involution. It is pro- duced Avhen the disintegrating process set up after delivery goes on to such an excessive degree as to reduce the uterus to a size decidedly bc- Ioav its normal dimensions in the iinimpregnated state. He relates a case of a woman aged 20, who never menstruated after her first labor. Two years after labor she Avas admitted to the Edinburgh Infirmary. There Avas amenorrhoea, great constitutional disturbance, frequent attacks of diarrlnea, Avhich she believed to lie most severe at recurring monthly in- tervals, the dejections being sometimes tinged with blood. The mammae were shrunk and flat. The uterus Avas small; its cervix much atrophied, os contracted. Sound penetrated 1.5". Albuminuria and dropsy pre- ceded death. The uterus Avas one-third beloAV the natural bulk ; the ovaries avc re atrophied, shoAving no Uraafian vesicles. Sometimes atresia from cicatricial closure of the uterus is folloAved by a true amenorrhoea—not simply retention. Dr. Lize' reports such a case in the Union Medicate, 180o. The uterus seems to become atrophied from obstruction to the performance of its functions. In various parts of this Avork, this process of hyper-involution or pre- mature atrophy is referred to. I believe it is far from uncommon. Sometimes, as in the case quoted from Mr. Walter Whitehead (see p. 411), it may go to the extent of removing the uterus. I have encountered it sometimes Avith partial success by the use of the galvanic pessary. RESULTS OF INJURY TO CERVIX UTERI DURING LABOR. If Ave pursue the clinical, and, in this instance, the historical order, in the study of the most common morbid conditions of the uterus, Ave shall find succeeding the first stage of tumefaction, ecchymosis, and congestion of the mucous and sub-mucous tissues of the cervix, and the shedding of the bruised epithelium, the folloAving condition. The whole cervix, espe- cially the vaginal-portion, is sensibly enlarged, tumid, gorged Avith blood, cedematous ; for a definite area around the os, the part is bared of epi- thelium, giving a pulpy granulating appearance to the part; this part is further divided into lobes or prominences, the result of the small lacera- tions Avhich took place during the passage of the child ; this bared part is red, angry-looking from the villi being full of blood, bathed with viscid and purulent-looking secretion ; the part of the vaginal-portion, beyond the line of epithelial denudation, looks bluish-red, OAving to the gorged bloodvessels being seen through the epithelial investment. The vaginal- portion in this state easily bleeds under examination, under coitus, and under any exertion or emotion. Leucorrhcea is generally copious. Lum- bar pain is constant. General prostration certainly attends. Some de- gree of prolapsus is rarely absent. A similar state exists throughout the cervdeal canal. The rugae are prominent, bared at least in part. The surface is bathed in viscid, clear, INJURY TO CERVIX DURING LABOR. 427 or turbid mucus. The canal is more patulous than usual. Intensely vascular, and the vessels badly protected by delicate neAV epithelium, Avhich is being shed as fast as formed, the intra-cervical surface easily bleeds, so that metrorrhagia is common. All this can be easily seen through the metroscope, or even in part through the bivalved speculum, whose blades, made to diverge, open the os externum. At this stage the Fig. 101. Shows Condition often observed a Month after Labor. Congeuio.i of Vaginal-Portion Epithelia Denudation around the Os (K. B.). (From Nature.) glands on the vaginal-portion, sharing in the local congestion and inflam- mation, are apt to get obstructed. One may often see them as dark-red nodules shining through the granulations bared of epithelium. These persist often after the surrounding structures have recovered, and may become the foci of fresh irritation. They may be cured by lightly prick- ing them. Some of these objective conditions are fairly illustrated in Fig. 101, drawn from Nature from a case observed about a month after labor. This drawing shows also the enlarged relaxed state of the fundus of the vairina which attends this stage of the affection. The microscopical con- dition of such a case is represented in Fig. 102. Bv some this condition is called " inflammation ;" and the state of the os uteri, bared of epithelium, is called " ulceration." In some cases, 428 EFFECTS OF LABOR ON UTERUS. undoubtedly, inflammation intervenes ; and the question of ulceration is one of doctrine. What is ulceration? If avc consult the most recent authorities for an explanation, Ave find Simon (Holmes's System of Sur- gery) defining ulceration as a destructive process of inflammation: " It Fig. 102. Hassall and Tyler Smith.) is the process by Avhich holes are made through the surface-textures of the body (cutaneous, mucous, articular, or serous), and hence perhaps into deeper parts ; a process Avhich differs from gangrene mainly in the fact that it proceeds more gradually and molecularly. xVt the place Avhere an ulcer exists, the absent texture perished as truly as by gangrene ; but while gangrene Avould have occasioned its abrupt separation in mass, ulceration permitted its progressh'ely shedding as detritus. The dis- charge from any spreading ulcer, if examined under the microscope, invariably exhibits particles of disintegrating tissue ; and the so-called foulness is but gangrene on a smaller scale." Macleod (Cooper's Surg. Diet., 1872) gives a similar explanation. He says, " Ulceration is a result of inflammation, and consists in the molecular death and removal by minute disintegration and solution of the superficial vascular particles of the inflamed part. There is a minute atomic division of the particles of the affected tissue, and these molecules are removed in the ' ichor' or discharge Avhich escapes from the surface of the sore or ' ulcer' Avhich forms. The terms desquamation, or excoria- tion, or abrasion, are applied to the removal of epithelium alone, Avhile ulceration implies a deeper penetration of the destructive action." If Ave next examine Avhat is meant by inflammation, Ave find Simon giving the folloAving account of Avhat takes place in this process :— " The capillaries alloAv fluid to SAveat through their coats from the liquor sanguinis to the tissues. In this Avay they minister to groAvth. If the "ulceration" of cervix. 429 membrane be ruptured or dissolved, normal transudation is at an end, and capillary hemorrhage takes place. u The arteries are more relaxed, carry a profusion of blood. The veins carry more blood than usual; but not all that the arteries carry into the tissues: something is left behind in the tissues." Now, in the typical case before described, is there not greater relaxation of the arteries ? do they not visibly carry more blood ? do not the veins carry more blood ? and is there not something left behind in the tissues ? It is impossible not to ansAver all these questions in the affirmative. And so of ulceration: is there not gradual shedding of tissue as detritus ? does not the discharge exhibit particles of disintegrating tissue ? is there not a hole through the mucous surface-texture ? Or is this breach of surface the result of gangrene ? According to the historical and clinical points of view from Avhich I have regarded the condition, it appears to be a combination of the tAvo processes of gangrene and ulceration. The first step is traumatic ; the mucous membrane is really killed by the bruising it underAvent, and the partial severance from the deeper textures upon which it greAV. Hence it is cast off by a process Avhich cannot be distinguished from gangrene. It is remarkable that the area of epithe- lial denudation is almost ahvays strictly limited. There is a more or less indented irregular line of demarcation where the epithelium stops abruptly at a distance of about half an inch from the centre of the os uteri. This line represents accurately the extent of the mucous surface which fell under the crushing of the passage of the head. The fissures very seldom go beyond this line. Nor does the area of denudation tend to spread beyond it. In this respect the case differs from that of surface-ulceration. If there be ulceration it must be by destruction of tissue within this circumscribed area : that is, in depth. Of such action, hoAvever, there is usually very little. Probably the eroded appearance of the bared villi accurately, as I knoAv it is, repre- sented in Hassall's draAving (Fig. 102), is also due, like the casting of the mucous surface, to traumatism and necrosis. I do not think that the de- structive process is commonly progres- sive in depth any more than it is in su- perficies. The process is essentially and truly one of repair; often, indeed, ar- rested by the excess of congestion of the part, and by the general blood-degrada- tion of the system. But still it is a rare event for this process of arrested repair to pass into the opposite condition of ex- tending destruction. The hypothesis of ulceration has been faArored by the as- pect of the denuded part, Avhich strik- ingly simulates that of a granulating ulcer on the skin. But the observations and figures of Dr. Hassall, in Tyler Smith's Memoir on Leucorr/uva, conclusively shoAv that the apparent granulations are really the projecting villi jutting out irregularly on the surface, hav- Epithelial Abrasion several weeks after Labor. Tendency to Hypertrophy. (K. B.) (Ad. nat.) 430 effects of labor on uterus. ing lost the projecting epithelium which bound down smoothly all surface inequality. After "all, it may be said, this is a dispute about words. A condition Avhich so closely corresponds to the classical definition of ulceration may fairly be called ulceration. This might be conceded, were it not that the common, vulgar as well as professional, conception of ulceration em- braced the idea of a spreading, eroding action; and that thus the word bears a more formidable significance to the patient than the reality justi- fies. Noav, Ave all know that the morbid surface is not so affected. There is a bared, secreting, easily bleeding surface trying to heal. It is often slow to heal. It may take weeks and months to recover its nor- mal investment of epithelium ; but during all this time ulceration cannot be said to go on, otherwise than in the most languid imperceptible form. But another process is certainly going on. This is exudation. The gorged vessels, through which their contents are only imperfectly pro- pelled, leave something behind in the tissues. " Exudations," says Druitt, (Article "Inflammation," Cooper's Surgical Dictionary, edition lJ-i"2), " cannot remain dormant. They rapidly undergo changes either in the Avay of development or degeneration." In this case the tendency is to- wards development. This means hyperplasia and hypertrophy. The connective tissue, or fibrous tissue of the cervix especially, becomes in- creased in quantity ; the cervix becomes after a time denser ; it elon- gates. This latter part of the process, the conversion of exudation into permanent tissue, may be averted by subduing the vascular engorgement, and healing the denuded surface. The treatment of this condition has been described in the preceding chapter. It consists essentially in " rest," tonics, good diet, and local astringents. If a cure be not effected at this stage, the case will often become more obstinate. The natural tendency to heal can hardly be trusted to if the powers of the system are sensibly reduced. If there be evident anaemia and attendent impairment of nutrition, repair cannot be expected to pro- ceed in a part exposed to constant disturbances, and periodical fluxes of blood. Generally, the vaginal-portion loses in bulk ; some degree of contraction takes place, OAving to the absorption of the fluid element of the exuded material, and the condensation of the plastic element ensuing upon its conversion into fibrous tissues. The abraded area looks smaller, and, in fact, is smaller, but this is often not so much the result of actual healing, as of the general contraction of the vaginal-portion. (See Fig. 103.) There is still a free secretion of mucus, viscid, coming from the cervical cavity. There is still more or less vascular engorgement, and some infiltration of tissue, with recent exudation. The denuded area looks red, granular, like a straAvberry or raspberry. The vagina is still relaxed, and some degree of epithelial shedding goes on from its mucous membrane. The lumbar and dorsal pains persist. There is often pain in the seat of one or other ovary, generally, as Bennet says, in the left. The treatment is still the same as for the earlier stage. The denuded surface should be lightly touched every five or six days Avith nitrate of silver, or tincture of iodine, and the like application should be made to the interior of the cervical canal. Occasionally the solid sulphate of FLUXION. 431 zinc may be substituted. Vaginal lotions of zinc, alum, bark, or tannin should be used daily. If there be any prolapsus, a Hodge pessary will be of essential sendee in maintaining "rest," and diminishing the local engorgement. Under this treatment, the denuded surface Avill often get covered in in a few weeks, and the excessive vascularity will be reduced. But exuda- tion has taken place ; and exudation has been followed by new growth. This hypertrophy, or hyperplasia, even although not attended by much increase of bulk, so as to induce prolapsus, or dragging, or pressure upon surrounding organs, is almost ahvays attended by irritation, Avhich keeps up increased attraction of blood, hypertrophy of the glands, and free leucorrhoea. Pain continues to Avear the nervous centres. Healthy nutrition is impeded. At this stage, the application of potassa cum calce, or the actual cautery to one or the other lip of the os uteri, Avill often exert the most beneficial influence. The mode of applying these agents will be described under the treatment of chronic metritis. The further history of hypertrophy, or fibroid degeneration of the cervix uteri, will be traced in connection Avith that of prolapsus. CHAPTER XIX. conditions marked by altered vascularity or blood-supply: fluxion ; hyper.emia ; congestion; inflammation; metritis; endometritis or uterine catarrh; tubercular and syphilitic endometritis; intra- uterine medication ; cystic endometritis ; softening and indura- tion of uterus ; senile catarrh. The vascular system of the genital organs and the proportion of blood supplied may be in excess or deficiency. The conditions characterized by excess may be distinguished as—1. Fluxion or simple determination of blood. 2. Hyperaemia. 3. Con- gestion or Engorgement. 4. Inflammation. The conditions character- ized by deficiency are summed up in Anaemia. Whilst fluxion, hyperemia, or congestion may each stop short, inflam- mation implies the previous existence of fluxion and congestion. It may be regarded as the climax of the first three conditions. 1. Fluxion in its simplest form may be defined as a transitory Aoav of blood to the parts. One example of it may be compared to the rush ob- served in the cheeks under the emotions of shame or anger. The uterus and ovaries are certainly subject to similar determinations of blood under 432 VASCULAR DISORDERS OF UTERUS. the influence of various emotions, as the sexual passion, and of reflex ir- ritation, as that produced by the child sucking at the breast. This fluxion is of course perfectly physiological; and, if occurring in healthy organs, entails no ill effects, unless it be artificially and inordinately stimulated. An example of simple fluxion is the physiological determination of blood excited by ovulation at the menstrual periods. The vascular fulness determined by the developmental attraction of pregnancy may be regarded as an example of fluxion. Analogous to this is the fulness dependent upon the abnormal, developmental attraction produced by the groAvth of fibroid tumors in the uterus. One difference which exists in the two cases, is that in the first, the fluxion is more uni- formly persistent, less disturbed by the periodical molimen of ovulation; it is a steadily maintained active hyperaemia. In the second, the per- sistent hyperaemia induced by the developmental stimulus is further liable to the periodical molimen of ovulation. Hence the tendency, where fibroid tumors, polypi, or cancer exist, to metrorrhagia. Fluxion has its pathological as Avell as its physiological significance. Using the term in this relation, it takes the place of those states commonly described as " active hyperaemia" and " active congestion." As Billroth observes, Hhe vessels dilate or suffer themselves to be distended, under the influence of some irritation, and then quickly disgorge themselves when the irritation has ceased. It may be difficult to discover the true cause, but it is generally easy to observe the phenomenon. The ex- aggerated afflux of blood is the reaction or the response of a vascularized part excited to irritation: " ubi stimulus ibi flux us." If the ovaries and uterus be in an abnormal condition, Avhether from congestion, inflammation, displacement, from being the seat of new for- mations, their liability to fluxes is increased. The diseased organs will commonly be even more susceptible than the healthy to irritations which provoke the afflux of blood. If the uterus be imperfectly involved after pregnancy, or engorged, or its tissues relaxed from other causes, this fluxion, otherwise harmless, may give rise to hemorrhages. And it is probable that the hemorrhages so arising act in some cases as an evacuant, saving the uterus from pass- ing into congestion or inflammation. Fluxion, then, may occur in healthy organs and in diseased organs. Therefore, Avhen studying the pathology of the ovaries and uterus, Ave must bear in mind not only their actual or essential morbid conditions, but also the influence, beneficial or injurious, of accesses of fluxion to Avhich they are liable. Fluxion is naturally a more frequent complication during the period of active sexual life. But even after the menopause, fluxions at uncertain times may recur. These fluxions, in fact, form a most important element in the history of uterine and ovarian diseases. They are the immediate occasion of some of the most distressing and dangerous phenomena. By being prepared for them, by moderating their intensity, or by preventing their recurrence, Ave shall often accom- plish the most useful therapeutical results. It may be doubted Avhether simple physiological fluxion, howsoever 1 Elements de Fatliologie Chimrgioale Geuerale, 1868. FLUXION. 433 frequently repeated, will often produce inflammation of the uterus, ovaries, or their investing peritoneum. It is true that peritonitis and oophoritis are common in prostitutes, and that these events are attributable to sexual excesses. But it is certain that in many of these cases the determining cause has been the propagation of gonorrhceal inflammation, or exposure to cold or other form of violence. The chief symptoms of simple fluxion are subjective. The patient feels a sensation of local heat and fulness, depending upon the turgidity of the organs affected, and the tension of the plexuses and erectile portions of the \rascular system. The fluxion may subside as quickly as it arose ; and it mostly leaves the organs exactly in their previous condition, unless they were diseased; in which case the fluxion, especially if often repeated, may produce in- jurious consequences. Should varicose veins exist in the legs, thighs, or groins, the effect of fluxion is seen in a marked manner at the menstrual periods. The veins Adsibly swell, become tumid, deeper-colored. The patient is conscious of the increased turgidity. Sometimes the vessels are relieved by oedematous transudation. In this periodical oedema, Avhich I have often observed, Ave may see a natural provision for relief of high vascular tension. When fluxion occurs in morbid structures, the symptoms are commonly more severe. Pain is more marked; the sense of fulness, of weight, is more oppressive ; dragging pain is felt in the loins and groins ; and often sharp colic spasms in the stomach in the region of the umbilicus. In the more severe cases, and depending somewhat upon the kind and degree of the local morbid condition, the fluxion develops all the symptoms of con- gestion. The vascular tension seeks relief in discharges ; these present themselves as hemorrhage, leucorrhoeal or mucous discharges, and escape from the mucous membrane of the uterus, vagina, bladder, or rectum. These are sometimes accompanied by dysenteric and dysuric pains. Certain general symptoms precede and attend the local phenomena. The premonitory signs may be defined as an exaggeration of those which mark the approach of the ordinary menstrual molimen. There is a state of tension marked by a chill or even by a rigor, by spasm, vague nervous phenomena, irritability or depression of temper, restlessness, perhaps hysteria. The attendant signs are the reactionary phenomena which reveal the participation of the organism in the distress of the ovaries and uterus. There is an exasperation of the nervous erethism, with circumscribed pains in certain parts, neuralgia, gastric disturbance, headaches; and, lastly, when the fluxion is often repeated, or has continued an unusual time, there occur Avhat seem to be blood-determinations to the head and lungs. The objective signs are : distension of the hypogastrium, increase of heat, and slight development of pain on pressure. The vagina is relaxed, perhaps secreting mucus ; the uterus is increased in bulk, lower in the pelvis, and is tender to the touch. The variation of volume observed in the uterus is at times very great. For example, in a case of anteversion I have felt the uterus, at the time of the menstrual fluxion, assume twice its usual size, and return to its ordinary bulk as the fluxion subsided. 28 434 VASCULAR DISORDERS OF UTERUS. The neck of the uterus feels softer, swollen. For the time the mucous membrane of the uterus and vagina is of a deep-red color. Courty describes a chronic fluxion. But it appears to me that the essence of the idea of fluxion is an active transitory Aoav. \\ hen the vascular tension of a part becomes permanent, there is either hypenemia or congestion. The treatment of fluxion will, of course, be determined by the degree of the affection, and by the condition of the organs to Avhich the fluxion is determined. Even the ordinary physiological fluxion of the menstrual period requires some management, for influences, othenvise harmless or even beneficial, may, as is Avell known, act at this time injuriously. The treatment consists in the observance of hygienic precautions, and these may be almost summed up in the one Avord, " Host." During this time no operation that can be safely postponed should be performed. The treatment of fluxion in diseased organs resolves itself in part in the special treatment adapted to relieve the disease. But the fluxion itself demands special management. The periodical fluxions of menstru- ation Ave ought to be prepared for. "Rest" here is even more important than in the simple fluxion. But the irregular fluxions, provoked by acci- dental emotional and local irritations, cannot ahvays be foreseen or guarded against. Familiarity with the idiosyncrasy and surroundings of the patient, however, Avill often enable us to avert some of these irritations. We have the indication of one natural mode of relief of fluxion in the hemorrhage of menstruation; and of another in the quiet subsidence of the local vascular excitement. If the fluxion occur at a menstrual epoch it will be pretty sure to seek relief in hemorrhage by an exaggeration of the normal menstrual Aoav. It will rarely be necessary to take measures to excite or to increase the flow. It will more often be necessary to moderate it; for it is one of the remarkable phenomena of hemorrhage that when once begun fluxion is determined with increased force towards the organ whence blood finds a ready escape. The bleeding organ seems to acquire the faculty of attracting more blood from the aorta only to pour it out of the system. The heart becomes excited, and acts with greater force and frequency. The chain of the circulation is broken. The blood escapes at the capillaries instead of being carried on to the veins ; and in some cases, perhaps many, there is reason to believe that the raptus tOAvards the accidental outlet is so active that blood is even drawn tOAvards it in a retrograde course from the veins. These phenomena are nowhere so well marked or so easily observed as in the hemorrhage of the gravid, puerperal, and diseased uterus. The treatment of hemor- rhage is considered elseAvhere. Our only point here is how to manage the fluxion. There is one very effective agent in turning aAvay the fluxion from the organ predestined to be its seat, Avhich it is almost hopeless to recommend at the present time. The doctrine of revulsion teaches that we may divert the torrent of the circulation from an organ towards which irritation conducts it, by setting up an artificial fluxion to another part. This is most certainly effected by venesection. This principle of control- ling the circulation was, perhaps is, in great repute on the Continent. I have frequently seen it most beneficially acted upon by Lisfranc. A small bleeding from the arm, timely practised, may not only save a HYPEREMIA. 435 greater effusion, by turning aside the current from the morbid surface, but by lessening the vascular activity in the diseased organ, may check the progress of the disease. The condition of usefulness from bleeding depends upon the observ- ance of the principle of revulsion. The bleeding must be practised at a distance from the organ Ave Avant to relieve. It need not be large in amount. A feAv ounces draAvn from the arm by venesection or from the temples or nucha by leeches, will commonly suffice. It should, hoAvever be remembered that all fluxions are not alike benefited by this treatment. It is especially useful in young plethoric persons ; and Avhen the fluxion is recent or only impending. It is also useful in some cases of more languid fluxion in women, laboring under hepatic difficulty, or heart disease dispos- ing to portal obstruction. Another form of revulsive treatment, less powerful, and more likely to commend itself to current ideas, consists in causing derivation to the skin or intestinal canal. By epispastics, by blisters, or fomentations, Ave can excite some degree of local afflux to a distant part of the body. By pur- gatives we can cause a derivation to the intestines, and take off some degree of vascular tension, by draAving off a portion of the watery element of the blood. A revulsive recommended by Hippocrates, is the application of dry- cupping to the breasts. The illustrious father of medicine Avell knew the sympathy which existed between the breasts and the ovaries and uterus. This idea has in recent times been applied by the Germans and the late Dr. Rigby, to excite the uterus to contract after labor, and by Scanzoni, Avho sought to provoke labor by thus stimulating the breasts. Courty speaks highly of the efficacy of dry-cupping the breasts to obtain the revulsive effect Ave are discussing. I am able to give a qualified ap- proval to the practice of Rigby. That of Scanzoni has been condemned by the results of observation. The irritation of the breasts, whilst not always fulfilling the purposes in vieAV, not seldom caused inflammation and abscess. I should fear similar accidents from Courty's practice, especially as he insists that the method, to be useful, must be kept up for several hours, even days. It is further open to the objection that irritation of the breasts is likely to excite fluxion to the uterus, and thus to cause the very accident it is sought to avert. Again, it is not desirable, for obvious reasons, to irritate the breasts in young Avomen. Certain medicines possess the valuable property of allaying and regu- lating vascular excitation. Of these the most useful are the acetate of ammonia, nitrate of potash, tartarated antimony, aconite, digitalis, vera- trum, salicylic acid. A very useful formula is—R Liquoris ammoniae acetatis, 3 iij-; nitratis potassre, gr. xv.; vini antimonialis, nrxv. ; infusi digitalis, 3 ij-; aquae, §j. M. This dose may be taken every three or four hours. It deter- mines to the skin and intestinal canal; 'it may possibly provoke nausea or vomiting, but this has a powerful influence in checking hemorrhage. 2. Hyperaemia must, I think, be distinguished from fluxion on the one hand, and from congestion on the other. It is a continuous or chronic fulness of the vessels of a part Avhich does not necessarily imply morbid action in that part, but which at most leads to languid, passive changes. 436 VASCULAR DISORDERS (»F UTERUS. Hyperaemia occurs especially in connection with excessive menstrual congestion; the uterus is full of blood, dark-red, SAvollen, softened ; the mucous membrane is injected, red, swollen, with a spongy, flocculent as- pect from the development of its uterine tubular glands, softened and bleeding. The development of the uterine glands is at times quite extraordinary. Rokitansky saw in the body of a girl, Avho died in course of typhus whilst menstruating, the mucous membrane, especially on the posterior uterine wall, dark-red, and converted into a thick stratum of villous-looking folds packed together, in Avhich the uterine glands were elongated to &" or more. I have specimens of dysmenorrhceal decidua shoAving the same thing. In the course of typhus, cholera, typhoid, the exanthemata, scurvy, hyperaemia of the uterine mucous membrane occurs. The uterus becomes hyperaemic and swollen Avhen the pelvic system of veins is overloaded, and especially Avhen flexions or displacements of the organ exist. In the latter cases, the hyperaemia is most marked in the anterior or posterior Avail. New formations cause and keep up hyperaemia, sometimes more marked in the uterine substance, sometimes in the mucous membrane. It also occurs in heart disease, in obstructions to the return of blood through the vena cava. Often, it principally affects the lower segment of the cervix and the vaginal-portion. Persisting hyperasmia leads to persistent secretion of mucus, and to hypertrophy of the uterus, commonly of the eccentric form; to hyper- trophy of the vaginal-portion, with predominance of the connective tissue ; and thence to induration, the so-called infarctus. Hyperaemia disposes to oedema of the tissues and to hemorrhage. The hemorrhage takes place from the mucous membrane into the uterine cavity as the expression of hyperaemia. The outpoured blood Aoavs aAvay, or sometimes, even with- out marked obstruction of the canal, forms clots, or one, which compressed takes the form of the uterine cavity. There is often a chronic pelvic hyperaemia in aged women, leading to hemorrhage. The hyperaemia is mostly due to portal obstruction and to the general Avant of vascular tone arising from obesity and Avant of exer- cise. This state may induce softening, fragility of the uterine substance, and fragility of its vessels. Its seat is the fundus, and especially, almost exclusively, says Roki- tansky, the posterior wall. The soft uterine substance looks black-red, infiltrated Avith blood so as not to be recognizable, and blood is seen in variable quantity in the tissues Avhen section or rent is made. The mucous membrane is commonly in the same condition ; and often blood is found in the uterine cavity (the apoplexia uteri of Cruveilhier). If the vaginal-portion be examined by the speculum it is seen to be swollen, dark-red, and the whole vagina commonly exhibits the same ap- pearance. There is a sense of weight and heat; often some degree of prolapsus; and also a troublesome form of pruritus. Considerable improvement sometimes folloAvs a spontaneous hemorrhage; and hyperaemia being essentially a passive condition due to superior ob- struction, a feAv leeches applied to the os uteri will occasionally be ser- CONGESTION: ENGORGEMENT. 437 viceable. But our chief effort should be directed to correcting the con- dition of the central organs of circulation and digestion, to restoring the general health, and to removing any uterine complication. 3. Congestion or engorgement of the uterus and ovaries. This condi- tion implies a more prolonged fulness of the vessels than mere fluxion; it rarely exists Avithout some amount of retardation of the blood in the vessels, that is, hyperaemia; and this retardation almost certainly entails more or less effusion of the serous or aqueous elements of the blood into the tissues of the organs affected. This implies swelling or tumefaction. Once set up, this condition is extremely liable to persist. The frequently dependent position of the organs favors the accumulation of blood in them, whilst their liability to fluxes, under the influences already men- tioned, is a constant source of aggravation and impediment to cure. Congestion may arise from many causes. If the organs are caught whilst under the influence of physiological fluxion by constitutional shock, by exposure to cold, or protracted fatigue, fluxion may pass into con- gestion. Congestion of the uterus very frequently takes its rise in the state of imperfect contraction and involution folloAving pregnancy and labor. The relaxed tissues and dilated vessels form a ready receptacle for the blood, and the want of tone and contractility obviously favors its retention. Whatever the cause of congestion, it is soon aggravated by displace- ment of the womb. Implying, as congestion does, increased bulk and weight, and attended, as it almost necessarily is, by relaxation of the structures which ought to support the Avomb, this organ almost invariably sinks lower in the pelvis, or its body falls backAvards or forwards. The effect of displacement is almost surely to add to the congestion, or to induce it. Take, for example, the case of anteversion or retrover- sion. Under the repeated rushes of ovulation, of sexual relations and other causes, congestion is brought about by the obstruction Avhich the displacement interposes to the return of blood. The body of the uterus rolled over on its transverse axis in the broad ligaments, twists, distorts, and compresses the vessels at the point of entry and exit. Blood still enters the uterus by virtue of the propelling vis d tergo through the arte- ries ; but the veins, thin-walled, flaccid and valveless, rendered tortuous and compressed, afford but a difficult return. This state gives rise to what French authors distinguish as engorgement, but which it seems more convenient to describe as a phase or consequence of congestion. It is difficult to imagine that pure congestion can long exist Avithout giving rise to the infiltration of tissues which constitutes engorgement. Uterine congestion complicates, or plays an important part, in a large proportion of cases of uterine disease. It constitutes one of the most serious obstacles to their cure. It tends, by its very conditions, to per- petuate itself. It exhibits little or no tendency towards spontaneous re- covery. The organ in which it occurs is rendered permanently larger, its tissues are infiltrated Avith serum or semi-plastic extravasations, its contractile force, the tonicity of its vessels are impaired; the blood brought to the uterus, either by the ordinary distribution or by intermittent flux- ions is delayed ; a kind of haemostasis is induced; and these conditions are aggravated by time, by the increasing mechanical impediment to the 438 VASCULAR DISORDERS OF UTERUS. course of the pelvic circulation, which displacement of the uterus in rela- tion to the broad ligaments induces. Uterine congestion may be primary, and for an indefinite time consti- tute the chief morbid condition. It rarely exists long without inducing displacement, as prolapsus of the uterus ; and sooner or later, it is likely to lead to other evils, as hypertrophy and inflammation. It may be secondary upon other conditions. There is one which in my experience almost infallibly induces congestion. That is the fixing of the womb ; Avhether this be from perimetric adhesions, from compres- sion of tumors, from pressure against the symphysis pubis by retro-uterine hasmatocele, or other cause. But the most frequent cause is retroflexion Avith locking of the fundus beneath the sacral promontory. The symptoms of congestion are essentially the same as those Avhich mark the combination of fluxion and hyperaemia ; the diagnostic test being the persistence of the symptoms, and the accidental intermittent character of the fluxions Avhich may or may not complicate this conges- tion. There is also more pain than in hyperaemia. The enlarged uterus, by its proximity to the bladder and rectum, irritates these organs, keeps up hyperaemia in the surrounding pelvic tissues. The reflex excitation, or the proximate irritation, causes frequent desire to void urine, and dysuria; the same causes may induce dyschezia, tenesmus, straining, at times diarrhoea. Expulsive efforts are caused, at first involuntary, after- Avards perhaps intensified by the semi-involuntary bearing-down, excited by the sensation that there is something to be expelled. The contraction of the abdominal Avails, as in the act of defecation, of sneezing, of cough- ing, is attended by indirect pelvic pain, more or less acute. A frequent consequence of congestion is dysmenorrhoea. This symp- tom, Avhen not accounted for by obstruction from stenosis or angulation of the uterine canal, is, I belieA^e, most commonly due to the accumula- tion of blood in the uterine cavity, its coagulation there, and retention, which is favored by the quantity poured out. It has time to clot, partly because its quantity is in excess of the mucus Avhich helps to keep it fluid, and partly because it is alloAved to rest by the uterus, Avhose power of contraction is enfeebled by the congestion. Retention means irritation, and irritation means uterine colic, that is, dysmenorrhoea. This symp- tom is the more certain to folloAV in proportion to the degree of displace- ment of the uterus. The difficulty Avhich congestion occasions to the uterus in the perform- ance of its functions becomes a source of aggravation of the congestion. It not uncommonly happens that the menstrual function is disordered in its periodicity, as well as in its other characters. The patient often be- comes irregular, sometimes she even loses the reckoning so as no longer to know Avhen her periods are due. The menstrual Aoav is merged°in hemorrhage. It may last for a Aveek or a fortnight, leaving a fortnight or three Aveeks interval only ; or a Aoav of blood, Avhich it becomes diffi- cult to distinguish as menstrual, appears at irregular intervals. Not seldom, hoAvever, the menstrual discharge becomes scanty, or ceases to be noted othenvise than doubtfully in the shape of irregular discharges of blood. Leucorrhcea is an almost constant effect of congestion; the gorged CONGESTION: ENGORGEMENT. 439 vessels of the uterus seek relief by secretion of mucus ; and Rokitansky has shoAvn that the glands, under hyperaemia and congestion, undergo enormous development. The local signs are the increased bulk and weight of the organ, in- volving diminished mobility, and more or less displacement expressed by prolapsus and retroversion or flexion, or anteversion. By the speculum the vaginal-portion is seen SAvollen, deep red. The vaginal-portion and cervical ca\'ity easily bleed on examination by touch, speculum, or sound. Congestion is often more or less limited to the vaginal-portion when there is stenosis of the os uteri externum. This condition is discussed under the head of "Dysmenorrhoea." Congestion of the vaginal-portion also occurs in prolapse Avith hypertrophy of the vaginal portion. In this condition the vaginal-portion is liable to get constricted by the circular compression of the vagina, and between the boAvel and bladder. This constriction retards the circulation in the lowest part of the vaginal-por- tion, makes it tumid, and increases the disposition to hypertrophy. This is exemplified in a figure from a preparation in King's College Museum. (See Prolapsus : hypertrophy.) Congestion may affect the whole uterus; or it may affect the body or the cervix only. The congestion bears most obAdously on the mucous membrane. The treatment of congestion and engorgement must be determined greatly, in most instances primarily, by the indications for the removal of the complicating conditions. Thus, attending prolapsus, version, or flexion, demands special care. The displacement corrected, the asso- ciated congestion will almost certainly be relieved, if not removed. The management of the complications is described Avhere they are treated of as primary or essential disorders. It is necessary to remember that congestion or engorgement of the uterus is curable, whilst old-standing hypertrophy is not. Again, many Avomen who have passed the climacteric, scarcely need to be treated for congestion. This condition, Avhen existing, is no longer so liable to exacerbation by fluxions ; it becomes more passive ; the pain subsides ; and tolerance is acquired. But, on the other hand, youth is favorable to cure ; the activity of the circulation and of all the functions facilitates the absorption of effused matters; and the very functions of the uterus, as menstruation and pregnancy, by virtue of the retrograde iiwolution Avhich seizes upon the uterus Avhen these functions are com- pleted, may involve the morbid hyperplastic structures, and thus dissolve them. A remarkable example of this process is seen in the occasional diminution or even disappearance of fibroid tumors after labor. The question of local depletion Avhen there is congestion is important. Its action is poAverful, and resort to it requires discretion both as to the selection of the cases and the method to be employed. If the congestion is liable to periodical aggravation, especially if attended by hemorrhages, from menstrual fluxion, the principle of derivation and revulsion already discussed, should be invoked. Where the congestion is accompanied by intense pain and sense of weight, the bulk of the uterus being sensibly increased, benefit will sometimes be derived from local depletion. This may be practised either by leeching or scarification. Leeching has been 440 VASCULAR DISORDERS OF UTERUS. extensively employed in the treatment of uterine disease ; and if one may be permitted to judge from the observation of cases Avhere it has failed to do good, or has done harm, under the advice of other practi- tioners, I should say that it is employed much too often. The effect of the suction of leeches on the loAver segment of the uterus is often to attract blood to the pelvic organs. The free anastomoses of the branches of the internal iliac, the numerous plexiform structures, the numerous valveless veins constitute a peculiar formation unfavorable to local bleed- ing by exhaustion. The vascular system of the pelvis has been likened, not inaptly, to a sponge. DraAv blood from any one part, and it is im- mediately replaced by a neAV supply ; the vessels can hardly be emptied; you may attract any quantity of blood through this channel, producing marked systemic effect, but the local engorgement may be little dimin- ished. That this is often the effect of leeching the os uteri and upper part of the vagina I am very confident; and therefore, I now resort to this practice Avith very great circumspection. The method of scarification is not open to the same objection, at least not to nearly the same extent. Superficial scratches or incisions made on the vaginal portion Avill give vent to the blood gorging the part ope- rated upon, Avithout entailing a fresh fluxion to tbe organ. The most marked benefit from incisions in the vaginal-portion, is often seen Avhen the os externum is divided on account of stenosis and dysmenorrhoea. In this condition the mucous membrane is often intensely gorged ; and Avhen cut, it is left pale and less swollen by the very moderate loss of blood Avhich attends the operation. The mode of applying leeches to the cervix uteri is to introduce a Fer- gusson's or other tubular speculum, bringing the cervix Avell into the field ; to Avipe off any secretion with a bit of cotton avooI or sponge ; then to put the leeches, three or four in number, into the speculum, and push them doAvn upon the cervix by a pledget of cotton-wool. The operation is often troublesome, and this is another objection to it. The leeches at times refuse to bite, and Avorm their way out most assiduously betAveen the wool plug and the speculum, and easily escape altogether unless carefully watched. Leeches have even got into the uterine cavity, and have thus caused acute metritis and hemorrhage. For this opium is the best treatment. In the event of excessive bleeding from the bites, it is generally enough to expose the bite and to apply a small compress soaked in perchloride of iron. If bleeding break out afterwards, the same course is still the best. Get at the wound and apply the styptic to it direct. As a temporizing measure we may sometimes apply one plug soaked in a strong solution of alum, and then pack the vagina Avith a succession of other plugs lubricated Avith vaseline or carbolic acid oil. One leech at a time may be more conveniently applied by means of a long glass tube open at the uterine end, and provided Avith a piston to push the leech onAvards. In London there are several nurses who take charge of this little operation for a moderate fee. Scarification is to be preferred to leeching for the reasons assigned, and also because it is more convenient to carry out. The operation is performed through a speculum. The most convenient is my " crescent speculum." It brings the os uteri nearer to the outlet, exposes it more METRITIS. 441 freely and under greater tension, than the tubular speculum. Almost any bistoury long enough may be used, but it is most convenient to em- ploy a scarificator designed on the model of Sime's knife. It is carried by a forceps and kept fast by two pins Avhich go through the forceps. It gives stabs into the vaginal-portion rather less than half an inch deep. The number and depth of the stabs will be determined by the nature of the case, and the Aoav Avhich folloAvs the first one or two punctures. Inflammation.— What is called endometritis or uterine catarrh, mean- ing, more or less precisely, inflammation of the mucous membrane of the uterus, is the form of metritis the most frequently met with, and that presumedly as a distinct disease. It might on this ground be considered desirable to describe it separately. But regarding the frequency of its complication Avith inflammation of the parenchyma, either in its origin or in its course, it appears to me on the Avhole more useful to study metritis and endometritis together. In discussing the treatment, it will be diffi- cult to point out the modifications Avhich the predominance of one or the other form may especially indicate. Metritis may be analyzed as folloAvs : 1. There is the puerperal me- tritis springing from comrection of foul matter in the venous and lym- phatic channels, from the cavity of the uterus. This usually runs a rapid course, and Avhen fatal, it is rather by general infection of the cir- culation and peritonitis, than from the simple metritis. This puerperal metritis may be: a, general, or b, limited more or less to that portion of the uterine wall which corresponds with the attachment of the placenta. Both forms are likely to be attended by peritonitis. Both may become chronic. In either case, the due involution will be retarded, and the uterus will remain larger than normal. 2. Aery similar conditions may folloAV in the non-pregnant state, from the sIoav necrotic inflammation to which polypi and fibrous tumors are prone ; from necrotic or inflammatory changes in cancerous groAvths ; from peculiar fungoid or other morbid conditions of the uterine mucous membrane. 3. We are, perhaps, most familiar with acute metritis, apart from the puerperal state, as the result of injury or irritation produced by surgical treatmeat. Thus, operations upon the uterus, as incision of the cervix ; scraping, or cutting, or tearing aAvay of fibroid tumors ; the application of caustics to the interior of the uterus, especially in the form of injec- tions ; the use of tents, laminaria or sponge ; and above all the Avearing intra-uterine pessaries, may induce metritis. In all these cases there may be absorption of foul matter by the vessels Avhich permeate the walls of the uterus. In all these cases, the inflammation mostly invades all the tissues of the uterus, mucous, muscular, vascular, and peritoneal, and almost inva- riably spreads to the cellular tissue on either side of the neck, involving the broad ligaments. Generally, the extra-uterine inflammation predomi- nates over the metritis proper. Metritis may be simple or complicated. The inflammatory complica- tions are: inflammation of the ovary, of the tubes, of the perimetric cellular tissue, of the pelvic peritoneum, perimetric phlegmons or ab- 442 VASCULAR DISORDERS OF UTERUS. scesses, lymphangitis, phlebitis, phlegmasia dolens. All these complica- tions, or some of them, may arise not only as consequences of labor, but also from suppressed menstruation, cold, local injury, conditions arising out of uterine tumors, or of tubercular or cancerous disease. Dr. West has described as " metritis hemorrhagica" the intense acute inflammation which occurs when a piece of nitrate of silver falls into the cavity of the uterus. In such a case, free hemorrhage is very apt to arise. The difference of structure and of function of the cervical portion of the uterus confers upon it pathological liabilities distinct from those of the body of the organ. It may be true that by continuity of tissue, and by receiving its blood supply in great part from the same vascular sys- tem, inflammation of the cervix is apt to spread to the body, and vice versa; but practically, we often have to deal with cases in which one or the other part is so much more profoundly affected than the other that it demands special attention. This consideration, and the advantage of avoiding much repetition, have led me to curtail in this place the description of inflammation of the cervical portion. The complement of this subject will be found in the section devoted to the changes consequent on labor, and in that on pro- lapsus and hypertrophy. INFLAMMATION OF THE SUBSTANCE OF THE UTERUS : METRITIS. The inflammation of the submucous stratum which occurs in acute en- dometritis spreads sometimes to the Avhole uterine substance, and rises to such a height that the uterus sAvells to the size of a goose's egg, becomes softened, reddened, unusually succulent and infiltrated with small extra- vasations. This acute metritis next invades the peritoneal covering of the uterus and of the neighboring organs. In some rare cases the issue has been in suppuration, and the formation of abscesses in the walls of the uterus, which, like the puerperal abscesses, lead to various secondary destructive actions. Chronic metritis proceeds from the acute form, or is developed out of persistent hyperaemia. It not uncommonly arises slowly, even insidiously, out of irritation produced by other morbid conditions, as tumors or cancer; and that without being preceded by any condition that can rightly be called acute inflammation. It leads to hypertrophy of the uterus, Avith preponderance of the connective tissue, Avhich affects the whole organ or prevails in the body, cervix, or vaginal-portion. Its most frequent foun- dation is undoubtedly laid in retarded involution after labor. Much, therefore, of Avhat might, in strict order, be discussed in this place, has been anticipated in the chapter on the consequences of labor; and which should, therefore, be read in connection Avith the description of metritis. Chronic metritis thus takes its rise in hyperaemia. Whatever produces retardation and accumulation in the uterus or in the utero-ovarian system of vessels, leads to chronic metritis. Scanzoni1 says the influence of heart disease in producing chronic metritis is under-estimated. Stenosis and 1 Die Chronische Metritis, 1863. METRITIS. 443 insufficiency of the mitral valves, by inducing retrograde Arenous stagna- tion, causes hyperaemia of the uterus. He also insists that chlorosis and other forms of anaemia, by favoring pelvic hyperaemia, frequently lead to chronic metritis. Scanzoni has distinguished tAvo stages of metritis: namely, 1, a stage of infiltration or softening, in Avhich is observed more or less extensive hyperaemia, a sero-sanguinolent infiltration of the uterine tissue, which in consequence becomes soft, relaxed, thickened ; and 2, a stage of thick- ening or induration, in which general or partial anaemia of the organ, dryness, firmness, and hardness of tissue are the principal lesions. In the first stage, that of softening and hyperaemia, there may be ex- cess or alteration in the secretions of the mucous follicles; especially, neAV formations may arise, or there may be general hypertrophy of the organ. In this stage the softened uterus is flaccid, so that it can be bent backwards or forwards, and pressure of the finger leaves a depression. The surface of the organ often exhibits stringy peritoneal adhesions to the neighboring structures. When a section is made Avith a scalpel, there is absence of that creaking sound which is heard Avhen the healthy dense tissue is cut through. It is like cutting through an ordinary muscle. Fluid blood Aoavs from the cut vessels, and serum from the tissue. The cut vessels are seen of larger calibre, gaping in place-3, but not univer- sally. In intervening spaces the vessels may, to the naked eye, sIioav no alteration. The parenchyma itself has lost something" of its resistance ; it is more succulent and friable. The increase in thickness of the Avail at this stage, Scanzoni says, is not demonstrably due to increase of mus- cular fibre, but mainly to the serous infiltration. It is more SAvelling than neAV groAvth. He has also observed advanced fatty metamorphosis of the muscular-bundles, and in the interposed connective tissue a great number of free fat-globules. This more especially applies to the upper part of the organ. The mucous membrane is almost invariably the seat of chronic catarrh. In the second stage, that of thickening or induration, there is a general or partial anaemia of the organ. The tissue is dry, tough, and hard. This hardness strikes the observer as the next feature after the increase of volume. The hardness resembles that of dense fibroid tumors. These characters are very clearly seen Avhen the hypertrophied vaginal-portion is amputated. Tliis tissue-change, Scanzoni says, is more evident in the posterior than in the anterior wall, and he attributes this to the fact that the hinder Avail is the more frequent seat of the placenta. The indurated places look pale, vcIIoav, or yelloAvish-red, and this appearance is made more striking in those cases Avhere these places are surrounded by others still in the stage of infiltration, and Avhich will be soft and red. But cases are frequently observed in Avhich the Avhole organ is thickened and indurated. In the hardened parts the vessels are contracted. The chief contribution to the increase of volume of the tissue is made by excessive growth of the connective tissue, although the muscular element may to some extent contribute. As far as I can trust my OAvn observations made upon the hypertrophied vaginal-portion after amputation, I must concur in this statement. The same operation also gives evidence of the con- traction of the vessels. Incision made with the knife divides no large 444 VASCULAR DISORDERS OF UTERUS. vessels ; there is at most an oozing from the surface. The greatest part of the blood comes from the divided mucous membrane. Chronic metritis, although it may predominate in the body or cervix, almost invariably affects the entire uterus, more or less. Scanzoni has taken great pains to verify the statements of those pathologists Avho con- tend that the anterior or posterior Avail or the fundus may be the especial seat of hypertrophy from chronic infiammation. He has occasionally found a part more thickened than the rest; but invariably the entire body of the organ is enlarged. The growth is outwards ; it leaves the cavity expanded, impairing more or less its triangular shape, so that it becomes more ovoid. This is in exact conformity with my own observa- tions. The mucous membrane is SAvollen, softened ; the glandular orifices are prominent, open, visible under Avater. The gland-tubes themselves are much elongated. Mucus, stained with pus, is generally found in the cavity. The origin of the increase of bulk undoubtedly, in many cases, lies in acute metritis. The effused fluids not being entirely absorbed, Avhat re- mains becomes organized. But there are many cases in Avhich it is diffi- cult to prove the existence of inflammation. Under simple hyperaemia fluids are effused into the tissue, and the non-absorbed excess may undergo the same change into dense tissues. It is thus that during long-persistent hyperaemia there may be intercurrent attacks of metritis. But this is not shoAvn to be necessary—the process is one of disordered nutrition. Klob denies that the hyperplasia is due to inflammation, and says the origin is in habitual hyperaemia. The changes produced in the cervix uteri by chronic inflammation in- volving the Avhole uterus have been partly described in a preceding chap- ter. Those which are necessarily dependent upon antecedent pregnancy, are the folloAving:— The follicular excoriations of the cervical canal arise, according to C. Mayer, in the following manner: There is an inflammatory process in the mucous membrane, so that the follicles being involved, their excretory orifices are closed. Then three several pathological changes proceed: 1. The follicles swTell gradually to the size of a millet seed, and form round, smooth, elastic cysts containing a delicate, viscid, stringy matter, known as ovula Nabothi. Often the contents assume a purulent condi- tion : and at length the follicles burst, and leave round, follicular ulcera- tions. 2. The follicles do not reach the above-described development, but stop as it Avere on the way, as small, roundish bodies with thickened investments, and scanty contents, like hard knots on the surface, and so persist. 3. Or the follicles project more and more out of the mucous membrane, like ovula Nabothi, become bigger, and hang doAvn, stalked, like scarlet-red pearls out of the os uteri. These are called mucous polypi. These three forms give rise to three distinct forms of follicular ero- sions and ulcerations, different in their symptoms and in their appearance. In the first form the os uteri is nearly ahvays large, gaping, its scarred borders everted ; its whole surface feels rough, uneven. The profuse secretion is often yelloAvish, puriform, not seldom mixed with blood, and METRITIS. 445 offensive. The lips are dark-red, even purple, hyperaemic. The promi- nent smooth follicles are easily recognized ; they have a turgescent, often finely granular surface. A thick stream of opaque, yelloAvish-Avhite secre- tion Aoavs from the cervix. Where the follicles have burst, roundish ulcers remain. This condition is not limited to the os uteri, it extends to the interior of the cervix. These follicular affections, C. Mayer says, are almost ahvays asso- ciated Avith chronic metritis. Scanzoni associates them Avith retarded involution of the uterus. The mucous membrane, with its glandular ap- paratus, hypertrophied during pregnancy, remains stationary, and gives rise to the affections described. That this is in many cases true, I do not doubt. But the explanation I have given in the chapter on the changes the cervix undergoes after labor is, I am equally sure, more generally true. The mucous membrane, at least its epithelial element, falls by a necrotic process; and one does not usually see in the post- puerperal cases distinct rounded follicular ulcers, but a large surface bared of epithelium ; the granular aspect being due, not so much to the enlarged follicles, as to the SAvollen villi no longer bound down by their epithelial investment. (See Fig. 102.) The roundish erosions resulting from burst follicles described by Mayer, are often seen independently of pregnancy, that is, years after the last pregnancy, and even in Avomen avIio have never had children. There is another form of erosions described by Scanzoni and others, which ought not to be confounded Avith the foregoing. These result from aphthous eruptions. Partly in the immediate proximity of the os uteri, partly scattered at some distance are small vesicular points as big as a pin's head. The epithelium is easily rubbed off by a brush, leaving a small livid red spot. Sometimes several of these vesicles run together, and give rise to a large erosion. This kind of erosion is distinguished from the preceding one in the absence of follicular SAvelling of the cervical mucous membrane, by the thinness of the superficial Avail of the vesicle, by the ease with which the vesicles burst; and in their leaving, not a sharp deep ulcer, but a superficial, perhaps irregular, erosion. This ap- pears to be the herpetic, dartrous or eczematous ulceration of Huguier and Courty, terms, which, I think, Aran rightly finds fault with, since they imply a connection with herpetic disorders of the skin, of Avhich there is no proof. On the other hand, Scanzoni relates a case of an othenvise healthy Avoman who suffered from aphtha? of the mouth, who, Avhenever she had a fresh eruption here, always had attacks of pruritus vulvae and slight leucorrhoea, attended by vesicular eruption on the mucous mem- brane of the vaginal-portion. These Avere speedily cured by light touches with nitrate of silver; but a relapse ahvays followed the formation of aphthae in the mouth. The papillary erosions I have described under the changes following labor under the name of " villous." I believe they are more frequently the cause than the consequence of chronic metritis. Dating from the act of labor, arising in traumatism, they precede metritis. Although the metritis may, and often does, arise out of the hyperaemia attending re- tarded involution, yet even in cases where involution has proceeded fairly avcII, the raAV surface left by the fall of the epithelium, keeps up 440 VASCULAR DISORDERS OF UTERUS. irritation and attracts an undue Aoav of blood to the part: maintaining a condition constantly liable to merge into subacute inflammation. In connection with chronic metritis, it is not rare to find a form <>f erosions to Avhich the name of " cock's-comb ulceration" has been given. It appears to be a transition-form from the papillary or villous erosion to the cauliflower-excrescence. When this occurs, the tumefaction ami enlargement of the whole cervix as well as of the vaginal-portion are considerable. There is intense hyperaemia, and often some degree of loss of mobility of the lower segment of the uterus. This appears to be due, at least in those cases where evidence of malignant disease is not pronounced, to infiltration of serum, Avith some inflammatory process in the cellular tissue immediately outside the cervix. These cases are diffi- cult to deal with. Absolute rest is essential. Local applications of chromic or nitric acid answer the most effectually. Scanzoni, in 1850, described the " varicose ulcer" as a form of disease of the cervix uteri arising in this way: Some time after the existence of a marked increase of volume of'the uterus, and of a profuse secretion from its cavity, a bluish-red coloration is developed on the vaginal-portion and the adjoining part of the vagina ; some dark blue spots gradually appear, upon which, after a time, numerous varicose venous branches become manifest. Upon these spots the mucous membrane softens, and forms elevations recognizable by sight and touch. The epithelium is throAvn off, and an erosion is the result. At a further stage the loss of substance extends deeper, usually giving rise to free hemorrhage. The surface of the sore looks remarkably pulpy, so that the sound easily penetrates it. Scanzoni has only seen these varicose ulcers in women who had borne children, and in Avhom there had long existed obstruction to the portal circulation, or in the subjects of heart disease. I have, however, notes of a case taken at the London Hospital, in which there Avas a vascular naevus-like groAvth on the os uteri of a Avoman who had never had children. She Avas said to have had three abortions ; but the cervix and os uteri had the features Avhich I have almost invariably found significant of sterility. This woman had frequent metrorrhagia. Under applications of nitrate of silver the varicose mass disappeared, and the hemorrhage ceased. Chronic metritis sometimes brings about a papillary SAvelling of the mucous membrane of the vagina. This Avas at one time called " follicular." But since Hassall, Henle, Mandl, Kolliker, and others, have shoAvn that the mucous membrane of the vagina is nearly destitute of glands, the papillary nature of the affection has been recognized. It is generally attended by a profuse milky or creamy leucorrhoea. This papillary hypertrophy is often observed in the course of pregnancy, Avhich condition must be regarded as its chief cause. After labor it is sometimes so marked as to resemble a papilloma. The Course of Metritis.—Inflammation, if it does not terminate in resolution, may become chronic, and lead to hypertrophy, or it may tend to softening and liquefaction. This termination is, I believe, not very uncommon in Avomen past the climacteric. In such cases the whole oro-an is enlarged. It feels flaccid, swollen, pulpy, betAveen the internal and external examining fingers. The body falls either forwards or backAvards METRITIS. 447 or may seem to squat down on the vagina. The sound passes the os in- ternum easily, provided there is no flexion, or Avhen the doAvn-bent body is tilted up. It penetrates usually rather more than tAvo and a-half inches before resistance is encountered ; and the Avail of the uterus is so pulpy, that the point might easily penetrate into or through its substance. More or less oozing of blood commonly folloAvs the examination. By the specu- lum the os externum and vaginal-portion are seen deep purple or dark red; the mucous membrane is villous-looking, it easily bleeds. If there be» a tubercular element complicating this metritis, recovery is hardly to be expected. It may be doubted Avhether, even apart from such complication, recovery takes place, if the softening be general or far advanced. Abscess in the uterine wall is, I believe, rarely seen unless in the puerperal state ; and in this case it does not, unless exceptionally, arise in the parenchyma, but may be traced from the foci formed in the venous tissues or lymphatics, Avhose Avails are first inflamed by the reception of septic matter from the cavity of the uterus. Abscess does not occur readily in purely muscular tissue. Metritis proper may, hoAvever, run on rapidly to the formation of ab- scess, as in the following case told by Scanzoni. A young woman had Adolent metritis after suppression of menstruation. The pains were very acute, resisting all treatment for eight days. The sensibility increased, rigors Avere repeated several times, and suddenly there Avas developed, above the horizontal portion of the pubes, a tumor the size of a hen's egg, someAvhat resisting, and accurately defined. On the tAventy-second day of the illness, symptoms of violent and extensive peritonitis set in, and the patient died on the thirty-first day. Dissection proved that the cause of death Avas the rupture of an abscess, situated in the right and upper part of the uterus, the pus from Avhich had Avorked through the outer strata of the uterus and its peritoneal investment. It can hardly be doubted that this case Avas one of metritis proper passing into abscess. But a case related by Hervez de Chegoin (Soc. de Chirurgie, 180S), in Avhich an abscess Avas found at the fundus of the uterus quite closed, the size of a uterus at the fifth month of pregnancy, Avith enormous development of the fleshy fibre, was probably the result of suppuration in a fibro-cystic tumor. This source of fallacy must be borne in mind. Amongst the consequences of chronic metritris, Scanzoni lays stress upon the frequent implication of the ovaries. Supplied by the same system of vessels, these readily partake in the like hyperaemia, and in the increased action attending the uterine condition. He says ovarian cysts are a frequent complication. They arise out of chronic oophoritis; probably in this Avay an ovum may ripen, but owing to thickened condi- tion of the surrounding stroma the follicle cannot burst, and the fluid cannot escape. Succeeding menstrual periods with attendant hyperaemia cause fresh exudation into the follicular cavity, and so this groAvs to a cyst. The other forms of cystoid of the ovary are also often found as complications of chronic metritis. Chronic catarrh of the Fallopian tubes often comes as an extension of the aftcction of the uterus; and one of its consequences is adhesion to 448 VASCULAR DISORDERS OF UTERUS. the ovary. And, either by adhesion or by simple closure of the tube at its abdominal end, the tube may become distended by accumulation, pro- ducing dropsy. The vagina, in the higher grades of the disease, is almost constantly in the state of chronic catarrh, with more or less swelling and relaxation of its tissues. This is especially true of the upper part or fundus of the vagina. The bladder participates in the disordered circulation of the pelvis, being involved in chronic catarrh, and perhaps thickening of its coats. The rectum is also, in like manner, liable to chronic catarrh, attended with varicose dilatations of the hemorrhoidal veins, especially Avhen there is retroversion or retroflexion of the uterus with enlargement. In various ways the skin shows evidence of disordered nutrition. Hebra says the influence which uterine disorder exerts over the origin of skin diseases, especially of the eczemata, is manifested in the fact that all the chronic skin affections in women undergo a marked deteriora- tion, a fresh irritation, during menstruation. Many Avomen, he says, feel a day or two before this process—commonly in the course of the vessels of the extremities—smarting, burning, and twitching, so that by these symptoms they can foretell Avith certainty the speedy appearance of men- struation. Hebra also calls attention to the frequency with which Avomen suffering from uterine disorder lose their hair. Every one Avho sees much of these disorders is familiar with this complaint. In not a feAV cases it is asso- ciated with syphilitic complication. But in a great number of cases there is no reason to invoke this explanation. It appears to be induced by the deteriorated nutrition which folloAvs upon chronic uterine disease. It is often cured, the hair-groAvth being quite restored, Avhen the uterine disease is removed. The influence on pigmentation is often very striking. Independently of the pale, sallow, or dull earthen hue, the result of the circulation of impoverished blood, more or less tainted with unhealthy elements, there are frequently seen on the face, namely, on the forehead, cheeks, or chin, broAvnish spots or patches of lentigo or chloasma uterinum. This chlo- asma is a form of pityriasis versicolor. I have seen marked examples on the chest, which underwent striking increase in depth of color during menstruation. Although in all likelihood due to disordered nutrition of the skin, it is not determined whether the yelloAvish-brown color of the epidermic scales depends upon the peculiar fungus developed in this dis- ease, as G. Simon believes, or upon the marked accumulation of fat— smegma—as Wedl suggests. Acne is not at all uncommon. I have known this disfiguring eruption disappear soon after cure of uterine disorder, aided by iodide of potas- sium, arsenic, and other appropriate remedies. Fugitive attacks of erythema, erysipelas, or furuncle, are more fre- quently observed during the anaemia of amenorrhoea, but are not uncom- mon at the climacteric period. Nervous Symptoms or Complications.—The seat and intensity of the pain are very variable. There is most commonly a painful sense of weight, pressure, at times of forcing, in the hypogastrium and pelvis. NERVOUS COMPLICATIONS. 440 This is more or less constant, but is aggravated by standing, Avalking, or other exertion. There is often a sensation as of a large body tending to force its way out of the vulva. On coughing, sneezing, or other forci- ble expiratory acts, the pain is increased, and these bring out new pains in the loins, sacrum, and groins. There is often distress at the anus, and doAvn the thighs. At the menstrual epochs, the hyperaesthesia is more generally diffused. The frequency with Avhich pain is felt in those regions which are supplied by the lumbar plexus, is remarkable. It is deserving of attention in a diagnostic point of vieAV, that the intense pain often complained of in chronic metritis in the inguinal region is so ex- plained, and is therefore not indicative of oophoritis. In two cases, says Scanzoni, in Avhich an autopsy Avas made of Avomen Avho had suffered in- tensely from pain in the ovarian region, so that he Avas all but convinced that they had organic disease of the ovaries, these organs Avere found perfectly sound. Bennet, as Ave have seen, has long insisted that this pain is pathognomonic of chronic inflammation of the cervix. I have on several occasions knoAvn intense ovarian pain produced at the moment of touching an abraded surface of the os uteri Avith caustic. The nerve most frequently affected appears to be the ileo-hypogastric. The pain often runs along the course of this nerve from the anterior border of the crest of the sacrum, dowmvards to the inguinal ring. When the pain extends to the labia pudendi, Ave have to conclude that the exter- nal pudic nerve has been seized. I have knoAvn this, or the external pudic nerve, to be the seat of persistent pain concentrated there, of the most distressing kind. It seems as if, after long irritation of the nerves hrvolved, pain settles in a particular branch, and becomes difficult to dis- lodge, even after the disease which provoked the nervous trouble had ceased. This remark applies peculiarly to the dorsal, lumbar, and sacral aching pain Avhich often lasts weeks and months after the uterus has been restored to a comparatively healthy condition. In these cases, it seems highly probable that the long-continued irritation of the lower part of the spinal cord has induced a chronic alteration of nutrition. This lingering ill is often the source of disappointment and discouragement to patients avIio have really reco\rered from metritis. It is necessary to explain that effects do not immediately cease after the cause is removed; that the return to healthy nervous function, to vigorous muscular power, is neces- sarily gradual. Muscles long disused have fallen aAvay; all the func- tions exhibit the Aveakness of structure of the organs Avhich execute those functions. Healthy tissues can only be built up by regulated exercise and other hygienic measures. A not uncommon attendant symptom of chronic metritis is the " Coc- cygodynia" of Simpson. This is sometimes so distressing that the suf- ferer cannot sit in the ordinary way, but is obliged to rest upon one or other ischium; and some Avomen on this account constantly use an air- cushion. Pain is often felt on defecation. Since the metritis to which this pain is due, itself probably arose after labor, it is natural to conjec- ture that the sacro-coccygeal joint received injury during labor, and be- came the seat of chronic inflammation. In some instances this is really the case. But in most no evidence, beyond the pain, will be found of local mischief. It is a form of neuralgia. It is, however, desirable to 29 450 VASCULAR DISORDERS OF UTERUS. determine the local condition by examination. For this, the forefinger of one hand is passed into the rectum, whilst the other hand feels along the sacrum or down the joint externally. In this way the joint is closely approached on either side, and the relation of its constituent bones, the mobility of the coccyx, the condition of the joint can be accurately made out. The removal of this sacro-coccygeal neuralgia must be Avaited for in the same way as the subsidence of other nervous disorders, avIich the causing disease is cured. Dysuria and dyschezia are apt to be especially troublesome at the menstrual epochs. A nervous affection of a peculiarly distressing kind is pruritus vagi me et vulvce. This is not an uncommon symptom of chronic metritis. It is due to the general hyperesthesia of the pelvic nerves, and, in some cases, to inflammation of the mucous membrane. The nervous filaments dis- tributed in the papillae being involved, of course present extensive points of peripheral irritation. Where there is inflammation of the mucous membrane, there will commonly be more or less spasmodic contractility of the vulva, constituting vaginismus. But an equal degree of irritability is not uncommon Avhere there is no local inflammation. This distressing complication is sometimes successfully treated by belladonna or morphia pessaries. But the only effectual remedy is the use of the " vaginal- rest." The Avear and tear of the nervous system, and the degradation of the blood attending chronic metritis, hardly ever fail to bring about disturb- ance of distant parts. This is manifested in various sympathetic nervous disorders. One of the most frequent is facial neuralgia. The associa- tion of this disorder Avith uterine and ovarian trouble, is placed beyond doubt by the exacerbations Avhich so often accompany the menstrual periods. Hysteria is another frequent attendant. Where the disease has lasted some years, being prolonged into the climacteric age, the nervous disorders characteristic of that epoch will be earlier and more strikingly produced. A symptom, says Peaslee,1 almost pathognomonic of uterine affections, is the " uterine headache," referred to the top of the head, usually ex- tending over a circular or oval surface, and relieved by pressure. Some- times a "crazy feeling," a sensation of cold or heat, or a numbness is complained of, or the surface is tender on pressure, or hot. The Symptoms and Diagnosis.—The disease is usually so protracted, coming under treatment, perhaps, long after its earlier stages have been passed through, that it is difficult to gather up a complete orderly history of the symptoms. The later symptoms will, in many respects, differ from the earlier ones. Still, the subjective symptoms, when corrected and complemented by the objective ones, are clear enough to mark what is going on. The most marked symptom is acute hypogastric pain, differing from the pains of retention by being persistent, and becoming more intense. It frequently comes on suddenly, with initial protracted rigor. Fever is constant in acute metritis, and not rare in the chronic form. Inflamma- tion is apt to spread to the surrounding organs, and if the peritoneum 1 Americau Medical Monthly, 1860. NERVOUS COMPLICATIONS. 451 become involved, as it frequently does, the pain may extend from the pelvis to the abdomen. The patient complains of a feeling of burning heat in the bypogastrium, vagina, and vulva. She usually lies on her back, with the knees drawn up. On examination, the vagina feels hot, tense, tumid ; pressing the cervix uteri produces acute pain, especially if so pressed as to move the uterus. Arterial pulsations may be felt in the utero-vaginal sinuses. The uterus is felt to be increased in bulk. If the sound be introduced—and this ought to be avoided if we find the foregoing signs present—the most acute pain is caused by the passage along the cervix, and some oozing of blood is very likely to ensue. The diagnosis, indeed, admits of being perfectly established, Avithout the sound. The state of the uterus—perhaps softened, easily bleeding, even easily penetrable by the point of the instrument—is a valid reason for not using it. The pain is intensified by movement, by the slightest jar or shock, and even by the action of the boAvels or bladder. If acute metritis attack during menstruation, the menstrual Aoav is commonly suppressed. In the chronic form it may also be suppressed ; but sometimes an attack of menorrhagia or metrorrhagia supervenes. Dysmenorrhoea is almost inevi- table. Suppression of menstruation is more characteristic of parenchy- matous metritis. When the mucous membrane is principally affected, there is more often menorrhagia. Nausea and vomiting are hardly ever absent. Bennet looks upon nausea as a characteristic symptom of parenchymatous inflammation. The active engorgement of the vessels and tissues stretching the uterine fibre accounts for this symptom. The "fades uterina" is commonly Avell marked. Sterility is almost constant in metritis. In the acute stage pain would prevent intercourse, and in the sloAver chronic forms the altered tissues and secretions are unfavorable to conception, and to the retention of the embryo in the rare e\rent of conception taking place. In the more chronic forms of metritis, the simple vaginal touch may not in every case produce pain. If the surrounding structures be not involved, so as to impede the mobility of the uterus, and the body of the orjxan be the chief seat of the infiammation, it rises and retreats before tyie examining finger, so that the tender inflamed part escapes pressure. But Avhen Ave combine external pressure by the hand above the pubes, pushing the fundus doAvn we evoke pain by bringing the infiamed part under compression. By this mode of examination Ave are sure to bring out Avith precision the signs of disease in the uterus ; and by, in like manner, examining the remaining organs in the pelvis, Ave may exactly trace the disease to the uterus. The enlargement of the uterus Avhich ahvays attends metritis, chronic or acute, is easily determined by the abdomino-vaginal, or the recto-ab- dominal touch. The fundus of the uterus in acute puerperal metritis almost invariably rises above the symphysis pubis. In the non-puerperal acute, and in the chronic forms, it is usually not difficult to feel the fundus by pressing the fingers a little firmly behind the symphysis, having previ- 452 VASCULAR DISORDERS OF UTERUS. ously emptied the bladder. Indeed, in the acute and sub-acute forms, the fundus may be generally felt three or four inches above the symphy- sis. If the infiammation arise out of, or be associated Avith, cancerous, fibroid, or other disease, the enlargement of the body of the uterus is usually greater, and the fundus rises proportionally so as to be easily reached. This enlargement of the uterus imparts some degree of tumefaction to the loAver abdomen. And it is a point to attract attention, that the tume- faction or distension of the abdomen is almost ahvays much greater than the mere increase in size of the uterus can account for. The surplus is, I believe, often due to the disturbance in the state of the intestines, Avhich the neighboring infiamed organ produces. All parts in contact with an inflamed organ are constantly disordered. This is especially the case when movement is a necessary condition to the due performance of the organs implicated by proximity. The intestines are in this case ; and they appear to be compelled to a state of inaction or paralysis, in order to spare the sensitive inAamed uterus. Hence distension. This is made manifest by tympanites. So long as the inflammation is limited to the uterus, not involving the peritoneum or the broad ligaments, the uterus remains mobile. If it be found at all fixed, we may conclude that the infiammation has extended to the surrounding structures. Although in a large proportion of the cases of chronic metritis the uterus retains its mobility, we must ahvays be prepared for extension of inflammation to the neighboring parts. In acute metritis the uterus is almost invariably more or less fixed. When this occurs, as it may do under the influence of cold, over-exertion or vio- lence, especially if encountered during a menstrual period, there will be exacerbation of pain, and this more Avidely spread ; and there will be some febrile excitement. Metritis may be mistaken for congestion, fluxion, uterine tumor, or perimetric disease. The diagnosis will be made out by the comparative study of the description given of these several disorders. In simple congestion, fever is usually absent. There is not the burning heat in the vagina, nor the same degree of tenderness of the uterus. The duration of acute parenchymatous metritis, if not complicated Avith septic conditions, or perimetritis, is generally from a month to two months. The usual termination is in resolution. But in patients Avho have neglected care, rest, and appropriate treat- ment, and especially in those who are the subjects of strumous or other morbid diathesis, or who are simply of weak constitution, the inflamma- tion merges into the chronic form, and is not unlikely to spread to neigh- boring structures. Perimetritis, or inflammation of the peritoneal investment of the uterus, will be more conveniently described in connection with pelvic cellulitis and pelvic peritonitis in a subsequent chapter. The^ Curability of Metritis, Acute and Chronic.—There can be no doubt in the mind of those Avho have had large opportunities of observing puerperal diseases, that acute and even subacute metritis is often followed by virtual, if not complete, recovery. We can avoid this conclusion, if we accept as evidence of restoration the return to healthy functional METRITIS: TREATMENT. 453 activity. Who has not knoAvn Avomen who have suffered metritis after labor or abortion, subsequently menstruate easily, become pregnant, go through labor, lactation, and resume the duties of life Avith comfort? It is scarcely possible that a history such as this should be frequent, if any decided uterine disease persisted. The case is someAvhat different, hoAvever, with chronic metritis. Slow changes of tissue, continuing over months and years, are Avith difficulty counteracted. Still, appealing to the same evidence Avhich proves the cure of acute metritis, we cannot absolutely deny the curability of chronic metritis. Pregnancy is assuredly, if I may trust my OAvn observation, not infrequent. It sometimes, no doubt, takes place whilst the uterus is still in an imperfectly restored condition. But the value of this test of return to functional Avork is strong. I think this fact should qualify the discouraging conclusion of Scanzoni that, perhaps, Avith the exception of some extraordinarily rare instances, it is not in the poAver of the physi- cian so to cause the tissue-changes of chronic metritis to disappear, that the uterus is completely brought back to its normal condition. AVhen once the process of hypertrophic induration Avith condensation of tissue has been accomplished, it is certainly contrary to experience to find that, either by internal remedies or by local applications, Ave can reverse the process Avhich has taken place, cause the neAV material to be absorbed, and restore the uterus to its pristine condition. We have the clearest evidence of the permanent character of the tissue-changes wrought by chronic metritis brought directly under our senses in the chronic hy- pertrophic elongation of the cervix. GroAvth with induration having taken place, it may be confidently said that nothing short of surgical agency will remove the disease. It may by analogy be contended that like changes in the body of the uterus will be equally permanent Although this part is liable to similar tissue-changes, still this does not appear to be so frequent. Noav if, as Scanzoni himself asserts, there is no such thing as chronic metritis absolutely limited to one part of the organ, of course Avhen we have hypertrophic induration of the cervix, about Avhich there can be no doubt, before us, we must infer that the body of the uterus is similarly affected. Noav, it is a fact beyond dis- pute that pregnancy is not uncommon in cases of very advanced, even extreme, hypertrophic elongation of the cervix. I have notes of many such cases. Some are described in my Obstetric Operations, 3d edition. We are driven, then, to conclude that the hypertrophy resulting from chronic metritis may either be so far cured that the uterus can resume its highest function, or that the persistence of the hypertrophic change is not an absolute bar to this resumption of function, or, what is more likely than either, that the hypertrophy of the cervix, a part not essen- tial to pregnancy, may exist Avithout involving the body of the uterus. This brings us to another question of great practical interest. What is the influence of pregnancy in curing chronic metritis and its results ? If Ave assume that all must be cured before gestation can go on, of course the question falls to the ground. But if, on the other hand, Ave assume that conception may take place and gestation proceed to term, in an organ Avhich is the scat of chronic metritis or of its results, what will be the effect upon these conditions ? Speaking from clinical observation and 454 VASCULAR DISORDERS OF UTERUS. analogical reasoning, I feel confident that, under this condition, a cure may be effected, that is, that the new hypertrophied tissue may be re- moved, and the uterus brought back to its pristine state, or nearly so. In- stances have come under observation proving that fibroid tumors have been dispersed by absorption—I do not mean by sloughing or by casting off in mass, more common events—under the influence of pregnancy. These tumors, composed of tissue, not dissimilar from that of the morbid hyper- trophic element, are caught in the involution-process, Avhich reduces the normal hypertrophic element, and like it, they vanish. Is it not in the highest degree probable that the new hypertrophic matter, uniformly distributed in the midst of the proper uterine tissue, may be equally caught in this absorption-process, and be thus removed ? I have seen distinct diminution in bulk of the hypertrophied cervix follow upon labor. But I have also seen hypertrophy of this part persist through several pregnancies. I think, then, Ave may conclude that the uterus hypertrophied under chronic metritis may be restored, at least, sufficiently for the resumption of its duty. And if the morbid hypertrophic matter can be removed by gestation, Avhy not by other means ? I do not pretend that other means at our disposal arc of equal efficacy Avith pregnancy. But if we can es- tablish a reasonable presumption that the condition is curable by any means, surely Ave need not despair of finding other means that may accom- plish the same end. Again, uterine fibroids occasionally undergo a process of degeneration or atrophy, the senile involution, after the climacteric. The proper uterine tissue itself undergoes this atrophic involution. Why should not the abnormal hypertrophic tissue undergo the like change ? As a rule new formations are more ready to undergo atrophy by absorption or de- generation than healthy tissue ; and, as a matter of observation, I think I shall be supported when I affirm that hypertrophic induration, the result of chronic metritis, does undergo atrophy under this condition. It is in accordance with general opinion that active inflammatory pro- cess of the uterus and ovaries tends to spontaneous remission and cure at the climacteric period. Ceasing to be stimulated by the periodical hyperaemia of ovulation, the local inflammation naturally subsides. But Ave must not hastily conclude that uterine disease will ahvays undergo spontaneous cure or alleviation at this period. In many cases the disease continues, often attended with hemorrhage. The morbid action, once set going, is maintained by the hyperaemia of obstructed venous circula- tion, and by the disposition to local haemostasis so common at this period of life. And there seems to be also a more or less persistent ovulation- effort going on, in many cases, for years after the climacteric has, accord- ing to all presumption, arrived. Scanzoni urges many reasons why sterility is the doom of women suffering from chronic metritis. 1. There is the accumulation of more or less unhealthy secretion. 2. Premising that the shedding of the mucous membrane itself is much more common than is generally thought, he says he has never known a case in which considerable fragments of mucous membrane having been regularly cast at each menstruation the Avoman has conceived. The membrane is cast just at the end of the period, the METRITIS : TREATMENT. 455 very moment Avhen the impregnated ovum Avants a decidua to attach itself to. 3. The ovaries are frequently implicated in chronic metritis. 4. There is pain or indifference attending the sexual act. Certainly sterility is a frequent consequence, but it is far from univer- sal. Scanzoni himself admits that pregnancy may occur, and he rightly says that its course is generally unfavorably affected by the morbid state of the uterus. Can the so-called benign tumefactions caused by chronic hyperaemia and inflammation pass into cancerous degeneration ? This is another question often anxiously put. The evidence in support of the affirmative is very fallacious. The treatment of acute metritis will be governed by the opinion Ave may form as to whether the case is one of metritis simple, or of metritis complicated Avith septic infection. In the former case the treatment Avill be more purely antiphlogistic. TAvelve to tAventy leeches may be use- fully applied above the pubes. Aran and most French physicians advise six or eight leeches to the cervix uteri. Fomentations give relief. A plasma consisting of one drachm of extract of belladonna mixed Avith half- an-ounce of mild blue ointment and two ounces of simple cerate, spread in a thin layer on a piece of lint, and applied to the hypogastric region, the Avhole covered over with a light packing of cotton avooI, Avill not only give ease, but be of material use in subduing the inflammation. Ex- perience has proved the importance of completely securing the surface covering inflamed organs from contact Avith the air. It is by acting in this Avay that the cotton-Avool packing undoubtedly does good. It is desirable to unload the rectum of any fecal accumulation by an enema. But this done, it is not advisable to disturb the inflamed parts by purging until the acute stage is past. When the stage of resolution is advanced, purgatives are useful. Piillna, Flunyadi, or Friederickshall waters answer well. Tepid vaginal irrigations Avith Avater or decoction of poppyheads, or with a little laudanum, are useful. In the beginning there is nothing that acts so Avell as calomel and opium. One grain of calomel, Avith half a grain of opium, may be given every six hours for a day or tAvo, taking care to stop short of salivation. After this salines, especially the acetate of ammonia and nitrate of potash combined Avith sedatives, constitute the best internal remedies. It is needless to add that absolute rest is the essential condition of successful treatment in the more acute forms of the affection. Precaution is especially necessary Avhen the menstrual epoch is approaching. When there is septic complication, leeching must be avoided. The mercurial belladonna ointment may, hoAvever, still be useful. Salines must be early combined with, or give place to bark, quinine, and general tonic treatment. The discharges should be carefully examined. If they be in any de- gree offensive, tepid intra-uterine injections of Aveak solution of perman- ganate of potash or carbolic acid should be used. Septicaemia is kept up by the continuous or intermittent imbibition into the vascular system of fresh doses of septic matter. The system may frequently be able to throw off a moderate dose of the poisonous element, and the local inflam- 456 VASCULAR DISORDERS OF UTERUS. mation, as Avell as the general disturbance, may soon subside if the re- newal of the irritating cause be prevented. The treatment of chronic metritis is conducted essentially on the same principles as that of arrested involution. The first question to decide is as to the application of what is called antiphlogistic treatment. Upon the usefulness of local abstraction of blood, opinions are very much divided. The indication seems clear to relieve the local hypenemia Avhich is so essentially concerned in the genesis and maintenance of the disease. And I am willing to admit that great ease is often felt by pa- tients after leeching the cervix uteri. But it has appeared to me that this benefit is chiefly experienced Avhen the disease is in the early or sub- acute stage, that is, during Scanzoni's first stage of infiltration. When induration has set in, I believe not much good is to be expected from bleeding. And the indication to relieve the tension of the local circula- tion may often be greatly met by supporting the loaded organ at its proper level by a lever or other suitable pessary. This contrivance Avill often not only facilitate the return of blood by the veins, but it also, by nursing the uterus, as it Avere, secures a degree of rest Avhich is essential to cure. There is ahvays some degree of prolapsus, if not of version or flexion, Avhich involves more or less strangulation of the vessels at the point of their entry and exit. If this sinking or displacement be coun- teracted, one great cause of the maintenance of the disease is pro tanto mitigated. This mechanical support Avill be used chiefly in the earlier stages, but it will be of service at times all through. One great recom- mendation of it is, that it renders " lying down" less necessary. I am sure that in many cases a woman will obtain more effectual " rest" for the uterus, by a properly adapted pessary, Avhilst taking a moderate dose of exercise, than she will by rigorous " lying down" Avithout it. If, therefore, leeches be employed, it will be Avise to watch the effect well, and not to repeat them unless Ave are Avell assured that they do what is Avanted of them by relieving gorged vessels. It is Avell to remember—I do not mention this as an objection to the proper use of leeches—the more or less troublesome events that may attend their use, to which reference has already been made. Scanzoni, Avho is a strenuous advocate for leeching, signalizes another consequence. He describes a peculiar erythema or urticaria which comes on a feAv minutes after the leeches have been taken. A shudder or even a rigor is followed by swimming in the head, disorder of the senses, even delirium. Then the urticaria blebs come out. Leeches should not be applied when there is marked anaemia ; when the signs of acute hyperaemia are not present; when the disease is of long standing, and the induration process has made way. Warmth is of the greatest service in the treatment of chronic metritis. When there is any exacerbation of pain from fatigue or exposure, heat may be applied dry, by heated bags of salt or bran, or Avater, to the hypo- gastrium. But in almost every stage, Avarmth, combined Avith moisture, renders eminent service. The Avhole bath at a temperature of 90° to 95° F. is perhaps the best method of applying it. It acts in a twofold manner. It exerts a not unimportant resolutive influence upon the o-oro-ed loaded uterus. Not that any marked poAver can be proved in promoting METRITIS: TREATMENT. 457 absorption when the organ has become hypertrophied and indurated. But in the earliest stages, there seems reason to believe that warm moisture may aid in relieving congestion. No one doubts the beneficial soothing action of hot fomentations on superficial phlegmasiae. A similar action can be exerted on the uterus. Secondly, Avarm baths are useful in pro- moting a healthy secreting action of the skin; and this is an essential condition of the relief of internal hyperaemic processes. The hip-bath may often be conveniently substituted for the Avhole bath, although it is open to the objection that it compels an uncomfortable position. To get the full benefit from Avarm baths, it is necessary to give the Avater free access to the vagina. This can be accomplished by the use of the bath-speculum. The most convenient form is a conical one, with a very wide inferior opening. The cone—the part introduced into the vagina—is perforated Avith holes the size of a sixpence. The patient can easily apply it. Another method is by irrigation. The warm douche can be kept playing upon the cervix for fifteen or twenty minutes at a time, either by help of a syphon, or of a Higginson's syringe. In many cases, the Aralue of Avarm baths is enhanced by the addition of various medicinal substances. Amongst those I have found the most useful are Vichy salts, or the Wroodhall Spa waters. Gallard, hoAvever, cautions against the prolonged use of Vichy or other alkaline or mineral waters. He advises, in preference, more simply thermal springs, as Plombieres. The general treatment should be sustaining and tonic. Iodine, iron, strychnine, quinine, and arsenic, become extremely useful Avhen active inflammatory conditions have been subdued. Of late years, so-called resolutive pessaries of iodine, made up into conical balls, with cocoa-nut butter or other ingredients, have been largely used. Most patients find it troublesome, if not difficult, to apply tbem properly: often, Avhether from being badly made or other causes, they fail to melt down in situ as desired ; and, not seldom, they are a source of so much irritation that they have to be given up. I have, for some time past, found it better to introduce into the cervi- cal canal, or into the cavity of the uterus, iodine ointment or solution by means of the instrument figured at p. 155. The subject of intra-uterine medication will be more fully discussed when dealing Avith Endometritis. Since intra-uterine medication can only be carried out by the physi- cian, and as it is essential to apply iodine frequently, the method of Scanzoni can be employed at the same time. This consists in introduc- ing, by means of a small bath-speculum, a drachm of iodide of potassium in an ounce of glycerine to the fundus of the vagina, keeping it there all night. A better plan is to apply a pledget of cotton-Avool soaked in the iodized glycerine by means of the speculum figured at p. 156. C. Mayer speaks highly of the value of pyroligneous acid in treating the bleeding papillary affections of the os uteri and cervical canal. He savs there is no more efficacious means. He applies it either alone or Avith equal parts of aqua creasoti, through the speculum. It is left in contact long enough to stop the bleeding, and until the abraded spot 458 VASCULAR DISORDERS OF UTERUS. assumes a Avhite appearance. It is then Avashed aAvay by a syringe. For this condition I have found the acid nitrate of mercury recommended by Henry Bennet more useful. Amongst the most effective measures for substituting a healthy for the morbid nutritive process going on, and of promoting absorption of mor- bid tissue, are the various forms of cautery, actual and potential. The actual cautery Avas extensively used by the late M. Jobert. It was in his clinique at St. Louis that I first became acquainted with its action and use. I think it would have become more firmly established as a re- source in the treatment of the results of chronic metritis, were it not for the fear lest so potent an agent may do harm, and the formidable pre- parations which the use of the hot iron involves. Paquelin's cautery greatly lessens these objections. With this apparatus, where simple cautery is required, we may dispense with the cumbrous galvano-caustic apparatus. The following precautions are necessary when applying the incandes- cent iron to the vaginal portion: 1. To use a horn speculum, Avhich is less heat-conducting than metal; or else, if using a metal speculum, to interpose a packing of lint outside the blades, so as to protect the vagina. 2. To be careful to have nothing in the field of the speculum but the vaginal-portion, so that no risk be run of cauterizing the vagina. 3. To apply the cautery to the outer edge of the os uteri, avoiding the cervical cavity. It is useful to apply a bit of ice immediately after the cautery, or to syringe the vagina Avith a stream of cold Avater. The best substitute for the actual cautery is the potential cautery. Various caustics have been used. They all act substantially in the same way. By chemical action they kill a portion of tissue, which is thrown off as a slough or eschar, leaving a sore which has to heal by granula- tion. During this healing, some amount of absorptive action is set up in the proximate tissues ; and the healing taking place by cicatrix, further diminution of bulk is effected by the contraction. The substances most employed are : the acid nitrate of mercury—this is very convenient and effective ; potassa cum calce fused in sticks—this is the most convenient and generally useful caustic with which I am acquainted. It differs from the acid caustics, such as nitric, chromic, and sulphuric acids, Avhich, absorbing moisture rapidly, and coagulating albumen, produce only a superficial slough. Potash also has a great affinity for water; but not possessing the property of coagulating albu- men, it is carried more deeply into the substance of the part to Avhich it is applied. Herein consists the advantage it possesses. Upon this pene- tration it is that the absorptive action it sets up depends. The time selected for applying it should be Avithin a feAv days after the termination of a menstrual period, so as to secure ten days or more for the granulating process to go on undisturbed by the menstrual flux. The mode of using it is to introduce the speculum so as to get the vaginal-portion Avell into the field; to wipe off all adhering secretion ; then, holding a small piece of the potassa cum calce in a long speculum- forceps, to rub it across one or both lips of the os uteri several times. This produces a blackish bar. Care should be taken not to touch beyond the hard substance of the cervix, avoiding the vagina. When a sufficient metritis: treatment. 459 application has been made, a pledget of cotton-Avool steeped in vinegar is immediately applied to the part. This neutralizing any remains of the caustic, obviates extension of its action to the vagina. A bit of string attached to the wool, enables the patient to withdraw it, Avhich may be done in a few hours. Unless these precautions be adopted, cicatricial bands or contractions may ensue. After such an application no further local treatment is necessary until after the lapse of ten days. The granulating surface may then be lightly touched with nitrate of shVer, or tincture of iodine. At one time a very favorite remedy, one employed, it is true, without precise diagnosis of metritis, Avas blistering by tartar-emetic ointment. By rubbing this substance over the groins or hypogastrium, or inside the thighs, a revulsive action is produced, which is sometimes serviceable. It has been recommended to establish a seton in the vaginal-portion as a derivative and resolutive. I have not put this to the test; but I ean quite understand that it may act beneficially. The potassa cum calce, hoAvever, answers the same indication. The cautery, potential or actual, should not be employed Avhilst there is any degree of active inflammation. It comes in most beneficially Avhen vascularity is subdued, Avhere there is a languid process of tissue-change going on. Laxatives become important in chronic metritis. The compound decoc- tion of aloes and lenitive electuary are useful forms. But 1 have found the greatest benefit from the daily or occasional use of a pill containing two grains of Avatery extract of aloes, half a grain of extract of belladonna, half a grain of extract of nux vomica with Castile soap. Scanzoni speaks emphatically against the plan of enforcing the " repos absolu," that is, " lying-doAvn," as one of the most serious errors that can be committed. I have seen so much evil from this course, and have seen so many Avomen avIio have been kept for months in the recumbent posture, not only Avithout benefit, but Avith decided detriment, get well quickly when subjected to a more liberal treatment, that I heartily en- dorse Scanzoni's conclusion. Scanzoni says the Friederickshall, Pullna, Kissingen, Ems, Carlsbad, and the other Avaters, act only on the diseased uterus through their virtue as purgatives. In all chronic uterine diseases the habitat becomes an important matter. Women, far more than men, especially when invalids, are " adscriptae glebae." If the soil be damp, or other hygienic conditions be unfavorable, Avomen suffer seriously, and often in such a degree as to frustrate, the best-directed medical treatment. Change of air, then, Avhich means change of soil, is often essential to recovery. A dry elevated site is generally the most suitable. The restorative treatment comes into use Avhen the local disease has at least, in part, subsided. Iron is usually badly borne whilst inflamma- tion, no matter how slight, is going on. The Avay must be prepared by salines, laxatives, bismuth, and other agents which allay irritation of the stomach. 460 VASCULAR DISORDERS OF UTERUS. ULCERATIVE PROCESSES. Besides the uterine abscesses, the result of acute metritis, the cancer- ous and tuberculous ulcerations, and the puerperal suppurations, ulcers occur on the vaginal-portion. In the course of uterine and vaginal catarrh there arise excoriations or abrasions of a stellate or annular form around the os externum which commonly extend into the cervical canal. These at times pass into ero- sions and ulcerations marked by papillary granulations, of a fungoid aspect, or the surface is tuberous through the exuberant development of ovula Nabothi. The origin and persistence of this state are favored by hypertrophy, hyperaemia, and varicosity of the vessels of the vaginal- portion. The so-called phagedenic ulcer, the corroding ulcer of Charles M. Clarke, of the os uteri, is very rare. Its existence otherwise than as a stage of concroid or cancer is questioned. But I believe I have seen it as an indented holloAved ulcer on a hypertrophied, hard, callous vaginal- portion, eating away the cervix uteri, and seizing upon the neighboring structures, in a manner very similar to that of lupus exedens. The syphilitic ulcer possessing the proper characters of the primary chancre is not common ; but it may at times be observed exhibiting a closely similar aspect to that Avhich is seen on the penis, and producing in like manner sores more or less sharply defined on the vaginal dupli- cature which lies in contact Avith the cervix uteri. On examining by the finger, the sharply-defined edge of the syphilitic sore may at first impose on the sense of touch for the os uteri, the pit or depression formed in the fundus of the vagina is so distinct. It is best treated by nitric acid, the acid nitrate of mercury, or the actual cautery. ENDOMETRITIS : UTERINE CATARRH. Inflammation may be more or less limited to the lining membrane, con- stituting endometritis. This may take its rise in childbirth ; and it may be general, or chiefly restricted to the original seat of the placenta. The placental seat remains rough, presenting papillary projections ; perhaps one or more may be large enough to deserve the name of polypus. In the case of endometritis proper, the uterine contraction after labor has been efficient, so as to prevent the entrance of septic matter into the venous channels and lymphatics, and thus to obviate metritis. Where the constitution is sound, free from morbid diathesis, endome- tritis, treated early, admits of easy cure. Rest alone may be sufficient. The regenerative poAver of the uterine mucous membrane is so active, that the degenerated tissue being cast off, a new sound one is easily formed. But if there be a morbid diathesis, as trumous, tubercular or syphilitic, the cure may be indefinitely protracted. The mucous mem- brane of the uterus and its glands is not less prone to receive the stamp of these diatheses than is the mucous membrane of other organs. The strumous mucous membrane of the uterus is tumid, undergoing constant epithelial shedding, its glands are hypertrophied, and secrete an excess ENDOMETRITIS. 461 of mucus. This, in fact, is one of the most troublesome forms of uterine catarrh. Chronic endometritis leads to the exuberant production of ovula Na- bothi in the cervix and on the vaginal portion. Indeed, Lancereaux has designated this as " cystic metritis." In some cases the cervix is virtu- ally closed by a collection of cysts disposed in a loculated stroma, and containing gelatinous mucus, compressing each other. The vaginal-por- tion is hard, tuberous, from the distension caused by these projecting distended sacs. Often, one or more of these cysts make their way through the os externum, and, becoming more pedunculated than the rest, appear in the vagina as vesicular polypi. When these occur in Avomen past the climacteric, the touch and appear- ance forcibly suggest the suspicion of commencing malignant disease. The shot-like hard projections around the os; the red, or bluish-red, angry-looking mucous membrane in which they are set, make up a condi- tion hard to distinguish. Usually, however, the vaginal portion does not become so large as in cancer; it does not become fixed, and it is less apt to assume the mushroom shape. It is best treated by decided applica- tions of actual cautery, or of potassa cum calce. The ovula Nabothi are partly closed dilated mucous sacs of the mucous membrane of the cervix, but much more frequently they appear as small collections of nuclei at various depths in the submucous tissue of the cer- vix ; these capsules grow with transformation of the nuclei to cells, and project upon the surface Avhere they dehisce, or prolapse as polypi. They contain a gelatinous mucus, mixed Avith cells and nuclei, fatrglobules, spindle-shaped and many-branched cells, and colloid granules. When there is free secretion of mucus, these polypous, mucous-mem- branous groAvths, vesicular polypi, and small sarcomata lead to contraction or even closure of the os uteri, by means of a richly nucleated, fibrinous outgrowth of connective tissue. This leads to retention of the gradually increasing pus or mucus in the uterine cavity and cervical canal. The uterus may thus be distended to the size of a goose's egg, of a fist, or even to that of a man's head ; its walls become hard, sometimes thinned ; its mucous membrane is transformed into a smooth or papillary connective tissue groAvth ; its contents are a colorless synovial-like, or yelloAvish, red-brown, or chocolate-colored glutinous-fatty fluid shoAving cholesterine or pus. This is the so-called hydrometra. When the canal of the cervix gets distended, in like manner, the os internum remaining narrow, the hour-glass form of uterus is produced—the uterus bicameratus. In some rare cases, perforation has occurred through an ulcerative process alloAV- ing the contents to escape into the peritoneum. °This distension of the uterus almost necessarily leads to retrograde distension of the Fallopian tubes, which are even more likely than the uterus to undergo perforation. Within the period of generative capacity, chronic catarrh may lead to hypertrophy of the uterus. During decrepitude, it leads to relaxation and a pulpy state. An exudative or croupous endometritis is seen in rare cases as a secondary appearance in the course of typhoid, cholera, exanthemata; and especially with a diphtheritic inflammation of the vagina in childbed. 462 ENDOMETRITIS. Bennet says internal metritis is a rare form of uterine inflammation; that it has only been considered common because it has been confounded Avith inflammation of the cavity of the cervix, a disease which is very common. On the other hand, it may perhaps not unfairly be said that internal metritis, being out of sight, may often escape recognition. Cer- tain considerations, however, incline me to think that the reaction against Bennet's too exclusive limitation of inflammation to the cervix, has been carried too far:—1. In a large number of cases, treatment directed solely to the os and cervix uteri cures all the disease. 2. Not infre- quently, before the cervical disease is healed, pregnancy, a function which pertains to the body of the uterus, and Avhich therefore implies a healthy condition of that part, occurs. 3. The proportion of cases in Avhich it is necessary to resort to intra-uterine medication, although cer- tainly greater than Bennet Avould seem to acknowledge, is limited. 4. The cervix is far more subject to injury in parturition. Generally speaking, endometritis proper takes its origin in imperfect involution after labor or abortion, in obstructed or interrupted menstrua- tion, and in irritation from foreign bodies ; whilst inflammation of the cervical cavity far more frequently takes its rise in the traumatic process of labor, in excessive sexual intercourse, and in infection. Under com- mon origin, or by extension, there may be, and frequently is, co-existent inflammation of the mucous membrane of both cervix and body. It is especially, however, subjects of strumous or lymphatic diathesis Avho are prone to this disease. It is remarkable what slight causes Avill in such subjects produce it. And it is in these that the disease is also most rebellious to treatment. Uterine and Vaginal Catarrh.—The uterine and vaginal mucous mem- brane is liable to similar morbid influences to those Avhich attack other mucous membranes. For example, it is liable to inflammation from sup- pression of function, as from cold acting Avhilst the membrane is in phy- siological hyperaemia. It is liable to be affected by morbid poisons, as variola, scarlatina, syphilis, measles, Avhich are carried to it in the blood. It is liable to be affected by poisons or irritants directly applied, as the poison of syphilis or gonorrhoea, or, as in labor, by the poison of scarla- tina carried by the touch. Just as catarrh is produced in the air-tubes and intestinal canal by ex- posure to cold, clamp, and irritating agents, so it is with the mucous membranes of the genital tract. The catarrh so produced is a subacute form of inflammation. The membrane becomes vivid red, there is a sense of local heat; and almost ahvays there is a mucous discharge, more or less tenacious, and varying in color from cream-white to yelloAv and yel- loAvish-green ; sometimes it is sero-mucous. If the discharge is yelloAV- ish-green, very abundant, and coming from a highly-injected surface, and the vagina and urethra be implicated, so that there is pain on micturition, the presumption is that the source of the inflammation is gonorrhceal in- fection. But the greatest circumspection is necessary in giving an affirm- ative opinion. Cfonorrhoeal infection is only one of numerous causes of colpitis, which may involve the cervical and even the uterine cavities. In very many cases it is impossible to assign the particular cause. There is often no CATARRHAL ENDOMETRITIS. 463 distinctive mark. Colpitis is colpitis. It is often no more possible— apart from history—to declare that a particular colpitis arose from a specific cause, than it is to declare the actual cause of a case of bron- chitis. The practitioner, who is not on his guard, is constantly in danger of falling into etiological errors that may entail the most painful social and domestic consequences to the patient and others, and involve himself in serious complications. I have knoAvn the existence of leucorrhoeal dis- charges in girls give rise to the suspicion of their having been abused, when there was tbe strongest reason to believe that the true source Avas struma, and in one or two cases, scarlatina. Here, as in so many difficult positions in medical practice, we must be content to limit our utterances, verbal or written, to the strictest conclusions from exact observations. The history or extraneous considerations must be rigorously excluded. To admit in these delicate scientific questions the historical element in forming a diagnosis, is to make our opinion the reflexion of the errors, the prejudices, the suspicions, the malice of others. Science has nothing to do wtith all this. The only safe course is to discard from our consid- eration everything but what we can subject to actual observation. The physician can diagnose colpitis Avhen the disease is before him. He can only form a conjecture as to the cause, which cannot be before him. The most common form is the catarrhal endometritis.- This may be acute or chronic. The acute catarrhal endometritis arises from the sudden action of cold, especially if acting at a menstrual period, from excessive sexual inter- course, from gonorrhceal infection ; it occurs in acute fevers, especially the exanthemata. It is in cases of the latter kind that opportunities of studying the affection in the dead body occur. The mucous membrane of the body of the uterus presents red streaks or spots from injection, or it is uniformly red, more or less SAvollen, softened, here and there bleed- ing, and covered with a red-streaked mucus, or creamy fluid Avith pus. The submucous layer is, in severer cases, hyperaemic, softened, pulpy. The mucous membrane of the cervix is at times greatly injected, the contents of the ovula Nabothi are turbid ; Avhen burst, they yield a thin- ner fluid. The mucous membrane of the vaginal-portion is remarkably reddened, its papillae are SAvollen, near the os externum abraded. The parenchyma of the vaginal-portion is itself SAvollen. The acute endo- metritis often passes into the chronic. The vagina is also frequently involved. In acute catarrhal endometritis, Schroeder says the ciliary epithelium soon disappears, the secretion of the diseased mucous membrane increases ; that of the body of the uterus supplies at first a thin Avatery serum, which soon becomes thickened Avith the cast-off epithelium-cells, and later by an abundance of pus-cells, so that the discharge finally becomes whitish and opaque or purulent {Ziemssen's Cyclopaedia, 1875). The vitreous secretion of the cervix, too, becomes turbid and purulent, and often streaked Avith blood. Chronic Catarrhal Endometritis.—This is frequently a continuation of the acute form, and especially of repeated acute endometritis in cachectic persons. It is also frequent as the result of morbid deposits 464 ENDOMETRITIS. or processes in the mucous membrane, as tuberculization, or from the irritation of tumors protruding into the uterine cavities. The mucous membrane of the body of the uterus appears uniformly or in patches reddened, SAvollen, spongy, decidua-like, or has a granular papillary aspect; it is covered with a mucous-purulent moisture or pus. Aery often, chronic catarrh consists essentially in blennorrhcea, that is, in a condition of profuse secretion of a more or less hyaline or crearny opaque mucus, from a SAvollen, partly pale, partly injected, dark broAvn or grayish pigmented membrane. The mucous membrane of the cervix is \rery often, but not constantly reddened, SAvollen, especially on the summit of its folds. It is commonly studded Avith Nabothian ovules, and covered Avith a clear or yellow- streaked turbid mucus. The vaginal-portion is often swollen, the mucous membrane reddened, its papillae swollen and injected. This condition and the simultaneous presence of small cysts, give it a villous granulating appearance. And not seldom there is actual excoriation or ulceration. Although Ave can only admit the word "ulceration" as describing the loss of epithelial investment in the case Avhich forms the subject of the last chapter Avith some qualification, it seems impossible to discard the term " inflammation" as inapplicable. It may be described as engorge- ment, congestion ; but if this congestion, or Avhatever else it may be called, produce all the effects usually attending upon inflammation, the distinction becomes too subtle to be followed out. And Avhen it is re- membered that the increased action going on, takes place in a part ex- posed to frequent fluxions of blood, to functional work, to accident, it is hard to imagine hoAv it can long escape passing the imperceptible bound- ary Avhich rigorous theory, rather than actuality, places between it and inflammation. One fact may at any time be verified, which appears to lend support to the theory that inflammation is an essential factor in the case. It is the abundance of chlorides in the viscous secretion exuding from the cervix. The concentration of chlorides in inflamed tissues is an estab- lished fact. The moment nitrate of silver is allowed to touch the cervi- cal surface bared of epithelium, a dense opaque white layer is produced, and any viscid secretion is instantly turned into a white clot characteristic of chloride of silver. The indication thus obtained of the presence of an excess of chlorides is very marked, and it appears to me that it may be explained in the Avay described. What is the seat of this inflammation ? I should say it is exactly that of the original traumatism sustained in labor, namely, the cervix uteri, more especially the lower part of the vaginal-portion. So far as it concerns the case under consideration, I agree with Henry Bennet. It is essentially inflammation of the neck of the womb, sub- acute or chronic. I rest this conclusion more upon clinical observation than upon the anatomical grounds so much insisted upon by him. It is true that the structure of the body of the uterus differs from that of the cervix in that there is more connective tissue in the cervix, and also that the latter part is in more direct communication Avith the source of vascu- lar supply. But the great reason Avhy the cervix is more frequently the ENDOMETRITIS. 465 seat of inflammation is, that it is more directly exposed to injury. At the same time I am of opinion that chronic inflammation of the body, in a less intense degree perhaps, commonly attends inflammation of the cer- vix. Indeed, it is hardly possible for one part to escape being involved in a process Avhich has seized upon the other. The tissue, muscular and mucous, is continuous : the Arascular supply is nearly the same. And, as a fact, we observe by the touch and sound, that in these cases there is frequently some enlargement, and increased sensitiveness of the body of the uterus. Still, there is a striking feature in uterine pathology which lends Aveight to Bennet's vieAvs. The frequent sharp limitation of tubercular disease to the body of the uterus, and of cancerous disease to the cervix, seem to point to some decided distinction in the pathological proclivities of these regions. And their physiological destination is equally distinct. Both incontrovertible facts point to a difference of structure which greatly favors the idea of a difference in liability to inflammation. Another fact forcibly insisted upon by Bennet is, that treatment applied to the cervix uteri is in the majority of cases sufficient to cure the patient. This appeal to the Hippocratic maxim, " Treatment reveals the disease," is difficult to resist. But it is not unansAverable. Counter-irritants ap- plied to one part of a diseased structure may, by derivation, or by setting up healthy nutrition in contiguous parts, cure the whole diseased organ. And I am in a position to affirm that the cure is much more quickly at- tained if the treatment is extended to the body of the uterus. It appears to me that attention has been too strictly fixed upon the visible changes in the cervix and os uteri; and that, thus engrossed, the mind has been closed against the less telling evidence of changes in the body of the uterus. The body of the uterus Avhich formed the nidus of the embryo, which undenvent the most Avonderful process of development, is liable to inter- ruption in a process which concerns the cervix in a very secondary de- gree. Involution especially affects the body of the uterus. It has to repair the placental seat and to restore the mucous lining. Disorders of involution, then, principally affect the body of the uterus. Traumatism principally affects the cervix. But in some degree both processes affect the Avhole uterus. Although the formative elements of a new mucous lining exist in the cavity of the uterus at the time of the separation of the placenta and decidua, it can hardly be said that a mucous membrane, comparable in development to that of the cervix, exists. Whatever changes, then, of a pathological character occur in the body of the uterus after labor must have their chief seat in the walls of the body, if Ave except the placental- seat. That inflammation may spread from the lining membrane to the substance of the uterine Avail can scarcely be doubted; but this inflam- mation does not often extend deeply. The more usual origin of metritis is in the invasion of the vessels and lymphatics by foul matter ; the coats of the vessels are so delicate that irritation easily spreads from them to the substance of the uterus in Avhich they run. The veins of the uterus can scarcely be said to possess distinct coats ; at least, it is difficult to isolate a venous channel from the wall in Avhich it runs; fibre-cells, iden- 30 466 ENDOMETRITIS. tical Avith those of the uterine Avail, are always seen in abundance in the walls of the veins. It is easy to conceive liow a tissue, permeated by channels which carry irritating matter, may become inflamed in its sub- stance. This may be actually seen in the acute septicannic metritis of child-bed. Collections of pus are seen in the venous channels, and the surrounding muscular structure is softened. There is evidence enough to shoAv, apart from analogical argument, that a similar process takes place in the non-pregnant uterus. But, especially in young Avomen, in Avhom the affection is the result of menstrual suppression from cold, the inflammation may be strictly limited to the body of the uterus. The neck being less concerned in the men- strual hyperaunia, and not subject to the same physical disturbance as in married women, more often escapes. In such cases, examination, limited to inspection through the speculum, will fail to detect the intra-uterine disease. But in most cases the cervix becomes involved at no distant period. Endometritis is a frequent consequence of obstruction at the os inter- num or os externum. Hence it is not uncommon in women who have never been pregnant, and even in virgins. The contracted os exter- num, by impeding the discharge of the menstrual fluid and ordinary uterine mucosities, leads to congestion, irritation, and inflammation of the lining membrane of the body as well as of the cervix. Retention by valvular closure of the os internum from flexion leads to the same conse- quences. The cavity enlarges under the distending influence of accu- mulation ; the retained discharges undergo decomposition, resulting in irritating matter. It is not uncommon for Avomen subject to this affection, to describe themselves as subject to " gathering and bursting of an ab- scess." That is, there is a stage of accumulation of muco-purulent mat- ter, during which the pain of distension is felt, merging in spasm or colic, the pain of expulsion ; and then, expulsion effected, relief is felt. The quantity of the fluid thus collected varies, and it is difficult by direct ob- servation to define it correctly. But there is little doubt that it amounts in some cases to an ounce or more. The condition and the symptoms resemble in many points those of dysmenorrhoea from retention. Indeed, dysmenorrhoea is often associated with it, as arising from similar mechani- cal causes. The discharge occasionally becomes exceedingly offensive, has acrid properties, causing redness of the vaginal canal and vulva ; and is, in all probability, capable of exciting blenorrhagia in the male. Endometritis may occur at all ages, beginning from the outset of men- strual life doAvn to old age. I have already said that endometritis may be limited to a particular area of the uterine cavity, and that this area is that which Avas originally the seat of the placenta. In many cases the return of this area to the normal state is sIoav and imperfect; and for weeks and months after labor it may present a rough surface, secreting a muco-purulent discharge, cut off by a sharp line of demarcation from the smooth, perhaps healthy, mucous membrane of the rest of the cavity. In the earlier periods after labor, the uterine Avail at this part is thicker, and remains more vascular than at other parts ; and this comparative thickness may persist for some COURSE, SYMPTOMS, DIAGNOSIS. 467 considerable time. There is, in fact, imperfect involution, especially of this part of the uterus, as the first step of a condition which merges into partial endometritis and metritis. Since the most common seat of the placenta is near the fundus, this variety of disease might be called " Fundal Endometritis." But this name has been used by Dr. Routh to describe a condition1 which does not necessarily depend upon pregnancy. He says that part of the mu- cous membrane Avhich lies between the Fallopian tubes is especially prone to inflammation. If he is correct in his intepretation of the cases he re- lates, he establishes the conclusion that there is an endometritis limited to this particular area, which has been confounded with general endome- tritis. Quoting Dr. Beck, he shows that the fundus is supplied with nerves by a branch coming from the ovary, that is, from a different source from that which supplies the loAver part of the body and the neck of the womb. The symptoms are exactly those described by Dr. Gooch as be- longing to the "irritable uterus." "The abdomen is painful just over the pubes. Indeed pressure here will often make the patient sick." If the sound be passed jter anum or per vesicant, and the point be turned upon the fundus, pain will be produced. If passed into the uterus, there may be no pain until the point has passed the os internum, and has struck the fundus. " If it be pressed at all forcibly against the fundus, abso- lute agony may result, Avhich may produce vomiting, an hysterical faint or fit, sometimes a regular epileptic fit." The disease, Dr. Routh says, is often the result of the use of intra-uterine pessaries, of retained men- struation, or the retention of mucoid discharges. Recognizing, as my OAvn observations compel me to do, the limited endometritis of the pla- cental seat, to which I confess to have been led more by post mortem in- spections at various periods after labor, than by clinical diagnosis, I am not prepared to accept Avithout further evidence Routh's description. I concur in the opinions expressed by Tilt and Fordyce Barker, at a dis- cussion on the subject in the Obstetrical Society, that the symptoms relied upon are not sufficiently distinctive. As Barker pointed out, the fundus is more sensitive than other parts of the uterus. When the sound touches it, pain is almost ahvays felt; and this Avhether the organ be diseased or healthy. I am disposed to merge fundal endometritis in general endometritis. The inflammation may be chiefly limited to the cervical cavity. To specify this form, the objectionable term endocervicitis, a barbarous compound of Greek and Latin, is in common use. It Avould be better to sacrifice conciseness, and to speak of endometritis of the uterine neck. This is a very common affection ; and from its seat being partly Avithin direct observation by touch and sight, it has engrossed an undue share of attention. It is the source of the most common form of leucorrhcea. The Course, Symptoms, and Diagnosis.—The diagnosis of endo- metritis rests upon the subjective symptoms, the history, and the objec- tive signs. The patient complains of pain referred to the uterus, increased by exertion, attended often by dysuria; the pelvic pain radiates to the back, and there is more or less constant lumbo-sacral heavy aching dis- 1 On Fundamental Endometritis, Obstetrical Traus., vol. xii. 468 ENDOMETRITIS. tress. Headache is also frequent, and various nervous symptoms of a depressing character arise as the disease becomes chronic. The history begins with pregnancy, with arrest of menstruation, with intra-uterine irritation or injury, as from wearing a pessary, with reten- tion of menstrual discharge, with flexion or version; in short, the origin is in many cases the same as that of other forms of uterine inflammation. The symptoms have probably at first been acute ; the uterine pain was intense, setting in with rigor, perhaps Amounting, and attended by fever. Passing into the chronic or subacute form, the pain has become less severe ; it has been intermittent, brought out into exacerbations by over- exertion or by menstruation. The objective signs are made out by palpation, by the sound and by the speculum. Palpation, vagino-abdominal or recto-abdominal, will generally establish increased Aveight and bulk of the uterus, and bring out pain or tenderness in the body of the uterus. The sound will com- monly cause more pain than is usual on entering the healthy uterus; it will often cause a little oozing of blood. Unless there be flexion, the sound passes easily, because the orifices are almost certain to be ex- panded. And when the point is in the cavity, the dilatation of this part is made manifest by the freedom with Avhich the sound can be turned round. The uterus has lost its flattened condition, having become more pear-shaped. Diagnostic purpose being fulfilled, it is henceforth desirable to use the sound as little as possible. It is often a source of irritation. The specu- lum will in most cases show some amount of congestion of the vaginal- portion, perhaps abrasion or other lesion; but this is an accidental not a necessary complication. Gosselin and Aran, describing the frequency of so-called ulcerations seen around the margin of the os uteri in chronic endometritis, affirm that they have little significance, and are generally the result of the maceration of the epithelium in the mucous secretions. As soon as the discharge lessens the ulceration heals rapidly. I must, hoAvever, remark that in most cases Avhich folloAV labor, the loss of epithelium is due to the necrotic action I have described. When chronic or subacute catarrh arises primarily, that is, without acute beginning, leucorrhcea is often the first symptom which attracts attention. Then pain on excretion follows. Dysmenorrhoea becomes more pronounced. This last symptom is the more important in Avomen who preAdously had not suffered from dysmenorrhoea. There are many Avomen in whom dysmenorrhoea may be called secondary, that is, it is acquired as a consequence of metritis or non-involution after labor. Menorrhagia is a frequent attendant. The tumid, engorged, vascular mucous membrane easily alloAvs blood to exude. The catamenia return in advance of the proper period, that is, every three Aveeks or fortnight, and last for a week or more, sometimes profusely. The blood-floAV is commonly succeeded by a muco-puriform discharge; and not seldom, slight causes will determine a flow of blood in the intermenstrual periods. A common remark is that the Aoav returns a day or tAvo after having apparently ceased, so that the subject hardly knows when the period is fairly at an end. Sometimes clots of dark blood "like leeches" are COURSE, SYMPTOMS, DIAGNOSIS. 469 voided. In one case of intense endometritis the woman passed every morning a cylindrical mass about three inches long, slimy and streaked with blood. The glands become obstructed, presenting bluish eminences ; the contents retained cause cystic elevations, sometimes becoming turbid. When punctured, puriform matter may exude. It is in these cases that scarification is so useful. Dysmenorrhoea more especially attends the catarrhal inflammation of the body of the uterus, probably because this condition is apt to involve some degree of inflammation of the uterine Avail itself. The form in which dysmenorrhoea appears is uterine, that is, pain is felt shortly be- fore and at the time of the uterine flux; it is referred to the uterus or middle of the pelvis, and radiates to the loins and sacrum. In the milder forms of catarrh, the discharge is chiefly mucus entang- ling epithelial cells ; it may be clear or opaque. The hypertrophied uterine glands at times pour out a profuse, even exhausting, secretion. In severer forms it is often tinged Avith blood. This, Bennet says, is as characteristic as is the rusty sputum of pneumonia. It is due to the in- tense congestion, the blood easily permeating the thin epithelial covering. The neighboring organs are commonly someAvhat disturbed. In the acute forms, even dysenteric symptoms may be produced. In the chronic forms diarrhoea is not uncommon, alternating perhaps Avith constipation. Diarrhoea in the acute form, hoAvever, is not alone the consequence of neighboring irritation ; it is more likely to be due to septicaemia. Both in the acute and chronic forms some bladder-distress is a frequent attend- ant. Dysuria and frequent micturition, and sometimes cystitis, are ob- served. Disorder of nutrition and of the nervous system are sure to follow sooner or later upon chronic uterine catarrh. The abnormal derivation of vascular and nervous action leaves the digestive organs imperfectly supplied; and the constant Avear and tear of pain exhausts the nervous centres. Hence the appetite is impaired, capricious, difficult to stimu- late. Despondency, fretfulness, sometimes hysterical symptoms harass the patient. Nausea, vomiting, gastralgia, distension of the stomach folloAV. The urine becomes turbid, loaded Avith uric acid or phosphates, and sometimes Avith mucus. This is especially the case in women tOAvards middle age, Avith a tendency to obesity and sluggish liver. In other cases, the discharges and the impaired nutrition entail ema- ciation. The face puts on a dull, languid, Avorn expression ; the fades uterina becomes formed. The features fall; dark circles surround the eyes. Acute endometritis may end in spontaneous recovery. Perhaps rest and careful regimen for a feAv weeks may suffice for cure. But of the accomplishment of this we cannot be certain, until one or two menstrual periods have passed by Avithout rekindling the symptoms. The signs of cure are : the cessation of febrile movement and of local pain ; the mode- ration of discharge, the return of the os externum uteri to its ordinary calibre ; the recovery by the vaginal-portion of its epithelium-investment; and the return of the mucous membrane to its natural pink color. Chronic endometritis, on the other hand, is a most obstinate disorder. It sIioavs little disposition to spontaneous cure. Some observers, indeed, 470 ENDOMETRITIS. doubt Avhether it can even be cured by art. Scanzoni throws almost equal doubt upon the curability of chronic endometritis, that he does upon that of chronic metritis. Chronic catarrh, he urges, is the almost never-failing companion of chronic parenchymatous metritis, and how shall it be healed whilst the disorders of the circulation in the Avails of the organ persist ? How shall the hyperaemia, swelling, and hyper- secretion of the mucous membrane disappear whilst the causative disor- ders in the wall of the uterus persist? I have already discussed the possibility of cure of parenchymatous metritis. If this possibility be admitted, then the possibility of curing endometritis follows as a corollary. I cannot help attributing this eminent physician's unfavorable opinion, in some measure, to his imperfect estimate of the etiological importance of constriction of the os externum uteri, and of flexion. Treatment which fails to take cognizance of these conditions must necessarily be imperfect, and will therefore often fail. The Treatment.—The indication to begin by removing any complica- tion, such as flexion, inflammation of the vaginal-portion or cervix, or atresia, is obvious. Indeed, the principal remedies, those to be applied to the interior of the uterus, cannot be fairly brought into use until the cervical canal is made permeable for at least a No. 8 or No. 9 catheter. Inflammation or engorgement of the cervix must be subdued by the methods already described. And when this is done, it will sometimes be found that the signs of endometritis have disappeared. Whether it be by derivation or by other agency, curing inflammation of the cervix will sometimes cure inflammation of the body too. But, although this is an essential part of the treatment, it ought not to be trusted to alone. For, if it occasionally is sufficient to cure, yet the process being indirect is sIoav and tedious. It is remarkable and gratifying to observe, in some cases, hoAv quickly a long-standing case of endometritis is cured by direct treatment. In the acute stage, which is most likely complicated with metritis proper, the application of tAventy leeches to the hypogastrium, fomentations, seda- tives, salines, will be necessary. In the chronic stage, the cure will de- pend greatly upon the judicious use of intra-uterine remedies. The solid nitrate of silver, Avhich acts so well elsewhere, is of signal service in this case. The sulphate of zinc I have found almost equally beneficial; and it has the advantage of being safer. Tincture of iodine is perhaps the most effective and safe. Carbolic acid, chromic acid, chlorate of potash, perchloride and persulphate of iron, nitric acid, acetic acid, have all been extolled. These remedies are best applied either solid or in the form of ointment, or as liquid carried on swabs. The practice of injecting liquids into the uterine cavity offers no marked advantages over the methods de- scribed, and the attendant objections are so serious that it is desirable to discuss the subject of intra-uterine medication with special care. INTRA-UTERINE MEDICATION. 471 THE VARIOUS MODES OF APPLYING REMEDIES TO THE INTERNAL SURFACE OF THE UTERUS. The treatment of morbid conditions of the body of the uterus by intra- uterine injections is a subject that calls for earnest discussion on account of its utility and its dangers. If Ave treat morbid conditions of the eye, mouth, throat, larynx, bladder, rectum, and vagina by injections with such manifest advantage that Ave have come to look upon this method as in many cases indispensable, it seems reasonable to expect equal ad- vantage from its action on the mucous membrane of the cavity of the uterus. Experience amply justifies this expectation. Topical applica- tions to the diseased mucous membrane are in many cases essential to cure. But in the form of injected fluids they are not free from danger. Almost every author Avho has written upon the subject, refers to cases of accidents, ranging from seA^ere pain to shock, collapse, metritis, peri- metritis, and death. It is desirable to refer to some of these cases which best illustrate the conditions of danger. Henry Bennet relates a case Avhich occurred under Jobert. A girl, aged twenty-four, had a large fibroid of the uterus. Jobert made an astringent injection into the cavity of the neck. Almost immediately there arose shiverings, agonizing pains in the abdomen, then fever, then death in a feAv days from metro-peritonitis. Bennet performed the autopsy. He found nothing besides the marks of peritonitis. The folloAving history Avas supplied to me by Dr. Hermann, assistant obstetric physician to the London Hospital, and the account of the autopsy is by Dr. Sutton. A Avoman, aged forty-eight, had had six children and five abortions. For eighteen months she had suffered from menorrhagia. On admission there Avas decided retroflexion of the uterus. An injection of perchloride of iron, in the proportion of one part of the saturated solution to six of Avater, Avas used. About half a pint of this was injected through a double-channel catheter attached to a Higginson's syringe, the patient lying on her left side. The fluid appeared to flow out as fast as it entered. The catheter Avas kept half-rotated, so as to hold the uterus in its proper axis during the injection. The os uteri had been Avell dilated. Immediately after the operation the patient com- plained of intense pain in the abdomen. In the evening the pain Avas Avorse, and she had vomited. The pulse and temperature rose, and she died in collapse fifty-eight hours after the injection. In the peritoneal cavity was found a quantity of blackish-green opaque puriform fluid. Much of the peritoneum covering the intestines around the uterus was of a black color. There Avas a quantity of pus in the pelvis. The left Fal- lopian tube was enlarged, and the vessels on its peritoneal surface highly injected. The outer half of the tube Avas much dilated, and filled with dirty, pus-like fluid. There Avas marked retroflexion of the uterus. Dr. Sutton's opinion Avas that the fatal peritonitis Avas caused by the iron solution escaping through the Fallopian tube into the peritoneal cavity. Dr. V. Haselberg relates an instructive case.1 A paella publica, hav- ing had an abortion six months before, came under treatment Avith ante- 1 Monatsschrift fur Geburtskunde, 1869. 472 INTRA-UTERINE MEDICATION. flexion of the uterus to such an extent as to render the passage of the sound difficult. She suffered from profuse menorrhagia, and it Avas deter- mined to try injection of perchloride of iron. It Avas only after repeated trials that the svringe Avas made to pass beyond the scat of flexion into the cavity of the uterus. The patient suffered no pain at the time, but at night had a severe rigor. (>n the fifth night rigor Avas accompanied by severe vomiting, and abdominal pains immediately ensued. On the following night this -was repeated, Avhereupon she fainted and died. The intestines Avere found united by recent exudation. The loAver parts of the pelvis Avere filled Avith stinking pus; the source of this Avas discovered in a cyst in the right ovary, Avhich, through a small opening, gave issue to like matter. The right tube was permeable throughout its whole length by a large sound. The mucous membrane of the uterus Avas stained, as if with ink, and the same appearance extended along the right tube. The black patches shoAved iron by chemical tests. One fact, at least, is clear from this case—that perchloride of iron, like other fluids, may run along the Fallopian tubes. But it is not so obvious that the fatal result Avas due to this accident. No immediate symptoms folloAved the injection. The signs of intra-abdominal injury seem due to the perforation of the ovarian cyst under the pressure of vomiting. In dou/iu's Journal (1873) cases of mischief from injecting perchlo- ride of iron into the non-pregnant uterus are cited. Iron was found in the peritoneum. Hermann, of Lourcine Hospital, relates the following: A girl, aged nineteen, had profuse leucorrhoea. Fie injected a decoction of nut by a clysopompe into the uterus. At the first stroke she cried out, and put her hand to the left iliac region. Severe shivering set in, and lasted several hours ; then febrile reaction folioAved. The pain spread to the abdomen, indicating metro-peritonitis. Hemorrhage appeared in two days, and she Avas relieved. It deserves notice that the intense pain called forth by applying various substances into the cavity of the uterus is most frequently of the nature of colic ; it does not generally indicate metritis. Metritis may, hoAvever, be caused if the substances used are caustic, as distinguished from styptic or astringent. This difference may depend upon the kind, the degree of concentration, and perhaps temperature of the agents employed. The danger of fluids running along the Fallopian tubes seems to de- pend upon undue patency of these canals. This undue patency in its turn is OAving in many cases, at least, to obstruction at some loAver part of the utero-vaginal canal. Thus in V. Haselberg's case, and in the one at the London Hospital, there were decided flexion of the uterus and dilatation of the tubes. It is not enough to know that patients occasionally die after injections are throAvn into the uterine cavity—Ave Avant to know Avhy they die. Knowing this, we may learn how ho avoid the causes of danger, without abandoning the use of a mode of treatment which renders in many cases incontestable service. Many experiments have been made on the dead body to ascertain the behavior of injections. Hennig, Klemm, Guyon, Fontaine {on puerperai) INTRA-UTERINE INJECTIONS. 473 Alph. Guerin, Guichard, Scanzoni, and others have done this. The ex- periments generally sIioav that there is extreme difficulty in making fluids run along the tubes, especially if the injecting syringe does not com- pletely fill the os uteri internum. I will not relate or analyze these ex- periments, because they appear to me to be of little practical value. The conditions of the dead and of the living tissues are essentially dif- ferent. For example, in the dead body there is no muscular contractility, no irritability under stimulus, no response of the nervous centres to peri- pheral injury. Yet these are conditions Avhich come into play Avhen in- jections are throAvn into the living uterus. It may, indeed, seem at first sight that these experiments Avould at any rate illustrate the problem of the permeability of the Fallopian tubes. But, eA'en here, their value is small. They may prove that great force is necessary to drive fluid along these canals ; and that, unless the cavity of the uterus be closed beloAV, as at the cervix, fluids will rather regurgitate than run onwards. But it is certain that in some of the cases Avhere fluid injected into the living uterus ran along the tubes, the accident could not be accounted for by the very small amount of injecting-force employed. Another poAver, therefore, must have been in action and this could be no other than that exerted by the uterus itself contracting spasmodically upon the irritating fluid throAvn into it. This force, the loAver or cervical orifice of the uterus being closed, Avould pump the fluid onwards into the tubes. J. Whitehead, in a valuable practical paper {Brit. Med. Journal, 1873), suggests that fluids may be carried omvard into the peritoneum by capillary or ciliary action. He prefers the use of solid or unctuous substances. Again, it is not necessary for the production of alarming or even fatal accidents, that the fluid should run along the tubes. The fluid injected into the cavity of the uterus may cause metritis, and the inflammation may spread to the adnexa and to the peritoneum. Or severe pain, shock and collapse may be the immediate and simple result of the irritation produced on the uterine superficies by the contact and retention of the fluid. The agony attending some cases of dysmenorrhoea is simply due to the irritation set up by retained blood causing uterine contractions or colics. The pain, the prostration, the other nervous phenomena attend- ing dysmenorrhoea are sometimes as severe as those attending intra- uterine injections. In some unfortunate cases, as in one related by Tissier, the fluid in- jected has been, not simply of styptic and coagulating poAver, but actually caustic. It ought to be needless to point out so fundamental an error. But it has been committed more than once ; and the fault of the operator has been assigned to the method. It is not even necessary that fluids should be injected into the uterus at all. I have seen pain and collapse so severe as to cause the utmost anxiety for the result, folloAV an ordinary injection of Aveak sulphate of zinc into the vagina. This occurred in the case of a lady, whose maid was administering, as she had often done before, a zinc solution, by means of a Iligginson's syringe. The cervix in this case Avas patulous, but it is certain that the pipe of the syringe Avas not inserted into it. She re- covered in some hours, no inflammation supervening. 474 INTRA-UTERIXE MEDICATION. It will further be remembered that the mere touch of a sound or bougie against the fundus uteri will in some cases produce severe pain, and even prostration. Again, symptoms resembling in character and severity those caused bv injected'fluids, are occasionally observed when solid or unctuous sub- stances are used, which cannot from their nature Aoav along the tubes, which must, in short, act in loco. Thus, Aran savs he has known three cases of fatal peritonitis from actual cauterization of the os uteri, and one case of fatal ovaritis from the application of Alenna paste. I have known the most severe pain and prostration followed by hem- orrhage and metritis, caused by the application of solid nitrate of silver to the interior of the uterus ; and I have seen fatal metritis and perito- nitis follow the simple application of nitrate of silver to the cervix uteri. The severity of the accidents is not ahvays explained by the nature of the fluids injected. Alarming symptoms have folloAved the use of com- paratively Aveak solutions. It has been supposed in these and other cases that the untOAvard phenomena Avere due to the forcible propulsion of air along Avith the fluid. In some cases this hypothesis may be Avell founded. But I think its importance has been exaggerated. It is even doubtful whether a quantity of air at all calculated to produce serious distress can be driven into the vessels or tissues of the unimpregnated uterus ; and the small quantity that might possibly run along the Fallopian tubes into the peritoneal cavity could hardly do much harm. One all-important caution is to be religiously observed, namely, never to use any topical application to the uterus or vagina, or to perform any surgical operation upon the uterus, when a menstrual period is impend- ing or present. It is at this time Avhen the menstrual flux is imminent, Avhen the nervous system is at its acme of excitability, that even slight causes are sufficient to light up acute inflammation. At this time, it may be said, the uterus resents all interference. Dr. Cohnstein1 gives a careful historical survey of the practice and opinions of those Avho have related their experience upon this subject. The general conclusion arrived at is that injection of very poAverful caus- tics is likely to cause inflammation of the uterus and peritoneum, or severe prostration and uterine colics ; and that these dangers are less urgent if care be taken first to dilate the cervix. Dr. Lente2 discusses this question, passing under review the various topical methods of treating disease of the cavity of the uterus. Iodine in solution he has knoAvn cause intense pain and alarming collapse, Avhich, hoAvever. passed aAvay, no further bad effect ensuing. The leading gynaecologists of NeAV York have also discussed this ques- tion. Instances of serious accidents Avere adduced. The general opinion seemed adverse to the use of intra-uterine injections, Avhilst Dr. Thomas was especially emphatic in his condemnation. To avoid the dangers of intra-uterine injections, several precepts have Beitiiiee zu Clnonischen Metritis, lSiJS. New York Journal of Medicine, 1S70. VAGINAL INJECTIONS. 475 been enjoined. The great object aimed at is to avoid or lessen the risk of the fluid running along the tubes. This it is sought to attain— 1st. By securing free dilatation of the cervix uteri before injecting, so that the fluid may readily run back into the vagina. For this purpose the preliminary use of laminaria-tents is adAdsed. 2d. To secure against narrowing of any part of the uterine canal by flexion or angulation. 3d. By using only graduated quantities of fluids, and injecting very gently and sloAvly. 4th. By using a double canula, so as to secure a return-current. To effect this the more surely, the openings of the canulae at the uterine end are made at different levels. I have not much faith in the double canula. The end Avhich should serve for the return-current is liable to be choked. The preliminary free dilatation of the cervix and the use of gentleness in propelling the fluid should never be omitted. But I do not believe that the observance of these precautions is an absolute guarantee against accidents. It is pro- bable that the mere forcible impact of any fluid striking upon the inner surface of the uterus, especially upon the fundus, may cause severe pain and prostration. Since nothing is gained by forcible injection, this con- sideration affords additional reason for injecting Avith all possible gentle- ness. Hence, it is Avell to use injecting-pipes having lateral openings of very fine calibre, so as to " pulverize" the liquid. I strongly advise not to use injections at all in cases of marked flexion of the uterus. Even if avc dilate the cervix first by tents, and maintain the uterus erect during the injection, Ave cannot ahvays be sure that the flexion will not be repro- duced, so as to prevent the issue of the fluid ; and it must not be forgot- ten that it is especially in these cases that the uterine cavity is likely to be enlarged, and the Fallopian tubes dilated. The general conclusion at which I have arrived is to restrict the use of intra-uterine injections aa ithin the narroAvest limits. I rarely employ them noAV, except in cases of urgent danger from metrorrhagia. Danger of Vaginal Injections.—It must not be lost sight of, that eA*en vaginal injections are not free from danger. Lorain {Gazette des H6pit.aux, 1873) relates the case of a girl suffering from gonorrhceal vaginitis, Avho used an injection of a small quantity of a weak solution of nitrate of silver. It Avas made sloAvly, and Avith a glass syringe. This was followed by acute pain, rise of temperature, and vomiting. She mended sensibly for tAvo or three days, but died suddenly on the fourth day. No tympanites. Suppurative inflammation Avas found on the mu- cous membrane of the uterus. The Fallopian tubes Avere filled with pus; pus Avas also found in the peritoneal cavity, and there Avas diffuse peritonitis. Lorain cites cases in Avhich exploration or simple cauterization of the cervix has caused death, from Bourdel and Martin Cdsar, Dolbeau, Btmier, and Letecuterier ; and from Jobert, one in which death followed the actual cautery to the os externum. Lorain adopts the vieAV already ex- pressed, that the danger arises from the contractile action of the Fallopian tubes and uterus, and the nervous excitability of the ovario-tubo-uterine system. The injection plays but a minor part. In the particular case 476 INTRA-UTERINE MEDICATION. related by him it is probable that death was caused by the spasmodic contraction of the uterus and tubes driving the foul pus in them into the peritoneum. The nitrate of silver injection merely excited this con- traction. We may obtain almost all the advantages that injections are capable of giving by other means. For example, the same agents which are so useful in the form of solutions for injection, may be applied either by swabbing, or solid, or in the form of ointment. Thus, where the use of chromic or nitric acid, perchloride of iron, iodine, or bromide is indicated, these agents can be applied soaked on a sponge or piece of cotton, or on a glass or hair pencil, having previously Avell dilated the cervix. Nitrate of silver is far better applied in the solid form. Even then it is liable to cause severe colic. The risk of this may be lessened by reducing the caustic by fusing it with equal parts of nitrate of potash. The ordinary Avay of using the solid nitrate of silver, that is, by hold- ing a piece of the stick in a forceps or porte-crayon, is objectionable. The piece may fall out or break, and a fragment left behind in the cervix or body of the uterus may give rise to intense agony, hemorrhage, and even metritis. To avoid this accident I have for many years used the contrivance figured p. 154 (Fig. 50). This is far the best Avay of ap- plying nitrate of silver to the os and cervix uteri, and it is the only safe way of applying it to the interior of the uterine cavity. The armed end of a probe may be passed into the uterus Avithout the speculum, although the aid of this instrument is sometimes convenient. For example, unless the armed probe is protected by a canula, the caustic will first touch the vulva and vagina in its passage, Avhich is apt to have unpleasant effects, and the guiding finger of the operator will be stained. A very useful topical application to the mucous membrane of the cer- vix and body of the uterus is sulphate of zinc. The value of this agent, Avhen applied to the relaxed or morbid mucous membrane is familiarly knoAvn. Hoav to apply it to the uterine mucous membrane is therefore a matter of great interest. A solid stick of tAvo or three grains can be carried quite into the uterus Avithout having touched the vagina by the Avay by means of my canula (Fig. 51, p. 154), noAV generally sold by instrument makers. It is a great advantage of this contrivance that the use of the speculum is quite unnecessary after it has aided in establishing the diagnosis Avhich supplies the indication in treatment. When the instrument has gone the proper depth, the piston pushes out the stick, and the instrument is Avithdrawn, leaving the stick to dissolve. This it soon begins to do, and by its speedy effect in constringing the mucous membrane, it keeps itself in giVu, until it is completely dissolved. Nitrate of silver reduced by admixture Avith nitrate of potash may be used in the same Avay. So may persulphate of iron, but this should be considerably reduced. When used nearly pure I have knoAvn it cause severe colic and bleeding. A most precious Avay of applying astringents, caustics, solvents, or alteratives to the interior of the uterus, is in the form of ointment or pasma. In this Avay almost any substance may be applied. Where grease is objectionable as a vehicle, a pasma of suitable consistence may INTRA-UTERINE MEDICATION. 477 be made by glycerine, vaseline, or other substances. In this form we may use remedies Avhich cannot easily be applied in any other way. For example, Ave can hardly use bromine, or iodine, or mercury in a solid shape ; and to use them in the liquid form is open to the objections already discussed. Almost anything can be made into an ointment or pasma ; and we thus get a complete practical command over a large range of useful agents. When the object is to pass lirjuids as nitric acid, or tincture of iodine directly into the cavity of the uterus, without touching the vagina or cavity of the cervix by the way, the best plan is to use the piston-cathe- ter above described. This can be done without the speculum; a very great advantage, since it is almost ahvays much easier to pass a sound or tube into the uterus under the guidance and aid of a finger. But Avhere a slight contact of the fluid with the passages on the Avay is of little moment—and this applies to tincture of iodine—a readier way is to twist a bit of cotton-avooI on the roughened probe (Fig. 50), and having charged it by soaking in the fluid, to pass it into the uterus, under the guidance of a finger on the os externum. If properly tAvisted on the probe there is no fear of leaving the Cotton-Avool behind. The instrument noAV known as Playfair's probe is an adaptation of the one referred to. To introduce ointment into the cavity of the uterus, the instrument figured at p. 155, Fig. 52, is both convenient and effective. It is used without aid of the speculum. It is charged by dipping the end into the ointment. This carries a sufficient quantity into the uterus, Avhen, by pushing home the piston, the ointment is deposited there. Vaginal lotions of tannin, sulphate of zinc, acetate of lead, or alum, render important aid. There is often some complication of chronic in- flammation of the fundus of the vagina, with ulceration; and it is useful to remedy this condition. This is the more important since the patient can herself keep up this treatment. A useful mode of medication appli- cable to the vagina is to wrap about twenty grains of alum in poAvder in a pledget of cotton-Avool; and to insert this in the vagina daily or every other day. This contrivance acts in two ways ; first, there is the astrin- gent, corrective action of the alum gradually acting as the powder melts doAvn; and, secondly, the cotton plug acts by keeping the irritable vagi- nal Avails from contact and friction. It secures "rest." Sometimes, however, plugs act as foreign bodies, cause irritation, and are not toler- ated. They should not be alloAved to remain more than four hours. They can be applied by help of the plug-speculum figured at page 156. The fuming nitric acid is highly extolled by Dr. Lombe Atthill.1 He advises first local blood-letting by scarification. Then he proceeds to the SAvabbing the interior of the uterine cavity Avith strong nitric acid. In order to secure its due application, he dilates the cervix uteri with a faggot of laminaria-tents ; then he introduces an intra-uterine speculum, which makes a channel, protecting the cervix, through Avhich the charged SAvab can be carried direct to the fundus of the uterus. The uterus is draAvn doAvn and steadied by seizing the os uteri Avith a vulsellum. Dr. Kidd, Dr. Ringland, Dr. Evory Kennedy, Dr. J. A. Byrne, all speak 1 Dublin Medical Journal, January, 1873. 478 TRAUMATIC INFLAMMATION. highly of the efficacy and safety of this method. For my OAvn part, I feel compelled to repeat that experience has amply proved that the dila- tation by tents of the cervix uteri, howsoever necessary it may be in some cases, is almost invariably a painful, and sometimes a dangerous proceeding, and that in the cases where nitric acid is likely to be useful, the canal Avill generally be patent enough Avithout artificial dilatation. The action of the nitric acid itself, I know, is useful, and as safe as most other agents. Constitutional treatment of Endometritis should not be neglected. In the acuter stages salines and sedatives, with a bland unstimulating diet, should be given. In the stages of debility, when nutrition has become impaired, and Avhen the nervous centres have suffered from long-continued impressions of pain, and the wear and tear of illness, neuralgia, in one or more of its numerous forms, is almost sure to be developed. Remedies presumedly directed ad hoc, constantly fail, unless, indeed, the exhaust- ing disease, the endometritis, be cured. But still, the use of tonics and other remedies calculated to improve nutrition, to procure ease from pain, to regulate the secretions, should go on pari passu. Copaiva, which may be given in the form of capsules, appears to pos- sess some virtue in restraining secretion from the mucous membrane of the uterus, although it is less to be depended upon than in the case of the lungs or bladder. Ergot and digitalis are also at times useful; quinine, bark, and strychnine, I think, are even more so. Purgatives become of essential importance. Saline aperients, aloes, an occasional mercurial alterative, generally combined with belladonna, give the best results. Aran speaks highly of aloetic enemata. Indeed, no indication is of more general application than that of keeping the rectum free from accumulation. Exercise should be regulated by the patient's strength, and her liability to pain. A sense of weight, of oppression, of pain, in the pelvis, extend- ing down the legs, should be taken as a warning to rest. Hip-baths and the consequent friction bring some of the benefits of exercise. When the active symptoms have been subdued by local treatment, the stimulating saline, sulphur or iron Avaters will be useful in confirming the cure. Hip-baths of plain cold water, combined with vaginal irrigation, often render great service. But in most cases warm baths are safer and more useful. z There is a form of inflammation of the cervix, chiefly limited to the mucous membrane, unconnected Avith pregnancy, which may also be called traumatic. It is the result of undue or aAvkward sexual intercourse, associated or not Avith infection or local poisoning. Although most fre- quent in young married women, I have seen a similar condition indepen- dent of sexual intercourse. In some of these the cause was obscure ; in others the disease ensued upon cold or violent exertion. The patient complains of pain, more or less acute, in the centre of the pelvis, radiating to the hypogastrium and groins. She stoops in walking, in order to relieve the pain. Any exertion quickly induces such pain and exhaustion that she is compelled to rest. There is often some degree of constitu- tional irritation and disturbance of the function of the stomach. Some- times there is leucorrhcea; but often the reply to questions upon this SYPHILITIC INFLAMMATION. 479 point is in the negative. On examination, it may be found that there is a copious accumulation of muco-puriform matter in the fundus of the vagina, where it lodges, being retained there as in a sac by the contrac- tion of the vagina below. Such a collection maybe voided unconsciously during defecation. The rugae are prominent, angry-red ; copious, epithe- lial secretion is found between the rugae, and viscid glairy secretion is seen oozing from the cervix uteri. The membrane covering the vaginal- portion of the cervix may be smooth, or may present spots of epithelial abrasion ; but it is in either case intensely red, injected, and someAvhat SAvollen. This form of disease not uncommonly induces vaginismus. Dyspareunia is often very marked. The treatment consists in " rest." Injections of lead are especially useful. In aggravated cases, especially those marked by vaginismus, the vaginal-rest, or a cotton avooI plug soaked in glycerine, renewed daily, will be of essential service, and will greatly shorten the period of treatment. One form of endometritis leads to exfoliation in mass of the mucous membrane. This constitutes the dysmenorrhoea membranacea, which has been described in Chapter VIII. In some cases of this kind I have knoAvn inflammation affect the mucous membrane of the cervix, as Avell as of the body. The epithelium of the os uteri, and presumably that of the cervical canal as Avell, being throAvn off, leavdng a pseudo-ulcerated or denuded surface, although there had been no labor. If there be a tubercular diathesis the case is more troublesome still, probably incurable ; for tuberculization is rarely limited to the uterus. The syphilitic taint is commonly acquired through the gestation of a diseased ovum, and often first becomes manifest after the birth of a child, at times shoAving marks of the disease, or, more frequently, after the premature birth of a dead child, or after an abortion. The syphilized mucous membrane is thickened—constantly tending to rapid superficial decay ; and its regeneration is imperfect. The taint remains, as in the skin, for an indefinite time. Such a mucous membrane is unfitted to develop a healthy decidua, and yet it is not a bar to im- pregnation. Hence conception after conception issues in abortion; and every time the neAV mucous membrane is reformed Avith the same charac- ters. It may lead to protracted retention of placental remains after abortion as Avell as after labor at term, and greatly disposes to sub-invo- lution. More or less chronic engorgement or inflammation of the body of the uterus commonly attends. Unlike the tubercular diathesis, the syphilitic commonly affects the cervix as well as the body of the uterus. There is ahvays hyperaemia, sometimes chronic inflammation; and the menstrual disposition is tOAvards excess in loss. The appearance of the vaginal-portion has struck me in many cases as being peculiar, so that I have thought I could recognize the syphilitic complication by the sight. But in practice we are not often obliged to trust exclusively to the local symptoms. It is rare that the history and the presence of symptoms in various parts of the body do not reveal the nature of the case. Gum- mata about the vulva and anus, sore throat, fissured or ulcerated tongue, characteristic eruptions on the skin, falling of the hair, w ill generally be found. 480 EXCRESCENCES ON OENITALS. Leucorrhcea, the discharge being often more offensive than usual, is a constant symptom. The treatment must obviously be both constitutional and local. Iodide of potassium, occasionally iodide of mercury, bark, should be persisted in for several months. A cure cannot be effected in a few Aveeks. The calomel vapor bath of Henry Lee is an excellent remedy. Baths of Vichy salts, or better still, the internal and external use of bromo-iodic Avaters, as those of the AVoodhall Spa, Kreuznach, Carlsbad, or Wies- baden, will render eminent service. The best local remedies are the iodide of lead or iodide of mercury ointment applied inside the uterine caAdty. The direct contact with the diseased mucous membrane I have found especially beneficial. Some- times the part may be touched Avith solid nitrate of silver, or a small stick of sulphate of zinc may be inserted. The applications should be made every fourth or fifth day between the menstrual epochs. The local treatment may be partly carried on by the patient herself. Sulphate of zinc injections daily will be of service, although they touch the vagina and vaginal-portion only. Should pregnancy occur, and it is to be deprecated until the mucous membrane shall have recovered its soundness, the local treatment must be stopped. But the constitutional remedies should be sedulously per- sisted in. We may usefully combine Avith the iodide of potassium five- or ten-grain doses of chlorate of potash. In this way abortion is sometimes averted. Growths or excrescences vary according as they are developed from the mucous membrane of the cavity of the uterus, cervix, or vaginal- portion. 1st. The groAvths in the mucous membrane of the body occur in the form of circumscribed elevations, tAvo or three lines thick, in fat pAaques, the surface of the mucous membrane being tumefied by catarrh. These puffed elevations are red, shiny, velvety, smooth. On scraping them a milky fluid exudes, which under the microscope exhibits glandular epi- thelium, sometimes transparent vesicles and colloid bodies. Specimens hardened in chromic acid, and thin slices treated with glycerine, exhibit areolar stroma of connective tissue with utricular glands, partly enlarged, partly obliterated. The vascularity of these groAvths is sometimes extra- ordinary. Sometimes with the naked eye one can see yelloAvish white clots Avhich under the microscope are recognized as obliterated glands Avith fatty degeneration of epithelium. In other cases small vesicles are visible in these tumors, resulting from constriction, and cystic degeneration of the utricular glands. This latter forms the transition from these tumors to vesicular polypi of the uterus. They vary in size from one inch to more in diameter. The sub-mucous uterine tissue becomes hypertrophied into connective- tissue outgrowths {sarcomata), Avhich gradually form the so-called fibrous- polypi, in whose interior are often contained separated portions of elon- gated uterine glands, or gland-tubes, of new formation, which degenerate into cysts {cysto-sarcoma adenoides). Sometimes the uterine mucous membrane degenerates into a more or less hard, richly-nucleated,fibrillous, callous, connective-tissue substratum, CYSTIC ENDOMETRITIS. 481 in Avhich the glands have shrunk aAvay. Often it is studded Avith small cysts, containing mucus or colloid, the remains of the separated portions of the uterine glands. CYSTIC ENDOMETRITIS : CIRCUMSCRIBED PROLIFERATION OF THE UTERINE MUCOUS MEMBRANE, VESICULAR POLYPI.. The deArelopment of cystic tumors at the cervical orifice out of ob- structed glands is not uncommon. It is less frequent in the cavity of the uterus, but still it is occasionally observed as a result of chronic endome- tritis. The utricular follicles may, as Ave have seen, be greatly hyper- trophied. They may be seen as small rounded tumors, projecting as hemispheres, or sometimes pedunculated: their Avails are transparent; they feel like little resisting grains, slightly elastic. They range from the' size of a pin's head to that of a small nut. They contain a trans- parent liquid. They are often associated Avith the so-called fungosities, granulations, or vegetations. Ch. Robin has shoAvn that these bodies are formed of exactly the normal elements of the uterine mucous membrane. There is a disposition to fatty degeneration at their base. In some rare cases the elongation of the uterine glands takes place in both directions, that is, into the uterine cavity on the one hand, and into the uterine parenchyma on the other. These little cystic growths sometimes form a cluster, hanging round the upper end of the cervical canal, near the os internum; or may be more or less isolated ; or they may occur in groups or singly, near the os externum. When they form in the cervix the os externum is usually patulous, and the finger passed into the cavity feels them as rough pro- jections, or as soft pedunculated bodies rolling under the finger. Some- times, as in a case figured by Lancereaux, these cervical cystic growths are associated with a similar formation in the body of the uterus. In this case the enlarged uterus contained a thick viscid fluid; its mucous membrane was red,' injected, had at its fundus a mammellated mass, gravish, formed of vascular connective tissue, in which Avere found mul- tiple cavities filled with clear serosity. Sometimes a group will form a distinct polypoid outgrowth. Of this there is a striking example in the museum of'St. Thomas's Hospital. These changes of the mucous membrane probably include some of the most difficult "pathological and therapeutical problems. The " fungosi- ties," " carnosities," "excrescences," so often associated Avith some degree of enlargement of the body of the uterus, attended by hemor- rhage, and inducing cachexia, not seldom, by their obstinacy and other characters, simulate malignant disease. Sometimes, indeed, there is good reason to believe that the endometritis is dependent upon, and modified by, a tubercular or cancerous complication. But even apart from such 'complication, the changes of structure resulting from long- standing slow congestion or inflammation are exceedingly troublesome. Thev° may sometimes be distinguished from the malignant disease which attacks the lining membrane of the uterus after the menopause by this circumstance: if there have been a distinct interval after the meno- pause, marked by absence of blood-discharge, then the sudden appear- ' 31 482 TREATMENT. ance of hemorrhages is strongly presumptive of the rise of malignant disease. Forming sessile or pedunculated tumors, they resemble, and sometimes may be, early papillary epithelioma. But where during the latter years there has been persistent menorrhagia, followed by hemor- rhages more or less periodical, without any prolonged break to mark the cessation of ovarian life, although the insidious invasion of malignant disease may be possible, the presumption is greater in favor of chronic inflammatory change in the mucous membrane. Whether malignant or benign, a symptom Avhich cannot be overlooked any more than the hemorrhage is almost constant, that is, severe pain. This I have found, both when the growths Avere in the cendx and Avhen they Avere in the proper cavity of the uterus. The bleeding is often profuse to the extent, by its quantity and fre- quent recurrence, of endangering life. When the seat of the disease is the cervix the blood is sometimes bright arterial; Avhen the seat is in the body of the uterus, and the blood is liable to temporary or partial reten- tion, it may be darker, even black. This gradual rise of the affection tOAvards the advent of the menopause, and its comparatively rare occurrence at an earlier age, supply evidence of its sIoav development out of chronic inflammation. They are not uncommonly associated Avith fibrous tumors or polypi in the body of the uterus, as may be seen in illustrations in the chapter on those affections. As already said, the body of the uterus is almost invariably enlarged ; its Avails are thickened. This commonly induces some signs of prolapsus, but flexion is by no means a necessary concomitant. I think I have more frequently observed ante-version. The enlargement of the womb is the result of slow hyperplastic process. There is generally a degree of softness of structure. Increased vascularity or congestion, aggra- vated by ovarian stimulus, leads to menorrhagia, now and then amount- ing to alarming flooding. Dyspareunia commonly attends, and inter- course is sometimes the exciting cause of hemorrhage. The uterus is found by touch to be increased in bulk and Aveight, and to be unusually sensitive. The sound will often cause bleeding, and more pain than usual. The speculum shoAvs tumefaction and vascularity of the vaginal- portion, and a patulous state of the cervical canal, and blood or mucus issuing from the uterus. The systemic symptoms are the expression mainly of the losses of blood, and of the impairment of the functions of nutrition and innerva- tion, consequent on anaemia and local irritation. This exhaustion and the attendant pain will commonly give the patient a peculiar, worn, haggard expression of countenance. The first indication in treatment is usually the urgent one to arrest bleeding. To carry this out the most effectual means are the topical application of perchloride or persulphate of iron in styptic strength, or rather fuming nitric acid, or tincture of iodine. These agents may be carried into the uterine cavity on a sponge or cotton-wool, mounted on a whalebone probang, or on a glass pencil, through a speculum, if the canal of the cervix is open and straight enough; or better still, by the fenes- trated tube. In the contrary case it may be necessary first of all to TREATMENT. 483 dilate the cervix by spongy or laminaria tents. Indeed, the rule laid doAvn in the chapter on " Hemorrhages" to " obtain and maintain free patency of the cervical canal" applies strictly to this case. So true is this, that in many cases the mere artificial dilatation will check the hemorrhage. Dr. Routh1 even affirms that the action of "the sponge- tent itself suffices to cause absorption and diminution of volume of the uterus.'" When the hemorrhage has been checked, tonics, as strychnine, quinine, ergot, Avill be useful. The diet should be light; stimulants should be sparingly given. The introduction into the cavity of the uterus, every fourth or fifth day, of solid sulphate of zinc, nitrate of silver solid or in strong solution, of tincture of iodine, or of iodide of mercury in ointment or pasma, will render eminent service. In obstinate cases, Avhere topical applications fail, the expediency of removing the diseased tissue must be considered. It Avas in such cases that Re'camier practised the operation of scraping off the excrescent fungo- sities by a curette. The proceeding seems a bold one, even rough ; but the condition of the patient is serious. Undoubtedly women have been rescued by it from imminent danger. In this affection, as in undoubted malignant disease, it is the surface, the papillary projections, Avhich are the immediate source of the bleedings. When the superficial stratum is removed, the bleeding is usually arrested for a time. Fig. 104 represents Marion Sims's curette, Avhich I have found a very convenient instrument. It has tAvo sizes, one at either end of a stem, about ten inches long. Fig. 104. Mariou Sims's Curette. Fig. 105. Fig. lOo represents Re'camier's curette. The two forms may be con- veniently united in one instrument, so that either end may be used. The curette held in the right hand is passed into the body of the uterus, guided by a finger of the left hand applied to the os uteri, the fundus being supported°by the hand of an assistant above the symphysis. The subacute edge of the curette is then drawn over the entire internal surface, so as to break down and detach any projecting masses. Sometimes small 1 " Cases of Menorrhagia treated by Injection, or the Removal of the Uterine Mucous' Membrane by the Gouge." By C. II. F. Routh, M.D., Obstetrical Trans., vol. ii. 484 SENILE UTERINE CATARRH. pisiform or pyriform bodies, like minute vascular or mucous polypi, are brought aAvay. Bv injecting a light stream of Avater these bodies Avill be washed out, and may be collected for examination. It is not gene- rally necessary to apply anything to the surface after the curette has done its work." But there 'is better security against bleeding, and pro- bably useful modifying action, if the surface be mopped with tincture of iodine, nitric or carbolic acid. Absolute rest is essential. Metritis may follow. The operation should not be resorted to except when milder proceedings have failed to relieve urgent symptoms. Occasions arise when timidity on the part of the surgeon will seal the patient's fate ; and when his duty is calmly to balance the dangers of expectancy, and those of resort to even a doubt- ful remedy. After this decisive course of action Ave have reason to hope that a healthier mucous membrane will be produced. But the truth must be admitted that the disease is apt to return. This, hoAvever, may not happen for several months ; and during this time the patient may suffer little from hemorrhage or other trouble. During this period of inter- mission, much may be done to bring doAvn the chronic congestion and tumefaction of the uterus. Strychnine, quinine, iodide of potassium, even iodide of mercury will be useful. And, internally, the application of iodine, or of iodide of mercury, or of nitric acid will prove serviceable. Senile Uterine Catarrh.—This disease has been adverted to when dis- cussing atresia. It deserves separate consideration, on account of its frequency and importance. It probably, in most cases, is continuous from chronic metritis acquired before the menopause. Notwithstanding the disposition to uterine senile involution or atrophy, a change which, in some cases, may terminate that vascular activity upon Avhich inflamma- mation and even secretion depend, a degree of morbid action is often per- petuated. The pelvic vessels often continue engorged after the meno- pause from impeded hepatic circulation. The uterus in these cases will remain unduly congested, and the sIoav chronic inflammatory process is easily fed. This condition will account for the occasional apparent return of the menstrual discharge several months after the function had been supposed to have ceased. This is one form of senile uterine hemorrhage. In other cases there is not so much vascular fulness; yet the mucous membrane continues to throAV off a more or less abundant thin opaque mucous secre- tion. The walls of the uterus are usually someAvhat thicker than usual. Atrophy, in fact, has been arrested. The cavity is almost always en- larged. The sound readily turns round in it. The flaccid condition of the uterus disposes to flexion, most frequently to retroflexion ; although it is certain that in many cases the flexion existed before, and may have been the cause of the endometritis. When this occurs there will of course be more or less retention of mucosities in the uterus. And it is to this retention that some of the most marked symptoms are due. It brings about a sense of fulness ; weight and oppression, Avith pain in the pelvis. The constant Avear and tear tells upon the nervous system and upon general nutrition. The most distressing nervous symptoms, despondency SENILE CATARRH AND ATRESIA. 485 being the most characteristic, are often produced. The quantity of the discharge is at times also great enough to make a serious drain. In a considerable number of cases I have found complete, or nearly com- plete, closure of the cervical canal, generally at either the os externum or os internum. The Avails have groAvn together by a process compounded of inflammation and atrophy. (See Fig. 98, p. 411.) But the uterine cavity continuing to secrete, the secreted fluids accumulate, and thus retention and its consequences ensue. Expulsive pains are felt, Avhich generally subside, to be renewed at variable intervals. In some cases, the aged uterus, not receiving the stimulus of menstruation, and but feebly responding to other stimulus, accommodates itself to the distension. Atrophy progressing, the fluid part of the mucous may disappear, or be retained Avithout causing further trouble. But in other cases, and those, if I may judge from my own experience, not a feAv, the distress does not subside. Advice is sought on account of the pelvic suffering, or metror- rhagia. Then Ave find the roof of the vagina contracted into a cone, at the apex of Avhich is a small depression, recognized as the os uteri. There may be little or no projecting vaginal-portion. Behind this de- pression Ave may feel the retroflected body of the uterus ; or this part may be in natural position. On trying to pass the sound we find it soon meets with an obstruction. The os externum is occluded. Sometimes a little steady pressure with the point of the sound will penetrate the ob- struction. But I have several times found it necessary to restore the cervical canal by incision or puncture. For this purpose a most conve- nient instrument is the sheathed male urethral stricture bistoury, or the modification of it, designed by me for gynaecological purposes. This done, an ounce or more of muco-purulent fluid has escaped Avith manifest relief. To prevent relapse it is necessary noAV and then to pass the uterine sound : and to correct the morbid state of the cavity to introduce a stick of sulphate of zinc, or to swab with tincture of iodine, or ni- trate of silver, every three or four days. By this treatment a cure is commonly effected in a feAv weeks. The atrophic process goes on undisturbed. In chronic internal metritis, especially in elderly Avomen, Aran advises the use of the holloAV sound or catheter, as a means of diagnosis. The retained mucous fluids are thus draAvn off, and their quality and quantity may be estimated. We may use a male silver or elastic catheter, but the curved must be moderate. The ointment-carrier (Fig. 52, p. 155) ansAvers the purpose. Dr. Charles Hennig lent to the Obstetrical Society's Exhibition an aspirator-tube designed to draw out fluids from the uterus. The folloAving remarks apply generally to the treatment of chronic endometritis. The exhaustion wrought by disordered nutrition may, there is great reason to believe, in some instances end in the development of tubercular mischief in the lungs. This is not surprising, when we remember that a strumous or lymphatic diathesis is a very poAverful fac- tor in producing and in giving the stamp of obstinacy to chronic metritis. In some cases marked by peculiar obstinacy there is indeed a tuber- cular condition of the uterine mucous membrane. For this I doubt if there is any cure. To pursue local treatment in such cases, beyond 486 PELATC INFLAMMATIONS. perhaps applying an occasional detergent or disinfectant, would be to inflict needless distress. It may also become a question how far, when hinir mischief has become revealed, it is desirable to persist in treating the"uterine catarrh. It should not I think be always given up. Ihe principle of curing as far as we can, every component part in a chain of morbid complication obtains here. But often it will be found the most judicious course to abandon local treatment, and to address all our care to the general system, and the alleviation of the lung-distress. Anomalies of Consistency.—-One of the most remarkable is the pulpi- ness of advanced age, coming on after long-continued mucous secretions, which disposes to 'ecchvmosis or uterine apoplexy. Another form of softening is that ensuing upon childbearing, when involution is arrested by marasmus. The mucous membrane may also become soft from repeated hemorrhage. From constant infiltration or maceration it swells and disintegrates. Abnormal hardness of the uterus affects chiefly the vaginal-portion in consequence of the predominance of connective tissue in hypertrophy. Lesion8 of Continuity of the Uterus.—Lacerations may occur in the non-pregnant uterus. I have carefully described the lacerations of the pregnant uterus in my Lectures on Obstetric Operations, 3d edition, lSTtJ. Under excessive distension from collections of blood or mucus, laceration or perforation has occurred. The uterus also has ruptured from the pressure of a polypus in its cavity. The tumors of the uterus will be described in a separate chapter. CHAPTER XX. PELA'IC CELLULITIS (PARAMETRITIS): PELVIC PERITONITIS (PERIMETRITIS): GENERAL DISCCSSION ON PATHOLOGY ANI) CAUSES ; PERIMETRIC INFLAM- MATION (PERI-UTERINE INFLAMMATION) J METRO-PERITONITIS. The subject of inflammation of the pelvic tissues connected Avith the uterus and its appendages has been worked out, of late years, with great clinical skill: and, I may venture to add, Avith superfluous critical acu- men. There is a natural tendency to embody or condense the neAV vieAvs Ave arrive at as to an essential pathological condition, by assigning to this condition a neAV name. If this name be tolerably precise and descrip- tive, it is often readily accepted as the last expression of science. Hence a name is apt to impose upon the learner the belief that he has caught the true clinical idea. And then in accordance with another tendency, the mind, satisfied with the seeming fulness of the idea embodied in a PELVIC INFLAMMATIONS. 487 ne\v term, proceeds to eject every other term hitherto associated with the condition under discussion as false. Unable to entertain two ideas at the same time, hastily concluding that one or the other must be false, the one which is presented in the most attractive or authoritative manner is accepted, to the absolute exclusion of the other. This reflection is remarkably illustrated in the history and varying no- menclature of inflammations of the pelvic structures. These inflamma- tions of course remain, or continue to be reproduced, as they ahvays have been. Noav names may represent neAV theories, but the clinical facts are unchanged. It is these Avhich it is important to understand. It is to be feared that neAV names have tended rather to obscure these facts than to elucidate them. In attaching too much importance to names, that is, in alloAving the mind to be dominated by the theories that names represent, Ave are apt to lose sight of the truth which lies in the rival names and theories. A true theory and a false theory are antagonistic. If Ave accept the one Ave must, logically, reject the other. But there is no antagonism betAveen tAvo true theories. These must be reconcilable, hoAv- ever widely observation and reasoning carried on in different lines may place them in opposition. I Avill iioav endeavor to state the case plainly, divested of all theory or school-doctrine. All the structures in the pelvis are liable to inflamma- tion. It is conceh'able, and true in fact, that any one of them may be alone the seat of inflammation. It is conceivable, and true, that two or more of them may be inflamed together. . We have already endeavored to trace the history of inflammation of the ovaries, Fallopian tubes, and uterus. It remains to fill up the account by tracing the history of in- flammation of the other adjoining structures. What are these structures ? We are not called upon in this place to consider inflammation of the rectum, bladder, or vagina, otherwise than incidentally. The structures with Avhich we are noAV concerned are the cellular or connective tissue, the peritoneum, and the broad ligaments. No one disputes that each of these structures may be the principal focus of inflammation. For ex- ample, hoAvever Ave may cavtil at the term " pelvic cellulitis," Ave cannot deny that the pelvic cellular tissue, that is, the connective tissue in rela- tion Avith the uterus and broad ligaments, is liable to inflammation. Paris, Frarier, Courty,1 E. Simon, Alph. Guevin, each relates cases of distinct pelvic cellulitis. "Pelvic cellulitis" expresses this fact, and nothing more. Again, hoAvever we may caAdl at the term "pelvic peritonitis," Ave cannot deny that the peritoneum which invests the organs in the pelvis is liable to inflammation. " Pelvic peritonitis," then, is a good term, as expressing this fact. So again, at the bedside we are often called upon to speak of inflammation of the broad ligaments. When we so speak we do not pretend to define rigorously Avhich of the constituents of the broad ligaments—connective tissue, vessels, muscular fibres, or peritoneum—is especially the seat of inflammation. Although undoubt- edly inflammation may begin in the vessels, or in the connective tissue, or in the peritoneum, Ave shall rarely find an instance in Avhich inflamma- tion does not involve the proximate tissues more or less. We are there- 1 Maladies de 1'Uterus, etc. 1870 4S8 PELVIC INFLAMMATIONS. fore generally compelled to speak of inflammation of the broad ligaments in the aggregate. It is scarcely possible for the vessels and connective tissue inclosed in a thin lamina between the folds of the peritoneum to be inflamed, without involving the peritoneum. Now, the cellular tissue is chiefly situated on cither side of the uterus surrounding the vessels and nerves at the line of ingress and egress: in front of the lower third of the uterus where its cervix is attached to the bladder : behind the uterus and vagina, where a stratum connects these organs with the peri- toneum and rectum; and between the peritoneal folds of the broad liga- ments. All this cellular tissue may be described as continuous ; and therefore inflammation beginning at one part may spread to the rest. The part Avhich seems most isolated from the rest is that mass of tissue which connects the cervix uteri with the base of the bladder. Accordingly this part is occasionally the seat of inflammation, which may run its course Avithout spreading beyond its oavh limits, and Avithout implicating the peri- toneum, at least in any important degree. But the like limitation can hardly be predicated of any other part of the cellular tissue. The vessels which so often carry the cause of inflammation, and the peritoneum, are in such intimate relation with the cellular tissue at the sides of the uterus, and Avith that in the broad ligaments, that the serous investing membrane can rarely escape. We thus come to the general conclusion, one amply borne out by clinical observation, that pelvic cellulitis, pure and simple, is a rare affection. Thus when we use the term ". pelvic cellulitis," in the great majority of cases we use a term which only expresses a part of the morbid process. So far then the term is open to objection. Again, the peritoneum covering in the pelvic organs being continuous Avith the abdominal peritoneum is subject to inflammation spreading to it from the abdomen. With this secondary inflammation Ave are not noAV concerned. The pelvic peritoneum is far more frequently the primary seat of inflammation, Avhich, beginning here, may spread to the abdominal portion of the serous membrane. Noav, if Ave ask Iioav it is that the pelvic peritoneum is so prone to inflammation, Ave shall find a plain answer in the clinical and pathological facts. There is not—I say this Avith some confidence, yet not Avithout reserve—evidence to show that inflammation begins in the pelvic peritoneum ; inflammation in this membrane is excited by a morbid condition of the structures Avhich it invests. That is, where the uterus, tubes, ovaries, vessels, and cellular tissue are healthy, scarcely any cause, other than extension of inflammation from the abdominal peri- toneum, can produce inflammation of the pelvic peritoneum. The chief exceptions to this proposition are those cases where inflammation is kindled by some irritating matter poured into the peritoneal cavity, and which by gravitation or proximity to the seat of injury is chiefly'concentrated in the dependent pouches of the pelvic peritoneum. And even in these cases Avhere the peritonitis takes its rise in conditions independent of in- flammation or disease of the pelvic organs, the cellular tissue, at least in some degree, soon becomes involved. We come then to the further conclusion, that pelvic peritonitis, pure and simple, is also a very rare affection. Disease rarely consents to the limits Avhich medical nomenclature would PERIMETRITIS--PARAMETRITIS. 4*9 assign to it. All terms, therefore, Avhich profess to be precise definitions are pretty sure to be fallacious. If then we conclude that the terms " pelvic cellulitis" and " pelvic peritonitis," Avhich have been for some time in use, imperfectly, and therefore inaccurately, represent what we find at the bedside, the more recent terms, Avhich are equally exclusive, must be equally fallacious. The more recent terms to Avhich reference is made are those introduced by one of the greatest of living pathologists, one from Avhose authority no one can dissent without hesitating long. Virchow1 proposes to substitute the terms " Perimetritis" and " Parametritis." He bases the first term on the analogy with " Pericarditis." Just as the serous investment of the heart may be the special seat of inflammation, so may the serous in- vestment of the uterus. Perimetritis, then, may be taken as the equiva- lent of pelvic peritonitis. It is difficult to see any sufficient grounds for preferring the neAV to the older term. The analogy Avith the heart is surely strained. The heart is completely, solely, and everywhere closely invested by its own exclusive serous membrane ; the pericardium reflected upon itself forms a special bag, Avithin Avhich the heart alone is inclosed. The pericardium then enjoys absolute immunity from inflammation extend- ing from serous investment of other organs ; and comparative immunity from inflammation extending from any other source than the heart itself. Pericarditis probably, like pleurisy, chiefly OAves its origin to offending matters carried in the blood. Peritonitis undoubtedly often owes its origin to like conditions. But the pelvic peritoneum, whilst not free from liability to inflame under general toxicohaemic influences, is exposed to inflammation from other causes. These are, as Ave have seen, metritis, salpingitis, oophoritis, pelvic cellulitis, inflammation of the vessels carrying septic matter from the uterus, irritating matters poured into the peritoneal sacs of the pelvis, and extension of inflammation of the abdominal peritoneum. The serous investment of the body of the uterus forms a very small part of a membrane which has numerous other relations, and which is there- fore exposed to numerous sources of disease. If the term " perimetritis" he limited to the few square inches of peritoneum Avhich covers the body of the uterus, it only expresses a very small part of the clinical case. Inflammation so limited is extremely rare. If the term be made to em- brace inflammation of the serous membrane of the tubes, ovaries, and broad ligaments, then it is strained beyond its etymological meaning, and is wholly inadequate for clinical purposes. The correlative terms, " peri- salpingitis" and '•'■perioophoritis," proposed to supplement "perime- tritis," prove the inadequacy of this latter term. Themselves, they are hardly worthy of discussion. I submit, then, that there is no sufficient reason for adopting the term " Perimetritis." The term " Parametritis," intended to describe inflammation of the cellular tissue in the neighborhood of the uterus, is also open to objection. It is less comprehensive than ik pehdc cellulitis." It is not alone the tissue immediately surrounding the uterus Avhich is exposed to inflamma- tion. Indeed, inflammation of the cellular tissue is rarely so limited. Nor does it even always begin in this part. The inflammation in the 1 Archiv. fur Pathol. Anat. und Phys. 1S62. 490 PERIMETRIC INFLAMMATIONS. broad ligament often begins from disease of the Fallopian tubes or ovaries, and may never reach the cellular tissue near the uterus. We are driven then alike by etymology and by clinical observation to reject both the terms *' Perimetritis" and kw Parametritis" as being inad- equate, and not justified by scientific necessity. The truth being that the pelvic peritoneum and the pelvic cellular tissue being each liable to inflammation, Ave Avant the terms k' pelvic peri- tonitis" and " pelvic cellulitis." And it being also true that in a great, perhaps the greater, proportion of cases, both peritoneum and cellular tissue are inflamed together, we Avant a term Avhich shall express this common affection. The term " peri-uterine inflammation," adopted by Courty, answers to this Avant. It is indeed open to an objection, Avhich not seldom meets us in medical nomenclature, namely, that it is a dis- cordant compound of Greek and Latin. This may be avoided by substi- tuting the term " perimetric inflammation." In adopting this term I mean to include inflammation involving the broad ligaments and their contents. This term carries us back someAvhat to the term " Phlegmonous intra- pelvic abscesses," adopted by Marchal (de Calvi), to whom science is indebted for the most important of all modern contributions to this subject.1 His is the great merit to have shown that the chief seat of the puerperal and many other abscesses in Avomen was in the pelvis. He thus exploded the erroneous ideas which connected these inflammations with the iliac fossae. And, since perimetric inflammation is so frequently consequent upon, and therefore complicates, inflammation of the uterus or its appendages, to express this compound condition Ave Avant the term " metro-peritonitis." The researches of Bernutz2 and of MM. Bernutz and Goupil,3 conducted in the most admirably philosophical spirit have been pre-eminently useful in extending and in correcting our knoAvledge of the subject. These researches have demonstrated that Avhat had hitherto commonly passed for pelvic cellulitis Avas often pelvi-peritonitis. The phlegmonous masses rising out of the pelvis, and extending into the iliac fossae, so frequently met Avith after labor, are shoAvn to be, strictly speaking, not pelvic cellu- litis, but peritonitis. This much, Avith some qualification, may be granted. But it is to be feared that here again is an instance of one idea making good its way by driving out another from ground where both have a com- mon right. In these post-puerperal cases, with Avhich we are the most familiar, because they most frequently come under clinical and post-mor- tem observation, there is almost always a complication "of cellulitis and peritonitis ; and it might also be added, of metritis as well. The perito- nitic element will, it may be admitted, generally predominate. But the other elements coexist. It appears to me then that Bernutz, whilst ren- dering incontestable service in calling attention to the important part played by peritonitis in these cases, has rather undervalued the other factors of the disease. ' Des abces phlegmoneux intra-pelviens. 1844. 2 Archives generales de Medecine. 1857. 3 Clinique niedicale snr les maladies des feinmes : Me moire de la pelvi-peritonite et de ses diveises varietes. Paris, 1862. PERIMETRIC INFLAMMATIONS. 491 In post-puerpertd perimetric inflammation, Avhich must serve for a type or illustration of other orders of cases as Avell, there may be distinguished three kinds :— 1st. That kind Avhich, as far as Ave can judge, is simply inflammatory. -dly. A kind in which septicaemia plays a conspicuous part. The in- flammation is of a Ioav type. There is a tendency to diffuse, or erysipe- latoid inflammation and to a general systemic empoisonment. 3dly. There is a kind intermediate betAveen the two preceding, in Avhich there is a septic factor, but which is held in abeyance by the supe- rior vigor of the blood. In these cases the septic matter is blocked out by the healthy blood coagulating in the efferent pelvic vessels, and inter- cepted by the lymphatic glands. In this Avay the system escapes, and the morbid influences are mainly concentrated in the pelvis. In the first, or purely inflammatory kind, the action is chiefly spent upon the peritoneum. These may properly be called cases of pelvic peri- tonitis. They are analogous to the cases of pericarditis and of pleurisy, which supervene on a sudden impression of cold, Avhen the pericardium and pleurae have undergone unusual strain, the blood being also modified, under violent bodily exertion. The violent perturbation of parturition induces a peculiarly susceptible condition of the uterine and pelvic peri- toneum, and an alteration of the blood which is favorable to the develop- ment of inflammation, if an exciting cause, such as cold or emotion, be applied. These are the cases to Avhich the description of Bernutz more strictly applies. In this order of cases the peritonitis, in many instances, does not break out until two or three weeks or more after labor. Thus, a young lady of delicate organization, suckled imperfectly for seven Aveeks ; Avhilst menstruating she Avent to toAvn, undergoing great fatigue, and came home with intense abdominal and pelvic pain and fever. Pelvic peritonitis had been produced. This is not an uncommon history. In another case a young Avoman Avas doing Avell until the fourteenth day after labor, when she Avas subjected to sexual intercourse. Shivering set in a feAv hours afterwards, and perimetric inflammation ensued. But not even in all these essentially inflammatory cases is the inflam- mation chiefly expended upon the peritoneum. There is a sub-order of cases Avhich appear to be essentially of traumatic origin, in Avhich the chief, or at least the primary, seat of the inflammation is in the perimetric cellular tissue. During the passage of the child's head through the cer- vix uteri there is commonly laceration of the margin of the os, bruising of the mucous membrane, and of the Avhole substance of the neck, at- tended by a dragging or gliding movement of the structures in most imme- diate contact with the head upon the deeper parts. The cellular tissue around the cervix, Avhere cellular tissue most abounds, is especially con- tused, stretched, vessels in it are torn, effusion of serum and ecchymosis take place in it. All this I have frequently verified by actual inspection. Everything is prepared for inflammation. There is the local injury, the effusion. There is the altered blood charged with effete matters, hyperi- notic, under the influence of pregnancy and labor. An exciting cause alone is wanting. A chill is often sufficient. The chief seat of the in- flammation in this case will be the Avounded cellular tissue. In this tissue 492 PERIMETRIC INFLAMMATIONS. it may run its course, ending in resolution or in abscess ; and affecting the peritoneum slightly, if at all. In the second order of cases, characterized by the predominance nf u sejitic factor, the inflammation of the pelvic tissues is universal. The uterus itself, its bloodvessels and lymphatics, the cellular tissue around and in the broad ligaments, and the peritoneum are all involved in a Ioav kind of inflammation. The inflamed pelvic peritoneum throwing out un- healthy lymph Avhich rapidly breaks doAvn into pus, sets up the like inflam- mation in every part of the abdominal peritoneum Avith which it comes into contact. The poisonous matter may be generated in the Avoman's system under the strain of labor, her blood becoming overcharged with noxious materials, resulting from tissue-changes. To this order of cases I have given the name, noAV generally adopted, of " auto genetic puerperal fever." In another order of cases the poisonous matter is inoculated, it comes from without. The woman, whilst in a highly susceptible state, takes in the poison of scarlatina or some other zymotic. The general infection of the blood here acts as the exciting cause of inflammation ; and the in- flammation will naturally, in the first instance, break out in the pelvic tissues, rendered susceptible by traumatic action. In these cases again the inflammation will not be limited to the peritoneum. It Avill invade the uterus, cellular tissue, and peritoneum alike. It must, however, not be forgotten that patients seized Avith this, the uheterogenetic" form of puerperal fever, not seldom die of the fever before any marked local in- flammation declares itself. A feature distinguishing cases of this order from the first or simple inflammatory kind, is that the disease commonly breaks out much earlier, that is, Avithin three or four days after labor. In the third, or mixed order of cases, in which there is a septic factor, controlled by a comparatively healthy state of the blood, the inflammation begins in the uterine sinuses and lymphatics. Under the combined in- fluence of traumatism, and of blood someAvhat impaired by the tissue- changes of pregnancy and labor, and sometimes of decomposing debris of placenta, membranes, and blood-clots in the uterus, foul matters form in the uterine cavity, get into the uterine sinuses and lymphatic, and, not arrested there, either from want of contractile energy of the uterine fibre, or because, being as yet too abundant for the blood it meets in its course to segregate by coagulation, it invades the vessels in the broad ligaments, where further progress may be stayed by the formation of clots. This thrombotic process is generally attended by inflammation of the peri-vascular tissues, and of the broad ligaments, which is pretty sure to involve the peritoneum. If the lymphatics be concerned as Avell as the veins, then the phenomena of phlegmasia dolens are developed. That the broad ligaments are chiefly involved in the majority of these cases, seems proved by the seat of the tumefaction being in the sides of the pelvis ; by the inflammation being in many cases unilateral; and by the uterus itself remaining in many cases apparently free from inflamma- tion. That is, in this rather considerable order there is not necessarily inflammation of the peritoneal investment of the body of the uterus; that is, there is no perimetritis. Trousseau may be cited as insisting upon the frequent complication of PELVIC CELLULITIS. 493 phlebitis with inflammation of the broad ligaments. He believed that phlebitis Avas the most frequent cause of this inflammation. A very similar description will apply to the perimetric inflammations supervening on abortion. It applies often very closely to inflammation of the broad ligaments leading to phlegmasia dolens beginning in cancer of the uterus. Hemorrhage at the time of labor or abortion powerfully predisposes to perimetric inflammation. The parts being so predisposed, comparatively slight causes set up inflammation. A frequent cause is cold, usually so freely applied by ice or cold Avater injections, or by cold douche to the abdomen. Exposure to chill and getting about too soon are common causes. It deserves to be remembered that pelvic peritonitis is not uncommon in the foetus ; and that in after-life the pelvic organs may remain bound by persistent adhesions. This condition, it is highly probable, renders the subject unusually liable to neAV attacks of peritonitis Avhen the organs are called into functional exercise. Perimetric inflammations occurring in the non-pregnant states, pre- sent features Avhich it is interesting to compare with those Avhich follow labor. They follow the same laws. When metritis is set up from the retention of decomposing matters in the body of the uterus, from trau- matism, as from injury by the sound or other instruments, or from an intra-uterine pessary, the primary inflammation being in the body of the uterus, the secondary inflammation will attack the uterine peritoneum, at least chiefly. On the other hand, Avhen the cervix is first attacked by inflammation, resulting from operations performed upon it, by the irrita- tion of tents or other causes, the nearest tissue external to the cervix— that is, the cellular tissue in Avhich the vessels run—will first catch the inflammatory process, and perimetric cellulitis will be the chief, perhaps the exclusive, secondary affection. Another illustration of this proposition may be found in the history of epithelioma of the cervix. This disease in its progress long respects the body of the uterus ; as it extends, it involves the perimetric cellular tissue, and it is often late before the peritoneum is attacked. Perimetric inflammation, apart from pregnancy, is not uncommon as the consequence of suppressed or disordered menstruation. During this function, Ave have in miniature the conditions of pregnancy and labor. The gorged organs, caught in a state of intense susceptibility, are exceed- ingly prone to become softened. Probably, too, in many of these cases there is some exudation of blood into the peritoneal cavity as a primary factor in the inflammatory process. In these cases, dissections of Ber- nutz and Goupil prove incontestably that it is the peritoneum Avhich is the chief seat of inflammation. They found the cellular tissue perfectly free. This is no subject for surprise. Abortion and arrested menstrua- tion differ from labor in this particular: the cervix escapes all traumatic injury ; the seat of functional activity, and therefore of susceptibility, is the body of the uterus, the tubes, and the ovaries. Hence the body of the uterus, the tubes, and ovaries are primarily subject to inflamma- tion, and inflammation of these organs is readily folloAved or attended by inflammation of their investing membrane. 494 PERIMETRIC INFLAMMATIONS. Bernutz and Goupil affirm, and, if I may be permitted to express my OAvn opinion, proA'e, that pelvic peritonitis, acute or chronic, takes its origin, in a vast proportion of cases, in disease of the uterus, tubes, and ovaries ; that peritonitis is, therefore, secondary, symptomatic of other disease. They further maintain that inflammation of the pelvic perito- neum proceeds more frequently from inflammation of the tubes and of the ovaries than from inflammation of the uterus. Although facts enough exist to prove that metritis, acute or chronic, may excite inflammation of the peritoneum, yet it is a remarkable clinical fact that, common as chronic metritis is, the uterus rarely becomes fixed, as it Avould be, were its peritoneum to become inflamed. Although pelvic peritonitis in a large proportion of cases is caused by disease of the uterus, tubes, or ovaries, or is secondary upon pelvic cellu- litis, it is nevertheless true that there is a large class of cases in Avhich this membrane is the seat of primary inflammation. For clinical purposes it is important fully to recognize this distinction. The history of the two orders of cases is often strikingly contrasted. The secondary form fol- lowing upon diseases of the pelvic organs is of course preceded by the symptoms which belong to those diseases ; the peritonitis is an epiphe- nomenon, declaring itself in the course of another disease ; its special characters often make their appearance .gradually, even insidiously, being for a time masked by those of the original disease. On the other hand, the primary peritonitis makes its appearance suddenly; it is ushered in by acute and severe symptoms, often by shock or collapse, and other signs of traumatism or local injury. Such is the history of peritonitis caused by the escape of offending matter from the Fallopian tube, either running from its fimbriated extremity, or from bursting or perforation of its walls ; from bursting or perforation of an ovarian cyst or abscess ; from rupture of the uterus, or of an extra-uterine gestation-cyst; from effusions of blood into the peritoneum; from perforation of the intestine ; from perforation of a dermoid cyst. Even in some cases of this class the symptoms are not marked by sud- denness of invasion or by great severity at first. For instance, Avhen an ordinary ovarian cyst or a dermoid cyst undergoes perforation, the amount of irritating matter escaping into the peritoneal cavity may be small and the consequent peritonitis will be limited and subacute. Pelvic peritonitis may, like inflammation of the peritoneum of the ab- dominal intestines, arise from 1, tubercular ; 2 cancerous ; or 3, traumatic affections. Encysted serous peritonitis may appear to be, and sometimes is, asso- ciated Avith antecedent pelvic disease. The connection of some unilateral pelvic or abdomino-pelvic abscesses with a pelvic origin is sometimes obscure. We make out clearly enough an abscess, and even define its limits ; but dissection only can reveal the cause of the peritonitis, the products of which envelop and shut out from observation the offending disease. This is illustrated in a case related previously, in which a small ovarian cyst was found embedded in a peri- toneal abscess. Perimetric inflammation is rare after the menopause. This fact con- firms the modern view that this inflammation takes its rise almost invari- PELVIC PERITONITIS: 495 ably from the inflamed uterus tubes or ovaries. This proposition, although generally true, is hoAvever often affirmed too absolutely. Malignant dis- ease, especially of the body of the uterus ; chronic metritis, depending upon stenosis or flexion ; the various forms of hypertrophy of the mucous membrane attended with hemorrhage, are very reliable, especially on rough surgical treatment, to lead to perimetric inflammation. It may also result from local violence, such as too frequent subjection to sexual intercourse. Bernutz gives a summary of the cases observed. Of 99 cases of pelvi- peritonitis— 43 were puerperal J 3*> a^er df'7J ^ term 11 ( o after abortion 28 Avere blenorrhagic 20 Avere menstrual 8 Avere traumatic 3 after venereal excess 2 after syphilitic disease of cervix 2 after use of the sound 1 after the use of a vaginal douche But to these causes must be added, the effects of diseases of the uterus, tubes and ovaries, and of the other organs of the pelvis ; the accidents arising during the growth and degenerations of tumors, ovarian, dermoid or other. Peritonitis meretricum; gonorrhoea! peritonitis.—When gonorrhceal infection is the starting-point, the course is usually as folloAvs:—The poison, acting first at the point of contact, lights up inflammation of the vaginal and cervical mucous membrane. This spreads to the mucous membrane of the body of the uterus, thence along the Fallopian tubes. The ovaries are very commonly engaged. In the case of gonorrhoea, Dr. MatthoAvs Duncan says " he has neArer seen pelvic inflammation come on without the presence of ovaritis in addition, and as the ovaritis follows the endometritis, so the latter is itself a consequence of the original vagi- nitis." In some of these cases, proof has been obtained that the perito- nitis Avas immediately caused by the escape of infected pus from the fim- briated ends of the tubes. But in many cases, probably, the peritoneal coat of the tubes and ovaries becomes inflamed, consequent upon the in- flammation of these organs. Mr. Giles1 relates three cases in which peritonitis, the result of gonor- rlnea, broke out after childbirth. It must not, however, be concluded the that peritonitis of prostitutes is always traceable to infection. In many instances there can be little doubt that it is due to the Avilful suppression of menstruation by the local application of cold, and to other forms of exposure and violence. In this place reference must be made to the doctrine of " latent gonor- rhoea" set forth by Dr. Emil Nceggerath.2 He submits that gonorrhoea apparently cured, may persist in certain sections of the organs of gene- ration, in the male as in the female, for life, constituting " latent gonor- rhea ;" .that in this form it may infect a healthy person with acute ' British Med. Journal, 1871. 2 American Gynaecological Transactions, 1876. 490 COURSE OF. gonorrhoea or gleet; and that in the female it may pass from the latent into the apparent form, and give rise to acute, chronic, or recurrent peri- metritis or ovaritis. It is obviously difficult to prove or to disprove how far this doctrine can be substantiated. 1 cite it, believing that it has at least an apparent basis in facts ; and that the subject is worthy of further investigation. Course.—When the opportunity occurs of examining the subject of pelvic cellulitis in the early stage, Ave may find a lax condition of the connective tissue ; its meshes infiltrated with serum, lemon-colored, and limpid, or turbid and broAvnish, from being stained Avith blood or mixed with pus. When the affection is the result of labor, there is commonly ecchymosis from the rupture of small vessels. At a later stage, the Avatery part of the serous effusion has disappeared; there is a firm, more or less circumscribed tumefaction, which on section exhibits reddish points, and evidence of hyperplasia. In some cases, comparatively rare, pus is found in the phlegmonous SAvelling. But almost always Avhen this is the case the peritoneum is involved, and the appearances are lost in those characteristic of peri- tonitis. The chief character of peritonitis, of course, is plastic effusion. But this is preceded by intense vascular injection of the membrane. It is bright with punctate, stellate, and arborescent injections, and it is often uniformly red. The membrane has lost its glistening smoothness ; it looks villous or granular. This condition probably lasts only a few hours. Plastic lymph is quickly throAvn out over the A\*hole inflamed membrane, and glues opposing surfaces together. It is common to find the ovaries and tubes enveloped in a mass of yellowish lymph, more or less solid, and united to the peritoneal lining of the iliac fossae, the summit of the bladder, the anterior Avail of the loAver part of the abdomen, and the front of the rectum. The fundus of the uterus is the part that most frequently escapes. As in life this part can often be felt and made out distinct from the firm tumefactions on either side or behind it, so after death we often find it cropping out comparatively unaffected from the fibrinous conglomerations of the sides and holloAV of the pelvis. At a stage more advanced in progress, but often even earlier in point of time, evidence, more or less extensive, of suppuration will be found. Where there was a septic factor, the lymph may be found in flakes, dirty red or yellow, adhering loosely to a dull-red peritoneum; easily breaking doAvn, this lymph will be seen pultaceous, semi-fluid, purulent. In the half-circumscribed cavities formed betAveen the imperfectly-adher- ing peritoneal surfaces, a dirty turbid serum collects ; or, in some cases, the lymph seems to have no plastic property at all; then on being opened streams of dirty serum and pus Aoav out from the general peritoneal cavity. In the stage of recent effusion, the parts can be separated by breaking dowm the still soft agglutinations. The ovaries or tubes or uterus, in which the inflammation probably began, Avill then be seen red or dull on their peritoneal aspect, generally SAvollen beyond their normal bulk, and fuller of blood. At a later stage, but still not remote from the beginning, PELVIC ABSCESS. 497 the effusions found will be increased in bulk and solidity. The organs, especially those of the pelvis, will be so buried in the consolidated masses of effused matter, that only by tedious dissection can they be traced and isolated; often the ovaries will be glued to the posterior Avail of the uterus. If a case in life correspond to the above description, recovery by reso- lution may still occur. The SAvelling seems to melt aAvay, and the only post-mortem evidence of Avhat has gone before are dull-Avhite strings or bands tying the ovaries and tubes to the sides or posterior surface of the uterus, or to surrounding structures. Perimetric or Pelvic Abscess.—In many cases suppuration takes place. Various estimates, fairly open to all the objections that invali- date most statistical operations performed upon pathological histories, have been made to express the proportion of cases Avhich end in suppura- tion. It is certainly large, probably much exceeding those Avhich end in resolution. McClintock, out of seventy-seven cases of puerperal pelvic cellulitis, found thirty-seven end in suppuration, Avith discharge of pus; tAventy-four burst or Avere opened externally ; six discharged through the vagina ; five through the anus ; and two burst into the bladder. The termination in suppuration is liable to be overlooked. Pus escaping into the rectum, or even into the vagina, may not be noticed, or, if observed, may not always be set doAvn to the right source. These undetected suppurations naturally go in a statistical table to swell the number of cures by resolution. The clinical physician Avill form a much more correct prognosis as to the advent or not of suppuration, by weighing the characters of the case before him. If there be septicaemia; if the patient be of strumous or lymphatic diathesis ; if she be reduced by hemorrhage ; if, in short, the individual conditions be of a depressing kind, the probability of suppu- ration is vastly increased. Generally, but not always, in this event a fresh increment of the febrile symptoms is observed. Shivering or rigor occurs ; the pulse is subdued in power ; sometimes vomiting is excited. These mark the first entry of septic matter into the circulation, and constitute the stage of shock. The characteristic is depression. Then come the signs of reaction. The pulse is accelerated, the temperature rises. If the amount of septic empoison- ment be great, signs of attempt at elimination appear. The poison, carried like almost all poisons to the intestines, irritates the mucous membrane and causes diarrhoea ; and perhaps vomiting is again excited. This is the stage of irritation or elimination. If only one moderate dose of the poison is imbibed, the signs of constitutional irritation quickly subside ; but if, as often happens, fresh doses continue to be imbibed, the symptoms of shock, reaction, and elimination will recur in regular order. This dependence upon the repeated dosing with, or accumulation of poison, is remarkably proved by the cessation of these signs when the purulent collection bursts or is artificially opened, or the case merges into chronic septicemia. The aspect becomes dull, earthy ; the patient emaciates; loses appetite ; she is harassed with irregular attacks of shivering and flushes ; prostration advances. This state may be protracted through many Aveeks. 498 PELVIC ABSCESS. Suppuration goes on, in many cases for tAvo or three or four weeks before the pus breaks through its investing sac. This event is achieved in one or more of three chief directions : 1. through the skin ; 2, through a mucous membrane ; 3, into the serous sac of the peritoneum. In some cases imperfect and temporary relief only is obtained on the discharge of pus. The hard tumefaction in the pelvis subsides but slightly. Hectic or irritative fever continues. Pus continues to Aoav in more or less remittent or intermittent discharge ; and sometimes successive puru- lent collections form, and burst at intervals, extending over weeks, months, and even years, until the patient sinks exhausted. In some cases of this class, happily the most frequent, the suppurative action at length ceases, the cavities contract, the solid deposits gradually become absorbed, and the recovery may be complete, even the adhesions disappearing. The rigors cease when the pus finds an external vent. But patient and physician must be prepared for a tedious course of treat- ment. Where the septic element has been inconsiderable, and especially Avhere the inflammation has been excited by disease of the tube or the ovary proceeding sloAvly, or only inflicting upon the peritoneum a succession of slight injuries, repeated at long intervals, the pelvic organs may, as in more acute cases, be found embedded in thick masses of hard braAvny effusion, involving the rectum and the superincumbent small intestines and omentum. This condition may last, kept up or extended by occa- sional accessions of fresh inflammation, for many months, or even years. This is the case especially when the inflammation is excited by a diseased ovary, cystic or dermoid. But sooner or later, under the irritation of the advancing disease, or of some accidental intercurrent cause, suppu- ration comes on. The pus forming in the substance of the effused mass, commonly beginning at the surface or in the substance of the diseased organ—by a process incident to the disease, one of the events of which is bursting or perforation—forms an abscess, or a congeries of purulent collections. Up to a certain time an abscess thus formed may be fairly encysted or isolated by effusions which shut it off from the healthy por- tion of the peritoneal sac. The imprisoned pus may even undergo a transformation which ends in absorption. But in the majority of cases the sac of the abscess, extending its adhesions by eccentric action, effects a consolidation with some structure through which a communication can be made with the exterior. Thus a pelvic abscess will make its Avay to the external surface through the skin, or into the intestine, bladder, vagina, or rectum; or unfortunately failing in these directions, it may perforate its OAvn sac, and pour its contents into the peritoneal cavity. In this latter event we shall have the ordinary phenomena of " abdominal shock," often fatal speedily; and if not so, then followed by peritonitis, from which the patient may or may not recover. If the pus work its way out by the skin, the place of election is most commonly the iliac region above Poupart's ligament. Before this hap- pens there will have been a history of irritative fever, marked generally by rigors more or less distinct; by small pulse, ranging from 100 to 120 ; by temperature running up to 101° F., 102" F., or l03c F. ; by SAveats; occasionally by diarrhoea. The hard, someAvhat elliptical mass, becomes SUPPURATION. 499 softer, doughy ; near the skin, a patch at first red, then bluish appears ; fluctuation becomes distinct; and then, if the abscess be not opened, it bursts. Sometimes the abscess points nearer to the median line below the um- bilicus. This is more likely to be the case if the cause of the peritonitis be a dermoid ovarian cyst. AVhere the inflammation takes its rise deep in the pelvis by the side of the vagina, it will sometimes find an exit by the outlet of the pelvis through the perineum. I have seen several ex- amples of this in puerperal cases. In these the evacuation has been pre- ceded by great distress from the intra-pelvic pressure on the bladder and nerves. It has also made its Avay by the sacro-sciatic notch, or by the side of the anus. I believe, however, the route most frequently selected is the Aragina. An opening is made through the roof, mostly behind or to one side, more frequently the left, of the cervix uteri. This issue, as Avell as that by the rectum, is sometimes overlooked. The pus escaping perhaps gradu- ally is not distinguished from the other discharges. When the inflamma- tion is retro-uterine, the pus will almost ahvays make its Avay by the roof of the vagina or by the rectum, just as a retro-uterine haematocele will do. I have known one or tAvo cases in Avhich the abscess opened into the cervix uteri. Occasionally abscess after abscess points in different places, or sinuses keep open, and continue to drain off the secretions formed in the suppu- rating cavities. These cavities seem to be prevented from closing by the rigid walls composing them being fixed to the sides of the pelvis or to the intestines. An exhausting suppuration then goes on, lasting for months and even for years, until the sufferer sinks from inanition, the wear and tear of pain, and the gradual impairment of vital functions. These cases of protracted suppuration are, I believe, mostly the result of inflamma- tions set up by the perforation of ovarian cysts, or of an extra-uterine gestation cyst, or a dermoid cyst into the vagina or the rectum or some higher part of the intestine. The issue is not seldom fatal. But 1 have seen similar cases which folloAved upon labor and abortion, after surgical operations upon the uterus, and after Avearing a fixed intra- uterine pessary. The protracted intermittent course of some of these suppurating cases is partly explained by the multilocular character of the abscesses or suppu- rating cavities. These burst successively. Perhaps the suppuration in one compartment sets up suppurative action in the rest, and so on. Hoav these multiple abscesses form is probably accounted for by the irregular shape and the movements of the organs Avhich form the framework or scaffolding of the peritonitic effusions. The intestinal fold and convolu- tions form endless recesses and projections, and the plastic layers Avhich invest them Avill follow, to a great extent, these recesses and projections; Avhilst the incessant vermicular movements and the alternations of disten- sion and collapse of the coiled intestinal tube, acting whilst the effused matter is still soft, Avill leave irregular spaces, divided partially or com- pletely by septa running in various directions. These hollo av irregular spaces will in the first place be filled Avith serum, or sero-purulent fluid, which at a later time is replaced by pus. When the solvent process of 500 PELVIC INFLAMMATIONS: suppuration has set in, the septa gradually break doAvn ; the pus-contain- ing spaces are fused together more or less completely. But the process is tedious, and it may be long before it is complete. This irregular multilocular arrangement will also account for the fact that perimetric abscesses sometimes open in several directions, thus Ave may see an abscess first make an exit at the iliac region; then, succes- sively, it Avill burst in the rectum and vagina. When such abscesses Avith thick walls, not capable of collapsing under atmospheric pressure, burst or are opened, air is sometimes drawn in. Decomposition of retained pus and blood ensues, so that the discharge becomes extremely offensive. The sac, which hitherto emitted a dull sound on percussion, will noAV be resonant. To a certain extent, often effectual, pressure by Avell-regulated compresses Avill supplement the fail- ure of atmospheric pressure, in keeping the Avails of the empty sac in contact. One possible termination, happily rare, of which I do not remember having seen an unequivocal example, is sloughing or gangrene. Grisolle1 describes it as folloAvs: " Gangrene is scarcely ever observed except in abscesses consecutive to mortification of the caecum or of its appendix, and to the escape of stercoraceous matter into the neighboring cellular tissue. I do not believe that gangrene has ever been observed in ab- scesses of spontaneous origin, which are developed in the sub-peritoneal cellular tissue. If, on the contrary, the inflammatory engorgement, al- though spontaneous, is subjacent to the fascia iliaca, this may produce there a true strangulation of the inflamed parts ; and it will be sufficiently common to see in those sub-aponeurotic abscesses the fibres of the iliac muscle blackish, softened, and exhaling a fetid odor. No symptom can produce a sure diagnosis of this unfortunate termination ; but, Avhen issue is given to the effused matter, it exhales a fetid odor, and brings with it gas, feces and bits of cellular tissue, of muscles, and of mortified ten- dons. One can understand that death should be the consequence almost inevitably of such disorders." I, however, once tapped an encysted serous peritonitic effusion giving issue to a small quantity of fecal matter, foul gas, and horribly stinking serum, which ended in recoArery. Matthews Duncan mentions as one " peculiarity of pelvic, and proba- bly of perimetric abscess only, that some have no tendency to burst at all. He has repeatedly opened such abscesses, whose existence certainly dated several years before his seeing them, and which showed no ten- dency to point in any direction." Such abscesses are occasionally found in the dead-house. One Avas observed in a Avoman who died shortly after admission into my ward at St. Thomas's. I had recognized in her a pelvic peritonitis six years before. The inflammation and suppuration were found to have arisen around a dermoid cyst. The course that perimetric inflammations run, and the pathological ap- pearances will vary according to the parts involved, the complication with, or absence of, septicaemia; the diathesis or constitutional state of the patient; the treatment and other accidental circumstances. Arch. Gen. de Medecine, iii. sene, tome iv. COURSE OF. 501 In puerperal cases, perimetric inflammation, including cellulitis, is especially prone to arise in Avomen of strumous diathesis. The same sub- jects are particularly prone to inflammation and abscess of the breast. I have little doubt, although I have not made out the fact with equal dis- tinctness, that the same diathesis also disposes powerfully to like inflam- mation in the non-pregnant state. In women of this constitution lymph is rapidly and freely throAvn out, forming large tumefactions. The effused matter, more readily than in sound constitutions, degenerates into pus. Dissections at different stages of perimetric inflammation appear to me to prove that it is not ahvays, perhaps not even generally, the plastic or seini-coagulated lymph which, in the first place, is transformed into pus. There is commonly a considerable quantity of thin serous fluid Avhich be- comes inclosed by the plastic effusion, forming a cyst single or many- celled around it. It is this serous fluid Avhich forms, as it were, the focus of the phlegmon Avhich becomes turbid and purulent. Very soon no doubt the innermost layer of the plastic investment breaks doAvn in part, and contributes to the purulent collection, helping to form the abscess. That this plastic investment does give Avay is proved by the abscess bursting or perforating. The effusion sometimes takes place with great rapidity, as in the fol- loAving not rare case : A young lady, Avho had been delivered of her first child about two months, and had returned to usual avocations, took a long walk, came home fatigued to her husband, Avas next day seized Avith in- tense pain in the loAver abdomen and vomiting ; constipation and tympa- nites folloAved. On the fifth day, I found the uterus set fast in a mass of firm effusion; the boAvel also Avas so compressed that there Avas nearly complete obstruction for nine days. Under rest, opium, and enemata, she got well. In a number of cases, very difficult to estimate, the inflammation termi- nates in resolution. The effused consolidated masses of plastic matter gradually disappear. As this process goes on, the uterus recovers its mobility, if not entirely, to a great extent. The finger begins to travel around the vaginal-portion. The subjective symptoms become moderated. This process usually takes several Aveeks, even months, for its comple- tion. In a considerable proportion of cases I have seen the Avhole pro- cess completed in eight, ten, or tAvelve weeks. But the last stage often lingers longer still. In not a feAv cases, when the bulk of the effusion has melted away, there remain cellular adhesions Avhich may restrain the movements of the uterus, and bind it doAvn in various directions. Thus, adhesions betAveen uterus and bladder Avill produce anteversion; adhesions in the retro- uterine pouch Avill produce retroversion ; and Ave may find lateral inclina- tion from ovario-uterine and alar adhesions. These adhesions undoubtedly often practically disappear—that is, under the constant strain of the pelvic organs in their functional movements, the adhesions incessantly stretched undergo atrophy complete or partial, so that they no longer impede the uterus. In the case of retro-uterine adhesions, I have often accelerated their atrophy by the use of a lever-pessary, which, lifting up the fundus uteri, puts these bands on the stretch. One very efficient cause of their 502 PELVIC INFLAMMATIONS. disappearance is pregnancy. The uterus enlarging, drags and attenuates them, so that they undergo atrophy. On the other hand, they sometimes last an indefinite time, binding the uterus doAvn in various abnormal posi- tions, impeding this organ in its natural movements, and thus leading, as Madame Boivin insisted, to abortion. The ovaries, Avhich possess much more limited natural movement, and are, moreover, smaller and less rigid bodies, are not so capable of exerting a strain upon adhesions, and are consequently more frequently doomed to perpetual bondage. Aran examined fifty-three Avomen Avho died in his wards with reference to this point. He found adhesions in twenty-nine. The adhesions were tAvice as common in Avomen Avho had had children as in Avomen Avho had not. These, of course, are selected cases dying in a special gynaecologi- cal Avard, and cannot represent the general proportion of adhesions. I have had the opportunity of watching the course of several cases of adhesions with requisite precision. A young Avoman Avas admitted into my ward with retro-uterine haematocele. The blood-mass made its way through the roof of the vagina, and on several occasions Ave saAv blood oozing through the opening. I passed a probe three inches into it. When the opening closed the tumor gradually disappeared, and it was found that the body of the uterus was pulled back, and held in that position by adhesions. Six months later the uterus had nearly recovered under the gradual lifting action of a Hodge-pessary. When the uterine adhesions are persistent and short, binding the uterus doAvn tightly, they may be the source of severe pain. They may keep up congestion or chronic metritis. And so long as adhesions remain there is a liability to reneAved attacks of peritonitis. This disposition to relapses, or the " redoublements" of French authors, is ahvays to be borne in mind in the antecedent stages Avhilst the inflammatory effusions are still thick and hard. The symptoms of perimetric inflammation are generally compound. In order of time, signs of disease of the uterus, tubes, or ovaries commonly take precedence. Then follow those of perimetric inflammation. And these are for the most part severe enough to overwhelm and obscure those of the original disease. This addition of perimetric inflammatory signs is usually more or less sudden. It is marked by acute intra-pelvic pain ; more or less shock, according to the cause ; acceleration of pulse to 120 or 130 ; heat of skin, the temperature rising to 103° F., 104° F., or even 105° F. There is a sense of fulness and pressure, sometimes of bearing-cloAvn. The bladder and rectum are often disturbed in their functions. Tympa- nites, the result of a kind of paralysis of the intestines Avhose peristaltic movements seem to be instinctively restrained in order to avoid pain, is a common symptom. This induces constipation, Avhich is further caused by the narrowing by compression of the rectum, and by the inability to exert effectually the expulsive movement necessary to defecation. Some amount of dysentery is not uncommon. Colic pains, tormina, flatulence, are often exceedingly distressing. The bladder symptoms are often distressing, but are not constant. There is dysuria, frequent call to pass Avater, an unsatisfied sense of the bladder not being emptied. This distress is partly due to the interference DIAGNOSIS. 503 with the contractile action of the bladder, and with the abdomino-pectoral act of expulsion, and partly to the irritating quality of the urine. This is often loaded Avith lithates and mucus. If an abscess be about to burst into the bladder, the dysuria increases, and not uncommonly there is re- tention of urine. When the bursting has been effected, of course pus will be voided with the urine. Retention may also precede the bursting of an abscess into the rectum or vagina. The ovario-uterine function is variously affected. Sometimes there is metrorrhagia. This is especially the case Avhen there is concomitant metritis or sub-involution of the uterus Avith abrasion of the mucous membrane of the cervix. But, not uncommonly, even in post-partum cases, in Avhich sub-involution is a tolerably certain attendant condition, menstruation is scanty or suspended. The secretion of milk is generally suspended either quickly or gradu- ally. In spite of the mother's anxiety to keep it up, it falls off; it is rather exceptional for it to last out the course of the disease ; and still more rarely is it judicious to make the attempt. When the seat of the inflammation is in one side of the pelvis, the thigh is commonly kept slightly flexed to relieve the pain Avhich extension by stretching the inflamed structures produces. This causes the patient to limp on the affected side Avhen walking. This lameness is so character- istic that I have often diagnosed lateral pelvic inflammation to my class on seeing a Avoman enter the consulting-room with the anaemic aspect following parturition, and this painful limp. In some cases the patient finds she cannot get the heel to the ground. In not a few cases one or both legs SAvell soon after labor, constituting the earliest sign to attract attention. Sciatica on the side of the effusion is a symptom I have several times observed. In one the pain along the sacral plexus of the left side Avas very severe, and underwent exacerbations marked by recurrent suppura- tions, over a period of twelve years. The sciatica disappeared when the disease Avas cured. When suppuration is proceeding, the sense of intra-pelvic tension and of pain is increased. In some puerperal cases I have observed pelvic inflammation to be complicated with metritis. This indicates, I believe, a strumous or leuco- phlegmatic diathesis. . The Diagnosis.—The objective signs are made out by abdominal, vaginal, and rectal touch. Palpation over the lower part of the abdomen, especially if the hand be pressed into the pelvic cavity, gives rise to acute pain. There is often some degree of tympanites; and almost always tension of the abdominal muscles, excited by the dread, even more than by the act, of examination. In the early stage no very marked tume- faction or irregularity may be felt in the pelvic brim; but very soon a firm mass, more or less rounded or cylindrical, is made out in one or other, or in both sides of the pelvic brim ; the hand encounters resistance in the attempt to pass it into the pelvis above Poupart's ligament; as the disease continues, this tumefaction extends out of the pelvis, spreading laterally and forwards into the iliac fossae, bulging out above Poupart s lio-ament, and sometimes rising as high as. the level of the umbilicus. 504 PELVIC INFLAMMATIONS. Fig. 106. This swelling is hard, brawny, tolerably uniform, cylindrical. At an early stage the skin can be moved over it; but later, especially if the process be tending to suppuration, the abdominal Avail becomes one with the tumefaction underneath. The shape and limits of the tumor rising out of the pelvis can usually be defined by the hand pressing in the abdominal wall above, and getting even a little way behind the tumor. By percussion the evidence thus obtained may be checked and extended. An area of dulness will corre- spond with the tumefaction behind the abdominal wall, Avhilst resonance will disclose the position of the intestines. The vaginal-touch gives the most decisive evidence. The examining finger entering the vagina is first conscious of increased heat and puffiness of the Avails. The os uteri is reached much more readily than in the ordinary state, because an almost invariable effect of the perimetric in- flammation is to bring the uterus doAvn to a lower level. The situation of the os uteri is usually near the centre of the pelvis. This is the case Avhen the chief seat of inflammation is in the broad ligaments or in the sides of the pelvis. If one side be chiefly affected, the cervix may be pushed over towards the opposite side. But if the case be one of retro-uterine cel- lulitis and peritonitis, the uterus is pushed bodily forwards, coming some- times so close to the symphysis pubis as to compress the neck of the blad- der, and cause retention of urine. In post-puerperal cases the os uteri is generally more or less patulous. Surrounded as it is by inflammatory effusion, contraction and involution are impeded. Feeling round the margin of the os uteri, we commonly fail to define accurately the usually projecting vaginal-portion. Instead of the hemi- spherical or conical smooth mass, merging at the fundus of the vagina into soft yielding tissue, Ave find hard braAvny bumps occupying the sum- mit of the vagina, encircling the os down to, or even beloAV its level, pre- venting our feeling any portion of the cervix. If the inflammation be general, that is what is felt. But if the inflammation be unilateral or anterior or posterior only, the inflammatory swelling projects in the cor- responding part only, leaving the remaining part of the circumference of the cervix accessible to the finger; and the uterus will be fixed on the side of the swelling. This is represented in Fig. 106, from a case under my care. When the inflammation is limited to the peritoneum of the body of the uterus and the utero-vesical reflection—and I have seen several such cases, strictly " perimetritis"—the adhesions contracting in the chronic stage pull the fundus doAvn in nutation; the os uteri is throAvn up and backAvards in the contrary direction, so that it is actually higher than Representing the Collar of Hard Inflamma- tory Effusion encircling the Cervix Uteri. (R. B.). DIAGNOSIS. 505 normal. And since the mass of cellular tissue between the cervix uteri and the base of the bladder may not be affected, the finger is free to travel all round the vaginal-portion in front as Avell as elseAvhere. But by pressing a little firmly in the anterior vaginal roof we are sure to come upon a firm resisting plane or prominence, which is caused by the inter- utero-vesical consolidation. Fixing or immobilization of the uterus may generally be accepted as a sign of peritonitis Avith adhesive effusions. In the case of localized cellu- litis, especially in the utero-vesical connection, the uterus may move alone with the phlegmonous mass and the bladder. In the case of retro-uterine peritonitis, the tumefaction or rather tumor formed by the effused lymph and serum, may attain considerable magni- tude, pushing the uterus forward, rising above the fundus of this organ, and coming Avithin reach of the fingers applied above the symphysis pubis. In not a feAv cases, eAren, the peritoneal investment of the opposed intestines and omentum being caught, a large firm tumor may be formed, reaching to the umbilicus and e\ren higher. This is especially the case Avhen the peritonitis is caused by a retro-uterine haematocele. When the inflammation is unilateral, I have often been struck with the sensation of a firm, almost knife-like, or rather " hog-back" ridge, run- ning from the edge of the os uteri across to the side of the pelvis. In these cases, in the adhesive stage, the fundus uteri is pulled tOAvards the affected side. The sound, although not generally necessary, often lends precision to the investigation. For instance, when adhesive inflammation prevents the finger in the vagina, or hand above the pubes from tracing tbe form and position of the body of the uterus, this being concealed in a mass of firm effusion, Ave cannot easily tell Avhether a hard rounded mass projecting the posterior roof of the vagina be the retroflected uterus or a retro- uterine mass of inflammatory deposit. The sound at once puts us right by defining exactly the course of the uterus. The sound in the uterus thus serves as a central axis from Avhich we may estimate the relations, bulk, and nature of all the surrounding structures. It also enables us to test more closely the degree of mobility the uterus enjoys. The sound being in the uterus, on depressing the fundus or the inflammatory mass above the pubes, any movement imparted is clearly seen and felt by the descent or obliquity communicated to the handle of the instrument. Mo- bility en bloc is preserved in a modified degree until the adhesions extend to the Avails of the pelvds. When suppuration has taken place and the abscess is pointing in the roof of the vagina, Ave may feel a part Avhich before had been hard, braAvny, become soft, permitting the tip of the finger to sink in, and immediately to bulge again as pressure is taken off. This is fluctu- ation. The pointing spot, soft and prominent, is surrounded by a hard mass. Rectal touch furnishes valuable assistance. It checks and extends the information obtained by abdomen and vagina. The finger, coursing along the anterior Avail of the rectum, can reach considerably above the level of the os uteri. If the case be one of inter-utero-vesical cellulitis, the finder can explore the posterior wall of the uterus, determine its condi- 506 PELVIC INFLAMMATIONS. tion, and ascertain if it be bent or straight, free or not from tumor. In the case of lateral cellulitis and peritonitis, the finger can commonly feel above the loAver margin of the inflammatory swelling projecting into the vagina, and even trace it as a curved ridge across to the sides of the pelvis. Combined with abdominal palpation, the size, position, and rela- tions of the uterus with the surrounding inflammatory swellings can often be defined. The finger, having reached the level of the os uteri, comes upon the hard peri-uterine tumefaction; it is commonly compelled by the back- ward projection of this tumefaction to be directed backAvards into the holloAV of the sacrum, folloAving the globe Avhich carries the anterior Avail of the rectum against the posterior wall. In this way we sometimes find the rectum remarkably compressed, and its calibre contracted. Tracing the inflammatory SAvelling to the sides of the pelvis, Ave find the pelvic structures, those of the broad ligament especially, fixed to the pelvic Avail, perhaps on either side of the rectum, by adhesive effusion forming a collar through Avhich the rectum passes. Four varieties of peritonitis in many points resemble pelvic peritonitis, and, indeed, frequently are associated Avith it. One is perityphlitis ; the second, a localized adhesive peritonitis, occupying one iliac fossa ; the third, peritonitis of the loAver part of the abdomen connected with can- cerous affection of the pelvic organs and lumbar glands ; the fourth is tubercular peritonitis, Avhich may have its first and chief origin in the pelvic hypogastric regions. In the case of perityphlitis, the tumor is ahvays on the right side ; it is higher, generally, than inflammations springing from the pelvis ; it rarely passes beyond the median line, and does not extend into the pelvic cavity; and the greatest bulk or diameter of the tumor is above the pel- vis, Avhereas in pelvic peritonitis, the supra-pubic portion of the tumor can be traced doAvmvards into the pelvic brim, and by combining vaginal touch is felt to be a part of inflammatory masses in the pelvis. The localized peritonitis of the hypogastrium is also distinguished by its not penetrating the pelvic cavity. And in both these cases the mobility of the uterus is commonly preser\red. The cancerous inflammation in many cases takes its rise in malignant disease of the ovaries; and especially when the lumbar glands are in- volved. In this case the disease is not so often localized or encysted. Dropsy of the peritoneum not seldom attends. The signs of the can- cerous cachexia will rarely be absent. But at certain stages of either disease vaginal examination may lead into error. Before the ulcerative tage of cancer has commenced, and therefore before the malignant cachexia has become marked, the uterine neck may be found set fast in the roof of the vagina by surrounding deposit, hard in some cases to distinguish from the deposit of simple inflammation. There are features of differentiation. In malignant disease of the vaginal-portion, in the first place, the history will generally be different; the disease has come on insidiously; its early stages have probably escaped observation; whilst in perimetric inflammation the starting-point is usually labor, abortion, a chill, accident, surgical operation, or other Avell-defined ante- cedent. In malignant disease, the perimetric effusion is usually pretty DIAGNOSIS — TREATMENT. 507 uniform, that is, it extends all round the vaginal-portion, catching the bladder ami rectum ; whilst in inflammation the deposit is often unilateral or anterior or posterior, causing deviation of the os uteri from its central position, and permitting the finger to touch a part of the circumference of the cervix, and ascertain that it is smooth. When these points are made out, the diagnosis of perimetric effusion is sufficiently decisive. But occasionally cancer is first noticed shortly after a labor; and not seldom inflammatory deposits encircle the vaginal-por- tion all around. In these ambiguous conditions, Ave must fall back on individual tactus eruditus ; and noAV and then Ave must suspend our judg- ment, Avaiting for the more characteristic changes which time will cer- tainly bring. That there is a difference in the feel of a cancerous os uteri and its entourage and that of inflammatory effusion is certain. The first is more nodular, perhaps harder, " stony ;" the disease, in short, may be traced to the cervix uteri itself, as its centre of departure, whilst this part is only engorged, abraded perhaps in the second case. But it is difficult to describe the tactile sensations produced by degrees of solidity and shape. Practice alone can teach the finger to recognize them. A difference Avorth remembering is, that cancer makes a hard cervix, whilst pelvic cellulitis or peritonitis makes hard masses round about the cervix. Cancer begins in the cervix ; inflammation is peri-cervical. The chief objective characters of perimetric inflammation are described with accuracy and point by Doherty.1 " On introducing the finger into the vagina Ave find the hardness, so remarkable in the iliac fossa, has ex- tended to the roof of the vagina, Avhich is tender to the touch, and as firm and inelastic as a deal board—a condition which must immediately arrest our attention. Not the slightest impression can be made on it by our pressure, while Ave may observe that the uterus is bound down to the affected side, either throughout its whole extent, by Avhich it suffers a lateral displacement, or only partially, so that the fundus is draAvn in one direction, Avhile the os tincae is turned in the opposite." An observation of Aran is important. He says small perimetric in- flammatory SAvellings may have their seat in the sub-peritoneal cellular tissue ; but the voluminous swellings are the result of perimetric peri- tonitis. The subject of diagnosis may be appropriately concluded with the cau- tion not to pursue it at the bedside Avith too much diligence. By insti- tuting repeated and minute explorations it is very easy to do harm—more than enough to counteract any good which the knowledge thus derived may enable us to apply. Nothing in the treatment is so necessary as " rest" of the affected parts ; ami examinations mean disturbance. The treatment, like that of metritis, must vary according to the types of the disease and its complications. If the result be puerperal metritis associated with septicaemia, the treatment of the perimetric inflammation is simply subsidiary to that of the puerperal fever. In the more purely inflammatory cases, whether post-puerperal or not, leeches, to the num- 1 On Chronic Inflammation of the Uterine Appendages occurring after Parturi- tion. 1S43. 508 PELVIC INFLAMMATIONS. ber of tAvelve or twenty, to the groins and hypogastrium, will generally be useful in the early stage. Fomentations or moist warmth applied by a large thick linseed-meal poultice or spongio-piline are of material ser- vice. In many cases I have seen leeches, calomel, and opium do good. A pill of one or tAvo grains of calomel Avith half a grain of opium may be given every four hours for twenty-four hours ; and then every six or eight hours for a day or two longer. If there is any disposition to diar- rhoea the calomel may be reduced, and the opium increased. Or, in some cases, I have been better pleased with pills or powders consisting of three grains of gray powder and five grains of Dover's poAvder. An obstacle to this and other treatment, hoAvever, often exists inobsti- nate nausea, hiccough, or vomiting. To subdue this sympton is the first necessity. Bismuth, hydrocyanic acid, pepsine, creasote, ice, soda- water in various combinations, will be useful. To allay fever, the acetate of ammonia and nitrate of potash with a sedative answer best. In the more chronic stages, Avhere there is no obvious process of sup- puration or pointing, blisters applied to the groins and hypogastrium are often of great service. In the same stage iodide of potassium becomes extremely serviceable, and may be combined Avith bark in decoction or tincture. The question as to opening abscesses does not seem to demand much discussion. Not seldom Nature sohres it for herself. The abscess bursts into the rectum or roof of the vagina without obvious warning ; and generally recovery progresses from that event. It seems to me that these are the easiest routes ; that evacuation by them takes place earlier, and often with less disturbance. This may be partly because the Avails of Douglas's pouch are thinner and more easily perforated than the ab- dominal Avail. At any rate the pointing and perforation of the abdomi- nal wall is often sIoav and painful. The progress of an abscess tOAvards the skin generally makes itself visible by the growing prominence and puffiness of the tumor, its reddening, its fluctuation, and finally by the skin becoming blue and palpably thin. It is possible to err by opening an abscess too soon and too late. If an inflammatory tumefaction be punctured before fluctuation is made out, Ave may fail to find pus ; the incision must be carried deeply through tender vascular structures, and cause serious bleeding ; and the suppuration-process will not be stopped. On the other hand, if we wait until the abscess is on the verge of burst- ing we shall have prolonged unnecesarily the patient's suffering; the blue skin may slough in spite of puncture, and will only heal Avith an ugly scar; and there is the risk of the abscess effecting an opening internally into the peritoneum or in some other direction as well. The proper time for opening an abscess pointing to the skin appears to me to be as soon as fluctuation is clearly ascertained. Incision may be made with a bistoury, or a Syme's knife ; and a drainage tube will be useful. The Avound should not be allowed to close at once, as pus will continue to flow for tAvo or three days at least. I think it is important to keep the cavity of the sac as small as possible, by adjusting compresses in such a manner as to bring the Avails together. If we find fluctuation in the roof of the vagina or in the rectum the TREATMENT. 509 same rule should be folloAved. The puncture may be made by a long sharp-pointed hernia knife, or by a long trocar—for the rectum the long curved trocar used for tapping the male urethra is very convenient. Where there is any doubt as to the presence of pus the fine aspirator- trocar is the proper instrument to use. It is sometimes an advantage to insert a drainage-tube in the case of opening an abscess by the vagina. An excellent and convenient drainage-tube will be found in the winged male catheter. It is easily inserted, by help of a stilet. Thus supported it is carried into the sac, where the end is retained by the wings. Say re's coil drainage-tube ansAvers well. Asa general rule, it is prudent, in the first instance, to tap any pelvic tumor suspected to contain pus or other fluid with the aspirator-trocar. In most cases the fluid, be it pus, serum, fluid blood, or the fluid of an ovarian cyst, can be more completely draAvn off by the vacuum process than by an opening by a bistoury. Thus, the aspirator-trocar, whilst superior as a diagnostic means, is often at least equally a therapeutical agent. And beyond this probable benefit of giving vent to discharge, it is a proved clinical fact that puncture of the indurated inflammatory masses hastens their removal. When an abscess has been opened, and sometimes earlier, quinine generally becomes useful. The diet should be nutritious and supporting. Best Avill still be necessary. At a later period, when suppuration has ceased, quinine may still be useful; but iron noAV comes into service. The boAvels must be kept gently acting. Bed may be changed in the day-time for the sofa; and gradu- ally, but Avatchfully, gentle exercise may be indulged in. If taken too soon, or exceeding moderation, it is ahvays probable, so long as any marked intumescence or diminished mobility of the uterus remain, that a return of inflammation may occur. In the advanced, or confirmed chronic cases, warm baths will render great sendee. The iron-Avaters are not always safe. I believe many experienced physicians have arrived at this conclusion. The best results I have seen have been derived from the Woodhall Spa. The most valu- able medicine in these cases is cod-liver oil. 510 PERIMETRIC HEMATOCELE. CHAPTEE XXI. perimetric hematocele; retro-uterine hematocele; pelvic h.emato- cele; blood-kfi -usions in the neighborhood of the uteris; patho- logical discission : OIIOUPS OF CASES: 1. FROM RUPTURE OF UTERIS, GRAVID; 2. RUPTURE OF ECTOPIC GESTATION-CYST ; 3. RUPTURE OF DIS- EASED OVARIES; 4. EFFUSIONS ATTENDING ABORTION; 5. EFFUSIONS FROM MENSTRUALOI5STRUCTIOX ; 6. FROM ALTERED CHARACTER OF BLOOD ; OTHER CAUSES ; SYMPTOMS AND DIAGNOSIS ; COURSE; TREATMENT. The study of perimetric haematocele most conveniently folloAvs imme- diately upon that of perimetric inflammation. Clinically, the tAvo condi- tions have close relations. Indeed, blood-effusions into the peritoneum almost necessarily entail pelvic peritonitis. And at the bedside the practical difficulty often is to distinguish haematocele from inflammatory effusions. It is certain that until Avithin the last tAventy years, or less, cases of perimetric haematocele Avere confounded Avith inflammatory effu- sions or with retroversion of the uterus. It can hardly be said that haematocele had been recognized as a distinct affection. And even now many men are sIoav to admit the evidence upon Avhich its existence is established, and are consequently unable to appreciate the frequency or the conditions of its occurrence. In 1850 the disease Avas so little known that Malgaigne is reported to have attempted the enucleation of a supposed fibroid tumor of the uterus, Avhich proved to be a collection of blood; and the operation was folloAved by a fatal issue. And Scanzoni says, in his Avork on Chronic Metritis, published in 1863: " We regret not to be in a position from personal experience to speak of this disease, for in our certainly extensive and protracted observation Ave have not been able to diagnose peri-uterine haematocele in a single case." So long ago, hoAvever, as 1831, Recamier described in the Lancette Frangaise, under the name of " Tumeur sanguine du bassin," a very clear case. A Avoman, aged tAventy-eight, after an abortion, had a large tumor formed in the pelvis, behind the uterus, which bulged the vagina forwards. Re'camier, believing it to be an abscess, opened it, but instead of pus, dark, half-coagulated blood escaped. The patient recovered. Velpeau, in his Medecine Operatoire, 1839, published additional cases. He Avas evidently acquainted with the characteristic features of the pelvic blood-SAvellings. In 1850 and 1851 NeTaton, in lectures in the Gazette des Hdpitaux, laid the foundations of the present more accurate knowledge of the sub- ject. It was he Avho proposed the name " retro-uterine haematocele." From this date cases and memoirs, still chiefly emanating from the French school, rapidly multiplied; proving that it was only necessary to look for examples of this hitherto unknown affection with intelligence, in order to PERIMETRIC hematocele. 511 find them. Yigu&s, Fenerly, Aran, Prost, Bernutz, Puech, Nonat, La- borderie, Laugier, Voisin, Gallard, Richet, Goupil, and Trousseau, have all contributed important materials. In England Tilt and West were the first to describe the affection. McClintock has given the best original account in the English language.1 He had published a case in the Dublin Hospital Gazette in 1860. In 1861 Dr. Madge communicated to the Obstetrical Society a very complete report of a case, illustrated by figures, representing the conditions found on dissection, and commented by a valuable revieAv of the subject. Dr. TuckAVell, in 1863, published an important memoir, entitled " On Effusions of Blood in the Neighborhood of the Uterus." This contains an excel- lent historical sketch, a tabular vieAV of ninety-eight cases collected from various sources, and histories of some original cases not before published. In Germany contributions have been accumulating since 1859. C. R. Braun, Alfred Hegar, SaYinger, Seyfert, Olshausen, and others have added materially to the casuistical history of the subject. Bernutz claims to have been the first to demonstrate by post-mortem examination the position and relation that these tumors hold to the uterus. He Avas the first to maintain that many cases directly depended upon re- tention of menstrual blood. The Seat of the Blood-tumor.—The term "perimetric haematocele" is used to define the state of tumor formed by effusion of blood in the neigh- borhood of the uterus. It is more comprehensive than " retro-uterine hematocele," which strictly means a blood-tumor behind the uterus. This latter term is correct as far as it goes. ItAvould be altogether cor- rect if it expressed the whole truth ; that is, if blood-effusions were not liable to occur elseAvhere than behind the uterus. But blood-effusions do occur in other relations to the uterus. To admit these into a general definition Ave want the term perimetric or peri-uterine haematocele ; or perhaps the term " pelvic haematocele," proposed by Dr. McClintock, being more comprehensive, is better still. If we start from the arbitrary definition which some have proposed, namely, to restrict the term haematocele to blood-effusions into the peri- toneal cavity, it would almost necessarily folloAV that the adjective, retro- uterine, is the proper and only one to employ. For, if blood be poured out into the peritoneal cavity in the neighborhood of the pelvis, it must gravitate to the retro-uterine pouch, which is the loAvest part of the gene- ral cavity. The ante-uterine or utero-vesical pouch is so shallow, and is so liable to disturbance or obliteration, by the filling and rising of the bladder, that lodgment of fluid blood in this position is rarely possible. If a little blood Avere to find its Avay into this pouch it Avould probably soon be dislodged, and made to run over the fundus of the uterus and the upper edge of the broad ligaments into the pouch behind. Moreover, the most frequent sources of effused blood are the ovary and the extremity of the Fallopian tubes, and these parts being in the posterior wing of the broad ligament, blood from them naturally falls direct into the posterior pouch. Intra-peritoneal effusions then are almost ahvays retro-uterine. But is this all Ave have to consider ? Are there no other blood-effusions ? 1 Diseases of Women, 1863. 512 PERIMETRIC HEMATOCELE. Adhering to the cardinal principle of this book, that of making scientific pathology subsidiary to clinical Avork, I have determined to bring together all the blood-effusions which may take place in the neighborhood of the uterus ; and then to proceed to analyze or differentiate them as best we can by the aid of the history and symptoms of individual cases and of general experience and pathological knoAvledge. It is only in this way that Ave can usefully investigate any given case. We may not know, in the first instance, what the source of the bleeding may be, or the particu- lar nature of the lesion which led to it. That is a problem to be solved bv clinical investigation. In a memoir on this subject1 I distributed in groups all the cases I had met with which Avere characterized by the escape of blood in considerable quantity in the pelvic peritoneum. Some of these groups included cases which those who look at the subject from a rigorously special point of vieAV refuse to recognize as legitimate ex- amples of retro-uterine haematocele. But the objection, I submit, is critical, not practical. It seems unreasonable to contend that a case of rupture of the uterus, or of an extra-uterine gestation-sac, one of the almost certain effects of which is effusion of blood into the peritoneum, is not a case of retro-uterine haematocele. It is quite arbitrary to re- strict the term to effusions of blood the result of one particular cause; for example, rupture of ovarian vessels. In no case is the outpoured blood the disease. It is only a consequence of some lesion or injury. In some cases the more immediately serious symptoms are due to the shock of the injury ; in others to the loss of blood and the attendant shock. This difference is an accident; of clinical importance, it is true, but still not such a difference as to dictate absolute separation of the cases possessing so important a common feature as hemorrhage. The clinical physician, indeed, must take even a wider survey. He must contemplate the probability of a given SAvelling behind the uterus, or apparently behind it, not being a blood-tumor. Numerous bodies oc- cupy precisely the same locality and relations ; may entail almost iden- tical symptoms, subjective and objective. So in the first instance Ave are compelled to study all these conditions together ; to analyze them if Ave would justify the hope of differentiating for the scientific purpose of pathology, or the practical purpose of treatment. In this spirit I have Avritten a further memoir on " Retro-uterine Tumors,"2 in which I have brought together and distributed in groups some of the most strikingly illustrative cases Avhich come under this general clinical description. In all the cases of haematocele, the hemorrhage, sooner or later, is a serious element. First by the shock caused by the sudden impression of the outpoured blood upon the peritoneum; secondly, by the loss of blood; thirdly, by the consequent peritonitis. The patient may be destroyed by the shock alone, or by the shock combined with the loss of blood, before there is time for inflammation to arise. This is to say, that in those most formidable cases, as of rupture of the uterus, or of an extra-uterine gestation-sac, life may be extinguished before a haematocele, properly speaking, is formed. But this is no more than is true of those usually less fulminating cases, in which the blood proceeds from burst ovarian 1 St. Thomas's Hospital Reports. 2 St. George's Hospital Reports, vol. viii., 1877. CLASSIFICATION. 513 vessels. In these cases sometimes the shock and bleeding kill before a tumor can be formed by the segregation of the blood by inflammatory effu- sions. In all there are common features which bind them together as members of one clinical family. Putting aside then for the present all pathogenic theories, we shall find that the cases of perimetric hemorrhage may be arranged as fol- Ioavs :— Peri-uterine Tumors (haematic). T AT , -, / 1. Rupture of uterus. 1. Non-encysted / 0 f, c , , , ,, / , i J ■ N [2. " of tubal or other ec- (cataclysmic). 1 , ,. v J ' 1 topic gestation- j cysts. / 3. " of ovary. A. Intra-perito- I j 1. " of sub-ovarian ves- neal (retro- / / sels, or from a uterine). ) f uterine varix. V 5. Aneurisms. (Wilks refers to intra-peritoneal effusions from liver and from heart-disease.) II. Encysted (peri- ( 1. Menstrual. ) tooitic). m | 2. Abortion. [ reSurSltant- p -p, , ., ( I. In the broad ligaments. ^P ■ ) jj# jn ceiiuPar tissue between cervix uteri and blad- neal. ( der. III. In cellular tissue betAveen uterus and rectum. I do not pretend that this is a rigorously exact classification. Hemor- rhage from rupture of an extra-uterine gestation-sac may become en- cysted ; hemorrhage from menstrual deviation may be cataclysmic. But if we regard the arrangement simply as a framework for description, it will be found useful in aiding to obtain a clear knowledge of the subject. When blood is rapidly poured out in large quantities into the perito- neal cavity the shock and loss of blood alone, as Ave have seen, may kill. No opportunity is given for the establishment of the conservative process of inflammation Avhich, by segregating the blood in one mass in one com- partment of the peritoneum, limits both the quantity of blood effused and the area of irritation, and hence the extent of shock. In such a case the hemorrhage is said to be " non-encysted." Looking at the terrible sud- denness and severity of the bloAv struck at the vital powers, I have called these cases " cataclysmic." The most common causes of the effusion in these non-encysted or cata- clysmic cases are rupture of the uterus, gravid or not gravid, rupture of a tubal gestation-cyst, rupture of a diseased ovary, or of a varix of the pampiniform plexus. But in some cases Avhere the hemorrhage is due to one of these causes the blood does become encysted. The course they run resembles closely that run by the cases of the second order in which the source of the blood is the gorged vessels of the ovary, or the Fallopian tubes during men- struation or abortion. And even in some of these latter cases the blood 33 514 PERI-UTERIXE HEMATOCELE. is poured out so rapidly that it does not become encysted. These too may be cataclysmic. Instances of encysted haematocele resulting from ruptured extra-uterine gestation-sacs are reported by Yoisin, Aran, and myself, and many others. Nor can the extra-peritoneal cases be on sound clinical or pathological grounds separated from the intra-peritoneal cases. If we base our clas- sification or definition on origin, Ave shall find that some of the same causes which lead to blood-effusions into the peritoneum may lead to blood-effusions outside the peritoneum into the perimetric cellular tissue. And more than this, Ave shall find cases in Avhich the blood being first effused into the cellular tissue has burst its Avay through the peritoneum into the peritoneal cavity ; thus breaking down the arbitrary barrier Avhich theory had placed between the two orders of cases. We see then from this statement that the perimetric blood-effusions are brought into close pathological and clinical relationship with the so-called "thrombus," or blood-effusion in the peri-uterine cellular tissue. It is this relationship which justifies the term "Pelvic Haematocele," proposed by Dr. McClintock. It is true some authors of deserved repute Avould exclude all but intra-peritoneal effusions. The objection to ranking extra- peritoneal effusions along with intra-peritoneal effusions has been insisted upon by Voisin and Bernutz. The latter author contends that the extra- peritoneal effusions are thrombi, and only result from labor. But the objection of Aran is more pointed, as being based on a clinical distinction. This excellent author affirms that there are no sub-peritoneal perimetric blood-tumors at all important in size, so as to come into consideration. They cannot become large because they are limited within the cellulo- fibrous layer covered in by the peritoneum. To this it may be ansAvered that intra-peritoneal retro-uterine effusions are not ahvays very large; and that small tumors of this description may be equalled in size by some extra-peritoneal ones, especially where complicated Avith inflammatory effusions, the extent of which can hardly be defined from the blood-effu- sion. And Huguier, Nonat, Robert, Becquerel, Verneuil, Prost, all maintain that haematocele may be extra-peritoneal. In some extra-peri- toneal cases, Nonat says, the tumor is nearer the anus. Prost relates two Avell-authenticated cases, in one of which the blood Avas effused be- tAveen the layers of the broad ligament, and in the other it occupied the connective tissue behind the uterus. Tuckwell cites Becquerel as relating a case in which more than two pounds of blood were found outside the peritoneum, the blood having dissected its way betAveen the different organs, and displaced them all. A specimen, presently to be described, in Bartholomew's Museum, seems a clear example of large extra-perito- neal haematocele. If we look to the source of some intra-peritoneal effusions, we cannot fail to see that the effusion into the peritoneum is accidental, that the blood would be quite as likely to make for itself a sac in the cellular tissue of the broad ligaments. For example, a varix or the dilated pam- piniform plexus may be supposed to give Avay without rupturing the peri- toneum, the blood finding a lodgment by separating the peritoneal invest- ments of the broad ligament. .CLASSIFICATION. 515 Olshausen {Arch, fur Gyn'dkol., 1870) relates a case of sub-peritoneal ante-uterine catamenial haematocele following on acute dysmenorrhoea. Fever, absorption, and recovery ensued. The anterior lip of the os uteri was short, whilst the anterior vaginal roof was driven backwards by a tumor of half-soft consistence. I have seen tAvo cases which I believed were examples of ante-uterine haematocele, probably extra-peritoneal, since they corresponded in rela- tions to the thrombus Avhich forms in front of the uterine neck during labor. Both cases came under my observation in the chronic stage ; in both there was a firm tumor, the size of a small orange, in front of the uterus, throAving the fundus uteri backwards. The diagnosis was confirmed by the gradual complete disappearance of the tumor, Avithout any signs of rupture or suppuration. These cases meet the objection of Aran that extra-peritoneal blood-tumors cannot be large enough to enter into clinical consideration. Professor G. Braun relates {Wien. Med. Wochenschr., 1872), a case—he thinks the only one—in Avhich ante-uterine intra-peri- toneal haematocele Avas diagnosed during life. A married woman, aged thirty-five, had a smooth elastic SAvelling in front of the uterus. Dieula- foy's trocar gave issue to a pint of dark-red blood. Collapse and death followed. A sac, the size of a foetal head, was found in the left side of the pelvis, in front of the uterus. There Avas also peritonitis. TuckAvell found in the synopsis of cases made by him that the blood was found to be intra-peritoneal in thirty-eight out of forty-one post- mortem examinations; that in tA\enty-six of the thirty-eight it was diffused, and in twelve circumscribed, and limited to the retro-uterine cul-de-sac. I have seen several cases of extra-peritoneal haematocele verified by punc- ture. There is an excellent specimen in St. George's Museum. We are then draAvn to the conclusion that there are cases of both kinds; but that the intra-peritoneal blood-effusions are by far the most common, apart at any rate from pregnancy and labor. Admitting that for clinical purposes Ave want not alone a comprehen- sive view of all pelvic blood-tumors, but also a comprehensive view of all pelvic tumors Avhich by location, relations, or symptoms resemble blood- tumors, it will be useful in this place to give a grouped arrangement of the non-haemetic tumors. The following table is drawn from the memoir on retro-uterine tumors referred to :— Retro-uterine Tumors {not Hcematic). I. Retroversion of the uterus, j £ N™JgravicL TT ^ . L. \ a. Tubal. II. Ectopic gestation-cysts, j ^ Abdominal< III. Ovarian cysts. IV. Dermoid cysts. V. Cystic tumors of broad ligaments. VI. Cvstic enlargement of Fallopian tubes. VII. Retro-uterine or peri-uterine inflammatory deposits or abscess. VIII. Uterine fibroids, j £ Pr°^ctmg from hinder wall of uterus. IX. Malignant tumors. 516 PERIMETRIC HEMATOCELE. Perimetric hemorrhage may occur in the pregnant state and in the non-pregnant state ; and in either case the effusion may be intra-perito- neal or extra-peritoneal. It does not fall within the scope of this work to describe the accidents of the pregnant state. But some of the condi- tions of uterine pregnancy, and more especially those of abnormal preg- nancy, are so connected with the history and diagnosis of perimetric haematocele that no complete idea can be formed of the subject, if Ave exclude the blood-effusion of pregnancy from the discussion. An all- sufficient reason for taking these into account is that in many instances we cannot know at the time of the accident what the source of the hem- orrhage is, or Avhether the subject is pregnant or not. The pathology of intra-peritoneal haematocele is Avell illustrated in the following cases. Olshausen relates1 the case of a woman, aged twenty- five, Avho was delivered in March, 1863, of her first child. Menstruation returned regularly until the middle of September. In the middle of October it returned too early, and Avith repeated pain in the belly, and vomiting. Thencefonvard metrorrhagia lasted for seven Aveeks. She Avalked into the physician's room. There was frequent desire to mictu- rate. In the median line of the abdomen was a ball-shape, someAvhat painful tumor, the size of a gravid uterus at three months. The os uteri Avas driven against the symphysis pubis ; behind it was a ball-shaped, slightly painful elastic swelling, filling the holloAV of the sacrum. The tumor became less in bulk, and harder. She died in June, 1864, of typhus. At the autopsy adhesions were found in Douglas's space, espe- cially behind the broad ligaments. A membrane extended from the point of insertion of the left broad ligament to the cervix uteri back- wards to the rectum, dividing off a small portion of the retro-uterine pouch ; in this a small coagulum remained, containing fluid in its centre. It lay quite free. The space showed a remarkable pigmentation abruptly terminating above, yellow and black in the tissue of the peritoneum. Both ovaries adhered to the uterus. The anatomical illustrations in the London museums are feAv. Amongst the most striking is one in St. Thomas's, a repiesentation of which is given in Fig. 108. There is a very interesting specimen in Guy's Museum (Fig. 107). It is not described in the catalogue. It shoAvs the remains of a blood- cyst, h, h, behind the uterus in Douglas's pouch. The area involved be- hind the left broad ligament and the left of the uterus further illustrates the anatomical relations of Douglas's sac Avhich I have described. The peritoneal surface is roughened by inflammatory deposits tinged with blood-debris. There is a specimen in St. BartholomeAv's Museum of special interest (No. 31.36) thus described: "Uterus and appendages. Between the layers of the right broad ligament is a globular cyst, about as big as a walnut, whose walls in the recent state were seen to be formed by the separated layers of the ligament, and whose cavity was filled with quite recent blood coagula. On the anterior aspect of the cyst were two small, recently formed irregular openings. Archiv fur Gynakologie, 1870. PATHOLOGY. 517 " From a patient, aged twenty-five, who, while in the hospital for treatment of Avarts on the vulva, Avas suddenly attacked Avith symptoms of internal hemorrhage, and died in twelve hours. Post-mortem: The cavity of the peritoneum contained five pints of recently shed blood, Fig. 107. Remains of a Retro-Uterine Hematocele (R. B.). o. The right ovary laid open, h, h. The roughened peritoneum of Douglas's pouch, which formed the anterior wall of the sac of the haematocele. (From Guy's Museum, half-size.) loosely coagulated; and dark fluid blood oozed slowly from the openings in the cyst above described. The interior of the uterus, along with all the other parts of the body, Avas very pale. Careful examination failed to discover the source of the hemorrhage. No evidence of extra-uterine pregnancy, no ruptured vessel was discovered. It is uncertain Avhether the patient was menstruating at the time of the attack." The nature of the cyst in the broad ligament is not clear. Was it a simple cyst, such as is not unfrequently seen in this situation ? If so, hoAv can Ave account for its becoming filled with blood ? Is it a true extra-peritoneal haematocele, resulting from rupture of a vessel in the broad ligament, the sac subsequently bursting, and givdng rise to a cata- clysmic intra-peritoneal effusion ? This seems to be the more probable conjecture. At any rate, the specimen gives anatomical demonstration of the possible existence of extra-peritoneal hematocele. The folloAvino- case from Olshausen affords distinct evidence of the genesis and nature of the affection. Atresia of the vagina after typhus ; haematometra and haematocele ; death by peritonitis ; regurgitation of blood through the tubes. When the subject came under treatment fluc- tuation Avas felt by rectum. Puncture made by rectum let out a little thick blood. Two days later at stool a larger quantity was voided. Peritonitis and death quickly folloAved. On dissection diffuse peritonitis, with copious purulent exudation, Avas found. Blood-remains were seen 518 PERIMETRIC HEMATOCELE. in Douglas's pouch. The uterus was much enlarged ; its cavity empty. Both tubes Avere much dilated, darkly pigmented inside, chiefly towards the uterine ends. Both ostia uterina allowed a sound to pass easily. The left ovary contained several small cavities filled with blood; it ad- hered to the uterus. Dr. Jiingel told Dr. Ferber that in about 3000 minute dissections of Avomen he had never found haematocele or remains. On the other hand, obvious remains of pelvi-peritonitis, and of slight pigmentation of Doug- las's pouch were very frequent. In puellis publids pelvi-peritonitis of old or recent date Avas ahvays found, but never hematocele. Since pigmentation is probably the residuum of blood, the presumption is that small haematoceles are not unfrequent. It is certain that adhe- sions often disappear so as to leave scarcely a trace behind. Heurtaux describes the following contents of hematocele: 1. Droplets like oil of a broAvn-yellow color; 2. Spherical cells entire or reduced to fragments, abounding in adipose nucleoli; 3. Amorphous fragments of haematoidine ; 4. Quadrilateral crystals, resembling ammonio-magnesian phosphates ; 5. Some blood-globules, Avell colored ; 6. An extraordinary quantity of blackish corpuscles, of various forms, resulting from the alteration of the coloring matter of blood. Dr. Madge describes the contents in his case as consisting of blood-corpuscles, some perfect, others undergoing various degrees of change ; also pus-globules and little black and yelloAv masses, some of them assuming a crystalline form; the chief part, however, Avas made up of undefinable debris of blood, fibrine, and pus. The Source of the Blood-effusions.—The seat of the blood-effusion being not constant, it almost necessarily follows that the source is not constant. I propose to enumerate the various sources to Avhich the hem- orrhage has been traced. This review will throw considerable light upon the subject. In the first place, we may state generally that blood may be poured out from the ovaries, the Fallopian tubes, the uterus, and from the broad ligaments; in the second place, it may proceed from an extra- uterine gestation-sac, ovarian, tubal, or abdominal; in the third place, it may proceed from lesion of some abdominal structure, as aneurism of the aorta, or of the mesenteric arteries. Group I.—In ordinary uterine pregnancy the uterus may rupture at any time. H. Cooper1 relates a case of rupture of the gravid womb in the third month. At subsequent periods rupture becomes progressively more frequent. In almost all, if not in all, cases of rupture during preg- nancy, the rent is through the body of the uterus; and therefore the blood escapes into the peritoneal cavity, the ovum or embryo being either retained in the uterus or expelled into the peritoneum. In the first case, there is strictly intra-peritoneal hemorrhage. In the second, there is intra-peritoneal hemorrhage, complicated with the presence of the em- bryo and ovum. In either case the blood may or may not coagulate, and become encysted. The more likely event is that it will not become en- cysted, but that the patient will die of the shock. The blood rarely coagulates more than partially : remaining liquid, it 1 British Medical Journal, 1S50. GROUPS OF CASES. 519 is diffused over the intestines, only a portion being able to settle in the pelvic cavity ; the conservative peritonitis Avhich under more favorable circumstances secludes the blood in the pelvic region by plastic effusions cannot take place. It does not, in technical language, become " encysted." It therefore does not form a tumor: it is not a " haematocele." It is the most severe form of intra-peritoneal hemorrhage, resembling the bursting of an aneurism. It is a cataclysm of blood, not a sIoav or gradual effu- sion. In this respect, but differing in some of its symptoms, cases of rupture of the gravid uterus resemble those in the next group, in Avhich the cyst of an extra-uterine gestation bursts. Group II.—In abnormal or ectopic pregnancy, rupture of the fruit-sac is a much more frequent issue ; and this at so early a period that the ex- istence of pregnancy may be unsuspected or doubtful. This subject has been treated of in some detail in a special chapter. It is only necessary here to call to mind, 1st, that the bursting of an abnormal fruit^sac is often preceded by metrorrhagia, resembling in this respect the more typical cases of intra-peritoneal hemorrhage, in Avhich the blood Aoavs from the ovary or Fallopian tube ; 2dly, that the severity of the injury, the quan- tity of the blood effused, and the rapidity with Avhich it is poured out, induce such a degree of shock that the blood rarely becomes coagulated and encysted, so that the case, like that of rupture of the gravid uterus, is "cataclysmic." Still in some cases there is reason to believe that the blood may coagulate, become surrounded by plastic effusions, and consti- tute a true haematocele. The folloAving case, in Avhich the diagnosis was verified by post-mortem examination, sIioavs the possibility of a true haematocele forming as the result of rupture of a tubal gestation-cyst: Fallopian Gestation—Pelvic Hematocele—-Death—Autopsy. In 1867 I met Mr. SAvales and Mr. Jaap, of Sheerness, and Dr. Jardine, of Chatham, in the case of Mrs. J. Being presumed to be tAvo months pregnant she had been taken Avith abdominal pain and flooding, but got better. On the 26th of November, being out at dinner, she Avas seized Avith acute abdominal pain, pros- tration, and Avas Avith difficulty got home. The following day she Avas much Avorse : vomiting, hiccough, tympanitis ; urine not retained. The case had at first been taken for retroversion of the uterus, as the os Avas near the pubes, and low doAvn, and a SAvelling Avas felt behind the os, simulating the body of the uterus. I passed a catheter into the bladder ; there Avas no obstruction. Per rectum : there Avas a firm swell- ing in the roof also felt by the vagina. The os uteri Avas open, admitting the tip of the finger; it Avas pointing dowmvards. The sound curved entered nearly an inch beyond the normal length in a fonvard direction, over the symphysis ; the SAvelling behind Avas, therefore, not the uterus. The uterus Avas fixed rather Ioav in the pelvis, and driven fonvards by the mass behind. The sickness and pain abated someAvhat, but othenvise there was no amendment. The patient died under the shock and loss of blood on the 30th. Mr. JaapAvrote to inform me that a " post mortem Avas performed on the 2d December by Mr. Swales, assisted by the staff surgeon of the dockyard and Mr. Keddell. It must be a melancholy source of gratifi- cation to you to knoAv that yoar diagnosis Avas verified in every iota." 520 PERIMETRIC HEMATOCELE. Mr. Swales communicated the following: "The body Avas completely blanched; I was shown what Avas called an adhesion between the left Fallopian tube and the intestines which had been cut away ; it certainly wras not an adhesion, the product of peritonitis, about the thickness of the thumb ; it was more like half-organized fibrin ; the Fallopian tube had been ruptured, in my opinion, at the point to which this so-called adhesion had been attached; the uterus Avas very pale, enlarged; all the other organs healthy ; an immense amount of coagulated blood was packed in among, and almost covering, the uterus and other pelvic contents, besides Avhich there was a large quantity of serum. No ovum Avas found. I formed the opinion that it was a case of arrested ovum in the Fallopian tube which had escaped into the peritoneum: but that she died more from the internal hemorrhage than from inflammation." Group III. Rupture of diseased ovaries.—This appears to be a very frequent source of the severer forms of intra-peritoneal hemorrhage. Cystic ovaries of all sizes may rupture. In some cases the fluid effused in chief proportion is that proper to the cysts, the amount of blood being inconsiderable. In other cases, the large vessels in the Avails of the cysts may be torn, so that hemorrhage may be great. In yet other cases, there may escape both blood in considerable quantity, and viscid or puriform matter from the cysts. In the latter cases, the blood effused being mixed Avith a peculiarly irritating fluid, peritonitis is sure to ensue if the patient survives the first shock of the injury. This peritonitis naturally tends to segregate the effused matters; but the segregation is rarely so complete as in cases where blood alone is effused. The peritonitis often takes the lead as the more urgent disease, and is commonly the immediate cause of death. Rokitansky describes as one source of the blood in haematocele the bursting of cysts of the ovary formed of distended follicles into Avhich blood has been extravasated. In those cases where the blood-effusion predominates, the symptoms and consequences resemble those of rupture of tubal gestation-cysts. There is at first preponderance of shock over anaemia; and the encyst- ment of the blood is rarely complete. But in a case which came under my care in St. Thomas's Hospital, and which I have related in detail in the memoir above referred to, complete encystment did take place. It thus connects the series very distinctly with the classical retro-uterine haematocele. As the case is made complete by a post-mortem examination, and is illustrated by the preparation preserved in the museum, and by a dia- gram, I think it desirable to reproduce it. Retro-uterine Hematocele from Rupture of a Diseaged Ovary—Punc- ture—Death—Autopsy. Condensed from Report of Dr. Seaton, Resi- dent Accoucheur. — M. A. C, aged thirty-six, married, havino- ein. fur. Geburtsk., 1857) a case diagnosed as rupture of a haematocele, folloAved by recovery. The haematocele, which had been made out before, quite disappeared after signs of rupture. The specimen described from St. BartholomeAv's Museum also may be referred to as illustrating the termination by internal rupture of the blood- tumor. In some cases, the intra-peritoneal perforation seems to be dealt with like the original effusion, by a fresh conservative peritonitis, which sur- rounds the neAV effusion of blood. Accordingly, in some cases, Dr. Madge's is an example, the blood-sac seems divided into two by a septum. Tavo cases have been recorded, one being that of Dr. Madge, and another by Bernutz, in Avhich phlegmasia dolens of one leg Avas developed in the course of the affection. The proportion of cases which disappear by absorption is hard to esti- mate. It can scarcely be doubted that in some cases assumed to have terminated in this Avay, an opening Avas really effected into the vagina or rectum, very small, perhaps, but large enough to admit of sIoav evacuation of the haematic cyst. The process may be so gradual, that the moderate rectal or vaginal blood-discharge is not suspected to come from the cyst. In other cases the discharge by rectum or vagina is manifest enough. At a variable time, ranging from tAvo Aveeks to two months, or more, blood escapes in one solid mass, or in small coagula mixed with fluid portions over several days. Dr. Willoughby AYade conjectured that in some cases the blood-tumor liquefying discharged itself by the Fallopian tubes and uterus. But distinct evidence of this is Avanting. As we have seen, a sanguineous discharge from the uterus and vagina is common; but it may be the COURSE AND DIAGNOSIS. 535 expression of the general congestion or turgidity of the uterus. It is not evident that it comes from the cyst in the way Dr. Wade suggests. In some cases the symptoms are essentially the same, but the general and local distress is less intense. The pain is slight, the fever moderate, the effusion is seldom large enough to be felt above the pubes. A feAv days, or at most a feAv weeks, suffice for recovery, the tumor disappearing almost as quickly as it came. All the best observers recognize this order of cases, and hold them to be not infrequent. Of the truth of this I am firmly convinced. There seems no valid reason to doubt that small as well as large quantities of blood may be effused into Douglas's pouch; and there is ample evidence to prove that small quantities of blood may give rise to only slight irrita- tion. If, as Tuckwell says, the objection be urged that as they do not terminate fatally, and are not large enough to necessitate puncture, the presence of blood as the cause of the tumor is merely conjectural, it may be ansAvered that their close resemblance to the more pronounced cases, the nature of Avhich is unmistakable ; the position of the tumor; and the rapidity with which it is absorbed, are sufficient to justify the diagnosis. Those who reject all evidence except that furnished by dissection, or by puncturing the tumor, shut themselves out from the possibility of instruc- tion by clinical observation and reasoning. In the milder order of cases, and in those Avhich end by discharging through the rectum or vagina, the sac itself formed by peritonitic effu- sions has to be absorbed. This is effected more or less rapidly and completely. In that order of cases in which the blood-mass undergoes disintegration, the symptoms of irritative fever supervene. The aspect becomes salloAv, earthy. The temperature and pulse rise; rigors, vomiting, SAveats appear ; and, unless a vent be found for the imprisoned matter Avhich is poisoning the system, the patient will be in great danger of sinking. There is commonly a complication Avith unhealthy peritonitis. The abdo- men becomes more tense, tympanitic, and painful. The diagnosis Aoavs from the appreciation of the symptoms described. It may be affirmed with confidence that nothing else but a haematocele will produce them in their aggregate or cumulative character. The con- ditions most likely to lead to error are :— 1. Retroversion of the gravid womb.—This is the error I have knoAvn most frequently made. The distinction is made out by the physical exploration described above ; by the history of pregnancy when there is retroversion; and by the absence of the fundus uteri from the pelvic brim or from the abdomen above the symphysis. 2. Fibroid tumor.—The presence of the body of the uterus in its nor- mal place, or at any rate its being made out separately from the tumor under investigation, distinguishes fibroid from haematocele. The history of the tAvo cases is essentially different. The fibroid is of slow groAvth; the haematocele of rapid or sudden growth. 3. A small ovarian or dermoid cyst locked in the holloAV of the sacrum behind the uterus. By the unaided physical exploration, it is sometimes difficult to bring out decisive differential signs. A small ovarian tumor is fluctuating, elastic, occupies exactly the position of a haematocele, dis- 536 PERIMETRIC HEMATOCELE. places the uterus forwards in a similar manner, causes retention of unne, and carries the vaginal canal forwards, compressing it. But there is a difference in the feel of the tumor manifest to the practised touch ; the history is different; the symptoms have usually come out gradually. The sudden shock of hematocele and the attendant peritonitis are Avanting. 4. A retro-uterine gestation-cyst. 5. Perimetric infiammation.—The invasion of this affection is some- times very similar to that of haematocele ; indeed, it may be concluded that in some cases of presumed perimetric inflammation there is haemato- cele as well. The characters of perimetric inflammations have been described in the preceding chapter. It is enough here to repeat that the seat and nature of the tumefactions felt in the vagina and rectum differ from those of hematocele. They are rarely so purely retro-uterine ; they are commonly lateral, often unilateral; they fix the uterine neck lower in the pelvis, and generally near the centre, or deviate it to one side ; they are more knobby, irregular in shape ; they are hard, braAvny. But in one case Nedaton found the walls of a haematocele hard, like car- tilage ; and Madge describes the same condition. Retention of urine is more exceptional, and in the issue not blood, but pus is voided. 6. Abscess in the neighborhood of the uterus.—This may be distin- guished by the folloAving differential signs: Abscess is rarely so dis- tinctly retro-uterine as haematocele. In all the cases I have seen Avhich gave rise to doubt there was some degree of laterality. It is not so frequently connected with menstrual accidents ; there is no coincident metrorrhagia. It does not attain suddenly its greatest intensity. The tumor is not formed from the commencement. The skin does not sud- denly become anaemic. The mass, hard at first, becomes later soft and fluctuating, the contrary being usually the case in hematocele. The con- stitutional symptoms follow an inverse order from those of hematocele. But I have knoAvn pelvic abscess cause retention of urine. The diagnosis may in some doubtful cases be assisted by the explora- tory needle, or Dieulafoy's aspirator-trocar. The finest puncture may set up inflammation ; and if the blood have coagulated, the negative result might betray the inexperienced explorer into the error that the tumor was not a hematocele. In the case of a hematocele, the blood drawn commonly resembles that taken from the uterus in cases of retained menses. It is treacly and dark-colored. Should pus escape, the diag- nosis of abscess is tolerably certain. I am tempted to add Dolbeau's picture of the diagnosis:— "The diagnosis," says Dolbeau, "is sometimes very easy, at others very difficult. Great importance must be attached to the more or less advanced stage of the malady. If the case is seen at the commencement, you must bear in mind that hematocele is not the only uterine malady Avhose onset is sudden. The lypothymic symptoms, the pain and disten- sion of abdomen, occur in both pelvic peritonitis and in intense ovarian congestions. Ovarian congestion and hematocele are never accompanied by fever. Pelvic peritonitis, on the contrary, is a malady essentially febrile. (But it is to be borne in mind that pelvic peritonitis and its attendant fever not seldom form an ulterior stage of hematocele.) TREATMENT. 537 ^Position of tumor.—In hematocele it gives rise to a projection just above the pubes, and sometimes almost reaches the umbilicus. The tumor in pelvic peritonitis never extends beyond the level of the sym- physis, or if it does, it extends sloAvly ; whereas, in hematocele, the tumor suddenly attains its maximum, and afterwards diminishes rather than increases. " The excessive pallor of the face, so important a symptom in hemato- cele, is never seen in pelvic peritonitis. " The direction of the cervix forwards belongs exclusively to hema- tocele." The treatment now admits of being indicated with some authority. Disposing, first, of the cataclysmic cases, it may be stated that the treatment merges in that of rupture of the uterus, of rupture of an extra- uterine gestation-sac, and of other great abdominal lesions. We must seek to rally from collapse by rest, by opium, and the sparing use of stimulants. In the milder class of cases of true encysted hematocele, as in all the other cases, rest is the first and most imperative prescription. If we suspect that hemorrhage is proceeding, we may apply cold to the abdo- men. When signs of peritonitis are coming on, salines and opiates are of eminent sendee. As topical applications, leeches to the abdomen are often of use ; then hot cataplasms or fomentations. Whenever there is retention of urine, the indication to use the catheter is obvious. It should be done at stated intervals—say every eight hours. If there is tenesmus or dysentery an opiate suppository should be administered. Purgatives, as breaking the law of rest, should be sedulously avoided. The boAvels will probably act by-and-by, as in other cases of obstruction, under the use of opium ; and an enema may be given after a few days, Avhen the fecal accumulation is marked. The great contention has been as to the expediency of puncturing the tumor. Experience has gradually led to definite rules upon this point. So long as the local distress is not urgent, so long as the tumor remains hard, so long as there is no sign of septicemia or irritative fever, so long is it Avise to folloAV the expectant method, observing strict rest, and ab- staining from all local interference. But Avhen the tumor softens, Avhen it enlarges immoderately, Avhen the pulse and temperature rising indicate septicemia, then it is time to consider the resort to puncture. This step being resolved upon, we have to Aveigh the method of performing the operation. The most convenient spot to select is the most bulging part behind the cervix uteri in the roof of the vagina. We must use a medium-sized trocar or a bistoury. But the best instrument is the long tube carrying a knife designed by me, Avhich can be fitted to the aspirator. The instrument should be plunged in the direction of the axis of the pelvic brim, parallel with the posterior Avail of the uterus. This line can be accurately defined by first passing the sound into the uterus. (See Fi^. 111.) We thus get a landmark. If the instrument be directed obliquely backwards, it is apt to perforate the rectum first, and to enter the hematocele obliquely, affording only an imperfect escape. It is well to leave the canula in sitti to serve as a drain, or to pass in a coil-tube through the tube-canula. If the blood be in great part coagulated, we 538 PERIMETRIC HEMATOCELE. may scoop out what can be easily reached Avith the handle of a spoon; but generally it is Aviser not to meddle too much. In some cases it may be more convenient to puncture by the rectum, a? shown in Fig. 111. An excellent Avay of opening the cyst is by the galvanic knife or Paquelin's cautery-knife. Fig. ill. This figure is intended to show the relative position of the uterus and rectum and intervening cyst. The sound in utero having settled the position of the uterus, the trocar is thrust as nea.r\y parallel as possible to the posterior wall of the uterus. The dotted line behind the sound shows how the peri- neum is held back by the finger during the use of the instrument. The direction of the os uteri, looking downwards and backwards, should be compared with that of the os uteri, the figure of retro- flexion in which the os is tilted a little/orward*. (r. b.) In cases where decomposition arises, the sac should be washed out tAvice a day with Condy's fluid, or weak carbolic acid. Out of fifty-three cases of recovery tabulated by Tuckwell, thirty were treated without any operation. The remaining tAventy Avere punctured. But it is at least doubtful Avhether in some of these latter the puncture Avas not superfluous, whether, indeed, it were not a source of danger. One source of such danger is the admission of air into the sac, and the consequent decomposition of its contents. Aran records a case of this kind in which puncture was made by an exploratory trocar, a fistulous opening remained, and death ensued from putrid infection. Here, as in all other pelvic and abdominal inflammations, it should be DISPLACEMENTS OF UTERUS. 539 a standing rule to avoid repeated examinations. Manipulation must dis- turb parts which above all things require repose ; it can hardly fail to irritate and aggravate inflammation ; it may burst the blood cyst, and lead to a fatal reneAval of hemorrhage and peritonitis. CHAPTEE XXII. DISPLACEMENTS OF THE UTERUS, GENERAL PROPOSITIONS : DEFINITION; VA- RIETIES of: prolapsus described; hypertrophy of the vaginal- portion; OBLIQUE OR LATERAL DISPLACEMENTS: ELEVATION; DEPRES- SION; ELONGATION BY STRETCHING AND PRESSURE; DISLOCATIONS OF UTERUS BY EXTERNAL PRESSURE; VERSIONS ANI) FLEXIONS; ANTEVER- SION; anteflexion; retroversion; retroflexion. Feav subjects in medicine have exerted keener controversy than that of displacements of the uterus. Some dispute the reality of these dis- placements ; others dispute their frequency or their importance. The first order of disputants, who simply deny what they have failed to recog- nize, chiefly consists of those Avho do not avail themseh^es of the necessary means to recognize the physical condition of the pelvic organs. To deny the existence of displacements of the uterus without physical examination is as unreasonable as it would be to deny displacement of the heart or of a joint Avithout physical examination. And there is something more than unreasonable in the pretension of those who, thus refusing to examine for themselves, repudiate the experience and authority of others who speak with knoAvledge. All who are in the habit of examining the pelvic organs Avhen they shoAv signs of distress recognize the clinical fact that displacements of the uterus are not only real but frequent. But amongst those who admit this clinical fact, there prevails a diver- sity of opinion as to the primary and essential, or the secondary import- ance of these displacements. I hope to evolve satisfactory conclusions upon this question in the progress of this chapter. We may usefully start Avith the following propositions: — 1. The uterus is naturally a mobile organ, possessing within the limits of health a considerable range and variety of motion. (These natural movements are described at p. 37.) 2. These natural limits are liable to be overstepped under the sudden or repeated or continuous application of undue force acting upon a uterus increased in bulk or Aveight, or imperfectly sustained by failure of its natural supports. 510 DISPLACEMENTS OF UTERUS. 3. The uterus is no exception to the general law that displacement beyond its physiological limits entails difficulty in the performance of its functions. 4. Nor does the uterus offer an exception to the pathological law that displacement, Avhich implies encroachment upon the seat of adjacent organs and pressure upon them, will cause distress in the organs imme- diately encroached upon. 5. Nor does the uterus offer an exception to the correlative law that distress in the performance of an organ, or a group of organs, Avill react upon the nervous, vascular, and nutritive systems, and thus entail remote symptoms and general disturbance of the organism. All these propositions are incontestably proved by anatomical, physio- logical, and clinical observations. '6. Another proposition maybe added: Although displacements are often initial or primary, disease ensuing as a consequence, Avhen disease assails the uterus, displacement or deformity more or less marked is sure to be induced, thus aggravating the original disease, and adding the morbid complications peculiar to displacement. 7. Admitting the foregoing propositions, it folloAvs, as a therapeutical corollary, that one essential factor in the successful treatment of all uterine diseases consists in correcting displacement or deformity. Definition.—The uterus may be said to be displaced Avhenever it is removed from its usual position by some more or less persisting cause. Of course alloAvance must be made for the normal mobility of the organ. Movement within certain limits, if followed by return to the normal stati- cal position, is not regarded as displacement. Varieties.—The displacements of the uterus are as follows: — Upwards or elevation. DoAvnwards or prolapsus. To either side or lateral deviation. Forwards. Backwards. In all the above displacements the uterus may for a time presence its normal form and size; its axis may remain unchanged; its shape may be unaffected. In displacement with reference to the axis of the pelvis, the uterus may be altered in its inclination : that is, its fundus may be inclined fonvards, constituting anteversion ; backwards, constituting retroversion ; to either side, constituting right or left lateriversion. These displacements are estimated chiefly by the deviation of the body of the uterus from its cen- tral position, the cervix remaining more or less fixed by its axis of suspen- sion to the base of the bladder. Displacements may be associated with change of form. Thus the uterus may be bent, its axis undergoing deviation. It may be bent for- wards, constituting anteflexion ; backwards, constituting retroflexion • to either side, constituting right or left lateriflexion. The uterus also may undergo torsion or tAvisting on its axis. (See Figs. 23, 21. 25 ^ij pp 19,50.) ' 'U* PROLAPSUS. 541 PROLAPSUS OR DESCENT OF THE UTERUS. It will be convenient to begin Avith the description of prolapsus. This is, if not the most common of all the displacements, at any rate that which most frequently comes under treatment. In the great majority of instances the history is a continuous one, be- ginning Avith labor, and marked successively by uterine engorgement, sub-involution, inflammation, prolapsus, retroversion, and hypertrophy. The most rational and profitable course then must be to folloAV the his- torical order; to study first immediate consequences of labor, and then to trace out the subsequent events to their full accomplishment. The first chapter of this history has been already traced. The leading fact then in the history of prolapsus of the uterus is im- perfect hwolution after labor. If this great fact be kept steadily in mind, and the lessons in practice which it dictates be carried out, many cases of prolapsus will be prevented altogether, and many more will be arrested in their early and most curable stages. Prolapsus uteri of course strictly means a falling of the womb. In- stead of swinging at its proper level, it descends loAver into the pelvis, and may even make its way through the vulva. Hence there are differ- ent degrees of descent. The minor degrees in which the womb only drops in the vagina are usually distinguished as prolapsus; Avhilst the extreme degrees in Avhich the womb passes forth through the vulva bear the name of procidentia. Etymologically vieAved, these terms have an arbitrary significance assigned to them ; but it is convenient to retain them in the sense which custom has associated Avith them. Prolapsus and procidentia may be more accurately defined as follows. If Ave regard the cavity of the uterus as a continuation of the walls of the vagina, the Avhole forming one tube, there Avill be, at the commence- ment of prolapsus, three duplicatures :— 1. A central portion, the uterus itself, dropping doAvn into the roof of the vagina, is invaginated. 2. Then there are the tAvo folds or reflections of the vagina, one of which, representing the part in.Avhich the uterus is inserted, is carried down inverted by the uterus ; the other is the part of the vagina which retains its normal position, and received the inverted portion containing the uterus. So long as this stage of depression, of partial inversion of the vagina by the squatting of the uterus continues, there is prolapsus. 3. Procidentia exists when the body of the uterus, continuing its in- vagination, has passed quite through the vulva. When this has taken place, there are only tAvo duplicatures, viz., the uterus Avhich has passed into the noAV nearly completely-inverted vagina. As Cruveilhier, Iioav- ever, obseiwed, some vestige of the second duplicature formed by the vagina is constantly met with in the furroAV of greater or less depth, situated behind the procident mass ; for though the inversion of the an- terior Avail of the vagina may be complete, that of the posterior Avail is scarcely ever so. Hence the tumor, caused by prolapsus uteri, is ahvays longer in the vertical direction in front than it is behind. The theory of prolapsus and procidentia uteri may be summed up as follows: Invagi- 512 DISPLACEMENTS OF UTERUS. nation or intussusception of the uterus is prolapsus ; complete inversion of the vagina or hernia uteri is procidentia. (See Fig. 112.) Fig. 112. Complete Procidentia Uteri (R. B.) p. Symphysis pubis. B. Bladder, u. Urethra drawn almost vertically downwards to open into B', a sacculated diverticulum of bladder outside the vulva, and in front of the procident uterus, o u. Os uteri, d. Douglas's pouch, extended outside the vulva, o. The ovary dragged down. a. The anus. (Half size, from St. George's Museum.) In complete prolapsus the inverted vagina contains the uterus. This is hypertrophied ; its cavity is mostly enlarged, filled Avith mucus. Be- sides the uterus, the vaginal-sac commonly contains in front a portion of the bladder-base ; behind, the anterior and loAver part of the rectum. Looking into the pelvis from above we see between the bladder and the rectum a funnel-shaped cavity, in the depth of which lies the fundus of the uterus, dragging doAvn after it the tubes and ovaries. (See Fig. 112.) Such then is the typical form of prolapsus and of procidentia. The uterus, by its attachment in front to the base of the bladder, is tethered to the pubic bone by its loAver third. The consequence is, that as the uterus descends towards the outlet, it must revolve round the pubic bone as a centre. The fundus then gradually rolls back, so that retroversion keeps pace with prolapsus, and when prolapsus has merged into procidentia, PROCIDENTIA. 543 the fundus will be directed backwards tOAvards the anus, whilst the os externum will be turned a little forwards. The exact position of the uterus at any point of this doAvnward course may be accurately deter- mined by the fingers and sound. The lower the uterus the more the point of the sound must be turned backwards to pass along its canal, and the more easily will the fingers in the rectum get above the fundus. When the procidentia is complete the whole uterus may be grasped be- tAveen fingers and thumb, and its contour and size exactly made out, through its sac of inverted vagina. (See Fig. 112.) Fig. 113. Diagram Illustrating successive Stages of Prolapsus of Uterus, and the attendant Degrees of Retroversion (R. B.). a, b. Axis of brim of pelvis, c, d. Axis of outlet, b, e. Curve of Carus, or curvillinear axis of pelvis. 1, 2, 3, Stages of prolapsus, i. Procidentia. The uterus tethered to the symphysis, re- volves round it in descent. The alteration in the course of the urethra somotimes makes it diffi- cult to introduce a catheter. The catheter passes backwards and down- wards into the substance of the tumor to a greater or less extent, accord- ing to the degree of procidentia. A good idea of this, as Avell as of the appearance of the tumor of procidentia, may be formed from Fig. 112, which I have draAvn from a specimen in St. George's Museum. The analogy betAveen procidentia uteri and hernia has ahvays attracted 544 DISPLACEMENTS OF UTERUS. attention. The inverted vagina is the hernial sac ; the uterus is the dis- placed intestine. Not uncommonly the sac contains a mass of small intestines besides. Owing to the peritoneum descending below the uterus and behind the upper fourth of the vagina before it is reflected upwards over the rectum, a deep pouch is formed, Avhich undergoes great exten- sion as the uterus and vagina are carried downwards. This pouch may receive an enormous mass of small intestines, so that the external SAvell- ing may be as big as a man's head. The intestine may be plainly felt by its gurgling. The anterior cul-cle-sac of the peritoneum formed by the reflection from the bladder on to the anterior Avail of the body of the uterus is too shallow to admit the small intestines into it. Fig. 114. o u Prolapsus uteri, Front View. Uterus, Bladder, and Pubic Bones Removed en mnsie. P. Symphysis pubis, r, b. Fundus of enlarged bladder, b. Bladder opened, bougie passed into it from u, urethra. A pouch of bladder is drawn outside by the uterus, o, u. Os uteri. Half-size, from specimen in St. George's Museum (R. B.). The descent and inversion of the anterior Avail of the vajrina neces- sarily drags the base of the bladder and urethra with it, causing saccu- lation of the bladder and deviation of the urethra from its natural course. The degree of displacement, hoAvever, will depend someAvhat upon Avhether the prolapsus have taken place gradually or quickly. If it have taken place quickly, the organs are carried down bodily together; but if the prolapsus be of slow production, the connective tissue uniting the vagina HYPERTROPHIC ELONGATION. 545 and bladder may yield and stretch a little, so that the urethra may not be so much distorted. But in the majority of cases the base of the bladder is so draAvn doAvn beloAV the level of the meatus, that its contents cannot be perfectly voided. The constant straining to accomplish this causes distension and the gradual formation of a vesical pouch, Avhich is partly outside the vulva. In this pouch there is a continual tendency to stagnation of urine. This leads to the deposit of lithates and phosphates, and the concretion of calculi in the diverticulum. But CruA^eilhier met with a case in which the whole cavity of the undisplaced portion of the bladder was filled by a calculus. Golding Bird pointed out hoAV it led to formation of phosphates and ammoniacal urine. Dr. G. Roper re- lated to me a case of prolapsus uteri et vesicae, in Avhich the bladder contained several calculi Avhich could be rattled about by the hand. A similar case of complete procidentia with eversion of the vagina, and calculi in the pouch of the bladder was under my care at the London Hospital. There is also great liability to kidney degeneration as a retro- grade consequence. According to Cruveilhier, the deviation of the meatus urinarius is less the effect of the displacement of the bladder than of the anterior wall of the vagina. The bladder generally is greatly enlarged. Wilks says (jPathological Anatomy, Ed. 1875), that Avhen the bladder is drawn under the pubic arch, the ureters may be compressed against the arch. On two occasions compression of the ureters thus in- duced led to fatal pyelitis. HYPERTROPHY OF THE VAGINAL-PORTION. Although, according to my OAvn observation, prolapsus and procidentia are distinct from hypertrophic elongation of the uterus, these conditions are so frequently associated in the same patient, and are othenvise so intimately related that it is most convenient to describe hypertrophy in this place. The greater number of cases of considerable hypertrophic elongation of the cervic uteri occur in women Avho have had children, and after the age of forty-five or fifty, although Ave see its incipient stages at an earlier age. The hypertrophic elongation observed in Avomen, married or single, avIio have never had children, is of a different form, and the cases are not very numerous. We may fitly describe this form first. 1. The hypertrophic elongation of the cervix uteri of women who have never borne children.—This form may be obsorved in comparatively young Avomen. If, in the majority of cases, it first comes under observa- tion in married Avomen, this is commonly because before marriage the malformation, for such I believe it to be, lies quiescent. When the en- larged structure comes to be exposed to the contingencies of married life, which include possibly a considerable amount of direct violence, and cer- tainly greater liability to congestion, distress arises. It entails all the inconveniences of a foreign body. It may be compared to a polypus in the vagina. It is usually conical in shape, the base starting from the fundus vau of the Lips exaggerated by their being parted by the Bivalve Specu- lum (R. B.) (Ad nat.) 1 Journal hebdomadal re, Juin, 1859. 552 DISPLACEMENTS OF UTERUS. This groAvth or extension of the cervix takes place from Avithin out- Avards, and involves a process of eversion. That is, the hyperplasia is most active at the inner and loAver part of the cervix. Growth being in excess at this part, eversion and elongation downwards necessarily folloAV. Then the increased bulk and weight of the organ favor descent, which is imperfectly opposed by the attendant relaxed state of the vagina, and the other supports of the uterus. The presence of the loAver part of the cer- vix near the vulva then excites reflex action, and the consequent straining efforts increase the protrusion and the congestion. In this prolapse the tAvo opposing forces of doAvnward pressure upon the fundus uteri, aided by the increased weight of the cervix, and of pulling up upon the cervix by the fundus of the vagina and the attachments to the bladder, tend still further to promote eversion and doAvnward growth. Fig. 121. Form of Advanced hypertrophic Elongation of the Cervix Uteri. The two Lips being extruded outside the Vulva, diverge (R. B.). (Half-size.) In some cases the two lips elongate separately, so that when a bivalve speculum is introduced, and the blades are expanded, the two lips are made to diverge, exposing the cervical cavity between them. I have re- presented this condition, which I believe is frequent, in Figs. 120, 121. The os gapes like an alligator's mouth. HYPERTROPHY OF CERVIX. 553 In the earlier stages, whilst the os is still in the vagina, the lips are flattened together by the Avails of the vagina closing upon them. When opened by the speculum, endometritis is always seen. When the part has groAvn outside the vulva, the two lips freed from outward compression diverge and expose the interior of the cervix, just as the bivalve speculum caused the lips to diverge whilst the part Avas still intra-vaginal. This eversion is also favored by the compression exerted by the vulva above the os. Fig. 122. Hypertrophic Elongation of both Supra and Infra-vaginal-portions of the Cervix Uteri, with Atrophy from Pressure and Dragging of the Cervix, and Tumefaction from Strangulation at the Os Inter- num. (King's College Museum, Xo. 991)2. Xat. size.) In a memoir on " Hypertrophic Polypi,"1 I directed attention to a cir- cumstance Avhich marks the extreme activity of the groAvth of the lower segment of the vaginal-portion. This is the frequent association of small ' St. Thomas's Hospital Reports, 1872. 551 DISPLACEMENTS OF UTERI'S. polypi at the os uteri with this hypertrophy. They are identical in structure with the hypertrophied cervix from which they spring. (Sec Fig. 119.) The hypertrophic polypus of the cervix uteri, then, is simply an acci- dental outgrowth from the hypertrophic cervix. It ditiers in this respect from the fibroid or myoma of the body of the uterus. The latter begins Fig. 123. Great Hypertrophic Elongation of the Supra-vaginal-portion of the Cervix Uteri. f. T. Fallopian tubes also diseased, v. Vagina containing spherical infra-vaginal-portion of cervix uteri, c. u. Cervix uteri elongated. (Bartholomew's Museum, No. 32.SO. Nat. size.) from what may be called an aberrant nucleus in the muscular Avail, and by its OAvn groAvth causes hypertrophy of the uterus. But they are met with occasionally in association with fibroid of the body of the uterus. These polypi sometimes form at a comparatively early period in the history of hypertrophy of the cervix. But they are more frequent in the HYPERTROPHIC ELONGATION. 000 advanced stages, and especially when the elongated cervix has protruded beyond the vulva. I may here call attention to a noteworthy fact in the history of hyper- trophic elongation of the cervix uteri. When this condition has reached its extreme limit, the cervix and uterus most frequently measure exactly 5 in.—that is, just double the normal length. This I have demonstrated so frequently to my classes by the sound that I have come to regard it as a law. The cases in Avhich this length is much exceeded are rare. There are other conditions which appear to cause hypertrophic elonga- tion of the uterus. These I have observed under various conditions Avhere the uterus Avas exposed to displacement and pressure, and to stretching. In some cases the first factor in the process was pregnancy. For exam- ple, in extra-uterine gestation, the uterus, feeling the stimulus, enlarges ; and the enlargement is maintained perhaps for some months by the ad- vancing development of the embryo ; then if the uterus becomes displaced, as by being pushed forwards, or to one side, adhesions forming betAveen it and the fetal sac, elongation is pretty sure to occur. A similar effect is produced sometimes Avhen involution of the uterus is prevented by pressure upon it from the masses of plastic matter resulting from perime- tritis. Fibroid tumors not uncommonly cause hypertrophic elongation by a combined process of interstitial groAvth, stretching, and pressure. Ascitic fluid distending Douglas's pouch, and thus causing a kind of vaginal rectocele, may induce prolapsus. Another form of hypertrophic elongation is seen in Fig. 123. In this case the elongation chiefly affects the supra-vaginal-portion of the cervix. Looking at the part beloAV the reflection of the vagina, there is little appearance of hypertrophy. The long thinned cylindrical ap- pearance of the cervix above the reflection of the vagina suggests the conjecture that the body of the uterus has been dragged upAvards, whilst the cervix has been grasped by the surrounding structures. The drawing (Fig. 121) accurately taken from a unique and valuable preparation in St. Thomas's Museum, illustrates many of the most inte- resting features in the history of hypertrophic elongation. An especial value of this preparation consists in the relative position of the parts being perfectly preserved. The changes undergone by the uterus are remarkable. The body of the uterus is decidedly elongated; it looks as if it had undergone stretching by pulling doAvmvards. Its Avails are a little thickened ; its cavity is enlarged, especially in length. The demar- cation between the canal of the cervix and that of the body is scarcely distinguishable. This may be partly due to senility. The cervix has undergone enormous elongation ; and the part between the sacculation of the bladder and the rectum is remarkably thinned ; it looks as if it had been draAvn out, so that its length had been acquired by pulling, as when Ave stretch an elastic tube. What is the cause of this elongation and thinning of the cervix ? In the first place, it must be observed that these tAvo conditions do not al- Avays coincide. If we examine a case of comparatively recent formation, before the subject has entered the climacteric, we shall not find the sub- stance of the cervix thinned. It is a thick, firm cylinder throughout its length. On the other hand, if Ave examine a case of long standing in an 550 DISPLACEMENTS OF UTERUS. old Avoman. Ave do find this thinning. The conclusion seems to be legiti- mate that the thinning is consecutive. It is a process of atrophy, partly senile, partly the result of continual stretching Avhich bears upon the Aveakest point of the canal, and partly from constant pressure betAveen the distended sac of the bladder and the loaded rectum. I believe the thinning is also caused by the constriction to which the elongated cervix is subjected where it is embraced by the vulva. Fig. 124. Hypertrophic Elongation of the Uterus (R. B.). (From a specimen in St. Thomas's Museum. One-third size.) The entire length of the uterus in this specimen is about seven inches. The fundus and body are somewhat lower in the pelvis than natural; the body has undergone apparently very little elongation, the chief excess of longitudinal growth being spent upon the cervix. The two lips of the os uteri are much hypertrophied and someAvhat everted. They form a mass covered by the everted vagina outside the vulva. That this is the result of downward growth, not of simple prolapsus or stretching, is seen in the condition of the bladder and of the ante-uterine and retro-uterine perito- neal pouches. The base of the bladder is carried down along with the HYPERTROPHIC ELONGATION". 557 doAvn-groAving anterior wall of the cervix uteri, forming a sacculated pouch beloAv the level of the urethra and therefore beloAv the symphysis pubis. The urethra is also distorted into a curve, of Avhich the convexity looks upwards, the bladder-end of it being carried dowmvards along Avith the base, so that a catheter to pass Avould have to be directed, first a little upAvards, then backAvards and doAvmvards. The body of the bladder is enormously enlarged ; that is, its capacity is greatly increased, but its walls are not materially thickened. The change seems to be simply dis- tension, probably the consequence, not of actual obstruction to the passage of urine, but to a habit of long voluntary retention acquired through the desire to avoid the irritation caused by the dribbling of urine over the protruding mucous membrane of the everted vagina. The fundus rose as high as the umbilicus, and considerably higher than the fundus of the uterus. The peritoneum, descending behind the abdominal Avail, is re- flected upAvards over the bladder at a point about tAvo inches above the symphysis pubis. It descends behind the bladder quite doAvn to a point on a level Avith the sacculated pouch of the bladder; that is, beloAV the level of the loAver margin of the symphysis pubis. Rising over the fundus uteri, the membrane descends behind, forming a Douglas's pouch quite beloAv the vulva. The only part not much disturbed is the rectum. Of course there is no apparent vagina, since the down-groAving os and cervix uteri have carried the vagina before them, completely everting it and turning it into an investment of the protruded parts. The specimen and the draAving exhibit very clearly the danger of am- putating the hypertrophied cervix. It would not be possible to remove more than a portion of the os without opening the retro-uterine peritoneal pouch. It also explains the difficulty commonly encountered in keeping the protruded parts inside the pelvis by pessaries. The drawing exhibits the relations of the bladder, uterus, and rectum, exactly as they were found; that is, in apposition Avith each other. There were no folds of intestine descending betAveen them in the anterior or posterior peritoneal pouches. In most cases probably Avhen prolapse has begun, the vagina contracting upon it tends to cause elongation. This constricting influence is most conspicuously seen Avhen a part protrudes beyond the vulva, where a ring of muscle embraces the protruded part. In some cases the elongation is not uniform. It affects the two lips of the os unequally. The anterior lip may be almost alone affected. This is thought to be explained by its being directly Avithin the influence of the traction made on it by the prolapsed bladder. This produces the singu- lar appearance termed by Ricord the "col tapiroide." The inner surface of the lengthened lip has sometimes a channelled appearance, the contin- uation of the cervical canal. I think this special elongation of one lip is to be explained as follows: In several cases, where the tongue-shaped elongation of the anterior lip Avas very marked, the posterior one remaining short, there was strong retroflexion of the uterus with enlargement.of the body of the uterus. The consequence of this condition was that the vaginal-portion was sub- jected to protracted compression against the symphysis pubis. In some cases the compression was brought into evidence by retention of urine. Under this compression, the anterior lip becomes flattened and elongated. DISPLACEMENTS OF UTERI" ion A similar change does not take place in the case of simple rctrovers in which the vaginal-portion is tilted up above the symphysis. X«>r does it commonly take place in ordinary cases of retroflexion in which the uterus, not "greatly exceeding the normal bulk, finds ample room in the Fig. 125. Diagram showing how Hypertrophic Elongation of the Anterior Lip of the Os Uteri is caused by Pressure under Retroflexion (R. B.). pelvis, and thus does not jam the vaginal-portion against the symphysis. When this elongation has become pronounced, it causes irritation of the vagina, and leucorrhcea. I have cured it by amputating the redundant portion, and maintaining the uterus in its due relations. (See Fig. 125.) The Etiology of Prolapsus, Procidentia, and Hypertrophic Elongation of the Uterus. In further studying this subject, it is desirable to start Avith an enumer- ation of the different circumstances under Avhich these conditions have been observed. I have seen prolapsus uteri in virgins caused, 1, by attacks of epilepsy; 2, by violent coughing ; 3, by the dragging of a polypus ; 1, by suectts- sion, as from a fall upon the nates, and from railway collisions. In the first, second and fourth cases the prolapsus may be called acute. It is produced by sudden violence, tending to drive the uterus and other pelvic ETIOLOGY. 5">9 contents out through the vulva. It is liable to be attended by acute inflammation, and is commonly marked by excessive local pain. 5, by the pressure of an ovarian or other tumor upon the uterus ; 0, by habitual over-exertion during menstruation, Avhen the local conditions resemble those of parturition ; 7, by straining at stool. Roberton and Whitehead, of Manchester, were consulted respecting a girl, aged fifteen, who had just received a sudden fright. The entire uterus Avas beyond the vulva and external to an intact hymen. It Avas replaced, and no future inconvenience resulted. McClintock has seen three cases Avhere the displacement resulted solely from the violent efforts required in defecation to overcome an organic stricture of the rectum. I have seen prolapsus in a virgin produced I think in the following manner: habitual loading of the rectum by scybala below the level of the os uteri tilted the cervix forward, and consequently the fundus backAvards. These efforts at defecation throAving the expulsive force more upon the anterior wall of the uterus would produce retroArersion and prolapsus. But it is during the exercise of the child-bearing function that prolapsus is most common. To the accidental causes Avhich produce it in virgins, are noAV added causes springing from sexual relations attended or not by pregnancy. The dominant feature of these causes is increase of bulk arising from physiological or morbid congestion, from inflammation, from imperfect involution after labor ; this is primarily or secondarily attended by relaxation of the structures Avhich support the uterus, including the ligaments, the vagina, and the connective tissue of the pelvis. The vagina alone, if in a state of healthy contractility, will maintain the uterus in situ ; but when its contractility is impaired, the uterus squats down, or sinks in it, producing a minor degree of vaginal depression or inversion. The close attachment of the anterior wall of the cervix uteri to the bladder, making the point of union the most fixed point or centre of movement of the uterus, renders it impossible for the cervix to fall without dragging the base of the bladder down with it. In discussing the etiology of prolapsus great importance is usually laid upon the study of the mechanism by which the uterus is suspended in its place. The attachments of the uterus have been described. (See Chapter 1.) AVe have seen that it is slung or suspended in the folds of the broad ligaments to the sides of the pelvis, and steadied to a certain extent by the round ligaments in front, and the utero-sacral ligaments behind ; that it is in a manner balanced upon the vagina, which, in its healthy state, forms an elastic muscular column of considerable strength ; that it is attached by its anterior Avail to the base of the bladder; and that it is further supported by what may be called the padding of the pelvis, constituted by the connective tissue between the peritoneal folds, the vessels, nerves, and other organs. No doubt the proper preservation of the position of the uterus is due to the integrity of all these struc- tures. The poAver of the vagina as a support to the uterus, and as an agent in restoring it to its place, is capable of demonstration. AVhen the speculum is introduced, the widening of the vagina produced by it, shortens the canal and brings the uterus down ; as the speculum is being AvithdraAvn, the vagina is seen to contract strongly behind it, and the con- sequent restoration of the organ to the normal columnar state carries the 500 DISPLACEMENTS OF UTERU>. uterus up again. And we may at any time by strong astringents restore the vagina, partly at least, to its original condition. West further insists that the curved direction of the vagina, and the angle at which the uterus is inserted into it, afford a further obstacle to prolapsus; whilst at either extremity the vagina is strengthened by its connection through the medium of the pelvic fascia Avith the bladder and rectum above, and by the sphincter Avhich surrounds it beloAV, as Avell as by the other muscles of the pelvic floor and by the perineal fascia be- tAveen the two layers of which those musclei lie. The value of experiments on the dead body designed to sIioav hoAV the uterus maintained its position, notAvithstanding that the vagina Avas cut away, as by Ffohl and others, or after division of the ligaments, seems to me to be exaggerated. It is clearly, indeed, proved that the uterus cannot be dragged out of the vulva, unless considerable force, amounting, says Le Gendre, to from thirty to one hundred pounds be used. But it is also certain that the broad ligaments must at the same time undergo great stretching or be severed. The conditions of the living bodv arc Avidely different. In the dead body there is no turgescence from vascu- lar fulness, elasticity of tissue, muscular contractility, constant movements from respiration and the varying states of the bladder and rectum; in- deed, all the conditions as we meet them in practice are wanting. De- ductions drawn from experiments upon the dead body can only be applied with great caution and reserve. For solution of the main questions we must rely upon clinical obsenTations. In the great majority of cases prolapsus is accomplished by small forces acting continuously or with brief intermissions over long periods of time. The fact that prolapsus does not occur in healthy structures, except under the influence of direct force, points to the necessary conclusion that the sustaining tissues of the uterus lose their power of resisting a doAvn-bearing force through changes wrought in them by disease. With the knoAvledge of these tAvo factors: force acting upon tissues Aveakened by disease, the explanation of the mechanism of prolapsus is not far to seek. The doAvmvard force is ahvays acting. It is exerted at every expiratory effort, and is exaggerated by coughing, or by straining at stool; by every exertion, in short, Avhich fixes the chest. If the resist- ance be diminished, the pelvic organs will be carried down, the ligaments will undergo gradual stretching, and the vagina, Avanting tone and con- tractility, squats doAvn under the pressure, the uterus sinking into it. Then the force of gravity is added, and is always at Avork Avhen the body is in the upright posture. The vagina, then, is a passive, not an active, factor in the production of prolapsus. It yields and permits prolapsus, because its contractility and poAver of resistance are weakened. It does not cause prolapsus, although when prolapsus has begun, it may aid the subsequent steps of the descent. This discussion is not Avithout practical interest, because the knowledge of the mechanism by which prolapsus is brought about must govern the principle of treatment. In studying the conditions of treatment, the first thing that strikes us is, that Ave cannot act directly upon the broad and other ligaments. AA'e cannot, in nautical phrase. brace up or tauten these. AA7e must act from beloAv. Hence Ave are PROLAPSUS. 561 reduced to two principal sets of mechanical expedients. The first set comprises the mechanical supports, as pessaries, which help to lift up the uterus and anterior wall of the vagina. The second set comprises the various methods of strengthening the vagina so as to restore its power of supporting the uterus. The efficacy of the vagina, especially of the muscular posterior Avail which includes the perineum, in sustaining the uterus will be clear to any one who will remember the opposition it offers to the descent of the child's head in labor. Nor can any one Avho has felt the thick firm inclined plane in which muscle so largely enters, formed by the perineum and the pos- terior vaginal wall, doubt its power to support the anterior Avail of the vagina and the uterus. AAre may, in fact, feel the uterus resting upon it. Thus, Avhen this inferior support is lost, as Avhen the perineum is lacerated, the tendency to prolapsus is greatly increased; and Ave find the use of an external perineal pad, Avhich acts as a substitute for the perineum, of signal service in supporting the uterus. It must not, however, be con- cluded that prolapsus is a necessary consequence of laceration of the perineum. I have seen many cases in Avhich the sphincter ani was torn through, and yet the uterus was held in situ by its other natural supports. AVe see that in virgins, force alone exerted upon healthy structures is enough to cause prolapsus. This force obviously comes from above. It is produced by the pressure of the intestines upon the uterus, bladder, and broad ligaments propagated from the diaphragm and abdominal walls. Noav, this force which acts alone in a certain number of cases, enters as an important factor into every case. It acts, of course, Avith special advantage after labor, Avhen the bulk and Aveight of the uterus are in- creased, and Avhen all the tissues are relaxed. After labor at term, and after abortion, the mobility of the uterus is enormously increased. Any one Avho has frequently been called upon to remove a retained placenta in abortion, will have satisfied himself upon this point. The uterus is, in the first place, at a loAver level than usual; and in the next, the most moderate traction will draw it doAvn to the vulva with a facility unknown at other times. This implies that the broad and other ligaments are elongated and more yielding, and that the vagina is relaxed. For the above reasons I am of opinion that, in the majority of cases, prolapsus of the uterus is a primary affection. But there are facts Avhich fa\or the vieAV more prevalent in Germany, Avhich is, that prolapsus is secondary upon prolapsus of the vagina. For example, if Ave examine a Avoman the subject of procidentia Avhen the mass is Avithin the vulva, ani tell her to bear doAvn, Ave see the anterior Avail of the vagina appear first; that is, there is apparent vaginal cystocele preceding the appearance of the uterus. It is inferred that the vagina drags down the uterus. The vaginal cystocele is also, it is said, the first condition. I suspect there is a fallacy in some of these observations. If by the hand in the Aragina Ave watch the course of events during an expulsive effort, Ave feel the uterus borne bodily doAvn under the force of the superincumbent pressure. Of course the uterus and bladder, being intimately adherent, must de- scend together. The vagina can only be forced dowmvards through pressure exerted upon the uterus, or bladder, or both. It is possible, of course, that frequent pressure exerted by the distended bladder may 36 562 DISPLACEMENTS OF UTERUS. push down the anterior wall of the vagina, wnich in its turn will drag down the uterus. But that such a process is not frequent, seems to Im- proved by the fact that one almost constant factor in prolapsus uteri i< enlargement and increased weight of the uterus, which must necessarily destroy the balance between the forces that suspend the uterus and those that tend to drive it down. This correlation being destroyed, the uterus cannot but fall, and it is unnecessary to invoke an independent or super- fluous force, such as the downward dragging of the vagina. I have frequently made the observation Avith such care that I am sure of the fact, namely, that the earlier stages of hypertrophic elongation of the cervix are accomplished whilst there is no perceptible descent of the bladder, no bladder distress, and no prolapsus of the anterior vaginal Avail. I have even seen cases of marked hypertrophy of the lips without perceptible prolapse. I have also seen the converse, that is, decided vaginal cystocele, the anterior vaginal Avail rolling out under straining, Avithout any hypertrophic elongation of the cervix. There is not, there- fore, any necessary connection between the two conditions, since each may exist without the other. I go further, and affirm that hypertrophy of the vaginal-portion may take place independently of prolapsus of the uterus. Symptoms, Effects, and Course of Prolapsus.—AVhen prolapsus is produced suddenly, the symptoms attending are generally complicated Avith the effects of the accident Avhich caused the displacement. This maybe called acute prolapsus. Thus, Avhen produced by a fall or con- cussion, there may be other injury besides the prolapsus, and there is ahvays more or less shock. Then, the sudden succussion occasions violent stretching of the uterine supports. As these are all connected with the peritoneum, inflammation of this membrane is very likely to folloAV ; there will be severe pain OArer the Avhole abdomen, especially acute in the pelvis, tenesmus, or bearing-doAvn, perhaps uterine hemor- rhage, and severe febrile symptoms; and bladder and bowel distress. Sometimes the parts quickly resume their normal position, especially if rest in the horizontal posture be duly observed. But this will not always be the case. The uterus may have been driven through the pelvis with such force as to break through the hymen : and the uterine ligaments, once stretched, do not quickly recover their pristine condition. Moreover, the general health may be so affected by the shock and local injury, that the recovery of tone of the muscles and other tissues will be retarded by impaired nutrition. AVhen prolapsus takes place slowly—chronic prolapsus—the symptoms are less urgent. As prolapsus is surely attended by antecedent or con- sequent engorgement, or other morbid state of tissue, the symptoms of course are a complication of effects depending upon the tissue changes. and of mechanical effects due to the displacement. The first class of symptoms will be described in their appropriate place. The mechanical conditions are traced to dragging and to pressure. The uterus having lost the support of the vagina, and of what may be called the paddino- 0f the pelvis, drags upon the utero-sacral and broad ligaments, which "are stretched and elongated. In the upright posture, especially, and under bodily exertion, the prolapsus is necessarily increased; the sense of PROLAPSUS: COURSE OF. 563 dragging and bearing-doAvn is then aggravated. At stool and during micturition, some additional difficulty being felt from the pressure of the uterus, greater straining is exerted to empty the bladder and rectum. The uterus itself being larger and pressing upon the loAver part of the vagina and near the anus, excites reflex irritation, the response to which is seen in increased bearing-doAvn or expulsive efforts. The uterus, in fact, acts noAV as a foreign body. Its presence in a situation not accus- tomed to receive it, is resented, and the effort at ejection increases the displacement, and constitutes a main difficulty in treatment. *The dysuria and dyschezia1 increase in proportion as the patient continues in an upright posture, and as the uterus descends nearer to the vulva. Besides these reflex effects upon the motor nerves, the patient feels pain from the congested state of the uterus, from its pressure upon surrounding organs, from dragging upon the peritoneum. These pains are intra-pelvic, sacral, dorsal, and lumbar, partly from indirect pressure upon the pelvic nerves and sacral plexus, partly from irritation of the ganglionic nerves, and partly from the spinal exhaustion, resulting from continual irritation. The congestion often leads to menorrhagia, or even to hemorrhages in the intermenstrual periods ; and leucorrhoea is hardly ever absent. AVhen the uterus in its descent comes to press upon the vulva, the muscles, the elastic tissue, and mucous membrane, and skin Avhich sur- round and constitute the Avails of this opening, undergo distension. Under continual pressure the opening enlarges, the perineum especially is thinned out, it dilates, is partially everted, and rounded. The contractility of the vulva is greatly impaired; the floor of the pelvis no longer gives ade- quate support to the structures above it. Prolapsus then easily passes into procidentia. The inverted vagina becomes virtually a hernial sac, Avhich receives the uterus and often a mass of small intestines. Although the peritoneum is draAvn doAvn so Ioav that Douglas's pouch is outside tbe vulva, the stretching of the ligaments having been very gradual and slow, a degree of accommodation and tolerance has been acquired, so that the pain of dragging may be even less than during the early stages of prolapsus. The uterus being now outside the range of the sphincters, the reflex expulsive efforts and pains may also be less troublesome. The subjective symptoms change in character. The local symptoms are dif- ferent. Under great exertions in the upright posture, the dragging upon the peritoneum may be very severe. Procidentia Uteri.—The swelling protruding betAveen the thighs is at first of an oblong, nearly cylindrical form, and terminates beloAV in a narroAV extremity, in Avhich a transverse opening, the os tincae, may be discerned. At a later period it has a pyriform appearance. The vagina turned inside out, Avhich forms the investment of the SAvelling, changes its character and appearance. From exposure to the air, the most villous character of mucous membrane is lost; the surface becomes dry, in places shining. • There is, as Virchow describes it, a histological transformation. The soft epithelium gives Avay to epidermis, the histological equivalent. Often there are patches of inflammation and ulceration. These patches get covered with a thin pellicle resembling cuticle. It is a kind of scab. 1 Difficult defecation, from Sus-- and x*lw' 501 DISPLACEMENTS OF UTERUS. If peeled off, the surface easily bleeds. Sometimes ulcerations occur where they are easily overlooked, namely, in the fold at the base of the prolapsus," especially "at the posterior part. I have seen nodular irritable ulcerations here which disappeared under rest. The patches are usually described as being the result of friction, of chafing against the thighs and dress, and of urinous irritation. I have certainly seen sores formed on the most depending part of the tumor where it was exposed to chafing on sitting doAvn: and on either side Avhere it came into contact Avith the thighs. The vaginal-portion is no longer conical; the cervical portion SAvells from stasis ; and the vagina on the stretch pulls open the os, exposing the inside of the cervix. The Avails of the vagina get thickened partly from hypertrophy, partly from infiltration and retention of serum in the connective tissue. This is an effect of the dependent position ; the vessels can Avith difficulty return the blood poured into them. The stretching smooths out the ruga?. The mass has often a dark-red or even a purple color, but is often pale. The friction of the mass against the clitoris is at times a source of distress. Chronic inflammation of the uterus is a frequent concomitant. The uterus becomes painful to pressure. Its situation exposes it to violence, which may induce acute inflammation. This may also be induced by the use of improper pessaries, and the inflammation may extend to the sur- rounding tissues. Inflammation of Bartholini's glands is not uncommon. The mass outside may be seized Avith gangrene, the result of strangu- lation at the vulva. After prolonged exertion in the upright posture, the parts get full of blood, the return being impeded by the attendant SAvelling of the labile vulvas. I do not think this event is common. But we have seen a remarkable example in St. Thomas's Hospital. A very large part of the surface of the procident mass fell into sphacelus. The labia vulva? were tumid, showing the dull-red of erysipelas or threatening gangrene. The patient sank in a feAv days. The autopsy was performed by Dr. Payne. The sphacelus had involved nearly the Avhole surface of the inverted vagina, and in some places perforation had almost been accomplished. The uterus had undergone no marked hypertrophic elon- gation. Nearly the whole of the organ had been contained in the in- verted protruded vaginal sac. The bladder Avas greatly enlarged ; there Avas retrograde dilatation of the ureters and of the pelves of both kidneys. Another danger to be borne in mind is that of rupture or laceration of the vagina. Dr. Fehling relates {Arch, jur Gyudk., 1871) the case of a woman, aged 63, Avho had long suffered from procidentia, forming a mass as big as a child's head. After carrying a bucket of water up some steps, she found she was unable to return the mass as she had done before. Using some force, she felt as if something had given way, and intestines came through. Collapse set in. Dr. Fehling found a mass of small in- testines as big as a man's head protruding, cold, Avithout movement. He in vain endeavored to return it. He punctured the intestines and still failed. The Avoman died in eleven hours. This history siu^ests the necessity of using the utmost gentleness in attempting to returna proci- dent uterus. The structures have undergone changes that impair their tenacity, making them more lacerable. prolapsus: accidents attending. 565 As a general fact, it may be stated that the tendency of prolapsus is towards aggravation. The cases of spontaneous cure are rare. The only qualification of this proposition applies to the minor degrees of pro- lapsus. Some cases have been cured by sloughing of the vaginal walls, and the consequent cicatricial contraction of the canal. Prolapsus may also be said to be removed Avhen, cancer supervening, the spreading dis- ease seizes the surrounding parts, and keeps the uterus fixed in the pelvis. The changes induced in the organs concerned in procidentia are Avell described by Scanzoni. The vagina, uterus, and broad ligaments, bladder and rectum being removed from the pelvis, we are struck with the size of the uterus, and Avitii the expansion, relaxation, and Avant of elasticity of the vagina. The vagina has lost its rugae ; its surface is usually smooth, often livid, and if the prolapsus has lasted long in an extreme degree, it is very dry, covered Avith a thick layer of pavement-epithelium, which gives to the mucous membrane the aspect of epidermis. The vaginal- portion, commonly hypertrophied, often indurated, but sometimes very swollen and softened, is of bluish-red or slate-gray color; around the orifice it is deprived of epithelium and covered Avith erosions and ulcera- tions. Often, after a long persistence of the disease, a true inversion of the cervix is produced ; the orifice begins by being sensibly" dilated; its borders form a circle an inch or more in diameter through Avhich the cervix is inverted, so that the mucous membrane peculiar to the neck, covered by its vitreous secretion, is seen. A section of the uterus dis- plays considerable hypertrophy Avith engorgement. The cavity is ahvays much dilated, especially lengtliAvise, and the mucous membrane sIioavs chronic catarrh. There is also frequently follicular inflammation at the os uteri in the younger Avomen. But in the more aged the follicles have commonly undergone atrophy after bursting. Three conditions may exist in apparent procidentia uteri: 1. Hyper- trophic elongation of the cervical portion of the uterus. This, of course, is attended by eversion of the vagina, the fundal portion of which is drawn down by the advancing os uteri. 2. The case may be one of eversion of the vagina, the pouch formed by Avhich, projecting, someAvhat in the form of a sausage, contains the uterus at the bottom perhaps of normal size, or, as in aged women, atrophied. 3. There is equally in- version of the vagina ; the pouch outside the vulva containing the uterus retroflexed or doubled up. The distinction between these three cases is easily demonstrated. 1. In the case of hypertrophic elongation, if we pinch the tumor upAvards from the os uteri, Ave may trace the elongated cervix as a hard cord up into the pelvis as far as the finger and thumb will reach. If we then in- troduce the sound, we find this instrument will pass up along the uterine canal quite into the pelvis, until its point is arrested about on a level with the pelvic brim—that is, the sound will usually run a length of five inches. If we turn the point of the sound Avhen thus arrested tOAvards the anterior abdominal Avail, we may generally feel the fundus of the uterus by pressing a hand in to meet it above the pubes. AVe also know when the point of the sound has reached the fundus uteri by the sense of 566 displacements of uterus. resistance : and by gently continuing the pressure we produce a degree of re-inversion or re-position. AVc sec the everted os uteri turn inAvards, and the mass outside becomes diminished in length. It is needless to say that this demonstration must be conducted with great care, lest we injure or even perforate the uterus. 2. The second condition, that of pure procidentia uteri, may be recog- nized by the fingers. First, the fingers compressing the tumor can trace the included uterus by its hardness, and determine with precision its form, size, and position ; the fingers get all round the uterus, grasping it completely, and thus demonstrating that it is wholly outside the vulva. Secondly, the sound again takes measure of the uterus, and proves that there is no elongation ; that it is tAvo and a-half inches long, or barely a little more. 3. In the third condition, that of procidentia of the retroflexed uteru3, the diagnosis is made out in a similar Avay. Since I meet all these three conditions, I cannot accept any doctrine Avhich absolutely excludes one of them as impossible. The real question to settle is the relative frequency of their occurrence. I believe the hypertrophic elongation is the most frequent, but I can give no numerical data. The tAvo conditions arise under different circumstances. Although both are observed in Avomen in the decline of life, the hypertrophic elon- gation is more frequently found at an earlier period. It is an active process of growth. The cervix elongates in continuation of a process of inflammation and engorgement, aided no doubt by other conditions, taking their rise from pregnancy and labor. The procidentia uteri more com- monly results from a process of which atrophy of the uterus and of the pelvic padding is the first step, and superincumbent pressure is the second. This is more frequently observed in women past the climacteric ; it first appears at this period ; it is not the climax of processes begun after child- birth. Indeed, it may occur in women who have never borne children. I have seen it in a girl aged seventeen, who had never borne a child. In these cases the uterus is sometimes so shrunken that it is scarcely bigger than a walnut, and there is commonly closure, complete or partial, of the os uteri. In one case I found atrophy of the uterus almost absolute. S. Cooper has cited cases of complete procidentia of the gravid uterus. I have seen a case of the kind in the practice of the Royal Maternity Charity. In this condition it is obvious that to expel the child the uterus can derive no help from the diaphragm or abdominal muscles. If the Avhole mass can be easily returned within the pelvis, this will be the better course. If not, it will be Avise to dilate the cervix uteri artificially by means of my water-dilators, and to deliver by forceps or turnino-, taking care that the uterus be well supported by the hands of an assistant during the delivery. AVhen this is effected, the uterus must be returned, and a firm perineal bandage be applied to prevent it from falling through again. Occasionally procidentia of the gravid uterus is simulated bv pregnancy with hypertrophic elongation of the cervix. AVhen labor comes on, the child passes along the lengthened canal of the cervix and is arrested at the os externum uteri, which lies outside the vulva. The os externum being thus enormously distended, has been taken for the uterus PROCIDENTIA. 567 itself, the body of Avhich is really in its normal position. I have seen several examples of this. In each case the practitioner attending assumed it to be complete procidentia. It may fairly be doubted whether some of the recorded cases of presumed procidentia of the gravid uterus were not in reality cases of hypertrophied cervix. The uterus, in a state of prolapsus, is sometimes affected Avith scirrhus and cancer. A case of this description wras met Avith by Ruysch ; such a complication Avas seen in one instance by Cruveilhier. {Anat. Pathol. livr. xvi.) Its extirpation Avas completed by MM. Reoamier and Marjo- lin, by means of a ligature, though the patient is stated to have died afterwards from some cause Avhich had nothing to do Avith the operation. Instead of this method, Avhich must inevitably be attended Avith great risk of tying a portion of the bladder, Cruveilhier recommends making an in- cision into the posterior parieties of the vagina, and thus getting into the great peritoneal cul-de-gae betAveen the bladder and rectum, draAving the uterus outward, and separating its cellular connections to the bladder. A woman, Avhose uterus Avas cancerous, and in a state of complete prolapsus, Avithout any inversion, was attended by Langenbeck, Avho succeeded in removing the diseased organ Avith a knife, and the patient recovered. According to this author's description, after the vagina had been sepa- rated from the uterus, the latter organ Avas detached from the peritoneum without opening into the peritoneal cavity, a small portion of the fundus uteri being left, however, apparently quite sound. The bleeding was very profuse, and required the use of the needle and ligatures. The Treatment of Procidentia and Hypertrophy of the Uterus.—The treatment best calculated to meet the early stages in the production of these conditions has been described in preceding chapters. It remains now to discuss the modes of dealing Avith the more advanced or confirmed cases. Keeping the uterus at its proper level is a very effectual factor in curing inflammation and hypertrophy of the cervix. This is due, I believe, to the relief Avhich the vessels supplying the organ obtain Avhen supported in their natural relations. When the cervix is sunk low in the pelvis the vessels are dragged down, become elongated, varicose, they form large loops, with a depending curve, liable to angulation by com- pression ; the circulation through them is necessarily sluggish, and seeks relief by serous effusions into the tissues, thus increasing the hypertrophy, and impeding curative processes. A considerable degree of oedema is a frequent complication of the advance degrees of prolapsus, Avith inversion of the vagina. To such an extent is this the case that occasionally the bulk of the protruding mass becomes so great that there is extreme diffi- culty in returning it into the pelvis. To facilitate this step it is necessary first" to get rid of the oedema. This is done by applying strips of plaster around the mass, so as to compress and support the tissues. It is often useful to prick the SAvollen tissues Avith a lancet, to let the serum drain off. After two or three days, the patient keeping her bed, the mass will com- monly be so far diminished as to enable it to return. If swelling be attended by inflammation of the surface of the mass, it will be proper first to subdue this by cooling astringent lotions ;■ lead or tannin answer Avell; or it may even be desirable to apply leeches. A properly applied pessary acts partly by reinverting the vagina and cervix, and partly by 568 DISPLACEMENTS OF UTERUS. restoring the vessels to their natural relations, thus oppodng two of the most prominent factors in the production of prolapsus. Maintaining the uterus at its proper level further acts by taking off the strain upon the ligaments, and thus giving them the opportunity of re- covering their tone. They are somewhat elastic, and if relieved of the drag upon them they slowly retract, and in time regain much—I believe rarely all—-of their pristine value. Sometimes the procidentia is irreducible. Inflammation may have been followed by adhesions which bind the uterus and appendage^ down. In one case pain was so much increased, and so obstinate a constipation came on, that it became absolutely necessary to let the uterus descend again. In any irreducible case we must be content Avith supporting the SAvelling, and preventing its increase by a suspensory bandage, and draw- ing off the urine by catheter, Avhenever requisite. Sometimes the dis. placement of the bladder causes an incontinence of urine. The extreme pain Avhich attends the attempt to return the procident mass into the pelvis is often clue to some degree of inflammation having been set up in the peritoneum lining the pouch, into which the intestines descend, at the upper and back part of the womb, or of the peritoneal investment of the intestines themselves ; and death may in these circum- stances take place, Avith many symptoms of the same kind as attend upon fatal strangulated hernia, or ileus. Another cause of the bulk of the tumor, and of the difficulty in replac- ing it, arises from the presence of the intestines in the sac, Avhich seldom reside there long Avithout inflammation of their peritoneal coat being set up ; not of so acute a character as to produce formidable symptoms, but matting their different coils together, and tying them firmly to the interior of the sac. Again, where a mass of intestine has been long protruded reduction is difficult, and retention in situ perhaps impossible, OAving to the loss of capacity of the abdomen to accommodate it. The abdomen has shrunk. These considerations, then, suggest that reduction should be tried very gently, closely observing any resistance that may be presented to the return or retention of the parts Avithin the pelvis. The immediate effect of returning the procident uterus to its place is to shorten the elongated neck, if the case be one of hypertrophic elonga- tion. The structure is elastic ; it retracts like the ligaments Avhen the strain is taken off. But much is not gained in this Avay ; perhaps nothing in extreme senile cases, where there is thinning of the cervix. In these cases when the procident mass is returned, the cervix being too lone for the space in the pelvis which has to receive it is doubled up. But the plan of reduction and supporting the mass inside the pelvis by mechanical means is not so irrational as it is by some thought to be. Certainly it is not a cure ; it is a palliative proceeding. But this indication is often fairly fulfilled. I could exhibit a considerable number of hospital patients who by help of suitable pessaries are placed in comparative comfort, and are enabled to earn their livelihood by Avashiiv and other laborious occupations. The keeping the uterus within the pelvis at its proper height is further an important condition preparatory to any of the various operations per- PESSARIES. 569 formed upon the vagina and cervix. By this means, aided by rest in the recumbent posture, the uterine supports regain strength ; and this will be of essential service when the patient recovers from the operation. A troublesome consequence of prolapsus is the " spasm" or reflex irritation, caused by the presence of the uterus near the AUilva. This distress is pretty sure to be removed by a pessary Avhich will carry the uterus up to its proper level. AVhatever other treatment be adopted, it is a point of great importance to keep the bladder periodically relieved. For Avant of attention to this the pouch formed at the loAver part of the bladder, by the dragging doAvn of the cervix uteri, tends to get bigger, and becomes an aggravation of the uterine and vaginal displacement. To empty the bladder fully it is necessary that the protruding mass should be returned into the pelvis. Some Avomen afflicted Avith procidentia have learned the trick of pressing the anterior part of the mass upAvards by the hand during micturition, and thus of emptying the bladder more completely. The collection of phosphatic deposits, and the formation of calculi may thus be prevented. Mode of Returning the Procident Mass.—The patient should lie in the semi-prone or knee-elbow posture. The tumor should be treated as a hernia; the part last emerging should be returned first. The base should be grasped by the two hands, and gentle pressure exerted at a part of its circumference at a time, whilst the mass is being pushed back in the direction of the axis of the pelvis. AArhen the parts have been reduced Ave have to consider hoAv to keep them in position. The patient should be in bed, the boAvels relieved, and an astringent lotion used tAvice a day, as a preparation for the use of a pessary. Under these precautions any inflammation or ulceration of the uterus or vagina soon heals, and the mucous membrane recovers its nor- mal moisture. The vulva also regains some portion of its natural firm- ness, and becomes better able to retain a pessary. It must not, however, be concluded that mechanical treatment is every- thing. It is ahvays indeed useful, but sometimes it is not the most important part of the treatment. It is essential to consider the complica- tions, as hypertrophy, inflammation, or engorgement. In many cases the prolapsus disappears Avhen the uterus is restored to health. In a considerable number of the slighter forms of prolapsus much benefit is obtained from the frequent use of astringent injections. And nothing more conclusively proves the value of the vagina in supporting the uterus than the action of astringents upon it. The corrugation and contraction of the canal Avhich these induce is often found sufficient to keep the uterus in place so long as the effect upon the vagina lasts. An effectual and convenient Avay of applying astringents for this purpose is to Avrap up a scruple of alum or sulphate of zinc in poAvder, in a piece of cotton avooI, and to insert this in the vagina. This the patient can com- monly do with her fingers ; but where this is difficult it is easily accom- plished by aid of the plug-speculum. The Use of Pessaries.—It is one of the many controverted points in gynecology whether the use of pessaries in prolapsus is or is not a scientific proceeding. If pessaries are found useful, it matters little whether they satisfy the conditions of science. That thousands of women 570 DISPLACEMENTS OF UTERUS. do find comfort and benefit from their use is a fact too notorious to be disputed. Still it is asserted that their usefulness being only palliative and temporary, and science supplying modes of treatment which are curative, pessaries should be discarded. If the premises were true we could not reject the conclusion. But they are only partially true ; and a wide field is still left for study and the application of various modes of treatment, according to the various forms of the malady. The operations to which alone the claim to be scientific is arrogated, however well devised, are not certain in their results ; they are not free from the dangers which attend other similar operations ; and they not seldom fail in their intent. No doubt these operations may be, and will be, improved, and become more certainly successful. But, in the mean time, it is not Avise to discard instruments so useful as pessaries. As prolapsus is a hernia, so a pessary is a truss. Mr. John AVood and other surgeons have devised and successfully executed admirable operations for the radical cure of inguinal hernia. These have not, how- ever, supplanted trusses. So it is with prolapsus. Notwithstanding the ingenuity and success of several of the operations for its radical cure, pessaries are still found necessary. Before applying pessaries it is necessary to ascertain the absence of adhesions binding doAvn the uterus. This is done by careful manipula- tion, and by the use of the sound. On carrying the uterus gently upAvards, obstruction, if existing, will be felt. Occasionally the part is returned, after a great deal of trouble: but OAving to the long altered state of the parts, the reduction brings on Avorse symptoms than resulted from the procidentia. Description of Pessaries.—The Avord pessary comes from 7tiaou>, to soften, and Avas originally used to signify a soluble medicinal substance, similar to a suppository. It is only by a corruption that it has come to be applied to the instruments designed to support the uterus. To these instruments it has been proposed to give the more appropriate name '• hysterophores," from iartpo., Avomb, and $<•>«, I bear. Pessaries, that is hysterophores, act on different principles. The object of most is to counteract prolapsus, or to keep the Avomb in proper form and place. Others are designed to stimulate development and function. Others to subdue inflammation and irritation and to overcome contraction of the vagina. Those Avhich have the first object in \deAv act on one or more of the following principles:— 1. By mere distension of the vagina beloAv the uterus they block up the outlet, and so keep the uterus from falling out. The balls and air- pessaries mostly act in this way. 2. Others act by utilizing the contractile power of the va. A fifth class are intra-uterine. These may be subdivided into two orders. A. Those designed to straighten the uterus when flexed. These are of tAvo kinds: those Avhich are attached to extra-uterine supports, and those which are simple. B. Those designed to stimulate development and function, as the galvanic. 6. A sixth class are vaginal pessaries, designed to overcome irritability and inflammation, by keeping the Avails apart and at rest—" vaginal- rests." An attempt to give anything approaching to a complete account of the pessaries that have been contrived Avould be hopeless. Dr. A. K. Gard- ner gives draAvings of 123 different forms ; and he is far from exhaustive. Almost all fall within one or other of the classes indicated above. Most, especially of those of the first and fourth classes, may be discarded as vicious in principle and faulty in practice ; and a judicious selection from the most approved specimens of the other classes will bring the really useful instruments doAvn to a very small number. The Choice of Pessaries, and the Mode of Applying them.—In one class of cases, chiefly of simple prolapsus, Ave can avail ourselves of the contractile property of the vagina. In another class, Ave can derive no assistance from this source. AVe must apply all the support. These conditions govern the choice of pessaries. The first class of cases includes those Avhere there is prolapsus, not procidentia, where it is comparatively recent, and the patient is not past the climacteric. For many of these cases, especially if there is any in- flammatory complication, and the patient's circumstances forbid her to rest, some modification of Hodge's pessary is the best. Since in the cases under consideration, it is assumed that the vagina preserves con- tractility, our study should be not to destroy or diminish this property, but to utilize it. Hence Ave must reject the whole array of box-wood balls, and huge thick rings, Avhich depend for their efficacy upon mere bulk. A globe of moderate size Avill not do, because it will in all proba- bility be soon expelled. To be retained, it must be large enough to cause some difficulty in getting it in through the vulva, it must then take a bear- ing upon the floor of the pelvis, resting upon the ischiatic tuberosities and sacro-sciatic ligaments. Thus placed in the way the uterus cannot escape. But the penalty is the destruction of the contractility of the vagina by constant distension, and often serious inflammation and ulceration of its walls. Offensive discharges of mucus, pus, and blood folloAV ; and pain compels the patient to seek relief. Under these circumstances the removal of the pessary is sometimes a task of difficulty, particularly if the ball is of large diameter. AVhen such a ball has been Avorn for some years, the vulva Avill be found so much contracted that it represents a ring, whose diameter is much less than that of the pessary. The vulva by age and abandonment of use may have, moreover, become extremely rigid. It becomes of greater practical moment to know hoio to remove these pes- saries than how to introduce them. 572 PESSARIES. The extraction of a ball-pcssarv under these circumstances resembles the delivery of a child whose head is impacted, with this difference, that the ball, although smaller, is absolutely unyielding. Sometimes the ball may be hooked out with the fingers by getting the last joint fairly above it and pressing it doAvn upon the perineum. But this is often difficult; the ball rolls over and cannot be fixed. It must be seized with a forceps. A small midwifery-forceps will perhaps answer the purpose, but the ex- treme rigidity of the vulva may prevent the introduction of the blades, unless the margin be first incised. It is better to do this than to use violence. To grasp the ball, whatever forceps is used, the ends must be curved so as to get beyond the equator, othenvise they will not hold. In one very difficult case that came under my care at the London Hos- pital, I got a long and strong polypus-forceps curved at the ends so that it held well. The ball Avas nearly as large as the head of a seven months' child. There are still to be found in the instrument-makers' shops huge rings or disks made of india-rubber or box-Avood, or other material, Avhich also act by bulk and by blocking up the pelvic outlet. The surgeon now and then becomes acquainted Avith them through the mishaps they occasion. Like the balls they set up vaginitis, ulceration, and cases are not rare in Avhich even perforation bas ensued, and the pessary has made its Avay wholly or in part into the bladder or rectum. The vaginal-portion also received into the ring has become swollen, inflamed, and incarcerated. Liiders1 relates a case of a lady avIio had a pessary of caoutchouc stuffed Avith hair, 3| inches long, 2\ inches broad, and 1 inch thick. Peritonitis folioAved, and then hectic. A SAvelling was felt betAveen the vagina and rectum ; the pessary Avas not found. A year later another physician found the same SAvelling; and a transverse scar in the poste- rior vaginal Avail. Two years later a fistulous opening appeared in the anterior Avail of the rectum, Avhich enlarged, and the pessary was re- moAred. The pessary had passed into Douglas's pouch. The patient recovered. AVhere resort is deemed necessary to the principle of filling the pelvis beloAv the uterus, the best of all means is the air-pessary contrived by Gariel. This consists of a globe of india-rubber prepared so as to resist moisture, and Avhich can be distended after it is introduced into the vagina. The patient can apply and remove it herself; and removal is easy by letting the pessary collapse. Some more modern forms of pessary are not free from objection. ZAvanck's instrument is, in my opinion, one of these. It had, and may still have, under various modifications, considerable vogue on the Conti- nent; and a few years ago it Avas much used in London. It does not, indeed, act like the ball by blocking the loAver cavtity of the pelvis : but it depends greatly for its efficacy upon stretching out the upper part of the vagina. The wings, when expanded in sitti, present margins narrow enough to bury themselves in a groove which they form in the vagina; after a time the vagina contracts below this groove, ulceration and granu- lation take place, and the granulations projecting through the fenestra Monatsschrift fur Gebnrtskunde, 1858. THE LEVER-PESSARY. 573 meet and unite, and thus the pessary is incarcerated. I have experienced considerable difficulty in extracting the instrument under these circum- stances.^ They can only be liberated by draAving doAvn the instrument, and dividing the incarcerating tissue. And sometimes the ulcerative pro- cess perforates the bladder or rectum. I do not say that these accidents are common, but considering the frequent carelessness of the class of women who use pessaries, we ought not to use instruments which require constant medical observation. The Hodge or lever-pessary ansAvers most of the indications Avith the least amount of draAvbacks. It is of essential importance to bear in mind what is too often forgotten—namely, that it is a lever. A lever must be freely movable. The lever-pessary, to act properly and safely, must float in the pelvis. Hence the correlative condition that the uterus itself must be movable. The lever is simply held in the vagina. It should not take any bearing upon the walls of the pelvis ; to make it do this would be to degrade it to the level of the old ring-pessaries, and to sacrifice its principle of action. This is what happens if too large an instrument is used. Then the vagina will be put on the stretch, its elas- ticity will be impaired, leverage is lost, and the pessary pressing unduly may cause inflammation and ulceration. The best material is flexible white metal. This admits of moulding by the surgeon. As sold the shape is rarely suitable. The best gene- ral form is that, Avhen vieAved edgeAvise the shape is sigmoid, the upper limb so curved as to be nearly concentric Avith the hollow of the sacrum Avhen in situ. The upper or sacral limb, when vieAved in front, is Avider and flatter than the lower or pubic limb. If the upper limb is convex, it can only touch the globe of the body of the uterus by a point, and thus the uterus may glide aside. Let us apply a lever to a case of prolapsus, with engorgement of the vaginal-portion. This can be done with safety, because the pessary does not, like ZAvanck's or many others, touch the os uteri. AVe select one moulded to the form of the vagina—that is, when viewed laterally, of a sigmoid shape. The size may be determined approximately by the measurement taken of the vagina by the finger. The length should be such that whilst the upper limb will rise into the vaginal duplicature be- hind the cervix uteri, the lower limb will sit behind the symphysis pubis well above the meatus urinarius. If it project beloAv this, it will be troublesome, and be liable to expulsion. Its breadth should be such as not to stretch the vagina. The mode of action is as follows : During inspiration or exertion, the intestines driven doAvn upon the uterus and bladder cause the anterior wall of the vagina to descend. The lo\ver limb of the pessary being applied to this wall is carried down with it, and the upper limb necessa- rily rises in the opposite direction, lifting the roof of the vagina and the uterus, and keeping the fundus of the uterus inclined forwards. So long as the body of the uterus is maintained in anteversion, it can hardly suffer prolapsus. The leverage action of the pessary is also greatly aided by the posterior Avail and floor of the vagina. This at the loAver part forms a thick elastic and muscular structure, which, partly by its contractile property, and partly under atmospheric pressure, is normally kept in 571 PESSARIES. close apposition to the anterior Avail giving it material support, and thus constituting one of the greatest impediments to prolapsus. The pressure so exerted of course will bear upon the upper limb of the pessary, which is embraced in the vagina. The sphincteric action of the vulva also comes in aid. This contracting the outlet, helps to support the instru- ment above it. The instrument is figured on a subsequent page under the treatment of " Retroversion." The instrument should be worn continuously. It is not necessary to remove it at night. It does not prohibit intercourse, although it would often be better that this should be avoided. Conception has often taken place whilst it Avas being worn. As it requires accurate adaptation, the patient or a nurse cannot ahvays be trusted to remove or replace it. But by help of diagrams and direct demonstration this may be accomplished. I have several patients who manage the instrument Avith perfect precision. After a time—several weeks, or perhaps months—the uterus having been kept in position, the vaginal-portion being prevented from chafing against the loAver part of the vagina, engorgement will have subsided, and the supports of the uterus ■will have recovered tone. In many cases, under proper adjuvant treatment, such as the use of local astringents and general tonics, a cure is effected. The uterus is sustained by its natural supports. If this favorable result is not more frequent, it is because so many interfering conditions occur. It should be enforced as an imperative rule that women wearing this or any other pessary should have it removed at fixed intervals, to avoid mischief, and to observe the condition of the parts. The manoeuvres for introducing the lever-pessary are described under " Retroflexion'." Some modifications of Hodge's pessary, designed to meet special cases, or to obviate special inconveniences, have been designed. One of Pro- fessor Hodge's original forms was that of the letter U, the legs being curved. The two ends being applied behind the symphysis have been found to dig holes into the bladder. A great gain Avas effected when these pointed ends were got rid of, by completing the ring. I have gen- erally found it possible to obviate all trouble by Avidening the lower arch—that is, by making the transverse portion a little straighter. This completion of the ring by adding the transverse portion, increases the leverage power, since it is the central portion of the vagina that descends most. If there be marked vaginal cystocele or rectocele, with large yielding vulva, it may be difficult or impossible to get a Hodge to act. It will generally fall out, and even if it keep in, the conditions upon which its leverage action depend are so feeble, that Ave must turn to other means. AVhen the Hodge fails, Ave have often a valuable resource in other forms of pessary, which act upon somewhat different principles. The next form to try is the stem-ancl-cupj pesssary. (See Fio-. 126.) To a certain extent, this, I believe, also acts upon the principle of a lever, but it does not depend entirely upon it. Here, as in the case of the lever, it is important to select an instrument as small as will ansAver the pur- pose. It consists of an upper expanded portion, the cup or corolla, which receives the vaginal-portion, and a somewhat tapering cylinder, PESSARIES. The Cup-and-stem Pessary. curved to correspond Avith the pelvic or vaginal Fig. 126. curve. It is likened to a horn. The. whole is hollow, for the escape of discharges. Noav, the bare instrument in this form will, under favorable circumstances, maintain itself in sitti, and act curatively. The study of them will best explain upon what principles the instrument acts. AVhen the instrument is in sit{i, the vaginal-portion resting on the corolla, the narroAV stem is grasped by the vagina, which contracts upon it. As the instrument repre- sents a cone, of which the apex is directed doAvn- Avards, a force grasping it necessarily carries the cone upAvards, and the uterus rises Avith it. Then the cone, by its length, is also a lever, and is sub- ject to exactly the same influences as Hodge's lever pessary. That the instrument acts in this way is proved by the facts that in suitable cases Avhen the vagina is contractile, the pessary is self-retaining, and that in many cases it ends by curing the prolapsus. In other cases, Avhere the power of the vagina is insufficient to grasp the stem, its retention is aided by external elastic bands Avhich are carried up in front and behind, and attached to an abdominal belt. The elastic bands, yielding at every inspiration, permit the natural ascent and descent of the uterus, and obviate the concussion and violence which rigid external supports would cause. The material of these pessaries should be vulcanite. The introduction is not difficult. A finger of the left' hand is intro- duced into the vagina, and presses back the perineum ; the corolla of the pessary held in the right hand is slipped by its edge beneath the guiding finger, and in front of the fourchette, being made to press backAvards, so as to make its way in by expanding the perineum. The direction given is tOAvards the hollow of the sacrum, and aAvay from the symphysis pubis. If the vagina be very much relaxed, if there be any considerable amount of rectocele and cystocele, the corolla must be proportionately large, or the folds of the vagina will bag over the corolla, and drag the uterus down by the side of it. AVhen there is no vaginal contractility, there is nothing but the external elastic bands to depend upon to keep the pessary in sit'd. But even under these circumstances it is still a very useful instrument. This is the case in prolapsus and procidentia of aged Avomen. AVhen the functions of ovulation and pregnancy are at an end, the uterus undergoes atrophy, losing bulk, increasing in hardness. At the same time, the cellular tissue of the pelvis loses much of its fat; the vessels haAdng less call upon them for supplies, bring less blood. The vagina, too, partakes in the atrophic process. The general result is a small uterus imbedded in shrunken tissues. The padding is gone, the uterus falls. Especially is this the case if the woman leads a laborious life. Under great exertion in the standing or kneeling postures, the ill-supported uterus easily falls through the pelvis. Hence, the prolapsus and procidentia of senility being mainly 576 PESSARIES. the consequence of atrophy, nothing short of mechanical support will avail. Another class of pessaries act upon the principle of directly supporting the anterior wall of the vagina. If this is kept up, as we have seen, the uterus is kept up with it. The essential constituents of all these are: first, a disk of suitable shape which is adapted to the anterior Avail of the vagina at the junction of its roof with the vaginal-portion ; secondly, an elastic Avire which supports the disk and Avhich is carried out of the vulva and curved up in front, to be connected Avith a pad which is secured by a spring or bandage against the symphysis pubis. Professor Martin used one which, instead of a disk taking its bearing upon the anterior vaginal Avail, has a ring-disk Avhich receives the vaginal-portion. Dr. Whitehead, of Manchester, uses one constructed on this principle, Avhich is very effective. Dr. Gibson, of Newcastle, describes {JJrit. Med. Journal, 1869) a truss adapted to support the vuhra. Professor Thomas has contrived a modification of the Hodge's pessary sometimes effective in extreme cases of prolapsus. It is made Avider, and the sigmoid bend is more pronounced. It acts not altogether as a lever, but takes a support on the floor of the pelvis. In practice I find it inferior to a pessary designed by Dr. S'-ott, of Woodstock, Canada (see Fig. 127). This being itself elastic and sup- Scott's Pessary. a, the intra-vagmal part; b, the part which fits the perineum ; e, the part which lies between the uates : d, an elastic loop to which a tape is tied, and which is in turn tied to an abdominal band. ported by an elastic band outside respects the normal movements. It can be taken out and replaced by the patient. The size, of course mus: be adapted to the individual circumstances. AVhere internal pessaries cannot be borne or do not answer, manv patients find relief in wearing a firm perineal pad, attached bv straps before and behind to an abdominal belt. This contrivance is a" kind of artificial perineum. The pad strengthens the floor of the pelvis and its pressure by keeping up the posterior wall of the vagina in contact with the anterior Avail, prevents the uterus from descending Before the introduction of Zwank's and Hodge's pessaries the use of external supports was much more frequent than it is now. But we should OPERATIONS FOR PROLAPSUS. 577 not lose sight of what has often proved a valuable remedy. Hull's utero- abdominal supporter is the best known ; and another—Dr. Ashburner's— is highly commended by Dr. AVest and others. I have seen many cases in Avhich one of these appliances answered the indications of keeping the uterus inside the pelvis, and of enabling the patient to get about, and even to go through severe Avork Avith comparative comfort. " Each of these instruments tightly embraces the hips. Hull's is furnished with a large padded metallic plate, fitted over the pubes, and Ashburner's is fitted with a similar plate, fitted over the sacrum. The chief utility of these metallic plates is that by their firm yet gentle counter-pressure they relieve the sympathetic pains referred to the back in one case, or the dragging and distress in the region of the ovaries in the other. To both of them a strap passing between the legs, with a perineal pad is adapted, and though it can be dispensed with at pleasure, will be found of great service in all cases of considerable relaxation of the vagina, Avith disposition to actual procidentia, Avhenusecl either alone or in combination with some form of internal support." (AVest.) The strap and perineal pad have, indeed, the disadvantage of heating the parts, and of keeping up leucorrhceal discharge ; and I have even known them to cause hypertrophy of the labia vulvae. In all the contrivances Ave have as yet discussed, the support is given beloAV the uterus, and they are designed to meet the uterus, and to resist its fall. But whilst adapting these often indispensable aids, we should not forget that Ave may often do much to take off the superincumbent pressure Avhich is the active factor in producing and maintaining the pro- lapsus. A Avell-adjusted abdominal belt will do this ; and patients often experience considerable relief from this contrivance alone. Some form of internal support may often be usefully combined with the abdominal belt. General Treatment.—But we should not confine our attention too ex- clusively to mechanical means. Portal congestion, hemorrhoids, dilatation of the rectum, and retrograde disorder of the digestive system, so fre- quently accompany prolapsus, and so surely aggravate its consequences, that special attention should be directed to mitigate these conditions. Alteratives, such as mercury or podophyllin, chloride of ammonium, and tonics as strychnia, quinia and iron will often be of signal service. We must act, in short, on the general principle of removing or mitigating all intercurrent or associated morbid complications. Amongst the most common are the climacteric affections, Avhich have already been discussed. Surgical Treatment.—Where artificial mechanical support adapted internally or externally is excluded, or where, for other reasons, a radical cure is indicated, several surgical proceedings are available. The several operations are based upon different principles, arising out of the different vieAvs entertained as to the causes of prolapsus. The first attempts at a radical cure Avere based upon the simple idea of closing the vagina or vulva. The folloAving historical account is taken from S. Cooper's Surgical Dictionary:— " The late Dr. Hamilton formerly suggested the propriety of endeavor- ing to relieve very bad and confirmed cases of prolapsus uteri, by exciting adhesive inflammation in the vagina, so as to bring about an agglutination 37 578 PROLAPSES. of its surfaces. However, notwithstanding the more or le*s partial closure of the vagina, occasionally met with in the practice of surgery and midwifery, every pathologist 'is aware of the difficulty of making a mucous tissue undergo the adhesive inflammation ; and this consideration led Dr. Hamilton not to attempt it. A more valuable and practical operation is that of treating such cases by approximating the pared sur- faces of the labia, and uniting them by suture. Dr. Ireland tried this method in Dublin, and has published an account of the success which attended it. (See Dublin Jouru. of Med. Science, vol. vi., p. ISl.) Cruveilhier prefers to this proposal the plan of bringing about a contrac- tion of the upper part of the vagina, by touching it with the nitrate of silver, or an acid. An anonymous writer remarks that a similar opera- tion has been several times since performed by Yelpeau, Boivin, Laugier, and others. Some produce adhesions betAveen the opposite surfaces by means of Avounds made with the knife ; others by means of sloughs and granulating surfaces, resulting from the application of escharotics. Dr. Ireland seems to attribute the merit of devising this operation to Dr. Marshall Hall; but it is probable that Girardin, Avho proposed it in the year 1828, has the claim of priority. (See Dublin Jouru. of Med. Science, vol. x., p. 126.) For an historical account of this operation, I must refer to the Annuli Universali di Medicina, edited at Milan by Omodei, for December, 1835. In 1831 the operation Avas performed by Dr. Fricke, of Hamburg, with a complete successful result, and he is a strong advocate for it. " The following quotation from Dr. Heming's translation of Madame Boivin's work, p. 53, affords some particulars of Dr. Marshall Hall's operation, Avhich appears to have consisted in the excision of a strip of the mucous membrane of the vagina: ' Dr. Marshall Hall has lately cured a case of complete prolapsus uteri by artificial contraction of the vagina: a strip of the mucous membrane, an inch and a half wide, Avas removed along the Avhole of the canal, and the wound Avas seAved up. We hear nothing of hemorrhage, and are assured that the patient suffered neither pain nor fever after the operation.' In a note, the translator mentions that there was scarcely any hemorrhage, and that in November, 1833, two years after the operation, the uterus and bladder were found by Mr. A'incent to be perfectly supported in their situation. " Dieffenbach treated bad cases of prolapsus uteri by removing an oval piece of the membrane of the vagina ; a plan suggested to him by the observation of a case in Avhich some parts of the vagina sloughed away, while the uterus Avas in a state of prolapsus. The uterus and the remains of the vagina were reduced during the granulating process, and the result Avas a complete cure of the disease." In recent years modifications and extensions of the proceedings initiated by Hamilton, Marshall Hall, Fricke, and Dieffenbach, have been devised under a more accurate knoAvledge of the causes of the displacement and of the conditions of cure. These have accordingly been attended with a far greater amount of success. The operation which first attracted attention arose out of that for restoration of the lacerated perineum. It Avas observed that prolapsus not infrequently arose in connection with rent perineum. The restoration OPERATIONS FOR PROLAPSUS. 579 of the perineum, especially if the rent extended through the sphincter ani, Avas indicated independently of consideration for the prolapsus. The restoration of the perineum Avas an effective means of restoring the in- tegrity of the A-agina, which is one of the chief supports of the uterus. Then as it Avas observed that, in many cases, prolapsus uteri Avas compli- cated Avith vaginal rectocele, it Avas hoped that by narroAving the vagina in its posterior Avail, it Avould be so far restored to its normal condition, that it Avould be able to support the uterus. As Ave have seen, the pos- terior Avail of the vagina and the perineum form a most efficient support for the anterior Avail. Much benefit might, therefore, reasonably be expected from making good this part. Mr. Baker Brown Avas one of the earliest and most energetic advocates of this plan. A considerable number of operations of this class have been performed by him and others, and Avith varying degrees of success. But there are clinical observations in abundance to prove that it is based upon imperfect appreciation of the causes of prolapsus. In many of the cases, notwithstanding the narrowing of the posterior Avail of the vagina, and the union of the labia much anterior to the normal fourchette, the prolapsus after a time returned. The true factors of the prolapsus remaining untouched, gradually the uterus made its Avay down again, and distending the neAV perineal floor appeared outside the vulva. It cannot, therefore, be called a radical cure, except in those cases in which vaginal rectocele is the essential cause of the prolapsus. Nor is the relief often permanent, unless the vulva be almost completely occluded. It has been seen that the small vulva and perfect hymen of the virgin are not an absolute safeguard against prolapsus. The narrowing of the vulva simply forms a shelf to receive the falling uterus. The operation is so similar to that for restoration of the rent perineum, that the description of the tAvo will be given together.. An operation that seems based upon a sounder vieAV of the pathology of prolapsus, is that proposed and practised by Dr. Marion Sims and Dr. Emmet, of NeAV York. Its object is to strengthen or brace up the vagina near the junction of the cervix uteri Avith the bladder. It con- sists in removing a portion of mucous membrane from the anterior Avail in the form of a V, the open part of* the V embracing the cervix uteri, and then the uniting the sides by sutures. I have performed this opera- tion as well as the preceding one several times. Although in each case the cure seemed perfect for some time afterwards, the parts gradually opened out again, and the prolapsus Avas reproduced. Then there is a third operation performed in yet a different part. It may be distinguished as Huguier's. It is the amputation of the hyper- trophied cervix. The principle appears to be different from Sims's ope- ration, but I think they touch each other in their mode of action. It is difficult to amputate the vaginal-portion of the cervix Avithout removing a portion of the contiguous mucous membrane in front; and Avhen heal- ing, a process of cicatricial contraction anteriorly necessarily follows. I have seen this in cases where nothing but amputation of redundant vagi- nal-portion Avas contemplated. But still the proceeding has independent advantages. In the first place, the elongated cervix is pro^ tanto short- ened ; and in the second place, a process of altered nutrition, attended 5s 0 PROLAPSUS. by retraction in the remaining portion, is set up, by Avhich a still further shortening is effected. Huguier's operation consists in taking away, together with the upper extremity of the vagina, the whole length of the neck, and, if necessary, the lower part of the body of the uterus, removing it by an incision slanting from without inwards, after having previously detached the bladder from the part to be excised. In connection Avith this rather for- midable proceeding, it is desirable to state the condition Avhich, in Hu- guier's judgment, absolutely contra-indicate it. These are, a capacious pelvis and a large opening at the vulva, more or less laceration of the perineum, and considerable relaxation of the soft parts of the pelvic floor. If these conditions exclude the operation, the cases must be very rare in which its performance Avould be admissible ; and an operation which cannot be applied in the cases which most urgently demand relief, can hardly be regarded as a very important acquisition to science. To this criticism must be added the serious dangers incurred of open- ing the peritoneal cavity, or the bladder, of hemorrhage from dividing the vessels high up at their entry into the substance of the uterus, and of consequent pyaemia. In ISiIO, Scanzoni1 had amputated the vaginal-portion sixteen times: nine times Avith Siebold's scissors, three times Avith the galvano-caustic. He says the operation is ahvays dangerous. The operation advocated by Gustav Simon, of Heidelberg, is based upon the idea of strengthening the posterior Avail of the vagina so as to obtain a firm support to the uterus and anterior wall of the vagina. I am indebted to Dr. James R. Chadwick, of Boston, U. S. A., for the folloAving condensed account. Simon calls it "posterior colporrhaphy." It consists in removing the mucous membrane from a large portion of the posterior vaginal Avail, and bringing the two sides of the denuded surface together, so as to produce great constriction of the vagina. The operation is generally performed while the vagina is dilated later- ally by a broad flat fenestrated speculum—a modification of Sims's. Through the fenestra the mucous membrane and a little of the subjacent tissues may easily be removed Avith the scissors or bistoury uptoAvithin £ to 1 inch of the vaginal insertion into the cervix uteri. The whole thick- ness of the vaginal wall should not be cut away, for a less firm cicatrix would then result. The upper end of the pared surface should not be pointed, but almost square, so that, when the healing process is completed, a sort of pouch is formed above the cicatrix, into which the cervix may sink and be retained, instead of being free to insert itself into the re- stricted canal of the vagina, where it would gradually force its way down, dilating the parts, and finally reach its former prolapsed position. At the vaginal entrance the denudation of the mucous membrane is carried out upon the posterior halves of the two labia majora, so that, when the latter are approximated and unite, the perineum is greatly lengthened and additional support obtained. The opposite edges of the wound are then brought together by fine silk sutures, which are allowed to remain four to six days or longer. A union takes place throughout the whole 1 Beitrage zur Gebertskunde, 1860. OPERATIONS FOR PROLAPSUS. 581 extent of the surfaces thus applied to each other, and a firm, dense, cica- tricial band is obtained, running almost the Avhole length of the posterior vaginal Avail. Professor Simon claims the folloAving advantages for this method of operating: That it forms a pouch in which the cervix rests ; that a firm barrier is by it opposed to the exit of the uterus at the point toAvard Avhich that organ naturally gravitates ; and that the vagina is made narrower and more rigid. In addition, the uterus is not drawn doAvn by the contraction of the cicatrix, as occurs in Sims's operation, OAving to the lower extremity of the cicatrix in the latter being almost fixed by its attachments to the unyielding pubic arch. Simon had tried Sims's pro- cedure in a number of instances with temporary relief, but after a time the procidentia invariably recurred. Having operated more than thirty times by his oavh method, with one exception, he effected perfect and per- manent cures, although the patients were chiefly poor peasants Avho did the heaviest kind of Avork in the fields. I have had more success with Simon's operation than with any other. The late Dr. Tracy, of Melbourne, performed an operation which unites the anterior and posterior colporrhaphy and the perineorraphy. The three proceedings are carried out at the same sitting. Like Simon, he was able to say that his patients Avere restored to the capacity of earning their living by hard work. The conclusion I have arrived at is, that in some specially appropriate cases each of these three operations Avill succeed ; that there are many cases in which one of them singly Avill effect but little good; and that a combination of tAvo or all three will often be necessary for complete success. The course to be adopted may be stated as folloAvs: 1. AAhen there is a prolapsus without marked elongation of the cervix, remove a portion of the mucous membrane of the anterior Avail of the vagina on Sims's plan. 2. If there be considerable elongation, amputate a portion of the redundant neck, and at the same time remove a triangular piece of the mucous membrane just in front of the cervix, the base of the triangle merging in the stump of the cervix, and bring the sides of the triangle together by sutures. 3. If there be considerable rectocele, with impair- ment of the perineum, perform the perineal operation, or posterior col- porrhaphy. 4. Where the three conditions coexist, all three operations should be performed. It will generally be best to do this in successive operations. There is undeniable truth in this passage from Dr. AVest: "It is sur- prising hoAV much the size of the procident Avomb is reduced after its return within the vagina by a month's rest in bed, hoAV completely a long- standing ulceration of its orifice heals, and Iioav effectually the organ is retained aftenvards Avithin the pelvis by a bandage. If in the majority of these cases an operation Avere performed, a similar result Avould doubt- less be obtained; the month's compulsory rest in bed Avould be followed by the same diminution in the size of the uterus, and the elongated peri- neum Avould ansAver for a time at least the same purpose as the perineal pad of an ordinary bandage ; Avhile by slow degrees the ligaments in the one case, as in the other, might regain some measure of power, and the womb might cease to fall down externally." 582 PROLAPSUS. Mr. Walter Whitehead, in a very able clinical memoir1 based on a con- siderable number of oj.erations performed by himself, looking back upon those operations, is strengthened in his opinion that to cure prolapsus we must aim more to relieve the pressure from above than to diminish the weight of the uterus, or to increase the strength of its supports. Such operations, he thinks, should beresen-ed for a last resource in the isolated cases, where all other means of supporting the uterus have been found useless. Yet his mode of operating seems to have been Avell devised and executed, and the success fair. It consisted in removing a triangle of mucous membrane from the posterior vaginal Avail, the apex being towards the os uteri; another triangle from the anterior wall with the apex down- wards, and in amputating the cervix. The amputation of the elongated vaginal-portion demands great care. There is very serious risk of opening the peritoneal cavity behind. Douglas's pouch, which in the normal condition descends as Ioav as the upper fourth of the vagina, that is, considerably beloAV the level of the vaginal-portion, is, in the ordinary condition of hypertrophic elongation, carried doAvmvards in the same proportion. A glance at the drawing. Fig. 112, p. 542, taken from nature, shows this very clearly. The bot- tom of Douglas's pouch is outside the vulva, and it Avould be impossible to amputate any considerable part of the protruded cervix Avithout opening into it. The accident, indeed, has several times happened. Marion Sims relates a case ; Dr. MeadoAvs has related another, and other cases are known. The accident is especially likely to occur if the chain or Avire-ecraseur be used. During the tightening of the chain especially, the traction is apt to drag within the grasp tissue beyond the line selected for amputa- tion. To obviate this, two measures are useful. First, the part to be amputated may be dissected aAvay from its vaginal investment, so as to isolate completely from the peritoneum the part Avhich is to be included in the loop of the chain or Avire. Secondly, the cervix may be transfixed by a long straight needle just above the part where the chain or Avire is applied. This will present an effectual barrier to the in-dragging of any tissue beyond what is intended. The accident may also be avoided by dissection and amputation Avith the knife. Even greater security is attained by removing only a small portion of the cervix. The piece removed need not be large. The retraction attending cicatrization com- pletes the cure. And Huguier's method of removing a conical portion gives further security. The danger of pyaemia may be almost eliminated by operating under the carbolic spray. The mode of amputating redundant vaginal-portion by the galvanic cautery-wire is illustrated at p. 546. The opening of the peritoneum is not, however, necessarily fatal, and the surgeon should be prepared to meet the dangers attending it. Among the more important congenital forms is the extra-median posi- tion of the uterus with eccentric implantation into the vaaimd roof. The uterus lies to right or left out of the median line, its form behv>- sym- metrical, the broad ligament of one side is small, the other bv so^much 1 Manchester Medical and Surgical Reports, 1871. DISPLACEMENTS OF UTERUS. 583 the Avider. On touching by Aragina the finger passes by one side of the vaginal-portion into an elevated empty roof, and on the other side into a shalloAV space. This anomaly, says Rokitansky—and from clinical observations on the living I venture to confirm his statement—is not uncommon. Some of the anomalies of position are congenital, some acquired. I have been brought by long observation to the conclusion that the congeni- tal aberrations from the normal position and shape of the uterus are far more frequent than is commonly supposed. The oblique position. This occurs sometimes with the Avell-formed uterus, but commonly it is combined Avith oblique or one-sided formation of the uterus ; and sometimes a congenital lateral inflexion is found. Inflammatory adhesions may bind the uterus doAvn in almost any posi- tion. Thus, in St. BartholomeAv's Museum (No. 32.38) is a specimen where there has been inflammation of the pelvic portion of peritoneum, and irregular adhesions have formed about the ovaries, Fallopian tubes, and broad ligaments. The left broad ligament is much contracted, and the body of the uterus is thus drawn to the left side, so that its axis is almost at a right angle to that of the vagina. © O © Dislocation of the Uterus upwards {Elevation of the Uterus).—The uterus rises when enlarging from pregnancy, fibroid tumors, accumula- tion of blood, mucus, or other matters in its cavity ; or it may be drawn or pushed upAvards by tumors, enlarged ovaries, haematocele, or by adhe- sions, or hernia of the tubes or ovaries, Avhich Avill drag it to the side of the hernia. Elevation of the uterus is attended by elongation or stretch- ing of the vagina, smoothing-out of its folds, unfolding of the duplicature which constitutes the roof of the vagina, and the vaginal-portion ; elonga- tion of the cervix, atrophic attenuation, and, lastly, lesion of continuity of the cervix. Sometimes this combined process of compression and stretching effects the actual separation of the body of the uterus from its neck. Mr. Nunn exhibited (see Pathol. Trans., vol. x.) a uterus, the body of Avhich Avas above twice or thrice its normal size, and Avhich had undergone nearly complete isolation from its cervix, Avhich Avas smaller than normal. The attenuation Avas due to the pulling of an ovarian tumor. Dr. Hare exhibited to the same society an enormous ovarian tumor weighing 106 lbs., removed from a dead woman. The vagina Avas stretched to 6| inches long, it was inclined very much tOAvards the left, and at its extremity the os uteri opened by a small aperture into the cavity of the uterus. This organ, like the vagina, was firmly adherent to the anterior surface of the tumor, and, like it, Avas exceedingly elongated, being 7| inches in length. Its body was also much thinned out and flat- tened. "These cases show that the uterus, if subjected to dragging and pressure from an ovarian tumor being adherent to it, is liable to similar transformations as the Fallopian tube in like case. I have seen quite similar changes produced in the uterus by its outer Avail forming part of the sac of an extra-uterine gestation. Analogous conditions may be produced by fibroid tumors in the uterus itself. 584 VERSIONS OF UTERUS. Simple compression betAveen a tumor and the symphysis pubis may produce similar attenuation of the uterus. The uterus mai/ enter into the contents of a hernial sac, constituting hysterocele. It has been found in inguinal and femoral hernia, in hernial openings of the abdominal aponeurosis between the recti muscles ; in an ischiatic hernia, and in hernia of the foramen ovale. Certain displacements of the uterus are caused by pressure. Thus, a tumor behind the uterus, or a hematocele in Douglas's pouch, will pudi the organ bodily forward, without affecting its axis of suspension, coin- pressing it against the svmphysis pubis. It may be pushed bodily back- ward by the distended bladder (see Fig. 3*, p. 126). A tumor in the side of*the pelvis may push the uterus OA-er to the opposite side. In either of these cases the uterus is liable to become elongated as avcII as deflected by the pressure. In some cases of ovarian tumor in the earlier stages the fundus of the uterus is pulled tOAvards the affected ovary, throAving the os upwards in the opposite direction, so that the uterine axis lies almost across the pelvis, but more commonly the fundus is throAvn over to the opposite side. A controversy Avas long keenly waged, and I do not knoAv that it is even yet set at rest, as to Avhich Avas the antecedent, and therefore causa- tive condition—namely, engorgement and inflammation of the uterus, or displacement. One school held that the displacement entailed the en- gorgement, the other school maintained that the engorgement produced the displacement. There Avas right on both sides. But both sides greatly overlooked a third chapter in the history—namely, the frequent occurrence of flexions and versions as a congenital disposition. THE INCLINATIONS OR VERSIONS AND FLEXIONS OF THE UTERUS. It is desirable to start by defining the meaning attached to the terms employed in describing the displacements of the uterus. Naturally, Ave understand by displacement, any deviation from the normal position of the uterus. If we could exactly determine the normal position, we should have a fixed point of departure from Avhich to measure the various devia- tions. But this fixed point it is not easy to settle. AVe must allow a certain range of location to a mobile organ like the uterus. Assuming, hoAvever, as Ave may, that the uterus is suspended in the upper part of the pelvic cavtity, so that its fundus is on a level Avith the plane of the pelvic brim, that its inclination coincides nearly Avith the axis of the pelvic inlet, and that it floats betAveen bladder and rectum about midAvav be- tween the symphysis pubis and the sacrum, but somewhat nearer to the symphysis, Ave shall have a standard position sufficiently defined for clinical purposes. Another point necessary to determine is Avhat Aran calls the axis of suspension of the uterus. This is defined as follows : Just above the vaginal-portion the cervix adheres to the bladder: behind, it is free and receives about the level of the union with the bladder, the utero-sacral or Douglasian ligaments. This point is the axis of suspension. Around this the body of the uterus can move in all directions. This axis is VERSIONS OF UTERUS. 585 however, susceptible of displacement en masse, owing to the flexibility and elasticity of the constituent parts. It ascends in the recumbent and prone postures and before the examining finger; it descends in the erect posture, and in prolapsus, and in straining efforts. It also rises and falls under expiration and inspiration. We may define version as inclination of the uterus forwards or back- wards, or to either side, with regard to its normal axis, the uterus re- taining its normal slight curve. The uterus, in version, rotates upon its axis of suspension, so that if the fundus dip fonvards and dowmvards, the vaginal-portion Avill rise in the opposite direction ; and if on the other hand the fundus rise and incline backwards, the vaginal-portion will come fonvards. In the first case there will be a corresponding degree of what I have called anterior vaginal roof-stretching ; in the second place there Avill be a corresponding degree of posterior vaginal roof-stretching. The anterior vaginal roof-stretching reaches its highest degree in early preg- Fio. 12?. Diagram to Illustrate Aversions and Flexians of the Uterus (R. B.). A b. Axis of inlet of pelvis, c D. PlaDe of brim. E f. Xormal axis and position of uterus. ef. Retroversion, yh. Anteversion. e'f. Retroflexion, g' h'. Anteflexion. nancy, Avhen anteversion of the enlarging uterus throAVS up and back the vaginal-portion under the sacral promontory, carrying the vaginal roof back with it. The diagram, Fig. 57, p. 164, will make this clearer. Of course it is not to be taken that the definition given is strictly true. Especially, the axis of suspension is rarely fixed. It moves en masse with the bladder, which helps to form it. It is deflected a little back- 5*6 FLEXIONS OF UTERUS. wards or fonvards Avhen the uterus inclines or is flexed. This varies with the size of the uterus and other circumstances. Flexion consists in bending of the uterus upon itself. The axis of suspension may not greatly shift. In anteflexion the body is bent for- wards, the vaginal-portion points doAvmvards, being, perhaps, but not necessarily, thrown up a little backwards. In retroflexion^ the body is bent backAvards, the vaginal-portion still points doAvmvards, and is, per- haps, but not necessarily, thrown a little forwards and upwards. In short, the flexions often involve a little version, that is, a slight rotation of the whole uterus upon its axis of suspension. The annexed diagram will serve to illustrate the versions and flexions of the uterus. (See Fig. 128.) In version the entire uterus revolves on the transverse axis, maintain- ing its ordinary shape. Asa lever, the dipping of the body or upper end elevates the loAver end in the opposite direction in a corresponding degree. In flexion, the lever may be considered as broken in its middle, so that dipping of the body gives only a small degree of elevation to the other end. Thus the os in version looks either fonvards or backwards, and is high in the pelvis ; whilst in flexion, the os still looks downwards, and is more central and often loAver in the pelvis. As anteversion and anteflexion are exaggerations of the normal condi- tions, Ave may fitly notice these first. Anteversion Avas carefully described by Levret. During the period of development, the uterus is bent upon itself, forming a curve or flexure, Avith the concavity directed forwards. This state of anteversion and anteflexion commonly continues in a more or less marked degree until the advent of puberty. It frequently persists in virgins and the sterile throughout life. Anteflexion, indeed, is a con- dition disposing to sterility, and is often associated with a conical vaginal- portion, a small os uteri externum, and a short vagina, all indications of imperfect development. Dysmenorrhea, with or without excess of men- strual Aoav, commonly attends. AVhen not of primitive origin, it is some- times induced by the development of a fibroid tumor in the anterior Avail of the uterus. The bend is commonly at the junction of the body and neck ; and here some degree of atrophy is often found. The fundus falls into the peritoneal fold behind the bladder, and thus sinks into the blad- der, depressing it, leading to irritability of the organ and dysuria. During early pregnancy, the fundus of the uterus inclines more down- wards and forwards, the os tilting more upAvards under the promontory, thus increasing its natural anteversion. But, the fundus pointing above the symphysis pubis as the uterus enlarges, it grows out of the pelvis, clearing the brim, and gradually rising, so as to assume a direction more approaching coincidence with that of the axis of the brim. The bladder also filling beloAv, tends to lift the fundus out of the pelvis. In some rare cases, hoAvever, of early pregnancy, the fundus has been locked behind the symphysis pubis in complete anteversion, forming the counterpart to the retroversion of the gravid uterus. (See V. Hiiter, Monatsschr. fur Geburtskunde, 1863.) The more common form of anteversion of preg- nancy, however, is rarely marked before the fifth or sixth month, and then there is usually flexion as Avell. It occurs especially in women who have had many children, and Avhose abdominal Avails are exceedingly re- ANTEVERSION. 587 laxed, the recti muscles, perhaps, having been stretched apart. Hold says it is favored by too great inclination of the pelvis. (Hohl, Eehrb. der Geburtshulfe, 1862.) It is favored by Avearing stays, which pressing on the growing uterus at the fundus, help to throw this part downwards and forwards. In this Avay, at term, Ave find the uterus lying on the symphysis, the cervix curving a little doAvnwards into the pelvis behind, whilst the body and fundus hang dowmvards in front of the pelvis, some- times even approaching the knees. The management of this condition is of course entirely obstetrical. It is carefully described in my work on Obstetric Operations. Anteversion also occurs from the body of the uterus being overweighted, as by hypertrophy, Avhen there is ever so little forward inclination of the organ. The uterus moves as a lever upon its axis of suspension. Its longer arm is above this axis or hypomochlion, so that the most mode- rate increase of bulk and Aveight at the extremity of this arm Aveighs it down. This condition of hypertrophic enlargement of the body of the uterus is not uncommon. I have seen it arise from imperfect involution, from congestion kept up by menorrhagia, over-exertion, and tumors. In Avo- men past the climacteric the foundation is commonly laid during the child- bearing period, but upon this foundation of sub-involution, a superstructure of further hypertrophic groAvth is laid by the obstruction to the portal circulation which so frequently exists after the climacteric. When this process is once set going, it tends to maintain itself. There is a more or less active developmental force kept up in the uterus ; blood is attracted to it, retained in it; there is haemostasis, and this condition constantly leads to increased deposit and bulk of the organ affected. This attraction of blood is continual^ liable to excess ; and then the uterus being an organ designed for, and habitually disposed to, the shedding of blood, hemor- rhage takes place. Long past the climacteric, and therefore probably long past the influence of ovarian stimulus, these hemorrhages observe a degree of order in recurrence. They do not, indeed, recur with such striking regularity as do the menstrual discharges ; but still they evince the subjection of the economy to the laAv of periodicity. The flexions are frequent, both congenital and acquired. These are of all degrees, varying from the slightest bending, or boAving, to the ex- treme degree in which the body is doubled up upon the cervix, as in Fig. 136. A slight degree of anteflexion must be considered as normal. It is the O © persistence of the infantile state. Indeed, the axis of the uterus is rarely quite straight. This axis is represented by a slight curve, passing through the cavities of the cervix and body. It corresponds more or less closely with the curvilinear axis of the pelvis. This is a point important to re- member, because the instrument makers invariably sell the uterine sound set at an angle from the shoulder, which marks the length of the two uterine cavities, this intra-uterine portion being quite straight. To pass in easily, this portion should be gently cuned. When the anteflexion exceeds a slight degree, it must be regarded as abnormal; indeed, symptoms more or less distressing rarely fail to attend. 588 VERSIONS AND FLEXIONS. The factors predisposing to acquired anteversion and anteflexion are 1st, undue softness or flaccidity of the uterine tissue ; 2d, increased bulk and weight of the body of the uterus, increasing leverage of this part. The immediate cause is'force acting upon the fundus uteri at its posterior aspect. 1. These conditions are present immediately after labor and abortion, and many cases of flexion date from one of these events. Undue softness, hoAvever, as Graily HeAvitt insists, may arise from malnutrition. 2. Professor Martin describes as a cause of anteflexion or retroflexion the sub-involution of the placental site. Thus, if the placenta had grown to the posterior wall, and this portion remain imperfectly reduced, being thicker and longer than the anterior wall, the fundus will be pushed over fonvards, producing anteflexion. If the placenta had groAvn to the ante- rior Avail, retroflexion would be produced. 3. Alrchow bases the origin of anteflexion on the relations betAveen uterus, bladder, and rectum, and chiefly on the pressure which the dis- tended bladder exerts on the cervix in the region of the os internum, where the peritoneal boundary of the distended bladder ceases. The atrophy of tissue, found principally at this place, is, he says, caused by this pressure. 1'artial atrophy in the region of the uterine neck, hoAvever produced, is a predisposing cause of flexion. This part becoming com- paratively weaker, the body is bent down upon the cervical portion, under the superincumbent pressure of the intestines. In some few cases there is flexion below the os internum, about the middle of the cendx ; and occasionally there is a double flexion, one back- Avards in the middle of the cervix, one fonvards at the os internum, so that the uterus and its cendx describe a bending like an S. 4. A tumor in the fundus or anterior Avail of the uterus. 5. The uterus is occasionally bound doAvn in anteversion by adhesions. These may be the result of pelvic peritonitis from haematocele in the an- terior peritoneal pouch ; from puerperal inflammation, or other causes. The folloAving history is not very uncommon: A Avoman Avho had never been pregnant had menstruated regularly until six months previously, when she had " inflammation," and great pain in the abdomen, for Avhich she was leeched and blistered. She was menstruating at the time of the attack. Menstruation irregular since ; has dragging pains in the loAver abdomen; great irritability of the bladder, frequent desire to pass water. The body of the uterus is enlarged ; it is fixed in anteversion, as if groAV- ing to the fundus of the bladder; it cannot be moved ; the cervix moves in a limited extent; there is a creamy discharge from the os. In this case, it seemed clear that there had been peritonitis, leaving adhesions which bowed down the fundus uteri. 6. A not infrequent cause of anteversion is coitus. Under certain conditions, the vaginal-portion is driven backAvards and upAvards, and in- clination of the fundus ensues. 7. Rokitansky says excessive inclination of the pelvis disposes to ante- version. Like most other diseases of the uterus, but in a more marked decree, displacements act in three ways, producing three sets of symptoms.0 1. Functional, relating to the organ itself. ANTEVERSION. 589 2. Mechanical, by pressure upon surrounding organs. 3. Ixemote, or constitutional, due to the reaction of the tAvo former. 1. The functional symptoms of anteversion.—Slight excess of inclina- tion may entail little distress. But if the axis of the uterus become hori- zontal, so that the fundus rests upon the symphysis pubis, or gets behind it, troublesome symptoms arise. In most cases, probably some enlarge- ment of the body of the uterus precedes the inclination. But in all cases increased enlargement of this part is sure to follow. This is the almost necessary consequence of the impediment which the displacement offers to the return of blood from the uterine vessels. This leads to chronic hypergemia, and hence a frequent symptom is menorrhagia or metror- rhagia. Leucorrhoea, another mode by Avhich the gorged tissue seeks relief, folloAvs the hemorrhage. The excess of blood collected in the uterus, and the obstacle presented to its escape by the abnormal position, and by the SAvelling of the tissues, cause dysmenorrhoea. Dyspareunia is a very common symptom. Pain is due to compression of tissue Avhich entails pressure on the nerves. 2. The pressure symptoms.—The enlarged fundus presses upon the bladder, and irritates this organ. Hence frequent urgency to pass water, without the want being ever satisfied. The patient may have to get out of bed many times a night. There is dysuria as well, and occasionally retention, for Avhich the catheter may be necessary. That bladder dis- tress is not more frequent is explained by the fact that the uterus often assumes an oblique position, the fundus not lying in the median line, but to one side, thus avoiding the bladder. The straining causes pelvic pain. If the axis of the uterus is preserved, as in anteversion simple, the vaginal-portion rises under the promontory, protrubes the posterior wall of the vagina, buries itself in the rectum, causing a distinct prominence in that cavity. Hence there is often dyschezia, leading to irritability of the boAvel, tenesmus, diarrhoea, or constipation. The pain is commonly increased in the upright posture and by exertion. Hence the patient is soon induced to lead an inactive life. I have knoAvn this projection into the boAvel provoke most intense suf- fering. It has led to the suspicion of disease of the bowel, especially of stricture. The strong projection against one point of the vagina also causes irri- tation, leucorrhoea, and sometimes even ulceration at this part. 3. The remote or sympathetic and constitutional symptoms are those which ensue upon most other uterine diseases. There is irritation of the nervous centres, and consequent disordered distribution of nerve force to the economy, entailing various functional disturbances. And after a time the hemorrhagic and leucorrhceal discharges impoverish the blood, and lead to impaired nutrition. The sufferings are commonly much increased at the onset of the men- strual periods, Avhich are marked by severe uterine colic, attended often by vomiting, hysteria, and other nervous disorders. The general course of anteversion or anteflexion is tOAvards aggrava- tion. There is little tendency to spontaneous reposition. Some amount of accommodation in the course of time may lead to tolerance. But as 590 VERSIONS AND FLEXIONS. a rule the artificial reduction of the uterus to its normal position is in- dicated. Diagnosis of Anteversion.—The diagnosis is not usually difficult. AVe have, in the first place, a series of subjective symptoms already described. The absolute diagnosis is made out by physical exploration. 1. Vaginal touch discovers the os uteri high up under the promontory of the sacrum, and generally pointing backwards ; feeling along the roof and anterior wall of the vagina in front of the os uteri, we find this in a state of more or less tension, strained backwards by the retreating cervix. Through this stretched roof Ave feel the solid mass of the uterus. 2. Now, com- bining abdominal touch with the vaginal touch, we can grasp the body of the uterus between the hand outside and the finger inside ; the fundus is felt through the abdominal wall, above or behind, but mostly above the symphysis ; pushing the fundus backwards, we feel the whole uterus move upon the examining finger. 3. By rectal touch, combined with abdominal touch, this is made even clearer, as the finger in the rectum gets more completely behind and above the os uteri, so that the finger on the os and the hand on the fundus measure the Avhole length of the uterus betAveen. 4. The uterine sound, moderately curved, is passed into the os uteri, whilst the vaginal-portion is depressed by the finger above it, the handle of the instrument then carried backAvards, directs the point forwards into the body of the uterus. It will often pass \ or | inch, or more, beyond the normal length, and when it has gone the full length, the vaginal-portion being brought doAvmvards by the instrument, the fundus rises and is felt more distinctly above the symphysis by the hand outside. Pressing upon the fundus, movement is imparted to the Avhole uterus and sound, which is very perceptible to the hand holding the in- strument. The foregoing methods of examination will also give accurate estimate of the increase of bulk from hyperplasia, and by irregularity of form of the presence of a tumor. The range of mobility of the point of the sound will also give an idea of the enlargement of the cavity of the uterus, and if there is anything inside it. But since early pregnancy may be the cause of the enlargement and anteversion, it is of primary importance to exclude the probability of this condition before using the sound. If menstruation have been sus- pended for a month or more ; if the os uteri feel soft; if there be the elastic anterior roof stretching (see p. 163) characteristic of pregnancy; if there be the dark-red coloration of the vagina and vulva; if there be present the recognized mammary changes, lay aside the sound. I have several times known the enlarged anteverted or anteflected uterus projecting over the symphysis mistaken for a tumor. Unless the sound be used it may be difficult to convince a person who has fallen into this error of the true nature of the case. But in practised hands the sound is rarely necessary to make out a satisfactory diagnosis. In most cases it will be useful, as the first step in physical diagnosis, to empty the bladder. Treatment of Anteversion. — The indications are threefold: 1. To allay the complications, as congestion, or inflammation of the uterus, which either preceded or arose after the displacement. I place this in- ANTEVERSION. 591 dication first, because the complications are often the most immediate causes of distress, and because, until they are somewhat relieved, me- chanical means to rectify the malposition cannot ahvays be borne. If, then, there be marked increase of bulk, with tenderness of the uterus, it may be desirable to apply four or five leeches to the roof of the vagina, or double that number to the abdomen above the pubes. The patient should keep the recumbent posture, the dorsal being the best adapted to counteract anteversion. Salines and sedatives will be necessary. And some advantage may be derived from tepid vaginal irrigation, and the use of sedative pessaries containing morphia or belladonna. If the os uteri externum be narroAV, we may commonly greatly promote the subsidence of congestion by the bilateral incision of the vaginal-por- tion. This is not only a very effectual method of local depletion, but the freer opening of the canal, by giving readier exit to menstrual blood and mucous secretions, obviates a great source of future engorgements, and hence of spasmodic attacks. 2. AVhen the first indication has been accomplished, Ave may proceed to carry out the second and third. The second is to rectify the malposi- tion. The sound is much relied upon by some practitioners. Of course it is immediately effective. But the version quickly returns. The me- chanical contrivances designed to maintain the due position are numerous. The first condition to fulfil is, as far as possible, to take off the superin- cumbent Aveight of the intestines. In many cases there is a disposition to pendulous abdomen, and hence to SAvagging of the intestines fonvards. This, besides pressing directly upon the posterior Avail of the uterus, Avhich looks upAvards, involves a sluggish imperfect action of the intestinal canal, Avith lodgment of faeces and distension Avith air. Under due sup- port this fault is greatly corrected. This is effected by the adaptation of a good abdominal belt, Avhich supports and strengthens the abdominal wall from its lowest part. In some cases Avhere the enlarged fundus uteri projects sensibly above the symphysis, the lower margin of the belt may be made to seize this part and directly lift it up, thus taking off the pressure from the bladder. To do this the more effectually, a pad may be inserted in the belt. The amount of success to be derived from the belt will depend greatly upon the intelligence and skill of the maker. The second condition is to support the anteverted fundus from within. The great difficulty in contriving a pessary which will do this, lies in the circumstance that pessaries naturally seek by their upper end to rest in the posterior vaginal cul de-sac, that is, to get behind the cervix uteri, whilst the lower end will rest upon the anterior vaginal wall. Regarding the uterus as a lever which has to be made to rotate upon its axis of suspension, Ave have to consider upon which arm of the lever we shall act. We may, for example, push up the longer arm by apply- ing some elevating poAver to the fundus ; or Ave may draw down the shorter arm by pulling upon the vaginal-portion. Instruments have been devised upon both these principles. Amongst those intended to lift up the fundus may be mentioned the modifications of the air-pessary described by Gil- lebert d'llericourt; and a modification of Dr. Roper's described in the Catalogue of Instruments of the Obstetrical Society, which bears in front of the axis of suspension. >92 VERSIONS AND FLEXIONS, " the cradle-pessary,' Fig. 129. The most ingenious contrivance is that of Dr. (rraily Hewitt. _ I his, seems to me the best designed. Fig. 129 gives a general idea of its form. But form and size require careful modification to the particular case. It should not fit tightly, but nursing the uterus, so to speak, it and uterus should move together. The middle arms, which support the anterior —-'*' surface of the uterus vary in length, but as a rule they must be long enough to reach the body of the uterus, that is, to bear on the body end of the uterine lever. Professor Thomas has also devised an anteversion pessary. Its basis is a Hodge's lever; but attached to the ante- rior aspect of this basis is a horse-shoe lever, set at a moderate angle. The curved part of this horse-shoe rises up behind the symphysis pubis, and lifts up the fundus uteri. The size of the instru- ment requires careful adaptation to the case in hand. I have derived consider- able satisfaction from this instrument. The anteversion pessaries, even more than those for the relief of retroversion, require careful observation. For the first few days the patient should observe nearly absolute rest. If pain occurs, the instrument should be remoAred, taking note of the cause of the distress, be it inflammation, improper shape, or size of the instrument; and care taken to obviate the cause on readjusting an instrument. During the wearing the patient should lead a life of moderate exertion at best; and submit to examina- tion at least once a month. I have made the acquaintance of many of the instruments for correct- ing malpositions through their failure in particular cases. I have been called upon to remove them Avhen they were the causes of distress and even of danger. I feel, hoAvever, that it would be wrong to draw from this kind of experience an unqualified adverse opinion. The use of these same instruments may in many other cases have been beneficial; and, naturally, these cases would not be so likely to come under the observa- tion of another physician. A pessary Avhich compels the wearer to forego exercise, to keep on the sofa, may be pronounced a failure. Under these conditions the health must give Avay ; there can be no improvement in tissue. Surgery, again, offers resources for the relief of this malposition. It is obvious that if Ave could so shorten the anterior wall of the vagina at its upper part as to drag upon the cervix, we should bring this part of the uterus dowmvards and forwards. This may in some cases be accom- plished by removing a triangular piece of mucous membrane from the vagina in front of the cervix, and contracting the part by bringing the To illustrateGraily Hewitt's "Cradle- Pessary." The dotted outline represents the ute- rus in anteversion. a. The posterior arm of the pessary. 6. The anterior arm which sits behind the symphysis, c. The mid- dle rise of the pessary which supports the anterior wall of the body of the uterus. ANTEFLEXION. 593 edges^ together. The object might also be attained by establishing a cicatrix at this part by potassa cum calce or the actual cautery. 3. Concurrently Avith the endeavor to correct the malposition, it is de- sirable to carry out the third indication, namely, to improve the general tone and nutrition. To complete and especially to maintain a cure, Ave want good muscular fibre and sound tissues. The first condition to obtain these is obviously healthy nutrition, the capacity for converting food into healthy structure. AVe may aid in correcting this fault by two methods. First, by placing the patient in good hygienic conditions, and the use of tonic medicines, as strychnine, iron, quinine ; and, secondly, by local applications to the Aveak tissues of the vagina and uterus. Some amount of uterine catarrh is almost constant. This is best treated by introduc- ing two or three grains of solid sulphate of zinc into the uterine cavity, or sAvabbing with tincture of iodine every four or five days. Astringents to the vagina, in the form of injections or pessaries, will lend material help. Emmet has arrived at some remarkable conclusions {Gynecological Trans., 187')) as to the etiology of flexions. He distinguishes flexions of the cervix and flexions of the body as a whole. His statistics shoAv that the woman Avho has been impregnated is rarely found Avith a flexion of the cendx, and that in comparison with other women, she is but little liable to flexion of the body. Future observation he thinks Avill settle the point that the existence of a flexion of the cervix should be proof that impregnation had never taken place. Flexions of the body fonvard are the most frequent. Emmet's observations are extremely interesting, and challenge further examination. I fully recognize the relative fre- quency of flexions in Avomen avIio have been pregnant. But I am unable at present to concur unreservedly in his opinion that flexion of the cervix is proof of non-impregnation. Flexions of the cervix have, says Emmet, their origin at about the age of puberty by the balance being lost between the relative groAvth of the body and cervix. ANTEFLEXION. Arersion may pass into flexion. The position of the cervix being main- tained by its relation to the bladder on the axis of suspension, and the body being movable and soft, pressure acting upon its hinder surface will gradually bend it down, breaking it as it were at the union of body and cervix. The causes of anteflexion arc similar to those Avhich lead to antever- sion, excepting coitus. To these may be added a state of Aveakness at the juncture of cervix and body from relaxation, Avhich disposes the organ to bend at this point. It may be congenital or acquired. The congeni- tal anteflexion, being a persistence of the natural condition in an exagge- rated form, tends to be corrected Avith time, and especially by pregnancy, should this take place. But not rarely the bending is much in excess of the normal degree. The organ has quite the form of a retort, the fundus nodding so Ioav that the summit looks doAvn, and is almost on a level Avith the os. There is commonly some degree of general deficiency of sexual 38 591 ANTEFLEXION. development associated with this condition, more especially a small coni- cal vaginal-portion Avith a minute os externum, and a short vagina. ihis form may lead to no trouble until the advent of puberty or marriage. It is difficult to form even a rough estimate of its influence as a cause of dysmenorrhea or of other disorder, since it is only those cases in Avhich actual disorder arises that come under medical care. There may then possibly exist many cases of extreme anteflexion, unattended by distress. On the other hand", it is certain that in many women who seek relief for menstrual disorder, dyspareunia, sterility, Ave find marked anteflexion ; and I am disposed to infer that anteflexion rarely fails to entail trouble. It is obvious that extreme flexion of the uterus, with a depending fundus, must present a mechanical difficulty to the flow of the menstrual fluid. Hence a degree of retention, causing pain, and engorgement of the organ ; Fio. 130. Extreme Anteflexion of the Uterus (R. B.). a. The os uteri; 6. the fundus, both looking forward. (Xat. size, London Hospital Museum.) and sooner or later hypertrophy of the fundus. Especially in married life these conditions are apt to be followed by metritis. Catarrh and dilatation of the cavity of the body of the uterus are rarely absent. Re- trograde ovarian irritation is induced. If under the general engorge- ment of the ovaries, tubes, and uterus attending a menstrual period, any perturbing cause, as cold, shock, sexual intercourse intervene, the transi- tion into inflammation in the form of metritis, oophoritis, peritonitis, or perimetritis is easy. AVhen relaxation of the uterine tissues and the surrounding structures has taken place, as from general loss of tone, or from local disorder, the fundus may be forced down upon, or behind, the bladder by the super- incumbent pressure. This may take place gradually, or suddenly under violent exertion or succussion. The same features are also Avell shown in Fig. 131, taken from Boivin and Dug&3. If not existing before the anteflexion, congestion, hyperplasia, hyper- trophy, are pretty sure to be developed afterwards, and to aggravate the displacement. Anteflexion has little tendeney to spontaneous cure. Rokitansky says that flexions sometimes tend to pass into versions, that is, the bent^doAvn cervix rises so that the uterus straightens itself. It is intelligible that the uterus Avhich has suffered sudden anteflexion may gradually, under a resilient force, lessen the bend imparted to it. But to do this, the rising cervix must drag upon the cervico-vesical connections, and either pull up DIAGNOSIS. 595 the base of the bladder, or the connective tissue betAveen must stretch. There must, in short, be shifting of the axis of suspension of the uterus. No doubt one or other or both these events take place in primary ante- version, and it is therefore not improbable that they may take place in Fir,. 131. Anteflexion of the Uterus. a. The fundus uteri ; 6. the vaginal-portion—both looking forward, c. The vagina. e. e. Fallopian tubes, d. d. The ovaries. (From Boivln and Dugfes.) the secondary anteversion of Rokitansky. But clinical evidence of this change has escaped me. I have known many cases of anteflexion that have lasted as such for lengthened periods. Anteflexion, like anteversion, produces three sets of symptoms. The first are due to changes in the uterus itself. These cannot be called special to anteflexion. They consist in difficult function, as dysmenor- rhoea, in the symptoms proper to congestion, inflammation, and hyper- trophy. Hence, menorrhagia and leucorrhoea are very common. But in many cases of congenital anteflexion, menorrhagia does not occur, or at least is not a continuous symptom. The second set of symptoms are those produced by the relations of the displaced uterus to surrounding organs. Irritation of the bladder, lead- ing to desire to often vroid it, is frequent. The third set of symptoms are the remote or constitutional. Jtiagnosis of Anteflexion.—All trustworthy means of diagnosis are centred in physical exploration. 1st. Yaginal digital touch feels the os uteri centrally or perhaps anteriorly or posteriorly situated, pointing downwards or a little backAvards. Passing the tip of the finger round the Araginal-portion, it feels behind, the elastic roof of the vagina at the angle of reflection from the vaginal-portion, and no solid substance through it; in front betAveen the vaginal-portion and the symphysis pubis it feels 59f poultices or warm water irrigations if the pain is great: by saline and sedative medicines. The mechanical treatment consists in the use of the sound and pessaries. The sound already used for diagnostic purposes is now applied to treatment. If by its means the uterus be replaced just before a menstrual period, Illustrating the mode of applying the Hodge or Lever-pessary lor Retroversion o Retroflexion (R. B.). The diagram represents the first stage of introduction. The pessary is passed edgewise in the line of the vulva fissure. During its passage the perineum is held back by the finger, and the pessary is pressed backwards so as to avoid the symphysis. and the patient be kept at rest, it is possible that the proper position may be maintained throughout the period. Should this happen, the period will pass off more easily, and a step will be gained towards cure. The uterus will escape an increment of excessive congestion : and it may soon be able to bear the contact of a pessary. The best form of pessary is one of Hodge* s. The size is selected according to the capacity of the vagina, bearing in mind the rule that it must not be so large as to stretch the canal. Its upper limb must rise to fill the cul-de-sac behind the vaginal-portion, whilst the lower limb rests upon the anterior wall of the vagina, not descending below the middle of the symphysis pubis. Imme- TREATMENT. 603 diately before applying the pessary it is desirable to restore the uterus by the sound or finger. One great test of the fitness of the pessary consists in its being borne Avithout pain. If it cause pain, it must Avith- out hesitation be withdrawn, and, guided by the information obtained by the failure, Ave select another pessary. Fig. 134. The Second Stage in the application of the Hodge-pessary (R. B.). The pessary has been turned in the transverse diameter of the pelvis after dealing the vulva. The upper limb runs up in front of the cervix uteri. If the pessary fits well, the patient needs no longer to be confined to the recumbent posture. It is not the least of the many useful points of this admirable instrument, that its beneficial action is even promoted by moderate exercise. In the upright posture the inspiratory effort carries down the anterior Avail of the vagina, and with this the loAver limb of the lever ; the upper limb rises and comes fonvard, gently pushing the body of the uterus before it; the long axis of the lever under these circum- stances oscillates lightly a little on either side of the vertical line ; every 601 RETROVERSION. movement, every respiration, carrying the fundus of the uterus tOAvards its natural inclination. (iradually under the influence of this support, the tumefaction of the body of the uterus diminishes, and with it the tendency to fall over back- Avards ; the vagina and other supports, relieved of undue strain, recover their tone ; and, by-and-bye, the pessary can be dispensed with. Fig. 135. Showing the Third and Final Stage of the Application of the Hodge-pessary (R. B.). The upper limb has been carried by the finger behind the cervix ; the lower limb lies behind the symphysis pubis. A shows the ordinary position of the pessary during expiration ; the dotted pes- sary b shows the retreat of the lower limb during inspiration. This is the essential principle of treatment; but certain accessory means are often useful. Morbid complications, local or general, must be dealt with according to their indications. Since not uncommonly there exist some engorgement with abrasion of the vaginal-portion, and catarrh of the centico-uterine cavity, an occasional touch of nitrate of silver or the introduction of a small stick of sulphate of zinc, or painting with tincture of iodine, will much accelerate the cure. Astringent vaginal injections will also be useful. An important point is to obviate constipation and accumulation of feces. AVhen adhesions bind doAVn the retroverted body of the uterus, the use RETROFLEXION. 605 of the sound to rectify the malposition must be omitted. But the lever- pessary will still be useful. It will sometimes be necessary to use in the first instance a smaller pessary. The adhesions will generally slowly stretch under the continuous gradual action of the lever ; and under this gradual elongation the adhesions disappear by atrophy. Pregnancy Avill sometimes in like manner stretch and induce atrophy of the adhe- sions. If not, by hindering the development of the uterus, they may cause abortion. Probably feAv cases of retroversion uncomplicated by tumors in the walls of the uterus, or not caused by the pressure of tumors outside, would long resist treatment, if Ave could exclude counteracting accidents. But it is difficult to command all the conditions of success : especially the securing functional rest of the organs affected, the postponement of preg- nancy, the avoidance of excessive bodily exercise, and other disturbing causes. Retroflexion consists in an arching of the uterus backAvards. AVe dis- tinguish tAvo forms: the primary, or congenital; and the secondary, or acquired. The primary cases may be often discovered in the early years of menstrual life. They are found in the virginal state. The rational clinical inference is that the flexion existed during childhood. During this period, the uterus, having no functional existence, lies small, undeveloped, passive, and gives rise to no subjective symptoms. But \vhen the organ becomes subject to the periodical hyperaemia of menstru- ation, the obstacle set by this malformation gives rise to dysmenorrhoea. And the body of the uterus being enlarged by the development incident to its entry upon functional activity, and also abnormally by the conges- tions to Avhich it is exposed, and the impediment offered to its circulation, becomes the source of other troubles Avhich cannot be overlooked. Still, although something beyond the normal degree of enlargement generally takes place after the onset of menstrual life, this primary form of retroflexion is rarely marked by such considerable enlargements of the body of the uterus as are commonly observed in the acquired forms Avhich ensue upon child-bed. AVhen Avomen having a retroflected uterus marry, their suffering com- monly becomes aggravated. A new source of congestion is added to the menstrual flux ; tlie organ fails to get the intervals of rest it needs ; a state of persistent hyperaemia is induced, Avhich borders on inflammation ; this easily leads to hyperplasia, and hence to hypertrophy of the body of the uterus. Its functions are performed Avith increasing difficulty. The dysmenorrhoea is more severe ; menorrhagia is not uncommon ; and dys- pareunia is almost constant. This last effect often entails another— sterility. But sterility in association Avith retroflexion is more commonly due to the frequent complication Avith a narroAV os externum. This com- plication also aggravates the other evils, especially the dysmenorrhoea. The secondary or acquired form of retroflexion most commonly arises after childbirth or abortion. Labors attended by exhausting conditions, as hemorrhage, dispose especially to this displacement. The retroflexion often takes place within a few days of labor. At this time its tissues are soft, flabby, pliable ; the bulk of the uterus, especially of its body, is greatly above the normal size ; its Aveight is greater; and as the 606 RETROFLEXION. increased weight is put upon a larger body, that is, upon a longer lever, it easilv falls over, bending at the junction of body and neck, below which point the neck is fixed and supported by its attachment tothe bladder. In some cases there is a predisposition to retroflexion from this condition having existed before the pregnancy. But in many cases it takes place where no predisposing cause can be traced. It is produced by pressure acting upon the enlarged heavy flaccid uterus. If undue pressure is exerted within the first few days after labor, before the uterine walls have undergone marked shrinking and have recovered a fair degree of firmness from contraction and involution, retroversion or retroflexion is almost sure to follow. If involution have advanced a little, so that the bulk of the uterus is sensibly diminished and the rigidity of its walls is increased, prolapsus is more likely to occur than flexion. I have said that flooding disposes to retroflexion by Aveakening tissue. It does so in still another Avay. A little blood or a clot is often retained in the uterine cavity ; this keeps up excessive bulk of the organ, and retards involution ; the expulsive efforts excited by the presence of clots bring the pressure of the abdominal muscles to bear upon the body of the uterus, and this is rolled over. This bearing of expulsive action upon the anterior sur- face of the uterine body is further promoted by the squatting of the uterus in the lax vagina, a condition of prolapsus Avhich already implies a minor degree of retroversion. Retroflexion, in its turn, keeps up secondary puerperal hemorrhage, and thus each evil aggravates the other. Professor Martin's explanation of the influence of defective involution of the placental site already cited (see p. 588) applies to retroflexion. Defective involution of the anterior Avail leads to retroflexion. Flexions are also caused by tumors in the fundus uteri, by pressure of tumors external to it—as ovarian, by pseudo-membranous adhesions. Retroflexion may long persist as simple bending or arching ; but grad- ually, although seldom, it proceeds to angulation, assuming the form of a retort. The angulation occurs at the point of extreme arching, and this corres- ponds more or less closely to the os internum uteri. Occasionally it occurs in the cervix itself, about the middle, betAveen the os internum and os externum. Sometimes, says Rokitansky, retroflexion passes into retroversion. The cervix folloAvs the bending back of the body, whilst it is draAvn up- Avards. In moderate retroflexions, there is observed an inclination of the vaginal-portion forwards and upAvards, so that the anterior lip seems flattened: and as the flexion increased, the duplicature Avhich constitutes it vanishes. I do not knoAv hoAV far this description is draAvn from clini- cal observations on the living. I am not myself in a position to affirm its accuracy. Sometimes the bending is so great that the fundus comes down to the level of the os, as in Fig. 136. (This preparation is, I think, erroneously described as an anteflexion in the catalogue). It also de- monstrates a very important point in the pathology of retroflexion. It s1ioavs that atrophy, or Avasting of tissue at the seat of flexion, is not a necessary condition. In this preparation the inferior wall is everyAvhere as thick as in the natural state. I am convinced that this is very fre- CAUSES OF. 607 quentiy, if not, indeed, most commonly, the case. Clinical observation satisfies me that on rectification of the position by the sound or a Hodge's pessary, the walls of the uterus commonly present their normal thickness. Fig. 13G. (From Nature, from a specimen in Middlesex Hospital Museum.) Extreme retroflexion of the uterus (R. B.). A section is made through the centre, showing atresia in places of the canal of the uterus. Still another point in the history of retroflexion is exhibited in this preparation. It shoAvs that the walls of the uterine canal have groAvn to- gether, producing atresia in the neighborhood of the os uteri internum. Rokitansky and VirchoAv both describe this atrophy and narrowing at the point of extreme flexion, but interpret it differently. Rokitansky says the mucous membrane of the cervix is normally thick and strong, becoming gradually thinner towards the body of the uterus. The seat of inflexion, he says, is ahvays the neighborhood of the internal os. 1 le finds the connective tissue at this spot thinner and looser, and says this is the result of catarrh of the uterus after labor. VirchoAv points out that the whole cervix, excepting the portio-vaginalis, is united by connective tissue to surrounding parts, especially to the hinder and under surface of the bladder. The cervix thus fixed, inflexions are produced by inflammatory adhesions dragging upon the body of the uterus. Thus, Rokitansky thinks the atrophy of the internal orifice primary; Yirchow thinks it secondary. Clinical observation proves that in the majority of instances, at any rate, there are no adhesions. The fundus can generally be lifted up to its normal position. Again the frequency of cure under the use of Hodge's pessary proves the same thing. Nor can it be admitted that Rokitansky's theory is more than occasionally true. Retroflexion is undoubtedly frequently first observed to folloAV labor immediately, that is, before uterine catarrh can have set in. The mechanism in these cases is simply this: the heavy fundus, being in a flaccid state, falls back, partly by its gravity, partly by being forced doAvn under the pressure of the intestines. In such cases, involu- tion becoming impeded, catarrh will almost always ensue, and from long- continued angulation, the tissues at the seat of flexion Avill undergo some amount of atrophy. It is this altered state of the tissues of the cervix, 608 RETROFLEXION. combined with the increased weight and bulk of the fundus, that makes restoration to the normal position so difficult and tedious in some cases. Retroflexion is far more frequent than retroversion, that is, than retro- version independent of prolapsus. Pathological deductions drawn from statistics are exposed to such numerous fallacies which no sacrifice of time and toil can obviate, that I do not attempt to give any numerical estimate of the frequency of the occurrence of retroflexion. It is enough to say that, in any given large number of women complaining of pelvic distress, a considerable proportion will be found to have retroflexion. It is a frequent cause of dysmenorrhoea, menorrhagia, uterine hemorrhage, leucorrhcea, abortion ; and this is not a contradiction of sterility. It pro- duces also distress by pressure on surrounding parts. The mass consisting of the enlarged bent-back uterus protrudes into the cavity of the rectum, and obstructs it like a ball-valve. The stools become flattened or ribbon- like. It is true the cases are rare in Avhich anything like absolute closure of the rectum by approximation of its Avails occurs. But a close degree of occlusion is not necessary to cause great disturbance of the function of the rectum. The effect of a foreign body constantly protruding into the intestine is something more than is accounted for by mere contraction of its calibre. The constant irritation disturbs or perverts the normal action of the muscular coat. The pain felt in defecation induces the suf- ferer to postpone the execution of this necessary act; hence there arise gradual accumulation of feces, and a habit of constipation ; these in time induce permanent distension of the canal, and a loss of peristaltic poAver, Avhich may fairly be considered as a degree of intestinal paralysis. If defecation produce these results, a retrograde obstruction and disturbance of the Avhole digestive functions is sure to folloAV. Retention of the residue of the food in the large intestines leads to decomposition ; hence flatu- lence and absorption of some of the elements of this decomposition. The effect of this form of blood-poisoning, to which the term "copraemia" may not improperly be applied, is seen in the sallow, dirty hue of the skin, and the unpleasant exhalations from it. Ascending the course of the alimentary canal, the difficulty presented beloAv leads to difficult and imperfect performance of the functions of the small intestine and stomach; hence fermentation, flatulence, pyrosis, nausea, and the various pheno- mena grouped under dyspepsia. The liver will hardly escape, especially when, as is frequently the case in Avomen of extreme nervous suscepti- bility, vomiting is induced. Imperfect digestion has for its inevitable consequence imperfect nutrition and disordered secretions. And thus it happens that in time no organ is left unimpaired, no function is healthily performed. The nervous system, often so susceptible in women, will exhibit the most marked aberrations. The nervous centres respond to the slightest impressions. Hysteria breaks out in all its manifold eccentricities ; neu- ralgia appears in one or more of its various forms, as sciatica, lumbago, tic douleureux, rheumatism ; headache and a disposition to vertigo or syncope frequently recur; emotional, moral and intellectual disturbance, as manifested in irritability, despondency, melancholy, loss of command OA-er feeling and thought are often developed. Many of these phenomena may be thus traced to bad nutrition; but there is good reason to believe EFFECTS OF. (\09 that some, especially the nervous phenomena, are more directly induced, or are at any rate aggravated by the influence of the displaced uterus upon the nervous centres. The congested displaced organ is a constant source of nervous irritation and exhaustion; it is constantly pressing upon the sacral plexus ; it is constantly sending painful impressions to the nervous centres ; constantly using up in a morbid direction the nerve- force which is wanted for the performance of healthy function. A not uncommon form of nervous disorder induced by retroflexion is severe, almost persistent pain in the lower part of the spine ; sometimes most intense in one fixed spot, where it is easy to evoke the sense of ten- derness on pressure. Many such cases have been treated as sufferers from spinal disease, and have been confined to the couch Avearing various spinal instruments for months and years, under the erroneous belief that the spinal suffering was primary and essential; its mere symptomatic character not being suspected. With or without this marked spinal pain, a sense of numbness, of want of power, especially of inability to walk, are often complained of, and tend to confirm the belief in spinal disease. Brown-Sequard distinctly traced paraplegia to a retroflected uterus. I can well imagine the surprise which the attribution of these formid- able consequences to retroflexion of the womb will excite in the minds of those physicians who are ignorant of the pathology of the pelvic organs. Such, they will perhaps exclaim, are the extravagances of specialists. Yet, I would ask, is not the sequence of events as narrated quite in harmony with sound physiology and pathology ? I am very sure they are in har- mony with accurate clinical observation. If this be doubted by those Avho are ignorant of gynaecology, may it not be because they have thought it possible to study successfully disease in women, whilst omitting to take note of the diseases of those organs which make her Avhat she is ? The test of treatment confirms the conclusion drawn from diagnostic exploration. In the great majority of cases the evils enumerated as found in association Avith retroflexion are relieved and finally removed when the retroflexion and its local consequences are cured. The persistence of flexion induces certain changes in the uterus. Ob- struction to its circulation brings congestion; this leads to hyperplasia and hypertrophy of its walls, especially of the body, the vaginal-portion often partaking only slightly in this change. The obstruction to the escape of menstrual and mucous secretions from the cavity of the uterus increases the congestion and leads to increased secretion ; these 'being retained, uterine contractions are excited to expel them ; the os internum being more or less closed, the uterus contracting as a sphere upon its contents, these tend to escape equally in all directions, and hence pressure is brought to bear upon the openings of the Fallopian tubes as well as upon the os internum. There is then, in proportion to the extent of the obstacle opposed in the os internum, dilating force applied to the mouths of the tubes ; these gradually yield, and a retrograde dilatation of the tubes sometimes Avill follow. The dilatation of the cavity of the retro- flected uterus is ahvays attended by some amount of chronic inflammation of the mucous membrane or catarrh. Perhaps the term inflammation is ill-chosen ; the condition is rather one of constant engorgement leading to rapid shedding of epithelium and mucous secretion ; it is analogous to 39 610 RETROFLEXION. chronic catarrh of the lungs. The occasional retention of mucus in the uterus sets up colic. A certain quantity of mucus must accumulate before the uterus becomes so distended as to excite it to contract; this quantity in many women is remarkably definite, taking in some a week, in others a fortnight to collect, Why the expulsive colic simulating dysmenorrhoea occurs midway between tAvo periods is simply because the uterus being emptied at the menstrual epoch, the secretions begin to gather again from that time. Not seldom a little blood is mixed with the mucus. This is not to be interpreted as the result of ovulation, but is simply hemor- rhagic, the product of engorgement. It is a common history to hear from Avomen suffering from uterine obstruction that they have periodical gather- ings like an abscess in the womb attended by severe colic and expulsive pains which are relieved by the " bursting" and escape of a quantity of discharge. These cases are of the kind above described, although they may not exhibit equally regular periodicity. Serious dangers attend retroflexion from the persistence of this condi- tion after conception has taken place. The unfavorable shape of the uterus, and its retention in the pelvis, oppose the due development of the organ. Hence frequently abortion ensues ; and when this does not hap- pen, there is the more formidable danger arising from the locking of the enlarged uterus in the pelvis about the third or fourth month. The history of this accident is fully described in my Obstetric Operations. These probable events strongly enforce the expediency of curing retro- flexion. The flexions found in advann'd /(/Vmaybe the persistent flexions from an earlier age. But some undoubtedly take their origin after the climac- teric period. The body of the uterus, which has failed to undergo the normal senile retrogression or atrophy is pulpy, traversed by degenerating vessels, it is softer and thinner; its cavity is dilated, filled Avith catarrhal secretion ; its cervix is beset in its connective-tissue substratum with Nabothian vesicles, and often from the persistent production of these bodies it is atrophied and degenerated to a mere frame-Avork from their dehiscence in the tissue. This condition is principally found at the seat of the os internum ; indeed, here it has often proceeded to a scar-like retraction of the atrophied connective tissue, amounting to atresia. This is seen in Fig. 136. At this spot the uterine body sometimes bends in the shape of a fracture ; it may be backAvards or fonvards. The diagnosis of retroflexion differs in some degree from that of retro. version. The os uteri, instead of pointing fonvards near the symphysis pubis, points more or less downwards, and may be near the middle of the pelvic cavity. AArhen the body is much enlarged, however, the vaginal- portion is pushed fonvards, so that the os points downwards near the symphysis. The position and direction of the os uteri being determined, the exploring finger feels in front of the vaginal-portion seeking to trace the cervix and body of the uterus fonvards through the anterior roof of the vagina, the normal seat of the organ. Instead of feeling it here, the finger misses the resistance of solidity, and by combining abdominal pal- pation, the two hands may be brought to approach each other, when the absence of the uterus from its natural place is determined. The ex- ploring finger next feels on either side, and determines the condition of this EFFECTS OF. 611 part of the roof of the vagina. It is then carried behind the roof of the vaginal-portion and feels a firm uniform globular mass through the posterior wall of the vagina. Tracing this on to the vaginal-portion, the tip of the finger sinks into a groove betAveen the two. It is generally possible to determine the continuity of these two parts. This is best done by keeping the finger behind the vaginal-portion, so as to feel the body of the uterus, then to combine the abdominal touch so as to embrace the cervix betAveen the two hands. Movement imparted by one to the body betAveen will be felt by the other. Fig 137. Illustrating the diagnosis of retroflexion hy the vaginal touch (E. B.). This is made clearer still by the rectal touch. The finger in the rec- tum Avill travel round the outline of the post-cervical tumor to a greater extent than can the finger in the vagina. The abdominal touch combined with the rectal also affords more positive evidence than the abdomino- vaginal touch. The experimentum eruds, hoAvever, is performed with the sound. Be- fore passing it the probability of pregnancy must be carefully weighed. In the "reat majority of single persons, and of those Avho have lived a 612 RETROFLEXION. married life for several years without having children, the probability is strongly in the negative. The presumption is also in the negative in those who, having had children, seek relief from the consequences of retroflexion. Among these consequences frequently is acquired sterility. Two things help in forming an opinion: the date of the last menstrua- tion, and the bulk of the uterus. If the bulk be sensibly increased, and a period have been missed, of course the sound should not be used. It should Fig. 138. Diagnosis and reposition of the retroflected uterus by the sound (R. B.). A. The uterus in retroflexion, the sound in its cavity. B The uterus brought forward by reversing the sound. The fundus can now be felt by fingers pressing in the abdominal wall above the symphysis. not, however, be forgotten that increased bulk of the uterus is an almost constant attendant upon retroflexion. To pass the sound a curve is given to it corresponding to the idea formed of the degree of retroflexion. (See Fig. 138.) For example, if the mass supposed to be the fundus of the uterus falls beloAv the level of the cervix, and the angle or groove behind the cendx be very marked, the curve given to the sound must be DIAGNOSIS, TREATMENT. 613 considerable. But in the majority of instances a moderate curve will be enough. By a little manoeuvre, by lifting up the fundus by the finger Avhilst the point of the sound is passing the os internum, the seat of chief flexion, the whole organ is someAvhat straightened. This wonder- fully facilitates the passing of the sound. The first stage of the intro- duction of the sound is best effected by passing the point into the os ex- ternum as far as the os internum, Avith the concavity of the curve directed forwards ; then the point should be turned backAvards by making the handle describe a large circle, thus bringing the concavity backwards. The handle is then carried fonvards whilst the guiding finger lifts up the fundus ; the point then folloAving the curve of the canal penetrates to the fundus. When the sound has gone the normal length of two and a half inches, the mobility of the uterus must be ascertained by gently bringing the point of the sound forwards again, so as to fill the fundus and bring it into anteversion. This must be executed gently lest adhesions exist. It is also important, in order to avoid dragging the uterus, and the pres- sure upon its internal surface Avhich-.a large revolution of the point of the sound Avould cause, to reverse the sound by making the handle describe a large revolution. The portion then inside the uterus, if moderately curved, vs ill move upon its axis describing a very small circle, and conse- quently turning in the cavity Avithout exerting any injurious pressure. In short, the uterine sound should be handled with the same gentle touch, and in a similar manner as the catheter in traversing the male urethra. The tour-de-maitre practised in reversing the catheter to clear the portion of the urethra under the pubic arch, must be imitated when Ave seek to bring the retroflected uterus forward into anteversion. The reduction of the dislocated uterus to its normal position is a dis- tinct stage of the operation. - The following rule should ahvays be observed, and the more carefully whenever the body of the uterus is enlarged and tender. The fundus uteri must not be lifted directly up- Avards, lest it impinge upon the lower surface of the overhanging promontory. To clear this, the fundus must be directed to the left, tOAvards the sacro-iliac joint. Here there is plenty of room. This movement is ef- fected by the combined pressure of the finner, and the revolution of the sound. (See Fig. 139.) When the fundus has cleared the promon- tory, it is then brought fonvard to the sym- physis pubis describing a half-circle round the left side of the pelvic brim. When restoration is accomplished the demonstration is complete. There is no room for ambiguity. The tumor behind the cervix has disappeared; it has been brought fonvard to the normal place of the body of the uterus. Supported on the sound it can noAV be felt by the hand pressed in above the symphysis pubis ; and the pressure so exerted upon it is felt by the finger Avhich keeps watch upon the vaginal-portion inside. On Avithdrawing the sound, the uterus will Fig. 139. To show reduction of retroflected uterus by finger. View from above. The tip of finger is seen pushing fun- dus of uterus to left of sacral promon- tory (R. B.). See also Fig. 140. 611 RETROFLEXION. Fig. 140. often for a time maintain itself in its restored position. But more fre- quently its fundus will roll back a-ain. If we get all this evidence it is superfluous to discuss what are the conditions Avhich might be mistaken for retroflexion. Nothing but retro- flexion will give the evidence de- scribed. But it may not be possible or prudent to pass the sound. The two conditions most nearly simula- ting retroflexion are : a fibroid tumor in the posterior Avail of the uterus, and a retro-uterine hematocele. In both cases a firm rounded mass may be felt behind the vaginal-portion separated from it by a groove, and bulging forward the posterior wall of the vagina. But in both cases the body of the uterus may be felt by combined vaginal and abdominal touch above or behind the symphysis pubis. In the case of the retro-ute- rine haematocele the uterus is pressed bodily forwards, and the cervix is generally very close behind the symphysis pubis. Neither of these conditions per se excludes the sound. If this be passed, it is easy to demonstrate the position of the body of the uterus, and to distinguish it from the tumor behind the cervix. The principle of treatment of retroflexion is essentially the same in all its forms. One primary object to strive for is to bring the cervico-uterine canal as nearly as possible into one axis, so as to afford free communica- tion betAveen the cavity of the uterus and the vagina. AVhen this is attained the distress due to retention of blood, clots, or mucus will sub- side. The fulfilment of this indication further implies a considerable rectification of the position of the uterus, Avhich is the next object to strive for. The uterus can hardly be made straighter Avithout at the same time lifting up the fundus. AA'hen this is done, the engorgement of the body of the uterus will diminish, very often quickly ; as the bulk lessens there is a smaller degree of Adcious leverage to counteract, so that the cure may be expected to go on at an accelerated pace. The combined progress of rectification and of diminution of bulk brings immense relief to the organs hitherto pressed upon. The rectum especially, and the in- ferior part of the alimentary canal, are amongst the first organs to benefit by the change. I have knoAvn constipation, heretofore obstinate, speedily give way to healthy and regular action of the bowels. And it is needless to sav that general amelioration soon follows. The local irritation being lessened, irregular nervous manifestations tend to subside. Greater power of locomotion is gained; and Avhat with freedom from pain and the reneAved capacity for exercise, nutrition is often remarkably improved. To show the reduction of the retroflected uteras by the finger. The body of uterus is pushed across to the left of the promontory (R. B.). TREATMENT. 615 A third indication to take is to treat the local complications, whether effects or causes, of the retroflexion. These, that is, the engorgement, endo-catarrh, and other changes in the uterus will, it is true, tend°to sub- side under the means employed to rectify the malposition. But their cure may be accelerated by treatment ad hoc. Fig. 141. To show the reduction of retroflected uterus by found. 1. The first position of sound. 3. The final position. The arrows and dotted lines show the movement of the handle and joint. (R. B.). The first indication is naturally the reduction of the uterus to its nor- mal relations:—1. The reduction of simple prolapse Avith its correspond- ing retroversion of the uterus is rarely difficult. It is generally enough to lift up the body of the uterus Avith the finger. 2. deduction of retroflexion when complicated Avith considerable en- largement of the uterus as from fibroid tumors or hyperplasia may pre- sent considerable difficulty. This difficulty increases Avith the size of the uterus and the degree of overhanging of the promontory of the sacrum underneath which the enlarged uterus may be locked. 616 RETROFLEXION. 3. Reduction of a retroflected uterus, enlarged as it rarely fails to be after long retention in this unnatural position, may be more difficult still. 1. In the more difficult cases then it is desirable to bring to our aid all the mechanical means at our disposal. The first of these is the pluming the jmtient in the most favorable />osture. There are tAvo positions which are eminently useful. The first is that knoAvn as Situs's, the semi-prone position. In this the woman lies on her left side, with the knees placed on the abdomen, the body Avell rolled over on the chest, the left arm turned over the back, and the head elevated as little as possible. For the greater number of mere digital examinations this is the best posture. For the reduction of the greater number of the complicated dislocations and distortions above referred to this posture is the most convenient and effective. It readily permits the operator to carry out all the manoeuvres by finger and sound which I have taken pains to describe and illustrate under the preceding paragraphs on diagnosis. In a certain proportion of cases still more difficult, when the enlarged retroflected uterus is impacted under a projected promontory, Ave may invoke the aid of the genu-pectoral posture, the advantages of Avhich are so Avell illustrated by Dr. H. F. Campbell {Gynaecological Transactions. vol. i. 187*)^. When the Avoman is placed in this posture the following mechanical powers come to our aid: (1) The abdominal viscera falling doAvmvards not only remove the pressure they exert upon the uterus in the ordinary postures ; but (2) by the falling forward and downward, this " draft of the viscera" exerts a suction-force, tending to draAv in air by the pelvic openings ; and now if (3) the hand or finger be introduced into the vagina, air rushing in restores the atmospheric equilibrium. This Campbell calls the ki pneumatic reduction of the dislocated Avomb." It will be observed that all these concurrent forces act without invoking the fourth, namely, the influence of gravity on the uterus itself, Avhich will of course tend to aid the rest. The first indication and the second can hardly be dealt with separately. To straighten the axis of the uterus and to restore the fundus to its normal position are objects attained concurrently by the same means. These means are mostly mechanical. Before applying these it is often desirable to give an opportunity for any excessive engorgement or in- flammation that may exist, to subside under rest in bed, perhaps local bleeding, salines, sedatives, and by the regulation of the boAvels by gentle aperients and enemata. Admitting the great importance of this course as a preliminary condition of cure, I cannot agree with those who rclv upon it as sufficient to cure. I have indeed, in not a few cases, seen retroversion and retroflexion of the secondary form relieved, the Avomb regaining its position apparently spontaneously under rest and the other means enumerated. But in some, at least, of these the cure would pro- bably have been accelerated and made more sure by the timely recourse to mechanical support. And expectancy, aided or not by these means, will certainly bring no rectification of a primary retroflexion. The man- agement of a primary retroflexion will often differ from that of a secondary retroflexion in this: The primary retroflexion is often complicated with a marked degree of stenosis of the os uteri externum. This is an addi- tional cause of obstruction and retention which rarely exists in the TREATMENT. 617 secondary form. It is the first thing that requires treatment. The os externum should be enlarged, Avhether it be the case of a sinode Avoman applying for relief of dysmenorrhoea, or that of a married one, to Avhose menstrual difficulty are superadded dyspareunia and sterility. The operation is in all respects the same as that described under dysmenor- rhea from stenosis of the os externum. The os is divided on either side so as to give a free opening into the cavity of the cervix. This in itself diminishes the doAvn-curving of the vaginal-portion, and independently of special means for straightening the uterus it virtually straightens its canal. This obstacle being removed, the treatment of the primary retro- flexion becomes the same as that of the secondary form, excepting in this, that there is more likely in the latter form to be an inflammatory complication of the cervix. This requires special treatment, Avhich may, hoAvever, go on concurrently Avith the treatment for rectification. The means brought forward at different times for the rectification of the retroflected uterus are numerous. Fxperience has eliminated some as ineffective or injurious, and has established the value of others. AVe need not dwell upon exploded contrivances ; but we cannot pass by Avithout discussion the merits of intra-uterine pessaries. The idea of straightening the bent uterus, and fixing it in its normal position by in- troducing a rigid stem into its canal, Avas revived, if not first conceived by the late Professor Simpson. It Avas taken up and largely tried by A^alleix. Cases, not a feAv, are known in which death from metroperi- tonitis followed the use of instruments of this kind. The intra-uterine stem being attached to an external support it could hardly be expected to be free from this danger. All instruments Avhich disregard the physiological fact that the uterus is a movable organ should, I think, be unhesitatingly discarded as vicious in principle and dangerous in practice. All intra-uterine stems carried on supports having a point d,appui outside the body fall under this ban, even although a certain amount of elasticity be introduced into some part of the apparatus. It may be said, without injustice to the ingenuity displayed in the elaboration of these contrivances, that they have fallen into disuse under the combined influence of the disasters Avhich attended their use, and of the introduction of better means, especially of Hodge's lever-pessaries. The objection above urged does not apply to the simple intra-uterine stems which are unconnected Avith external supports, and Avhich do not control the uterus in its movements. The best of these is the late Dr. Wright's, or a modification of it. The safest is made out of one piece of vulcanite. This instrument is about two or two and a quarter inches long. AVhen mounted on its carrier for the purpose of introduction it is a single solid stem. AVhen introduced and the carrier is AvithdraAvn, the stem opens by the elasticity of the two branches of Avhich it is composed, so that the ends fit the normal triangular shape of the cavity of the cervix. This expansion helps to lift up the fundus, and the uterus thus supported is kept nearly straight. Still this will not always bring the fundus fonvards ; it remains in retroversion. For complete restitution Ave must rely upon Hodge's lever-pessary. This will now operate with increased advantage, as the lever formed by the uterus upon which it 618 RETROFLEXION. has to act is straightcr and firmer. This separate mode of usi intra-uterine and the extra-uterine pessaries is, in my opinion, the Fig. 142. Illustrating occasional vicious action of the Hodge in extreme retroflexion of the uterus (R. B.). The upper limb gets wedged in the angle of flexion, and lifts the whole organ up without straightening it. and most satisfactory in its results. The mobility of the parts is suffi- ciently respected; and opportunity is given for the recovery of the natural tonicity of the cendx uteri (see Fig. 113). I cannot approve of those instruments in which the intra-uterine stem is set on a ball or ring, or the cross-bar of a Hodge's pessary. This is a kind of impalement which limits too much the mobility of the uterus, and which is apt to cause inflammation of the uterus or surrounding tissues. All intra-uterine pessaries are apt to cause pain, hemorrhage, and inflammation. The patient must be carefully watched during their use ; she should observe the utmost moderation in everything; and in the event of pain the instrument should be at once removed. Before using any form of intra-uterine pessary, it is desirable to ascer- tain whether the object cannot be attained Avithout using them at all. The cases where it is necessary to use them are exceptional. The Hodge has happily almost driven out of use the fixed intra-uterine stem. Before applying a Hodge, it is useful to bring the retroflected fundus fonvard TREATMENT. 619 into its proper position. AVe thus increase the length of the post-cervical vaginal cul-de-sac and give room for the pessary to rise well behind the cervix, a condition of its efficiency. Fig. 14o. Illustrating the combined action of the intra-uteriue pessary and the Hodge (R. B.). The first straighteus the uterus, converting it into a firm lever A b. Then the second forming another lever, c d, lifts up the fundus, e f shows the leverage-movement of the Hodge c d. Under inspiration, e lifts up the body of the uterus. In the majority of cases a simple Hodge-pessary modified in shape and size to suit the peculiarities of the case, is the best instrument to use. It may be worn continuously for several months, under occasional inspec- tion. Pregnancy not infrequently takes place whilst it is Avorn. Indeed, I have little doubt that the action of the instrument favors impregnation. When this occurs it is desirable to continue the use of the instrument until the end of the third month of gestation, that is, until the fundus of the uterus has risen out of the pelvis. By this plan the dangers of abor- tion and of locking of the uterus in the pelvis are greatly lessened. 620 INVERSION OF UTERUS. CHAPTER XXIII. inversion of the uterus ; definition: acute and chronic; cai'sks, in the parturient and non-pheci n an t uterus; symptoms, course, and terminations; prognosis; diagnosis; treatment. The history of recent inversion of the uterus belongs especially to obstetrics. In my Avork on Obstetric Operations, I have traced this his- tory Avith some care. This of course includes the study of the causes which lead to the greater number of inversions. A very large majority of cases follow immediately upon labor. But it is important to remem- ber that inversion has occurred quite independently of labor, although it seems necessary that conditions in some important respects analogous to pregnancy and labor should exist. Such, for example, is the case Avhen a polypus attached to the fundus uteri induces development of the mus- cular wall, an expulsive action being excited, the fundus uteri follows the tumor, producing inversion. Inversion of the uterus may be defined as a dislocation by Avhich the inner Avail of the uterus is turned outAvards ; its cavity disappearing, and another caAdty forming above, the inner surface of Avhich is the proper external covering of the uterus. This cavity contains a portion of the Fallopian tubes and of the round ligaments, Avhich are dragged in by the fundus uteri. Even convolutions of intestine may fall in. And in the recent state after labor, the ovaries also may be drawn in. But in the chronic state, Avhen the uterus is much reduced in size, the ovaries are found outside the artificial cavity. There are degrees of inversion. The most simple division is that pro- posed by Crosse (see Fig. 111). 1st. Depression; the fundus or pla- cental site falls inwards, projecting in the cavity of the uterus. 2d. In- troversion, or intussusception. So great a part of the fundus falls in that it comes within the grasp of the portion of the uterus into which it is received. In the extreme form of this degree the fundus reaches to the os uteri, through Avhich it may be felt like an intra-uterine polypus. 3d. Perversion ; the fundus passes through the os uteri. There are degrees of this. In the extreme form the inversion is so complete that even the cervix and os are inverted. Inversion is acute or chronic. In my article on this accident in Samuel Lane's edition of Samuel Cooper's Surgical Dictionary, I defined acute inversion as ending with the completion of the involution of the uterus. AVhen this process is complete, the case is chronic. The distinction is based upon the important facts that Avhilst involution is going on, the muscular fibres are still possessed of some active property, the oro-an is larger, and the cervix less rigid. During this stage the parts are^more yielding, and reduction is comparatively easy. It is the chronic form including cases which occur independently of labor with which we are CAUSES. 621 noAV principally concerned. But some reference to the conditions under which inversion is produced will not be out of place. Fig. 1.— Depression. Fig. 2.—Introversion. Fig. 3.—Perversion Illustrating the Three Degrees of Inversion of the Uterus (from Crosse). a. The inverted fundus. 6. The natural cavity, c. The vagina, d d. The upper margin of the cup formed by the inverted fundus uteri. The tAvo following drawings (Figs. 115, 146) represent the conditions of chronic inversion and the relations of the several parts. Fig. 145. Extreme Inversion iu Section. a. Vagina, b. Fundus uteri, e c. Angles of inflexion. cc,dd. Mark the extent of the uninverted rt-rvix. f. The peritoneal cul-d-soc of inverted uterus, g g. Fallopian tubes passing down to the inverted fundus, k k. Round ligaments, h h. Ovaries, i i. Broad ligaments. (Half-size. From Crosse's Essay, taken from a specimen of Dr. Mackenzie, of Glasgow.) Fig. 116 is reduced from an original drawing by M. Biot for Mr. Crosse (see his Essay). It represents a preparation in the Musde Du- puvtren at Paris. The subject died of exhaustion twenty-two months after labor. Causes.—The essential conditions for the production of inversion are : on the one hand, relaxation of some part or the whole of the Avails of the uterus, and, on the other, considerable enlargement of its cavity. When the uterus has contracted, its Avails are so thick, and the cavity is so re- duced, the anterior wall being flattened close in contact with the posterior 622 INVERSION OF UTERUS. wall, that inversion cannot take place. Of this any one may convince himself by passing his fingers into the living uterus during active con- traction, or by trying to invert a uterus out of the body which has been Avell contracted. Fig. 146. a Vagina. 6. Inverted fundus incised at fc to show its cavity, d. Point of inversion with round ligaments, Fallopian tubes, and ovarian ligaments drawn in. g g. Round ligaments, e e. Ovaries. //. Fimbriated extremities of tubes, h. Cervix covered by peritoneum. (Two-thirds size.) (After Crosse. Specimen in Mus6e Dupuytren.) Adhesion of the placenta groAving from the fundus is a frequent cause. This is often united with spastic narrowing of the loAver segment of the uterus. This narroAving will generally prevent complete inversion. In this case the os uteri may not relax until partial inversion has lasted some time. The mechanism by which inversion is produced, as illustrated by the Avritings of Smellie, Lucas, John Flunter, Crosse, and others, is explained in sufficient detail in the Obstetric Operations. Here we are more especially concerned with inversion in the chronic stage. John Hunter describing a specimen in the College of Surgeons, in which inversion was caused by the attempt to expel a tumor from the uterine cavity, likens the process to intussusception of the intestine. Professor E. Martin relates a case of complete inversion of the uterus in a multipara caused by a fibrous growth in the fundus. A woman, aged forty-six, was seized with profuse uterine hemorrhage, Avhich often returned. Tavo years later a tumor was observed protruding through the vulva, and causing retention of urine. The tumor was so little sensitive that the patient cut off a piece with scissors. It was as large as a fist. HOAV PRODUCED. 623 It was found united by a pedicle to the fundus of the inverted uterus, no trace of the os uteri being left. The tumor Avas cut off by an ecraseur. Attempt to reduce the inverted uterus Avas postponed. A feAv days aftenvards it Avas found that the spontaneous re-inversion had taken place. The patient recovered {3Ionatsschr. f. Geburtsk., 1869). B. Langenbeck {Med. Centr. Zeitung, I860) exhibited the inverted uterus of a Avoman who had never been pregnant. On the inverted fun- dus Avas seated a fragile, sarcomatous heterologous groAvth of broad basis, the size of a walnut. Abarbanell {Monatsschr. fur Geburtskunde, 1S61) relates the following: A woman had become very anaemic from frequent hemorrhages. A smooth tumor, the size of the fist, was first felt protruding from the uterus ; fourteen days later, under violent expulsive pains, with profuse hemorrhage, the tumor was driven through the exter- nal genitals, and the uterus Avas completely inverted. The tumor was amputated, Avhereupon the uterus quickly replaced itself. McClintock gives a case {Diseases of Women, Dublin, 1863.) Dr. Emmet {Amer. dourn. of Obstetrics, 1869) relates a case. He first amputated the tumor by the Avire ecraseur, and subsequently reduced the inversion by the manoeuvre described further on. In University College Museum is a remarkable specimen, Xo. 871. A large mushroom-shaped tumor is attached to the fundus uteri by a base so broad that it quite caps it. The uterus is laid open, shoAving the round ligaments and tubes draAvn into it. This specimen is thus referred to by Crosse (part i. p. lo) ; the case is published by D. D. Davis, Prin- ciples of Obstetricg (i. 618, pi. 21) : " The patient was brought to the Middlesex Hospital in a dying condition; the polypus tumor prolapsed beyond the external labia. The preparation is unfavorably displayed. Calculating from the ostium urethra', about one inch of the vagina remains uninverted, so that the angle of its reflection, where the circular cul-de- sac terminates, is situated at the depth of an inch, from which the in- verted vagina extends doAvmvards two inches, forming a tube, Avhich ter- minates in the uterus, at Avhich termination there is a distinct thickening or circular prominence, ansAvenng to the cervix uteri, completely inverted. The cut surface of the inverted uterus is nearly an inch in thickness, and the peritoneal pouch formed by it is very small, and its Avhole extent is laid open. There is no observable alteration in the bladder from its normal position, the superior fundus rising prominently towards the ab- domen ; and in the posterior view the ovaria are of large size, and lie close to each other at the margin of the peritoneal pouch, tucked in be- hind the bladder. The peritoneal pouch, though narroAV, must be about four inches in length, tAvo ansAvering to the inverted vagina, and the rest to the uterus totally inverted. The left corpus fimbriatum is adherent, the right loose and floating." In St. BartholomeAv's Museum is a specimen (Xo. 32.12) illustrating this point. " The uterus contains a large fibrous tumor Avhich has grown from its fundus, and projects into the vagina. The fundus of the uterus is partially inverted, being draAvn doAvn by the Aveight of the tumor. Its inner layers also, enveloping the tumor, are elongated, so as to form a pedicle or neck by Avhich the tumor is attached like a polypus. Similar tumors of smaller size have formed." In St. BartholomeAv's Reports, 621 INVERSION OF UTERUS. 18T2, another history is related of inversion caused by a polypus. The uterus Avas restored to its position. The symptoms of recent inversion are chiefly those of shock, indicat- ing sudden severe injury. They vary with the degree and progress of the inversion. Thus, the first degree, or simple depression, may be un- attended by pain, and indicated solely by hemorrhage and a correspond- ing depression of the vital powers. 'The hemorrhage comes from the re- laxed introcedent part. The depression at the fundus may be felt through the abdominal walls as a cup-like hollow. As the descent proceeds, and becomes introversion, urgent symptoms arise, according to the degree of compression exercised by the uninverted portion upon the inverted portion. A sense of fulness, weight, as of something to be expelled, is felt. Expulsive efforts, both uterine and abdominal, sometimes very violent, follow. Hemorrhage is not constant. It seems that when the inverted portion is firmly compressed, the hemorrhage is arrested, and that bleeding is a mark of inertia. AVhen the inversion is complete, the uterus is felt in the vagina, or may even be seen outside the vulva. Then pain and collapse are aggravated. Clammy swreats, cold extremities, vomiting, alarming distress, restlessness, extinction of the pulse occur. During the expulsion the woman has often exclaimed that her intestines were passing from her. A tumor appears in the vagina, or externally, generally covered by the placenta. The cord is traced up to the inser- tion, and the placenta, of convex form, is spread over the tumor. The shock, either with or Avithout hemorrhage, is sometimes so great as to quickly extinguish life. Cases are known where the shock attend- ing simple depression has been fatal. AVhere the case is not fatal, and the uterus is not reduced, the symptoms of chronic inversion succeed. First, the tumor by its bulk, causes distress of the bladder and rectum. Then it is probably forced externally. Chronic inflammation, thickening and induration of'the parts ensue; the surface may become dry from exposure, or ulcerated and bleeding from chafing. It may be difficult or impossible to reduce it within the vagina. If the tumor remain within the vagina, it may still be a source of chronic irritation to the vagina, and may itself be the seat of chronic inflammation. Congestion, abra- sion of surface, ulcerations, give rise to profuse muco-purulent leucorrhoea, frequently to hemorrhage. Irritative fever, emaciation, pain, discharges, break down the constitution, and after some months, or even years, the patient may sink from exhaustion. As AVindsor remarked, an epoch of especial danger is that of weaning and the resumption of menstruation. The discharges of blood then become more frequent and profuse. AVhen the climacteric age has been reached, the uterus undergoing natural atrophy, severe symptoms may subside, toleration ensuing. In the recent state retention of urine is not uncommon, OAving to the distortion and compression of the neck of the bladder and urethra. The retention has been relieved when the uterus was restored. Cases have been knoAvn of the inverted uterus sloughing off, Saxtorph (in Actis Soc. Med. Hav.) : Deborieir {Richter's Chir. Bibl.) ; Rad- ford {Dublin Journ. of Med., 1835). In other cases the strangulation caused by the cervix has ended fatally before there was time for slough- ing (Arelpeau). More marvellous still, cases have occurred in which the ACCIDENTS ATTENDING. 625 recently inverted uterus has been torn away by the attendant, the patient recovering (Dr. J. C. Cooke). J. L. Casper says {Handbook of Forensic Medicine, XeAv Sydenham Soc. Translation, vol. iii.) laceration of the pelvic ligaments may attend spontaneous inversion of the uterus. E. Clemensen relates1 a case of complete inversion, in which the uterus separated by gangrene. A Avoman of fifty had borne two children, the last thirteen years ago. Some eight years ago she observed that the uterus prolapsed (it Avas probably inverted). A profuse hemorrhage took place. The uterus Avas then found completely inverted between the thighs, the size of tAvo fists. In several spots lacerations Avere observed extending into the muscular tissue. Some days later the uterus seemed diminished in size ; irritative fever set in; gangrene showed itself in the left side of the uterus. The uterus contracted more and more. At last only the orifice remained as a scar. The woman recovered. Clemensen attributes the origin of the inversion to the altered texture of the organ, resulting from fatty regression after labor. In recent inversion death has ensued from strangulation of intestine in the uterus. Gerard de Beauvais relates a case {Acad, de Medecine, 1813). But such a termination can hardly occur when the inversion has become chronic. It is a remarkable circumstance that notwithstanding the extreme difficulty experienced in reducing an inverted uterus, it very rarely happens that the constriction of the os is sufficient to close the inverted cavity, or that adhesion exists. Commonly the finger is readily admitted, and even through the abdominal wall a passage into the cavity may be felt. Sometimes, the uterus being irreducible, death ensues from hemor- rhage, as in a case described in St. BartholomeAv's Catalogue (specimen Xo. 32.56), and reported by Dr. AVest {Pathological Proceedings, vol. iii.). " Uterus entirely inverted, with the exception of the os, which, however, does not cause any constriction, the finger passing easily be- tween it and the uterine wall. The openings of Fallopian tubes not discoArered. The peritoneum at the point of inversion is thickened and uneven, the insertions of the uterine appendages are drawn into the cul- de-sac of inverted uterus. This inversion Avas irreducible, and the dis- placement of the uterus caused death in consequence of frequently recurring hemorrhage tAventy-nine months after its occurrence." A remarkable termination is illustrated in the folloAving case, of which the specimen is preserved in the London Hospital (No. Ea 57). " Uterus perforated at its fundus by disease. Its mucous membrane appears to have been everywhere destroyed and at its fundus is an aperture the size of a shilling." Dr. Ramsbotham thus refers to it: "Ulceration having commenced in the Avhole lining membrane of the uterus has almost destroyed the uterine texture, and has formed an opening into the peri- toneal cavity. The uterus is turned inside out. Epithelial carcinoma of the internal uterine membrane. I have seen only one other such case." Crosse says " there is not a shadow of evidence of total inversion in the strict sense replacing itself spontaneously." A few cases, as those 1 Hospital Tidende, 1865. 40 626 INVERSION OF UTERI'S. related by Bover {Maladies C'hirurgicales) and Baudelocque {Dailies. These) are examples of reduction following external force in the form of a blow or succussion. Dr. Meigs, nevertheless, relates several cases. Of such cases Dr. AVest remarks that " it is easier to conceive that an experienced man should commit an error of diagnosis, than to understand how any efforts of Nature could cure a chronic inversion of the Avomb." The error may be one of the two folloAving—either the tumor was a polypus, which has disappeared by being spontaneously cast off, or it was a true inverted uterus, which has been separated by sloughing, and cast off in like manner. In some instances the subject of inversion has evinced more or less perfect toleration of her infirmity. This was the result in a case reported by Guyon {Journ. de Chir. et de Med. prat. 1861), in which inversion had existed twenty years without alteration of health; in one by Dr. Comstock {Boston Med. and Surg. Journ., vol. viii.) : the patient fol- lowed her occupation as a dairy-maid; in one by DeAvees {Midwifery) : she was enjoying good health*ten years after the accident; in one by Ramsbotham*: the patient regained flesh, her health became good; in one by Lisfranc {din. Chir., 1S13) : in the body of an old woman exam- ined at the Salpetriere, the uterus was completely inverted, this had not been suspected during life ; in one by Dr. C. II. Lee {American Journ. of Med. S<\, i860): inversion remained undetected for tAventy-five years, ablation was given up, the patient was so well ; in other cases referred to by Gregory Forbes,1 in one reported by Dr. AVoodman {Obstet. Trans., vol. ix.) brought to the London Hospital, Avhilst I Avas obstetric physician there, and in Dr. Mackenzie's case (see Fig. 116) toleration was established. AAThen reduction has been effected, the uterus may recover its function, and pregnancy ensue. There is also a probability, not indeed high, but suggesting caution, that inversion av ill again take place during labor. For a long time after replacement the cavity of the uterus probably remains shorter than normal. The thickened walls take time to resume their natural condition. I state this from the observation of a case re- duced by myself. This depends no doubt in some instances upon the reduction being imperfect, the fundus remaining in the state of depression, or squatting. The prognosis must ahvays be serious. AVeber truly calls inversion " nudum ingens periculique plenum." Crosse, who has shown the greatest industry in the collection of cases, says that above one-third of all the cases, under whatever circumstances, or in whatever degree they occur, proA'c fatal either very soon, or within one month. He analyzed 109 fatal cases. Seventy-tAvo proved fatal within a feAv hours, most of them within half an hour ; eight cases proved fatal in from one to seven days; and six in from one to four weeks. If the patient survive a month the case is chronic, and the immediate danger is small. But the danger re- commences at eight or nine months, when the menstrual function is resumed. Many of these will die within tAvo years. If the inversion take place suddenly and completely, the uterus remaining flaccid, the 1 Medico-Chirurgical Transactions, vol. xxxv. DIAGNOSIS. 627 danger is extreme ; if it take place sloAvly, that is, under spontaneous uterine action, the danger is less. 11 As to the prospect of reduction, a much more favorable expectation than Avas lately held is justified by the improved methods of treatment; and reduction will diminish the mortality. Denman thought that if two hours had elapsed reduction could not be effected. But more recent ex- perience has abundantly proved that both in the recent and chronic cases reduction can in the great majority of instances be accomplished. If the patient survive the first dangers of shock and hemorrhage the prospect of recovery under surgical treatment is good. The diagnosis is especially important; it is not ahvays easy ; and the most deplorable consequences have folloAved from error. M. A. Petit had a patient in the hospital at Lyons. Six surgeons decided that it was polypus, and a ligature was applied. A shriek caused suspicion of inver- sion ; the ligature Avas removed; but the woman died at the end of five days. On examination inversion Avas found. Dr. AVm. Hunter tied what he thought Avas a polypus in a young Avoman who said she had never been pregnant. She died ; the uterus Avas found inverted. Dubois {Dictionnaire de Med., 1816) says he knew of two cases of inversion mistaken for polypus by tAvo of the most skilful surgeons in Paris. In one case a ligature Avas put on ; the patient died in thirty-six hours. In the presence of the recent accident the most frequent mistakes have been to suppose the mass is a second placenta, or the head of a second foetus. The forceps has been applied to the inverted uterus to dra^ it a\vay. The diagnosis is especially difficult Avhen inversion is complicated Avith polypus. The polypus may be detected, but not the inversion, and a ligature applied to the polypus may include a portion of the uterus. Gooch relates {Diseases of Women) the following case: Dr. Denman passed a ligature round a polypus of the fundus ; as soon as he tightened it, he produced pain and vomiting. As soon as the ligature was slackened these symptoms ceased ; but whenever he attempted to tighten it the pain and \romiting returned ; the liagature Avas left on, but loose ; the patient died about six weeks aftenvards, and on opening the body it Avas dis- covered that the uterus was inverted, and that the ligature had included the inverted portion. The folloAving case occurred to Dr. Gooch at St. BartholomeAv's, in 1828: The patient had been delivered by forceps six months before. When standing, a large tumor protruded externally, but could easily be replaced. The os uteri could not be felt. The ligature was applied round Avhat Avas supposed to be the stalk ot the tumor: it occasioned little pain Avhen first applied, but tOAvards evening pain became so severe as to resemble labor. She died on the fifteenth day after the operation. The uterus was of natural size and structure. The tumor greAV from the orifice of the uterus all round, so as to be continuous Avith the cervix, and to make it impossible to say Avhere the neck of the uterus ended or the stalk of the tumor began. The ligature had included the projecting neck of the uterus. The posterior part had occasioned ulceration into the cavity of the peritoneum. There was no inflammation of the peritoneum. 628 INVERSION OF UTERUS. The diagnosis has to be made under the two different circumstances of recent occurrence and chronicity. In the recent case the history fur- nishes useful indications. The sudden sense of injury and shock, folloAV- ing labor, suggests immediate exploration. Negative and positive signs concur in pointing to a conclusion. In the first place the uterus is not felt, as it ought to be, a firm, round ball behind the pubes. On pressing the hand firmly into the pelvic cavity from above doAvmvards, behind the symphysis, a vacuum is felt. Keeping the hand in this situation, the fingers of the other hand are passed into the vagina, and there a mass rounded, soft, or firm is felt. The relations and position of this mass are clearly defined betAveen the two hands. If the placenta is attached, the uterus is obscured by it. But bared, the diagnosis will be cleared up, if the finger is carried all round the mass up to its insertion. On press- ing the mass upwards as in attempt to replace it, the fingers exploring through the abdominal wall will sink into a pit formed by the disappear- ance of the uterus through its os. Then the finger in the vagina explor- ing the root or insertion of the tumor comes to a circular furrow at the fundus of the vagina, and a prominent ring, which is the os uteri. If the inversion be not complete, the finger, or more easily the uterine sound, will pass a little way betAveen the ring formed by the os and the pedicle of the tumor. If the inversion is complete, only the furrow will be felt. If the inversion has been folloAved by prolapse of the mass beyond the vulva the exploration is easier, as the tumor may then be felt continuous by its origin Avith the inverted vagina. It may also be seen. Its aspect is that of a florid tumor Avith a very vascular velvety surface, easily bleeding on the slightest touch, or if the presenting part be that to which the placenta had grown, it is uneven, of a dark hue, Avith placental shreds or coagula attached to it. The tumor is painful to the touch. Any at- tempt to drag upon it causes a sensation described by the patient as if her inside were being pulled out. Pain is also felt down the legs. Vomiting is likely to occur. In size the tumor may equal a child's head, or it may be no larger than a fist. A crucial test is the alternation of the mass from contraction to dilatation. This vital act inducing characteristic changes of size and consistence pertains to the uterus alone. The diagnosis from polypus is not always easy. A polypus may complicate pregnancy. Pregnancy usually causes an intra-uterine poly- pus to grow at an accelerated ratio. After the birth of the child, the polypus will be extruded, perhaps dragging the fundus uteri a little with it, thus simulating, if not producing, a minor degree of inversion. To distinguish this from inversion it must be remembered that polypus thus appearing after labor is actually even more rare than inversion. The probability, therefore, of inversion ought to operate with at least equal force upon the mind of the surgeon. The chief points of distinction are : that a polypus is not sensitive ; it does not change its form, size, or con- sistency ; it does not contract or relax. Its expulsion rarely produces severe shock. In form and size polypus may resemble inversion, but it differs in relation to other parts. It is quite possible that the placenta may have been partially attached to the surface of the polypus : it will then exhibit placental shreds and clots like the uterus. The finger and sound must be relied upon to make the case manifest. The hand outside DIAGNOSIS. 629 will discover the uterus in sitH behind the pubes. The finger in the vagina will travel round the polypus, betAveen it and the ring of the os uteri Avhich embraces it. If the attachment of the tumor is to the cervix, the pedicle will be felt on one side of the circumference, whilst in the other parts the finger or sound will pass several inches beyond into the cavity of the uterus. If the attachment is at the fundus, then the sound will pass all round. The difficulty of distinguishing inversion in the chronic state from polypus is greater. Yelpeau having in error tied an inverted uterus, said, " I knoAv too well that there are cases in which doubt is the only rational opinion." Soon after the accident the uterus diminishes greatly in bulk, becomes harder, perhaps less sensitive, and, in these features, more nearly resembles polypus. But setting the history—ahvays a falla- cious diagnostic element—apart, the means of discrimination are satisfac- tory. Tbe speculum may reveal the oozing of the menstrual fluid. In other respects its use is doubtful. The sound is of more value. " If," says Simpson, " it passes two inches and a half or more beyond the edge of the cervix, the disease is not inversion of the fundus ; if it cannot pass at any point around the stem of the tumor to a greater extent than about one inch, the uterine cavity may be considered as shortened by inversion." The inverted uterus is flattened anteriorly and posteriorly ; its largest point is loAvest; it diminishes very gradually, presenting a comparatively large neck at its highest part, Avhere it is encircled by the inverted cervix, if the inversion is not complete, and by a thickened ring or ridge if complete. The size of the inverted uterus is scarcely larger, and is often smaller, than in the natural state. Herbiniaux placed so much stress upon this as to affirm " that if the tumor be so large as to distend the vagina and prevent your getting at the os uteri, it may be boldly pronounced polypus, and not a partial inversion, which is ahvays of small size, and fills the vagina." The form of the tumor has been taught to offer distinctive characters. S. Cooper described the inverted uterus as forming a mass Avider or as Avide above at its origin as at its most dependent part, whereas in poly- pus the neck is narroAver. This is often true, but not constantly so ; and it would not be safe to rely upon a variable sign. J. G. Forbes describes a case of complete inversion of eighteen months' standing, in Avhich the tumor close to the os Avas four inches and a quarter in circumference ; this Avas the Avidest part. This seems to be more especially the charac- ter of incomplete inversion. In many cases of complete inversion the upper part is narroAved so as not to be distinguished in this respect from many polypi. This Avas the condition in tAvo cases observed by myself. A sign insisted upon by Crosse is the feeling the stretched round ligaments Avithin the tumor (inverted uterus), and pain being produced in the groins on lowering the tumor a little so as to render the tension greater. To this I would add that by draAving the tumor Avell down by a vulsellum or a noose (see Fig. 117), the insertion of the root in the vaginal roof being put on the stretch, the continuity of the two parts is made manifest. Malo-aigne advises the folloAving method: Introduce a male catheter into the bladder, direct its end doAvmvards and backwards, so that, carry- 630 INVERSION OF UTERUS. ing the coats of the bladder before it, it may enter the peritoneal cul-de- sac formed by the hwersion, and be felt by the finger in the vagina through the coats of the inverted organ. Another method is this : The catheter in the bladder, direct the end backAvards so as to bring it to project in the rectum Avhere a finger will feel it with only the coats of the rectum and bladder intervening ; but if the firm resisting uterus be there, the end of the catheter will not be felt. Digital examination by the rectum will also enable the surgeon to explore the tumor in the vagina more fully. Often the end of the finger will get above the tumor, thus completely exploring it. If the uterus be in its place, it may thus be felt betAveen the finger in the rectum and the finger of the other hand pressed down behind the pubes. If the uterus be inverted, then the vacuity above the tumor felt in the Aragina will indicate that this tumor is the uterus. This mode of exploration should never be omitted. Dubois takes occasion, to say that the mistakes he refers to, in Avhich death occurred from ligaturing an inverted uterus, Avould not have been made if exploration by catheter in bladder and finger in rectum had been resorted to. AAliere doubt exists there is still another mode of exploration which ghres absolute evidence. Under anaesthesia the hand may be passed into the rectum, so that the fingers may feel above the tumor and completely command its whole contour. To get Avell at the root of the tumor the hand may be passed into the vragina. The operation is not Arery difficult, and if carefully performed no injury will result. An intra-uterine polypus sessile on a broad basis may simulate partial inversion. The diagnosis will be established by the hand outside feeling the unimpaired rotundity of the uterine fundus in the first case ; and the cup-shaped depression on its sphere in the second case. The sensitiveness of the inverted uterus furnishes indications. Thus Gueniot {Arch. Gen. de Medecine, 1868) recommends acupuncture of the tumor to test this property. But it must be confessed—at least, I make this admission on my own behalf—that the sensitiveness of the inverted uterus has been more distinctly revealed by applying a ligature or wire around its neck Avith a vieAV to removal for a polypus. Regarding this fact, and the associated fact, that a polypus is not sensitive, I have insisted upon the rule that patients should never be submitted to anaesthesia for the removal of a polypus. Pain may give the last warning, and save the patient at the last moment. The diagnosis from prolapse of -the uterus and vagina ought not to be doubtful. The presence of the os uteri at the loAvest point of the tumor, admitting the sound for a distance of two and a half inches or more, at once decides the existence of prolapsus. The difficulty of diagnosis has been felt even in the presence of the parts put up in spirit. Thus Crosse, by further dissection, proved that a specimen, which for years had passed for one of inversion in the Glas"-OAV museum, was in reality one of polypus growing from and perfectly occlud- ing the os uteri. He pleads with pardonable urgency that the mode of putting up these specimens is bad; and that the tumor ought to be slit open by a longitudinal cut so as to expose the cavity and its contents. I possess a wax-model taken from a patient who came under my care in the London Hospital. There Avas a procident mass outside the vulva TREATMENT. 631 which Avas for some time taken to be a fibroid tumor attached to the fundus of the inverted uterus. It Avas only after prolonged examination that a small opening, seated in the angle of junction of the tumor, was discovered by means of the sound to be the os uteri. The tumor had groAvn by a broad basis to the cervix, and had caused not inversion but prolapsus. The model is figured in the Obstetrical Trans., vol. iii. AVhat has been said will indicate some of the principles of treatment. The treatment of recent inversion will be found fully discussed in the Obstetric Operations. In this place we are chiefly concerned with chronic inversion. If the opportunity of reducing within a feAv hours or days be lost, the difficulty increases through advancing involution of the uterus and con- traction of the os. Still the same manipulation may be attempted. AVe must act steadfastly in the faith that pressure sufficiently long kept up upon the os uteri Avill cause it to yield. It is really a question of time —too long a time indeed for the hand of the surgeon to Avork—but not for other mechanical appliances. Dr. Tyler Smith is entitled to the credit of proving this point by success {Med.-Chir. Trans., 1858). In a case of inversion of tAvelve years' standing he effected reduction by maintaining pressure upon the tumor and thus upon the os by an air- pessary during several days. Pridgin Teale {Medical Times and Gaz., 1859) reduced an inversion of six months by the air-pessary in three days. Dr. C. AVest {Medical Times and Gaz., 1859) by similar means reduced an inversion of a year's standing. Dr. Bockenthal {Monatsschr. f. Geburskt., 1860) succeeded in six days in reducing an inversion Avhich had lasted six years. Mr. James Hakes {Liverpool 3Fed. and Surg. lieports, 1868) by same means reduced a chronic inversion in fourteen days. Schroeder {Berlin Klin. Wochenschr., 1868) thus reduced an inversion of two years. And latterly (1869), Mr. Lawson Tait, on my suggestion, effected reduction in the same manner. The last Avoman died; but her case Avas already desperate. Borggreve, indeed, had applied the same principle. He used a stem eight inches long Avith an egg-shaped knob Avhich he fitted to the inverted fundus, and held it in gentle pressure by a T-bandage. In three days the uterus was returned. Dr. Marion Sims relates an interesting instance of the influence of constant pressure. A stem-pessary Avith an external support, after pressing for some days upon the inverted fundus, Avas found to be taken up into the inside of the re-inverted uterus, the os having yielded and allowed both to pass in together. James P. AVhite succeeded in reducing in the folloAving manner: " Having succeeded in dimpling the fundus, pressure Avas maintained with the°thumb at that point until the hand had become nearly powerless. To preserve this depression whilst the muscles of the hand Avere permitted to rest, a rectal bougie Avas carried along in its place, fixed in the dimple, and pressure unintermittingly continued through it, by the left hand out- side the vulva. Gradually the concavity of the fundus Avas found to be deeper, until it finally became completely restored." In more obstinate cases he keeps up elastic pressure by means of a " Repositor" constructed as follows: it has a uterine extremity expanded and holloAved to receive the fundus of the uterus. The edge of this part is tipped Avith soft rub- 632 INVERSION OF UTERUS. ber; it is lf-in. diameter, and half an inch deep. This is supported on a stem of wood slightly curved to ansAver to the curve of the vagina, and this stem has attached a coil of steel Avire. In use the hand is passed into the vagina: the uterine cup of the repositor is then adapted to the fundus, where it is held by the hand. The coil is then pressed against the breast of the operator, keeping a pressure of about eight or ten pounds. Counter-pressure to prevent too great strain upon the Aragina is made bv the hand outside, so that the fingers dip into the inverted uterus {Transactions of the International Medical Congress. Philadelphia, 1S76). Courty {Maladies de V Uterus, 1866) relates a case in Avhich inver- sion had existed ten months, inducing repeated hemorrhage and extreme debility. He reduced it in the following manner. The uterus Avas dragged outside the vulva by Museux's vulsellum ; then, the index and middle finger of the right hand were passed into the rectum, and hooked fonvard over the neck of the uterus ; then the uterus Avas seized Avith the left hand, and passed back into the vagina ; still holding the neck hooked down, the fundus of the uterus was turned so as to look fonvards to the pubes, the neck turned to the sacrum. The fingers in the rectum sepa- rating, rest firmly in the angular sinuses formed by the utero-sacral liga- ments ; then the thumb and index of the left hand pressing on the pedicle of the tumor gradually increase the depth of the utero-cervical groove. The tAvo hands acting thus in concert, the uterus was reduced Avithout violence in a few minutes. He had failed with the air-pessary ; the patient could not bear it. He cites Barrier {Bull, de VAcad.,\><(\2) as having reduced a case of fifteen months' standing, Avho found a point cVappmi by pushing the back of the uterus against the sacrum. Dr. Em- met {Amer. Journ. of Med. Sci., 1866) succeeded in the following manner: he passed his hand within the vagina, and Avhilst the fundus uteri rested in the palm, the five fingers were made to encircle the por- tion Avithin the cervix as near as possible to the seat of inversion ; whilst the portion was thus firmly grasped, it Avas pushed forwards, and the fin- gers were immediately afterwards expanded to their utmost. This manipu- lation, with the aid of the other hand OArer the abdomen, Avas persevered in until the fundus had passed within the os uteri. The advance gained was in proportion to the amount of dilatation accompanied by the spread- ing of the fingers, thus increasing the transA-erse diameter of the uterus, and shortening its long diameter. AVhen the reduction had so far ad- vanced that the fingers could not be passed fully up to the seat of the inversion, steady pressure was applied to the fundus by the tips joined together, whilst an increased effort was made by the hand outside to roll out the parts by sliding the abdominal parietes over the edge of the funnel. It has happened in several cases that only partial reduction could be effected ; that is, the body would return through the cervix in a doubled form, the fundus still being depressed, and presenting just above the cer- vix. In such cases, continuous steady support by a cup-shaped pessary or the end of a stethoscope, may in time complete the restoration. This difficulty has been met in an ingenious Avay by Dr. Emmet. He effected the closure of the os externum by silver sutures, so that the fundus im- treatment: forcible taxis. 633 prisoned in the cavity of the neck tends to dilate the constriction near the os internum. At a subsequent period the stitches are removed, and the taxis practised again. Dr. Emil Noeggerath, of NeAV York, has described a method of taxis which deserves attention. " It consists in compressing the uterine body opposite to each horn, so as to indent one of these, and thus offer to the cervical canal a Avedge, Avhich passes up, and is followed rapidly by the other horn, and the Avhole body." Thomas reports that he has practised this manoeuvre on two occasions with success. From time to time a method which may be described as the forcible taxis has been employed. Of late years a proposition has been made, supported by several distinguished American physicians, to admit this method to a recognized place in the treatment of chronic inversion. The fact that death after rupture of the uterus or vagina has several times been the consequence of forcible taxis should alone be sufficient to dis- credit the method. No number of successes ought to outweigh failure so deplorable. Forcible reposition has been attempted either by the hand alone or by aid of a repoussoir, that is, some kind of blunt instrument of Avood or ivory. Depaul {Gaz. des Hop., 1851) used a repoussoir in a case eleven days after labor. The patient died in a feAv days from rup- ture of the uterus. Laceration has also occurred in several cases in America. It is true that success restores the Avoman to her former integrity, but the penalty of failure to return the uterus is not infrequently death. The part will not sustain more than a certain amount of violence Avithout laceration ; much force is necessary, and it is impossible to restrict with nicety the force employed within safe limits. Sustained solid or elastic pressure is free from the objections that surround the preceding methods. Success means restoration to integrity, and failure does not mean death or mutilation. It simply leaves the patient in statu quo, and in a con- dition to be treated with every prospect of success by the adjuvant method of cervical incisions to be presently described. This method of forcible taxis has been confounded Avith that of gradual reduction by sustained elastic pressure. The principles of the tAvo procedures are totally oppo- site. One tries to overcome resistance by sheer force rapidly applied, the other by Avearing out resistance by gentle pressure long sustained. The first is replete Avith danger, the second almost absolutely safe. A method of effecting reduction remarkable for its boldness has been put in practice by Professor Thomas. This consists in making an incision through the abdominal wall so as to get at the constricted os uteri from above, and then applying a dilating force. The idea was enunciated by the late Sir James Simpson at the discussion of my paper before the Medico-Chirurgical Society in 1869. A case in which it Avas carried out by Thomas is thus described : An assistant introduced his hand into the vagina, and " lifted the uterus so that I could detect the cervical ring against the abdominal wall. I then sloAvly cut doAvn upon the median line, as for an exploratory incision in ovariotomy, and leaving the wound exposed to the air until all oozing had ceased, cut into the peritoneum. I then inserted my finger into the uterine sac, and found no adhesion whatever to exist. Replacing the assistant's hand by my left hand, I 631 inversion of uterus. now inserted the steel dilator and dilated the stricture. (The dilator is constructed on the principle of a glove-stretcher. R. B.) The dilatation was exceedingly easy and rapid, but I found that as I withdreAv the dila- tor, the tissue of the organ would at once contract. After dilating the stricture fully, I partially returned the uterus.....DraAving it doAvn to the vulva, I rapidly pushed it up, and was gratified at finding that it Avas nearly replaced. DraAving it doAvn again, this time outside of the body, to my dismay I discovered that the artery cut one Aveek before was* spouting freely.....I rapidly returned the organ, and Avas delighted to find one horn rise into place. But the additional force employed was a little more than the vagina could bear, and one finger passed through betAveen the uterus and the bladder. One horn was still inverted. Passing the dilator into this, I stretched it open, and instantly the uterus resumed its normal position. The artery bled freely that day into the vagina and into the peritoneum through the vaginal rent. But the patient ultimately recovered." Dr. Thomas operated in the same way in another case. " She did perfectly Avell for forty-eight hours, but at the expiration of that time peritonitis developed itself, and proceeded to a fatal issue." Reflection upon these cases will hardly, I think, justify the recommen- dation of Dr. Thomas. In the first case, even after dilatation of the cervical ring, so much force was necessary in taxis as to rend the vagina; Avhilst in the second, fatal peritonitis Avas the result. A method Avhich requires gastrotomy for its execution, involves conditions of danger so great that even amputation seems preferable. Amputation may be likened to cutting the Gordian knot. It is an apt illustration of John Hunter's aphorism. * It is a confession of impotency to solve the problem of reduction. It is the last resource ; one to Avhich I am firmly comlnced we need hardly ever, if ever, be driven. Not- withstanding the histories of a considerable number of cases of recovery after the operation, it cannot be said to take rank as a scientific pro- ceeding. The conditions of safety depending upon Nature may be absent, and the surgical means at present knoAvn are imperfect. AVhen the uterus is cut across at the neck, of course a hole is made opening from the fundus of the vagina into the peritoneal cavity. The danger of fatal peritonitis is great. The shock of the operation also is serious. Hemorrhage is likely to ensue, and some blood will escape into the abdomen. There are various methods of performing the operation. The uterus has been seized by a vulsellum, drawn down, and the cervix cut through with a knife. Next, it Avas thought that the ligature applied to strangle and to slough through, as in the case of a polypus, would be less dangerous. Treated in this way the result has been varied. In several instances, where a Avhipcord ligature has been applied by Levret's or Gooch's double canula, agony so intense has been produced, as to render it necessary to remove the ligature, and the patient has died notwithstanding. The cause of the excruciating pain is, I believe, the compression of the included Fallopian tubes. I have observed the same pain in cases Avhere the tubes have been tied in the pedicle of an ovarian tumor. And it has been ob- served in several cases that the surface and substance of the uterus pro- treatment: ligature. 635 per Avas nearly insensible, pain being developed only on tightening the ligature. In some cases the patient has died Avith the ligature attached. There is a preparation illustrating this in the museum of St. Bartholo- meAv's Hospital, death ensuing from peritonitis eight days after tying. On the other hand, it seems not unreasonable to hope that a ligature gradually tightened may set up adhesive inflammation in the neighbor- ing peritoneum, and thus shut off the abdomen from communication with the vagina Avhen the uterus falls away. Certain it is that this hope is not ahvays realized. Thus McClintock relates a case in which a ligature Avas applied during eighteen days, occasionally relaxing it on account of the severity of the pain, before the uterus Avas separated. No peritoneal adhesion had taken place ; the Avoman, hoAvever, made a good recovery. In eighteen cases Avhere the time that elapsed before the uterus fell is stated, the ligature took from nine to tAventy-eight days to sever the parts. The average time was seventeen days. It has been remarked that the ligature has arrested the hemorrhage. Dr. Ramsbotham has related a case in Avhich the ligature had to be re- moved at the end of twenty-four hours, OAving to symptoms of violent peritonitis ; but the profuse sanguineous and mucous discharges ceased. J. G. Forbes {Med.-Chir. Trans., vol. xxxv.) suggests that the simple application of a ligature around the neck of the tumor to destroy its vitality appears to possess more advantages than the other modes of operating. McClintock relates tAvo cases in which strangulation was first effected by a ligature for four days, and then the uterus was removed beloAv the ligature by the chain-ecraseur. The patients recovered. This combined method seems likely to unite most conditions of success. Dr. Marion Sims relates {op. cit.) a case in which after vain attempts at reduction, and being compelled by the consequent pain and prostration to abandon the ligature, he resorted to the chain-ecraseur. AVhen the parts were all divided except the right broad ligament, " all at once the most fearful hemorrhage he ever encountered took place. It Avas happily stopped by passing the finger into the abdominal opening and compressing the source of the hemorrhage. The blood which had escaped into the peritoneal cavity Avas sponged out, and the divided edges of the cervix Avere united by five or six silver sutures. The patient recovered. Mr. Baker, of Birmingham, relates {Brit. Med. Journ., 1868) a case of recovery after amputation by the chain-ecraseur. The bleeding vessels Avere sealed^by actual cautery. Dr. Hall DaAus relates (Obstetrical Transactions, 1873) a case in which he amputated the uterus ten months after labor. He used the single wire ecraseur. He employed it Avithout first dragging upon the neck of the uterus, expecting thus to lessen the risk of the sudden springing up into the peritoneal cavity of the severed cervical portion of the uterus. No hemorrhage occurred. The patient recovered. Pain was subdued after the operation by subcutaneous injection of mor- phia every six hours during the first twelve days, it being found that any suspension of its use Avas followed by severe uterine and ovarian pains. The pulse was very small immediately after the operation, and the tem- perature fell to 97° F. It appeared that in this case there Avere perito- neal adhesions, a condition which, no doubt, supplied a safeguard against 636 INVERSION OF UTERUS. peritonitis, and which, as it would have rendered reduction impossible, justified the recourse to amputation. Professor Barba {II M<>rgagui, 1 sub- cartilaginous ;" then they Ave re called " fibrous ;" to this name suc- ceeded the one in common use, "fibroid," or " fibroma." In older writings the term " scirrhous" is often used. Some insist that" myoma," and " fibro-myoma" are more correct designations, whilst Broca regard- ing the similitude of their structure with that of the uterus, proposes the name " hysteroma." Cruveilhier observed that there were " hard polypi, Avhich consisted in hypertrophy of the tissue of the uterus—such is the one figured pi. vi. liv. xie of his work—and others consisting of fibrous bodies developed under the uterine mucous membrane." He thus de- scribes the structure of this polypus: " The figure represents an antero- posterior section of the polypus and of the fundus of the uterus. The tissue of the polypus is seen to be continuous, without any line of de- marcation, Avith the proper tissue of the uterus ; it is a prolongation of this proper tissue, and not a fibrous body developed in the thickness of the uterus, capable of being separated by enucleation. The identity betAveen the tissue of the uterus and the tissue of the polypus is such that the closest examination does not reveal the slightest difference." Cruveilhier does not appear to have suspected that the ordinary fibroid tumor, distinctly defined from the proper uterine tissue, and capable of enucleation, might also consist of muscular fibre in every respect resem- bling the muscular fibre of the uterus. Yogel1 demonstrated the essential identity of structure of the "fibrous" tumor Avith that of the muscular Avail of the uterus in which it takes its origin. One case (Fig. 8 in Vogel's Avork) exhibits the " mature fibres of a fibrous tumor of the uterus found in the body of a woman who died of puerperal fever. In the fundus uteri tAvo tumors of the size of al- monds Avere found projecting under the peritoneum. They consisted of parallel fibres, forming a thick, very dense, milk-white tissue. The fibres became pale, and gradually dissolved in acetic acid; most of them were long, spindle-shaped cells, Avhich were not affected by acetic acid. The normal substance of the uterus consisted of like fibres, resembling in every respect those of the tAvo tumors." I have cited the above passage because the observation it refers to was made upon a puerperal uterus. In 1844 {Guy's II»xpital Reports) Oldham describes the constitution of a polypoid mass which Avas driven down by the uterus after labor: " The prevailing tissue was a clear un- striped fibre, which, when examined with a portion of the muscular fibre of the uterus, differed only in the latter being more full of cells and blood-corpuscles, which rendered its definition as fibre less distinct than the former." I had an opportunity, in conjunction Avith Dr. Hassall, of verifying 1 Erlauterungstafelu zur pathol. Histologic, 1843. FIBROID, OR MYOMA. 643 this identity of structure between fibrous tumors and uterus in the non- pregnant state. {Lancet, vol. i., 1851.) Lebert, in 1852, describes these tumors as consisting of—1. Cellular tissue and fibro-plastic ele- ments ; 2. Muscular fibre-cells like those of the uterus ; these come out clearly with acetic acid. In 1853, BristoAve reported to the Pathological Society the result of his examination of two fibrous tumors. Robin says " the muscular fibre-cells are larger than those of the empty uterus, but smaller than in the gravid Avomb ; that they constitute from one-quarter to one-half of the morbid mass ; that there is also a large proportion of finely granular amorphous matter, very tenacious, half solid, binding the fibres of the cellular tissue, and also the fibre-cells together." The granular amorphous element tends to increase in proportion to the rapidity of the growth of the tumor. I am indebted to Mr. Henry Arnott for the illus- tration of the structure of the uterine fibroid or myoma, Fig. 149. The similarity of constitution, then, of "fibrous" tumors with that of the muscular Avail of the uterus in Avhich they originate is now amply de- Fig. 149. Structure of Fibroid Uterus , Showing structure of waving bands of the long-spindle cells, with rod-shaped nuclei of plain mus- cular tissue; the nuclei stained with carmine. At one point a few cells dlvided.transversely. (Ad nat., by H. Arnott.) termined. But I think this similarity is somewhat overstrained. At any rate we must distinguish two forms, the hard and the soft tumors. I am glad to find this opinion confirmed by Sevastopulo, Avho represents the views of Broca {Des Hysteromes, Paris, 1875). " Hard myomas," he says, " are chiefly or wholly formed of fibrous elements, so that the name myoma Avould be quite improper if it Avere not known that the fibrous element had been gradually substituted for the muscular, and had in a Avay choked it. Soft myomas, on the other hand (Virchow), are almost entirely constituted of muscular elements. They occur in younger women than the hard." We do, indeed, find the same histological ele- 614 TUMORS OF UTERIS. ments ; but certainly they are combined in different proportions, so as to produce marked differences in some of the physical characters, for ex- ample, the "fibroid" tumor is commonly pearly white, more striated, under the knife it gives a different sensation : compared Avith the uterine Avail in Avhich it is imbedded, its density and feel are different; its inte- rior is less vascular; it behaves in short in many respects as a foreign body. It is true that in the pregnant uterus it follows to some extent the same laws of development and of hwolution as the muscular wall; but even in this circumstance, remarkable differences are occasionally observed, especially in the course of involution. The fibroid tumor being of a different organic structure from and less vascular than the uterine wall, does not always follow pari passu the retrogression of the proper mus- cular tissue of the organ. It sometimes remains larger. And sometimes, having less vitality, less power of resistance to injury, it passes into a state of low inflammation, or necrosis, which leads to its death, entailing either total disappearance by absorption, or the spread of inflammation to the proper structures of the uterus, and pyaemia. This is especially liable to happen when such a tumor being situated in the lower zone of the uterus is exposed to unusual contusion by the passage of the head during labor. Looking at the histological characters of fibroid tumors we may imagine them to arise from accidentally aberrant groAvths of points of the original muscular structure of the uterus, that get surrounded by connective tissue or the regularly disposed muscular fibres, and thus become isolated hi masses instead of being disposed in strata in the general structure'. The seat of fibroid tumors varies infinitely. Beginning in the sub- stance of the muscular wall, they are all at first interstitial. As they increase in size they tend to bulge out either on the outer or inner sur- face of the uterus. In the first case they are called sub-peritoneal; in the second, sub-mucous. They are far more common in the body of the uterus than in the neck. This may be accounted for by the lesser pro- portion of muscular fibres in the neck. In shape fibroids vary greatly. All are at first probably rounded, and Avhilst single and of moderate size they generally remain so. The irregular nodulated tumors are mostly conglomerates of many nuclei growing together at different rates. When the tumors are separate, they may by mutual compression assume various shapes. In density they vary according to the stage of development from soft elastic to nearly cartilaginous. In color they vary from red to nearly pearly Avhite. Vascularity. — An important point in the constitution of fibroid tumors of the uterus is their vascularity. Cruveilhier observed that " it is in these bodies that the vascular system of fibrous bodies in o-eneral can best be studied. A considerable vascular network envelops them; this is entirely venous; it communicates largely with the veins of the uterus, which have acquired a calibre proportioned to that of the volume of the fibrous bodies, and to the development of the uterus. On the other hand this venous network receives all the veins which arise in the substance of these bodies. Xo uterine artery has appeared to me to penetrate the fibrous bodies Avhose circulation is reduced to its most simple expression ; no lymphatic vessel has been demonstrated ; no uterine FIBROIDS: STRUCTURE OF. 645 nerve has been traced into them. Hence the absolute insensibility of these bodies." But Virchow and Oldham have demonstrated large vessels in some tumors. The}'' are more marked in the soft fleshy tumors ; and vascularity diminishes as they become more fibrous. When a tumor is sub-mucous or polypoid, its mucous investment ex- hibits evidence of greater vascularity than is proper to the healthy membrane. When a ligature is put on such a tumor the vessels being strangled become gorged, dark-red, and easily bleed. When seized by vulsellum, ecchymosis is produced from the rupture of small vessels ; but this appearance is chiefly seen in the capsule of the tumor ; deeper in the substance the tissue even under section shows little sign of bloodvessels being divided. There is, hoAvever, an injected specimen in St. George's Museum (xiv. 65) which shows the injection throughout the substance. It appears to be a true fibroid. In St. BartholomeAv's is a specimen (32.12) shoAving " several tumors in the uterine Avail. The vessels of the uterus have been injected, and the injection has entered the tumors." Examination of this specimen will, however, shoAv that this is true chiefly of one large tumor near the inner surface of the uterus, and of looser texture ; and that this tumor is less vascular than the uterine wall itself, whilst two smaller tumors, sub-peritoneal, are scarcely injected at all. In another specimen in the same museum (32.6), " a section of a uterus, with a firm fibrous tumor imbedded in the middle of its anterior Avail, the vessels are minutely injected : but none of the injection appears in the morbid growth." This remains Avhite in remarkable contrast with the vascular uterus. This comparative absence of vessels, and the consequent Ioav vitality, accounts for the impunity Avith which these tumors can be cut or lacerated during surgical operations. The venous character of the bloodvessels on their surface explains the free hemorrhages occurring Avhilst they retain their relations, and the speedy cessation of the bleeding Avhen the tumors are removed. But in some cases there exists a largely-developed network of blood- vessels surrounding the tumor and in connection with it. Large sinuses are formed. This constitutes a serious danger in enucleation—1, of hemorrhage ; 2, of septicaemia. The danger is all the greater that Ave cannot discover before operating the presence or absence of such vascular relations. The rate of growth is hard to determine. It is not uniform. It is governed greatly by the ovarian stimulus. Probably the intra-mural or sub-peritoneal tumors grow more sloAvly than the sub-mucous. Many are comparatively small and inert for many years. That their usual rate of groAvth is slow may be inferred from their structure, Avhich is but scantily supplied with bloodvessels ; from the fact that fibroid tumors of consider- able size are rare in young Avomen; and in many it is a matter of observation. I have several Avomen under observation in whom the existence of fibroids in the uterus was established many years ago. It is almost exclusively in women approaching or after the climacteric that very large tumors are seen. Fibroid tumors are single or multiple, and some tumors apparently single are reallv compound, that is, conglomerates of single tumors. The 616 TUMORS OF UTERUS. characteristic of a single tumor is that it consists of one bundle or mass : in the case of multiple tumors there are tAvo or more masses situated apart from each other in distinct parts of the uterus ; whilst conglomerate tumors consist of several masses packed t >gether in close approximation. Fig. 150. Conglomerate of Fibroid Tumors of Uterus (R. B.). (Two-thirds nat. size, St. Thomas's Hospital.) There is scarcely a limit to their number. In size they vary from a pin's head to that of a man's head, or even bigger. Fig. 151. Sub-peritoneal Fibroid Tumor of Uterus (K. B.). The tumor is only attached by a thin pedicle to the fundus uteri. (Half-size, London Hospital.) Examples of the single and multiple tumors are seen in Fis and cervix normal. The uterus enlarged rapidly ; later a lobulated polypoid mass occupied the vagina connected with an intra-uterine growth. The discharge was very offensive ; the patient's aspect resembled that of malignant disease. A portion of the mass was removed by the hand. The patient's state Avas very critical for a fortnight afterwards, masses of slough coming aAvay. Then she recovered, and the uterus scarcely exceeded its normal size. But after some months of apparent good health flooding recurred, and the uterus Avas again found very large. Another attempt at enucle- ation Avas made by the hand. Again she recovered, the uterus returning to its ordinary size. Tavo or three months later the floodings returned, and a large groAvth Avas found in the uterus. It was removed by liga- ture, but she died in a fortnight. Every organ in the body was found healthy except the uterus and vagina. The uterus on section was found to contain a white soft groAvth, attached by a very broad basis to the \vhole of the fundus and posterior surface. The mucous lining of the cervix was healthy. The tumor greAV far too rapidly for a fibrous tumor, Avas too soft, and too lobulated. Fibrous tumors, too, do not reproduce themselves. There Avere no other deposits in any organ of the body, although the disease had existed three years. Its history is like that of recurrent fibroids elseAvhere. Bristowe, Avho reported on the tumor, confirms the opinion of Hutchinson. It did not present the characters of any of the forms of cancer usually met Avith ; it Avas certainly not fibrous; there Avas no cancer-juice. The tumors were composed of the characteristic oat-shaped cells freely mingled Avith others of a flattened fibroid form, each containing a single nucleus, having Avithin it several clearly defined nucleoli. Mr. Callender describes {Pathol. Trans., vol. ix.) a case of recurrent fibroid tumor of the uterus, with groAvths of a similar character in the pericardium, the lungs, and in the body of the sixth cervical vertebra. Partly by repeated operations, partly by sloughing of portions of the growth, considerable fragments were from time to time removed. The fragments removed presented the ordinary characters of recurrent fibroid tumor. Profuse hemorrhages occurred, portions of the tumor being discharged. This was her history for several years. The uterus at last increased greatly in size, being felt above the umbilicus, and a lobulated soft growth occupied the vagina, and was continuous with that which filled the interior of the womb. She died exhausted. The impression was that the operations did not retard the growth ; the reproductive power Avas so great. The uterus contained a tumor continuous with one in the iliac fossa. Passing up from the pelvis, the lumbar glands were found infiltrated with the fibroid material. Carswell figures {Pathol. Anatomy) an erectile tumor of the uterus. Fig. I06 " represents an erectile tumor of the uterus which gives rise to frequent and extensive hemorrhage, a. Vagina ; b. Cavity of uterus greatly enlarged; c. A fibrous tumor lodged in the substance of the uterus, and projecting inwards, covered by the mucous membrane d; e. The erectile tumor rising above the surface of the uterus, covered by a DEVELOPMENT AND DECAY OF. 655 smooth, glossy membrane, and traversed by a multitude of A^essels, from which the hemorrhage proceeded." Fig. 186. Erectile Tumor of the Uterus (Malignant?). (Half-size. Carswell.) In the same work CarsAvell figures a specimen of atrophy of the uterus and ovaries from ossification of the arteries. Projecting in the cavity of the uterus is " a tumor composed of dilated veins and cellulo-fibrous tissue." The Development and Decay of Fibroid Tumors. 1. During the period of Growth.—-A fibroid tumor being like in con- stitution to the uterine muscular Avail, groAving in it and depending upon it for its existence and nutrition, may be expected to follow closely the conditions of its parent organ. Accordingly, it grows during pregnancy, and undergoes retrogression or involution when pregnancy is over; and sometimes involution being thus started passes into atrophy, and the tumor disappears altogether, as in cases narrated by Dr. Sedgwick,1 Scanzoni, and others. Thus pregnancy may, in very exceptional cases, it is true, cure fibroid tumors. This process of complete absorption or atrophy has been questioned. It has been objected that the tumor was simply cast off unobserved. But since the uterus itself may vanish through atrophy, so a fortiori, may a fibroid tumor. The process, in most cases, no doubt is fatty degeneration the same as that Avhich melts away the useless muscular tissue of the uterus. Lancereaux says the fatty transformation of fibroids is the most common. VirchoAv says it is per- St. Thomas's Hospital Reports. 656 TUMORS OF UTERUS. haps constant. Klob expresses a similar opinion. Clinical observation Avill, I think, dictate a limit to this rather absolute doctrine. Thev may soften and become fluctuating, oedematous. Cavities or cysts may form in them containing pus, blood, or serum. AVhen these cysts are large, and the tumor rises into the abdomen, the tumor is called fibro-cystic, and may simulate ovarian disease. It is not often the pure fibroid Avhich is liable to this state, but the more fleshy tumor, whose texture is looser and more continuous with the proper structure of the uterus. The fibroid may undergo inflammation, suppuration, and gui- grene. This is also one of the ways in Avhich fibroids are eliminated under pregnancy and childbed. It has been supposed that fibroid polypi are liable to become converted into scirrhus or cancer. It can hardly be admitted that the abnormal muscular growth of which they are composed is more liable to such a change than is the normal muscular structure of the Avomb. A muscular fibre cannot be changed into cancer. It may, however, give place to it. It is quite possible that the cancer element may be developed in the substance of a uterine tumor, as it may be in the proper substance of the uterus; and that the activity of the neAV growth may cause the atrophy of the old, and the gradual substitution of a cancerous tumor for a be- nignant polypus. Or the normal structure of the uterus or vagina being first the seat of cancer, the disease may spread and invade the fibrous tumor. Of this I have seen examples. In one case I removed a large fibroid or muscular tumor Avhich shoAved no trace of malignant disease. The patient got. apparently Avell; but two years later it Avas found that malignant disease had been developed in the uterus. The folloAving history by Drs. Benporath and Liebmann illustrates this question: A Avoman, aged forty-eight, had suffered from metrorrhagia, had had in early life several abortions, and in the latter years had never conceived. A tumor became manifest in the abdomen. After death a careful examination was made. There Avas a fibroid near the right Fal- lopian tube ; another almost encircling the uterine cavity loAver down; carcinoma of the upper part of the vagina. It resulted that the lower segment of the uterus Avas invaded by the progress of the vaginal cancer, and with it the fibroid tumors contained in its Avails. The loAver parts of the tumor were most affected, the upper parts, those most remote from the original seat of the cancer, Avere free. The case may be summed up as follows : Uterine fibroids possess no immunity from cancerous degene- ration ; but they are scarcely more prone to it "than the proper uterine tissue. 2. During the period of Retrogression.—-When the normal ovarian stimulus to uterine growth ceases at the climacteric, there is a tendency in fibroid tumors to undergo the like retrogression or senile involution or atrophy which seizes upon the uterus. They sometimes diminish in bulk. They generally tend to become inert, offending only by their bulk and mechanical interference Avith surrounding organs. But not seldom, uterine fibroid growing prolongs the period of uterine growth. Hence hemorrhages continue recurring with more or less periodicity until the age of fifty or even beyond. CHANGES OCCURRING IN. 657 Onotification.—In muscular tumors and polypi of long standing, the vessels often become very scanty, or disappear. Their entire structure sometimes undergoes an earthy or bony degeneration. In this condition the hemorrhages which had attended the earlier stages of their growth often cease. They seem to be removed by this change from the sphere of organic activity, and excite little or no irritation in the organs with which they are connected. I examined the body of a lady Avho had died suddenly from heart- disease, at the age of about sixty. Thirty years previously she had suffered from repeated uterine hemorrhages, when she Avas thought by her physicians in Holland to be laboring under scirrhus uteri. I found one of the ovaries converted into bone ; the other partly into cartilage Fig. 157. Ossified or Cretified Fibroid Tumor of Uterus (R. B.). (Half-size, St. Thomas's, G.G. 402.) and partly bone. In the place of the uterus was an immense firm, fibrous tumor, partly converted into an osseous substance. This tumor had un- doubtedly been the cause of the floodings she had experienced in early life. This stony or bony conversion is not very uncommon. It especially affects the hard fibroid tumors. There are excellent examples in most of the hospital-museums of London. Fig. 157 is from a specimen in St. Thomas's. 42 y'yoS TUMORS OF UTERUS. The process of calcification may be manifested in two forms : one is peripheral incrustation, by which the tumor acquires a shell of calcareous matter ; the other is, calcareous infiltration, the substance of the tumor being pervaded with the earthy material. This is found to be phosphate of lime and carbonate of lime. Virchow showed that by decalcifying these uterine stones one might bring back into evidence the muscular fibres. It is therefore to be inferred that the calcareous change chiefly attacks the connective tissue. In St. Bartholomew's Museum is a specimen (Xo. 82.50) which affords clinical illustration of one feature in the history of calcification. " It is a large lobed fibrous tumor, spontaneously expelled from the uterus. The texture is softened and soaked with fluid, as if through partial decompo- sition. On its surface are numerous thin plates of bone-like substance, Avhich seem to have been nearly separate while it decomposed. The plates are simply calcification of the fibrous tissue. Patient, aged forty- six, had observed the tumor for tAventy years ; during that time bad borne many children. For many Aveeks prior to discharge of tumor, which was expelled with pains like those of labor, flakes of bones passed away. Her recovery Avas complete." (Catalogue.) This source of bone must be borne in mind. By examination, the masses discharged may be distinguished from the foetal bones of extra- uterine gestations. Effects of Fibroids upon the Uterus, surrounding Organs, and the System generally.—Let us first examine the connection of fibroid tumors with the uterus. The hard fibroids commonly have no continuity of tissue Avith the uterine substance. They are surrounded by a layer of loose con- nective tissue, and then by developed muscular tissue of the uterus dis- posed in a stratified manner. The tumor is therefore encapsuled. It is upon this disposition that the process of enucleation, spontaneous or sur- gical, depends. In some cases, hoAvever, it is presumed as the conse- quence of inflammation, the tumor contracts adhesions with the uterine wall. This may occur Avhilst the tumor is still intra-mural, attachments forming with the muscular wall in which it is imbedded. But Avhen the tumor has become polypoid, and projects into the uterine cavity, adhesions become more frequent. Thus a tumor may be more or less completely adherent to the mucous membrane of the uterus or vagina. There is a fine example of vaginal adhesion in St. George's Museum (xiv. 43). The uterine adhesion is not uncommon; it may usually be broken down by the finger. The source of the hemorrhage which is so common a consequence of fibroid tumors and polypi. It has been contended that the blood flows principally, if not exclusively, from the surface of the polypus. Lisfranc especially strenuously advocated this view. It has been urged in sup- port, that the hemorrhage is observed to be immediately arrested upon the removal of the tumor, and even in many cases upon the application of a ligature. It has been pointed out that the pedicles of large polypi frequently carry bloodvessels of considerable size, that the Investing membrane is highly vascular, and that it has been seen to pour out blood upon being injured. On the other hand, it has been urged that the real source of the blood is the mucous surface of the uterus. Whilst the particular facts urged in support of the view that the surface of the EFFECTS PRODUCED BY. 659 polypus pours out the blood, admit of a complete solution by the theory that it is poured out by the uterus, there are also special reasons Avhich support this latter opinion. It is observed that profuse hemorrhage at- tends very small polypi as well as those of large size ; and it is difficult to imagine hoAV the extensive and rapid losses of blood which often occur can escape from the surface of a tumor in many instances not larger than a small nut. Again, the hemorrhage mostly assumes the form of profuse menstruation ; and it Avill not be contended that the ordinary menstrual flow comes from any other source than the uterus. Metrorrahgia may arise from any cause Avhich sets up a preternatural action. The pres- ence of a polypus is a cause of increased afflux of blood. It is difficult then to avoid the conclusion that excess of the ordinary menstrual dis- charge, occurring when a polypus is present, Aoavs like the normal pro- portion from the womb. When the tumor or polypus is very large, almost the entire mucous membrane of the uterus may be protruded before it; that is, there is no mucous membrane but that investing the tumor. Why the hemorrhage ceases Avhen the tumor is removed, is exactly why it ceases after the expulsion of the ovum in abortion. The developmental attrac- tion of blood is at an end. It has been observed that in some cases the menstrual Aoav is actually lessened. Virchow suggests that fibrous bodies may possess a sort of erectility by virtue of which they may at any time be larger or smaller, harder or softer. This Avould depend upon the varying quantity of blood, and varying muscular action. It is certain that some tumors enlarge and soften at the menstrual epochs and during pregnancy. Some become oedematous; and it is by the absorption of the oedematous fluid that we may account for the occasional apparent diminution of these tumors under the treatment by ergot and other means. Fibroids almost invariably cause enlargement, more or less deformity, and displacement of the uterus. They may produce every variety of flexion, and even inversion. By attracting an undue supply of blood, they often induce congestion; sometimes chronic endometritis; these conditions give rise to hypertrophy of the uterus generally, and to glan- dular irritation and out-groAvths in the cervix. The disposition to neoplasmata or out-growths where fibroid tumors exist, is very great. Thus we frequently find not only multiple tumors in the body of the uterus, but tumors of various kinds in the cervix as well. And it is not uncommon to find complications in the form of cystic disease of the ovaries, and dilatation with obstruction of the Fallopian tubes. In St. BartholomeAv's Museum is a specimen (No. 32.52) of a uterus, in the side Avail of Avhich is embedded a large fibrous tumor. The tumor has bent the uterus laterally, and so encroached upon its cavity, that the cervical portion Avas shut off from that within its body. The cavity of the uterus is greatly dilated; its Avails are thinned ; its mucous membrane was intensely vascular, and it was filled with pus. Another specimen in the same museum (No. 32.13) shoAvs retrograde dilatation of the uterus above the seat of constriction. It exhibits the obliteration of that portion of its cavity Avhich is within the cervix. The 660 FIBROID TUMORS OF UTERUS. rest of its cavity is dilated. The extremities of the Fallopian tubes are adherent to the ovaries. But in a considerable proportion of cases the cervical portion remains free from other than mechanical distortion. A small fibroid in the ante- rior wall of the body may cause anteflexion, one in the posterior Avail retroflexion. A large tumor in the anterior Avail may, however, push the fundus over backwards, producing retroflexion, and vice versa. If grow- ing in the sides of the uterus, or indeed elseAvhere, if they develop un- equally they destroy the symmetry of the organ, may distort it in any conceivable manner, so that there is nothing in Nature more fantastic than the shapes which the uterus invaded by fibroid tumors may assume. The cervix itself, although generally free from tumor, may be twisted and distorted in the most extraordinary manner. It is often flattened out on the deformed body of the uterus ; the course of its canal is made tortuous, and its calibre compressed or obliterated. The os uteri may be small or large. Sometimes it is very difficult or impossible to pass a sound along it, so devious and narroAV is the canal. The uterus impeded in its functions gives rise to the folloAving symp- toms: dysmenorrhaa, dyspareunia, and sterility. These are especially apt to occur Avhen the body of the uterus is bent upon the cervix at a right or even an acute angle, constricting the os internum. In the event o <* " of pregnancy occurring, abortion is a very probable issue. Such cases may lead to profuse flooding. The uterine Avail is unable to contract uniformly. The course to adopt is—1, to remove the ovum completely. after dilating the cervix, if necessary; 2, by SAvabbing the interior of the uterus Avith persulphate of iron or tincture of iodine. Fibroids may cause dragging and atrophy. Thus Bristowe and Hutchinson {Path. Trans., vol. viii.) report on a case of absence of the cavity of the uterus and extreme atrophy. Tavo tumors existed, and had become pedunculated, and it is evident that betAveen them the uterus had been pulled out and attenuated. It is probable too that in this case, as in others, the tumors Avere at first surrounded by the substance of the uterus, and that as they became detached, they carried Avith them as a capsule a considerable portion of the uterine tissue, which has since Avholly disappeared, and betAveen these two processes, co-operating in the same direction, there can be no difficulty in understanding Iioav the body of the Avomb should have been reduced to the remarkable condition in which it was found. Fibroids may even cause axial twisting of the uterus, as in a case related by Dr. E. Kiister.1 "An unmarried Avoman, aged thirty-four, Avho had suffered from dysmenorrhoea, died of diarrhoea. The body of the uterus was as large as a man's head, and presented several projections on its surface. Through the enlargement of the body of the uterus, the neck was enormously drawn out and twisted. It had undergone two and a half turns, so that the right ovary Avas turned to the left and forwards, and the anterior surface of the uterus was turned backwards. The cervical canal Avas almost closed ; its Avails Avere very thin, its length was ten centimetres. The caAlty of the uterus Avas filled with blood." Beitrage zur Geburtskuude und Gyuakolo- fow?/."—Assuming that uterine tumors are governed in their growth by the ovarian function, it might be expected that the removal of the ovaries would arrest the growth and promote the retrogression of uterine tumors. Acting on this hypothesis, the ovaries have been amputated. Battcy, who seems to have been the first to propose, or at least to practice " normal ovariotomy," did so with the view of relieving various disorders, nervous especially, associated with aberrant ovarian function. He reports ten operations, in some of which one, in others both ovaries were removed. In one case he operated by abdominal section, in the rest bv the valood-]>oisoning. And this comes from several sources. The constant necrosis and ulceration of the surface of the diseased mass produce a granulating vascular surface capable of absorbing the foul ichor which bathes it; hence ichorrhaemia. Another source is the intestine. When- ever cancer has proceeded so far that the disease has caught the rectum, obstruction either by direct compression, or by interference with the con- tractility of the muscular coat, leads to accumulation and partial reten- tion of faecal matter above. This induces retrograde dilatation of the intestinal canal. The arrest of the excrementitious matters in the dilated bowel is followed by decomposition, marked by distressing flatus. Ab- sorption of the products of the decomposed and retained faecal matter takes place. Hence another form of blood-poisoning—copraemia. It is greatly to this that the unhealthy and dirty-sallow aspect of the skin is due. The cancer-juice is in many cases also absorbed. Evidence of this is seen in the infection of the glands, which arrest probably only a portion of the fluid in its transit towards the general circulation. The signifi- cance of the so-called cancerous cachexia is not ahvays free from ambi- guity. I have seen a Avoman who had no trace of cancer exhibit the appearance in a marked form. It Avas the sequela of typhoid. A ca- chexia hard to distinguish from the cancerous is not infrequent in fibroid polypus attended by partial necrosis of the tumor and retention of blood and necrotic debris'. It is not due, I believe, to any specific cancerous empoisonment, but to the absorption of the foul necrotic and decomposing debris and discharges from the ulcerating surface. I have seen it disap- pear for a time when the morbid processes on the surface were arrested by treatment, just as the cachexia attending polypus disappears when the polypus is removed. Added to these sources of blood-degradations, there is of course im- paired nutrition to accelerate the sinking from exhaustion. 4. Cancer may also lead to fatal ileus, either by pressure or through adhesions, the result of the peritoneal inflammations which so often com- plicate this disease. 5. Some Avomen die of actual starvation. Thus I have known cases of uterine cancer in Avhich the hemorrhage had ceased, and in which, from inability to bear any food, gradual exhaustion carried off the patients. 4G 722 CANCER OF UTERUS. 6. Combined Avith these causes of exhaustion and blood-poisoning, there is not infrequently such a retrograde impairment of the urinary apparatus that the function of the kidney is obstructed, and then urinaemia occurs. The obstruction beginning in the bladder, leads suc- cessively to dilatation of the ureters, of the pelvis of the kidney, and to atrophy*of its secreting structure: that is, to amyloid degeneration or hydronephrosis. Suppression of urine ensues, and after two or three days coma supervenes. This is the sure forerunner of a fatal issue, usually by convulsions, which is seldom delayed beyond two or three davs. But before the coma sets in the patient may shoAv so little suffer- ing beyond what she had long undergone that the imminent danger is hard to realize. 7. Rokitansky describes amongst the effects of cancerous infection osteomalacia, aneemia, fatty and amyloid degeneration of the liver and spleen as well as of the kidneys. 8. The circulation is yet exposed to another invasion. The vessels which supply the uterus run through the broad ligaments into the neck of the uterus on either side, just at the very seat of election of cancer. When the disease has extended into the connective tissue around these vessels, mechanical compression of the vessels ensues. They become imbedded in a dense mass which quite destroys that freedom of motion and elasticity which characterize the healthy vessels ; they are converted into rigid tubes, and these tubes are often contorted, and encroached upon by projections which destroy the evenness of their bores. The veins especially suffer from these changes. The blood moving with diffi- culty, subject to frequent delays, easily coagulates. Hence venous thrombosis, which is often promoted by the entrance into the blood of irritating matter which has the property of causing coagulation. This obstruction to the local circulation is probably a main agent in producing those profuse hemorrhages from the free surface of the disease which are so characteristic of cancer. But it entails other consequences. The first is progressive thrombosis in the veins extending to the internal iliacs, then to the common iliacs, even to the vena cava. The obstruction of the common iliac vein of course leads to obstruction of the external iliac, and the effect of this, concurrently with the necessary clogging of the lymphatics, is seen in phlegmasia dolens of the leg. And no doubt the lymphatics are affected like the veins. When it comes to this the end is not far off. As far as I knoAv phlegmasia dolens from cancer of the uterus is incurable. The sufferer lingers for a few Aveeks, perhaps, until life is extinguished by advancing exhaustion, unless another event, 9, embolism, occur to precipitate the fatal issue. In some cases I have seen the iliac veins and some inches of the vena cava filled with a dirty, soft, pulpy clot, resembling unhealthy pus. It cannot be a subject of surprise if matter so degraded easily gives rise to detached fragments, which are carried into the heart and thence into the pulmonary arteries. I have seen a lady die of phlegmasia dolens consecutive on cancer of the uterus, and embolism of the brain inducing hemiplegia. When, however, phlegmasia dolens supervenes on operative proceedings, as amputation of the cervix, it may be due to accidental septicaemic irritation, and this may subside. Of this I have seen several examples. SYMPTOMS AND DIAGNOSIS. 723 10. I have seen several sudden deaths in women suffering from cancer of the uterus. They have occurred under circumstances Avhich involved an unusual physical exertion or emotion. In one such case, that of a Avoman in St. Thomas's Hospital, I found conditions Avhich, to my mind, explained the catastrophe. The pelvic organs were matted together by the cancerous disease, the lumbar glands Avere infiltrated and enlarged, and these, Avith similar infiltration of the connective tissue, surrounded and fixed the aorta and vena cava nearly as high as the diaphragm. The elasticity of these vessels Avas thus quite destroyed. The aorta Avas vir- tually a rigid tube ; and the vein Avas bulged in in many places by the projecting masses outside. In the left heart were large decolorized fibrin- clots. Under such conditions, the circulation cannot go on Avell. Under the slightest increase of impulse of the heart, a difficulty Avould arise in the transmission of the volume of the blood projected by it into the nar- rowed rigid aorta; this would react upon the feeble heart, cause a strug- gle and asphyxia. In this particular case there Avere no emboli or thrombi found in the pulmonary arteries. In many cases, concurrently or not Avith the consolidation of the broad ligaments, peritonitis supervenes, either being the immediate cause of death, or leading to ulterior trouble by matting together the adjoining organs, and thus impeding them in the execution of their functions. 11. Death, more or less sudden, may be caused by the shock attending perforation into the peritoneal cavity. Dr. Priestley shoAved to the Obstetrical Society (1870) a specimen of a carcinoma of the body of the uterus. Death took place Avith symptoms of collapse. Perforation had taken place through the anterior Avail of the uterus. A similar case occurred at St. George's. I exhibited the specimen to the Obstetrical Society, 1878. Peritonitis may be excited Avithout perforation of the peritoneum. In this case it is probably caused by the irritation of the cancer groAvth in the structures immediately invested by the peritoneum. The peritonitis in these cases is of a chronic kind, and conduces to a fatal issue in a remote or secondary manner, as by causing obstruction to the action of the intestines. But sometimes the ulcerative process eats through the peritoneum, and thus sets up inflammation in this membrane, which may be the immediate cause of death. It may also be excited by a process of local septicaemia and thrombosis, extending along the veins and lymphatics, coming from the morbid mass towards the peritoneal surface of tfie uterus, or in the broad ligaments. 12. Secondary tumors may arise in various parts and interfere with the functions of important organs ; for example, such a tumor may obstruct the hepatic duct, and induce jaundice, disorganization of the liver, and thus death; or cancerous deposits, embolic or developed in some other way, may form in the brain or lungs, and so harass these organs as to bring life to a stand. Symptoms and Diagnosis.—I believe the sign that most frequently arrests attention in the first place is hemorrhage; and then, when Ave examine, avc find the disease far advanced. In several cases the first thino- to suggest the presence of disease has been hemorrhage on sexual intercourse. Pain of a marked character, even the stabbing, lancinating 724 CANCER OF UTERUS. pain described as almost pathognomonic of cancer, is often absent for a long time. So long as the disease is limited to the cervix uteri there is commonly little pain. But Avhen it has extended beyond, and especially in the last stages, pain is often constant and agonizing, destroying rest. Pain and SAvelling above the groin in the iliac region sIioav extension of the disease to the lymphatic glands and peritonitis. Broca and Cornil have shown that where women have long suffered extreme pain in the thighs, legs, and nates, there has been either an epithelial neoplasm or hypertrophy of the cellular tissue of the neurilemma of the sciatic or crural nerves, and that some nerve-tubules are partially affected, the medullary substance being transformed into granular fat-molecules. The pains have a radiating character, starting as it Ave re from the centre of the disease, and shooting to the sacrum, vertebral column, loins, groins, and thighs. In the earlier stages, no particular odor is perceived, but when ulcera- tion has begun, an odor, penetrating and offensive, is almost certain to be emitted. It is so peculiar that frequently by it the presence of a cancerous patient is made known. It clings tenaciously to the linen and to the examining finger. In advanced cancer the aspect of the patient is often enough to excite a strong suspicion of the nature of the disease. Emaciation is general, but not constant. The skin acquires a dirty straw tint, indicative of a profound alteration in the properties of the blood, and of impaired nutri- tion. It is true that a very similar tint is often seen in women Avho have long been draining from polypus or inversion of the uterus. But internal examination at once clears up the diagnosis. The alteration referred to is due to three causes: the influence of the cancerous cachexia, which, as Becquerel has shoAvn, first destroys the globules, and afterwards diminishes the quantity of albumen; to the hemorrhages, which very quickly diminish the globules; and to the serous discharges. Thus the Avater of the blood increases ; the globules and the albumen diminish. The cancerous cachexia is sooner or later folloAved by hectic or irritative fever. Sooner or later bladder-distress almost always comes. The first symp- tom to arrest attention is often dysuria or partial incontinence of urine, so that examining the bladder we find to our surprise cancer of the uterus. At a later stage the urine may all escape by a fistulous opening into the bladder near the cervix uteri. I had a case in St. Thomas's Hospital, where a valvular cicatrized opening into the bladder near the os uteri was the only opening found, the ordinary meatus urinarius being undiscoverable. Urine escaping from a fistula into the vagina may be retained there by the sphincteric action of the vulva, and thus mixed with blood from the cancerous surface may when voided appear as hematuria. I have several times known this apparent haematuria to be treated as due to bladder or kidney disease. The distinctive indications are different in the cases where cancer attacks the cervix, and in those where it attacks the body of the uterus. The diagnosis of cancer of the uterus in the early stages is beset with difficulties. The opportunities of studying the disease at this sta^e are so rare, that, even when seen, for want of knowledge of its characteristics DIAGNOSIS. 725 it may escape recognition. Thirty years ago there can be no doubt that cases of simple hypertrophy or inflammatory engorgement were not in- frequently assumed to be cancer; and credit Avas asked for having cured them. Duparcque, Lisfranc, Ashwell, and Montgomery certainly fell into this error. And, notwithstanding the more accurate knowledge since extended, mainly through the researches of Teillier and Henry Bennet, of the consequences of inflammation of the cervix uteri, enabling us in most cases to eliminate these conditions, the clinical observer is still liable to mistakes. Syphilitic condylomata forming on the vaginal-portion may simulate epithelioma. The cancerous disease may be distinguished by its more rapid growth, by its greater tendency to hemorrhage and necrosis, but most surely by the test of treatment. Under cautery and constitutional treatment the syphilitic disease quickly yields. Not so the cancerous disease. The characters assumed by the os and cervix uteri during the earlier stages of medullary cancer are less familiar and therefore less clearly defined than those which mark the later stages. At first, whilst strictly localized in the cervix, the cervix is larger than natural, and one or more bumps of the size of half a nut, hard, resisting the finger, quite insensible, may be found on the lips of the os uteri. There is often, also, some puckering of the os. At this stage the mobility of the uterus is not im- paired. Through the speculum these bumps shoAv a violet-red tint, quite distinct from the rosy tint of the rest of the cervix. Up to this time, and indeed long after, the patient may still exhibit the outward signs of florid health. A characteristic form of malignant disease of the os uteri in the earliest stage is due to the extension or spreading of the superficies of the os, whilst the cervix above remains the same. This gives the figure of a mushroom to the part. It is true that ordinary hypertrophic elongation of the cervix begins somewhat in a similar way ; but the " cancer-mush- room" is distinguished by its more complete resemblance to the mushroom shape, the spreading proceeding all round the os ; and by the everted os of hypertrophy presenting a smoother surface. Malgaigne describes the u Chamjdgnons cancereux." Another form not less characteristic might be described as the " cancer- crater." A rough jagged edge forms the boundary between the vaginal orifice of the cervix and the cervical cavity, which is scooped out beyond the crater-like orifice. But this character is more often found in ulterior stages. In forming the diagnosis of cancer, the speculum and sound are com- monly useless—except in the very earliest stage—and may be injurious. The tissues are brittle ; they often bleed freely even on the slightest touch of the finger; and if the speculum is introduced greater injury is caused, and the effused blood obscures what might otherwise be seen. The finger by the vagina and rectum tells all that is necessary to estab- lish the melancholy diagnosis. Cancer, Avhen limited to the vaginal-portion, that is, whilst the uterus still retains its mobility, has to be distinguished from the various con- ditions of inflammation, hypertrophy, and non-malignant tumors of this 726 CANCER OF UTERUS. part. The condition most likely to give rise to error is hypertrophy of the follicles of the os uteri from occlusion. This condition produces small nodular projections, the centres of angry, vivid congestion. They differ from commencing cancer, in showing a whitish translucent centre, clue to the retained mucous secretion ; and in being curable by puncture. But it sometimes takes time for observation before a sure diagnosis can be formed. Perhaps the best training for the eye to the recognition of early cancer of the os uteri is obtained by the observation of the appear- ance of commencing cancer at the mucous outlets of the body, for example at the vulva, anus, mouth, nose, and eyes. When cancer has spread from the vaginal-portion to the roof of the vagina, the cellular tissue between the cervix and bladder to the broad ligaments, the uterus will almost necessarily be set fast. The primary disease of the cervix will be partly obscured by the secondary surround- ing disease. It is in this condition chiefly liable to be mistaken for peri- metric inflammation and inflammatory deposits. An important distinction, often available, lies in this: in cancer the disease is in the cervix itself; in perimetritis it is around the cervix. Some cases of fibroid tumors distorting the cervix, and fixing the uterus in the pelvis, may give rise to error. In both cases the vaginal-portion is commonly brought down into a lower plane ; it is more easily reached. But it is especially in advanced cancer that the diseased mass is often carried so low down that the finger scarcely penetrating the vulva strikes at once upon it. And there are other points of distinction. By the time that the uterus is set fast by cancer, other characteristics are usually pronounced, as hemorrhage, foul discharges, pain. Perimetric inflammation, too, has a different history ; it dates from an epoch pretty clearly defined, beginning with labor, abor- tion, or menstruation. Foul-smelling, irritating discharge occasions great anxiety, because it is a popular belief that these characters are peculiar to malignant disease. But they are, in truth, acquired by the retention of discharges in the vagina. When cancer begins in the body of the uterus, the mobility of the organ may not be interfered with until very late in the course of the disease. It may be mistaken for endometritis, with or without sub- involution : for hypertrophy with engorgement; for fibroid or other non- malignant tumors, especially those of the sub-mucous or polypoid kind. One point of distinction, sometimes available, consists in the origin of the disease. Fibroid tumors begin in the muscular wall of the uterus, cancer more often on the mucous surface. A feature valuable in the diagnosis of intra-uterine cancer is the fol- lowing: The morbid tissue projecting into the cavity shortens it. so that the sound may penetrate two inches only, or less; at the same time the walls become incapable of collapse, they remain rigid, are kept apart forming a spherical hollow, rough inside. When Ave get this condition Ave may conclude that the disease has laid hold of the Avails of the uterus altering their physical property, destroying contractility. This is one cause of congestion and bleeding. If the uterine walls are felt yielding if the anterior wall can be flattened upon the posterior, there Is rarefy DIAGNOSIS. 727 cancer of the body of the uterus. Chronic metritis may induce a some- what similar condition, but it will be less marked than that produced by cancer. Pain is usually more intense, and comes on earlier in the cases where cancer invades the body of the uterus. This pain is, to a certain extent, diagnostic. Metritis and non-malignant tumors are not usually attended by pain so agonizing or so unremitting. But still even this symptom is not constant. For example, I saw in consultation Avith Dr. By ass and Dr. Saunders a lady, aged about fifty, a pluripara, Avho had ceased men- struating for tAvo years. For three years she had been subject to con- stant sero-sanguineous discharge, and her health had become impaired. 1 found the vaginal-portion of normal size, os closed; the uterus Avas movable, and its body was enlarged, firm, regular in form. The diagnosis was entered interrogatively as intra-uterine polypus, fibroid or malignant disease of the body of the uterus. I recommended dilatation by tents to explore the interior. Four months after this she died, and Dr. Saunders sent me the following account: " It turned out to be encephaloid cancer of the body of the womb. The following circumstances are remarkable : its duration of nearly four years ; the absence of any intense pain ; the absence of hemorrhage, the only discharge being considerable quantities of blood-stained serum of offensive odor, and this suddenly stopped about a month before death ; the perfect integrity of the os up to the very last, there being slight thickening, and its contractile power retained. At the post-mortem the whole of the fundus uteri was in a broken-down condi- tion, exhibiting the signs of encephaloid, the microscope subsequently verifying them. The patient died from asthma, there being hardly any prominent signs of the disease up to the last. I diagnosed, however, from the general cachexia and increasing weakness without an explainable cause. There were no secondary deposits in other organs ; the liver was, however, in a state of amyloid degeneration." Pain is due partly to the stretching of the muscular fibre, partly to the contractile efforts aroused by the parasitic growth, partly by the pressure of the enlarged uterus upon surrounding structures, partly to the invasion of surrounding struc- tures by the disease, and partly by the nerves themselves being affected by it. 'in some cases reflex irritation produces pain in distant parts, and vomiting is not infrequent, especially in the advanced stages. After lasting some time, the cervical canal will commonly undergo some dilatation. But the surest test of intra-uterine cancer is to bring away small frag- ments of the superficial projections from the cavity, and subject them to microscopical examination. In describing endometritis, Ave have seen that there are cases in which small pisiform excrescences exist, whose nature, or rather Avhose history, is for a time a source of doubt. In en- dometritis or metritis not complicated with cancer, the walls of the uterus are less rigid. This preliminary dilatation of the cervix may be effected by tents. This dilatation will also permit of digital exploration. Then Sims's curette may be introduced and a shred easily scraped off. The patient under chloroform, the hand may, if necessary, be passed into the vagma, the finder ayHI then easily survey the interior of the uterus, and recognize 728 CANCER OF UTERUS. the pulpy projections of malignant disease. Thus dilatation effected for diagnosis is useful for treatment. As a guide to treatment, as well as to prognosis, it is important to dis- tinguish the kind of malignant disease. Thus outbreaks of cancerous disease are comparatively frequently met with in neighboring glands, or in remote viscera. This furnishes a strong argument against hasty opera- tive interference with a vieAV to extirpating the disease. These secondary foci being greatly more common with true cancer than with epithelioma, the microscopic examination of the morbid structure becomes of great importance in determining on a line of treatment. " The scrofulous ulcerations are almost ahvays accompanied by con- siderable engorgement of the cervix uteri." On the other hand, under the microscope, the softened matter is found not to consist of the elements of tubercle, but of epithelial cells similar to those of the uterine mucous membrane, while the indurated callous structure which forms the base of the ulcer is formed of a mixture of fibro-plastic and epidermoid materials. Robin says this kind of ulcer is to the uterus what lupus or cancroid ulcers are to the face. The prognosis may in general terms be said to be settled when the diagnosis is determined. It is henceforth limited to the questions, How long will the patient survive ? In what manner and to what degree will she suffer ? Of course, if we adopt the more hopeful doctrine that at the initial stages the disease is a local one, the prognosis will be favorable in cases where the diagnosis is formed, whilst the disease appears to be isolated in the vaginal-portion in such a manner as to admit of complete amputation or destruction. But it is precisely in these cases that diag- nosis is liable to be fallacious; and erroneous diagnosis will vitiate the prognosis. What is the duration of cancer of the uterus ? As the early stages so often escape detection, it is not easy to determine the total duration. It is probable that the stage before ulceration, of limitation to the cervix, may last for some months, even two or three years. When ulceration has begun, the downhill course is often rapid. Prognosis will be affected by treatment. For example, if the disease be allowed to run its course uninterrupted, the fatal termination will in many cases come at an earlier date than in those cases where judicious surgical treatment has been adopted. It is very difficult to set out this comparative statement in figures. But a comparison of cases seems to justify certain deductions. Thus Ave take tA\o cases of cauliflower ex- crescences, apparently chiefly limited to the vaginal-portion, and ampu- tate as far as we can the diseased mass in the one case, and avoid surgi- cal treatment in the other. We may pretty'confidently predict that in the second case hemorrhage, watery discharges, and general infection will destroy the patient in a few months. We may Avith equal confidence predict that, if the diseased mass be fairly removed, the destructive pro- cesses will be arrested for a time, and that the patient's life will be pro- longed. I have knoAvn a patient recover so far that she and her friends believed recovery to be complete ; she became pregnant three months after operation, and was delivered by artificial induction of labor at the end of eight months' gestation. At this time there was return of the disease, PROGNOSIS. 729 but her general health was good. At the time of the operation she was so reduced by hemorrhages, and the disease was so progressive, that it seemed highly probable that she Avould sink within three months. So in some cases of superficial malignant disease, whether of the cer- vix uteri or of the interior of the body of the uterus, the removal or alteration of the diseased surface by actual cautery, by nitric, chromic, or acetic acid, by iodine, bromine, or by scraping, has stopped bleeding and decomposition, and thus cut off a source of blood-infection. Patients so treated have improved considerably, and it cannot be doubted have had their lives prolonged, and made for a time more endurable. In not a few cases of epithelioma in which no decided local treatment has been employed, life has been prolonged several years after the dis- ease has been recognized ; and we have no means of estimating how long it had existed before recognition. In cases of this kind the disease is not uniformly progressive. It seems to proceed by stages with intervals of halt. For a time, seldom indeed very protracted, the disease may even appear to be so completely arrested that the patient is tempted to accept the reprieve as a promise of cure. If one of these delusive halts coincide with a new treatment, especially if backed up by the bold assur- ances of a " cancer-curer," she eagerly interprets all things according to her wishes, and builds up upon this transitory foundation the most con- fident hope of recovery. These alternations of progress and arrest suggest another reflection which it is very important to bear in mind when Ave are called upon to pronounce a prognosis. If Ave express an adverse opinion without such qualification as the uncertain march of the disease demands ; if, straight- way, on forming a diagnosis of cancer, Ave declare the nature of the dis- ease and venture to foretell a brief duration of life, especially if Ave assign a specified limit, we commit a twofold error. One error inflicts needless misery on the patient, the other falls back with not undeserved retaliation upon ourselves. To utter the word " cancer," and to say the sufferer has only a short time to live, is literally to pronounce sentence of death unmitigated by the hope of reprieve. Such a sentence, when- ever it comes, even after long and advancing disease, even after suffer- ings to escape from which death may have been often silently invoked, falls like a crushing blow, adding to physical torture the agony of des- pair. Cancer differs in this respect from phthisis in its effect upon the mind. The buoyant hope that to the last so often sustains the subject of phthisis, that flatters him with the belief that the doctors are mistaken in his case, that there is nothing serious in it, has little or no place in cancer. It may be confidently said that, whereas many persons struck with incurable phthisis, refuse to believe in this reality, few or no persons struck with cancer long indulge in such a dream. Many who have no sign of cancer are ready to believe that they are suffering from the disease ; few or none who are really suffering from it fail to recognize their condition. And this they will do, although the physician may never have uttered the word. The error that rebounds upon the physician who is too hasty to con- demn is this: Not long after he has passed sentence the patient unex- 730 CANCER OF UTERUS. pectedly improves, or thinks she does ; one of those delusive halts is reached, and " another opinion," possibly less skilled and less honest than his own, encourages the welcome belief. For the time he is dis- credited ; to the patient's own injury probably he is discarded. And when at length the inexorable disease resumes its fatal course, he will hardly be forgiven. And as an additional caution against an absolute and uncompromising condemnation, humility should suggest the possibility of error in diagnosis. The proper course in framing an opinion, one dictated by truthfulness, the first law, by the modesty which is conscious of fallibilty, and tem- pered by mercy, is to explain that the case is only to a certain extent amenable to treatment, that, whilst some improvement may be expected, it is likely to be temporary only, and that the usual course of the dis- ease when once established is to shorten life. The patient will almost hwariably draw the true significance from such expressions. She will believe that she has cancer. But she will be grateful for having been spared the cruel word. The treatment may most conveniently be discussed under the leading heads of curative and palliative. The first question which always chal- lenges attention is that of curability. In the great majority of cases when first seen, unhappily, this is quickly answered in the negative. The disease has gone too far, or it has assumed a form which precludes the idea of removing it. But in a certain number of cases, the disease is sufficiently isolated in the vaginal-portion to justify the attempt; and in some cases of epithelioma of the cavity of the uterus, where the disease is ascertained to be superficial, an attempt to remove or destroy the dis- eased surface may also be made. The epithelioma or cauliflower excres- cence of the vaginal-portion offers the best prospect of cure by amputation. The best test of the fitness for amputation, I think, is the freedom in mobility of the uterus. Amputation was at one time a mode of dealing Avitii cancer of the uterus much in vogue. But it would be useless to invoke the experiences of the past generation of surgeons as to the efficacy of their practice, because error of diagnosis vitiates it to an un- knoAvn extent. The folioAving historical accown is from Samuel Cooper:— " According to Baudelocque, the excision of the cervix uteri was first suggested in 1780, by Lauvariot. M. Tarral even ascribes it to Tulpius ; but the tumors which the latter took away were, according to M. Vel- peau, evidently polypi. Lazzari, who puts in a claim for Monte™ia, is also believed to have made a similar mistake ; nor has M. Velpeau been able to satisfy himself that the operation was ever performed by Andre"- de-la-Croix and Lapeyronie, as M. Tarral represents. Troisberg recom- mended it, however, in 1787 ; and, as a critical writer observes, some- times the cervix uteri Avas removed accidentally with the knife by ignorant persons, who mistook it for a polypus. (See Edin. Med. and Sura. Journ., No. 103, p. 377.) Professor Osiander, of Gottingen, first exe- cuted the operation in 1801, on a widow, whose vagina Avas filled bv a very vascular fetid fungus, as large as a child's head, growing from the orifice of the womb. By means of Smellie's forceps, the fungus was drawn down; but it broke off, and a tremendous hemorrhage ensued. TREATMENT. 731 The operator, without loss of time, introduced several crooked needles, armed with strong ligatures, through the bottom of the vagina, and boly of the uterus, until they emerged at the os tincae. These ligatures served to draAv down the uterus, and retain it near the mouth of the vagina. Osiander then introduced a bistoury above the scirrhous por- tion, and divided the uterus exactly in the horizontal direction : for an instant the bleeding Avas profuse, but it was quickly stopped by means of a sponge, saturated with styptics. In about a month the Avoman recov- ered. Osiander afterwards performed eight similar operations upon different patients, all of Avhom are reported to have experienced a cure. The observations of Osiander Avere no sooner promulgated in France, than M. Dupuytren adopted the neAV operation, and made numerous trials of it. M. Be*camier followed Dupuytren ; so that, by 1815, the excision of the cervix uteri had become in France a common operation. However, it remained for M. Lisfranc to extend the practice, and to convince the most incredulous of the little danger resulting from it. (M. Velpeau, Nouv. ElSm. de Med. Oper., t. iii. p. 615.) Dupuytren also performed the operation eight times ; but, instead of employing the liga- tures and knife, as Osiander did, he drew down the uterus with hook forceps, and divided it above the scirrhous part with curved knives and scissors. One of the patients, on whom Dupuytren operated, had a return of the disease, and submitted to a second operation Avith no better result; but was afterwards effectually cured by the application of caustic, with the aid of the speculum invented by M. Becamier. " Even Avith regard to the excision of the cervix uteri, it is perfectly manifest to me that many of the cases in which it was performed Avere not truly cancerous. Doubts may be entertained, I think, Avhether the enormous tumor removed in the very first instance of such operation by Osiander Avas really a cancerous affection." In Guy's Museum is a preparation (No. 225920) of the vagina, bladder, rectum, and part of the colon of a Avoman, from Avhom Dr. Blundell a year before death had removed the whole uterus for cancer; disease invaded rectum, vagina, etc., Avhich proved fatal, but complete union had taken place between the pelvic organs. Dr. Wiltshire has recorded {Brit. Med. Journ., 187'3) a case in which the entire uterus Avas accidentally brought away or sloughed off after an operation, Avhich consisted in scraping the diseased surface. Some cica- trization of the vaginal roof took place, but the disease returned. The question of total extirpation of the uterus is one that scarcely admits of discussion. The circumstances under which it can be seriously contemplated must be very rare. West gives a table of recorded cases of total extirpation of the uterus on account of cancerous disease. In three only did the patient survive the operation, and that only for a month ; in tAventy-tAvo death Avas the consequence. The Selection of Cases for Amputation of the Vaginal-portion.—- There is one class of cases in which there should be no hesitation in operating. Just as the'surgeon recognizes the propriety of amputating the breast when the tumor is clearly circumscribed, movable, and no evi- dence of glandular or constitutional infection can be traced, so should he when similar conditions are found in connection with cancer of the uterus. 732 CANCER OF UTERUS. If, then, we find the uterus freely movable, a distinct neck above the diseased portion, so that we can work beyond the disease in sound tissue, and especially if the disease is ascertained by microscope to be epitheli- ornatous or cancroid, it is our duty to amputate. This should be done Avhether profuse bleedings occur or not. The plain course is to antici- pate the evils which will certainly come if we leave things alone. Com- plete cure is not hopeless; and a long respite may be confidently looked for. In another class of cases the indication, although not so urgent is still clear. I refer to those cases in which a certain degree of mobility of the uterus remains, but in Avhich the base of the disease has caught the roof of the vagina, so that no distinct neck or demarcation between healthy and diseased tissue can be made out. If a cauliflower-growth be found under such conditions, and be the source of hemorrhagic and other dis- charges, the ablation of so much of the diseased mass as can well be sur- rounded by a wire should be attempted. For a time, at least, the disease will be stayed. And there is little drawback in the shape of danger from the operation to deter from its performance. Where the vaginal-portion is attacked by medullary cancer, whilst in the stage of localization, espe- cially in the mushroom form, the uterus being still movable, amputation should be performed. The fixing of the uterus being generally due to the extension of the disease to the roof of the vagina, the base of the bladder, and the broad ligaments, is evidence that it has passed the boundary where it can be reached by topical remedies. This fixing is also, I think, in many cases evidence that the disease has invaded the lymphatic vessels and glands, a still further discouragement from resort to severe surgical treatment. When the operation is determined upon, we have to consider the best mode of performing it. If we use the knife or scissors, especial care must be taken to avoid opening the roof of the vagina behind, and perfo- rating the retro-uterine peritoneal pouch. To obviate this accident which might be fatal, the vaginal-portion of the uterus must be carefully isolated from the vragina. Dr. Emmet {Amer. Journ. of Obstetrics, 1869) re- commends before amputating to examine whilst the patient is placed on her knees and elboAVS. This, by favoring gravitation, enables us to note the length of the neck more accurately, since, in the ordinary posture the neck is always apparently longer from prolapse of the uterus. But since it is almost indispensable to the use of the knife or scissors that the whole uterus be brought low down near the vulva, there must always be danger of drawing doAvn the roof of the vagina and the retro- uterine peritoneal pouch with it. And in pursuance of the object to divide the cervix as high as possible in order to get into sound tissue, the danger of opening this pouch is serious. It constitutes an important objection to this mode of operating. The objection applies also to the chain-eora- seur, which is very apt to drag in the peritoneal pouch. It applies in a minor degree to the single-Avire-ecraseur. But the galvano-caustic wire is almost wholly free from this objection. The knife and scissors, and the single wire, further entail serious danger from hemorrhage. To arrest this it may be possible to transfix the stump with a curved needle carrying a silver wire. But the best way is to use the actual cautery. treatment: amputation. I-OO Copper or iron cauteries should always be ready when this operation is undertaken. The Operation of Amputating the Vaginal-portion of the Uterus affected with Malignant Disease.—By far the best plan is to use the galvano-caustic wire. The patient is placed under chloroform in lithotomy position. Sims's speculum is introduced to keep well back the perineum and posterior Avail of the vagina. An assistant on either side holds open the lateral and interior Avails of the vagina by small retractors. The diseased mass thus well exposed is seized as far back as possible with a vulsellum, taking care not to tear through the fragile structure. The mass thus brought fonvard near the vulva partly by gentle traction, but more by the firm pressure of an assistant's hand upon the fundus uteri applied above the symphysis pubis, is then encir- cled by the cold platinum-wire loop passed over the vulsellum. The loop is then accurately adjusted by the finger close to the base of the mass, and therefore close to the roof of the vagina. The slack of the wire is then drawn in, so that the loop, tightly embracing the root of the mass, buries itself in a groove all around. The heat now being turned on burns at once into the part to be removed, leaving the vagina quite secure. The loop is gradually screwed up as the burning proceeds. There should be no hurry in this proceeding. The wire being fine is rapidly cooled by the tissues ; it must have time to renew its heat, so that the substance is burnt through, not cut by over-tightening the loop. This slow process gives more effectual security against hemorrhage, and the more thorough burning of the surface also destroys more effectually the remains of the disease in the stump. When the wire has burnt its way through, the diseased mass is removed by the vulsellum, and the stump is carefully examined. A series of concentric rings mark the alternate incandescent and cooler states of the wire in its progress. The bleeding is generally arterial; one or more fine spirts may be seen. These I have ahvays succeeded in staunching by the actual cautery applied by the galvanic porcelain button. Light swabbing with small bits of sponge soaked in iced water will facilitate the search for bleeding points. And it is well to syringe out the vagina by playing a stream of iced water against the stump. All bleeding stopped, the vagina should be firmly, not tightly, packed with strips of lint soaked in carbolic oil. It is sometimes more convenient to place the patient in the semi-prone posture. The wire may be adjusted round the base of the tumor by the finger Avithout the aid of speculum or retractors. We are kept informed of the progressive action of the cautery by hearing the hissing sound it produces, and applying light gradual traction upon the loop whilst there is resistance. When the resistance ceases and the wire-loop comes home we knoAv the tumor is severed. It is then removed by finger or vulsellum, and the duck-bill speculum is introduced to obtain a full view of the stump and enable the operator to staunch any bleeding. The after-dangera are : hemorrhage and retention of urine. The first may be arrested for a time by further plugging. If this fail, all plugs should be removed, and the stump swabbed with perchloride or persul- phate of iron. If this fail, the patient must be placed in lithotomy posi- 734 CANCER OF UTERUS. tion, the part exposed by Sims's speculum, and the bleeding points or surface seared with the actual cautery. The carbolic oil dressing may be removed next day, and a single strip of lint soaked in the same fluid may be renewed daily for a Aveek. After this, Avashing out with Condy's fluid, or weak chloride of soda, will be useful. The surface will granulate and may cicatrize in two or three weeks. The os uteri should be watched, the sound being occasionally passed to obviate cicatricial closure. It would be better to abstain hence- forth from sexual intercourse. I have known pregnancy to occur after the operation. The stump, or granulating surface, may be sprinkled every three or four days with powdered sulphate of zinc ; or if any sprouting of malig- nant excrescence sIioav itself, it may be kept down by nitric acid or chromic acid. As already stated, amputation is sometimes advisable even when there is no reasonable hope that the operation will be curative. It is quite jus- tified in some cases Avhere the disease has extended beyond the vaginal- portion, on the principle sanctioned by experience, that much good is effected by removing the most active portion of the disease. The proceeding next in order to ablation by Avire or cautery, is scraping. This may be practised by Recamier's or Sims's curette, or by special instruments designed by Simon. It is more especially applicable to cases where the diseased mass is not so far isolated or raised above the level as to admit of surrounding by a wire, and yet Avhere the morbid surface is rough, foul, easily bleeding. The scraping is performed by decided strokes, so as to scrape off the superficial layers. Sometimes the bleed- ing stops by this treatment. But on the other hand, it is sometimes increased. I never resort to it Avithout having at hand an iron or copper cautery or Paquelin's apparatus to sear the surface afterwards ; and in the greater number of cases the actual cautery is better used alone. Amputation of the diseased part is not the only method Avhichhas been proposed and practised with the view of curing cancer. As in the case of cancer of the breast various caustics have been employed—as the chlo- ride of zinc, Vienna paste, and others. (See Cooper's Surgical Diction- ary.) Their use with the view of destroying the diseased mass is now, I believe, generally abandoned. But quite recently attempts to effect a radical cure by acting upon the cancerous growth have been made on a somewhat different principle. Bromine in solution has been recommended by Dr. Wynn Williams and Dr. Routh to be applied on pledgets of lint to the diseased surface. In some cases it has appeared to check the dis- ease by destroying the vitality of the cancer-cell. I have used it exten- sively, and have acquired the impression that disease is checked by it. And there is no doubt that it is most effective as a deodorant. Dr. Broadbent (1866) recommended acetic acid on the following reasoning: " Cancer owes its malignancy to its characteristic structure. . . . . To alter its cells is to put an end to their power of dividing and multi- plying, and consequently to arrest the growth of the tumor. In acetic acid we have an agent which on the microscopic slide rapidly effects im- portant changes in cells of every kind, dissolving the cell-wall and affecting the nucleus. Not coagulating albumen, it may diffuse itself TREATMENT: CAUSTICS. 735 through a tumor, and, reaching every part equally, it may probably pro- duce similar results when the cells are in sitii." He injects equal parts of acetic acid and water. I do not know how far this proposal has borne the test of clinical experience. But it seems that a hope of controlling this hitherto intractable disease may be found in its further pursuit. In one case in which I repeated the application several times, phlegmasia dolens supervened. The patient died. Dr. Skene {Amer. Journ. of (Jbstet., 1869) inserted arrows of chloride of zinc into a presumed can- cerous affection of the cervix uteri; recovery resulted. More lately chromic acid, nitric acid, and strong bromine have been used, more with the object of improving the superficial condition of the diseased surface, and of retarding the march of the disease, than with the hope of cure. The strong disposition to thrombosis in the pelvic veins in cancer must be considered in dealing with cases of this disease. The process may be started by the remedies employed, and thus the fatal issue may be pre- cipitated. The actual cautery, and sulphuric acid, chromic acid, per- chloride of iron, may easily cause coagulation of the blood in the vessels near the surface Avhere they are applied, and the thrombi so formed may* spread backAvards. The rule for this application may, I think, be laid doAvn as follows: If our hope is to cure or materially arrest the disease, the cauterizing agent must be applied boldly to the disease, so as to cause a slough of some depth. Now this cannot be done safely if the disease is not limited to the cervix or the lower part of the uterus. If the uterus still retain its mobility Ave have a reasonable assurance that the disease has not invaded the connective-tissue and vessels in the broad ligaments around the cervix. Under these conditions the caustics may be freely applied. But if the disease have extended high up in the cer- vix it will not be judicious to apply the cauteries named so freely as in the first order of cases. There is, however, another indication for the use of powerful cauteries—namely, to arrest profuse hemorrhage and to alter the character of the discharges. This may commonly be most effectually done by a superficial application of strong chromic acid, nitric acid, or perchloride of iron, or the actual cautery. The bleeding is quickly controlled ; and a thin slough is formed which, when thrown off, leaves a comparatively healthy granulating surface, from which for a time the discharge is not offensive. Considerable constitutional improve- ment often attends the local change. Mr. Campbell de Morgan says,1 in reference to the caustic treatment of cancer, there is an evil attending slow cauterization, namely, that while the caustic is doing its work increased action is going on in its neighbor- hood, with augmented groAvth of that part of the cancer Avhich the caustic has not yet reached. If the whole diseased structure be not included in one operation, the chances are that the undestroyed tissue will grow Avith greater rapidity, and quickly affect distant parts. Still, in many cases the method by gradual cauterization is safe and effective. He, however, urges it as an absolute rule that if caustics are employed with a curative intention, they must be used fully and decisively. 1 The Origin of Cancer cousidered with Reference to the Treatment of the Dis- ease. 1S72. 736 CANCER of uteri: S. Latterly Dr. Routh has advocated the topical use of pepsiue. Two successful cases had been published by Drs. Tansini and Pagello ( Gazctta Med. Lomb.. 1S69). Dr. Routh employs this agent in the following way : He first destroys the surface of the morbid growth by the actual cautery, by scraping, by bromine, or other agents. A raw surface thus obtained, or even whilst the slough still remains, he applies the gastric juice on a piece of lint, by help of a speculum. This is covered by a piece of oil- silk, and supported by a plug. This should be done twice a day, oftener if practicable. The digestive property of the pepsine acts powerfully upon the morbid structure. He reports cases in whicb decided benefit, even cure resulted. Of course the objection has been raised that the cases were not cancer. But the proper course, it appears to me. is to pursue the treat- ment in cases whose nature is not doubtful. I have seen one case treated in this way. I was satisfied that the solvent and antiseptic action of the remedy upon the diseased surface was great and beneficial. All objec- tions of a theoretical kind must ultimately fall before the evidence of clinical experience. But we should remember that pepsine does not act upon the structure of the living stomach ; that it only acts vigorously on 'dead tissue. At one of the first meetings of the Pathological Society I exhibited the stomach of a woman, a great part of which had been dis- solved after death by its own gastric juice. John Hunter's observations on this subject are well known. In its application to cancerous growths, as advised by Dr. Routh, a slough is first formed. This will be easily dealt Avith by the pepsine. But further observations are desirable to try hoAv far the pepsine can be made to act upon the deeper parts of the living morbid substance. I do not refer to the use of arsenic in this connection, on account of the danger there is of poisoning the system Avhen applied in quantity sufficient to do any local good to an ulcerating absorbing surface. In the case of sarcoma beginning in the body of the uterus, if we have the opportunity of recognizing the disease in its early stage whilst lim- ited to the lining membrane, caustics may be applied decisively, the cervix uteri having been previously dilated to allow this to be done. But this form of malignant disease also tends to advance into the cervix attacking the region where the vessels enter. When it has reached this point, and especially if any marked amount of fixing of the uterus exist, cauteries should no longer be applied with that degree of severity which is indi- cated when their curative agency is looked for. The mode of proceeding in dealing with intra-uterine cancer is, 1st. to dilate the cervix with one or more laminaria-tents ; 2dlv, havin^ ascer- tained the form which the disease assumes, we proceed, if there are pro- jecting masses more or less polypoid, to shave them off bv the wire-dcra- seur, and to cauterize the surface afterwards with the actual cautery or nitric acid, or if there are small excrescences to scrape them off with Sims's or Re'camier's curette, applying nitric acid afterwards. The actual cautery may be applied by an iron or copper olive-cautery through the cervix, held well open by tenacula. But this is difficult to accomplish Avithout burning the cervical canal in transit. The porcelain olive of the galvanic apparatus is decidedly superior. It can be intro- duced whilst cold to the very spot we want to cauterize ; and the heat treatment: palliative. 737 Fm. 175. being turned on and off at will, its action can be defined Avith absolute precision. To apply nitric acid, Ave insert a tube like Atthill's into the cervix to serve as a sheath or canula, through Avhich a rod carry- ing cotton-Avool steeped in the acid is passed. I have devised a funnel-shaped tube (Fig. 175), mounted on a stem for this purpose, which I find more convenient than Atthill's. I use a Sims's duck-bill speculum in the or- dinary way; then the cervical tube is passed into its place, and the stem and handle keep back the anterior wall of the vagina, affording ready access to the uterus. The instrument has also the advantage of being easily withdrawn. The nitric acid swab should be pressed firmly down upon the inner surface of the uterus, so as to insure decided action upon the morbid surface. It is often more convenient to apply nitric acid to the ute- rine cavity by the aid of the catheter (Fig. 52, p. 155). In this way the acid is carried through the cervix without touching this part, and is squeezed out into the uterine cavity. The action of the acid is superficial. There is no reason to apprehend danger from its use. The palliative treatment of cancer consists in control- ling pain, hemorrhage, and offensive discharges ; in miti- gating the distress produced by the extension of the disease to neighboring organs, especially the bladder and rectum; and in meeting, as best we may, the con- stitutional deterioration. Pain becomes especially exhaustive in the latter stages. We must have recourse to opium in its varied forms, in pill, draught, suppository, vaginal pessary, subcutaneous injection; to conium, belladonna, Indian hemp, chloral, and the other known narcotics and seda- tives. The local application of sedatives has been ex- tensively tried by Simpson. He played streams of carbonic acid, and of chloroform vapor upon the dis- eased parts. In some cases benefit resulted, but the difficulty is great in sustaining the action of these reme- dies. The effect is but temporary. The application of cold by ice or freezing mixtures was at one time urged by Dr. James Arnott, in the belief that it was even curative by killing the diseased tissue. I have tried the application of cold by means of the ether-spray in several cases. It produced such suffering that I have abandoned it. The necessity of restraining hemorrhage when pro- fuse becomes urgent. Patients, however, often affirm that they have felt material relief after an attack. No doubt local congestion is relieved by it, and the habit of free bleeding is commonly attended by a habit or capacity for making blood with rapidity. But Ave never knoAv that bleeding will not exceed 47 Intra-Uterine Spec- ulum (half size). (R. B.) 738 CANCER OF UTERUS. the recuperative capacity of the system, and in the long run repeated losses break down the constitutional powers. Bleeding, therefore, must, as a rule, be stopped. Three principles call for attention. The first is to produce such a change in the condition of the diseased part as will lessen its morbid activity and the determination of blood to it. The means of accomplishing this are included in the curative treatment: re- moval of the diseased mass wholly or in part, by cautery, by knife or scraper, and the securing a new surface. The second principle is that of simple haemostasis. This is carried out by the direct application of styptics. Amongst these the best are chromic acid, nitric acid, perchloride and persulphate of. iron, and iodine. To apply these effectually, the speculum must be used. Great care is neces- sary in passing this instrument, as the fragility of the morbid tissues is so great that it is often difficult to introduce it without causing fresh bleeding. If chromic acid be used, the crystals just moistened with water is the best form. A small pledget of lint or cotton avooI steeped in this is then pressed gently on the bleeding surface. It turns the part bright yelloAv, chars it, and generally stops the bleeding effectually. The superfluous acid can be washed out by a Iligginson's syringe. Nitric acid fuming should be used in a similar manner. The iron-styptics should also be used very strong. The third principle is that of regulating and moderating vascular ex- citement. This is promoted by salines, digitalis, bromides, hamamelys, perhaps ergot. It is important to obviate fecal accumulations in the lower bowel; and scarcely less important to keep the glandular system, includ- ing the skin, in good working order. But since an attack of hemorrhage may come on at any unforeseen time, and under circumstances which preclude skilled assistance, the pa- tient or her attendants must be armed with appliances and instructions to meet the emergency. As a temporary expedient, a lump of ice may be passed into the vagina. But a more certain way is first lightly to syringe out the vagina with cold water, then to introduce by means of my plug- speculum (see p. 156) a pledget of cotton-wool soaked in the strong so- lution of perchloride of iron. As a rule, the plug should not be left in more than an hour. Its retention is often accused by patients of causing heat, distress, and of provoking return of bleeding. The control of the offensive watery discharge includes the use of deo- dorants or disinfectants. Cleanliness is the first thing to secure. Syr- inging with Condy's solution is of service. But since the frequent use of instruments is attended with more than inconvenience, injection of more efficient disinfectants should be resorted to. The agent which has given me the most satisfaction on the whole is acetate of lead. The action of this is haemostatic, deodorant, and sedative. It has often struck me that it has a beneficial effect upon the diseased surface. It may be used in the proportion of one drachm to a pint of water. An excellent disinfectant is a weak solution of bromide made of five fluidounces of the British Pharmacopcea solution diluted with fifteen ounces of water. One objection to its use, inseparable hoAvever from its virtues, is that it has a pungent odor. A Aveak solution of carbolic acid is often useful. I have found creasote singularly efficacious, and in a ward where a cancerous TREATMENT: CONSTITUTIONAL. 739 patient is so often a source of annoyance to other patients, the nurses have assured me that the odor of creasote so used was not only not com- plained of, but was even liked. Chlorozone is an excellent disinfectant. Alum is one of the best deodorants. Its property of coagulating albu- minous matter makes it extremely useful in these cases. Chloride of zinc has also its advantages ; but the lead and alum, being poAverful astringents, are generally to be preferred. I have tried the much- vaunted chloralum Avithout discovering that it is superior to the agents described above. Dr. Butoav, of Konigsberg, speaks highly of the effect of the chlorate of potash upon ulcerating carcinoma. The surface is sprinkled once a day Avith the salt. The steady use of styptics and disinfectants is often attended by good effects in lessening constitutional infection. By removing the foul excre- tions as soon as formed, and by altering the excreting surface, absorption of noxious material is prevented. In this Avay the agents we have been describing exert an important secondary effect. The constitutioncd treatment or management of cancer patients is a matter of great importance. We may with advantage begin by eliminat- ing the bjedentia. Foremost amongst these is excess of alcohol. Stimu- lants carried beyond the most moderate extent are decidedly injurious. By exciting the circulation, they increase the determination of the blood to the diseased organ, and promote hemorrhage, if not also the advance of the disease. The diet of patients suffering from cancer is a matter of great moment. Mr. de Morgan called attention to a fact, the truth of which cannot be doubted, namely, that the disease occurs for the most part in persons strong and well-nourished and remarkable for general good health. This shows that the disease does not arise from want of tone or defect of nutrition. Hence it would appear very doubtful whether it is wise to recommend the patient, as is often done, " to keep up well," to take plenty of nourishment, to use stimulants, with the view of counteracting this supposed poisoned state of the system. If an undue amount of nourishment is taken, a fair share of it will go to the increase of the dis- ease, and stimulants which are taken to the extent of quickening the cir- culation will at the same time increase that of the tumor and accelerate its growth. The restriction to a light milk and farinaceous diet has been recommended from early times. A distinguished physician told Mr. de Morgan that his wife had cancer of the uterus ; he kept her for a long time on the sparest vegetable diet, just enough to sustain life ; the disease disappeared. Years afterwards the cancer reappeared and destroyed her, circumstances having prevented her from ob-.erving the same regime as before. Rest is commonly necessary. But if it be found that moderate exer- cise, as in driving, does not increase pain or hemorrhage, it is desirable to take it. Physiological rest is the most important. The wise physician will exercise great reserve in enforcing sexual abstinence in the great majoritv of cases of uterine disease. But in the case of cancer his injunction should be decided. The direct and remote evils produced by intercourse are so great that regard for the patient's safety leaves no doubt as to the necessity of abstinence. Attacks of hemorrhage, even 740 COLPITIS. fatal, have been traced to imprudence in this respect. That the activity of the disease is promoted by it there can be no doubt. And in the not improbable event of pregnancy, the risk encountered is vital. The internal use of remedies is greatly limited to the fulfilment of special accidental indications. The bowels commonly demand attention. Constipation is a troublesome complication. It must be met by suitable aperients, and by enemata. Bromine and iodine internally were greatly relied upon by Boinet. Iron seems indicated by the degraded state of the blood. But it is not often Avell borne. Salines I have found of great service. Bismuth, strychnine, hydrocyanic acid will occasionally be required to allay irrita- bility of stomach. I have seen in many cases remarkable benefit from cod-liver oil. CHAPTER XXVIII. THE DISEASES OF THE VAGINA. colpitis (vaginitis): simple, infectious, acute, chronic ; displace- ments; avounds ; dilatation; atrophy; contraction ; syphilitic, tuberculous, cancerous ulcerations; sloughing; cicatrices; lace- rations of the cervix uteri ; V'ESICO-vaginal and recto-vaginal fistula; ruptured perineum; new formations: fibrous tumors; sarcomata; cystic tumors ; hematoma; calculi. Some of the abnormal conditions of the vagina have been described in the preceding chapters (see Atresia, Leucorrhoea, etc). It will here be necessary to describe those which have received insufficient attention. Vaginitis or Colpitis. Acute vaginitis sometimes folloAvs labor, the result apparently of con- tusion of structures in a state of exalted vascularity. In these cases exfoliation or desquamation of the epithelial layer is very active, so that the bared surface presents a raAV velvety-red angry appearance. Even during pregnancy the intense vascularity of the vagina disposes to free shedding of epithelium, which often collects about the summit of the vagina in the form of a creamy pasma, or in shreds or pellicles. Acute vaginitis may also occur from exposure to cold during a men- strual period, from injury, from direct infection, from the introduction of foreign substances, from the use of irritating powders or injections. In children it may be caused by ascarides, by neglect of cleanliness, by im- proper manipulation. I have referred to the association of vaginitis with the eruptive fevers. Scarlatina, especially, affects the genito-urinary mucous tract, and thus I have known intense vaginitis produced. The COLPITIS. 741 first case of the kind I saAv was that of a young Avoman in Chomel's wards at the Hotel-Dieu, in 1840. In these cases there is prolific gene- ration and casting off of epithelium, attended and followed by a severe form of leucorrhcea. Leucorrhoea in children is not very uncommon, and when observed is sometimes the source of most distressing suspicions. It is therefore eminently necessary to call attention to the fact that children are liable to non-virulent discharges, depending upon accidental causes. The symptoms of vaginitis and vulvitis in children are : in the acute stage, the patient complains at the onset of itching or burning at the vulva. This is increased during micturition. A whitish opaque moisture is formed over the surface of the labia, and these are often redder than in the normal state. The patient has often a difficulty in walking, the fric- tion increasing the irritation of the inflamed surfaces. In the chronic state the discharge is a serous or lactescent moisture ; there is little pain in the vulva, but sometimes a dull pain above the pubes, spreading to the groins and inner part of the thighs. This form of vulvo-vaginitis has been noticed at the time of dentition, from indigestion, from exposure to heat and fatigue—as from dancing— from constitutional diathesis, especially the strumous, resembling in this respect the tumid chronic inflammation of the conjunctiva and nares. The treatment consists in putting the child in a Avarm bath every two or three days, applying demulcent lotions, as poppy-head, mallow, or linseed decoctions, or Aveak acetate of lead, and in re°;ulatina; the secre- tions ; in the use of iron, iodine, and cod-liver oil. The most common cause of acute or sub-acute colpitis is gonorrhoeal infection. In this case the mucous membrane, especially at the fundus of the vagina, is intensely red. There is copious muco-purulent secre- tion of a yelloAvish or greenish tint, sometimes tinged with blood. This is found chiefly at the fundus of the vagina, surrounding and bathing the vaginal-portion of the uterus, which is involved in the like condition. An experiened practitioner Avill generally recognize the specific cha- racter of this inflammation ; but it is easy to fall into error in diagnosis. The moral and social complications are at times so intricate, and the reasons for dissimulation on the part of the patients are so strong and various, that even in the presence of the most convincing clinical proof, it will rarely be wise to commit ourselves to a plain expression of opinion. The subjects themselves may, moreover, be perfectly innocent and uncon- scious of the nature of the affection. And we must not always expect to be dealt with candidly. What we say avIH perhaps be misinterpreted or misrepresented. A circumspect reticence therefore becomes a virtue and a duty in the physician. Gonorrhoeal colpitis is very apt to invade the cervical canal, and thence to pass into the chronic stage, a condition analogous to gleet in the male. It may spread upwards to the uterus and Fallopian tubes, and thus lay the foundation of an obstinate chronic metritis, and even give rise to peritonitis. It is also apt to spread along the urethra. This is more frequent, says Guerin, than is commonly thought. Occasionally the orifice of the urethra is inflamed, swollen, dotted Avith red points or pimples, corresponding to 742 DISEASES OF VAGINA. the openings of the lacunae, and in such cases recognition of urethritis is easy ; but when the disease is internal, and when no mucus or pus ap- pears externally, detection becomes more difficult. When any doubt exists, the patient should be prevented from emptying the bladder for several hours ; the finger should then be introduced into the vagina, and drawn along the anterior wall, so as to press out any purulent matter collected within the urethra. Chronic catarrhal inflammation commonly occurs after repeated acute inflammations, as from menstrual suppression, gonorrhoeal infection, child- bed, in chlorotic or scrofulous persons, from uterine catarrh, the irritation of uterine polypi, or hypertrophied vaginal-portion, dislocations of the uterus, the formation of morbid growths, and ulcerative processes. It is also frequent, and often at first acute in character, in newly-married women from excess or awkwardness in intercourse. Aaginal catarrh is of importance from its liability to spread to the uterus, and thence to the tubes; and it disposes to intussusception and prolapsus of the vagina. Inflammation of the sub-mucous fibrous coat of the vagina is not com- mon apart from traumatic causes. Kiwisch has called attention to the occurrence of abscesses in this tissue during pregnancy. But there is a chronic form, not very uncommon, the result in most of the cases which I have seen of imperfect or irritating intercourse. It is marked by thickening of the walls of the vagina, the formation of ab- scesses, and a degree, sometimes considerable, of atresia of the canal. Symptoms and Diagnosis.—In the acute stage there is pain, often severe, characterized as " burning" in the part. Dyspareunia is almost necessarily present. Some febrile excitement attends. Unlike metritis, it is very rarely complicated with peritonitis. Hence the local and con- stitutional symptoms are less severe. Dysuria generally attends the gonorrhoeal form. In this form also there is leucorrhcea of the character described. But absolute diagnosis can only be made out by the aid of the speculum, when Ave can take note of the vivid red mucous membrane, and see the discharge in situ. In the chronic and non-specific forms, pain is not so much complained of. I must refer to the chapter on " Leucorrhoea" for further informa- tion on this subject. When the disease has involved the cervical canal, vaginal injections are inefficient. Topical applications inside the cervix are essential. One form of pain, " Vaginismus," has been described in connection with " Dyspareunia." The treatment of colpitis consists greatly in observing rest and cleanli- ness. To aid in securing rest, an essential condition often is to keep the inflamed walls of the vagina apart. This is accomplished by wearing Sims's or my vaginal rest for several hours during the day ; by using a plug of cotton-wool steeped in tannin and glycerine, changing it two or three times a day, or by simple rest in the recumbent posture. Douches of tepid water or poppy-head decoction are often of signal service. In the more acute stages injections of lead in proportion of one drachm to a pint of water are best borne ; later, sulphate of zinc, chloride of zinc, alum, tannin are more serviceable. The gonorrhoeal inflammations may be treated exactly on the same principles as the similar affection in the HERNIA : FISTULA. 743 male. The quickest method of cure is undoubtedly to touch the diseased surface lightly every other day with solid nitrate of silver, solid or in solution, or with tincture of iodine. Diphtheritic infiammation most frequently occurs in childbed, and especially in lying-in hospitals; but I have seen an example in home practice. There is a form of vaginitis in which the mucous membrane is covered by pedicles, or flakes, white, very brittle, to which the name diphtheritis is sometimes given. At best this should be called pseudo- diphtheria. It is not usually attended by febrile symptoms. The vaginitis is not very acute, it is strictly limited to the mucous membrane, and the pellicle consists almost entirely of agglomerated epithelium-scales. The formation of the pellicle seems simply due to the preponderance of the scales over the mucous plasma. If the mucous plasma were more abun- dant, the discharge would be called leucorrhoea. Displacements of the Vagina.—Displacements of the vagina can hardly arise without the preliminary condition of relaxation, or of displacement of the uterus. Whether prolapsus of the uterus be the cause or the effect of prolapsus of the vagina is a question already discussed. No doubt, prolapsus of the vagina is commonly associated with prolapsus of the uterus, but I believe prolapse of the vagina may exist independently. There is a preparation in St. George's Museum (No. xiv. 106) which seems to shoAv that vaginal rectocele may exist Avithout prolapse of the uterus. Hernias consist in an inversion of the anterior wall of the vagina with the bladder—cystocele vaginalis; or in inversion of the posterior wall from the lower end of the rectum—rectocele vaginalis ; or in a hernia vaginedis posterior—enterocele vaginalis. This last form consists in dila- tation of Douglas's pouch to a hernial sac, so that the peritoneum is car- ried deeply doAvn behind the wall of the vagina to the perineum. The intestinal folds contained in it drag upon the vagina, then tilt it from be- hind, pressing from above downwards more and more of its circumference, according to the degree to which the uterus follows the traction and descends? The prolapsus of the vagina thus produced gradually proceeds to a complete inversion, which contains in its cavity the prolapsed uterus, which in consequence of this traction undergoes very frequently a con- siderable or even monstrous elongation of its cervix. Commonly the rectum is also protruded to a prolapsus by the hernia. In rare cases, in consequence of the mass of intestinal convolutions accumulating in the hernial sac between the uterus and the inverted vagina, laceration of the posterior wall of the vagina has occurred with a fatal issue. The tendency to rectocele is found in the natural bulging of the pouch or expansion of the rectum just above the sphincter ani. This is ahvays seen in operations for restoration of the perineum. To dissect a flap of mucous membrane from this pouch constitutes one of the niceties of the operation. When this pouch loses the support of the perineum, it becomes larger. It is also increased to rectocele under fecal accumulation, reten- tion, and straining at stool. The treatment of vaginal prolapse and hernia in most cases merges in that which is indicated for prolapsus of the uterus. In some few cases a Hodge or stem-pessary may be useful. Astringent injections are almost 744 DISEASES OF VAGINA. always serviceable. But when the prolapse is great, so that folds of vagina protrude through the vulva, becoming liable to chafing and inflammation, surgical treatment is necessary to remove the redundant portion. A piece of the mucous membrane of size and form indicated by the condi- tions of the case must be dissected off, and the edges brought together, so as to contract the canal. It will commonly be necessary to combine this proceeding with the perineal operation. The vagina is liable to wounds from the introduction of foreign bodies, from accidents, and from surgical operations. The most frequent cause of the lesions that come before the surgeon is seArere labor. The vagina is liable to undergo laceration, contusions. leading to partial necrosis or sloughs. Hence result cicatrices Avhich may lead to occlusion of the vagina, or fistulous opening into the bladder or rectum. Vesico vaginal fistula may be produced by the mere pres- sure of the head, long continued, jamming the bladder against the pubes. In precipitate labor, or in protracted labor in primaparae where the vulva is rigid, the perineum is apt to undergo laceration backwards to the anus. The anterior commissure also, as I pointed out many years ago {see Tyler-Smiths Obstetric Medicine), is liable to rupture, whence severe hemorrhage may arise. There is a singular preparation in the Museum of St. George's Hos- pital (Series xiv. 108). It is a case of laceration of the vagina from coition. There is a rent passing along the upper two inches of the vagina dividing the mucous membrane and the adjoining fibres of the muscular coat. The rent deepens as it ascends, and on a level with the os uteri has broken through into the peritoneal cavity. The hole in the perito- neum is not quite large enough to admit the little finger. The subject was an old Avoman. The most trivial wounds of the vagina are sometimes folloAved by pro- fuse bleeding. This is especially the case during pregnancy. But at any time the slightest nick, puncture, or incision may give rise to profuse bleeding if the patient assume the erect posture and be exposed to any exertion. A surgeon nipped off a very small Avarty excrescence from the vagina just inside the vulva. The Avoman nearly bled to death. Plug- ging and the application of styptics failed to arrest it. I passed a curved needle armed Avith a suture so as to get quite under the little wound. The suture drawn tight effectually controlled the bleeding. This is the surest plan to adopt. A short sewing needle held in a forceps nn>ht on emergency answer. But in some cases, steady pressure with a pad of lint steeped in perchloride of iron or other styptic may be enough, abso- lute rest in recumbent posture being understood. Professor E. Martin describes {Mmats.f. Geburstk, 1869) a tempo- rary dilatation of the fundus, not the result of stretching or distension, but which is caused by a pathological action of the neighborino- ligaments ; that is, the pubo-vesico-uterine, and the sacro-utenne, the muscular bun- dles of which contract. The examining finger finds the roof of the vagina so wide that it seems as if its Avails were applied close to the sides of the pelvis. This condition is found Avhen there is hemorrhage with uterine colic, and in secondary puerperal hemorrhage. I have commonly ob- SLOUGHING OF VAGINA. 745 served it during abortion. It seems to be associated with expulsive effort. In such cases the os uteri is open, and the roof of the vagina seems higher than usual. Under the use of means to arrest the bleeding this dilata- tion disappears completely in twenty-four hours. I have observed a more permanent dilatation of the fundus vaginae forming a large cavity in some cases of perimetritis. There is a form of atrophic contraction of the vagina which takes place in advancing age. The walls loose elasticity, the canal becomes smaller, sometimes funnel-shaped or conical, the apex being at the roof, Avhere the remains of the atrophied cervix uteri may be felt. Some cases of this kind are not easy to distinguish from the strictures which ensue occa- sionally upon cancer. This atrophic contraction is most common in women who have abandoned the habit of sexual intercourse. It explains the rupture in the specimen in St. George's Museum just alluded to (Series xiv. 108). In some cases the vagina is almost obliterated. The vagina may be the seat of various ulcerative processes. Excoriations occur from catarrhal suppuration or the chafing of fibroid polypus, of pessaries, etc. Syphilitic sores may occur in any portion of the vaginal canal, but the most frequent locality is the fold or duplicature at the fundus, into which the vaginal portion of the cervix uteri is inserted. This is com- monly attended by colpitis. To the touch an excavated syphilitic sore may at first impose upon the surgeon for the os uteri. The tuberculous and cancerous ulcerations generally begin on the vaginal-portion, and spread to the roof of the vagina. The latter espe- cially are unhappily frequent, and often lead to destruction of the walls between bladder and rectum, establishing cloacas or fistulse. The vagina is sometimes ulcerated from without, through the burrowing of sub-peritoneal abscesses which make their way into the vagina. Sloughing of the vagina occurs as the result of the bruising and pres- sure encountered during protracted labor, from diphtheria, from necrosis in severe fevers, from perivaginal hasmatoceles and abscesses, from necro- sis resulting from the pressure of fibroid tumors so large as to become impacted, or from the impaction of a retroverted gravid uterus. The healing of vaginal sloughs by granulation frequently results in the formation of cicatrices. Tnose cicatrices which lead to atresia or stenosis of the canal have been described, in their pathological and therapeutical bearing, under "Dysmenorrhoea from Retention." But cicatrices, in the form of bands or falciform projections into the vagina, not extensive enough to close the canal, are not uncommon. They pro- duce distress of a different kind. They may form crescentic or falciform bands seizing the os uteri by one horn and the vaginal wall by the other. This, contracting, may half shut off the os uteri from the canal of the vagina below, forming a pouch or sac above. It also not uncommonly pulls the cervix uteri to one side, or forwards or backwards, producing deviation of the uterus. But cicatrices are not uncommon which do not thus project as folds. They are felt as dense cords when the vaginal roof is stretched by the finger. They contract the fundal space, inter- fere with the mobility of the uterus, and maintaining a constant irritation, cause leucorrhcea, neuralgia, dyspareunia, and other distress. 716 DISEASES OF VAGINA. I have seen these cicatrices follow labor, instrumental and not instru- mental, also cauterization of the os uteri by potassa cum calce, and even by nitrate of silver incautiously applied. They have also followed the use of too concentrated chromic acid and perchloride of iron. The treatment consists in dividing the cicatrices so as to allow the vaginal Avail to resume its natural form. \Vhen the cicatrix extends up the vaginal-portion this part should be set free, by dividing the horn Avhich seizes and binds it to the vaginal Avail. The first step is to dissect off the adventitious membrane from the vaginal-portion, so as to restore this part to its normal condition; and then several nicks should be made at different points of the crescentic edge, as deeply as is felt to be safe, taking great care of course not to go through the vaginal wall. This operation is best done Avithout the speculum. The cicatrix is made tense by the forefinger of the left hand, and then the edge of a Simpson's metrotome is turned upon it. When thus nicked these cicatrices have a tendency to disappear. But it is likely that the incisions Avill have to be repeated from time to time before they are overcome. Sometimes the bleeding attending this operation is very profuse ; and it is, I think, ahvays prudent to plug the vagina firmly with pledgets of lint soaked in olive oil and carbolic acid. The operation should in every case, however slight it may seem to be, be performed on the patient in bed. Absolute rest in the recumbent posture should be rigidly enforced for four or five days afterwards. If these precautions are adopted there will probably be no bleeding of importance; if neglected, profuse, even fatal hemor- rhage may result. Under no consideration should the operation be performed in the out- patient's room of a hospital, or in the phy- sician's consulting-room. A day or two after the operation it is desira- ble to apply a Hodge-pessary, so shaped that it will keep the roof of the vagina on the stretch, so as to obviate the disposition to contract, which the scar frequently manifests. I have seen ex- tensive cicatrices gradually disappear under this continual stretching. In one case, that of a lady who had suffered extensive sloughing after labor, the vagina was very contracted. But in a year the canal was so nearly restored to its natural state that she subsequently bore a child at term without artificial aid. Fig. 176 repre- sents a not uncommon form of utero-vaginal cicatricial band. Raised on the finger it is made tense for division. Lacerations of the Cervix Uteri. — Ennnet calls attention to the frequency of lacerations of the cervix, and to the serious distress they entail {Amer. Journ. of Ohst., 1874). They are most frequent, he says, in the median line, and more frequent in the anterior than in the posterior lip. If in the median line and confined to the cervix, they generally heal rapidly. But when the lacerations extend through the vesico-vafinal Fig. 176. Cicatricial Band binding Os Uteri to roof of Aragina (B. B.). FISTUL.E. 747 septum a fistula may result; and this part of the rent may not heal. Lacerations through the posterior lip also heal readily; but sometimes when they extend far back inflammation may arise, and cause an intract- able form of retroversion. A cicatricial band is left which must be re- moved before relief is obtained. But it is the lateral lacerations with which we are chiefly concerned in practice. Whenever the rent has extended to the vaginal junction or beyond, there will exist a tendency for the tissue to roll out from within the cervical canal. Hypertrophy and cystic degeneration of the lips ensue; involution is arrested ; partial obliquity of the uterus is produced. On getting about the woman is soon the subject of great distress ; leucorrhcea, menorrhagia, dysmenor- rhoea, difficulty in Avalking impel her to consult her physician. The attendant abrasion, glandular inflammation, hypertrophy, leucorrhoea are readily recognized; and many such cases are treated for "ulceration" ineffectually for months. Emmet has successfully treated more than two hundred such cases, by paring the edges of the fissure and uniting them by silver sutures, so restoring the cervix to its normal shape. I can con- firm the accuracy of Emmet's views. I have performed his operation with satisfactory results. Fistube of the genital organs may be divided into four classes: 1. Between the bladder or urethra and vagina; the most common. 2. Between bladder and uterus; rare. 3. Between rectum and vagina; not very rare. 4. Between rectum and uterus ; very rare. To these might be added uterine fistulse, communicating with an abscess in the pelvis ; and fistula? opening into the vagina from perimetric abscesses or retro-uterine hgematocele. The most common seat of the vesico-vaginal fistula is near or half an inch below the anterior edge of the os uteri. Symptoms.—The urine may either be retained for a few days after labor, or it may flow by the urethra with more or less pain. But at the end of a week or so the patient becomes conscious that her water runs away by the vagina more or less continuously ; in fact, that she cannot hold it; that she is, as the expression goes, "always wet." Excoriation of the external genitals is a frequent consequence. Phosphates collect in the vagina and cause further irritation. Sometimes, in the recumbent posture, the vulvar sphincter being unimpaired, the vagina forms a pouch, which will retain a considerable quantity of urine, acting the part of a subsidiary bladder. But on rising or exertion this accumulation is dis- charged, and the dribbling goes on. The incontinence begins from the falling of the slough. This leaves a hole in the septum between blad- der and vagina, the edges of Avhich gradually cicatrize. In this process the hole contracts, often so much that there may be great difficulty in finding it. But a hole that will barely admit a fine probe is big enough to drain off the urine as fast as it is secreted. The hole may be big enough to admit the tip of the finger. The greater part of the urethra may be destroyed. In some cases the lower segment of the uterus is lost, as well as the base of the bladder. The anterior lip of the os uteri is not uncommonly lost. In one case I could find no cervix. There was nothing in the roof of the vagina to be found, but a fistulous opening 748 DISEASES OF VAGINA. admitting the tip of the finger. This was cured in tAvo operations : and the patient menstruated through the bladder. The diagnosis is established by sight and by touch. AVhenever incon- tinence of urine has come on after labor, examination by finger and sound, and by speculum is indicated. The patient in semi-prone posture, the sound is passed into the bladder, and the forefinger in the vagina carried to the os uteri, and then brought down along the course of the urethra, feeling for the sound through the fistula, if one exists. Gen- erally the puckered cicatrix of the fistula is felt, and guides to the open- ing. Through this opening is felt projecting a velvety nipple-like mass, the mucous membrane of the bladder. Through this the point of the sound is sometimes carried from the bladder. This evidence, complete in itself, maybe extended by the use of Sims's speculum. The perineum being lifted aAvay the aperture may usually be seen ; the mucous mem- brane of the bladder bulging like a cherry or a raspberry, and urine oozing or dribbling through it. The point of the sound may be seen in the fundus of the vagina. When the opening is very small or overlapped by mucous membrane, it may be made out by injecting milk through the bladder. This will be visible when the source of clear urine might not be detected. In the case of recto-vaginal fistula, the opening may have become so contracted that escape of feces into the vagina is only occasional, that is, when the stools happen to be liquid. It may require some pains to detect the opening. It usually lies rather low down, at the point where the floor of the perineum begins to incline fonvard from the hollow of the sacrum. It may be made evident by finger and sound. The etiology of fistulse properly belongs to obstetrics. It is, however, important to state here that fistulse are caused in two distinct ways. 1. By slough, the result of long pressure between the child's head and the pelvic bones, or between an edge of the forceps and the pelvis. The latter is comparatively rare ; the timely and skilful use of the forceps is indeed the best way to obviate the danger of sloughing from pressure of the child's head. 2. By laceration, extending from the edge of the os uteri into the bladder. This, according to Emmet, whose experience is unsurpassed, is frequent. The laceration of the os uteri may heal, and yet the opening into the bladder may remain. In these cases there is no loss of tissue. Any constitutional taint should be carefully treated. Before operating, the fitness of the parts should be tested. The edges of the fistula should be seized at opposite points Avith a tenaculum, and the degree of tension estimated by approximation in different directions. Wherever a contraction-band is thus brought into prominence, it should be divided. Very free hemorrhage may follow this proceeding. It will be controlled by rest and plugging. The time selected for the operation should be a Aveek after the cessa- tion of menstruation. If done later the operation is very apt to precipi- tate menstruation; and this process may mar success. No operation should be attempted during pregnancy. The boAvels should be relieved by enema the day before operating. FISTUL.E. 749 Preparatory Steps.—Emmet insists ( Vesieo-vaginal Fistula, etc., NeAV York, 1868) strongly upon the necessity of carefully preparing the parts before attempting to close the fistula. All phosphatic deposit must be carefully removed by a soft sponge, and the raw surface touched with Fig. 177. Showing the relations of the Ureters to Vesieo-vaginal Fistula (R. B.). The specimen is seen from the posterior aspect. The cavity of the uterus is laid open. Bougies are passed into the ureters, the ends project into the bladder, and are seen at the orifice of the fistula. A bougie in urethra meets them. (From a preparation in St. Thomas's Hospital.) weak solution of nitrate of silver (or iodine). Warm sitz baths and irrigating the vagina with warm water render great service. After bath- ing, the external parts should be protected from urinary irritation by annointing with cerate. The greatest care should be taken to lessen the contact of urine with the parts. A healthy condition, fitted for operation, is not reached until the hypertrophied and indurated edges of the fistula have attained a natural density and color. This, says Emmet, is the secret of success: without it the most skilfully performed operation is almost certain to fail. No pains to remove cicatrices can be superfluous. Cicatricial contractions may pull upon the edges of the fistula and frus- trate union. Cicatrices are generally best made out by the touch. When thus put upon the stretch they are felt as tight bands. They may be divided or nicked in several places by scissors or knife. And to promote relaxation they should be kept stretched by wearing a vaginal rest of glass or vulcanite. I have found a Hodge pessary answer well. This nicking and stretching may have to be repeated several times before perfect smoothness and mobility of the tissues are attained. The Operation.—The posture of the patient may be either the semi- prone, the knee-elboAV, or the lithotomy. The American operators mostly 750 DISEASES OF VAGINA. prefer the semi-prone. If the semi-prone posture is adopted, an assistant holds back the perineum with Sims's duck-bill speculum. If the lithotomy- posture is adopted, the ankles and wrists may be secured by Pritchard's anklets, whilst assistants on either side hold open the vulva by fingers or retractors, and the perineum is depressed by the duck-bill speculum. In this way sufficient access to the wound may generally be attained. But Simon usually dragged the parts near to the vulva by hooks and strings attached to the mucous membrane of the vagina and to the os uteri. Operators differ as to the mode of performance ; but all aim at the same end—a clean paring of the margin of the fistula and accurate adap- tation of the fresh wound. Emmet prefers scissors, of which several pairs, expressly curved, must be at hand. The edge of the fistula is seized with a very fine tenaculum at the most depending part, and then the edge is removed in a continuous strip all round. The paring should be extended as near the mucous membrane of the bladder as possible, without actually wounding it. To pass the sutures, the tenaculum is again introduced, the point towards the fistula at a convenient distance from its vaginal edge ; then by a rotation of the hand in the opposite direction, the bladder end of the fistula will be turned out. The needle is then introduced behind the tenaculum, bringing out its point just at the bladder surface, and while still grasping it with the forceps, the tenacu- lum is withdrawn, and its hook is passed over the point of the needle to make counter-pressure whilst the needle is passing through. The needle seized and drawn through, the opposite edge of the wound is seized by the tenaculum in like manner, and the needle is carried on, introduced at a corresponding point near the bladder-surface. If a transverse wound is made Aveling's revolving needle answers well. Four to five sutures to the inch should be used, and one or more should be passed at each extremity beyond the fistula. Sometimes a good flap for removing by knife can be seized by a broad toothed forceps, or Hilliard's three or four-pronged fork may serve. The simple interrupted suture is much to be preferred. The wire may be secured by simple twisting, or by Aveling's coil-clamp and shot. It was long thought that the recent success attained was mainly due to the use of silver wire sutures, upon which the revivers of the operation, Sims, Bozeman, and others, have so much insisted. But the antecedent experience of Charles Brooke has been strangely overlooked in the history of this operation. More than thirty years ago this surgeon cured fistuke by silk sutures secured by his beads. He was also, as I testify by per- sonal observation, eminently successful in curing perineal lacerations by his bead sutures. Indeed I am not sure that any considerable improve- ment has been made upon his perineal operation/ The paring the edge of the fistula may be done either in the transverse or in the long axis of the vagina. The choice is determined greatly by the direction of the longest diameter of the fistula. Where the opening is circular, the transverse paring is to be preferred, because the mobility of the walls of the bladder is greater in the longitudinal direction than from the sides. When the opening is very large and irregular in shape. the paring and line of union will be also irregular, perhaps oblique, or even Y shaped or T shaped. FISTULA. 751 The after treatment, consists mainly in rest. As to emptying the blad- der the different practice of surgeons seems to shoAv that the method to be selected is not of essential importance. Emmet and Bozeman retain a catheter in the bladder. Simon thought this unnecessary. The catheter may be passed every eight hours, or the patient may be permitted to empty the bladder in the usual way. Accidents that may Occur During and After the Operation.—One is the presence of the ends of the ureters of the fistulous opening, so that they might be included in the stitches. It is to illustrate this complica- tion that I have introduced Fig. 177. The ureters may sometimes be seen yielding urine stillatim. To avoid stitching up these orifices, we may so pass the needles as to run between the two mucous membranes, or as Simon did in one case, we may slit up the ureter for half-an-inch inside the bladder, so as to secure an opening higher up out of the way. More frequently the fistulous opening being smaller, the orifices of the ureters are not visible ; still they are liable to be taken up by the stitches. Generally they are avoided, because they are placed near the extremities of the pared wound where the needles penetrate less deeply; if one lip only of the orifices is included, no obstruction to the flow of urine occurs ; and even if the whole orifice be taken up, the urine will commonly find a passage along the tract of the suture, and thus re-establish the orifice. Primary and secondary hemorrhageg. In one case in Avhich the vesico- vaginal artery was divided, Simon tied it with silk, and brought the ends of the ligature down through the bladder and urethra, in order to avoid its interference with the healing of the wound. But in two other cases he had equal success by bringing the ligature out into the vagina. He insists that tying the artery, if at all big, is the only security. But oozing is almost always stopped by pressure, cold, and by approximation of the wounded surfaces by the stitching. Secondary hemorrhage may take place either into the vagina or into the bladder. In the first case, if arterial, it may be necessary to undo the stitches and secure the vessel by a ligature. Occasionally a vessel may be cut by the needle in passing the sutures, so that time should always be given for the fresh bleeding to stop before tightening the sutures. Bleeding into the bladder almost necessarily frustrates the closure of the fistula. Alarming symptoms attend. The bladder may be so distended as to reach the umbilicus, and the urethra being perhaps obstructed by clot, there is retention of urine. Severe pain and vesical colic arise. At length the blood and clots may be expelled through the stretched-open wound and through the urethra. To stop the bleeding ice may be applied to the abdomen, and to ease pain morphia-injections may be made. But it may be necessary to reopen the wound and to dilate the urethra to break up the clots and to empty the bladder. A source of hemorrhage I have witnessed several times is the unex- pected return of menstruation. This event is very apt to be provoked by vaginal operations. Peritonitis may supervene. The peritoneal fold between bladder and anterior uterine wall may come very near the range of the operation, and might in some cases of fistula high up be Avounded. But peritonitis is far°more likely to happen from extension of irritation from the proximate 752 DISEASES OF VAGINA. wound. Absolute rest, opium by mouth, or morphia-injections are the best means of meeting it. Incontinence of urine may persist after the healing of fistula. This may be due to paralysis of the sphincter urethrge, or to injury of the structure of the urethra. As a palliative, an urethral pad may be used. Lacerations, or loss of tissue by sloughing, may be treated by plastic operations. Retention of urine may occur either as the immediate effect of the operation, so as to compel resort to the catheter; or later as the result of cicatricial atresia at the seat of the operation, especially when this is at the junction of bladder and urethra. In such a case gradual dilatation must be effected by bougies, or by wearing a catheter. In rare cases, calculi have formed in the bladder after operation. When the cervix uteri is involved in the loss of substance it becomes a question whether the opening can be closed without also closing the os uteri. Sometimes it is necessary to pare the posterior surface of the os uteri, making this one side of the wound which is to be united to the neck of the bladder. In many cases the anterior lip of the os uteri may be pared and made to form one side of the wound. This, united with the neck of the bladder, leaves the os uteri open behind it. When the fistula is vesico-uterine, it may be impossible to get at the fistula itself. In such a case Jobert closed the os uteri. J. R. Lane, having operated in this manner, found that the uterus enlarged afterwards. This was at first thought to be due to retention of menstrual fluid, and a puncture was made through the place of union. This resulted in an abortion of four months' gestation. It is conjectured that the semen got access along the track of one of the sutures. The patient was cured by repeating the operation. In those still more severe cases in which the urethra, neck, and floor of the bladder have been destroyed, various attempts more or less suc- cessful have been made. The proceedings for relieving these cases of extreme deficiency consist in 1. Closing the lower part of the vagina (Jobert) so that the upper part forms a common receptacle for the secre- tions of the uterus and the urine ; 2. Including the vaginal-portion in the wound so that the os uteri opens into the bladder or urethra; 3. Simon has shown that when there is much deficiency of bladder and urethra, the vaginal-portion may be brought downwards so as to be united in a curved line with the lower margin of the fistula, thus short- ening the vagina. Emmet succeeded in cases where there was too great loss of vaginal tissue in utilizing the mucous membrane of the bladder to supply part of the flap. In some cases of total loss of the urethra a new urethra has been made by plastic operations. Emmet relates successful cases. I have seen a good restoration made by Chambers at the Chelsea Hospital for Women. Emmet and Simon may be consulted for practical details con- cerning cases of this nature. At one time small fistulae were treated by the actual cautery, in the hope that the resulting slough would be followed by cicatricial contraction and closure. This method cannot be depended upon. The more certain and scientific procedure by suture ought to be adopted at once. But in FISTULA. 753 the recent state whilst the slough is being cast, the opportunity should be taken to promote healthy granulation. Dr. Goodell relates {Amer. Journ. of Obst., 1874) a case in which he treated a large slough of the vagina Avhich opened the bladder by fuming nitric acid. The opening gradually closed completely, cure being effected. Vesieo-vaginal fistulge once fairly healed are not very liable to relapse. But Dr. Bourdon {Arch. Gen. de Med., 1872) reports four cases of re- lapse from Verneuil's (Unique, all in women who became pregnant. Recto vaginal fistula' are far less frequent than vesieo-vaginal. The hinder wall of the vagina is much less exposed to injury than is the an- terior wall. Violence is far more likely to rend through the perineum than to cause a fistula. Moreover, the distress arising from rectal fistulge is less urgent. It may be only when the stools are liquid that any fecal matter comes through the fistulge into the vagina. The recto-vaginal septum differs from the vesieo-vaginal septum in being much more mov- able and yielding, so that less strain comes upon the opening. Some recto-vaginal fistulge heal spontaneously or under the action of cautery, so that longer time may be given for observation than is justifiable in the case of bladder fistulge. Emmet finds that a large proportion of recto-vaginal fistulge are com- plicated with vesieo-vaginal fistulas. The vesical lesion, he says, should be treated first. And owing to the greater amount of cicatricial tissue found in the rectal fistulge, longer preparatory treatment is generally necessary. The operation for closing these fistulge from the vaginal aspect is essen- tially the same as for vesieo-vaginal fistulge. Simon observes that since the contraction of the cicatrix is very strong in the longitudinal direction, the fistula must be pared in the transverse direction whenever possible, so that the drag of the scar may favor the healing. It is only when the longitudinal diameter of the opening much exceeds the transverse diameter that the paring should be made in the longitudinal direction. Where the fistula is large and close to the os uteri, it may be necessary to direct the os uteri into the rectum, so that the menstrual flow may take this route. Another mode of proceeding, one especially adapted to fis- tulas seated just above the sphincter ani, and to those cases where an opening is left after the operation of perineal restoration, is to slit up the remains of the perineum through the bridge of tissue below the fistula, and then paring the edges and bringing them together, as in the operation for perineorrhaphy, where the sphincter ani has been torn through. Simon has practised yet a third proceeding. In cases where the fistula is seated in the uppermost part of the septum, and the vagina is very constricted, neither of the two preceding operations will succeed. In these Simon operated through the rectum. The sphincter being divided in two places, dilatation of the anus and access to the fistula, although high up, were surprisingly easy. In this way he succeeded, after several failures by the vagina. But in similar cases Emmet succeeded by operating by the vagina, relying mainly upon the sense of touch, when the parts could not be brought into sight. 48 754 DISEASES OF VAGINA. Lacerations of the Perineum.—These are of varying extent and kind. Some slight rent of the anterior edge or fourchette is common in first labors. It entails no distress. Those lacerations which demand surgical treatment may be divided into three classes: 1st. Those in which the rent does not involve the sphincter ani. 2d. Those in Avhich the whole perineal body is divided, so that the sphincteric control of the anus is lost. 3d. Those in which the perineum is perforated by the child, a cen- tral hole, resulting in a fistula, being made, the fourchette in front and the anus behind remaining intact. In a considerable proportion of cases of the second order spontaneous healing sufficiently complete takes place; and this healing may be greatly promoted by keeping a strip of lint soaked in solution of chloride of lime betAveen the wounded surfaces. Granulation takes place from the fork behind forwards. In other cases where the sphincter is involved, imme- diate union should be attempted by applying sutures within a feAv hours after the injury. If the hindmost suture is Avell applied so as to bring the rent surfaces of the sphincter together, union is generally accom- plished. In France immediate union is practised by the use of " serres- fines," or spring-clips, which bind the torn surfaces together. Mann, in a good practical memoir on this subject (Amer. Journ. of Obstetrics, 1874-75) adduces satisfactory evidence in support of this practice. Even where nothing is done, a surprising degree of restoration is not seldom accomplished. Granulations meeting from opposite surfaces may unite and consolidate into firm tissue. This is unmistakably seen in those cases of incarceration of pessaries, where rings of strong tissue are formed encircling the pessary. But when the rent does not heal, serious distress is often felt, even in those cases of minor injury in which the sphincter is intact. The loss of the perineal floor is attended by other inconveniences besides the increased liability to prolapsus. Indeed, prolapsus uteri does not always follow on laceration of the perineum. I have known sterility persist until the perineum was restored. Probably the loss of the retentive capacity of the vagina was the cause. The subject feels " open." She is conscious of being unsound. There is no support for a Hodge-pessary. The nature of the injury will be understood on referring to Fig. 178, modified from Thomas, and to Figs. 1 and 10 in this work. Fig. 1 rep- resents the " perineal body" in its integrity. It forms a thick musculo- membranous cushion which supports the posterior and the anterior walls of the vagina. If the forepart of this cushion be divided, as shown by the dotted line in Fig. 178, the support of the anterior vaginal wall is impaired, but the sphincter being uninjured, control of the anal aperture is preserved. But if the rent extends quite through into the rectum, not only is the natural support of the vagina lost, but the control of the anus is also lost. In restoring the perineum it must be borne in mind that this body or structure is of a triangular shape, the base below at the skin, the apex at the summit; and that anything less than the restoration of this triangle will be ineffective. For example, a superficial union as indicated by the dark shadowing in Fig. 178 will fail to give adequate support to the vaginal walls, and will in all probability give way at the next labor. PERINEAL LACERATIONS. 755 The Operations for Restoring the Perineum: Preparatory Steps.— All morbid complications should be as far as possible removed. A healthy condition of the parts should be obtained by cleanliness, and the cure of any complicating uterine disease. The bowels should be cleared by aperients and enemata. The time chosen is within a week after men- struation. The operation differs in the two cases of partial and complete rupture. In the first case the operation is very simple, and should rarely fail. In the second case, the difficulty is often serious, and success has sometimes to be pursued in two or more trials. The Operation for Partial Rupture.—The patient is placed in lithot- omy-posture. It is convenient to keep the knees fixed steadily apart by a transverse bar having a semicircular rest for the knees at each end. Fig. 178. Diagram representing the "Perineal Body" modified after Thomas (R. B.). A, anus ; b, bladder; r, rectum ; u, uterus: v, vagina; p, perineal body; the upper part more lightly shaded represents the recto-vaginal septum, the darkly-shaded lower triangle is the perineum proper. The broken vertical line shows the limit of simple lacerations not involving the anal sphincter. The lips of the vulva are held apart by assistants by fingers or retrac- tors. The operator marks out the outline of the surface to be pared. This is triangular, the deepest part extending from the skin-surface as high as the apex of the normal perineal body (see Fig. 178). From this apex the wound extends forward on either side to the edge of the labia minora narrowing to meet the skin. The paring should not extend forward beyond the natural extent of the perineum. The paring may be effected by carrying a sharp straight bistoury from behind forwards through the central line of the vagino-rectal septum, taking up only the 756 DISEASES OF VAGINA. mucous membrane. The knife is then carried outwards, so as to raise the mucous membrane in a thin flap on either side. The Avound is then examined, and any projecting bit of mucous membrane or skin lying in the wav of the parts to be brought into apposition is cut off. Bleeding Fig. 179. V «B Fig. 180. B B represents the split Sphincter Ani, A a ; c, the course of the Suture necessary to bring the ends, B B, of the Sphincter together. (After Thomas.) is arrested by waiting awhile, by pressure, and by twisting any arterioles that may be severed. The sutures are then passed, beginning with the hindmost. The needle used may be one fixed in a handle, well curved, or a free needle carried by a forceps. The handle-needle is preferable. A double silver wire is carried. The first suture is passed on a level with the lowest edge of the pared surface about f in. from the edge. It is carried fairly into the tissue behind the wound, so that, buried beneath, it is never seen until it emerges on the opposite surface at the same level. A second suture is passed in like manner, also buried, about \ in. in front of No. 1. A third suture is passed which should not be buried ; it runs across and is seen (Fig. 181, No. 3) travers- ing the vaginal orifice. More may be passed in like manner, according to the length of the wound. Thomas insists upon a point Avhich appears to be of primary importance. He shows that to repair an injury involving the sphincter, the parted ends of the muscular ring constituting this structure must be brought into accurate apposition. Fig. 179 represents the sphincter torn open, and the way of reuniting the ends to reform the ring. The needle passed in at A, is buried along the course of the dotted line, passes under c, the anterior boundary of the anus, and comes out at a to the left. Drawing the suture up, the ring of the sphincter is reformed, as seen in Fig. 1*0, in which the two ends of the sphincter are brought nearly together. A little further tightening will complete the ring. To fix the sutures some Showing the Ring of the Sphincf-r -Ai.i nearly re- stored by drawing up the Suture pasted as in Fig. 179. (After Thomas.) PERINEAL LACERATIONS. 757 Fig. 181. prefer the quills, some various modes of twisting. Charles Brooke used broad flat beads, and contended, I think, with reason, that each suture could by this means be so set as to effect the most accurate contact of the wound. It is obvious that the pressure must be different in the case of the suture which is applied to the thickest part of the perineal triangle from that which is enough to draw together the thinner part of the wound in front. The beads adapt themselves perfectly to this varying condition. The drawback is that they are apt to bury them- selves in the skin, causing sores. To obviate this the sutures should not be drawn too tight, and the beads should be large. The quills effect much the same end as the beads. But being con- tinuous rods they can hardly exert pressure adapted to the degrees of thickness of the Avound as the beads do. And they also are apt to bury themselves in the skin. The best form of quill is the rounded ivory bar of James Lane, perforated in three or four places for the wires. But many operators now discard quills, simply twisting the ends of the sutures. If it be determined not to use quills or beads, the best plan is to bring tho ends of the sutures together by Aveling's coil-clamps and shot. This, like Brooke's beads, admits of regulating the tightness of each suture, according to the situation. I think the best plan is to pass the suture ends through a large Brooke's bead, and then to secure them by the coil- clamp and shot. A broader surface is thus insured next the skin. It is not necessary to divide the sphincter ani, to relax the tension on the wound, as Baker Brown did. The sutures may be removed at the end of six or seven days. The bowels need not be restrained by opium for seven or eight days. A winged catheter should be kept in the bladder, or the urine should be drawn off every eight hours. The deep sutures should be cut and re- moved, together Avith the ivory clamps, at the end of three or four days. Some oedematous swelling generally takes place, but soon subsides when the pressure of the sutures is removed. If left longer than this, irritation and suppuration are apt to be set up, and no compensating advantage is obtained. The superficial sutures need not be removed till the sixth or seventh day. The bowels may now be opened by a mild aperient, fol- lowed by an enema. In the cases where the perineum has been torn through into the anus, Showing Wound and application of Sutures in re- storation of the Perineum. 1, 2, 3 represent the course of the Sutures and the order in which they are introduced. (After Thomas.) 758 DISEASES OF VAGINA. somewhat greater care is necessary to secure accurate contact, and espe- cially to prevent any aperture being left between the rectum and newly- made perineum. The latter untoward result may be best avoided by splitting the recto-vaginal septum for a short distance in the horizontal direction, at the point where it forms a sort of eperon at the centre of the torn part. Then, by turning up the vaginal portion of the split septum, and causing the two lowest of the deep sutures to take a hold of it on its new surface as they are passed through, it will effectually cover the spot where otherwise recto-vaginal communication might probably be left, while it will at the same time increase the thickness of the lower part of the new perineum. In this class of cases division of the sphincter is bene- ficial, as the action of the muscle otherwise tends to separate the surfaces, and especially to open the torn angle of the wound. But an incision on one side only is sufficient. In the still more severe cases in which the recto-vaginal septum is torn for a greater or less extent upwards, the operation above described will be insufficient, as a recto-vaginal communication would be almost certain to remain. It is therefore necessary first to unite the recto-vaginal sep- tum, and afterwards to restore the perineum. To unite the recto-vaginal septum the edges must be pared on each side, and a sufficient number of wire sutures inserted. These may be secured by simply tAvisting their ends, no quill suture being required. When union is complete and firm, Avhich will usually be at the end of about three weeks, the second opera- tion for the restoration of the perineum above described may be under- taken. To secure fine adaptation of the rectal and vaginal mucous and of the cutaneous structures, the operation as described by Mr. Hulke is effec- tive : Two triangular flaps of vaginal mucous membrane are first dissected up ; then the cleft in the rectum is sewn with three fine silk sutures, the ends of which are left in the bowel. Several sutures of the same material are then adapted to the vaginal mucous membrane that had been pre- viously dissected up. Next, the raw surfaces made by thus raising the flaps of mucous membrane are brought together with quilled sutures passed deeply, making a long and thick perineum; and lastly, the tegu- mentary edges of this are joined with fine silk sutures. The new formations in the vagina are not numerous or frequent. They consist almost exclusively in fibrous tumors, cystic tumors, sarcomata, the papillary excrescence, and cancer. Fibrous tumors and sarcomata are developed in the fibrous or muscular coat of the vagina, and often but not invariably are associated with similar formations in the uterus. The fibroid tumors project into the vagina, and sometimes assume a considerable bulk. Tumors also form in the connective tissue, between the rectum and vagina, and are developed equally towards either canal, or bulge out more into one or the other. The sarcomata proceed mostly from the uterus, and from the cervix. Mr. Curling (Pathol. Trans, vol. i.) describes a firm solid tumor grow- ing from the upper part of the vagina, to which it was attached by a broad peduncle, which commenced just beh nd the meatus of the urethra. The tumor consisted of a mass of dense fibrous tissue partly arranged in lar«-e globules, and developed in the submucous areolar tissue of the vagina. CANCER OF VAGINA. 759 It had been forming for many years, and lately had projected outside the vulva. Free bleeding occurred from one or two large vessels at the posterior part of the peduncle. Papillary outgrowths are not so common in the vagina as on the cervix uteri, but they sometimes assume a cauliflower shape, with a more or less defined stalk. At the entrance of the vagina they take the form of condylomata. Cystic tumors are occasionally found in the walls of the vagina. They are certainly of rare occurrence. Thus Scanzoni says (1856) that he had only met with one case, and West's experience furnishes only two. Several clear examples have come under my observation. McClintock gives the histories of two cases. The origin and nature of these cysts are not clearly determined. In some cases possibly they resemble fibro- cystic tumors of the uterus, the cystic element being specially developed. In others, according to Huguier, they originate in obstructed mucous follicles. Scanzoni says, in autopsies one meets with cysts the size of a pea or of a cherry; but accurate information always proves that these neoplasms Avere not developed in the walls of the organ, but in the peri- vaginal cellular tissue. Bokitansky also says the primitive seat of these cysts is outside the vagina, with which they have only a secondary rela- tion. This, I think, I have verified in some cases. Strictly vaginal cysts must be distinguished from vulvar cysts, Avhich are not uncom- mon. There are tAvo specimens of cysts removed from the vagina in Guy's Museum, Nos. 228180 and 228182. I have removed two by wire- dcraseur. In one case it appeared to me that the origin of the cyst was a blood-tumor or hgematoma. I have seen several hgematomas of the walls of the vagina not always traceable to labor. The absorption of the blood would leave a cyst which would subsequently be filled with serum or muco-purulent fluid. The treatment consists in removing the tumors altogether, if this can be done without involving too extensive a wound. Otherwise they may be laid freely open by bistoury, and the cavity plugged with tincture of iodine on lint. They sometimes burst and continue to pour forth an offensive discharge. In a case under my care in St. Thomas's a cyst burst into the urethra. It gave rise to extreme dysuria. It caused a considerable fluctuating swelling in the vagina. It was cured by free cauterization with nitrate of silver of the cavity of the cyst through the urethra. Dr. Gibb described {Path. Trans., vol. v.) a specimen in which small calculi (phlebolithes) were taken from between the coats of the vagina in a colored woman. Nitric acid or the actual cautery may arrest the disease, or produce for a time a healthier surface. Bleeding may be controlled by plugging with pledgets of lint soaked in solution of perchloride of iron, or m tinc- ture of iodine, or with the styptic cotton-wool. Primary cancer of the vagina is rare. McClintock says no well-marked and undoubted instance has fallen under his notice. In all cases of vagi- nal cancer, the disease he found had spread from the uterus or the vulva. Dr. West believes that the rarity of primitive vaginal cancer has been exaggerated. And I have seen several cases where epithelioma began 760 DISEASES OF VAGINA. at the meatus urinarius. I have now and then met with a peculiar contraction of the vagina in old women, attended with ulceration and offensive discharges, which I believe to be of cancerous nature, and in which I concluded that the uterus was not involved. In one case which came under my care at the London Hospital, that of a woman aged seventy, there had been for ten months a sanguineous discharge of " dirty Avhite" color, pain doAvn inside thighs and lower belly, chiefly at stool. She was obliged to lie down; she felt as if sitting on a sharp instrument. About one inch up the vagina, an annular constriction was felt just admitting the finger; through this was a pouch, at the back of which was the enlarged and hardened os and cervix uteri. The sensation was much as if the finger passed through a fistula into the rectum. But passing one finger into the rectum and one into the vagina, the septum was felt perfect, and her " stools passed the right Avay." Blood flowed on examination. Atresia of the canal is not uncommon when the vagina is the seat of cancer. Bare as is vaginal cancer, there may occasionally be seen here and there scattered over the vaginal surface independent roundish, or flat medullary watery projections, discoid or honeycomb elevations of the cauliflower excrescence. The vagina affords, like the peritoneum, clear opportunities of observ- ing how cancer can propagate itself by contact. Thus it is not uncom- mon to find a patch of cancerous growth on the opposing surface of the primary seat of the disease. Dr. Cayley describes {Pathol. Trans., xvii.) a case of epithelioma propagated by contact from the posterior to the anterior wall of the vagina. The diagnosis, presuming that a digital examination is made, is easy. The rough, hardened, contracted walls of the vagina communicate a sen- sation different from that of the healthy, or of any other diseased state of the vagina. The speculum will expose the disease. The examination, howsoever gently made, is moreover pretty sure to cause a little bleeding ; and the offensive discharge supplies further evidence. The course and terminations of vaginal cancsr resemble those of ute- rine cancer. Indeed, in almost every case vaginal cancer is but an ulte- rior stage of uterine cancer. The disease extending deeper invades the rectum and bladder, leading probably to perforation. Death occurs through exhaustion, blood-infection and degradation, mechanical impedi- ment to the functions of the bladder, kidneys, and intestines. In treatment unhappily little can be done. There is no room for at- tempt at ablation. We can but seek to arrest progress by poAverful caus- tics, and failing this, fall back on palliative measures. The palliative treatment differs in no respect from that described as applicable to cancer of the uterus. VULVA, DISEASES OF. 761 CHAPTER XXIX. THE DISEASES OF THE VULVA. inflammation': general or partial; of the vula70-vaginal glands; abscesses; ulceration's; sloughs; hematoma; varicosity; pru- ritus; eczema; folliculitis; hypertrophy of labia and clitoris; "endermoptosis;" neuromata; cysts; syphilitic avarty excres- cences; lupus; cancer; melanosis; vascular excrescence and other growths of the meatus urinarius and urethra; fissure of the vulaa. coccygodynia. Soaik of the diseases of the vulva are marked by exquisite pain. The free distribution of sentient nerves, the richness and complexity of the vascular apparatus, and the multiplicity of the delicate organs accumu- lated in this region, account for this feature. Another condition to be noted is the active reflex association with the nervous centres, cerebral and spinal. This is remarkably manifested when Ave induce anaesthesia to facilitate examination or operations. The vulva seems almost the last part in which the reflex irritability is suspended. The reactions upon the general nervous system are often complicated and distressing, and are not seldom overlooked. In addition to these conditions, which always exist, there is often found a morbid neurotic element inherited or acquired, or a blood dyscrasia or diathesis, as gout. Infiammation of the vulva—vulvitis—may be partial, that is, limited to a part of the structures of the vulva, as to one vulvo-vaginal gland and one labium: or it may be general, that is, involving all the structures of the vulva on both sides. It may be limited to the vulva, which is not uncommon, or it may be complicated with colpitis. The vulva is liable to various forms of inflammation: Erythema, phleg- monous inflammation of the labia, acute or chronic, furuncle, erysipelas, herpes, eczema, prurigo, and the follicular inflammation of Iluguier. (Edema is a frequent complication of these affections. They often leave a degree of thickening, hypertrophy, or sclerosis of the tissues of the nymphae, clitoris, or vulva. Inflammation of Bartholin?'s glands is frequently caused by unclean sexual intercourse, especially of a gonorrhoeal character. I have seen a chronic inflammation, which had lasted ten months, disappear quickly under no other treatment than iodide of potassium. I had suspected syphilitic disease. It may be the result also of want of cleanliness, and the irri- tation produced by the retention and partial drying of leucorrhceal dis- charges. Inflammation having attacked the substance of the gland, causes ex- treme pain from the distension of the gland within its capsule and the surrounding connective tissue. The inflammation may be limited to the 762 VULVA, DISEASES OF. gland and its duct, or may spread to the loose connective tissue around. In either case abscess may form. When the gland is the chief scat of the inflammation, a SAvelling forms of an ovoid shape, distending one labium major, and causing it to protrude so as to overlap and conceal the labium on the other side. The surface of the tumor is usually vivid red, shining from tension, and bathed with a serous mucus. The size varies from that of a pigeon's egg to that of a hen's egg. Bulging over towards the opposite side, it narrows the entrance of the vulva so that the intro- duction of the finger causes exquisite pain. It is generally possible to detect the orifice of the duct of the gland on the inner surface of the labium. Pus accumulating in the gland may from time to time force its way out of the duct, then collect again. But most often this mode of evacuation is imperfect, and great distension is the result. Even when the abscess has burst, an obstinate secretion of pus may go on for an indefinite time. The subjective symptoms are intense pain and a sense of throbbing in the part. When the inflammation spreads to, or has its chief seat in the cellular tissue of the labium, the symptoms and appearances are similar. Per- haps the pain is less ; but pain is a relative term, often more expressive of individual susceptibility than of the intensity of the disease, so that no conclusion can be drawn from this. Where the cellular tissue is affected, the swelling extends much beyond the limits of the gland. It may terminate in resolution, but suppuration is, I think, the more com- mon event. In this case fluctuation soon becomes evident. Abscess of the gland itself will not often burst. After a time the inflammation may even subside, and the cyst formed may be tolerated. I have knoAvn many examples of this condition. It is nevertheless desira- ble to lay them open Avhen detected, as they may at any time be the occasion of renewed trouble. In the treatment of inflammation of the labia majora and Bartholini's gland, the first thing to enjoin is rest. Indeed, this injunction is not very likely to be disregarded, the pain on movement, especially in the upright posture, is too agonizing for that. If suppuration has not begun, leeches, poultices, and lead lotion give most relief, and dispose to resolution. When the formation of pus is made out, a tolerably free incision should be made. As the part is very vascular, free bleeding may follow ; but this gives such obvious relief that it ought not to be immediately stopped. If it goes beyond desirable bounds it can be readily stopped by compresses alone, or by a tent soaked in perchloride of iron or tincture of iodine. A poultice should be applied after the incision. An abscess of the cel- lular tissue thus treated will commonly heal without further trouble. But if it is the result of inflammation of the gland itself, something more may be necessary. The contents of the inflamed Bartholini's gland are not always simple pus ; a glairy tenacious mucus often is mixed with pus. This distension may have produced a cystic dilatation of the gland, the inner surface of which will secrete even after it is laid open, unless its character be changed by the free application of some strong escharotic or irritant. I have never found any trouble with these cysts, if the cavity be stuffed with a strip of lint soaked in tincture of iodine. They quickly shrivel up; the remaining cavity gets filled by granulations. HEMORRHAGE. 763 If abscesses of the vulva are allowed to burst, or have been insuffi- ciently laid open, fistulous tracts are apt to form, which keep up great irritation and discharge, and even inflammation and induration of the tissues around. The treatment of these sinuses consists in giving them a free external opening, and in injecting a solution of iodine into the tract. Ulcerative loss of substance occurs in the form of excoriations, super- ficial ulcers, and small follicular and larger abscesses. The vulva is also liable to lupus and syphilitic sores. Sloughs of the vulva are especially apt to follow severe labor, and may result in various degrees of cicatricial atresia. They may occur after typhoid, scarlatina, diphtheria, and may be primary, as in the noma of young children. There is a gangrenous vulvitis sometimes seen in girls following on scarlatina. For this Guersant and Trousseau applied the actual cautery. Billiet and Barthez used chloride of zinc. Parrot {Progrh Medical, 1871) recommends iodoform in powder. He says it is almost painless. It must be used freely, and renewed twice a day for two days. Hemorrhages of the Vulva.—Hgematoma, or thrombus of the labia majora, is produced under the obstruction caused to the return of blood by the advancing head during labor, and also by the bruising and lace- ration occasioned by the passage of the head. It may also proceed from submucous rupture of varicose veins. It sometimes attains the size of a fist, or even a child's head, and consists sometimes more in a diffused extravasation of blood in the connective tissue of the labia, sometimes rather in a collection of blood poured out into a sac formed by rending away of the mucous membrane from the underlying tissues. If the mucous membrane be torn through, free external bleeding may ensue. The extravasation may spread upwards, dissecting the mucous membrane up, and burrowing behind it far into the pelvis. Suppuration at times takes place in the sac, and gives rise to repeated bleedings. I have seen a marked case of hgematoma of the clitoris and urethra. The pudenda are subject to a varicose dilatation of the vessels, a con- dition which may prove serious. During pregnancy the vaginal and pudendal plexuses become still more highly developed; the augmented afflux of blood, and the occasionally increased obstacle to its return from the pelvis, may lead to considerable dilatation of these plexuses. The inside of the vulva and loAver part of the vagina at times assume a dis- tinctly convoluted appearance, OAving to the prominence of the vessels; these bulge forth turgid, elastic, deep red, or purple. In this condition, should a breach of surface take place at any point, profuse, even fatal bleeding may easily occur. A blow may rupture the vessels by bruising them against the pubic bones. Simpson says, " In the Scotch law courts during the last five-and-twenty years a considerable number of trials have taken place in consequence of women bleeding to death after sustaining some injury of the pudenda. In most of these cases all that was alleged as the cause of death Avas that the Avoman had received a kick on the part at the time she was pregnant, and that a slight laceration had been produced, from which the fatal hemorrhage took place." Some years ago a butcher Avas tried at Bristol for killing a mar- 761 VULVA, DISEASES OF. ried woman. Bupture of the pudendal vessels had taken place during coitus. But rupture of the gorged vessels may occur spontaneously, that is, without any direct violence to the part. Varicose veins of the legs during pregnancy may present a similar state of turgidity, entailing a like danger. I have known a woman bleed to death from a slight injury inflicted on a bunch of such veins. The varicose condition, of which the foundation was laid in pregnancy, persists more or less when the pregnancy is ended. The affected vessels become less turgid, but may undergo changes disposing to danger in another way. Thrombosis taking place in them, necrosis of the walls of the vessels may ensue, and thus becoming perforated, may be the source of hemorrhage or ulcers ; inflammation of a low, sometimes erysipelatous type is common. When hemorrhage takes place from varicose vessels of the vulva or vagina, the one effectual remedy is pressure. This must be firmly ap- plied. The best way is by plugging the vagina above and doAvn to the level of the bleeding points. The horizontal posture and moderate diet of course will be enforced. Simple compresses dipped in cold water will ansAver the purpose. But occasionally it may be found desirable to soak them in a solution of perchloride of iron. Although pregnancy is the usual antecedent of varicose veins, I have knoAvn very severe cases Avhich could not be traced to this condition. Pruritus is one of the most distressing of the affections of the vulva. It is associated Avith, or dependent upon, a variety of conditions, so that it may generally be regarded as symptomatic. Before determining upon a course of treatment, it is a clear indication to investigate thoroughly the state of the pelvic organs, and even to study the general condition of the system. In some cases the irritation depends upon diabetes. In some there is a gouty diathesis or lithiasis, the blood carrying irritating elements to every organ and tissue of the body ; pain is especially evoked in certain elected parts, the vulva being one of these. In some there is congestion or inflammation of the cervix uteri, and the attendant dis- charges appear to be the immediate cause of the vulvar pruritus ; but, in some instances, there is pruritus, intra-vaginal, as well as pudendal, with- out any discharge. Then, in a considerable number of cases, there is obvious pudendal disease, as herpes, eczema, erythema, scabies, pediculi. In some apparently inflammatory cases, it is difficult to say whether inflammation or neurosis predominates. In many of the most painful of these disorders there is no very obvious inflammation, and in others, where inflammation is obvious enough, the pain, although generally troublesome, is more endurable. Some of them have been described under the head of climacteric diseases. It is at this period that the most troublesome cases occur. This, indeed, is especially the epoch of irregu- lar disorderly nervous affections. But other forms may occur in young Avomen, married or single. One form especially arises during pregnancy, a time Avhen the nervous system is in a state of peculiar erethism, and when the seat of the pruritus is peculiarly vascular and hyperaesthetic. I have seen a very troublesome form in single young women following a sedentary occupation as governesses. The sitting may have an injurious local effect, but probably emotional and other centric nervous conditions PRURITUS. 765 may be influential. And this may, I think, be stated as a general propo- sition : there must be exaggerated centric irritability as well as an eccen- tric irritation to produce the marked forms of pruritus. This is why it is so frequent in pregnancy. Indeed, it is not uncommon to find in obstinate cases that a general irritation or hypergesthesia of the skin becomes grad- ually developed. It is remarkable that most of these painful affections of the vulva are aggravated at the menstrual epochs. This is due, no doubt, to the exalted centric irritability attending ovulation, as Avell as to the increased local vascular fluxion. A similar exacerbation is observed in neuralgia of the face and other parts. Indeed, there are cases of intense vulvar pruritus where no local lesion can be detected, which might with propriety be called vulvar neuralgia. A considerable proportion of cases are due to inflammation of the struc- tures about the vulva. These are already described. A not uncommon form in climacteric Avomen tending to obesity is eczema. In cases of this kind the disease is not limited to the vulva, but extends to the dependent fold of the abdomen, to the folds of the groins, to the upper parts of the thighs—in fact, to all those skin-surfaces which overlap each other and chafe. The skin loses its natural epidermal character, becomes moist, red, angry-looking, approaching to the appearance of inflamed mucous membrane. Sometimes aphthous or diphtheritic patches form. The labia majora are often much SAvollen, even hypertrophied. Minute vesicles or pustules give place to scabs. Sometimes little abscesses form and burst. I have seen pruritus from eczema brought on by gonorrhoea, and the use of irritating lotions. In one such case, that of a young woman, a pustular eczema spread all over the mons Veneris, the labia, and inner side of the thighs. Nitrate of silver had been used freely Avithout benefit. She Avas cured by healing the attendant metritis and vaginitis, and by the local application of zinc ointment. Pruritus is not uncommon in connection with cancer of the uterus or vagina. My observation confirms the statement of McClintock that, in many cases, pruritus of the vulva is one of the earliest symptoms of cancer of the womb. In some cases the pruritus is due to the breeding of pediculi. These are effectually treated by mild mercurial ointments. In hospital, the nurses ask for stavesacre for this purpose. It answers well. But there are other cases in which the affection is in no way associated with para- sites, Avhich are remarkably benefited by stavesacre. The prurigo senilis, for example, is successfully treated by Mr. Balmanno Squire's formula, consisting of oil of the seeds 1, lard 7. In this disease I have also seen great advantage from the application of a pasma formed of flower of sulphur and water. A not uncommon form of vulvitis is the vulvar folliculitis of Huguier. This affects the labia majora, the external aspect of the labia minora, the genito-crural folds, and is limited to the sebaceous glands and hair-bulbs of these parts. These parts appear slightly swollen, rosy, and are the seat of small elevations due to inflammation of the sebaceous glands and hair-bulbs. These are very numerous, are at first small, then enlarge, and resemble pustules, and soon suppurate. Bursting, they discharge an 766 VULVA, DISEASES OF. irritating, offensive, purulent matter. This vulvitis is frequently compli- cated Avith erythema, ecthyma, sometimes with oedema, erysipelas, or abscess. It is principally observed during pregnancy, when this secre- tory apparatus is very active. In a variety called " vulvite folliculeuse" by Bobert, the mucous mem- brane of the vestibule and that covering the interior of the crypts only are affected. The mucous crypts present at their orifices a vivid red areola ; their cavities inclose a droplet of pus, which can be squeezed out. This vestibular vulvitis, Bobert says, is always more or less allied to urethral blennorrhagia. The treatment should first of all be directed to the removal or relief of the complicating conditions, local and constitutional. Where there is uterine disease attended by discharges, this should be cured. Perfect cleanliness by vaginal injections of water or astringent solutions should be enjoined. Thomas advises the use of a cotton tampon saturated with glycerine mixed with a little borax or acetate of lead, applied daily in the vagina. It protects the vulva from irritating discharges. If there is acute or subacute inflammation of the skin or mucous mem- brane, the local applications must be of a soothing kind. It may be necessary in the first instance to apply poultices or poppy-head fomenta- tions, lead lotions, copious vaginal irrigation with tepid water or bran- water, observing rigorously a light diet and avoiding stimulants. Constitutional treatment is often of the greatest importance. It is necessary, in the first place, to remove, if we can, any complicating, local, or general disease. In women who have reached the climacteric, in whom there is probably a gouty or lithic acid diathesis, strict attention must be paid to the correction of this state. Alteratives, mercurials, salines, alka- lies, aloes, colchicum, podophyllin, taraxacum, are often indicated. The peculiar nervous condition of the climacteric age must be studied. Bro- mide of potassium in large doses is of essential service. Digitalis and aconite are useful. Sometimes we are compelled to resort to more decided narcotics, as opium or chloral. When clear urine and well-acting bowels indicate that the blood is com- paratively freed from lithic acid and other impurities, tonics as bark or quinine are often useful. Guerieau de Mussy insists that a gouty or other diathesis is often present, lie advises the use of small doses of arsenic. Such patients should avoid stimulants, especially beer; and moderate exercise in the open air should be enjoined. When the inflammatory condition is subdued, we may try in succession a variety of local measures. Gu&ieau de Mussy recommends the follow- ing means: Emollient baths containing poppy, or laurocerasus, bella- donna, aconite, or pulverized water with belladonna ; a weak solution of bichloride of mercury, alkaline washes, vaseline or glycerine with calomel, tannin, or benzoin. Intra-vaginal washes of decoctions of rice and poppy- heads are useful. In the chronic form, strong sulphur baths, some hypo- sulphite baths, as those of Aix, pomades Avith mercury and belladonna, carbolic acid lotions or black Avash come into use. But we must be pre- pared to find some cases for a long time rebellious to all treatment. The pruritus of pregnancy is associated Avith the exalted centric ner- vous irritability developed by pregnancy, and with the increased local DISEASES OF CLITORIS. 767 afflux of blood. Leucorrhcea generally attends, and the vascular fulness exceeds the usual degree. Saline purgatives, as Piillnaor Friedrickshall water; alkaline baths, as Vichy, which can be prepared at home ; or even bathing with plain cold or tepid Avater constitute the best palliatives. Salines and colchicum may be indicated. Bromide of potassium may be useful. Amongst the acquired abnormities of the vulva is hypertrophy, which sometimes assumes a monstrous appearance. In its ordinary forms it consists of increase of volume of the cutis and subcutaneous connective tissue. It affects the entire vulva, or only a part, as the nymphae, or the labia majora, or the clitoris. The mass thus formed may attain the weight of several pounds. The surface of the enlarged part is smooth, or rough from irregular growth of epidermis, generally warty, uneven, lobulated. In these cases the tumor reproduces all the marked characters of the papillary growth, and resembles the condyloma. In its substance it consists of dense fibrous connective tissue. Often the hypertrophy spreads upwards over the mons Veneris, and backwards over the peri- neum. Frequently the mass, under traction of its own weight, becomes pedunculated, and its removal is then easy. I have known the labia minora enlarged so as to form flaps hanging down below the labia majora to be a source of trouble, especially during the menstrual periods, when they SAvell from congestion, and by chafing against each other produce irritation and leucorrhcea. It may assume the character of elephantiasis. Atrophy of the labia occasionally follows chronic syphilitic affections of the vulva, attended by progressive cicatricial formations. The clitoris is subject to abnormal enlargement. This, says Roki- tansky, is more often congenital than acquired. This is one of the con- ditions Avhich, especially Avhen conjoined with excessive development of the nymphge, as is often the case, simulates hermaphroditism. The gland may be very large, and the prepuce so developed as to resemble a penis, whilst the enlarged nymphge assume the appearance of a scrotum. There is a good example of this malformation taken from an infant in St. Thomas's Museum. As the subject of hermaphroditism has little clinical interest, I must refer those who seek information on it to Rokitansky's Pathological An- atomy. Little tumors are sometimes found in the labia, which Huguier has described under the name ^Endermoptosis." These are due to hyper- trophy of the sebaceous glands. They are not painful; they give vent on squeezing to sebaceous matter. The radical cure is to cut them out with scissors. Kcuromata of the vulva have been described by Simpson as sensitive points and structures external to the orifice of the urethra, and as analo- gous to the caruncles of this part. True small nodular neuromata may be found under the mucous membrane here as well as in other parts of the body. They are the occasion of much suffering, and to obviate this the removal of the offending nodules is necessary. Vagcular outgrowthg occur as teleangiectasis in the labia majora, and as the vascular excrescence of the meatus urinarius. The tumors or outgrowths of the vulva are so well described by 768 VULVA, DISEASES OF. M'Clintock that I am induced to follow his account. He classifies them as—1. Warty and hypertrophic ; 2. Fibrous and fatty ; o. Cystic : 1. Vascular ; 5. Cancroid and carcinomatous. Warty {syphilitic) excrescences may grow from any part of the vulva, but they most commonly appear around the orifice of the urethra or of the vagina; in this latter case they look like elongations of the corpora myrtiformia. They are usually found in clusters, but sometimes occur singly. Often three or four grow by a common root. Their color is nearly white, and their structure tolerably firm. They are probably always of syphilitic origin. They seldom cause much pain, but they cause more or less local irritation and mucous discharge. At least two varieties of warts are met with on the vulva. One of these, says M'Clintock, is the true warty excrescence, the verruca or thymion of Celsus. It is very similar to the warts which appear on the hands, except that it.frequently has a pedunculated shape, the stalk or neck having a smaller diameter than the body of the growth. When of large size they are apt to be fissured at the top, and to bleed if scratched or otherwise hurt. They have the color of the surrounding skin, and do not yield any discharge. The greater labia and adjacent common integument are the parts from which these warts generally spring. Warts of the other kind or variety grow from the vestibulum, meatus urinarius, carunculae mytiformes, or some of the parts ordinarily concealed within the vulvar sinus. Their structure is firm, but they are remarkably pale in color and semi-transparent, so as to bear much resemblance to the white muscular tissue of fish. Considerable hypertrophy of the nymphge, clitoris, or more rarely of the labia majora, is not unfrequently associated Avith these warty excres- cences, a circumstance which M'Clintock suggests strengthens the proba- bility of their being due to some venereal taint. But these enlargements frequently occur when there are no warts, and they may unquestionably occur Avhere there is no syphilitic taint. The syphilitic hypertrophy is generally marked by a rugous warty surface ; and other evidence of syphilis, either historical, or still impressed upon other parts of the body, as the skin or throat, Avill rarely be Avanting. Surgeons are familiar with the mucous or gummous tubercle or condyloma of the anus in syphilitic patients. Not infrequently the anus is affected at the same time as the vulva, and then the syphilitic nature of the vulvar growth is at once recognized. In St. BartholomeAv's Museum is a specimen, No. 32.80, of a large fibro-cellular tumor, which was attached by a broad pedicle to the left labium of a woman aged thirty-five. It had existed for ten years. Three years previous to its removal she had syphilis, since which time it rapidly enlarged. These growths should be treated in the same manner as the gummous tubercle of the anus. In the early stage the warts may sometimes be dispersed by astringent and caustic applications ; keeping the parts very dry, and dusting them frequently with prepared chalk, or some other ab- sorbing powder, will occasionally remove them. The syphilitic growths are often effectually treated by frequent powdering with calomel. A EXCRESCENCES. 769 very effective application is painting with strong acetic acid. This has seemed to me even better than nitric acid. But when the growths have attained a considerable size, extirpation by knife, scissors, Ecraseur, or galvanic cautery is by far the best plan. When cut off on a level with the surrounding mucous membrane they are not likely to be reproduced ; but if a portion of the base or stem be allowed to remain, this is very apt to throw out fresh shoots or processes. I have removed a very large mass of syphilitic tubercle of the labia at an ad- vanced stage of pregnancy, on the ground that during labor laceration might occur. It is, I believe, under all circumstances, best to remove them. Should hemorrhage occur after ablation, it may be restrained by pressure with or without perchloride of iron, by the actual cautery, o"r still better by acupressure. Needles transfixing the bleeding surface and twisted sutures will effectually stop the bleeding. Although I believe the syphilitic excrescence can generally be dis- tinguished from other forms, we meet in practice with growths which present considerable resemblance to them Avhere there is no room to admit the complication Avith a venereal taint. Dr. West is undoubtedly right in his statement that some of these belong to the same class as lupus, " and are quite independent of venereal taint, and of these some pass by gradations, difficult to seize, into the same class with epithelial cancer." To these forms the names herpes exedens, lupus, rodent ulcer, tertiary syphilis, esthiomenus (Alibert) have been applied. Iluguier adopts the last. Cancer, frequent in the uterus, rare in the vagina, again becomes frequent in the vulva. The medullary cancer occurs very rarely as a primary disease of the labia. It is most commonly a propagation of the disease from the vagina in association Avith cancer of other organs, and especially Avith medullary warts in the skin and consecutive cancer of the inguinal glands. More frequent is the epidermal cancer (cancroid), which appears as a proliferating widely spreading degeneration of the labia or clitoris. This latter organ is especially prone to cancer, and like the same disease in the penis, it may for a considerable time be limited to the organ. Owing to its almost external position, and the distress which the disease and attendant enlargement produce, it is generally detected early. These circumstances make ablation especially hopeful. It is not Avise to be de- terred from operating even when there is evidence of enlargement of the inguinal glands. A respite of comparative ease may at any rate be counted upon. The operation should be thorough. The patient is placed in the lithotomy position. The diseased part is firmly seized by a curved Museux's forceps, and drawn out so as to put its attachments upon the stretch. With strong scissors the mass is cut away close to the pubic bones. Free hemorrhage is likely to follow. This may be restrained by the actual cautery, or by very firm pressure by compresses. A mode of proceeding.preferable when the diseased mass can be fairly commanded by the wire-loop, is the galvanic cautery. Beginning in the clitoris, cancer spreads to the contiguous structures, and soon invades the labia minora et majora. When this is the case, the 49 770 VULVA, DISEASES OF. prospect of relief is much diminished. Still ablation may in some cases be attempted. Where ablation has to be abandoned, we must fall back upon caustics or palliative treatment. All the measures adopted in the case of cancer of the uterus find application here. In St. Bartholomew's Museum is a specimen (No. 32.til) of melanosis of the labia and vagina. The parts were removed by operation, on ac- count of a large mass of melanotic disease, which, arising at the front part of the vagina, encroached equally upon either labium. In the same museum is another specimen (No. 32.12) of a labium on the surface of which is an oval elevated warty growth of moderately firm texture, and with a finely-granulated surface, very similar to the chimney- sioeepers cancer of the scrotum. The vascular excrescence, caruncle, or tumor of the meatus urinarius. —This is in many cases an outgroAvth from the mucous membrane of the urethra, most commonly found at the meatus. At this orifice it often protrudes, bulging out as a small tumor, sometimes, but rarely, as large as a cherry. When it so bulges, of course it is easily seen, and so it has come to be described as a disease of this particular spot. But a similar condition not seldom extends a little distance up the urethra. The word " vascular" gives a good idea of its appearance. It may be roughly described as an outgrowth of vessels loosely held together in a mass by a little connective tissue, and covered by a thickened mucous membrane. The surface is irregular, a little lobulated, deep red or blue- red. It is soft, difficult to seize with tenaculum or forceps, it so readily breaks down. The morbid mass and appearance are generally bounded by the margin of the urethral orifice, that is, the growth seems to be peculiar to the urethral mucous membrane ; it stops abruptly at the mucous membrane of the vulva. Quekett examined one of these vascular groAvths, and found it to be composed of epithelial cells, and a number of capillaries coming up close to the surface. This explains the occasional tendency to bleeding. Wedl, in his Pathological Histology, describes and figures the appearance pre- sented by the urethral caruncle. He regards these bodies as " dendritic, papillary new formations of connective tissue." The one he examined was of a somewhat elongated figure, of a bluish-red color, and spongy texture, and exhibited Avhen cut into, cavities containing colloid matter. The most interesting point was the distribution of the bloodvessels, which could be very distinctly traced in transverse sections, moistened with a solution of sugar or common salt. Their ramification precisely resembled that seen in the vasa vorticosa. Several vessels of considerable size entering one of the lobules divided into a multitude of smaller ones, which, though not of capillary dimensions, made numerous undulating curves, extending up to the periphery of the lobule, where they terminate in mostly short and abrupt loops. The walls of these vessels Avere every- where simple, like those of capillaries. There were extravasations of blood at several points, of old and recent occurrence. The late Dr. John Reid examined for Sir J. Simpson a very sensitive and painful caruncle, and came to the conclusion that there was a very rich distribution of CARUNCLE OF MEATUS. 771 nervous filaments in it. It seems, in many cases, to be analogous to hemorrhoids in the anus. It is most frequent, according to my observation, in women who have reached the climacteric, or passed it, and who have been married. But it is found occasionally in girls and young women, single or married. There is a tendency to venous hgemostasis in the pelvic organs, especially in the mucous membrane of women advancing in years, which appears to me to predispose to these irregular vascular protuberances. The excrescence may be "gummous." At least, I have seen cases connected with secondary syphilis. And Scanzoni believes they result from chronic urethritis. In many instances there is a history of gonorrhoea. The principal symptom of the disease is acute agonizing pain on mictu- rition, compelling the sufferers to postpone the inevitable torture by sub- mitting as long as they can to retention in the bladder. Hence there is a retrograde risk of inflammation of the mucous membrane of the bladder, and distension. Not uncommonly a little blood is passed with or after the urine ; and bleeding may occur at other times, as from rubbing to ease the pain, friction in walking, and sexual intercourse. Dyspareunia is almost a necessary consequence. Often there is a muco-purulent dis- charge from the urethra and from the vagina, which may be an accidental complication. Pains in distant parts seem to take their rise from this local disease as reflex or sympathetic phenomena. The general health is often seriously impaired. It may give rise to the suspicion of stone in the bladder. The constant pain exhausts the nervous force, inducing prostration and disorder of the functions of other organs. The real source of the mischief is often long overlooked by those who neglect the prime clinical maxim of making a direct examination of the part which is the central seat of pain. The diagnosis is made out by taking the indication furnished by sub- jective sensations as the guide to objective exploration. The patient lying on her side, the upper labium is drawn up so as to expose the structures of the vestibulum, when the angry-looking orifice of the urethra will be seen. By passing a catheter gently we gain information as to the state of the urethra beyond the meatus. And it is often useful to dilate the urethra with a Weiss's dilator, or the excellent instrument con- trived by Dr. Emmet for dilating the cervix uteri. The treatment consists in destroying the offending growth. This may be done more or less successfully by various methods. Where there is much irritation, and the patient declines to submit to operation, some relief may be had from lead lotion, or poppy-head fomentations. Simp- son speaks highly of an ointment consisting of two drachms of hydro- cyanic acid to an ounce of lard. A bit of this of the size of a pea is applied to the part three or four times a day. Aconite and chloroform ointments are also useful. But things of this kind can only be sanctioned as temporary and trivial palliatives. If the tumor present a distinct polypoid form, it may be removed by a ligature, by snaring it, and cut- ting through its base by a fine wire dcraseur, or by snipping off with scissors. Excision is better than the ligature. The tumor must first be seized with a small hook or forceps, and lightly drawn out, so as to enable the scissors to get well at the base. Some bleeding usually fol- 772 COCCYGODYNIA. lows, but compression with a bit of lint steeped in solution of perchloride of iron, or touching Avith the actual cautery will soon stop it. Still these troublesome growths are very apt to recur. There seems an active germi- nating or proliferous property in the mucous membrane from which they rise, so that the smallest particle left retains the property of reproducing the disease. Mere excision, says Bichet {Gaz. des Hep., 1*72), will not remove the contraction and hypertrophy of the urethra, which often give rise to the most painful symptoms. To effect this he advises forcible dilatation of the urethra. I have applied nitrate of silver repeatedly, always with good effect for a short time, although causing great pain at the moment of application. I have also used potassa cum calce, nitric acid, strong carbolic acid, and other caustics, all with more or less advantage. But the best plan, I believe, is to touch them with the actual cautery, either the hot iron or copper, or the galvano-caustic wire or button. Cold-water dressing should be applied after the operation, and astringent lotions when the sloughs have fallen. Bizzoli, in a useful clinical memoir (1875) on the growths which are deA-eloped inside the female urethra, describes a case of angioma of the urethra, and another of the clitoris. These excrescences were formed of vessels possessing a degree of erectility. Small mucous polypi may form in the urethra, cause dysuria and bleeding. Polypi of fibro-cellular structure are also found. They may be removed by scissors; and if any bleeding ensue, a light touch with the actual cautery, or pressure with a plug soaked in tincture of iodine, will stop it. The orifice of the vagina is subject to fissures. These are found as linear irritable ulcers, or clefts in the mucous membrane. The most frequent seat is the posterior commissure, but I have seen them at the anterior commissure. They are sequelge of slight lacerations experienced during labor: they have been produced by coitus, and have resulted from an altered condition of mucous membrane, caused by inflammation, especially of a syphilitic character. As fissure of the anus is a source of pain during the performance of the functions of this part, so is fissure of the vagina or vulva. It may be chafed and irritated by walking, by discharges, by a drop of urine ; but the most distressing symptom is dys- pareunia. The painful spot may be detected by digital examination, and by retracting the labia it may be brought into sight. The treatment is the same as for anal fissure. The edges may be torn open by the fingers, or it may be divided by the knife. But the incision should not be deep, lest severe hemorrhage ensue. It is enough to make a shalloAV incision through the base of the ulcer. I have in several cases observed that epithelioma began around the orifice of the urethra. The actual cautery may in such cases be applied with fair success. COCCYGODYNIA. This disease has become familiar to gynaecologists through the writings of Sir James Simpson {Diseases of Women, 1*72, vol. ii., edited by A. COCCYGODYNIA. 773 B. Simpson). But Dr. J. C. Nott, of New York, in an interesting memoir on the subject, refers to two cases published by himself in the New Orleans Medical Journal fifteen years before Simpson's first com- munication. The name is derived from coccyx and obvvrj, pain. The leading symp- tom is pain in the region of the coccyx felt by the patient whenever she sits doAvn and rises, and sometimes Avhen she remains in a sitting posture. Most of the patients affected Avith it are obliged to sit on one hip, or with only one side resting on the edge of a chair, or with the weight partially supported by a hand on the chair. Some patients dread sitting down. There are other movements of the coccyx liable to be attended by pain. Thus, patients have pain with every step they take, whilst in others walk- ing causes no uneasiness. Others feel the pain most when the bowels are being evacuated, or under any circumstances in which the sphincter or levator ani, or the ischio-coccygeal muscles are called into action. The pain is not in every case very acute, nor at all times equally severe. The distinguishing feature of the disease in every case is that the pain is felt at the lowest part of the spine, or rather in the seat of the coccyx, and where pressure always aggravates it. Pressure and movement of the coccyx too, with the finger in various directions, produce pain, and the kind of movement which is then attended with suffering differs in different cases. Simpson believes the pain is due to inflammation of the coccygeal joint or other morbid change, when any action of the muscles in connec- tion with it, by moving the joint, produces pain. We might naturally look for the origin of the disease in some injury of the part; and in a considerable proportion of cases injury can be traced. But it is remarkable that the disease occurs in the unmarried, and where no history of injury can be made out. I, myself, have known several aggravated cases follow labor. In these I cannot doubt that the joint received injury during the passage of the child's head. In some cases we knoAv the sacro-coccygeal joint is anchylosed, the tip of the coccyx projecting so much forwards as to form an angle with the loAver part of the sacrum. The anchylosis is likely to give way during labor. And where there is no anchylosis, as the head emerges, the coccyx may be felt to be stretched very much backwards, and under the strain some of the fibres of the anterior ligaments which bind this bone to the sacrum may be torn, and in the joint thus exposed and injured inflammation is very apt to be set up. Simpson saw abscess follow. The coccyx again is liable to fracture or dislocation from direct vio- lence, as from a fall on the seat. Patients have complained that" a bone grows in," and so it is found. It is also liable to malformations, to defi- cient development, to tumors, and even double monstrosity by inclusion. But in a certain proportion of cases no local lesion can be made out, and we are driven to conclude that the disease is a neurosis, a form of neuralgia, the expression perhaps, of some remote morbid condition. But latterly some new light seems to be cast upon these more anomalous cases. In Virchow's Archiv, i860 {Die Steissdruse deg Menschen), Luschka gives an account of a small gland situated just at the anterior end of the coccyx; it is in immediate relation with the hind ermost part 771 COCCYGODYNIA. of the levator ani, and is connected with filaments from the ganglion im- par of the sympathetic nerve, and with small branches of the middle sacral artery, between the levator ani and the posterior end of the ex- ternal sphincter. The gland is rich in nerves, which form a network perforating its stroma. This, the " glandula coccygea," Luschka says, is probably the seat of the hygroma cystica perinaealea. And when we consider its highly vas- cular and nervous elements, and its position, we can hardly doubt that it may in some cases be the seat of coccygodynia. Some cases called coccygodynia I have found to be due to fissure of the anus, and to the conditions which induce the spasmodic action of the vulvar and perineal muscles, and known as tw vaginismus." I have also traced it to retroflexion of the uterus. The diagnosis is made out by local examination. The forefinger in- troduced into the rectum is applied to the inner aspect of the sacro-coccy- geal joint, whilst a finger of the other hand is applied to the outer aspect. The bones and the joint thus embraced between the two fingers are com- pletely explored, and the seat of pain and the condition of the parts are easily determined. The treatment, according to Simpson is surgical. But I have met with cases which, after long and intense suffering, got Avell spontaneously, or when uterine disease and general disorder Avere removed. At the same time, I am satisfied that surgical treatment is occasionally essential to relief. One may exhaust sedatives, neurotics, and tonics, and still the pain persists. When there is evident inflammation, leeches will be serviceable, followed by counter-irritation. Temporary ease may be ob- tained by the local subcutaneous injection of morphia. The surgical treatment is to completely separate from the coccyx the muscular and tendinous fibres that are in connection with it. This is done by a tenot- omy-knife passed under the skin at a short distance from the tip of the coccyx, and made to shave along the posterior aspect of the bone, and then to divide the muscular and tendinous attachments, first on one side then, and lastly, all round the tip of it. It is not in every case necessary to make the division so free. In some instances the division of the fibres of the gluteus maximus of one or the other side, or detachment from the coccyx of the sphincter and levator ani may be enough. No bleeding attends the operation, which possesses also the other advantages of sub- cutaneous sections. Simpson admits that this operation occasionally fails, and that he consequently suggested the removal of the coccyx. Dr. J. C. Nott prefers extirpation of the bone. Simpson's subcuta- neous incision around the coccyx would divide the nervous branches which supply Luschka's gland, and in this way its success in some cases may be explained. INDEX OF AUTHORS. A BARBANELL, 623 j\ Abeille. 675, 676 Addison, 346 Aitken, L., 228, 530 Alibert, 70, 258, 769 Allbutt, Clifford, 179 Aiuussat, 203, 212. 661 Anderson, 293, 384 Andral, 297 Andre-de-Ia-Croix, 730 Aran, 39, 198, 418, 474, 478, 507, 511, 515, 525, 584 Aristotle, 170 Arnott, Henry, 290, 643, 687, 707, 711, 714, 715,716, 718, 719 Arnott, James, 737 Ashburner, Dr., 577 Ashforth, 720 Ashvvell, 725 Atlee, 343, 372,375, 396,401, 641, 650, 670, 673, 674,676, 677 Atthill, Lombe, 477, 670, 737 Aveling, 330, 385, 750 BACCHETTI. Dr., 310 Baedeker, 373 Baillie, 241, 284, 335, 338, 642 Bainbridge, 385 Baker, 635 Bantock, 340 Barba, 636 Barker, Fordyce, 180,196. 467 Barlow, 528 Barnes, Fancourt, 173, 325 Barrier, 632 Barthez, 763 Basedow, 310 Basset, Dr., 182 Bassius, 77 Battey, R., 403, 676 Battye, Mr. R. F., 342 Baudelocque, 29, 626, 730 Beck, 467 Becker, 306 Becquerel, 514, 724 Beclard. 207 Begin, 385 Behier, 475, 670 Behse, 328 Bennet, Dr. Henry, 39, 103, 143, 216, 227,430,458,462, 464, 465, 467, 471, 725 Benporath, Dr., 656, 718 Berard, A., 673, 689 Bernutz, 209, 241, 312, 490, 493, 494, 511,514, 525, 526, 528, 529, 534 Beronius, Dr., 204 Berry, Mr., 350, 351 Billroth, 432 Biot, 621 Bird, Dr. Frederick, 376 Bird, Golding, 195, 545 Bischoff, 27, 170, 313 Blatchet, 325 Blundell, Dr , 375, 385, 731 Bockenthal, Dr., 631 Bb'hmer, 85 Boinet, 194, 294, 335, 382, 384, 680 Boivin, 241, 267, 292, 578, 594, 698 Borggreve, 631 Bouchut, 178 Bouillaud, 528 Boulard, 39, 59 Boullard, 227 Bourdel, 475 Bourdon, Dr., 753 Boyer, 626, 672 Bozeman, 750, 751 Braun, C, 249,511, 689 Braun, G., 515 Breslau, 305, 534 Bright, Dr., 159, 342, 387 Briquet, 236 Bristowe, Dr., 279, 280, 285, 348, 349, 643, 660 Broadbent, Dr., 734 Broca, 66, 643, 681, 724 Brodie, Sir Benjamin, 152, 193, 281, 291, 387, 526 Brooke, Charles, 750 Brown, Baker, 376, 386, 579, 672, 675 Browne, B. B., 662 Browne, Dr. Crichton, 251, 263 Bruce, A., 716 Burd, Mr., 401 Burnhara, Dr. AT., 396 Burrow, Dr., 739 Burton, Mr. 522 Byass, Dr., 727 Byford, 650, 670 Byrne, Dr. A. J., 477 pAMERON, 671 U Campbell, Dr., 178, 616 Callender, Mr., 654 Carswell, 341, 412, 654, 699, 701 Caseaux, 51 Casper, 625 Cass, Mr., 527, 529 Cayley, Dr., 760 Celsus, 768 Cesar, Martin, 475 Chadwick, Dr. J. R., 5S0 Chalice, 295 Chambers, Dr., 385, 392, 653, 752 Chambon, 292 Charcot, 127, 236 Chassaignac, 636, 694 Chaussier, 53 Chomel, 70, 741 Churchill, 241 Cintrat, Dr., 678 Clapton, Dr., 259, 365 Clark, Dr. Andrew, 246, Clarke, Charles M., 460, Clarke, Dr. John, 182, 717 Claudius, 41 Clay, Mr., 324, 376, 391, 677 Clemensen, 625 Cloquet, 549 Cockburn, Mr, 196 Cockle, Dr., 685 Cohnstein, Dr., 474 Coindet, 194 Comstock, Dr., 626 Conolly, 250 Cook, Dr., 719 Cooke, Dr. J. C, 624 Cooper, Sir Astiey, 178 Cooper, H., 518, 699 Cooper, Samuel, 146, 566, 620, 629, 704, 721 Cornil, 724 Coste, 25, 170, 176, 242, Courty, 85, 111, 115,435, 487, 490, 632, 702 Cowper, 67 Crane, Dr., 343 Crisp, Dr., 132, 298 Croft, Mr. John, 290 Crosse, 621, 622, 623, 625, 629, 630 Cruveilhier, 36, 85, 327, 436, 541, 545, 549, 550, 578, 642, 644, 650, 664, 689, 703, 704, 705, 706 655, 349, 395, 686 711 711, 395, 577, 313 445, 624, 408, 567, 681, I It) INDEX OF AUTHORS. Curling. Mr., 119, 261, 267, 522, 758 Cusco, 143, 693 Czihak, 32S DANCE, 650, 689 Davies, Dr., of Hertford, 181 Davis, D. D., 623 Davis, Dr. Hall, 316, 636 Davis, Dr. R. A., 262 Deboirieir, 625 Deccs, 203, 528 Delamotte, 85 Deleurye, 85 Del fray sse. 311 Demarqnny, 680 Deneux, 207, 385 Denison, Mr., 522 Denman, 241, 243, 627 Depnul, 41, 666, 670, 669 Deville, 30 Dewees, 626 Dieffenbach, 578 Dieulafoy. 536, 675 Dionis, 328 Disse, 345, 369 Doherty, 507 Dolbeau, 475, 525, 533, 536, 681 Donne, 76, 175 Down, Dr. Langdon, 197 Drejer, 328 Druitt, 174,430 Drysdale, 374 Dubois, 85, 214, 303, 627, 630 Duchenne, 195, 320 Duer, 319 Duges, 241, 267, 392, 594, 698 Dumenil, 662 Duncan, Dr. Matthews, 114, 166, 177, 206,495, 500, 534, 638 Dunn, AV. L., 349 Dupuytren, 115,214,303, 693, 731 Duverney, 67, 313 Dyce, Dr.. 314 D'Andrade, 182 D'Angers, Ollivier, 529 De Beauvais, Gerard, 625 De Blainville, 30 De Boismont, Brierre. 178 De Chegoin, Hervez, 447 D'Etoilles, Leroy, 386 De la Faille, 327 D'Hericourt, Gil lebert, 591 De Morgan, 707, 735, 739 De Mussy, Gueneau, 766 De Saint Morissey, 313 EADE, Peter, 661 Edwards, St. John, 343 Eichwald, 373 Emmet, 84, 570, 593, 622, 632, 633, 677, 732, 747, 749, 750, 751, 752, 771 Engelmann, 173 Ewart, Dr., 37 FARR, Dr., 114 Farre, Arthur, 32, 207, 246, 27C, 313. 689 Faye, Prof. 276, 641 Fenerly, 511 Ferber, 518. 530 Ferguson, Robert, 216, 218, 241 Fieber, 38f> Fletcher, 212 Fock, Dr., 381 Foil in, 29, 39 Fontaine, 472 Forbes, Gregory, 675, 629, 635 Fox, "Wilson, 284, 289, 292, 341, 716 Frank, 292 Frarier, 487 Fricke, 578 Friedreich, Prof., 310 Friedreichs, 295 Fritze, 329 GIAERTNER, 29 [ Galen. 239 Gallard, 457, 511, 525, 720 Galton, Mr., 11.3 Gardien, 29, 320, 322 Gardner, 211, 571 German, Mr., 523 Gendrin, 27, 170 Gentilhomme, Dr., 673 Gerdy, 685 Gervis, Dr., 344 Gibb, Dr., 759 Gibbes, 297 Gibson, 576 Giles, Mr., 495 Girdwood, 27, 170 Goddard, 402 Gooch, 216, 218, 467, 621,634, 690, 696, 711 Good, Mason, 251 Goodhart, Dr., 284 Goodell, 319, 763 Gosselin, 468 Gouey, 330 Goupil, 302, 313, 490, 493, 494, 511 Graef, 86 Graefe. Prof, 694 Granville, 328 Gray, 295 Greenhalgh, Dr., 228, 310, 676 Grisolle, 500 Gueniot, 630, 667 Guerin, 385, 473, 487, 741 Guersant, 763 Guichard, 473 Gull, 347 Guntz, 328 Gusserow, 715 Guyon, 44, 46, 472, 626 Guzzo, 699 HABIT, Dr , 719 Hakes, Mr. James, 631 Hall, Marshall, 57S Haller, 526 Hamilton,-578 Hannover, 712, 717 Hare, 296, 58.'! Harley, George, SS Harley, John, 688 Harris, Dr., 178 Harvey, 146, 241 Hasselberg, 471, 472 Hassall, 56, 75, 76, 492, 44f,, 642 Hausmann, Dr., 243 Haydon, Dr., 318 Heath, Christopher, 282, 362, 678 ! Hebra, 448 Hecker, 304, 313 Heckford, 704 Hegar, 511, 677 Helie, 52, 528 Henkel, 276 Henle, 23, 64, 374, 446 Hennig, 309, 472. 485 Heming, Dr., 578 Herbiniaux, 629, 683, 712 Herman, Dr., 471 Hermann, 472 Heschl, 688 Heward, Dr., 719 Hewitt, Graily, 588, 592, 598 Heyfelder, 328 Hicks, Braxton, 214, 318, 320 Higginson, 155 Hildebrandt, 670 Hilliard, 750 Hippocrates, 414, 435, 465 His, 22 Hodgkin, 289 Hodgson, Mr.. 95 Keening, 166, 641 Hoffman, 195 Hohl, 560, 587 Holmes, Timothy, 396, 428 Hooper, 332, 335, 642 Hue bard, 244 Huguier, 58, 67, 115, 146, 302, 345, 366, 445, 514, 551,579, 580, 759, 761. 767, 769 Hulke, 295, 636, 758 Hull, 577 Hunter, John, 241, 625, 634, 736 Hunter, Dr. W., 624 Hutchinson, 285, 319, 322, 324, 391,396, 399,421,653, 660, 698 H'uter, 586 Huschke, 45, 64 TNGLEBY, 328 1 Ireland, Dr., 578 TAAP, 519 »J Jardine, 519 Jobert, 349, 475, 752 Jones, Sydney, 391 Jones, Wharton, 306 Joret, 195 Jiingel, 518 T^EITH, 375, 388. 393, 394, IV 400, 653 Keddell, Mr., 519 Keller, 320 INDEX OF AUTHORS. 777 Kemp, AV. G., 637 Kennedy, Emory, 302, 477 Kesteven, AV. B., 172 Kidd, 343, 477, 661, 667, 671, 672 Kiwisch, 133, 273, 278, 285, 292, 300, 309, 314, 319, 322, 325, 378, 381, 689, 721, 742 Klemm, 472 Klob, 202, 208, 306, 307, 344, 641, 656, 686 Kobelt, 28, 64 Koeberle, 317, 319, 321, 322, 360, 398, 676, 677, 680 Kohlrausch, 295 Kblliker, 32, 446 Kiichenmeister, 148 Kundrat, 54, 173 Kunert, 716 Kussmaul, 179, 203, 306, 329 Kiister, E., 660 LAASER, 115 Laborderie, 511 Laboulbene, 528 Lair, 146 Lallemand, 153 Lancereaux, 462, 656, 683, 717 Lane. J. R., 752, 757 Lane, Samuel, 621 Langenbeck, 623 Lapeyronie, 730 Larcher, 327, 661, 684 Laugier, 511, 525, 560 Lauvariot, 730 Laycock, 127, 173, 189 Lazzari, 730 Leake, 77 Le Beau, 178 Lebert, 294, 374, 642, 703, 712, 717 Ledran, 384 Lee, Dr. C. C , 360 Lee, Dr. C H., 626 Lee, Robert, 170, 480, 692 Leger. 68 Legrand, 383 Leith, 178 Lente, 474 Leroy, 203 Lesouef, 310, 312 Letecuterier, 475 Letheby, 27, 207 Leuret, 262 Levret, 548, 586, 634, 691, 711 Liebmann, 656, 718 Liebreich, 182 Lisfranc, 303, 626, 673, 694, 725, 730 Lister, 389 Litchfield, Mr., 365 Little, Dr., 101, 106 Little, L. S., 101 Lize, 207, 426 Locock, Sir Charles, 694 Logan, 396 Loir, 662 Longet, 59 Lorain, 475 Lb'wenhardt, R., 383 Lucas, 622 Lucas-Championniere, 59 Liiders, 572 Lunier, 197 Luschka, 307, 327, 349, 774 MACCORMAC, 396 McDiarmid, Dr., 178 McDowell, 375 Macdonald, 386 McClintock, 89, 367, 511, 514, 559, 623, 635, 662, 665, 669, 672, 673, 689, 692, 693, 759, 765, 768 Macintosh, 226 Mackenzie, 621, 626 Macleod, 428 Madge, 511, 518, 534, 536 Magrath, 305 Maisonneuve, 67.3 Malgaigne, 385, 510, 639, 689 Malins, 343, 401 Malpighi, 52 Mandl, 175, 248,446 Mann, 754 Marchal, 490 Marjolin, 567 Marotte, 262 Martin, E , 68, 166, 243, 311, 588, 606, 622, 744 Mason, Dr., 182 Maurer, 306 Mayer, C, 444, 445, 457, 689, 698, 712, 715 Mayer, Louis, 178, 404 Maygrier, 36, 303 Meadows, 334, 582 Meckel, 75, 296 Meigs, 626 Meissner, 689 Mery, 68 Miner, J. F., 394, 396 Monro, 52 Monteggia, 730 Montgomery, 241, 689, 694, 720 725 Moore, C. H., 261, 295 Morgagni, 53, 77, 241, 292, 350, 548, 642 Moxon, 289 Muller, H., 207, 291, 306 Murchison, Dr., 347 Murray, of Newcastle, 207 Museux, 769 • NAEGELE, 85 Negrier, 27, 170, 179, 235, 236, 238, 262. 273 Nelaton, 510, 525, 536, 672 Neugebauer, 144, 662 Newman, 720 Nicholson, 123 Nissen. 692 Noeggerath, Emil, 495, 633 Nonat, 511, 514, 689 Nott, J. C, 773, 774 Nunn, Mr., 583 0BRE, 95 0'Byrne, 397 Ogle, 279, 689 Oldham, 203, 214, 226, 241, 306, 336, 642, 645, 686 Olshausen, 511, 515,516, 517, 526 Omodei, 577 Ord, 129 Osiander, 730, 731 PAGELLO, 736 Paget, 281,285,296, 686, 716 Pallen, 207 Paquelin, Dr., 458 Pare, 227 Paris, 487 Parker, Dr., 138, 344 Parkinson, 677 Parrot, 763 Parry, J. S , 319, 323,366 Parvin, 650 Paterson, 170 Payne, Dr., 564 Pean, 677, 678, 680 Peaslee, 230, 335,375, 450, 677 Perroud, 246 Petit, 627 Phillips, J. J., 123 Pinault, 662 Piorry, 236 Playfair, 529 Poppel], 309, 326 Portal, 335 Pott, 171, 267 Pouchet, 27, 175 Power, Dr , 170 Pozzi, 669, 680 Prieger, 669 Priestley, 234, 723 Prichard, 750 Prost, 511, 514 Puech, 207, 511 Puzos, 85 AUEKETT, 770 RACIBORSKI, 27, 170, 171, 245 Radford, 196, 375, 624 Rainey, 35, 58, 115 Ramsbotham, 283, 284, 296, 298, 324, 325, 625, 635, 694 Rasch, A., 89 Raulin, 77 Recamier, 3S5 483, 510, 567, 731, 734 Reid, John, 770 Richard, 30, 32, 292, 349 Richet, 35, 45, 511, 529, 680, 772 Richter, 692 Ricord, 557 Rigby, Dr., 247, 265, 435, 668, 669, 673 Rilliet, 763 Ringland, Dr., 477 Ritchie, 172, 286 Rizzoli, 772 INDEX OF AUTHOR? Roberts, Lloyd, 294, 391, 392, 412 Roberts, 514. 766 Roberton, 179, 559 Robin, 32, 76, 481, 717 Roederer, 85, 171 Rokitansky, 138, 202, 203, 244,268, 271, 278, 280, 281, 286, 295, 296, 306, 326, 339, 343, 344, 436, 583, 5S8, 600, 606, 607, 689,699, 706,712, 716, 722, 767 Romberg, 236 Roper, George, 308, 319, 545, 591 Ross, Sir John, 178 Rouget, 22, 35. 58 Routh, 203, 467, 483, 734, 736 Rupin, Dr., 311 Ruysch, 85, 115, 526, 567 SABINE, 694 Saechi, 385 Sappey, 21, 45, 47, 59, 64, 126 Saunders, Dr , 727 Savage, Dr., 672 Saxinger, 511 Saxtorph, 624 Sayre, 509 Scanzoni, 111, 115, 117, 186, 195, 207, 231,232, 267, 272, 284, 2S8, 318, 379. 424,435, 442, 443, 145, 447, 453, 454, 455, 456, 457,459,470, 510, 528, 565, 580, 655, 663, 669, 689 Schatz, 123 Schmidt, 372 Schnabel, 296 Schoenbein, 195 Schroeder, 166, 178, 463, 530, 631 Schultze, 307 Schutz, 712 Schutzenberger, 236 Scott, Dr , 576 Seaton, Dr., 520 Sedgwick, Dr., 655 Seller, 267 Sevastopalo, 647, 653 Seyfert, 511,534 Sibley, 705 Siebold, 580, 694 Simon, E., 487 Simon, G., 204, 448, 580, 734, 751, 752, 753 Simon, John, 428 Simpson, Professor, 226, 241, 338, 386, 637, 716 Simpson, Sir James, 112, 146, 147, 150, 166, 180, 211, 311, 417, 426, 449, 617, 629, 633. 66S, 673, 694, 737, 746, 767. 771, 772, 773, 774 Sims, Marion, 109, 110, 144, 150, 228, 401, 483,579, 580, 581, 616, 631, 635, 637, 672. 677, 693, 727, 733, 734, 737, 750 Sireday, 525 Skene, Dr , 735 Smellie, 622, 730 Smith, Mr., of Coventry, 179 Smith, Sydney, 389 Smith, Tyler, 53, 57, 75, 76, 82, 184, 243. 307, 318, 338, 429, 631, 637, 744 Soltau, W. F., 345 Southam, Mr., 381 Spiegelberg, 300, 313, 34S, 362 Squire, 194 Squire, Balmanno, 765 Stewart, 522 Stirling, 307 Stocks, 350 Stone, Dr., 72, 233 Stone, Mr., 650 Storer, 393 Sutton, 208, 471 TAIT, Lawson, 166, 631 Tansini, 736 Tarral, 730 Teale, Pridgin, 631 Teallier, 725 Thomas, Gaillard, 148, 211, 283, 372. 474, 576, 592, 633, 634, 638, 756, 757 Thompson, Mr. Charles, 381 Thorburn, 412 Thorman, 315 Thornton, Knowsley, 297, 343, 399 Thudicum, 373 Tiedeman, 404 Tilt, 237, 467, 511 Tissier, 202, 473 Tracy, 581 Troisberg, 730 Trousseau, 181, 194, 385, 492, 511, 763 Tuckwell, 208, 511, 514, 515, 529, 535, 538 Tulpius, 730 Turner, 330, 343, 404, 651 DCELLI, 313 Uhde, 313 Ulrich, 325, 347 Urdy, 677 T7ALLETTE, 636 V Vallieux, 617 A'an Buren. 343 Velpeau, 36, 115, 295, 3H8, 313, 316,319, 322, 510,578, 624, 629, 673, 685, 730 Verneuil, 39, 514, 653, 753 Vignes, 511 Vincent, 573 Virchow, 90, 191, 243, 309, 489, 530, 550, 607, 641, 643, 659, 702, 712, 715, 773 Vogel, 642, 647 Voisin, 511, 514, 530 ATTACKS, 179 \Y AVade, AVilloughby, Wagner, 335 Waldeyer, 23 Wallace, Ellerslie, 319 AValne, 376 Walsham. 284 AValter, 313 Ward, Ogier, 351 Wardell, 123 AVatkins, 318 Weber, 626 Webb, Woodham, 286 AVedl, 770 AVeit, 715 Well?, Spencer, 123, 341, 353, 369, 375 379, 387, 402, 527, 669, 670 West, 129, 132, 442, 511, 577, 581, 625, 626, 631, 706, 715, 716, 717, 759, White, J. P., 631, 640 Whitehead, J., 76, 175, 473, 559, 576 Whitehead, Walter, 411, 426, 582 AVilks, 284, 289, 295, 361, 653 AVilliams, John, 54, 244 Williams, Wynn, 734 Willigk, 313 Willoughby, 697 AVilson, J. G , 179, 530 Wilson, AV. A., 638 Wiltshire, 7.31 AVindsor, 624 Wood, 296, 570 Woodman, 626, 689 ^WANCK, 572, 573 534 347, 392, 534, 669, 769 197, 412, 545 INDEX OF SUBJECTS. The words in small capitals and the figures principally treated of. The rest indicate i ABDOMINAL gestation, 314 Abortion, 72 Abrasion of os after labor, 429 Abscess, pelvic, 497, 508 of breast, 425; of vulva, 761 Acetic acid, in cancer, 734 Acne, 260 Acupuncture in tumors, 671 Adhesions of uterus, 501 Albumen in urine, 131 Amenorrhoea, real and occult, 71 primitive, 190 secondary, 197 from retention, 200 Anatomy of Pelvic Organs, 18 Angioma urethroe, 772 Anteflexion of uterus, 593 Anteversion of uterus, 586 Armamentarium, the gynaecologists', 140 Ascites, 364 Atresia, vaginae, vulvae, uteri, 203 Atrophic contraction of vagina, 745 Axis and movements of uterus, 37 BARNES'S nitrate of silver cautery, 152 intra-uterine positor, 152 speculum, 144 speculum for patient's use, 156 tent introducer, 152 uterine ointment positor, 152 whalebone sound, 147 Bartholini's glands, anatomy, 67 pathology of, 767 Bladder, Disorders of, in Uterine Dis- ease, 121 malignant disease of, 132 Blood in faeces, 139 effusions in pelvis, 511 ; tumors, 511 in urine, 131 Bones in fajces, 139; in urine, 132 Breast, abscess of, 425 Broad Ligament, Diseases of, 340 CANCER, amputation of vaginal-portion in, 733 of bladder, 132 cauliflower form of, 711 corroding ulcer of, 717 course of, 707 crater, 725 definition of, 703 in strong type indicate where the subject is ncidental references to the subjects named. Cancer— degrees of malignancy of, 703 effects of, 718 encephaloid, 707 epitheliomatous, 711 forms of, 705 frequency of, 704 hereditary transmission of, 704 intractable ulceration of, 716 is it contagious, 705 medullary, 707 modes of termination of, 719 myxomatous, 717 of uterus, 703 of vagina, 759 of vulva, 769 prognosis of, 728 sarcomatous, 715 scirrhous, 716 terminations of, 719 treatment of, 736 Cancroid, 711 Catamenia, 170 Catarrh of uterus, 460 ; senile, 484 Cauliflower excrescence of uterus, 711 Cautery in uterine disease, 458, 674, 695, 733, 736 Cautery-clamp, 395 Cellulitis, pelvic, 486 Cervix uteri, injury to in labor, 426 hypertrophic elongation of, 546 lacerations of, 746 varicose ulcers of, 446 Chloro-anaemia, 190 Chlorosis, 190 Cholesterine in ovarian fluids, 373 Clamp, 392 "Climacteric, menstrual irregularities of, 249 disorders of, 251, et seq. Climate, in relation to menstruation, 177 Clitoris, anatomy of, 66 enlargement of, 767 Coccygodynia, 112, 772 Colpitis, 740 Colporraphy, 580 Congestion of uterus, 437 Consanguinity, 113 Constitutional reactions of ovario-uterine dis- orders, 69 Convulsions, significance of, 106 in climacteric, 254 Copraemia, 137 780 INDEX OF SUBJECTS. Corpus luteum, 25 Corroding ulcer of uterus, 717 Cradle-pessary, Graily-Hewitt's, 592 Cryptorchids, 119 Cusco's speculum, 143 Cysts, dermoid, 294 of broad ligaments, 340 of Fallopian tubes, 335 Cystic disease of ovary, 286 Cystitis, 129 Cystocele, 743 DECIDUA, 53 gravida, 245 menstrualis, 242 Decrepitude, disorders of, 257 Deodorants and disinfectants, 738 Dermoid cysts of ovary, 294 Diagnosis of pelvic disease, 157 instruments for, 140 Dilatation of uterus, 99; by incision, 228 Discharges, uterine and vaginal, 73 fleshy, 95 gaseous, 88 hemorrhagic, 91 membranous, 95 mucous, 75 purulent, 90 ■watery, 85 Displacements of the uterus, 539, 583 of the vagina, 743 Douglas's pouch, its anatomy, 37 things that may get into it, 516 Dropsy of Fallopian tube, 335 of ovary, see Cystic Disease of, 287; of peritoneum, 364 Dyschezia, 13S Dysmenorrhoea, 72, 215 essential cause of, 72 ; from retention, 221; from obstructed excretion, 223 inflammatory, 240 membranacea, 241 neuralgic, 215 ovarian, 233 tubal, 240 Dysootocia, 233 Dyspareunia, 72, 107 Dysuria, significance of, 131 ELECTRICITY in ectopic gestation, 310 ovarian tumors, 386 tumors, 671 Enchondromatous tumors of ovary, 293 Endermoptosis, 767 Endoeatarrh, 460 Endometritis, 460 acute, 463 catarrhal, 463 chronic, 463 cystic, 464 Endoscope, 146 Enucleation of tumors, ovarian, 396; of fibroids, 673 Epilepsy, 106, 261 Ergot and ergotine, 670 Examination, conditions indicating local, 69 modes of, manual and instrumental, 161 F^CES, blood in, 139 bone? in, 1.39 fcetal elements in, 139 hair in, 139 mucus in, 139 pus in, 139 retention of, 136 Fallopian tubes, anatomy of, 29 nbsence of, 331 cancer of, 340 dilatation of, 333 dropsy of, 335 fibroma of, 338 inflammation of, 331 tubercle of, 339 Fat in urine, 132 Fergusson's speculum, 143 Fibro-cystic tumors of uterus, 652 Fibroids, fibroma, fibro-myoma of uterus, 641 development and decay of, 655 diagnosis of, 664 effects of, 658 extrusion of, 649 growth of, 645 progress of, 648 structure of, 642 treatment of, 667 Fibroma of the ovary, 283 Fibrous tumors of vagina, 758 Fissure of the anus, 136 Fistula vaginae, 744 Flexions of uterus, 584 Flexion of uterus and ovaries, 432 Folliculitis, vulvar, 766 Function, disorder of, 68 Function of uterus, ovaries, and vagina, dis- turbance of, 71 GASEOUS discharges, 88 Gestation, abdominal, 314 Ectopic, or extra-uterine, 300 hernial, 330 interstitial, 325 one-horned uterine, 327 ovarian, 313 ; tubal, 300 Gonorrhoeal infection, 462, 741 guminata, 768 "latent," 495 peritonitis, 495 Gynaecologists' armamentarium, 140 H^IMATEMESIS, 181 Hematocele, pelvic, 510 contents of, 518 Haemotoma of vulva, 762 Haemotometra, 205 Haemoptysis, 181 Haemostatics, 98 Haemorrhagic discharges, 91 Hemorrhages, classification of, 94 active, passive, 98 Hemorrhoids, 134 Hair in faeces, 139 in dermoid cysts, 298 in urine, 132 Headache, uterine, 450 Heredity, 113 Hernial gestation, 330 Hernia of vagina, 743 INDEX OF SUBJECTS. 781 Higginson's syringe, 155 Hodge's pessary, 573 Hydrorrhoea, gravidarum, 85 Hymen, imperforate, 200, 212 Hyperaemia of uterus, 435 Hypertrophic elongation of cervix uteri, 545, 556 Hysteria, 107, 236 Hysterocele, 579 Hysterophores, 571 Hysterotomy, 675 IDIOCY and menstruation, 197 Illumination, in use of speculum, 167 Imperforate hymen, 212 Incontinence of urine, 131; of faeces, 136 Inflammation of ovary, 271 of uterus, 441 ; of vagina, 740 Inguinal pain, 102 Injections, intra-uterine, 471 danger of, 475 of ergotine, 670 Injury to cervix in labor, 426 Instruments of diagnosis, 141 for topical medication, 152 Intramural gestation, 325 Intra-peritoneal haematocele, 515 Intra-uterine caustic carrier, 152 injecting apparatus, 153 medication, 471 positors, 153 Inversion of the uterus, 620 Irritable ovary, 103 Irritable uterus, 103, 222 Ischuria, 127 "J7UCHENMEISTER'S metrotome, 149 LABOR, effects of on uterus, 415 Laceration of cervix uteri, 746 Laceration of perineum, 754 Lactation, effects of on uterus, 415 Laminaria tent carrier, 151 Laparotomy, for ectopic gestation, 323 for ovariotomy, 386 for removal of uterus, 677 Leeching, 439 Leptothryx, 76 Leiicorrikea, 77; significance of, 77 cervical, 80 uterine, 80 vaginal, 80 in children, 81, 866 Ligaments of uterus, anatomy, 33, 34, 35, 36 broad, disease of, 340 Lithiasis, 255 Lumbo-dorsal pain, 102 MANIA, 188 Mastodynia, 104 Materia Medica, the gynaecologists', 142 Meatus urinarius, epithelioma of, 772 excrescence of, 770 ; caruncle of, 770 small mucous polypi of, 772 Medullary cancer of uterus, 707 Melanosis vaginae, 770 Menorrhagia, 71 Menstrual blood, its source, 176 ; quantity of, 176 discharge, its characters, 175 flow, retention of, 201 haematocele, 527 Menstruation, 170 arrested, 197 disappearance of, 179 disordered, 190 during gestation and lactation, 185 influence of on the milk, 185 occult, 202 precocious, 178; protracted, 180 relation to various diseases, 258 suppressed, 197 suspended, 184 vicarious or ectopic, 181 Mental disorder, 107, 187 Metritis, 442 curability of, 452 diagnosis of, 450 influence of on pregnancy, 453 treatment of, 454 Metorrhagia, 254 Metrotome, Kiichenmeister's, *149 Simpson's, 150 Mimetic neuroses, 255 Mucous discharges, 75 Myxoma of uterus, 717 NERVOUS phenomena, 102, 261 ; nervous disorders of climacteric, 254 Nervous symptoms of metritis, 448 ; of retro- version of uterus, 608 Neuralgia, 103 Neuromata of vulva, 767 Neuroses, 106 Nipples, bleeding from, 182 OMENTUM, tumors of, 361 One-horned uterine gestation, 327 Oophoria, 238 Oophoritis, 271 Ovarian and ascitic dropsies, differentiation of, 365 cystic disease, treatment of, 375 disease, incision of the cyst in, 384 injection of fluids into cyst of, 382 medicinal treatment of, 376 tapping in, 379 temperament, 235 "Ovarian cell," 372 fluids, 372 gestation, 313 tumors, 286, 342 adhesions of with bladder and bowel, 347 bursting of, 345 course of, 342 diagnosis of, 351 exploratory incision for, 371 gangrene of, 343 hemorrhage from, 347 menstruation of, 353 microscopical examination of fluid con- tents of, 371 palpation of, 353 percussion of, 355 782 INDEX OF SUBJECTS Ovarian tumors— perforation of, 348 spontaneous resorption of, 344 with pregnancy, 358 Ovaries, pathology of, 170 relation of to menstruation, 171 Ovariotomy, 375, 386 adhesions in, 396 after-treatment in, 397 by the vagina, 403 cautery in, 393 cleansing the abdomen in, 393 closing abdominal wound in, 394 complications in, 395 drainage in, 394 dressing in, 395 enucleation in, 396 hemorrhage after, 398 historical note of, 375 instruments in, 389 ligature of pedicle in, 393 mode of operating in, 386 normal, 403 pedicle, treatment of, 391 peritonitis after, 398 preliminary preparations, 389 septicaemia after, 399 with pregnancy, 401 wounds of intestine in, 397 Ovary, anatomy of, 19 ; abscess of, 276 absence of, 264 adhesions of, 267 cancer of, 279 cystic disease of, 286 ; terminations of, 342; diagnosis of, 351 dermoid cysts of, cutaneous or piliferous, 295 displacements of, 265 enchondroma of, 285 fibroid tumor of, 270 fibroma of, 283 hernia of, 267 inflammation of, 271 irritable. 103 pathology of, 170 prolapsus of, 265 tubercle of, 278 Oviducts, 29 Ovula Nabothi, 56, 461 PAIN, significance of, 102; varieties of, 102, et seq. Paramenia, 189 Parametritis, 486, 489 Paraplegia, 106 Parovarium, anatomy of, 28 Pelvic, abscess, 496 cellulitis, 486 disease, the diagnosis of, 157 inflammation, 503 organs, anatomy of, 17 peritonitis, 495 Perimetric haematocele, 510 Perimetritis, 487, 495 Perineum, lacerations of, 754 operations for, 755 Periodicity, 177 Perityphlitis, 506 Pessaries, description of, 569 intrauterine, 617 Phlebolithes of broad ligament, 341 Phlegmasia dolens in cancer, 735 Phthisis uteri, 698 Physo-haematoroetra, 207 Pigmentation during menstruation, 188 during metritis, 448 Placenta, fatty degeneration of, 689 Placental polypus, 689 Polypus uteri, 681 crushing of, 694 definition of, 6bl excision of by scissors, 693 fibrinous, 689 fibroid, or myomatous, 684 glandular or mucous, 686 hypertrophic, 550, 553, 688 operations for, 694 placental, 689 slow strangulation of, 692 symptoms of, 685 torsion of, 693 treatment of, 691 varieties of, 682 vascular, 689 Precocious menstruation, 178 Pregnancy, diagnosis of, normal, 351 ectopic, or extra-uterine, see " Gesta- tion." false or spurious, 251 Procidentia uteri, 541 treatment of, 567 Prolapsus uteri, 541 treatment of, 577 vaginae, 743 Pruritus pudendorum, 415, 450 vaginae, 764 Pseudocyesis, 251 Purulent discharges, 90 Pus in urine, 132 RACE in relation to menstruation, 177 Rectal touch, the, 162 Rectum, obstruction of, by ovarian tumor 344 symptoms in uterine disease, 134 Recto-vaginal fistula. 753 Reflex nervous phenomena, 106 Retention of faeces, 136 of urine, 121 of menstrual fluid, 199 Retroflexion of uterus, 605 Retrouterine haematocele, 570 tuinor3, 515 Retroversion of uterus, 599 SALPINGITIS, 333 Sarcoma uteri, 715 Scarification of uterus, 440 Scirrhus of uterus, 716 Scott's pessary, 576 Senile uterine catarrh, 484 Senility, disorders of, 257 Simpson's metrotome, 150 sound, 147 Sims's speculum, 145 tenaculum hook. 150 Sound, the use of, 164 the uterine, 146 accidents from, 166 INDEX OF SUBJECTS. ~g'S Speculum, the, 143; the tubular, 167 Barnes's, 145; introduction of, 169 Cuzco's, 143 Fergusson's, 144 Sims's, 144; introduction of, 168 Spermatozoa, 116 Sphygmograph, in menstruation, 174 Spinal irritation, 102 Sponge tent carrier, 152 Stem and cup pessary, 575 Stenosis of uterus, 526 Sterility, 112, 232 Subjective signs, the indications from, 70 Syphilitic leucorrhoea, 78; condylomata, 768 Syringe, Higginson's, 155 mACTUS eruditus, 160 I Tapping in ovarian disease, 388 Teeth in faeces, 139 dermoid cysts, 296 Tenaculum hook, Sims's, 150 Thrombus, 513 Thrombosis in cancer, 735 Touch, the, 160 Trichomonas, vaginalis, 76 Tubes, see " Fallopian." Tubal catarrh, 332 gestation, 300 Tubercle of the Fallopian tube, 339 of the ovary, 278 of uterus, 698 Tubo-ovarian cysts, 292 gestation, 314 Tumors, fibroid or muscular, 641 ; fibro- cystic, 652 ; retro-uterine, 515 ; peri- uterine, 510 ovarian, 342 ; vaginal, 758 ; blood or haematic, 510 uterine, 640 of broad ligaments, 340 IjLCERATIVE processes of os uteri, 460 I Urethra, vascular tumor, excrescence, caruncle of, 770 Urine, abnormal matters in, 131 incontinence of, 131 retention of, 121 Uterine catarrh, 460 senile catarrh, 484 headache, 450 cavity, obliteration of, i 12 pathology, general observations on, 413 Uterus, anatomy of, 33 abnormal shapes of, 413 absence of, 203 amputation of, 634 atresia of, 203 atrophy of, 410 axis of, 37 bicornis, 406 bipartitus, 407 cancer of, 703 ; see " Cancer." catarrh of, 460 congestion of, 436 corroding ulcer of, 717 dimensions, measurements of, 45 Displacements of, 539 fluxion of, 432 hyperaemia of, 435 Displacements of— hypertrophy of, 408, 545 Inflammation- of, 441 Involution impeded, 416 movements of, 37 polypus of, 681 procidentia of, 542 prolapsus of, 541 senile, 42 shape of, 40 special pathology of, 403 stenosis of, 412 subinvolution of, 46 superinvolution of, 426 tubercle of, 698 tumors of, 640 ulceration of, 427 unicornis, 404 weight of, 40 AGINA, absence of, 202 anatomy of, 60 atresia of, 202; by cicatrix, 745 atrophic contraction of, 745 calculi of, 759 cancer of, 759 cicatrix of, 746 cystic tumors of, 758 dilatation of fundus of, 744 diseases of, 740 displacements of, 743 exfoliation of its mucous membrane, 245 fibrous tumors of, 758; fissures of, 772 fistula of, 744 haematoma of, 759 hernia of, 743 prolapse of, 743 sarcomata of, 759 sloughing of, 745 syphilitic disease of, 745 tubercle of, 745 tumors of, fibrous and cystic, 75S wounds of, 744 Vaginal injections, danger of, 475 touch, the, 160 Vaginal-portion, the, 41 elongation of, 547 hypertrophy of, 547 Vaginismus, 107 Vaginitis, 740 ; gonorrhoeal, 741; diphtheri- tic, 743 Varicose ulcers of cervix uteri, 446 Versions of the uterus, 584 Vesieo-vaginal fistula, 748 Vicarious menstruation, 181 Vomiting, 106 Vulva, abscesses of, 761 Vulva, anatomy of, 65 atresia of, 202 cancer of. 763, cysts of, 768 Diseases of, 761 eczema of, 765 esthiomenus of, 769 gangrene of, 763 hemorrhages of, 763 haematoma of, 763 hypertrophy of, 767 inflammation of, 761 lupus of, 769 784 INDEX OF SUBJECTS Vulva— melanosis of, 770 neuromata of, 767 pruritus of, 764 rodent ulcer of, 769 sloughs of, 763 syphilis of, 769 teleangiectasis of labia majora, 767 ulceration of, 763 vascular growths of, 767 varicosity of, 763 warts of, 768 Vulvar folliculitis, 765 Vulvitis, 761 , Vulvo-vaginal glands, inflammation of, aillard Thomas, M.D., Prof. Obstetrics. Sec. Coll. Phvs. and Surg., N. Y. J. M. DaCosta, M.D., Prof. Prin. and Prac. of Med., Jeff. Med. Coll., Philada. Roberts Bartiioi.ow, M.D.. Prof. Theory and Practice of Med., Med. Coll. of Ohio. T. G. Richardson, M P., Prof. Genl. and Clin. Surg., Univ. of La., New Orleans. William Coodell. M.D.. Prof. Clin. Gynaecology, Univ. of Penua. Fordyce Barker. M.I)., Prof. Clin. Midwifery, &c. Bellevue Hosp. Med. Coll , N.Y. N. S. Davis, M.I)., Prof. Prin and Prac. of Med.. Chicago Med. Coll. L. A. Duhring, M.D., Clin. Prof, of Diseases of the Skin, Univ. of Penna. Theophilus Parvin M.D.. Prof Obstetrics.&c. Coll. Phys.and Surg., Indianapolis. Lewis A. Sayre, M.D.. Prof. Orthopaedic Surg., &c. Bellevue Hosp. Med Coll., N Y. W. H. Van Buren. M.D.. Prof. Surgery. Bellevue Hosp. Med. Coll., N Y. J. P. White, M D.. Prof, of Obstetrics. &c, Univ. of Buffalo. John Ashhurst, Jr., M t)., Prof, of Clin. Surg., Univ. of Penna. D. Warren Brickkll. M.D., Prof. Obstetrics, &c, Charity Hosp. Med Coll., N. 0. William Pepper, M.D.. Prof. Clin. Medicine. Univ. of Penna. J. Lewis Smith, M.D., Clin. Lee. on Dis. of Chil., Bellevue Hosp. Med. Coll., N. Y. William F. Norris, M.D., Clin. Prof, of Diseases of the Kye. Univ. of Penna. P. S. Conner, M.D., Prof, of Anat. and Clin. Surgery, Med. Coll. of Ohio, Cin. Thomas G. Morton, M.D., Surgeon to Penna. Hospital, Philada. F. J. Bumstead, M.D., late Prof, of Venereal Dis., Coll. Phys. and Surg., N. Y. J. H. Hutchinson, M.D., Physician to Penna. Hospital. F. Peyrk Porcher, M.I) . Prof, of Mat. Med. and Cliu. Medicine, Med. Coll. of S.C. Christopher Johnson, M.D., Prof, of Surgery, Univ. of Md., Baltimore. S W. Gross. M.D.. Surg, to Philada. Hospital. William Thomson, M.D., Lecturer on Ophthalmology, Jeff. Med. Coll., Philada. With contributors such as these, representing every portion of the United States, the publisher feels safe in promising to the subscriber a series of practical lectures unsurpassed in variety, interest, and value. As stated above, the subscription ,.>rice of the " Medical News and Library" is One Dollar per annum in advance; and it is furnished without charge to all advance- paying subscribers to the "American Journal of the Medical Sciences." III. THE MONTHLY ABSTRACT OF MEDICAL SCIENCE is issued on the first of every month, each number containing forty-eight large octavo pages, thus furnishing in the course of the year about six hundred pages. The aim of the " Abstract*' is to present—without duplicating the matter in the "Journal" and ' News"—a careful condensation of all that is new and important in the medical journalism of. the world, and all the prominent professional periodicals of both hemi- spheres are at the disposal of the Editors. To show the manner in which this plan has been carried out it is sufficient to state that during the year 1877 it contained— 3'J Articles on Anatomy and Physiology. />'* " " Materia' Mediea arid Therapeutics. 1!U; " " Medicine 149 " " Surgery. Sfi <■• » Midwifery and Gynaecology. U " " Medical Jurisprudence and Toxicology— making in all .")'27 articles in a single year. The subscription to the " Monthly Abstract," free of postage, is Two Dollars and a Half a»year, in advance. As stated above, however, it will be supplied in conjunction with the "American Journal of the Medical Sciences" and the "Medical News and Library," making in all about Twenty-one Hundred pages per annum, the whole free of postage, for Six Dollars a year, in advance. In this effort to bring so large an amount of practical information within the reach of every member of the profession, the publisher confidently anticipates the friendly 4 Henry C. 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Any gentleman who will remit the amount for two subscriptions for 187ri, one of which must be for a new subscriber, will receive as a premium, free by mail, a copy of " Browne on the Use of the Ophthalmoscope" (for advertisement of which see p. 2'.i), or of "Fox on Skin Diseases" (see p. 20), or of "Flint's Essays on Conserva- tive Medicine" (see p. 15), or of "Sturges's ClinicalvMedicine" (see p. 14), or of the new edition of "Swayne's Obstetric Aphorisms" (see p. 22), or of "Tanner's Clinical Manual" (see p. 5), or of "Chambers's Restorative Medicine" (see p. 18), or of " West on Nervous Disorders of Children" (see p. 21]. %* Centlemen desiring to avail themselves of the advantages thus offered will do well to forward their subscriptions at an early day, in order to insure the receipt of complete sets for the year 1878. Ig^T The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned. AVhere these are not accessible, remittances for the "Journal" may be made at the risk of the publisher, by forwarding in registered letters. Address, HENRY C. LEA. Nos. 706 and 708 Sansom St., Philadelphia, Pa. T\UNGLISON (ROBLEY), M.D., "^ Late Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary of Medical Science: Con- taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae fir Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology cf the Terms, and the French and other Synonymes; so as to constitute a French as well as English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- ified and Augmented. By Richard J. Dunglison, M.D. In one very large and hand- some royal octavo volume of over 1100 pages. Cloth, $6 50 ; leather, raised bandB, $7 50. {Just Issued.) 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 which has existed for the work has enabled him, in repeated revisions, to augment its completeness and usefulness, until at length it has attained the positicn of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en- viable reputation. During the tf n years which have elapsed since the last revision, the additiors to the nomenclature of the medical sciences have been greater than perhaps in any similar period of the past, and up to the time of his death the author labored assiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor has been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention has been bestowed on the accentuation, which will be found marked on every word. The typographical arrangement has been much improved, rendering reference much more easy, and evary care has been taken with the mechanical execution. The ■work has been printed on new type, small but exceedingly clear, with an enlarged page, so that the additions have been incorporated with an increase of but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. A book well known to our readers, and of which every American ought to be proud. When the learned author of the work passed away, probably all of us feared lest the book should not maintain its place in the advancing science whose terms it defines. For- tunately, Dr. Richard J. Dunglison, having assisted his father in the revision of several editions of the work. and havingbeen, therefore, trained in the methods aDd imbued with the spirit of the book, has been able to edit it, not in the patchwork manner so dear to the heart of book editors, so repulsive to the taste of intel- ligent book readers, but to edit it as a work of the kind should be edited—to carry it on steadily, without jar or interruption, along the grooves of thought it has travelled during its lifetime. To show the magnitude of the task which Dr. Dunglison has assumed and car- ried through, it is only necessary to state that more than six thousand new subjects have been added in the present edition.—Phila. Mtd. Times, Jan. 3,1874. A bout the first book purchased by the medical stu- dent is the Medical Dictionary. The lexicon explana- tory of technical terms is simply a sine qua non. In a tcience so extensive, and with such collaterals as medi- jine, it is as much a necessity also to the practising physician. To meet the wants of students and most physicians, the dictionary must be condensed while somprehensivc, and practical while perspicacious. Jt was because Dunglison's met these indications that it became at once the dictionary of general use wherever medicine was studied in the English languaee. In no former revision have the alterations and additions been 30 great. More than six thousand new subjects and terms nave been added. The chief terms have been set in black letter, while the derivatives follow in small caps; an arrangement which greatly facilitates reference. We may safely confirm the hope ventured by the editor " that the work, which possesses for him a filial as well as an individual interest, will be found worthy a con- tinuance of the poj-ition so long accorded to it as a tandard authority."— Cincinnati Clinic, Jan. 10, 1874. It has the rare merit that it certainly has no riTal in the English language for accuracy and extent oi' references.—London Medical Gazette. Henry C. Lea's Publications—(Manuals). 5 A CENTURY OF AMEHirAX MEDirrXE. 177(1-1876. By Doctors E. H. -/1- Clarke, H J. Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one very hand- some 12mo. volume of about 350 pages : cloth, 82 25. (Just Ready.) ThiF work has appeared in the pages of the American Journal of Medical Sciences during the year 1X76. As a detailed account of the development of medical science in America, by gentle- men of the highest authority in their respective departments, the profession will no doubt wel- come it in a form adapted for preservation and reference. TJOBLYN (RICHARD D.), M.D R A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, M. D., Editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume of over 500 double-columned pages; cloth, $1 50 ; leather, $2 00. It U th» best book of definitions we have, and ought always to be upon the itudent'* table.—Southern M-'t. and Surg. Journal. OD WELL (G. F.), F.R.A.S.. §•«. A DICTJONARY OF SCIENCE: Comprising Astronomy, Chem- istry, Dynamics, Electricity, Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, Mechanics, Meteorology, Pneumatics, Sound, and Statics. Preceded by an Essay on the History of the Physical Sciences. In one handsome octavo volume of 694 pages, and mnny illustrations: cloth, $5. KTEILL (JOHN), M.D., and &MITH (FRANCIS G.), M.D., "*■ Prof, of the Institutes of Medicine in the Univ. of Penna. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with 374 wood cuts, cloth, $4; strongly bound in leather, with raised bands, $4 75. H ARTSHORNE (HENRY), M. D., Professor of Hygiene in the Un imrsity of Pennsylvania. A CONSPECTUS OF THE MEDICAL SCIENCES; containing Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, Surgery, and Obstetrics. Second Edition, thoroughly revised and improved. In one large royal 12tno. volume of more than 1000 closely printed pages, with 477 illustrations on wood. Cloth, $4 25 ; leather, $5 00. (Lately Issued.) ients, but to many others who may desire to refresh their memories with the smallest possible expendi- ture of time.—.V. T. Med. Journal, Sept. 1874. The student will find this the most convenient and useful book of the kind on which he can lay his hand.—Pacific Me.d. and Surg. Journ., Aug. 1S74. This is the best book of its kind that we have ever examined. It is an honest, accurate, and concise compend of medical sciences, as fairly as possible representing their present condition. The changes and the additions have been so judicious and thorough as to render it, so far as it goes, entirely trustworthy. [f students mast have a conspectus, they will he wise We can say with the strictest truth that it is the best work of the kind with which we are acquainted It embodies ina condensed form all recent contribu- tions to practical medicine, and is therefore useful to every busy practitioner throughout our country, besides being admirably adapted to the use of stu- dents of medicine. The book is faithfully and ably executed.—Charleston Med. Journ., April, 1S7.5 The work is intended as an aid to the medical stu- dent, and as such appears to admirably fulfil its ob- ject by its excellent arrangement, thefullcompilatiou of facts, the perspicuity and terseness of language, and the clear and instructive illustrations in some parts of the work —American Journ. of Pharmacy, l'hiladelphia, July, 1S74. The volume will be found useful, not only to stu- to procure that of Dr Hartshorne.—Detroit Rev. of Med. and Pkarm., Aug. 1874. J UDLOW (J.L.), M.D. A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised and greatly extended and enlarged. With 370 illustrations. In one handsome royal 12tno. volume of 816 large pages, cloth, $3 25 ; leather, $3 75. The arrangement of this volume in the form of question and answer renders it especially suit- able for the office examination of students, and for those preparing for graduation. fANNER (THOMAS HA WKES), 31. D.. £c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- NOSIS. Third American from the Second London Edition. Revised and Enlarged by Til3ury Fox, M. D., Physician to the Skin Department in University College Hospital, tfec. In one neat volume small 12mo., of about 375 pages, cloth, $150. *** On page 4, it will be seen that this work is >ffered as a premium for procuring new subscribers to the "American Journal op the Medical Sciences." > Henry C. Lea's Publications—(Anatomy). QRA Y (HENRY), F. R. S., Lecturer on Anatomy at St. George's Hospital, London. ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by H. V. Carter, M.D.,and Dr. Westmacott. The Dissectionsjointly by the Author and Dr. Carter. With an Introduction on General Anatomy and Development by T. Holmes, M.A., Surgeon to St. George's Hospital. A new American, from the eighth enlargec and improved London edition. To which is added " Landmarks, Medical and Surgical," by Luther Holden, F.R.C.S., author of " Human Osteology," " A Manual of Dissections," etc. In one magnificent imperial octavo volume of nearly 1070 pages, with 522 large and elaborate engravings on wood. (Nearly Ready.) The author has endeavored in this work to cover a more extended range of gubjeots than is cus- tomary in the ordinary textbooks, by giving not only the details necessary for the student, but also the application of those details in the practice of medicine and surgery, thus rendering it both a guide for the learner, and an admirable work of reference for the active practitioner. The en- gravings form a special feature in the work, many of them being the siise of nature, nearly all original, and having the names of the various parts printed on the body of the cut, in place of figures of reference, with descriptions at the foot. They thus form a complete and splendid series, which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, with a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of essential use to all physicians who receive students in their offices, relieving both preceptor and pupil of much labor in laying the groundwork of a thorough medical education. Since the appearance of the last American Edition, the work has received three revisions at the hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed requisite to maintain its reputation as a complete and authoritative standard text-book and work of reference. Still further to increase its usefulness, there has been appended to it the recent work by the distinguished anatomist, Mr. Luther Holden—"Landmarks. Medical nnd Surgical" —which gives in a clear, condensed, and systematic way, all the information by which the prac- titioner can determine from the external surface of the body the position of internal parts. Thus complete, the work, it is believed, will furnish all the assistance that can be rendered by type and illustration in anatomical study. No pains have been spared in the typographical execution of the volume, which will be found in all respects superior to former issues. Notwithstanding the increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, at a price rendering it one of the cheapest works ever offered to the American profession. Also for sale separate— TTOLDEN (LUTHER), F.R.C.S., Surgeon to St. Bartholomew's and the Foundling Hospitals. LANDMARKS, MEDICAL AND SURGICAL. From the 2d London Ed. In one handsome volume, royal 12mo., of 128 pages : cloth, 88 cents. {Now Ready.) The title of this book is very suggestive of its ' radical value, while the perusal of the work itself Verifies the most extravagant expectations. The object of the author has been to collect in compact form the landmarks, or surface-marks of the different parts of the body, and indicate their relation to the deeper-seated parts. The value of this sortof know- ledge to the physician, but especially to the surgeon who, with anatomical eye, can make the tissues transparent before him, is incalculable. The map- ping out of the human body is one which is most in- structive to the practical man, and he is enabled, after considerable experience, to have landmarks of his own; but in the little work before us this knowledge is systematized in such an intelligible manner as to place it within the reach of all. It is one of the most interesting little works we have seen for a long time.—S. T. Med. Record, May 11, 1878. Of all the recent new works published we have no hesitancy in declaring this by far the most valu- able to every practitioner. The author his here given a series of landmarks that will enable one to locate with certainty, by means of external appear- ances, nearly every important part practically con- sidered in the body. We would advise every practi- tioner to procure a copy, and keep it always by him. —Nashville Journ. if Mid.and Sv.rg.YeX>. 1S78. This little work is a most valuable collection of plain, simple, and practical hints; it contains in- struction which will be invaluable to the busyprac- titioner as well as to the student of medicine, and we heartily commend it to our readers. — Canada Med. and Surg. Journ., April, 1S78. UMITH (HENRYH.), M.D., and JJORNER ( WILLIAM E.), M.D., Prof, of Surgery in the Univ. of Penna., Ac. Late Prof, of Anatomy in the Univ. of Penna., A e AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, cloth, with about six hundred and fifty beautiful figures. $4 50. The plan of this Atlas, which renders it so pecu-1 the kind that has yet appeared ; and we must add liarly convenient for the student, and its superb ar-1 the very beautiful manner in which it iB "got up ''' tistical execution, have been already pointed out. We ! is so creditable to the country as to be nattering to must congratulate the student upon the completion our national pride.—American Medical Journal of this Atlas, as it is the most convenient work of I HORNER'SSPECIAL ANATOMY AND HISTOLOGY. iSHARPEY AND QUAIN'S HUMAN ANATOMY He- Eighth edition, extensively revised and modified. vised, with Notes and Additions,by Joseph Leidt In 2 vols. 8vo., of over 1000 pages, with 320 wood- M. D., Professor of Anatomy in the University of cuts : cloth, $6 00 , Pennsylvania. Complete in two large octavo vol- HODGE3' PRACTICAL DISSECTIONS. Second1 umes. of about 1300 pages, with 511 illustrations; Edition, thoroughly revised. In one neat royal I cloth, $6 00. 12mo.volume, half bound,$2 00. i Henry C. Lea's Publications—(Anatomy). 7 W A LLEN (HARRISON. M.D.), •*-*■ Professor of Cowparutivr Anatomy and Physiology in the Univ. of Pa. A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL and Surgical Relations. For the Use of Practitioners and Students of Medicine. With an Introductory Chapter on Histology. By E. 0. Shakespeare, M D, Ophthalmologist to the Phila. Hosp. In one large and handsome quarto volume, with several hundred original illustrations on lithographic plates, and numerous wood-cuts in the test. (Preparing.) In this elaborate work, which has been in active preparation for several years, the author has sought to give, not only the details of descriptive anatomy in a clear and condensed form, but also the practical applications of the science to medicine and surgery. The work thus has claims upon the attention of the general practitioner, as well as of the student, enabling him not only to re- fresh his recollections of the ditsec.ing room, but also to recognize the significance of all varia- tions from normal conditions The marked utility of the object thus sought by the author is self-evident, and his long experience and assiduous devotion to its thorough development are a sufficient guarantee of the manner in which his aims have been carried out. No pains have been spared with the illustrations. Those of normal anatomy are from original dissections, drawn on stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure, after the manner of "Holden" and "Gray" and in every typographical detail it will be the effort of the publisher to render the volume worthy of the very distinguished position which is anticipated lor it. ILSON (ERASMUS), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 large pages ; cloth, $4 ; leather $5. TJEATH (CHRISTOPHER), F. R. C. S., &■■*- Teacher of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. W. Keen M. DM Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia In one handsome royal 12mo. volume of 578 pages, with 247 illustrations. Cloth $3 5fj • leather, $4 00. ' ' "In presenting this American edition if Heath's ■ f.ndeed, we do not hesitate to say, the best of its clas' eractica) Anatomy,' I feel that I have leen In- vith which we are acquainted; resembling Wilson Ptrumental in supplying a want long felt for a\ n terse and clear description, excelling most of the real dissector's manual," and this assertion of its s i-called practical anatomical dissectors in the scone elitor we deem is fully justified, after an examina- of the subject and practical selected matter tion of its contents, for it is really an excellent work. ] — St. Louis Med. and Surg. Journal, Mar. 10 1871 -DELLAMY(E.), F.R.C.S. THE STUDENT'S GUIDE TO SURGICAL ANATOMY: A Text- Book for Students preparing for their Pass Examination. With engravings on wood Ie one handsome royal 12mo. volume. Cloth, $2 25. (Lately Published.) We welcome Mr. Bellamy's work, as a contribu- I clear and concise style, and its practical suggestions tion to the study of regional anatomy, of equal value idd largely to the interest attaching to its technical to the student and the surgeon. It is written in a | details — Chicago Med. Examiner /March 1 lb~i HLELAND (JOHN), M.D., ^ Professor of Anatomy and Physiology in Queen's College, Galway. A DIRECTORY FOR THE DISSECTION OF THE HUMAN BODY. In one small volume, royal 12mo. of 182 pages : cloth, $1 25. (Just Issued.) This is a plain, convenient, dissecting guide, to be I in coranuo use, but merely supplements them and used over the subject. As such, it will commend it I prepares the dissector for many practical difficulties self to the student by the lucid composition and dis- j that are apt to perplex the inexperienced It is of a tinct directions of the author. — Med. and. Surg, con venientsize for carrying in the pocket, and should Reporter, Feb. 1877. he in the possession of every student of medicine - This volume does not interfere with the text-books I *• r- Med- ^urn., March, 1877. S CHAFER (ED WARD ALBERT), M.D., Assistant Profetsor of Physiology in University College, London. A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with numerous illustrations: cloth, $2 00. (Just Issued.) We are very much pleased with the book, which teaches the student simply how to use his instruments and conduct his studies without going further into the microscopic anatomy of the tissues and organs than is absolutely necessary. What we particularly praise in it is the way in which it takes the student by the hand, as it were, showing him what to do, aud explaining simply, but thoroughly, how to do it.—Bust n Med. and Surg. Journ., April, li>77. As a whole, the book is an admirable one. The descriptions are brief, but they are clear and detail- ed. The author has learned the art of stopping when he has said his say. The book has also the still more uncommon merit of bearing everywhere the impress of the author's own thought. There is no such thing in the book as a condensation of a chan- ter, or section or paragraph from any one else. Even when describing some of the commonest processes ha shows, such a practical familiarity with the details as to give liis description the flavor of originality In conclusion, we can confidently recoimiend the work as the most useful manual for the practical histolo gist with which we are acquainted.—Chicago Mtd Journ. and Exam., Sept. 1S77. ■««<*. 8 Henry C. Lea's Publications—(Physiology). riARP ENTER (WILLIAM B.), M.D., F.R. S.„F.G.S.. F.L.S., ^ Registrar to University of London, etc PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by Henry Powfr, M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. A new American from the Eighth Revised and Enlarged English Edition, with JSoUs and Addi- tions, by Francis (J. Smith, M. D., Professor of the Institutes of Medicine in the Univer- sity of Pennsylvania, etc. In one very large and handsome octavo volume, ot 1On:J pages, with t* opiates and 373 engravings on wood; cloth,$5 50; leather, $6 50. (Jnst Issued.) The great work, the crowning labor of the distinguished author, and through which so many generations of students have acquired their knowledge of Physiology, has been almost metamor- phosed in the effort to adapt it thoroughly to the requirements of modern science. Since the appearance of the last American edition, it has had several revisions at the experienced hand of Mr. Power, who has modified and enlarged it so as to introduce all that is important in the investigations and discoveries of England, France, and Germany, resulting in an enlargement of about one-fourth in the text. The series of illustrations has undergone a like revision, a large proportion of the former ones having been rejected, and the total number increased to nearly four hundred. The thorough revision which the work has so recently received in England, has rendered unnecessary any elaborate additions in this country, but the American Editor, Pro- fessor Smith, has introduced such matters as his long experience has shown him to be requisite for the student. Every care has been taken with the typographical execution, and the work is presented, with its thousand closely, but clearly printed pages, as emphatically the text-book for the student and practitioner of medicine—the one in which, as heretofore, especial care is directed to show the applications of phyfiology in the various practical branches of medical science. Notwithstanding its very great enlargement, the price has not been increased, rendering this one of the cheapest works now before the profession. fectly certain of the fulness of information it will con- voy, and well satisfied of the accuracy with which it will there befouud stated.—London Med. Times and Gazette, Feb. 17, 1876. We have been agreeably surprised to find the vol- ume so complete in regard to the structure and func- tions of the nervous system in all its relations, a subject that, in many respects, is one of the most diffi- cult of all, in the whole range of physiology, upon which to produce a full and satisfactory treatise of the class to which the one before us belongs. The additions by the American editor give to the work as it is a considerable value beyond that of the last English edition. In conclusion, we can give our cor- dial recommendation to the work as it now appears. The editors have, with their additions to the only work on physiology in our language that, in the full- est sense of the word, is the production of a philoso- pher as well as a physiologist, brought it up as fully as could be expected, if not desired, to the standard of our knowledge of its subject at the present day. It will deservedly maintain the place it has always had in the favor of the medical profession.—Journ. of Nervous and Mental DUease, April, 1877. "Good wine needs no bush" says the proverb, and an old and faithful servant like the " big" Carpenter, as carefully brought down as this edition lias been by Mr. Henry Power, needs little or no commendation by us. Such enormous advances have recently been made in our physiological knowledge, that what was perfectly new a year or two ago, looks now as if it had been a received and established fact for years. In this encyclopaedic way it is unrivalled. Here, as it seems to us, is the great value of the book; one is safe in sending astudent to it for information on almost any given subject, per- Thusfully are treated the structureand functions of all the importaut organs of the body, while there are chap- ters on sleep and som uauiOulism; chapters on etnnology: a full section on generaiion, and abundant references to the curiosities of physiology, as the evolution of light, heat, electricity, etc. In short, this new edition of Car- penter is, as we have said at the start, a very encyclo- pedia of modern physiology.—Thf. Clinic, Feb. 24,1877. The merits of " Carpenter's Physiology are so widely known and appreciated that we need only allude briefly to the fact that in the latest edition will befouud a com- prehensive embodiment of the results of recent physio- logical investigation. Care has been taken to preserve the practical character of the original work. In fact the entire work has been brought up to date, and bears evidence of the amount of labor that has been bestowed upon it by its distinguished editor, Mr Henry Power. The American editor has made the latest additions, in order fully to cover the time that has elapsed since the last English edition.—N. Y. Mnl. Journal, Jan. 1877. A more thorough work on physiology could not be found. In this all the facts discovered by the late re- searches are noticed, and neither student nor practi- tioner should be without this exhaustive treatise on an important elementary branch of medicine.—Atlanta Med. and Surg. Journal, Dec. 1876. ITIRKES (WILLIAM SENHOUSE), M.D. A MANUAL OF PHYSIOLOGY. Edited by W. Morrant Baker, M.D., F.R.C.S. A new American from the eighth and improved London edition. With about two hundred and fifty illustrations. In one large and handsome royal 12mo. vol- ume. Cloth, $3 25; leather, $3 75. (Lately Issued.) Kirkes' Physiology has long been known as a concise and exceedingly convenient text-book, presenting within a narrow compass all that is important for the student. The rapidity with which successive editions have followed each other in England has enabled the editor to keep it thoroughly on a level with the changes and new discoveries made in the science, and the eighth edition, of which the present is a reprint, has appeared so recently that it may be regarded as the latest accessible exposition of the subject. On the whole, there is very little in the book the hands of students.—Boston Med. and Sura which either the student or practitioner will not find [ Jn^irn., April 10 1873. of practical value and consistent with our present I T„ ,. , ,' .... .... ,. knowledge of this rapidly changing science ; and we . In?.t8 enlarged form it is, in our opinion, still the have no hesitation in exposing our opinion that hest book on physiology, most useful to the student. this eighth edition is. one of the best handbooks on I -?Ma. Med. Times, Aug. 30, 1873. physiology which we have in our language.—N. Y. | This is undoubtedly the best work for students of Jfed. Record, April io, 1873. physiology extant.—Cincinnati Med. Ne.ws, Sept. '73, The book is admirably adapted to be placed in j H ARTSHORNE (HENRY).M.D., Professor of Hygiene, etc , in the Oniv. of Penna. HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second Ed:'- tion, revised. In one royal 12mo. volume, with 220 wood-cuts: cloth, $1 75. (Just Issued.) Henry C. Lisa's Publications—(Physiology). 9 £%ALTON (J. C), M.D., •*~^ Professor of Physiology in the College of Physicians and Surgeons, Ne.w York, Ac. A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use of Students and Practitioners of Medicine. Sixth edition, thoroughly revised and enlarged, with three hundred and sixteen illustrations on wood. In one very beautiful octavo vol- ume, of over 800 pages. Cloth, $5 50 ; leather, $6 50. (Just Issued.) From the Preface to the Sixth Edition. In the present edition of this book, while every part has received a careful revision, the ori- ginal plan of arrangement has been changed only so far as was necessary for the introduction of new material. The additions and alterations in the text, requisite to present concisely the growth of positive physiological knowledge, have resulted, in spite of the author's earnest efforts at condensation, in an increase of fully fifty per cent, in the matter of the work. A change, however, in the ty- pographical arrangement has accommodated these additions without undue enlargement in the bulk of the volume. The new chemical notation and nomenclature are introduced into the present edition, as hav- ing now so generally taken the place of the old, that no confusion need result from the change. The centigrade system of measurements for length, volume, and weight, is also adopted, these measurements being at present almost universally employed in original physiological investiga- tions and their published accounts. Temperatures are given in degrees of the centigrade scale, usually accompanied by the corresponding degrees of Fahrenheit's scale, inclosed in brackets. New York, September, 1875. This popular text-book on physiology comes to us in its sixth edition with the addition of about fifty percent. of new matter, chiefly in the departments of patho- logical chemistry and the nervous system, where the principal advances have been realized. With so tho- rough revision and additions, that keep the work well up to the times, its continued popularity may be confi dently predicted, notwithstanding the competition it may encounter. The publisher's work is admirably done.—St. Louis Med. and Surg. Journ , Dec. 1875 We heartily welcome this, the sixth edition of this admirable text book, than which there are none of equal brevity more valuable. It is cordially recommended by the Professor of Physiology in the University of Louisi- ana, as by all competent teachers in the United States and wherever the English language is read, this book has been appreciated. The present edition, with its 316 admirably executed illustrations, has been carefully revised and very much enlarged, although its bulk does not seem perceptibly increased.—New Orleans Medical and Surgical Journal, March. 1876. The present edition is very much superior to every other, not only in that it brings the subject up to the times, but that it di e- so more fully and satisfactorily than any previous edition. Take it altogether, it remains in ourhumble opinion, the best text book on physiology in any land or language.—The. Clinic. Nov. 6, 1875. As a whole, we cordially recommend the work as a text-book for the student, and as one of the best__ The Journal of Nervous and Mental Disease, Jan. 1S76. Still holds its position as a masterpiece of lucid writ- ing, and is, we believe, on the whole, the best book to place in the hands of the student.—London Students' Journal. During the past few years several new works on phy- siology, and new editions of old works, have appeared, competing for the favorof:the medical student, butnone will rival this new edition of Dalton. As now enlarged, it will be found also to be, in general, a satisfactory work of reference for the practitioner.—Chicago Med. Journ. and Examiner, Jan. 1876. Prof. Dalton has discussed conflicting theories and conclusions regarding physiological questions with a fairness, a fulness, and a conciseness which lend fresh- ness and vigor to the entire book. Rut his discussions have been ao guarded by a refusal of admission to those speculative and theoretical explanations, which at best exist in the minds of observers themselves as only pro- babilities, that none of his readers need be led into grave errors while making them a study.—The Medical Record, Feb. 19, 1876. The revision of this great work has brought it forward with the physiological advances of the day, and renders it, as it has ever been, the finest work for students ex- tant.—Nashville Journ. of Med. and Surg., Jan. 1876. For clearness and perspicuity, Dalton's Physiology jommended itself to the student years ago, and was a pleasant relief from the verbose productions which it supplanted. Physiology has, however, made many ad- vances since then —and while the style has been pre- served intact, the work in the present edition has been brought up fully abreast of the times. The new chemical notation and nomenclature have also been introduced into the present edition. Notwithstanding the multi- plicity of text-books on physiology, this will lose none of its old time popularity. The mechanical execution of the work is all that could be desired.—Peninsular Journal of Medicine, Dec. 1875. T)UNGLISON (ROBLEY), M.D., •U Professor of Institutes of Medicine in 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 of about 1500 pages, cloth, $7 00. JEHMANN (C. G.). . PHYSIOLOGICAL CHEMISTRY. Translated from the second edi- tion by George E. Day, M. D., F. R. S., Ac, edited by R. E. Rogers, M. D., Professor of Chemistry in the Medical Department of the University of Pennsylvania, with illustrations selected from Funke's Atlas of Physiological Chemistry, and an Appendix of plates. Com- plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two hundred illustrations, cloth, $6 00. T>Y THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- vania. With illustrations on wood. In one very handsome octavo volume of 336 pages, cloth, $2 25. 10 Henry C. Lba'8 Publications—(Chemistry). J^TTFIELD (JOHN). Ph.D., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Ac. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. Seventh American edi- tion, revisec from the Sixth English edition by the author. In one handsome royal 12mo. volume of 668 pages, with 87 illustrations : cloth, $2 75 ; leather, $3 25. (Just. Issued.) . This work hasreceived a very careful revision atthe hands of the author, resultingin aconside- rable increase in size, together with the addition of a handsome series of illustrations Notwith- standing these improvements, the price has been maintained at the former very moderate rate. It is a valuable work for the busy practitioner, ex- cluding as it does everything that wonld be of in'e- rest only to the scientific chemist, and having a com- prehensive index which renders after consultation easy. That portion devoted to urinalysis and prac- tical toxicology, and the tests forimpiirities in medi- cinal preparations, is especially valuable to the practising physician. For the studentit is desirable, for the reason that it is so arranged that he may, without an instructor, study the science experiment- ally.—Am. Practitioner, March, 1877. After having used it as a text-book in the laboratory of the Philadelphia (■ollegeof Pharmacy during thelast five years, we can speak from our own experience, and testify to its intrinsic value in the instruction of the student. The more we have used it, the more we were pleased with it,and on theappearanceof anew, revised. and enlarged edition, we take occasion to again cordi- ally recommend it, believing that for the practical in- struction of pharmaceutical students in chemistry it his no superior in the English language.—Am. Journ. of Pharm . Nov. 1876. The book, by a well arranged system, introduces the student into the Science of Chemistry, giving him at each step sufficient information to enable him to per- form experiments with his own hands; the experiments are partly of synthetical and partly of analytical inte- rest: in this way the editor succeeds admirably in avoiding a dry monotonous enumeration of facts. The variety which he gives is certainly well calculated to prevent the reader from getting tired. This variety, however, is not such as to bewilder the mind, nor are ihe experiments described calculated only to serv» as a pleasant pastime. The student who reads the book and executes the experiments mentioned, cannot help but feel deeply interested in the subject, and indeed, will, going through the practical work, find it. a very agree- able recreation.—fV>/«/mafi Clinic, Oct. US. 1876. It brings up our knowledge of the subject to the pre- sent date, and has been enriched with numerous wood engra vings il I u-t nil ive of apparatus and modes of work. The arrangement of the work is admirable, and to each element Us more important compounds used in medi- citieor pharmacy are uiven, together with both syntheti- cal and analytical reactions. The systematic analysis of compounds, substances or fluids is also treated of, and copious tallies are given showing the modes of sys- tematically separating the different elements from one another.—Canada Med. and Surg. Journ , Nov. 1876. As a compact manual of the general principles of the science and their applications in medicine and phar- macy, it has no rival, and the frequent and thorough revision it receives keeps it in all respects up with the times The American edition, which covers the United States Pharmacopoeia, is prepared under the author's supervision —Boston Journal of Chemistry, Nov 1*76. Admirably adapted to the use of medical students.— Atlanta Med. Journ., Oct. 1876. Fc JOWNES (GEORGE), Ph.D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. Revised and corrected by Henry Watts, B. A., F R.S., author of " A Diction- ary of Chemistry, etc. With a colored plate, and one hundred and seventy-seven illus- trations. A new American, from th< twelfth and enlarged London edition. Edited by Robert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; cloth, $2 75 ; leather, S3 25. (Now Ready.) V Two careful revisions by Mr. Watts, since the appearance of the last American edition of " Fownes," have so enlarged the work that in England it has been divided into two volumes. In reprinting it, by the use of a small and exceedingly clear type, cast for the purpose, it has been found possible to comprise the whole, without omission, in one volume, not unhandy for study and reference. The enlargement of the work has induced the American Editor to confine his additions to the narrowest compass, and he has accordingly inserted only such discoveries as have been an- nounced since the very recent appearance of the work in England, and has added the standards in popular use to the Decimal and Centigrade systems employed in the original Among the additions to this edition will be found a very handsome colored plate, representing a number of spectra in the spectroscope. Every care has been taken in the typographical execu° tion to render the volume worthy in every respect of its high reputation and extended use, and though it has been enlarged by more than one hundred and fifty pages, its very moderate price will still maintain it as one of the cheapest volumes accessible to the chemical student. ~DOWMAN (JOHN E.), M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London Sixth American, from the fourth and revised English Edition. In one neat volume, royal 12mo pp. 351, with numerous illustrations: cloth, $2 25. •BY THE SAME AUTHOR. (Lately Issued.) ---- INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Sixth American, from the sixth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., cloth $2 26. KNAPP'S TECHNOLOGY ; or Chemistry Applied to the Arts, and to Manufactures. With American additions by Prof. Walter R. Johnson. In two very handsome octavo volumes, with 500 wood eDgravings, cloth, $6 00. Henry C. Lisa's Publications—(Chemistry). 11 T?LOXAM (C. L.), ■*-* Professor of Chemistry in King's College, London. CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illustra- tions. Cloth, $4 00; leather, $5 00. (Just Issued.) It has been the author's endeavor to produce a Treatise on Chemistry sufficiently comprehen- sive for those studying the science as a branch of general education, and one which a student may use with advantage in pursuing hischemical studies atone of the colleges or medical schools. The special attention devoted to Metallurgy and some other branches of Applied Chemistry renders the work especially useful to those who are being educated for employment in manufacture. We have In this work a complete and most excel- lent text-book for the use of schools, and can heart- ily recommend it as such.— Boston Med. and Surg. Journ., May 28, 1874. The above is the title of a work which we can most conscientiously recommend to students of chemistry. It is as easy as a work on chemistry could be made, at the same l ime that it presents a full account of th at science as it now stands. We have spoken of the workaRadmirablyadapted to the wants of students ; It is quite as well suited to the requirements of prac- titioners who wish to review their chemistry, or have occasion to refresh their memories on any point re- lating to it. In a word, it is> a book to be read by all who wish to know what is the chemistry of the pre- sent day.—American Practitioner, Nov. 1873. Prof. Bloxam possesses pre-eminently theinestima- ble gift of perspicuity. It is a pleasure to read his books, for he is capable of making very plain what other authors frequently have left very obscure.— Va. Clinical Record, Nov. 1873. o 'LO WES (FRANK), D.Sc, London. Senior Science-Master at the High School, Newcastle-under Lyme, etc. AN ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the Laboratories of Schools and Colleges and by Beginners. From the Second and Revised English Edition, with about fifty illustrations on wood. In one very handsome royal 12mo. volume of 372 pages : cloth, $2 50. (Now Ready.) The methods are modern, and the present approv- ed system of nomenclature and notation are used exclusively—facts which especially commend the book to new students in qualitative analysis.— Chi- cago Med. Journ. and Examiner, Oct. 1877. It is short, concise, and eminently practical. We therefore heartily commend it to students, and espe- cially to those who are obliged to dispense with a master. Of course, a teacher is in every way desi- rable, but a good degree of technicil skill and prac- tical knowledge can be attained with no other instructor than the very valuable handbook now under consideration.—St. Louis Clin. Record, Oct. KS77. The work is so written and arranged that it can be comprehended by the student without a teacher, and the descriptions and directions forthe various work are so simple, and yet concise, as to be interesting and intelligible. The work is unincumbered with theoretical deductions, dealing wholly with the practical matter, which it is the aim of this compre- hensive text-book to impart. The accuracy of the analytical methods are vouched for from the fact that they have all been worked through by the author and the members of his class, from the printed text. We can heartily recommend the work to the student of chemistry as being a reliable and comprehensive one.—Druggists' Advertiser, Oct, 15, 1877. With this manual before him the advanced stu- dent can undertake experiments without the assist- ance of the professor. The aim of the author has been to make it as simple as possible, and for this purpose he has abandoned many technical phrases, and substituted therefor simply paraphrased terms. —Nashvitle Med. and Surg. Journ., July, 1S77. R EM>'EN(IRA), M.D., Ph.D., Professor of Chemistry in the Johns Hopkins University, Baltimore. PRINCIPLES OF THEORETICAL CHKMISTRY, with special reference to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 232 pages: cloth, $1 50. (Just Issued.) For such study, essential forexactness in scientific thought. Prof. Remsen's book supplies valuable ma- terial. It is uniformly clearand logical Theauthor seldom overstrains a theory, and in several cases, as for instance, in his remarks on atomicity (p. SI, et seq.) points out difficulties whichare too often over- looked. He has made many things easy of compre- hension, which are generally very difficult, and al- together his book will be real treasure to earnest students. — London Lancet, Aug. 1877. This volume is devottd to the principles upon which the theoretical structure of modern chemistry is based, and as such it is a very valuable addition to our litera- ture, insomuch as it discusses, in a clear and compre- hensive manner, the various laws governing chemical combination and decomposition, and the varioustheo- ries which have been advanced for explaining an- nounced facts. In our opinion, the work will prove to be a valuable aid to the chemical student who would familiarize himself with the theories of the science that have led to many important discoveries.—Am. Journ. "f Pharm., June, 1877. It is an admirable presentation of the leading doc- trines of modern chemistry. If some subjects seem briefly treated, it is simply because so little is really known about them, and the author has had the rare good sense not to lumber his pages with unprofitable speculations and mere " guesses at the truth."—Boston Journ. of Chem., May, 1877. w> TOHLER AND FITTIG. rr OUTLINES OF ORGANIC CHEMISTRY. Translated with Ad- ditions from the Eighth German Edition. By Ira Remsbn, M.D., Ph.D., Professor of Chemistry and Physics in Williams College, Mass. In one handsome volume, royal 12mo. of 550 pp., cloth, $3. As the numerous editions of the original attest, this work is the leading text-book and standard authority throughout Germany on its important and intricate subject—a position won for it by the clearness and conciseness which are its distinguishing characteristics. The translation has been executed with the approbation of Profs. Wcihler and Fittig, and numerous additions and alterations have been introduced, so as to render it in every respect on a level with the most advanced condition of the science. 12 Henry C. Lea'* Publications—(Mat. Med. and Therapeu-ttos). pARRISH [ED WARD), Late Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulas and Prescriptions. Fourth Edition, thoroughly revised, by Thomas S. Wikoano. In one handsome octavo volume of 977 pages, with 280 illustrations; cloth. £5 50; leather, $6 50. [Lately Issued.) The delay in the appearance of the new U. S. Pharmacopoeia, and the sudden death of the au- thor, have postponed the preparation of this new edition beyond the period expected. The notes and memoranda left by Mr. Parrish have been placed in the hands of the editor, Mr. Wiegnnd, who has labored assiduously to embody in the work all the improvements of pharmaceutical sci- ence which have been introduced during he Inst ten years. It is therefore hoped that the new edition will fully maintain the reputation which the volume has heretofore enjoyed as a standard text-book and work of reference for all ergaged in the preparation and dispensing of medicines. n n honored place on our own bookshelves.—Dublin Med Press and Circular, Aug 12, 1874. We expressed our opinion of a former edition in terms of unqualified praise, and we are in no wood to detract from that opiuion in reference to the pre- sent edition, the preparation of which has fallen into competent hands. It is a book with which no pharma- cist can dispense, and from which no physician can fail to derive much information of value to him ia practice.—Pacific Med. and Surg. Journ.. June,'74. With these few remarks we heartily commend the 01 Dr Parrish's great work on pharmacy it only remains to be said that the editor has accomplished his work so well as to maintain, in this fourth edi- tion, the high staudard of excellence which it bad attained in previous editions, under the editorship of its accomplished author. This has not heen accom plished without much labor, and many additions and improvements,involvingchangesin the arrangement of i he several parts of the work, and the addition of much new matter. With the modifications thus ef- fected it constitutes,as now presented, acompendium of the science and art indispensable to the pharma- cist, and of the utmost value to every practitioner j work, and have no doubt that it will maintain its of medicine desirous of familiarizing himself with i old reputation as a text-book for the student, and a the pharmaceutical preparation of the articles which work of reference for the more experienced physi- he prescribesforhispatients.—Chicago Mtd.Journ., j cian and pharmacist.— Chicago Med. Examiner, July, 1874. I June 15, 1874 The work is eminently practical, and has the rare Perhaps one, if not the most important book upon merit of beingreadable and interesting, while it pre-j pharmacy which has appeared in the Knglish lan- serves astricily scieniiBccharacter The whole work gunge has emanated from the transatlantic press. reflects the greatest credit on author, editor, and pub- "Parrish's Pharmacy" is a well-known work on this li slier It will convey some idea of i he liberality which side of the water, aud the fact shows us that a really has been bestowed upon itsproduction when we men- useful work never becomes merely local in its fame. tion thatthereare no less than 2S0carefully executed Thanks to the judicious editing of Mr. Wiegand, th« illustrations. In conclusion, we heariily recommend posthumous edition of "Parrish" has been saved to the work, not only to pharmacists, but also to the the public with all the mature experieDceof its an- multitude of medical practitioners who are obliged ! thor. ano perhaps none the worse for a dash of new to compound their own medicines. It will ever hold | blood.—Lond. Pharm. Journal, Oct. 17, 1874. VTILLE (ALFRED), M.D., *3 Professor of Theory and Ptactice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Fourth edition, revised and enlarged. In twolarge and handsome 8vo. vols, of about 2000 pages. Cloth, $10; leather, $12. (Lately Issued.) The care bestowed by the author on the revision of this edition has kept the work ont of the market for nearly two years, and has increased its size about two hundred and fifty pages. Not withstanding this enlargement, the price has been kept at the former very moderate rate. It is unnecessary to do much more than to an- nounce the appearance of the fourth edition of this well known aud excellent work.—Brit, and For. Med.-Chir. Review, Oct 1675. For all who desire a complete work on therapeutics and materia medica for reference, in cases involving medico-legal questions, as well as for information concerning remedial agents, Dr. Still^'s is "par ex- cellence" the work. The work being out of print, by the exhaustion of former editions the author has laid of the present edition, a whole cyclopaedia of thera- peutics.— Chicago Medical Journal, Feb. 1875. The magnificent work of Professor Stille is known wherever the English language is read, and the art of medicine cultivated ; known so well that no enco- mium of ours could brighten its fame, and no unfa- vorable criticism could tarnish itsreputation.—Phil- adelphia Med. Times, Dec. 12, 1S74 The rapid exhaustion of three editions and the uni- versal favor with which the work has been received the profession under renewed obligations, by the by the medical profession, are sufficient proof of its i, important additions, and timely re- j excellence as a report careful revision Issuing a work not exactly supplemented by any other in the English language, if in any language. The mechanical executiou handsomely sustains the well-known skill and good taste of the publisher.— St. Louis Med. and Surg. Journal, Dec 1874. The prominent feature of Dr. Still6 s great work is sound good sense. It is learned, but its learning is of inferior value compared with the discriminating judgment which is shown by its author in the dis- cussion of his subjects, and which renders it a trust- worthy guide in the sick-room.—Am. Practitioner, JaD. 1875. From the publication of the first edition "Stille's Therapeutics" has been one of the classics; its ab- sence from our libraries would create a vacuum repertory of practical and useful in- formation for the physician. The edition before us fully sustains this verdict, as the work has been care- fully revised and in some portions rewritten, bring- ing it up to the present time by the admission of chloral and croton chloral, nitrite of amyl, bichlo- ride of methylene, methylic ether, lithium com- pounds, gelseminum, and other remedies.—Am. Journ. of Pharmacy, Feb. 1875. We can hardly admit that it has a rival in the multitode of its citations and the fulness of its re- search intocliuical histories, and we must assign it a place iu the physician's library; not, indeed, a* fully representing the present mate of knowledge in pharmacodynamics, but as by f, LL.D., and IfAlSCH (JOHN M.). Ph.D.. A-7 Prof of Theory and Practice of Clinical -L'J- Prof, of Mot Med. and Bot. in Phila. Med. in Univ. of Pa. Coll. Pharmacy. Secy, to the American Pharmaceuti ca 1 Association. THE NATIONAL DISPENSATORY: Embracing the Chemistry, Botany, Materia Medica, Pharmacy, Pharmacodynamics, and Therapeutics of the Pharmaco- poeias of the United States and Great Britain. For the Use of Physicians and Pharma- ceutists. In one handsome octavo volume, with numerous illustrations. (In Press.) The want, has long been felt and expressed of a work which, within a moderate compass. should give to the physician and pharmaceutist an authoritative exposition of the Pharmaco- poeias from the existing standpoint of nieiicil and pharm iceutical science. For several years the authors have been earnestly engaged in the preparation of the present volume, with the hope of satisfying this want, and their labors are now sufficiently advanced to enable the pub- lisher to promise its appearance during the comin<* season. Their distinguished reputation in their respective departments is a guarantee that the work will fulfil all reasonable expectation as a guide in the selection, compounding, dispensing, and medicinal uses of drugs, complete in all respects, while convenient in size, and carefully divested of all unnecessary and obsolete matter. UIARQUHARSON (ROBERT). 31. D.. ■*- Lecturer 600. cloth *•> 50 TODD'S CLINICAL LECTURES ON CERTAIN ACUTB Diseases. In one neat octavo volume, of 320 page* cloth. #2 60 STURGES'S INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. Being a Guide to the In- vestigation of Disease. In one handsome 12mo. volume, cloth, $1 2") (Lately Issued.) STOKES' LECTURES OX FEVER Edited by John Wm.i.iam Moore, M. D.. Assistant Physician to the Cork Street Fever Hospital. In one neat 8ro. volume, cloth, *2 00. (Just Issued ) HenryC. Lea's Publications—(Practice of Medicine). 15 [PLINT (AUSTIN), M.D., M- Professor of the Principles and Practice of Medicine in Bellevue Med College, N. Y. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fourth edition, revised and enlarged. In one large and closely printed octavo volume of about 1100 pp.; cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. (Lately Issued.) By common consent of the English and American medical press, this work has been assigned to the highest position as a complete and compendious text-book on the most advanced condition of medical science. At the very moderate price at which it is offered it will be found one of the gheapest volumes now before the profession. This excellent treatise on medicine has acquired I dents and abook of ready reference for practitioners. for itself in the United States a reputation similar to The force of its logic, its simple and practical teach- that enioyed in England by the admirable lectures | ings, have leftjt without a rival in the field —N. 1 >( Sir Thomas Watson. It may not possess the same charm of style, but it has like solidity, the fruit of long and patient observation, and presents kindred moderation and eclecticism. We have referred to many of the most important chapters, and find there- vision spoken of in the preface is a genuine one, and that the author has very fairly brought up his matter to the level of the knowledge of the present day. The work has this great recommendation, that it is in one Med Record, Sept 15, 1874. Flint'sPracticeof Medicine hasbecomeso fixed in its position as an American text-book that little need be said beyond the announcement of a new edition. It may, however, be proper to say that the author has improved the occasion to introduce the latest contributions of medical literature together with the results of his own continued clinical observations. Not so extended as many of the standaid works on volume, and therefore will not be so terrifying to the practice, it still is sufficiently complete for all ordi student as the bulky volumes which several of our nary reference, and we do not know of a more con English text-books of medicine have developed into. — British and Foreign Med.-Chir. Rev., Jan. 187*. Itis of course unnecessary tointroduce or eulogize this now standard treatise. All the colleges recom- mend it as a text-book, and there are few libraries in which one of its editions is not to be found. The present edition has been enlarged and re vis«d to bring it up to the author's present level of experience and reading. Hisown clinical studies and the latest con- tributions to medical literature both in this country and in Europe, have received careful attention, so that some portions have been entirel y rewritten, and about seventy pages of new matter have been added. —Chicago Med Journ., June, 1873. Ha6 never been surpassed as a text-book for stu- venient work for the busy general practitioner.— Cincinnati Lancet and Observer, June, 1873. Prof. Flint, in the fourth edition of his great work, has performed a labor reflecting much credit upon himself, and conferring a lastingbenefit upon the pro- fession. The whole work shows evidence of thorough revision, so that it appears like a new book wiitten expressly for the times For thegeneral practitioner and student of medicine, we cannot recommend the bookintoostrongterms.—N. Y. Med. Jour , Sept '73. It is given to very few men to tread in the steps of Austin Flint, whose single volume on medicine, though here and there defective, is a masterpiece of lucid condensation and of general grasp of an enor- mously wide subject —Lond. Practitioner, Dec.J'73. T)Y THE SAME AUTHOR. ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED TOPICS. In one very handsome royal l2rao. volume. Cloth, $1 38. (Just Issued.) EJA R TSHORNE (HENR Y), M. D., H Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. Fourth edition, revised and im- proved. With about one hundred illustrations. In one handsome royal 12mo. volume, of about 550 pages, cloth, $2 63 ; half bound, $2 88. (Lately Iss?ied.) As a handbook, which clearly sets forth theEssEN- | advances in medicine, is admirably condensed, and ALSOf tllO PRINCIPLES AND PRACTICE OF MEDICINE, we o not know of its equal.- Va. Med. Monthly. As a brief, condensed, but comprehensive hand- bonk, it cannot be improved upon.—Chicago Med Examiner, Nov. 15, 1874. The work is brought fully up with all the recent yet sufficiently explicit for all thepurposf sintended, thus making i"t by far the best work of its character ever published.—Cincinnati Clinic, Oct. 24, 1S74. Without doubt the best book of the kind published in the English language.—S'f. Louis Med. and Surg. Journ , Nov. 1874. JJTA TSON (THOMAS), M. D., frc. ¥V LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC Delivered at King's College, London. A new American, from the Fifth re- vised and enlarged English edition. Edited, with additions, and several hundred illustra- tions, by Henry Hartshorne, M.D., Professorof Hygiene in the University of Pennsylva. nia. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. (Lately Published.) It is a subject for congratulation and for thankful- 1 rarely been equalled, and never surpassed The re- ness hat SU Thomas Watson, during a period of com- vision has evidently been most carefully done,and paraUve leisure, after a long, laborious, and most the results appear..*j almos! every page.-Brtt. Med. honorable professional career, while retaining full Journ., Oct. 14, 1871. possession of his high mental faculties, should have The author"e rare combination of great scientific employed the opportunity to submit his Lectures to a more thorough revision than was possible during the earlier and busier period of his life. Carefully passing in review some of the most intricate and im- portant pathological and practical questions,there- suits of his clear insight and his calm judgment are now recorded for the benefit of mankind, in language which for precision, vigor, and classical elegance, has attainments combined with wonderful forensic elo- quence has exerted extraordinary influence over the last two generations of physicians. His clinical de- scriptions of most diseaseshave never been equalled ; and on this score at least his work will live long in the future. The work will be sought by ail who appreciate a great book.— Amer. Journ. ofSyphil- ography, July, 1S72. 16 Henry C. Lea's Publications—(Practice of Medicine). DRISTU WE {JOHN SYEll), M.D., F.R.C.P., J—) Physician and Joint Lecturer on Medicine, St. Thomas's Hospital. A MANUAL OX THE PRACTICE OF MEDICINE. Edited, with Additions, by James H. Hutchinson, M.D., Physicinn to the Penna. Hospital. In one handsome octavo volume of over 1100 pnges : cloth, $5 50; leather, $6 50. (Just Ready.) In the effort of the author to render this volume a complete and trustworthy guide for the student and practitioner he has covered a wider field than is customary in text-books on the Practice of Medicine, and has sedulously endeavored to present each subject in the light of the most modern developments of observation and treatment. So much has been done of late years to enlarge our knowledge of disease by improved methods of diagnosis, and so many new agencies have been called into service in treatment, that a condensed and compendious work, thoroughly on a level with the advance of medical science, can hardly fail to prove of value to the profession. Dr. Bristowe has long been before the profession I practitioners who purchase few books will And this as an able thinker and writer on professional sub- a mod opportune publication, because to many top- jects. His present work is second to none of its kind, the part on diseases of the nervous system being, psrhaps, the most deserving of praise. It is eminently readable, both in matter and print, and fully deserves the success it is sure to obtain.— Edin. Med. Journ., Oct. 1S77. The treatment of the various diseases is admirably summed up, and we pronounce Dr. Bristowe's book to be eminently practical on this subject. A fair space is given to the dietetics of disease, and we are glad that this subject is receiving more and more attention in the works on medicine. We give the author our hearty congratulations, and his book our best commendations and wish it all success.—Loud. Med. Times and Gaz., Sept. 15, 1877. Anyone who wants a good, clear, condensed work upon Practice, quite up with the most recent views in pathology, will find this a most valuable work. The additions made by Dr. Hutchinson are appropriate and useful, and so well done that we wish there were more of them.—Am. Practitioner, Feb. 1877. This portly volume is a model of condensation. In a style at once clear, interesting, and concise, Dr. Bristowe passes in review every conceivable subject connected with the practice of medicine. Those not usually embraced in a work on practice are adequaiely handled. The book is a thoroughly good one, and its usefulness to American readers has been increased by the judicious notes of the Kditor.— Cincinnati Clinic, Jan. 7, 1S77. An immense amount of information has been com- pressed into this volume. Every page is character- ized by the utterances of a thoughtful man. While we could wish a fuller discussion and greater detail in relation to many subject, we are constrained to say that, what has been said has been well said, and the book is a fair reflex of all that is certainly known on the subjects considered.—Ohio Med. Re- corder, Jan. 1S77 Upon the whole, we know of no work which we could more confidently recommend to the studentor the practitioner, intending a review of the field of theory and practice, than this book of Dr. Bris- towe's. We thus commend it, because the vast ar- ray of facts pertaining to the practice of medicine, as it is to.day, are here presented ably, and with that method, order, and perspicuity which, in all depart- ments of education, distinguish the lessons of an ac- ceptable and profitable teaclmr —Chicago Med. Journ. and Examiner, Aug. 1877. JJAMILTOX (ALLAN McLANE), 31.D. Attending Physician at the Hospital for Epileptics and Paralytics. Blackwell's Island, N. Y. and at the Out-Patients' Department of the New York Hospital. NERVOUS DISEASES; THEIR DESCRIPTION AND TREATMENT. In one handsome octavo volume of 512 pages, with 53 illus.; cloth, $3 50. (Just Ready.) The object of the author has been to furnish to the student and practitioner in a clear and concise form a guide to the diagnosis and treatment of affections of the nervous system, em- bodying the very great advances made during the last few years in our knowledge of these dis eases. Unusual opportunities in public and private practice have qualified him for this work, and his desire has been to render it strictly practical, adapting it to the wants not only of the spe- cialist, but of the general practitioner. Particular care has therefore been devoted to the manage- ment ofnervous diseases, and in an appendix willbe found a careful selection of well-tried formula. The thorough manner in which the subject has been treated may be understood from the fol- lowing very condensed SUMMARY OF CONTENTS. Introduction. Hints in regard to Examination and Study ; Apparatus for the Treatment of Nervous Disease. Chap. I. Diseases of the Cerebral Meninges. Chap. II. to Chap VII. Dis- eases of the Cerebrum and Cerebellum. Chap. VII. Diseases of the Spinal Meninges. Chap. VIII. to Chap. XII. Diseases of the Spinal Cord. Chap. XII. Bulbar Diseases Chap. XIII. to Chap. XV. Cerebro-Spinal Diseases. Chap. XV. Diseases of the Peripheral Nerves. Chap. XVI. Neuritis. Chap. XVII. Local Paralyses. Chap. XVIII. Lead Poisoning ; Functional Spasm; Professional Cramp: Formulae. flHARCOT (J. 31.), Professor to the Faculty of Med. Paris, Phys. to La Salpelrilre, etc, LECTURES ON DISEASES OF THE NERVOUS SYSTEM. Trans- lated from the Second Edition by George Sigerson, M.D., M.Ch., Lecturer on Biology, etc., Cath. Univ. of Ireland. With illustrations. (Publishing in the Medical News and Library, commencing with the July No. 1878. See page 2 ) T)UNGLISON, FORBES, TWEED IE, 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, Ac. Ac. In four large super-royal octavo volumes, of 3254double-columned pageB, strongly and handsomely bound in leather, $15; oloth, $11. Henry C. Lea's Publications—(Practice of Medicine). 17 WOTHERGILL (J. MILNER), M.D. Edin., M.R.C.P. Land., •*- Asst. Phys. to the West Lond. Hasp. : Asst. Phys. to the City of Lond. Hosp., etc. THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the Principles of Therapeutics. In one very neat octavo volume of about 550 pages : cloth, $4 00. (Now Ready.) It may be said that the scope of this work is not dissimilar to that of the well-known " Principles of Medicine,'' by Dr. J. C. B. Williams, now long out of print, which in its day met with such unusual acceptance. More practical in its character, however, it seeks to bring to the aid and elucidation of positive therapeutics, the vast accumulation of scientific facts and theories made by the present generation, pointing out the measures to be adopted at the bedside and establishing them on firm rational grounds. Such a work, by a first-rate man, and fully up. to the advanced condition of science, cannot fail to prove of the utmost service to both student and practitioner. Our friends will find this a very readable book; and that it sheds light urfcn e\ory theme it touches, causiug the practitioi er to feel more certain of his diagnosis in difficult cases. We confidently commend the work to our readers as one worthy of careful perusal. It lighis the way over obscure and difficult passes in medical practice. The chapter on the circulation of the blood is the most exhaustive and instructive to be found. It is a book every practitioner needs, and would have, if h<; knew how sui j .• rience and authority will have great woiihl with il.y seeker after truth. As the result of clinical -tody, the work is unequalled.—St.Louis Med.and Surg Journal, March, 1876. JDY THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, cloth, $4. Dr. Flint Chose a difficult subject for his researches, iud clearest practical treatise on those subjects, and and has shown remarkable powers of observation should be in the hands of all practitioners and stu- and reflection, as well as great Industry, in his treat- lents. It is a credit to American medica 1 literature. ment of it. His book musi be considered the fullest -Amer. Journ. of the Med. Sciences, July, 1SHI). 75T THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, cloth, $4 50. Dr. Flint's treatise is one of the most trustworthy] incy to over-reflnement and unnecessary minuteness guides which we can consult. The style is clear and vhich characterizes many works on the same sub. distinct, andis also concise, being free from that tend- Iject.—Dublin Medical Press, Feb. 6,,lSt>7. WILLIAMS (C.J.B.), M.D., Senior Consulting Physician to the Hospital for Consumption. Brampton. PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- ment. With an Analysis of One Thousand Cases to exemplify its duration. In one neat octavo volume of about 350 pages, cloth, $2 50. (Lately Published.) c 'HAMBERS (T. K.), M.D., Consulting Physician to St. Mary's Hospital, London, &c. A MANUAL OF DIET AND REGIMEN IN HEALTH AND SICK- NESS. In one handsome octavo volume. Cloth, $2 75. (Just Issued.) DIPHTHERIA ; its Nature and TreatHent, with an [ LECTURES ON THE DISEASES OF THE STOMACH. account of the History of its Prevalence in vari- With an Introduction on its Anatomy and Physio- ous Countries. By D. D. Slaoe, M.D. Second and logy. Bv William Brinton. M D.. F.R S From revised edition. In one neat royal 12mo. volume, cloth, $1 25. WALSHE ON THE DISEASES OF THE HEART ANI GREAT VESSELS. Third American edition, in 1 vol. 8vo.. 420 pp.. cloth. *3 00 FULLER ON DISEASES OF THE LUNGS AND AIR- PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages : cloth, $3 50. LA ROCHE ON PNEUMONIA. 1 vol. 8vo., cloth, of 500 pages Price $3 00. SMITH ON CONSUMPTION; ITS EARLY AND RE- MEDIABLE STAGES. 1 vol. 8vo.,pp.254. 82 26 the second and enlarged London edition. With il- lustrations on wood. In one handsome octavo volume of about 300 pages; cloth, ^3 25. CHAMBERS'S RESTORATIVE MEDICINE. An Har- veian Annual Oration. With Two Sequels. In one very handsome vol. small 12m,o , cloth, $1 00. PAVY'S-TREATISE ON THE FUNCTION OF DI- GESTION; Us Disorders and their Treatment. From the second London edition. In oue hand- some volume, small octavo, cloth. *2 00. PAW'S TREATISE OX FOOD AND DIETETICS. Physiologically aud Therapeutically Considered. In one handsome octavo volume of nearly 600 pages, cloth, $1 75. Henry C. Lea's Publications—(Venereal Diseases, &c). 19 J>UMSTEAD (FREEMAN J.), M.D., ■*-* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, Ac. THE PATHOLOGY AND TREATMENT OF YENEREAL DIS- EASES. Including the results of recent investigations upon the subject. Third edition, revised and enlarged, with illustrations. In one large and handsome octavo volume of over 700 pages, cloth, $5 00 ; leather, $6 00. In preparing this standard work again for the press, the author has subjected it to a very thorough revision. Many portions have been rewritten, and much new matter added, in order to bring it completely on a level with the most advanced condition of syphilography, but by careful compression of the text of previous editions, the work has been increased by only sixty-four pages. The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a complete and trustworthy guide for the practitioner. A valuable work on Venereal Diseases, which not i venereal diseases, that it may seem almost superfln- only has a wide circulation in this country, and ; ous to say more of it than that a new edition has been been accepted as the standard, but appears to have formed tlio basis, to a large extent, of mmy of the books and articles which have been written on the same subject aud published in England — The Glas- gow Med. Journ.. Oct. 1877. It is the most complete book with which we are ac- (juaintad in the language. The latest views of the best authorities are put forward, and the information Is well arranged—a great point for the student, and itill more for the practitioner. The subjects of vis- ceral syphilis, syphiliiic affections of the eyes, and the treatment of syphilis by repeated inoculations, are very fully discussed.—London Lancet, Jan. 7, 1S71. Dr. Bumstead's work is already so universally known as the best treatise in the English language on fiULLERIER (A.), and v Surgeon to the Hdpital du Midi. issued. But the author's industry has rendered this n<»w edition virtually a newwoTk,and so merits as much special commendation as if its predecessors haa not been published. As a thoroughly practical book on a class of diseases which form a large share of nearly every physician's practice, the volume before us is bv far the best of which we have knowledge.— N. Y. Medical Gazette, Jan. 2S, 1871. It is rare in the history of medicine to find any one book which contains all that a practitioner needs to know; while the possessor of "Bumstead on Vene- real'' has no occasion to look outside of its covers for anything practical connected with the diagnosis, his- tory, or treatment of these affections.—N. Y Medical Journal. March, 1871. T>U3tSTEAD (FREEMAN J), ■*-" Professor of Venereal Diseases in the College oj Physicians and Surgeons. N Y AN ATLAS OF YENEREAL DISEASES. Translated and Edited by Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, with 26 plates, containing about 150 figures, beautifully colored, many of them the size of life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- lars a Part, tbus placing it within the reach of all who are interested in this department of prac- tice. (ie:,;,lemen desiring early impressions of the plates would do well to order it without delay. A specimen of the plates and'text sent free by mail, on receipt of 25 cents We wish for once that our province was not restrict- td to methods of treatment, that we might say some- thing of the exquisite colored plates in this volume. —London Practitioner, May, 1869. As a whole, it teaches all that can be taught by means of .plates and print.—London Lancet. March 13, 1869. Superior to anything of the kind ever before issued on this continent.—Canada Med. Journal, March, '69, The practitioner who desires to understand this branch of medicine thoroughly should obtain this, the most complete and best work ever published.— Dominion Med. Journal, May, 1869. This is a work of master hands on both sides. M Cullerier is scarcel y second to, we think we may truly »ay is a peer of the illustrious and venerable Ricord, while in this country we do not hesitate to say that Dr. Bumstead, as an authority, is without a rival Assuring nnr readers that these illustrations tell the whole history of venereal disease, from its inception to its end, we do not know a single medical work, which for its kind is more necessary tor them to have. —California Med. Gazette, March. 1869. The most splendidly illustrated work in the Ian ?uage, and in our opinion far more useful than the French original— Am. Journ. Med. Sciences, Jan. 6fc. The fifth and concluding number of this magnificent work has reached us, and we have no hesitation in saying that its illustrations surpass those of previous numbers. — BostMed and Surg.Jl.,3&n. 14 1869. Other writers besides M. Cullerier have given us a good account of the diseases of which he treats, but no one has furnished us with such a complete series of illustrations of the venereal diseases. There is however, an additional interest and value possessed bv the volume before us ; for it is an American reprint and translation of M. Cullerier's work, with inci- denti'.l remarks by one of the most eminent American syphilographevs, Mr. Bumstead. —Brit, and For. ifedim-Chir. Review, July, 1869. T EE (HENRY), Prof of Surgerif at the Royal College of Surgeons of England, etc. LECTURES ON SYPHILIS AND ON SOME FORMS OF LOCAL DISEASE AFFECTING PRINCIPALLY THE ORGANS OF GENERATION. In one handsome octavo volume: cloth; $2 25. (Lately Published.) The work is valuable, as it treats quite fully of sub modifications of these processes in patients previously ects whirli are not dwelt upon in the systematic works of other Kn^lish authors of the present da,v. as the inoc ulubility of >yphilitic blood : the conditions under which the secretions of primary and secondary syphilitic man- ifestations maybe inoculated naturally or artificially : the morbid processes produced by such inoculation: the yphilitic: primary and secondary syphilitic diseases Of the mucous membranes and their liability to commu- nicate constitutional svphilis, etc. The book is full of clinical material illustrating these topics, original or quoted—Arcltive$$fDermatology, April, 1876. J JILL (BERKELEY), Surgeon to the Lock Hospital, London. ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. one handsome octavo volume ; cloth, $3 25. In 20 Henry C. Lea's Publications—(Diseases of the SHr, <¥-<'.). F 'OX (TILBURY). 3f.D.,F.R.C.P..and T. C. FOX. B.A.. M.R.C.S.. Physician to the Department for Skin Diseases, University Cnlhgt Hmtj.ital. EPITOME OF SKIN DISEASES. WITH FORMULAE. For Stu- ln one handsome 12mo. volume, of 120 pages : cloth, $1. dents and Practitioners. (Just Issued.) A very clear and concise description is given of the elementary lesions and ihe author's remarks on the general character, complications, and modifications of eruptions, together with their practical hints on the ex- amination of skin diseases, will be of great assistance to the novice in this department of medicine. We know of no other which, in so little space, contains so much reliable information.— N. Y. Med. Journ., Dec. 1876. It has no especial features other than it is concise and quite practical. The early chapters, treating of ele- mentary matters, in the study of skin diseases, are very good, and the list of formulae is excellent.— Archives of Clinical Surgeiy. Dec. 1876. If doctors neglect the study of diseases of the skin, it will not be for lack of opportunities of instruction. This little handbook contains wonderfully condensed know- ledse that, cannot but be most useful to every one who will read it.—American Practitioner, Jan 1877. This little work cannot fail to acquire a large circle of readers. In a very small compass all the essential points of the classification, diagnosis, symptoms, and treatment of skin diseases arc accurately and completely stated without being cramped. The hook is so well ar- ranged that the render will have no difficulty in finding at once exactly the information lie inny require. A carefully compiled formulary of remedies for skin affec- tions and some notes on diet in skin diseases, considera- bly enhance the value of the epitome.—London Lancet, Nov. 4. 1S76. It must be admitted that even those well prepared for general practice find diseases nf the skin difficult ofclas- sifieathn.and as difficult of diagnosis, and that nothing is more desirable than some work which, not elaborate in nature, shall be a useful ordinary guide, and issued bv some one of recognized authority. It is believed that this manual of Tilbury Fox and T. C. Fox exactly meets the wants indicated. It epitomizes, in a very short com- pass, the clinical features in the treatment of diseases of the skin. The volume is so small that it can be car- ried in the pocket, while the text furnishes briefly, but clearly, the information desired by the general practi- tioner. It meets fully an almost Universal want.—vim. Bi-Weehly, Jan. 6, 1877. TV~ILSON (ERASMUS), F.R.S. ON DISEASES OF THE SKIN. With Illustrations on wood. Sev- enth American, from the sixth and enlarged English edition. In one large octavo volume of over 800 pages, $5. A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, and embracing accurate representations of about one hundred varieties of disease, most of them the size of nature. Price, in extra cloth, $5 50. Also, the Text and Plates, bound in one handsome volume. Cloth, $10. J£>Y THE SAME AUTHOR. ---- THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- eases of the skin. In one very handsome royal 12mo. volume. $3 50. ffELIGAN (J.MOORE), M.D., M.R.I.A. ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, with exquisitely colored plates, &c, presenting about one hundred varieties of disease. Cloth, $5 50. to which the particular case may belong. While ooking over the "Atlas" we have been induced to ixamine also the "Practical Treatise." and we are inclined to consider it 8 very superior work, com- bining accurate verbal description with sound view* of the pathology and treatment of eruptive diseases. —Glasgow Med. Journal. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless, Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the student and practitioner in drawing a diagnosis as to the class, order, and species TJILLIER (THOMAS), M.D., ■*•-*■ Physician to the Skin Department of University College Hospital, Ac. HAND-BOOK OF SKIN DISEASES, for Students and Practitioners. Second Am. Ed. In one royal 12mo. vol. of 358 pp. With Illustration! Cloth, $2 25. We can conscientiously recommend it to the stu- j It is a concise, plain, practical treatise on the vari- dent; the style is clear and pleasant to read, the ous diseases of the skin ; just such a work, indeed, matter is good, and the descriptions of disease, with as was much needed, both by medical students and the modes of treatment recommended, are frequently practitioners. — Chicago Medical Examiner, May, illustrated with well-recorded cases.—London Med. 1865. Times and Gazette. April 1, 1865. 1 UMITH (EUSTA CE), M. D~ Physician to the Northwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged English edition. In one handsome octavo volume, cloth, $2 50. (Lately Issued.) This is in every way an admirable book. The modest title which the author has chosen for it scarce- ly conveys an adequate idea of the many subjects upon which it treats. Wasting is so constant an at- tendant upon the maladies of childhood, that a trea- tise upon the wasting diseases of children must neces s rily embrace the consideration of many affections of which it is a symptom ; and this ib excellently well done by Dr. Smith. The book might fairly be de- scribed as a practical handbook of the common dis- eases of children, so numerous are the affections con- sidered either collaterally or directly. We are acquainted with no safer guide to the treatment of children's diseases, and few works give the insi>rb: into the physiological and other peculiarities of chil ■ dren that Dr. Smith's book does.—Brit. Med. Journ April 8, 1871. Henry C. Lea's Publications—(Diseases of Children. 21 SMITH (J. LE WIS), M. D., *■* Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Third Edition, revised and enlarged. In one handsome octave volume of 726 pages. Cloth, $5 ; leather, $6. (Just Issued.) The eminent success which this work has achieved has encouraged the author, in preparing this third edition, to render it even more worthy than heretofore of the favor of the profession. It has been thoroughly revised, and very considerable additions have been made throughout. To accommodate these the volume has been printed in a smaller type, so as to prevent any notable increase in its size, nnd it is presented in the hope that it inny attain the position of the American text book on this important department of medical science. This work took a s(and as an authority from its first appearance, and every one interested in studying the diseases of which it treats is desirous of knowing what improvements are apparent in the successive editions. The principal Additions to which we refer, and which will be the distinguishing features of the third edition, arc chapters on diphtheria, cerebro-spinal meningitis, and riithcln. The former disease is considered much more in detail than formerly, and a great amount of very practical information is added, and altogether it is oneof the mostenmprehensive and one of the best writ- ten chapters of the subject we have thus far read. His description of cerebrospinal meningitis, founded also for the most part on personal experience, is admirably clear and exhaustive.— The Med. Record, Feb. 19, 1876. In presenting this deservedly popular treatise for the third time to the profession, Dr. Smith has given it a careful preparation, which will make it of decided su- periority to either of the former editions. The position of the author, as physician and consultant to several l&ree children's hospitals in New York City, has fur- nished him with ronstantoccasions to put his treatment to the test, and his work has at once that practical and thoughtful tone which is a marked characteristic of the best productions of the American medical press.—Mtd. and Surg. Reporter, Feb. 1876. The former editions of this book have given it the highest rank among works of its class, and the present edition will confirm and add to its reputation Having been brought up to the present mark in the rapid ad- vance of medical science, it is the best work in our language, on its ranjie of topics, for the American prac- titioner.— Pacific Med. ami Surg. Journ., Feb. 1^76. Dr. Smith's Diseases of Children is certainly the most valuable work on the subjects treated that the practi- tioner can provide himself with. It is fully abreast with every advance: it should be in the hands of prac- titioners generally, while, becanse of the conciseness and clearnessofstyleoft.be writing of the author, every professor of diseases of children, if he has not already done so, should adopt this as bis text-book—Va. Medical Monthly, Feb. 1876. The third edition of this really valuable work is now before us. with a hundred pages of additional matter, an altered size of page, new illustrations, and new type. Of the diseases treated of for the first time, we notice rotheln and cerebro-spinal fever, which lately prevailed in epidemic form in some parts of the country. The article upon diphtheria, containing the latest develop- ments in the pathology and treatment of that dread dis- ease, which so lately ravaged our country, is peculiarly interesting to every practitioner. We gladly welcome this standanl work, and cheerfully recommend it. to our readers as the best on this subject in the Knglish lan- guage.—Nashville Journal of Med. and Surgery, March, 1876. ffONDIE (D. FRANCIS), M.D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large ootavo volume of nearly 800 closely printed pages, cloth, $5 25 ; leather, $6 25. The present edition, which is the sixth, is fully up I teachers. As a whole, however, the work la the bes* to the times in the discussion of all those pointsinthe | American one that we have, and in its special adapta- pathology and treatment of infantile diseases which tion to American practitioners it certainly has no have been brought forward by the Germau and French | equal. —.New York Med. Record, March 2, 1868. TU'EST (CHARLES), M.B., ' ' Physician to the Hospital for Sick Children, fee. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fifth American from the sixth revised and enlarged English edition. In one large and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. (Lately Issued ) The continued demand for this work on both sides of the Atlantic, and its translation into Ger- man, French, Italian, Danish, Dutch, and Russian, show that it fills satisfactorily a want exten- sively felt by the profession. There is probably no man living who can speak with the authority derived from a more extended experience thnn Dr. West, and his work now presents the results of nearly 2000 recorded cases, and 600 post-mortem examinations selected from among nenrly 40,000 eases which have pnssed under his care. In the preparation of the present edition he has omitted much thnt appeared of minor importance, in order to find room for the introduction of additional matter, and the volume, while thoroughly revised, is therefore not increased materially in size. Of all the English writers on the diseases of chil-I living authorities in the difficult department of medi- dren, there is no one so entirely satisfactory to ub as ' cal science in which he is most widely known.— Dr. West. For years we have held his opinion as I Boston Med. and Surg. Journal. Judicial, and have regarded him as one of the highest | 1>Y THE SAME AUTHOR. (LatelyIssued.) ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- don, in March, 1871. In one volume, small 12mo., cloth, $1 00. Henry C. Lea's Publications—(Diseases of Womtn). JfH03IAS (T. GAIL LARD), M. D., Professor of Obstetrics, Ac, in the College of Physicians and Surgeons, N. Y., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Fourth edition, enlarged and thoroughly revised. In one large and handsome octavo volume of 800 pages, with 191 illustrations. Cloth, $5 00 ; leather, $6 00. (Just Issued.) The author has taken advantage of the opportunity afforded by the call for another edition of this work to render it worthy a continuance of the very remarkable favor with which it Las beet received. Every portion has been subjected to a conscientious revision, and no labor has been spared to make it a complete treatise on the most advanced condition of its important subject. A work which has reached a fourth edition, and -ion would remark that, as a teacher of gynaecology, that, too, in the short space of five years, has achieved I both didactic and clinical, Piof. Thomas has certainly a reputation which places it almost beyond the reach of criticism, and the favorable opinions which we have already expressed of the former editions seem to re- quire that we should do little more than announce this new issue. We cannot refrain from saying that; as a practical work, this is second to none in the Kng- lish. or, indeed, in any other language. The arrange- ment of the contents, the admirably clear manner in which the subject of the differential diagnosis of several of the diseases is handled, leave nothing to be desired by the practitioner who wants a thoroughly clinical work, one to which he can refer in difficult cases of doubtful diagnosis with the certainty of gain- ing light and instruction. Dr. Thomas is a man with a very clear head and decided views, and there seems to be nothing which he so much di-likes as hazy notions of diagnosis and blind routine and unreasonable thera- peutics. The student who will thoroughly study this book and test its principles by clinical observation, will certainly not be guilty of these faults.—London Lancet, Feb. 13, 1S7.1. The latest edition of this well-known text-book retains the essential characters which rendered the earliest so deservedly popular It is still pre-emi- nently a practical manual, intended to convey to students in a clear and forcible manner a sufficiently complete outline of gynaecology. In a word, we should say that any one who intended to make a special study of gynaecology could hardly do better than to begin with a minute perusal of this book, and that any one who intended to keep gynaecology sub- ordinate to general practice, should hardly fail to have it on hand for future reference.—N. Y. Med. Journ., Jan. 137.}. Reluctantly we are obliged to close this unsatis- factory notice of so excellent a work, and in conclu- taken the lead far ahead of his confreres, and as an author he certainly has met with unusual and mer- ited success.—Am. Journ. of Obst< tries, N'ov. 1874 This volume of Prof. Thomas in its revised form is classical.without being pedantic, full in I he details of anatomy and pathology, without ponderous translation of pages ofGermnn literature, describes distinctly the details and difficulties of each opera- tion, without wearying and useless minutiae, and is in all respects a work wcrthy of confidence, justify- ing the high regard in which its distinguished au- thor is held by the profession.—Am. Supplement, Obstet. Journ. Oct 1874. Professor Thomas fairly took the Profession of the United States by storm when his book first made its appearance early in 1S68. Its reception was simply enthusiastic, notwithstanding a few adverse criti- cisms from our transatlantic brethren, the first large edition was rapidly exhausted, and in six months a second one was issued, and in two years a tliird oue was announced and published, and we are now pro- mised the fourth. The popularity of this work was not ephemeral, and its success was unprecedented in the annals of American medical literature. Six years is a long period in medical scientific research, bnt Thomas's work on " Diseases of Women" is still the leading native production of the United States. The order, the matter, the absence of theoretical disputa- tiveness, the fairness of statement, and the elegance of diction, preserved throughout the entire range of the book, indicate that Professor Thomas did no! overestimate his powers when he conceived the idea and executed the work of producing a new treatise upon diseases, of women. —Prop. Pallen, in Louis- ville Med. Journal, Sept. 1874. B ARNES (ROBERT), M. D., F.R. C.P., Obstetric Physician to St. Thomas's Hospital, &c. A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- CAL diseases OF WOMEN. Second American, from the Second Enlarged and Revised English Edition. In one handsome octavo volume, with many illustrations. (In Press.) ft WAYNE (JOSEPH GRIFFITHS), M.D., *^ Physician-Accoucheur to the British General Hospital, &c. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised London Edition, with Additions by E. R. Hutchins, M. D. With Illustrations. In one neat 12mo. volume. Cloth, $1 25. (Lately Issued.) *#* See p. 4 of this Catalogue for the terms on which this work is offered as a premium to subscribers to the "American Journal op the Medical Sciences." ODGE (HUGH L.), M.D~ Emeritus Professor of Obstetrics, Ac, in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN; including Displacements of the Uterus. With original illustrations. Second edition, revised and enlarged. In one beautifully printed octavo volume of 531 pages, cloth, $4 50. From Prof. W. H. Btforo, of the Rush Medical I Professor Hodge's work Is truly an original one College, Chicago. from beginning to end, consequently no one can pe- The book bears the impress of a master hand, and "n8e itB PaSes withont learning something new. As a must, as its predecessor, prove acceptable to the pro- contribution to the study of women's diseases.it is of fession. In diseases of women Dr. Hodge has estab- 8r«at value, and is abundantly able to stand on its lished a school of treatment that has become world- own nierits.—N. Y. Medical Record, Sept. 15, 1868. wide in fame. H CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WOMEN. 1 vol. 8vo.,pp 450, cloth. $2 50. MEIGS ON THE NATURE, SIGNS, AND TREAT MENT OF CHILDBED FEVER. 1 vol. 8vo 166, cloth. $2 00. PP. Henry C. Lea's Publications—(Diseases of Women). 23 QUAD WICK (JAMES R.). A.M., M.D. A MANUAL OF THE DISEASES PECULIAR TO WOMEN. In one nent volume, royal 12mo., with illustrations. (Preparing.) America hns contributed so largely to the advances which have made the treatment of Dis- eases of Women a distinctive department of medical science, that the student will naturally turn to Atmricnn Books for the latest and most trustworthy instruction on the subject in its most modern aspect. Yet there has thus far been no attempt in this country to produce a handy manual, presenting in a condensed and convenient form the information requisite for the learner or for the general practitioner. This want it has been the effort of Dr. Chadwirk to supply, and the special attention which he has devoted to the subject is a guarantee of the value of his labors. A distinguishing feature of the work will be a number of diagrammatic illustrations, facilitating greatly the comprehension of the text. UriNCKEL (F.), ' ' Professor and Director of the Gynecological Clinic in the University of Rostock. A COMPLETE TREATISE ON THE PATHOLOGY AND TREAT- M ENT OF CHILDBED, for Students and Practitioners. Translated, with the consent of the author, from the Second German Edition, by James Read Chadwick, M D. In one octavo volume. Cloth, $4 00. (Lately Issued.) We feel quite sure that the profession of Ihis country will give this interesting and learned work a cordial welcome — Cincinnati Med. News, June. 1876. In Germany this treutise is rezarded as a standard authority in this branch of medicine, and as it con- tains the recent advances in the pathology and treat- ment of diseases that pertain to the puerperal condition. will be gladly received by a large portion of the profes- sion in this country.—Cincinnati Lancet and Observer. June, 1876. This work was written, as the author tells us in hjs preface, to supply a want arising from the very brief consideration given to puerperal diseases by writers on Obstetrics, in which respect it seems the profession in his country is not different from ours, and to fill a blank left between the treatises upon the subject already in the field, and the present standpoint of science. The work has reached a second edition, and bears evidence throughout of careful study and practical experience As its title implies, it is a manual rather than a treatise. —Ameri'-an Journal of Med. Science*. April, lsi"l. TfifEST (CHARLES), M.D. LECTURES ON THE DISEASES OF WOMEN from the Third London edition $3 75 ; leather, $4 75. Third American, In one neat octavo volume of about 550 pages, cloth, DBWEES'S TREATISE ON THE DISEASES OF FE- MALES. With illustrations. Eleventh Edition, with the Author's last improvementsand correc Dions. In one octavo volume of 536 Dages. win plates, cloth. $8 00. ASHWELL'S PRACTICAL TREATISE ON THE DIS- EASES PECULIAR TO WOMEN. Third American, from the Third and revised London edition. 1 vol. 8vo., pp. 52S, cloth. $3 50. JIANNER (THOMAS H.), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates andillustratior s on wood. In one handsome octavo volume of about 500 pages, cloth, $4 25. rVHE OBSTETRICAL JOURNAL. (Free of postage for 1878.] THE OBSTETRICAL JOURNAL of Great Britain and Ireland; Inoluding Midwifery, and the Diseases of Women and Infants. With an American Supplement, edited by J. V. Ingham, M.D. A monthly of about 96 octavo pages, very handsomely printed. Subscription, Five Dollars per annum. Single Numbers, 50 cents each. Commencing with April, 1873, the Obstetrical Journal consists of Original Papers by Brit- ish and Foreign Contributors ; Transactions of the Obstetrical Societies in England and abroad ; Reports of Hospital Practice; Reviews and Bibliographical Notices; Articles and Notes, Edito- rial, Historical, Forensic, and Miscellaneous; Selections from Journals; Correspondence, Ac. Collecting together the vast amount of material daily accumulating in this important and ra- pidly improving department of medical science, the ,value of the information which it pre- sents to the subscriber may be estimated from the character of the gentlemen who have already promised their support, including such names as those of Drs. Atthill, Aveling, Robert Barnes, J. Hbnrt Bennet, Nathan Bozeman, Thomas Chambers, Fleetwood Churchill, Charles Clay, John Or.Av, Matthews Duncan, Arthur Farre, Robert Greenhalgh, Graily Hew- itt, Braxton Hicks, Alfred Meadows, W. Leishman. Alex. Simpson, Heywood Smith, Tyler Smith, Edward J. Tilt, Lawson Tait, Spencer Wells, Ac. Ac.;.in short, the repre- sentative men of British Obstetrics and Gynascology. In order to render the Obstetrical Journal fully adequate to the wants of the American profession, each number contains a Supplement devoted to the advances made in Obstetrics and Gynaecology on this side of the Atlantic. This portion of the Journal is under the editorial charge of Dr. J. V. Ingham, to whom editorial communications, exchanges, books for re- view, Ac, may be addressed, to the care of the publisher. *** Complete sets from the beginning can no longer be furnished, but subscriptions can com- mence with January, 1878, or Vol. VI., No. I, April, 1878. 21 Henry C. Lea's Publications—(Midwifery). pLAYFAIR ( W. S.) 3f.D., F.R.C.P.. -"- Professor of Obstetric Medicine hi King's College, etc. etc. A TREATISE ON THE SCIENCE AND VKAOTTCK OF MIDWIFERY. Second American, from the Second and Revised English Edition. Edited, with Addi- tions, by Robert P. Harris, M.D. In one handsome octavo volume with numerous illus- trations. (Preparing.) The very remarkable success which has in so short a time exhausted the first editions of this work, in both England and America, shows that the author has successfully supplied an acknowl- edged want of a work which, within a moderate compass, should serve as a guide to the most recent condition of obstetric art and science. A few notices of the previous edition are appended. The author's reputation was sufficient to warrant Breat expectations, when his forthcoming work was an- nounced, and its appearance has caused no disappoint- ment It deals in a masterly way with many disputed points, and gives conclusions which it would be difficult to gainsay. The work is the most valuable acquisition to the subject on which it treats which has been given the profession in a long time, and in saying this we do not forget the many admirable treatises which have re cently appeared. No practitioner can afford to be with j thairany~other work in the field of obVtetric literature. out it —Peninsular Journ. of Med., Sept. 1875. [ jn prajse 0f tnjs work too much cannot be said—in ad- i verse criticism very little We advise every student The high reputation already won by Dr. Playfair in j ani everv graduate to obtain it. and hope, ere long, to this special departmentof medicine is a sufficient iruar-. see it adopted as the principal text.booK of obstetric autee for the meritorious characterof this work. Every [ medicine in every college in the United ritates.—Nash- page is replete with interesting and instructive matter, ville Med. and Surg. Journ., Oct. 1876. containing the very latest information regarding the subject of obstetrics, full of hints of the greatest prac- tical value. This work will find, we predict, a large and ready sale The book is profusely illustrated with valu- able woodcuts, and is printed in beautiful type.— Cin- cinnati Lancet and Observer, Nov. 1876. This is pre-eminently a work adapted to the wants of students, and will do more towaid accomplishing the profession a*, large in that particular branch of medicine H ODGE (HUGH L.), M.D., Emeritus Professor of Midwifery, Ac, in the University of Pennsylvania, Ac. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in cloth, $14. The work of Dr. Hodge is something more than alobstetricians. Of the American works on the subject limple presentation of his particular views in the de- it is decidedly thebest.—Edinb. Med. Jour., Dec. '64. partment of Obstetrics; it is something more than an We have read Dr. Hodge's book with great plea- ordinary treatise on midwifery ; it is, in fact, a cyclo- gure, and have much satisfaction in expressing oni paedia of midwifery. He has aimed to embody in a commendation of it as a whole. It is certainly highly single volume the whole science and art of Obstetrics instructive, and in the main, we believe, correct. The An elaborate text is combined with accurate and va- great attention which the author has devoted to the ried pictorial illustrations, so that no fact or principle mechanism of parturition, taken along with the con- Is left unstated or unexplained.—Am. Med. Times, elusions at which he has arrived, point, we think, Sept. 3, 1864. conclusively to the fact that, in Britain at least, th» It Is very large, profusely and elegantly illustrated, doctrines of Naegele have been too blindly received. and is fitted to take its place near the works of great —Glasgow Med. Journal, Oct. 1864. #*# Specimens of the plates and letter-press will be forwarded to any address, free by mail, on receipt of six cents in postage stamps. RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., Professor of Obstetrics, Ac, in the Jefferson Medical College, Philadelphia. In one large and 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 is all nearly 200 large and beautiful figures. $7 00. C HURCHILL (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 Diseases of Chil- dren," Ac. With one hundred and ninety-four illustrations. In one very handsome octavo volume of nearly 700 large pages. Cloth, $4 00 ; leather, $5 00. MONTGOMERY'S EXPOSITION OF THE SIGNS RIGBY'8 SYSTEM OF MIDWIFERY. With Notes AND SYMPTOMS OF PREGNANCY. With two I and Additional Illustrations. Second American exquisite colored plates, and numerous wood-cuts. | "dition. One volume octavo, cloth, 422 page* In lvol.8vo.,ofnearly600pp.,cloth. $3 75. | $2 50. Henry C. Lea's Publications—(Midwifery, Surgery). 25 TEISHMAN ( WILLIAM), M.D., i Regius Professor of Midwifery in the University of Glasgow, Ac A SVSTKM OF MIDWIFERY, INCLUDING THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. Second American, from the Second and Revised English Edition, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia Hospital, Ac. In one large and very"handsome octavo volume of over 700 pages, with about two hundred illustrations: cloth, $5; leather, $6. (Just Issued.) That thit- book is recommended as a text-book by mauy of the Uading scholars of medicine in this country, is sufficient evidence of the favor in which it is held. In a word, we know of no better book in >ur language, both for the student and practitioner. The value of the book is enhanced by this second edition, which contains many notes by our late Dr. Parry.—Chicago Med. Journ. and Examiner, March, 1877. Hut the most valuable additions to the volume are those made by the American editor. One of the best tests of a man's ability is for him to take a standard work in our profession, like this of Dr. LeishmHii.-and materially Improve it. Many a one, with more ambition than wis- dom, has attempted it with other books and failed. Rut Dr. Parry has succeeded most admirably. We know no obstetrical work that has anything better on the use of the forceps than that which Dr. Parry has given in this, and no work that has the rational and intelligent views upon lactation with which he has enriched this. Having used "Leishman" for two years as a text-book for stu- dents, we can cordially commend it. and are quite satisfied to continue such use now.—Am. Practitioner, Mar. 1876, This new edition decidedly confirms the opinion which we expressed of the first edition of the work, in the May. H74, number of this Journal, that this is "the best modern work on the subject in the English language." The excellent practical notes contributed by Dr. Parry refer principally to the use of the forceps, lactation, and the puerperal diseases, and are intended to inert a.-e the usefulness of the work in this country. An entirely new chapter on diphtheria of puerperal wounds has been added (Dr. 1*. has had uuusual experience in this form of puerperal fever), and also a number of illustrations of the principal obstetrical instruments in use in Ame- rica. We have no hesitation in saying that the work, in its preset shape, is a great improvement on its prede- cessor, and in recommending it as the one obstetrical textbook which we should advise every English speak- ing practitioner and student to buy.—American Jour- nal of Obstetrics, Feb. 1876. Perhaps the most useful one the student can procure. Some important additions have been made by the editor, in order to adaplthe work to the profession in this coun- try, and some new illustrations have been introduced, to represent the obstetrical instruments generally em- ployed in American practice. In its present form, it is an exceedingly valuable book for both the student and practitioner.—New York Med. Journal, Jan. 1876. In about two years after the issue of this excellent treatise a second edition has been called for. We regard the treatise as thoroughly sound and practical, and one which may with confidence be consulted in any emer- gency. — The London Lancet, Dec. 11, lb/6. pARRY (JOHN S.), M.D., -^ Obstetrician to the Philadelphia Hospital, Vice-Prest. of the O^stet. Society of Philadelphia EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS, AND TREATMENT. In one handsome octavo volume. Cloth, $i 50. (Lately Issued.) out of something very like chaos.—Philadelphia Med. Times, Feb. 19, 1876. It is with genuine satisfaction, therefore, that we read the work before us, which is far in advance of any mo- nograph upon the subject in the English language, and exceeding very much, in the number of cases upon which it is based, we believe, any work of the kind ever published. The author has given great care and study to the work, and has handled his statistics with judg- ment; so that, whatever was to be gained from them, he has gained and added to our knowledge on the sub- ject. We owe the author much for giving us a clear, readable book upon this topic. lie has, so far as it is at present possible, removed the obscurity attending certain points of the subject. He has brought order In this work Dr. Parry has added a most valuable contribution toobstetricliterature. and one which meets a want long felt by those of the profession who have ever been called upon to deal with this class of cases.— Boston Med. and Surg. Journ., March 9,1876. This work, being as near as possible a collection of th e experiences of many persons, will afford a most useful guide, both in diagnosis and treatment, for this most interesting and fatal malady. We think it should be in the hands of all physicians practising midwifery.—Cin- cinnati Clinic, Feb. 5, 1876. A SHHURST (JOHN, Jr.), M.D., "**■ Prof, of Clinical Surgery, Univ. of Pa., Surgeon to the Episcopal Hospital, Philadelphia. THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, cloth, $6 50; leather, raised bands, $7 50 Its author has evidently tested the writings and experiences of the past aud present in the crucible of a careful, analytic, and honorable mind, and faith- fully endeavored to bring his work up to the level of ipinions of others. He is conservative, but not hide- bound by authority. His style is clear, elegant, and scholarly. The Work is anadmirabletext-book, and a useful book of reference. It is a credit to American the highest 'standard ~ oTpractical surgery. He is ! professional literature, and oneof the first ripe fruits rank fnd definite"andOgives us opinions/and gene- .f the soil fertilized by the blood of our late unhappy rally sound ones, instead of a mereresume of the \ var.-iv". Y. Med. Record, Feb. 1, 1872. SKEY'S OPERATIVE SURGERY. In 1 v«l. 8vo. cl., of 660 pages; with about 100 wood-cuts. $3 25 COOPER'S LECTURES ON THE PRINCIPLES AND PracticeofSfrhery. Inlvol Svo cloth,750p. $2. GIBSON'S INSTITUTES AND PRACTICE OF SUR- okry. Eighth edition, improved and altered. With thirty-four plates. In two handsome octavo vol- nmes. about 1000pp..leather raised band?. *" ft* THE PRINCIPLES AND PRACTICE OF SURGERY. By William Pirkib.F.R S.E., Professor of Surgery in the University of Aberdeen. Edited by John Neill, M.D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hos pital, &c. In one very handsome octavo volume of 780 pages, with 316 illustrations, cloth, $3 75. MILLER'S PRINCIPLES OF SURGERY. Fourth Ame- rican, from the Third Edinburgh Edition. Tn one large Svo. vol. of 700 pages, with 340 illustrations : cloth, $3 75. MILLER'S PRACTICE OF SURGERY. Fourth Ame- rican, from the last E^'uhurgh Edition. Revised by the American editor. In onelarge Svo. vol. of nearly 700 pages, with 364 illustrations: cloth, $3 75. 26 Henry C. Lea's Publications—(Surgery). G yROSS (SAMUEL D.), M.D., Professor of Surgery in the Jefferson Medical College of Philadelphia. A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, carefully revised, and improved. In two large and beautifully printed imperial octavo vol- umes of about 2300 pages, strongly bound in leather, with raised bands, $15. (Just Issued.) The continued favor, shown by the exhaustion of successive large editions of this great work, proves that it has successfully supplied a want felt by American practitioners and students. In the present revision no pains have been spared by the author to bring it in every respect fully up to the day. To effect this a large part of the work has been rewritten, and the whole enlarged by nearly one-fourth, notwithstanding which the price has been kept at its former very moderate rate. By the use of a close, though very legible type, an unusually large amount ol matter it condensed in its pages, the two volumes containing as much as four or five ordinary octavos. This, combined with the most careful mechanical execution, and its very durable binding, render; it one of the cheapest works accessible to the profession. Every subject properly belonging to the domain of surgery is treated in detail, so that the student who possesses this work may be said to have in it a surgical library. We liuve now brought our task to a conclusion, and i " Primus inter Pares." It is learned, scholar-like, me- have seldom read a work wilh the practical value of thodical, precise, and exhaustive. We scarcely think which we have been moreimpressed. Kverychapter is | any living man could write so complete aud faultless a so conci-ely put together, that the busy practitioner. when in difficulty, can at once find the information he requires. His work, on the contrary, is cosmopolitan. the surgery of the world being fully represented in it. The w>rk. in fact, is / the Infir fur Dis oftlu Ear, Phila. THK EAR, ITS ANATOMY. PHYSIOLOGY, AND DISKASKS. A Practical Treatise for the Use of Medical Students and Practitioners. In one hand. some octavo vo'ume of 615 pages, with eighty-seven illustrations : cloth, $4 50; leather, $5 50. (Just Ready.) Recent progress in the investigation of the structures of the ear. and advances ma^e in the modes of treating its diseases, would seem to render desirable a new work in which all the re sources of the most advanced science should b<» placed a^ the disposal of the practitioner. This it has beep the aim of Dr. Burnett to accomplish, and the advantages which he has enjoyed in the special study of the subject are a guarantee that the result of his labors will prove of service to the profession at large, as well as to the specialist in this department. As the title of the work indicates, this volume the medical student aud general practitioner, this work is indispensable, aud will not be found void of interest to the specialist —Maryland Med. Journ , Nov 1S77 treats of the anatomy and physiology of the ear, as well as of its diseases, and the author has taken special pains to make this difficult and complicated matter thoroughly clear and intelligible. The book is designed especially for the use of -tudents and general practitioners, nnd places at their disposal much valuable material. Such a book as the pre- sent one, we think, has long been needed, and we may congratulate the author on his success in fill- ing the gap. Both student and practitioner can study the work with a great deal of benefit. It is profusely and beautifully illustrated —X r. Hos- pital Gazette, Oct l.>, 1877. The medical student and general practitioner have long felt the need of a book of this character on an organ so little understood and yet so important as the ear. The author has presented in lie volume clearly but concisely the greatadvancfs which have been made of late yo;u-s in otology and has indicated the direction in which further researches can be most profitably carried on. The work is divided into two pares. Iu Part I. the anatomy and physiol- ogy of the ear are minutely, yet explicitly, detailed in a manner not to be found ia any of the ordinary text-books. In Part II the diseases aud treatmeut of the ear are fully and practically presented. To The appearance of this book is another proof of the i rapidly increasing amount of honest, valuable work that is now r>-=ing done in the various branches of medical science iu this country. Dr Burnett is to be commended for having written the best book on the subject in the English language, and especially for the care and attention he has given to the scientific side of the subject. — N. Y. Med Journ., Dec. 1S77. There is probably no other book of the kind in the English language which contain'- bo concise and yet so complete an account of the numerous dis- eases to which the «ar is liable. We can safely pre- dict that every intelligent medical man who takes the trouble to make himself f miliar with the lead- ing facts concerning this class of disease, as given by Dr. Burnett, will not only admit that the time thus employed was far from being wasted, but that the earnest labors of Otologists within the last few years have taken away the sting of reproach con- tained in the hackneyed phr.ise that'• nothing can be got out of the ear but fees 77. fAYLOR (ALFRED S.), M.D., Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. (Just Issued.) The present is tui^d upon the two previous edi- tions ; " but the completeievision rendered necessary by time has couverted it into a new work." This statement from the preface contains all that it is de- sired to know in reference to the new edition. The works of this author are already in the library of every physician who is liable to be called upon for medico-legal testimony (and what eneis not?), so that all that is required to be known about the present book is that the author has kept it abreast with the times What makes it now, as always, especially valuable to the practitioner is its conciseness and practical character, only those poisonous substances being described which give rise to legal investiga- tions.— The Clinic, Nov. 6, 1875. Dr. Taylor hat brought to bear on the compilation of this volume, stores of learning, experience, and practical acquaintance with his subject, probably far beyond what any other living authority ou toxicol- ogy could have amassed or utilized. He has fully sustained his reputation by the consummate skill aud legal acumen he has displayed iu the arrange- ment of the subject-matter, and the result is a work on Poisons which will be indispensable to every stu- dent or practitioner in law and medicine.— The Dub- lin Journ. of Med Set., Oct. 1870. ' B Y THE SAME AUTHOR. MEDICAL JURISPRUDENCE. Seventh American Edition. Edited by John J. Reese, M.D., Prcf of Med. Jurisp. in the Univ. of Penn. In one large octavo volume of nearly 900 pages. Cloth, $5 00; leather, $6 00. (Lately Issued.) To the membersofthelegaland medical profession, , best authority on this specialty in our language. On it is unnecessary to say anything commendatory of | this point, however, we will say that we consider Dr. Taylor's Medical Jurisprudence. We might as well i Taylor to be the safest medico-legal authority to fol- undertake to speak of the merit of Chitty's Plead-' low, in general, with which we are acquainted in any ings.—Chicago Legal News, Oct. 16, 1873. language.—Pa. Clin. Record, Nov. 1S73. It is beyond question the most attractive as well ThislasteditionoftheManualisprobably the best as most reliable manual of medical jurisprudence of all itcontains raore materialLd is worked np P? Sl^^f/,^Oct 1873 g g t0 the latest views of the auth°r »* expressed in the of Syphilography, Oct. 1873. . last edition of the Principles. Dr. Reese, the editor It is altogethersuperriuous for us to offer anything I of the Manual, has done everything to make his in behalf of a work on medical jurisprudence by an work acceptable to his medical countrymen.—N. Y. author who isalmost universally esteemed to be the Med. Record, Jan. 15, 1874. rjf THE SAME AUTHOR. THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo volumes, cloth, $10 00: leather, $12 00 This great work is now recognized in England as the fullest and most authoritative treatise on every department of its important subject. In laying it, in its improved form, before the Ameri- can profession, the publisher trusts that it will assume the same position in this country. Henry C. Lea's Publioatiomb—(ifisrpZ/a»eo?/s). 31 fHOMPSON (SIR HENR Y), ' Surgeon and Professor of Clinical Surgery to University College Hospital LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. Second American from the Third English Edition. In one neat octavo volume. Cloth, $2 26. (Just Isstied.) T> Y THE SAME AUTHOR. ------ ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHBA AND URINARY FISTULA. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, cloth, $3 50. (Lately Published.) T>Y THE SAME AUTHOR. THE DISEASES OF THE PROSTATE, THEIR PATHOLOGY AND TREATMENT. Fourth Edition, Revised. In one handsome 8vo. vol. ol 355 pages, with 13 piates, plain and colored, and illustrations on wood. Cloth, $3 75. (Just Issued.) UKE (DANIEL HACK), M.D., Joint author of "The Manual of Psychological Medicine," Ac ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. (Lately Issued.) ■QLANDFORD (G. FIELDING), M. D., F. R. C. P., X5 Lecturer on Psychological Medicine at the School of St. George's Hospital, rdinary manuals in the English language or (so fai ral practitioner. If we pass from theoretical conside- as our own reading extends) in any other.— London rations to descriptions of the varieties of insanity as, Practitioner, Feb 1871. T T EA (HENRY C). ^SUPERSTITION AND FOKCE: ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Third Revised and Enlarged Edition. In one handsome royal 12mo. volume of about 550 pages. (Shortly.) A few notices of the previous edition are appended. We know of no single work which contains, in so • mall a compass, so much illustrative of thestrangest operations of the human mind. Foot-notes give the authority for each statement, showing vast research and wonderful industry. We advise our confreres li read this book and ponder its teachings.—Chicago Med. Journal, Aug. 1870. As a work of curious inquiry on certain outlying points of obsolete law, "Superstition and Force" is one of the most remarkable books we have met with. —London Athenaeum, Nov. 3, 1866. He has thrown a great deal of light upon what must be regarded as one of the most instructive as well as interesting phases of human society and progress. . The fulness and breadth with which he has carried out his comparative survey of this repulsive field of history [Torture], are such as to preclude our doing justice to the work within our present limits. But here, as throughout the volume, there will be found a wealth of illustration and a critical grasp of the philosophical import of facts which will render Mr. Lea's labors of sterling value to the historical stu- dent.— London Saturday Review, Oct. S, 1870. As a book of ready reference on the subject, it is ol the highest value.— Westminster Review, Oct. 1S67. T)l* THE SAME AUTHOR. (Lately Published.) STUDIES IN CHURCH HISTORY—THE RISE OF THE TEM- PORAL POWER—BENEFIT OF CLERGY—EXCOMMUNICATION. In one large royal 12mo. volume of 516 pp.; cloth, $2 75. The story was never told more calmly or with greater learning or wiser thought. We doubt, indeed, If any other study of this field can be compared with this for clearness, accuracy, and power. — Chicago Examiner, Dec. 1870. Mr. Lea's latest work, "StudiesinChurch History," fully sustains the promise of the first. It deals with three subjects—the Temporal Power, Benefit of Clergy, and Excommunication, the record of which has a peculiar importance for the English student, and Is a chapter on Ancient Law likely to be regarded as final. We can hardly pass from our mention of such .......-----.„..,_._ works as these—with which that on "Sacerdotal j Psychol. Medicine, July, 1870. Celibacy" should be included—without noting the1 literary phenomenon that the head of one of the first American houses is also the writer of some of its most original books.—London Athenaum, Jan. 7, 1871. Mr. Lea has done great honor to himself and this country by the admirable works he has written on ecclesiologicaland cognate subjects. We have already had occasion to commend his "Superstition aud Force" and his "History of Sacerdotal Celibacy.' The present volume is fully as admirable in its me- thod of dealing with topics and in the thoroughness— a quality so frequentl y lacking in American authors— with which thev are investigated.—N. Y. Journal of 32 Henry C. Lea's Publications. INDEX TO CATALOGUE American Journal of the Medical Sciences Abstract, Monthly, of the Med Sciences Allen's Anatomy . Anatomical Atlas, by Smith i%d Horner Ashton on the Rectum and Anns Attfleld's Chemistry Ashwell on Diseases of Females Ashhurst's Surgery Browne on Ophthalmoscope . Burnett on the Ear . Barnes on Diseases of Women Bellamy's Surgical Anatomy Bryant's Practical Surgery . Bloxam's Chemistry Blandford on Insanity . Basham on Renal Diseases . Brinton on the Stomach Bigelow on the Hip Barlow's Practice of Medicine Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Bristowe's Practice .... Kumstea,d on Venereal .... Bumstead and Cullerier's Atlas of Venereal Carpenter's Human Physiology Carpenter on the Use and Abuse of Alcohol Cornil and Ranvier . , Carter on the Eye .... Cleland's Dissector Clowes' Chemistry .... Century of American Medicine Chad wick on Discuses of Women . Charcot on the Nervous System . Chambers on Diet and Regimen . Chambers's Restorative Medicine Christison and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Puerperal Fever Condie on Diseases of Children . Cooper'6 (B. B.) Lectures on Surgery . Cullerier's Atlas of Venereal Diseases Cyclopedia of Practical Medicine. Dalton's Human Physiology Davis's Clinical Lectures Dewees on Diseases of Females . Druitt's Modern Surgery Dunglison's Medical Dictionary . Dunglison's Human Physiology . Erichsen's System of Surgery Farquharson's Therapeutics . . i Fenwick's Diagnosis .... Flint on Respiratory Organs . Flint on the Heart..... Flint's Pvactice of Medicine . Flint's Essays..... Flint on Phthisis..... Flint on Percussion .... Fothergill's Handbook of Treatment . Fothergill's Antagonism of Therapeutic Age Fownes's Elementary Chemistry . Fox on Diseases of the Skin . Fuller on the Lungs, &c. Green's Pathology and Morbid Anatomy Qibson's Snrgery..... Gluge's Pathological Histology, by Leidy Gray's Anatomy ..... (Sritflth's (R. E.) Universal Formulary Gross on Urinary Organs Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gosselin's Clinical Lectures on Surgery Hamilton on Dislocations and Fractures Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of the Medical Sciences Hartshorne's Anatomy and Physiology Hamilton on Nervous Diseases Heath's Practical Anatomy . Hoblyn's Medical Dictionary Hodge on Women . Hodge's Obstetrics . Hodge's Practical Dissections Holland's Medical Notes and Reflections PAGE 1 3 7 6 ts Holmes's Surgery .... Holden's Landmarks lorner'* Anatomy and Histology Hudson on Fever .... Jill on Venereal Diseases lillier's Handbook of Skin Diseases lones (C. Handfleld) on NervouB Disorder! Kirkes' Physiology .... Knapp's Chemical Technology . Lea's Superstition and Force Lea's Studies in Church History . Lee on Syphilis..... Lincoln on Electro-Therapeutics . Leishman's Midwifery .... La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery Lawson on the Eye . Lehmann's Physiological Chemistry, 2 vols Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever .... Medical News and Library . Meigs on Puerperal Fever Miller's Practice of Surgery . Miller's Principles of Surgery Montgomery on Pregnancy . Neill and Smith's Compendium of Med. Science Neligan's Atlas of Diseases of the Skin Obstetrical Journal Parry on Extra-Uterine Pregnancy Pavy oh Djgestion .... Pavy on Food...... Parrish's Practical Pharmacy Pirrie's System of Surgery . Playfair's Midwifery .... Quain and Sharpey's Anatomy, by Leidy Roberts on Urinary Diseases . Ramsbotham on Parturition . Remsen's Principles of Chemistry Rigby's Midwifery..... Rodwell's Dictionary of Science . Stimson's Operative Surgery Swayne's Obstetric Aphorisms Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Skey's Operative Surgery Slade on Diphtheria .... Schafer's Histology .... Smith (J. L.) on Children Smith (H. H.) and Horner's Anatomical Atl Smith (Edward) on Consumption . Smith on Wasting Diseases in Children Stille's Therapeutics .... Stille & Maisch's Dispensatory Sturges on Clinical Medicine Stokes on Fever..... Tanner's Manual of Clinical Medicine . Tanner on Pregnancy .... Taylor's Medical Jurisprudence Taylor's Principles and Practice of Med Ji Taylor on Poisons . Tuke on the Influence of the Mind Thomas on Diseases of Females . Thompson on Urinary Organs . . . Thompson on Stricture .... Thompson on the Prostate Todd on Acute Diseases .... Walshe on the Heart .... Watson's Practice of Physic . Wells on the Eye..... West on Diseases of Females . . West on Diseases of Children West on Nervous Disorders of Children What to Observe in Medical Cages Williams on Consumption . Wilson's Human Anatomy . Wilson on Diseases of the Skin . Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Wohler's Organic Chemistry Winckel on Childbed risp For "The Obstktrical Journal," Fivk Dollals a year, see p. 23. 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